| In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | |
| Annual Deductible |
||||||
| Individual | $3,000 | $6,000 | $6,350 | $19,050 | $2,000 | $4,500 |
| Family | $6,000 | $16,500 | $12,700 | $38,100 | $4,000 | $13,500 |
|
Coinsurance (what you pay) |
20% | 50% | 0% | 50% | 20% | 40% |
| Out-of-Pocket Max (includes deductible) | ||||||
| Individual | $6,000 | $16,500 | $6,350 | $19,050 | $6,000 | $13,500 |
| Family | $12,000 | $33,000 | $12,700 | $38,100 | $12,000 | $40,500 |
| Physician Services | ||||||
| Office Visit | 20% After deductible | 50% After deductible |
0% After deductible | 50% After deductible | $30 copay | 40% After deductible |
| Preventive Care | 100% Covered | 50% After deductible | 100% Covered | 50% After deductible | $0 copay | 40% After deductible |
| Hospital Services | ||||||
|
Inpatient/ Outpatient |
20% After deductible | 50% After deductible | 0% After deductible | 50% After deductible | 20% After deductible | Plan pays 60% |
| Emergency Room | 20% After deductible | 50% After deductible | 0% After deductible | 50% After deductible | $200 copay; then plan pays 100% | $200 copay; then plan pays 100% |

















