Benefits |
Tier 1 - Delta Health |
Tier 2 - First Health Network |
Deductible |
Individual: $0
Family $0
|
Individual: $1,500
Family $3,000
|
Coinsurance |
You pay 0%
Plan Pays 100%
|
You pay 20% (after deductible)
Plan Pays 80%
|
Out-of-Pocket Maximum |
Individual: $0
Family $0
|
Individual: $3,500
Family $7,000
|
Office Visit |
You pay 0%
Plan Pays 100%
|
$40 copay
|
Specialist Office Visit |
You pay 0%
Plan Pays 100%
|
$40 copay
|
Preventive |
You pay 0%
Plan Pays 100%
|
You pay 0%
Plan Pays 100%
|
Emergency Room |
You pay 0%
Plan Pays 100%
|
$300 copay then you pay 20% (after deductible)
Plan Pays 80%
|
Urgent Care |
You pay 0%
Plan Pays 100%
|
$75 copay
|
Hospitalization |
Inpatient:
You pay 0%
Plan Pays 100%
Outpatient:
You pay 0%
Plan Pays 100%
|
Inpatient:
You pay $300 copay + 20% (after deductible)
Plan Pays 80%
Outpatient:
You pay 20% (after deductible)
Plan Pays 80%
|
Prescription Drugs |
Prescription Drug Out-of-Pocket Max:
$1,500/$3,000 (prescription drug cost only)
Tier 1 & 2 Generic: $15 copay
Preferred Brand: 35% copay to max of $150
Non-Preferred Brand: 40% copay to max of $200
Specialty Tier: $200 copay
|
|
Can I use a Health Care Flexible Spending Account (FSA)? |
YES
|