IN-NETWORK
BENEFITS |
POS 500 PlanP5003060ek0LX |
POS 2000 PlanP2000i80LX21B |
POS 5000 PlanP5000i80LX21B |
Deductible |
Individual: $500
|
Individual: $2,000
|
Individual: $5,000
|
Coinsurance |
You pay 20% (after deductible)
|
You pay 20% (after deductible)
|
You pay 20% (after deductible)
|
Out of Pocket Maximum |
Individual: $3,000
|
Individual: $5,000Family: $10,000 |
Individual: $8,150
|
Office Visit Copay |
$30 PCP$60 Specialist$100 Urgent Care$0 Virtual Visits (Designated Provider Network)
|
$25 PCP$75 Specialist$50 Urgent Care$0 Virtual Visits (Designated Provider Network)
|
$25 PCP$75 Specialist$50 Urgent Care$0 Virtual Visits (Designated Provider Network)
|
Preventive Office Copay |
Covered at 100% |
Covered at 100% |
Covered at 100% |
Emergency Room Copay |
$300 copay |
$300 copay |
$300 copay |
Hospitalization |
Inpatient In-network:
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Inpatient In-network:
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Inpatient In-network:
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Prescription DrugDeductibleCost Per Tier |
In-network:
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In-network:
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In-network:
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