IN-NETWORKBENEFITS |
$1,000 HMO |
$1,500 HMO |
$3,300 HDHP PPO |
Deductible |
$1,000 Single$2,000 Family |
$1,500 Single$3,000 Family |
$3,300 Single$5,600 Family |
Coinsurance |
You pay 20% (after deductible)Plan pays 80% |
You pay 20% (after deductible)Plan pays 80% |
You pay 0% (after deductible)Plan pays 100% |
Out of Pocket Maximum |
$3,500 Single$7,000 Family |
$5,000 Single$10,000 Family |
$3,300 Single$5,600 Family |
Office Visit Copay |
$20 Designated PCP$25 PCP$50 Specialist$10 Doctor on Demand$25 Urgent Care |
$20 Designated PCP$25 PCP$50 Specialist$10 Doctor on Demand$25 Urgent Care |
Deductiblethen 0% coinsurance$59 Doctor on Demand
|
Preventive Office Copay |
Covered at 100% |
Covered at 100% |
Covered at 100% |
Emergency Room Copay |
$150 copay |
$150 copay |
Deductiblethen 0% coinsurance |
Prescription DrugDeductibleCost Per Tier |
$100 Single /$200 Family
Tier 1: $15Tier 2: $30Tier 3: $50Tier 4: $50
Generic Specialty: $100
Preferred Specialty: $150
Non-Preferred Specialty: $300
|
$100 Single /$200 Family
Tier 1: $15Tier 2: $30Tier 3: $50Tier 4: $50
Generic Specialty: $100
Preferred Specialty: $150
Non-Preferred Specialty: $300
|
Deductiblethen 0% coinsurance |




































