Summary of base plan (1)
Overall deductible: $1,000 individual / $3,000 family
What is the out-of-pocket limit for this plan? $5,000 Individual / $12,700 Family
Primary care visit to treat an injury or illness: $30 copay (in network, out of network)
Specialist visit: $30 copay (in network, out of network)
Preventive care: No Charge
Diagnostic test (x-ray, blood work) 20% coinsurance
Imaging (CT/PET scans, MRIs) 20% coinsurance
In-network Prescriptions:
Generic drugs $5 copay/retail option; $10 copay/mail order option
Preferred brand drugs $25 copay/retail option; $50 copay/mail order option
Non-preferred brand drugs $50 copay/retail option; $100 copay/mail order option
Specialty drugs 20% coinsurance up to $150 maximum per 30 day supply
What is the out-of-pocket limit for this plan? $5,000 Individual / $12,700 Family
Primary care visit to treat an injury or illness: $30 copay (in network, out of network)
Specialist visit: $30 copay (in network, out of network)
Preventive care: No Charge
Diagnostic test (x-ray, blood work) 20% coinsurance
Imaging (CT/PET scans, MRIs) 20% coinsurance
In-network Prescriptions:
Generic drugs $5 copay/retail option; $10 copay/mail order option
Preferred brand drugs $25 copay/retail option; $50 copay/mail order option
Non-preferred brand drugs $50 copay/retail option; $100 copay/mail order option
Specialty drugs 20% coinsurance up to $150 maximum per 30 day supply
Summary of buy up plan (2)
Overall deductible: $500 individual / $1,500 family
What is the out-of-pocket limit for this plan? $2,500 Individual / $7,500 Family
Primary care visit to treat an injury or illness: $25 copay (in network, out of network)
Specialist visit: $25 copay (in network, out of network)
Preventive care: No Charge
Diagnostic test (x-ray, blood work) 20% coinsurance
Imaging (CT/PET scans, MRIs) 20% coinsurance
In-network Prescriptions:
Generic drugs $5 copay/retail option; $10 copay/mail order option
Preferred brand drugs $25 copay/retail option; $50 copay/mail order option
Non-preferred brand drugs $50 copay/retail option; $100 copay/mail order option
Specialty drugs 20% coinsurance up to $150 maximum per 30 day supply
What is the out-of-pocket limit for this plan? $2,500 Individual / $7,500 Family
Primary care visit to treat an injury or illness: $25 copay (in network, out of network)
Specialist visit: $25 copay (in network, out of network)
Preventive care: No Charge
Diagnostic test (x-ray, blood work) 20% coinsurance
Imaging (CT/PET scans, MRIs) 20% coinsurance
In-network Prescriptions:
Generic drugs $5 copay/retail option; $10 copay/mail order option
Preferred brand drugs $25 copay/retail option; $50 copay/mail order option
Non-preferred brand drugs $50 copay/retail option; $100 copay/mail order option
Specialty drugs 20% coinsurance up to $150 maximum per 30 day supply
Summary of HDHP (3)
Overall deductible: $1,400 individual / $2,800 family
What is the out-of-pocket limit for this plan? $5,000 Individual / $12,700 Family
Primary care visit to treat an injury or illness: $25 copay (in network, out of network)
Specialist visit: $25 copay (in network, out of network)
Preventive care: No Charge
Diagnostic test (x-ray, blood work) 20% coinsurance
Imaging (CT/PET scans, MRIs) 20% coinsurance
In-network Prescriptions:
Generic drugs $5 copay/retail option; $10 copay/mail order option
Preferred brand drugs $25 copay/retail option; $50 copay/mail order option
Non-preferred brand drugs $50 copay/retail option; $100 copay/mail order option
Specialty drugs 20% coinsurance up to $150 maximum per 30 day supply
What is the out-of-pocket limit for this plan? $5,000 Individual / $12,700 Family
Primary care visit to treat an injury or illness: $25 copay (in network, out of network)
Specialist visit: $25 copay (in network, out of network)
Preventive care: No Charge
Diagnostic test (x-ray, blood work) 20% coinsurance
Imaging (CT/PET scans, MRIs) 20% coinsurance
In-network Prescriptions:
Generic drugs $5 copay/retail option; $10 copay/mail order option
Preferred brand drugs $25 copay/retail option; $50 copay/mail order option
Non-preferred brand drugs $50 copay/retail option; $100 copay/mail order option
Specialty drugs 20% coinsurance up to $150 maximum per 30 day supply
This web site is not a legal document. This web site is not a guarantee of coverage, eligibility, or provider status and is designed for informational illustration only. Benefits outlined on this web site are subject to change at any time. Please consult your benefit plan provider(s) or administrator(s) for legal documents regarding your plan and to check coverage and/or eligibility.
