Calendar Year Deductible |
$1,750 individual; $3,500 family |
Out-of-Pocket Maximum
|
$6,000 individual; $12,000 family
|
Primary Care Office Visit
|
Plan pays 90%; Subject to the deductible |
Specialist Office Visit |
Plan pays 90%; Subject to the deductible |
Telephone and Online Video Consultations |
You pay $45 per consultation
|
Outpatient Surgery
|
Covered at 90%; Subject to calendar year deductible
|
Emergency Room
|
Covered at 90%; Subject to calendar year deductible
|
Pediatric Routine Dental Cleaning and Yearly Eye Exam |
Routine Dental Cleaning: you pay 0% after you meet the calendar year deductible; Yearly Eye Exam: you pay 10% after you meet the
calendar year deductible |
Prescription Drugs |
Tier 1: You pay 10% after you meet the calendar year deductible / Tier 2: You pay 10% after you meet the calendar year deductible / Tier 3: You pay 10% after you meet the calendar year deductible / Tier 4: You pay 10% after you meet the calendar year deductible / Tier 5 (preferred specialty):
You pay 10% after you meet the calendar year deductible / Tier 6 (nonpreferred specialty): You pay 10% after you meet the calendar year deductible / Generic drugs are mandatory when available |
Notes |
This plan uses the Source+Rx 1.0 Prescription Drug List and the ValueONE Network, which does not include all major retail chains.
Check the pharmacy network. |