Calendar Year Deductible |
$3,500 individual; $7,000 family |
Out-of-Pocket Maximum
|
$8,150 individual; $16,300 family
|
Primary Care Office Visit
|
$50 copay. Each member must designate a Primary Care Select physician |
Specialist Office Visit |
$75 copay. You must have a referral from your Primary Care Select physician |
Telephone and Online Video Consultations |
You pay $45 per consultation
|
Outpatient Surgery
|
25% member coinsurance, after meeting the calendar year deductible |
Emergency Room
|
25% member coinsurance, after meeting the calendar year deductible
|
Pediatric Routine Dental Cleaning and Yearly Eye Exam |
Routine Dental Cleaning: you pay $0; Yearly Eye Exam: you pay 25% member coinsurance, after meeting the calendar
year deductible |
Prescription Drugs |
Tier 1: $20 copay / Tier 2: $30 copay / Tiers 3-6: 25% member coinsurance, after meeting 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. |