| Calendar Year Deductible |
$2,700 individual; $5,400 family |
Out-of-Pocket Maximum
|
$8,150 individual; $16,300 family
|
Primary Care Office Visit
|
$45 primary physician copay or $75 specialist physician copay |
| Specialist Office Visit |
$75 copay |
| Telephone and Online Video Consultations |
You pay $45 per consultation
|
Outpatient Surgery
|
Lower member cost share: $450 copay / Higher member cost share: $850 copay |
Emergency Room
|
$450 hospital copay; $75 doctor copay
|
| Pediatric Routine Dental Cleaning and Yearly Eye Exam |
Routine Dental Cleaning: you pay $0; Yearly Eye Exam: you pay 20% after you meet the calendar year deductible |
| Prescription Drugs |
Tier 1: $20 copay / Tier 2: $30 copay / Tier 3: $85 copay / Tier 4: 50% member coinsurance / Tier 5 (preferred specialty): $250 copay / Tier 6 (nonpreferred specialty): 30% member coinsurance / 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. |