| Calendar Year Deductible |
$750 individual; $1,500 family |
Out-of-Pocket Maximum
|
$6,000 individual; $12,000 family
|
Primary Care Office Visit
|
$40 copay. Receive a discounted copay of $25 when visiting your designated Primary Care Select physician |
| Specialist Office Visit |
$60 copay. Receive a discounted copay of $45 when referred to a specialist by your designated Primary Care Select physician
|
| Telephone and Online Video Consultations |
You pay $45 per consultation
|
Outpatient Surgery
|
Lower member cost share: $300 copay / Higher member cost share: $600 copay |
Emergency Room
|
$300 facility copay; $60 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: $10 copay / Tier 2: $25 copay / Tier 3: $45 copay / Tier 4: 40% member coinsurance / Tier 5 (preferred specialty): $175 copay / Tier 6 (nonpreferred specialty): 20% 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. |