Medical Benefits

Deductible
(Individual/Family)

$2,500/$5,000 In-Network
$2,500/$10,000 Out-of-Network

Coinsurance

20% In-Network

40% Out-of-Network

Out-of-Pocket Max
(Individual/Family)

$4,500/$9,000 In-Network

$9,000/$18,000 Out-of-Network

Office Visit

$40 PCP & Specialists In-Network

Telehealth Visit (Virtual Care)

$40 Copay

Routine Preventive Care

(contract lists covered services)

100% In-Network

Wellness Related Office Visit 100%

Inpatient Hospital

Member Coinsurance

Outpatient Hospital

Member Coinsurance

Emergency Room Copay

$100 copay then deductible and coinsurance

Urgent Care

$50 copay (office visit and lab only) In-Network

Vision Exam
(limited to 1 every
calendar year)

$40 copay In-Network

Generic

$10

Preferred Brand

$50

Non-Prefered Brand

$70

Mail Order

$20/$100/$140

Employee Only

$165.82

$188.46

$241.28

Employee + 1

$417.87

$492.45

$641.63

Family

$587.68

$736.11

$884.53

Employee Only

$373.47

Employee + 1

$738.36

Family

$1,049.45

Deductible
(Individual/Family)

$1,500/$3,000

Coinsurance

100%

Out-of-Pocket Max
(Individual/Family)
(Includes Deductible & Coinsurance)

$1,500/$3,000

In-Network Office Visit

Covered at 100%

Telehealth Visit (Virtual Care)

Covered at 100%

Routine Preventive Care

(contract lists covered services)

Covered at 100%

Inpatient Hospital

Deductible

Outpatient Hospital

Deductible

Emergency Room

Deductible

Urgent Care

Deductible

Vision Exam
(limited to 1 every
calendar year)

N/A

Generic

$0

Preferred Brand

$50

Non-Preferred Brand

$60

Mail Order

$0/$125/$150

Employee Only

$131.17

$154.97

$184.73

Employee + 1

$335.89

$406.48

$488.84

Family

$501.33

$618.39

$635.11

Employee Only

$294.67

Employee + 1

$582.55

Family

$828.00