Medical Benefits
In-Network |
Non-Network |
|
|---|---|---|
Deductible |
$2,000/$4,000 |
$4,000/$8,000 |
Member Coinsurance |
30% |
50% |
Out-of-Pocket Max |
$6,000/$12,000 |
$12,000/$24,000 |
Physician Visits |
||
Primary Care Office Visit |
$35 |
Deductible + 30% |
Routine Preventive |
Covered at 100% |
Deductible + 30% |
Specialist |
$65 |
Deductible + 30% |
Hospital Services |
||
Physican Services |
Deductible + 30% |
Deductible + 50% |
Inpatient/Outpatient Hospital |
Deductible + 30% |
Deductible + 50% |
Urgent Care |
$75 |
Deductible + 30% |
Emergency Room |
$200 Copay + Deductible + 30% |
$200 Copay + Deductible + 30% |
Retail Prescriptions |
In30-Day |
31-60 Days |
61-90 Days
|
|---|---|---|---|
Tier 1 |
$10 |
$20 |
$25 |
Tier 2 |
$35 |
$70 |
$87.50 |
Tier 3 |
$65 |
$130 |
$150 |
In-Network |
Out-of-Network |
|
|---|---|---|
Deductible |
$3,400/$6,800 |
$3,400/$6,800 |
Member Coinsurance |
0% |
20% |
Out-of-Pocket Max |
$3,400/$6,800 |
$6,000/$12,000 |
Physician Visits |
||
Primary Care Office Visit |
Deductible + 0% |
Deductible + 20% |
Routine Preventive |
Covered at 100% |
Deductible + 20% |
Specialist Visit |
Deductible + 0% |
Deductible + 20% |
Hospital Services |
||
Physician Services |
Deductible + 0% |
Deductible + 20% |
Inpatient/Outpatient Hospital |
Deductible + 0% |
Deductible + 20% |
Urgent Care |
Deductible + 0% |
Deductible + 20% |
Emergency Room |
Deductible + 0% |
Deductible + 0% |
Retail Prescriptions |
||
|---|---|---|
Tier 1 |
Deductible + 0% |
Deductible + 20% |
Tier 2 |
Deductible + 0% |
Deductible + 20% |
Tier 3 |
Deductible + 0% |
Deductible + 20% |