| Key benefits | Bronze 60 | Silver 73 | Gold 80 | Platinum 90 |
|---|---|---|---|---|
| Benefits in Orange are Subject to the Annual deductible amounts listed below. You will pay the full cost for these services until the Deductible is met. Then you will pay the specified amount that is shown until Annual Maximum Out-of-Pocket is met. The deductible counts toward the Maximum Out-Of-Pocket. |
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| Copays in Black are NOT Subject to any Deductible and count towards the Annual Maximum Out-Of-Pocket. The Annual Out-Of-Pocket Maximum and Deductible amounts are always based on the Individual amount listed even under a family plan. Two or more people in the family have to reach the family amounts listed below in order for them to apply to the entire family. |
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| Individual Deductible | $6,300 medical $500 pharmacy |
$3,700 medical $275 pharmacy |
$0 | $0 |
| Family Deductible | $12,600 medical $1,000 pharmacy |
$7,400 medical $550 pharmacy |
$0 | $0 |
| Preventative Care | no charge1 | no charge1 | no charge1 | no charge1 |
| Primary Care Visit Copay | $652 | $35 | $30 | $15 |
| Specialty Care Visit Copay | $952 | $75 | $65 | $30 |
| Urgent Care Visit Copay | $652 | $35 | $30 | $15 |
| Lab Testing Copay | $40 | $40 | $40 | $15 |
| X-Ray Copay | 40% | $85 | $75 | $30 |
| Imaging Copay | 40% | $325 | $275 or 20%3 | $75 or 10%3 |
| Outpatient services | 40% | 20% | $340 or 20%3 | $125 or 10%3 |
| Emergency Room Copay | 40% | $400 | $350 | $150 |
| Emergency Room Transportation Copay | 40% | $250 | $250 | $150 |
| Prenatal care during Pregnancy and preconception visits | No charge1 | No charge1 | No charge1 | No charge1 |
| Inpatient Hospital Stay (e.g. Labor & Delivery, Mental Health, Substance abuse, surgery, etc) | $40% | $20% | $600 per day up to 5 days or 20%3 | $250 per day up to 5 days or 10%3 |
| Tier 1 - Most Generic Drugs | $18 | $16 | $15 | $5 |
| Tier 2 - Preferred Brand Drugs | 40% up to $500 Maximum Copay per prescription | $55 | $55 | $15 |
| Tier 3 - Non-Preferred Brand Drugs | $85 | $80 | $25 | |
| Tier 4 - Specialty Drugs | 20% up to $250 maximum per prescription | 20% up to $250 maximum per prescription | 10% up to $250 maximum per prescription | |
| Maximum Out-Of-Pocket For One | $7,800 | $6,500 | $7,800 | $4,500 |
| Maximum Out-Of-Pocket For Family | $15,600 | $13,000 | $15,600 | $9,000 |
| 1 in-network only 2 Copay is limited to the first three non-preventive visits. That includes any combination of Primary Care, Specialist, Mental Health or Urgent Care visits. After three visits, future visits will be at full cost until the deductible is met and then the copay shown will apply again. 3 See the plan's Summary of Benefits to determine if Copay or Coinsurance is due. |
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| Key benefits | Bronze 60 | Silver 73 | Gold 80 | Platinum 90 |