| Key benefits | Silver 94 |
|---|---|
| Benefits in Orange are Subject to Deductibles | |
| Copays in Black are Not Subject to any Deductible and Count Toward the Anual Out-Of-Pocket Maximum | |
| Individual Deductible | $75 medical $0 pharmacy |
| Family Deductible | $150 medical $0 pharmacy |
| Preventative Care | no cost1 |
| Primary Care Visit Copay | $5 |
| Urgent Care Visit Copay | $5 |
| Specialty Care Visit Copay | $8 |
| Mental Health & Substance Abuse Outpatient Office Visits | $5 |
| Lab Testing Copay | $8 |
| X-Ray Copay | $8 |
| Imaging Copay | $50 |
| Outpatient services | 10% |
| Emergency Room Copay | $50 |
| Emergency Room Transportation Copay | $30 |
| High cost and inpatient services (e.g. Hospital stay) | 10% |
| Tier 1 - Most Generic Drugs | $3 |
| Tier 2 - Preferred Brand Drugs | $10 |
| Tier 3 - Non-Preferred Brand Drugs | $15 |
| Tier 4 - Specialty Drugs | 10% up to $150 maximum per prescription |
| Maximum Out-Of-Pocket For One | $1,000 |
| Maximum Out-Of-Pocket For Family | $2,000 |
| 1 in-network only 2 Copay is limited to the first three visits in total. That includes any combination of Primary Care, Specialist or Urgent Care visits. After three visits, future visits will be at full cost until the out-of-pocket maximum is met. 3 See the plan's Summary of Benefits to determine if $ or % is due. |
|
| Key benefits | Silver 94 |