Medical Benefits

Deductible
(Individual/Family)

$1,000 / $2,000

$2,000 / $4,000

Member Coinsurance (Individual/Family)

80% / 20%

60% / 40%

Out-of-Pocket Max
(Individual/Family)

$5,000 / $10,000

$10,000 / $20,000

Routine Preventive Care

Fully Covered

Not Covered

Primary Care Visit

$35 Copay

Ded. + 40%

Specialist Visit

$70 Copay

Ded. + 40%

Inpatient Hospitalization

Ded. + 20%

Ded. + 40%

Outpatient Surgery

Ded. + 20%

Ded. + 40%

Urgent Care

$50 Copay

$100 Copay

Emergency Room

$250 Copay and 20%

$250 Copay and 20%

Retail Prescriptions

Tier 1/ Tier 2/ Tier 3/ Tier 4

$15/$50/$75/20% up to
a maximum of $150

50%

Mail Order Prescriptions

Tier 1/ Tier 2/ Tier 3/ Tier 4

$45/$150/$225/20% up
to a maximum of $450

Not Covered

Employee Only

$56.00

$112.00

Employee + Spouse

$118.00

$236.00

Employee + Child(ren)

$112.00

$224.00

Employee + Family

$176.00

$352.00

Deductible
(Individual/Family)

$1,500 / $3,000

$3,000 / $6,000

Member Coinsurance (Individual/Family)

80% / 20%

60% / 40%

Out-of-Pocket Max
(Individual/Family)

$5,000 / $10,000

$10,000 / $20,000

Routine Preventive Care

Fully Covered

Not CoveredNot Covered

Primary Care Visit

$35 Copay

Ded. + 40%

Specialist Visit

$70 Copay

Ded. + 40%

Inpatient Hospitalization

Deductible, then 20%

Ded. + 40%

Outpatient Surgery

Deductible, then 20%

Ded. + 40%

Urgent Care

$50 Copay

$100 Copay

Emergency Room

$250 Copay, then Deductible + 20%

$250 Copay, then Deductible + 20%

Retail Prescriptions

Tier 1/ Tier 2/ Tier 3/ Tier 4

15/$50/$75/20% up to
a maximum of $150

50%

Mail Order Prescriptions

Tier 1/ Tier 2/ Tier 3/ Tier 4

$45/$150/$225/20%
up to a maximum of
$450

Not Covered

Employee Only

$54.00

$108.00

Employee + Spouse

$115.00

$230.00

Employee + Child(ren)

$110.00

$220.00

Employee + Family

$172.00

$344.00