| Deductible |
|---|
| Individual |
$1,600 |
| Family |
$3,200 |
| Coinsurance Out-of-Pocket Maximum |
|---|
| Individual |
$1,975 |
| Family |
$3,950 |
| Total Out-of-Pocket Maximum |
|---|
| Individual |
$3,575 |
| Family |
$7,150 |
| Health Savings Accounts Seed Money |
Individual/Family |
|---|
| Band 1: Less than $45,000 |
$800/$1,600 |
| Band 2: $45,000.01 to $60,000 |
$600/$1,200 |
| Band 3: $60,000.01 to $90,000 |
$400/$800 |
| Band 4: More than $90,000 |
$200/$400 |
| Member Coinsurance (after deductible) |
|---|
| Percentage |
10% |
| Services |
|---|
| Preventive Care |
Covered at 100% |
| Office Visits |
Deductible and Coinsurance |
| Specialist |
Deductible and Coinsurance |
| Urgent Care |
Deductible and Coinsurance |
| Emergency Room (waived if admitted) |
Deductible and Coinsurance |
|
|
| Prescription (after deductible) (deductible does not apply to Technical service) |
|---|
| Preventive drugs |
|---|
| Generic Drugs |
10% Coinsurance |
| Preferred Brand Drugs |
20% Coinsurance |
| Non-Preferred Brand Drugs |
40% Coinsurance |
| Retail (30-day supply) |
|---|
| Generic Drugs |
10% Coinsurance |
| Preferred Brand Drugs |
20% Coinsurance |
| Non-Preferred Brand Drugs |
40% Coinsurance |
| mail (90-day supply) |
|---|
| Generic Drugs |
10% Coinsurance |
| Preferred Brand Drugs |
20% Coinsurance |
| Non-Preferred Brand Drugs |
40% Coinsurance |
| Specialty Medications |
|---|
| Preferred Brand Drugs |
20% coinsurance, $65 Minimum |
| Non-Preferred Brand Medications |
40% coinsurance, $100 Minimum |
| Out-of-Pocket Maximums |
Integrated with Medical |
