Not a Member ? I am a:

  HDHMO HSA-Qualified 44   Standard HDHMO HSA-Qualified 40   HDHMO HSA-Qualified 45   Standard HDHMO Non HSA-Qualified 60
In-Network Deductible   Individual: $6,250
Family: $12,500
  Individual: $6,100
Family: $12,200
  Individual: $6,900
Family: $13,800
  Individual: $4,700
Family: $9,400
Preventive Care**   $0   $0   $0   $0
Office Visit   30%*   50%*   0%*   $50 Copayment.*
First 3 visits to a PCP/Specialist are not subject to the deductible
Doctor on Demand Visits   0%*   50%*   0%*   $50*
Specialist Visit   30%*   50%*   0%*   $75 Copayment.*
First 3 visits to a PCP/Specialist are not subject to the deductible
Prescription Drugs**   Tier 1: 50%*
Tier 2: 50%*
Tier 3: 50%*
  Tier 1: $10*
Tier 2: $35*
Tier 3: $70*
  Tier 1: 0%*
Tier 2: 0%*
Tier 3: 0%*
  Tier 1: $10*
Tier 2: $35*
Tier 3: $70*
Urgent Care   30%*   50%*   0%*   $75*
Emergency Room   30%*   50%*   0%*   $500*
Inpatient Hospital   30%*   50%*   0%*   $1500*
Outpatient Surgery   30%*   50%*   0%*   $150*
Plan Documents   Summary of Benefits & Coverage
Health Plan Contract
  Summary of Benefits & Coverage
Health Plan Contract
  Summary of Benefits & Coverage
Health Plan Contract
  Summary of Benefits & Coverage
Health Plan Contract

*Subject to Deductible
**Preventive Care and Preventive Drugs Are Not Subject to Deductible

 

Get a Quote