| In-Network Deductible |
|
Individual: $200 | Family: $400 |
|
Individual: $0 | Family: $0 |
|
Individual: $0 | Family: $0 |
| Preventive Care |
|
$0 |
|
$0 |
|
$0 |
| Office Visit |
|
$15 |
|
$15 |
|
$0 |
| Doctor on Demand Visits |
|
$0 |
|
$15 |
|
$0 |
| Specialist Visit |
|
$20 |
|
$35 |
|
$25 |
| Prescription Drugs |
|
Tier 1: $1
Tier 2: 10%
Tier 3: 40% |
|
Tier 1: $10
Tier 2: $30
Tier 3: $60 |
|
Tier 1: $5
Tier 2: $15
Tier 3: $45 |
| Urgent Care |
|
$40 |
|
$55 |
|
$50 |
| Emergency Room |
|
10%* |
|
$100 |
|
$200 |
| Inpatient Hospital |
|
10%* |
|
$500 |
|
$250 |
| Outpatient Surgery |
|
10%* |
|
$100 |
|
$100 |
| Plan Documents |
|
Summary of Benefits & Coverage
Health Plan Contract |
|
Summary of Benefits & Coverage
Health Plan Contract |
|
Summary of Benefits & Coverage
Health Plan Contract |