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Core Plan
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Buy Up Plan |
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Network
Primary Physician Office Visit |
Open Access Plus (OAP)
In-Network: $25 Copay
Out-of-Network: 40% after Deductible
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Open Access Plus (OAP)
In-Network: $20 Copay
Out-of-Network: 40% after Deductible
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| Specialist Office Visit |
In-Network: $50 Copay
Out-of-Network: 40% after Deductible
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In-Network: $40 Copay
Out-of-Network: 40% after Deductible
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| Urgent Care |
In-Network: $55 Copay
Out-of-Network: 40% after Deductible
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In-Network: $45 Copay
Out-of-Network: 40% after Deductible
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| Emergency Room |
In-Network: 20% After Deductible
Out-of-Network: 20% After Deductible
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In-Network: 20% After Deductible
Out-of-Network: 20% After Deductible
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Inpatient Care
Ambulatory Surgical Center |
In-Network: 20% After Deductible
Out-of-Network: 40% After Deductible
In-Network: 20% After Deductible
Out-of-Network: 40% After Deductible
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In-Network: $600 per admission deductible
Out-of-Network: 40% After Deductible
In-Network: $200 copay
Out-of-Network: 40% After Deductible
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| Child Wellness |
In-Network: Covered at 100%
Out-of-Network: 40% After Deductible
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In-Network: Covered at 100%
Out-of-Network: 40% after Deductible
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| Adult Routine Physicals |
In-Network: Covered at 100%
Out-of-Network: 40% After Deductible
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In-Network: Covered at 100%
Out-of-Network: 40% after Deductible
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Prescription Drug Plan
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Prescription Drug Plan
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30 Day Supply (Retail)
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30 Day Supply (Retail)
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| Tier 1 |
In-Network: $10
Out-of-Network: Member pays 100% at time of purchase, reimbursed 50% after applicable copay |
In-Network: $10
Out-of-Network: Member pays 100% at time of purchase, reimbursed 50% after applicable copay
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| Tier 2 |
In-Network: $50
Out-of-Network: Member pays 100% at time of purchase, reimbursed 50% after applicable copay |
In-Network: $30
Out-of-Network: Member pays 100% at time of purchase, reimbursed 50% after applicable copay
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Tier 3
Tier 1
Tier 2
Tier 3 |
In-Network: $80
Out-of-Network: Member pays 100% at time of purchase, reimbursed 50% after applicable copay
Mail Order (90 Day supply)
In-Network: $20
Out-of-Network: Member pays 100% at time of purchase, reimbursed 50% after applicable copay
In-Network: $140
Out-of-Network: Member pays 100% at time of purchase, reimbursed 50% after applicable copay
In-Network: $230
Out-of-Network: Member pays 100% at time of purchase, reimbursed 50% after applicable copay |
In-Network: $50
Out-of-Network: Member pays 100% at time of purchase, reimbursed 50% after applicable copay
Mail Order (90 Day Supply)
In-Network: $20
Out-of-Network: Member pays 100% at time of purchase, reimbursed 50% after applicable copay
In-Network: $80
Out-of-Network: Member pays 100% at time of purchase, reimbursed 50% after applicable copay
In-Network: $140
Out-of-Network: Member pays 100% at time of purchase, reimbursed 50% after applicable copay |
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 Calendar Year Deductible |
Calendar Year Deductible |
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| Individual |
In-Network: $1,500
Out-of-Network: $3,000 |
In-Network: $500
Out-of-Network: $750 |
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Family
Member Cost Share |
In-Network: $4,500
Out-of-Network: $9,000
Coinsurance
In-Network: 20% after Deductible
Out-of-Network: 40% after Deductible |
In-Network: $1,500
Out-of-Network: $2,250
Coinsurance
In-Network: 20% after Deductible
Out-of-Network: 40% after Deductible |
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Calendar Year Out-of-Pocket Maximum |
Calendar Year Out-of-Pocket Maximum |
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| Individual |
In-Network: $5,000
Out-of-Network: $8,000 |
In-Network: $2,500
Out-of-Network: $5,000 |
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| Family |
In-Network: $10,000
Out-of-Network: $16,000
Lifetime Maximum Benefit
Unlimited |
In-Network: $5,000
Out-of-Network: $10,000
Lifetime Maximum Benefit
Unlimited |
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*This site provides a brief summary of your plans; it is not a contract. Please see insurance contracts (available from Human Resources) for complete details and limitations.
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