Page 7 - 2017 FutureSteps

Beneit descriptions are provided in the table below.

Future Steps plan
In-Network Out-of-Network
Calendar Year Deductible
Individual $2,600 $5,200
Family $5,200 $10,400
Coinsurance (you pay)
20% after deductible 40% after deductible
Out-of-Pocket Maximum (includes deductible)
Individual $5,200 $10,400
Family $10,400 $20,800
Physician Ofice Visit
Primary care 20% after deductible 40% after deductible
Specialist 20% after deductible 40% after deductible
Urgent care 20% after deductible 40% after deductible
Emergency room 20% after deductible 40% after deductible
Hospital Services
Inpatient 20% after deductible 40% after deductible
Outpatient 20% after deductible 40% after deductible
Preventive care 0% no deductible 0% no deductible
Prescription Drug Beneits*
Retail (30 days supply)
Tier 1 20% after deductible 40% after deductible
Tier 2 20% after deductible 40% after deductible
Tier 3 20% after deductible 40% after deductible
Tier 4 20% after deductible 40% after deductible
Mail Order (90 days supply)
Tier 1 20% after deductible N/A
Tier 2 20% after deductible
Tier 3 20% after deductible

* Prior authorization, step therapy and limitations on quantities dispensed may apply
Note: the plan does not include coverage for mental/behavioral health and substance abuse.

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