Page 5 - 2016 Enrollment
P. 5
Out-of-Pocket Medical Expenses
Gold Plan Silver Plan Bronze Plan
In- Out-of- In- Out-of- In- Out-of-
Network Network Network Network Network Network
Calendar Year Deductible
Individual $1,500 $2,000 $2,500 $5,000 $3,000 $6,500
Family $3,000 $4,000 $4,500 $10,000 $6,000 $13,000
Out-of-Pocket Maximum (includes deductible)
Individual $1,500 $4,000 $4,500 $10,000 $6,000 $10,000
Family $3,000 $12,000 $9,000 $20,000 $12,000 $20,000
Physician Office Visits Amount Plan Pays after Deductible has been Met
Primary care 100% 60% 90% 50% 70% 50%
Specialist 100% 60% 90% 50% 70% 50%
Urgent care 100% 60% 90% 50% 70% 50%
Wellness/preventive 100%* 60% 100%* 50% 100%* 50%
Lab Services Amount Plan Pays after Deductible has been Met
Physician office 100% 60% 90% 50% 70% 50%
Outpatient facility 100% 60% 90% 50% 70% 50%
Outpatient hospital 100% 60% 90% 50% 70% 50%
X-Ray/Radiology Services Amount Plan Pays after Deductible has been Met
Physician office 100% 60% 90% 50% 70% 50%
Outpatient facility 100% 60% 90% 50% 70% 50%
Outpatient hospital 100% 60% 90% 50% 70% 50%
Hospital Services Amount Plan Pays after Deductible has been Met
Inpatient 100% 60% 90% 50% 70% 50%
Outpatient 100% 60% 90% 50% 70% 50%
Emergency room 100% 60% 90% 50% 70% 50%
Prescription Drugs
Preventive medications 100% 100% 100%
Retail—Supply Limit 30 days 30 days 30 days
Generic 100% after deductible 90% after deductible 70% after deductible
Preferred brand 100% after deductible 90% after deductible 70% after deductible
Non-preferred brand 100% after deductible 90% after deductible 70% after deductible
Specialty injectables 60% after deductible 50% after deductible 50% after deductible
Mail Order—Supply Limit 90 days 90 days 90 days
Generic 100% after deductible 90% after deductible 70% after deductible
Preferred brand 100% after deductible 90% after deductible 70% after deductible
Non-preferred brand 100% after deductible 90% after deductible 70% after deductible
Purchased outside of retail or Not covered Not covered Not covered
mail order plans
* No deductible
The Silver & Bronze plans have embedded out-of-pocket maximums. See Insurance Terms 101 for details.
2016 - 17 Benefits
Gold Plan Silver Plan Bronze Plan
In- Out-of- In- Out-of- In- Out-of-
Network Network Network Network Network Network
Calendar Year Deductible
Individual $1,500 $2,000 $2,500 $5,000 $3,000 $6,500
Family $3,000 $4,000 $4,500 $10,000 $6,000 $13,000
Out-of-Pocket Maximum (includes deductible)
Individual $1,500 $4,000 $4,500 $10,000 $6,000 $10,000
Family $3,000 $12,000 $9,000 $20,000 $12,000 $20,000
Physician Office Visits Amount Plan Pays after Deductible has been Met
Primary care 100% 60% 90% 50% 70% 50%
Specialist 100% 60% 90% 50% 70% 50%
Urgent care 100% 60% 90% 50% 70% 50%
Wellness/preventive 100%* 60% 100%* 50% 100%* 50%
Lab Services Amount Plan Pays after Deductible has been Met
Physician office 100% 60% 90% 50% 70% 50%
Outpatient facility 100% 60% 90% 50% 70% 50%
Outpatient hospital 100% 60% 90% 50% 70% 50%
X-Ray/Radiology Services Amount Plan Pays after Deductible has been Met
Physician office 100% 60% 90% 50% 70% 50%
Outpatient facility 100% 60% 90% 50% 70% 50%
Outpatient hospital 100% 60% 90% 50% 70% 50%
Hospital Services Amount Plan Pays after Deductible has been Met
Inpatient 100% 60% 90% 50% 70% 50%
Outpatient 100% 60% 90% 50% 70% 50%
Emergency room 100% 60% 90% 50% 70% 50%
Prescription Drugs
Preventive medications 100% 100% 100%
Retail—Supply Limit 30 days 30 days 30 days
Generic 100% after deductible 90% after deductible 70% after deductible
Preferred brand 100% after deductible 90% after deductible 70% after deductible
Non-preferred brand 100% after deductible 90% after deductible 70% after deductible
Specialty injectables 60% after deductible 50% after deductible 50% after deductible
Mail Order—Supply Limit 90 days 90 days 90 days
Generic 100% after deductible 90% after deductible 70% after deductible
Preferred brand 100% after deductible 90% after deductible 70% after deductible
Non-preferred brand 100% after deductible 90% after deductible 70% after deductible
Purchased outside of retail or Not covered Not covered Not covered
mail order plans
* No deductible
The Silver & Bronze plans have embedded out-of-pocket maximums. See Insurance Terms 101 for details.
2016 - 17 Benefits
