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CDHP Plan
In-Network Out-of-Network
Calendar Year Deductible Embedded
Individual $2,700 $5,000
Family $5,400 $10,000
Coinsurance (plan’s portion)
80% 50%
Out-of-Pocket Maximum (includes deductible, coinsurance, and medical copays)
Individual $5,000 $15,000
Family $10,000 $30,000
Hospital
Inpatient 80% after ded 50% after ded
Outpatient Surgery 80% after ded 50% after ded
Outpatient Other 80% after ded 50% after ded
Emergency Room 80% after ded 80% after ded
Physician Oice Visit
General Practitioners, Pediatricians 80% after ded 50% after ded

Specialist 80% after ded 50% after ded
Urgent Care
80% after ded 50% after ded
Routine Preventive Care, Physicals, and Well-Child Care
100% no ded 50% after ded
Telemedicine
Teladoc $45 copay N/A
Chiropractic
80% after ded 50% after ded
Mental/Substance
Inpatient 80% after ded 50% after ded
Outpatient 80% after ded 50% after ded
Pharmacy
Retail 80% after ded 50% after ded
Mail 80% after ded Not available
Out-of-Pocket Maximum Pharmacy expenses are included in your medical out-of-pocket maximum

Embedded Deductible
The deductibles and out-of-pocket maximums in the Basic, Premium, and CDHP plans are embedded .

Embedded means when subject to the family deductible or out-of-pocket maximum, each member of the family is capped at
the individual amount .

4 2019 Benefits Enrollment