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Lifetime Maximum Unlimited Unlimited Unlimited
Deductible (Annual)
- Individual $0 $0 $500
- Family $0 $0 $1,000
Co-Insurance (Plan Pays) 75% 100% 80% 60%
Office Visit Copay
- Primary and Specialist $25 Copay $20 Copay $35 Copay Deductible, 40%
- Access + Specialist $40 Copay $30 Copay Not applicable Not applicable
Out-of-Pocket Maximum
- Individual $3,000 $2,000 $3,500 $10,500
- Family $6,000 $4,000 $7,000 $21,000

Hospitalization
- Inpatient $100 Copay, 25% $500 Copay Deductible, 40%
- Outpatient 25% $125 Copay in ASC*, Deductible, 40%
$250 Copay in Deductible, 20%
hospital
Lab and X-Ray No Charge No Charge $35/visit MD; $60/ Deductible, 40%
visit facility
Emergency Services $100 Copay $100 Copay $100 Copay, 20%
Urgent Care $25 Copay $20 Copay $35 Copay Deductible, 40%
Preventive Care No Charge No Charge No Charge Not covered

Pharmacy Deductible
- Individual $0 $0 $0 $0
- Family $0 $0 $0 $0
Retail Pharmacy
- Tier 1 $10 Copay $10 Copay $10 Copay 25% + $10 Copay
- Tier 2 $30 Copay $30 Copay $30 Copay 25% + $30 Copay
- Tier 3 $50 Copay $50 Copay $50 Copay 25% + $50 Copay
- Tier 4 20%, $200 max 20%, $200 max 30%, $200 max Not covered
- Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Tier 1 $20 Copay $20 Copay $20 Copay Not Covered
- Tier 2 $60 Copay $60 Copay $60 Copay Not Covered
- Tier 3 $100 Copay $100 Copay $100 Copay Not Covered
- Supply Limit 90 Days 90 Days 90 Days N/A
*ASC = free-standing Ambulatory Surgical Center
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