| Annual Deductible |
$1,000 Single
$3,000 Family |
$2,000 Single
$6,000 Family |
$2,000 Single
$4,000 Family |
$4,000 Single
$8,000 Family |
| Out of Pocket Max |
$4,000 Single
$12,000 Family |
$25,000 Single
$75,000 Family |
$5,500 Single
$11,000 Family |
$25,000 Single
$75,000 Family |
| Physician Visits Primary / Specialist |
$20 copay / $40 copay |
50% |
20% / 20% |
50% |
| Virtual Visits (per member) |
Visits 1-3: $0
Visits 4+: $20 copay |
Not Covered |
20% |
Not Covered |
| Preventive Care |
$0 |
50% |
$0 |
50% |
| Outpatient Lab Services |
$50 copay
(deductible waived) |
50% |
20% |
50% |
| Outpatient Radiology Diagnostics |
$100 copay
(deductible waived) |
50% |
20% |
50% |
| Outpatient Advanced Radiology Diagnostics (CT Scan, PET Scan or MRI) |
$250 copay
(deductible waived) |
50% |
20% |
50% |
Childbirth / Delivery
Facility & Professional Fees |
20% |
50% |
20% |
50% |
| Emergency Room Services (per member) |
Visits 1-2: $200 Copay + Deductible + 20%
Visits 3+: $500 Copay + Deductible + 20% |
Visits 1-2: $200 Copay + Deductible + 20%
Visits 3+: $500 Copay + Deductible + 20% |
Visits 1-2: 20%
Visits 3+: 30% |
Visits 1-2: 20%
Visits 3+: 30% |
Outpatient Surgery
Facility & Surgeon Fees |
20% |
50% |
20% |
50% |
Inpatient Hospitalization
Facility & Physician Fees |
20% |
50% |
20% |
50% |
Prescription Coverage
(Tier 1, 2, 3 & 4) |
Retail:
$0 / $10 / $40 / $60
Mail:
$0 / $27.50 / $110 / $165
(deductible waived)
Mandatory generic |
Not Covered |
Retail:
$0 / $10 / $40 / $80
Mail:
$0 / $27.50 / $110 / $220
After Deductible
Mandatory generic |
Not Covered |
Prescription Coverage
(Tier 5 & 6) |
30%
(deductible waived) |
Not Covered |
20% / 50%
After Deductible |
Not Covered |
| Tobacco User Fee |
$25 per pay period |
| Team Member Premiums |
Refer to the Rate Chart below |