Coverage Area | Individual Coverage - Network | Individual Coverage - Out-of-Network | Family Coverage - Network | Family Coverage - Out-of-Network |
|---|---|---|---|---|
Calendar Year Medical Deductible | $1,800 | $2,300 | $3,600 | $4,600 |
Individual Prescription Drug Deductible | $75 | N/A | N/A | N/A |
Medical Coinsurance Maximum | $3,000 | $4,000 | $6,500 | N/A |
Out-of-Pocket Limit | $6,500 | N/A | $13,000 | N/A |
Telehealth Minor Medical Care Visit | $10 copayment | Not Covered | Not Covered | Not Covered |
Primary Care Office Visit | $25 copayment | 40% | Not Covered | Not Covered |
Specialty Physician Services | 20% | 40% | Not Covered | Not Covered |
Inpatient Hospital Services | 20% | 40% | Not Covered | Not Covered |
Emergency Room Visit | 20% + copayment | 20% + copayment | Not Covered | Not Covered |
Adult Wellness Services | Plan pays 100% | Not Covered | Not Covered | Not Covered |
Prescription Drug Type - Preferred Generic Drug | $12 (1-30 Days) | $24 (31-60 Days) | $36 (61-90 Days) | $24 (Home Delivery 90 Days) |
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