Quick facts
Deductible - Individual
$0.00
Deductible - Family
$0.00
Out-of-Pocket Maximum - Individual
$10,600.00
Out-of-Pocket Maximum - Family
$21,200.00
Primary Care Office Visits
$50.00 copayment not subject to deductible
Specialist Office Visits
$125.00 copayment not subject to deductible
Emergency Room Facility Fee
$2,500.00 copayment not subject to deductible
Urgent Care Services
$75.00 copayment not subject to deductible
More details (34)
Tier 1A - Preferred Generic Drugs (Retail 30-day)
$3.00 copayment not subject to deductible
Preventive Care Visits
Covered in full
Pediatric Vision Exams
Covered in full
Lenses and Frames (Pediatric Vision)
50% coinsurance not subject to deductible; $150 allowance for Lenses and Frames, or Contact Lenses, one per Benefit Period
Prescription Drug Deductible - Individual
$7,000.00
Prescription Drug Deductible - Family
$14,000.00
Laboratory Procedures
$65.00 copayment not subject to deductible
X-rays and Diagnostic Imaging
$150.00 copayment not subject to deductible
Advanced Imaging (MRI/CT/PET)
$750.00 copayment not subject to deductible
Outpatient Rehabilitation Physical Medicine Services
$125.00 copayment not subject to deductible
Outpatient Habilitation Physical Medicine Services
$125.00 copayment not subject to deductible
Chiropractic Manipulation Therapy
$125.00 copayment not subject to deductible
Emergency Room Physician Fee
Covered in full
Emergency Transportation/Ambulance
$2,500.00 copayment not subject to deductible
Outpatient Hospital Facility Fee
$1,200.00 copayment not subject to deductible
Outpatient Physician/Surgeon Fee
$350.00 copayment not subject to deductible
Inpatient Hospital Facility Fee
$3,000.00 copayment not subject to deductible
Inpatient Physician/Surgeon Fee
$350.00 copayment not subject to deductible
Skilled Nursing Facility Fee
$3,000.00 copayment not subject to deductible
Inpatient Hospital and Birthing Center
$3,000.00 copayment not subject to deductible
Physician and Midwife Services for Delivery
$350.00 copayment not subject to deductible
Durable Medical Equipment, Prosthetics, and Orthotics
50% coinsurance not subject to deductible
Home Health Care Services
50% coinsurance not subject to deductible
Hospice Services
50% coinsurance not subject to deductible
Chemotherapy
50% coinsurance not subject to deductible
Diabetic Equipment
50% coinsurance not subject to deductible
Inpatient Mental Health Care
$3,000.00 copayment not subject to deductible
Outpatient Mental Health Services - Office Visits
$125.00 copayment not subject to deductible
Inpatient Chemical/Substance Use Disorder Care
$3,000.00 copayment not subject to deductible
Outpatient Chemical/Substance Use Disorder - Office Visits
$125.00 copayment not subject to deductible
Tier 1B - Non-Preferred Generic Drugs (Retail 30-day)
$35.00 copayment not subject to deductible
Tier 2 - Preferred Brand Name (Retail 30-day)
$125.00 copayment subject to prescription drug deductible
Tier 3 - Non-preferred Brand Name (Retail 30-day)
50% coinsurance subject to prescription drug deductible
Tier 4 - Specialty Drugs (Retail 30-day)
50% coinsurance subject to prescription drug deductible
Carrier contact
30523232323 — member services
Your member ID card: check the carrier website or app, or ask HR for a copy.
Plan documents
Confirm details with your carrier for current plan information.