Annual Deductible (You pay 100% of cost until deductible is met)
|
$900 individual $2,000 family |
$1,800 individual $4,200 family |
$4,000 individual $8,000 family |
Office Visit (Primary/Specialist)
|
$25/$45 (No deductible applied) |
20% |
$25/$50 (No deductible applied) |
Coinsurance (Your Cost)
|
20% |
20% |
None (After deductible is met) |
Out-of-Pocket Maximum
|
$3,000 individual $6,000 family |
$3,950 individual $7,050 family |
$4,000 individual $8,000 family |
Prescription Drugs3
|
No Rx Deductible/ Separate Rx Out-of-Pocket Maximum $3,750/$7,500 |
Combined with Medical Deductible and Out-of-Pocket Maximum |
Combined with Medical Deductible and Out-of-Pocket Maximum |
Retail (up to 30-day supply) |
Generic |
30% ($15 min; $60 max) |
30% ($15 min; $60 max) |
$10 no deductible |
Preferred |
30% ($45 min; $120 max) |
30% ($45 min; $120 max) |
You Pay 100% before deductible |
Non-Preferred |
50% ($70 min; $180 max) |
50% ($70 min; $180 max) |
Mail-Order (up to 90-day supply) |
Generic |
30% ($30 min; $120 max) |
30% ($30 min; $120 max) |
$25 no deductible |
Preferred |
30% ($90 min; $240 max) |
30% ($90 min; $240 max) |
You Pay 100% before deductible |
Non-Preferred |
50% ($175 min; $450 max) |
50% ($175 min; $450 max) |