Medical Benefits

Deductible
(Individual/Family)

$3,000/$6,000

Member Coinsurance

20%

Out-of-Pocket Max
(Individual/Family)

$5,000/$10,000

Primary Care

$40 Copay

Specialist

$40 Copay

Urgent Care

$40 Copay

Emergency Care

$100 Copay, Deductible +20%

Prescription Drugs

Retail

$15/$70/$110/$200

Mail Order

$37.50/$175/$275

Employee Only

$0.00

Employee + Spouse

$524.75

Employee + Child(ren)

$437.29

Employee + Family

$1,080.64

Deductible
(Individual/Family)

$1,500/$4,500

Member Coinsurance

20%

Out-of-Pocket Max
(Individual/Family)

$4,500/$9,000

Primary Care

$35 Copay

Specialist

$35 Copay

Urgent Care

$35 Copay

Emergency Care

$100 Copay, Deductible + 20%

Prescription Drugs

Retail

$15/$70/$110/$200

Mail Order

$37.50/$175/$275

Employee Only

$44.29

Employee + Spouse

$595.61

Employee + Child(ren)

$503.72

Employee + Family

$1,179.63