Plan highlights
| Plan Details | In-network | Out-of-network* |
|---|---|---|
| Deductible | $125 Individual $250 Family |
$500 Individual $1,000 Family |
| Annual out-of-pocket maximum | $500 Individual $1,000 Family |
$1,500 Individual $3,000 Family |
| Office Visits | $15 copay – Primary Care Physician $35 copay – Specialist |
30% coinsurance, after deductible – Primary Care Physician and Specialist |
| Preventive Care | 100% covered, deductible waived | 30% coinsurance, after deductible |
| Inpatient Hospital | 5% coinsurance, after deductible | 30% coinsurance, after deductible |
| Urgent Care | $35 copay | $35 copay |
| Emergency Room | $75 copay | $75 copay |
| Ambulance | 100% covered, deductible waived | 100% covered, deductible waived |
| Chiropractor | $35 copay | 30% coinsurance, after deductible |
| Short-Term Rehabilitation (300 visits per year) |
$35 copay | 30% coinsurance, after deductible |
*Note: The plan pays benefits for out-of-network services based on the allowable charge for a service. If your out-of-network provider charges more than the allowable charge, you will be responsible for any expenses incurred that are above this amount, in addition to your out-of-network deductible and coinsurance/copay. Any amount that you pay above the allowable charge will not apply to your out-of-pocket maximum.
