Benefit

Benefit Details

Monthly Cost Monthly Cost Includes:

  • Total Monthly Premium
  • Subsidized Premium
  • Non-subsidized
  • ACA Insurer Fee
  • Exchange Fee
  • Reinsurance Fee
Deductible(s) $3,500 (Does not apply to Tier 1 and Tier 2
Primary Care Visit to Treat an Injury or Illness You pay $45.00 – not subject to deductible
Out of Pocket Max $4,500 (includes deductible)
Specialist Visit You pay 0% after deductible
Most Generic Drugs (Tier 1) 30 day Retail: You pay $15.00 – not subject to deductible 90 day
Mail Order: You Pay $30.00 – not subject to deductible
Most Preferred Brand Drugs (Tier 2) 30 day Retail: You Pay $40.00 – not subject to deductible 90 day
Mail Order: You pay $100.00 – not subject to deductible
Most Non-Preferred Brand Drugs (Tier 3) 30 day Retail: You pay 0% after deductible 90 day
Mail Order: You pay 20% after deductible
Most Specialty Drugs (Tier 4) 30 day Retail or Mail
Order: You Pay 0% after deductible
Inpatient Hospital Services (e.g., Hospital Stay) You pay $500.00 after deductible
Outpatient Surgery Physician/Surgical Services You pay 0%
Emergency Room Services You pay $200.00
HSA Compatible No
Mental/Behavioral Health Outpatient Services You pay 0% after deductible
Urgent Care Centers or Facilities You pay $50.00 after deductible
X-rays and Diagnostic Imaging You pay 0% after deductible
Chiropractic Care You pay 0% after deductible limited to 12 Visit(s) Per Calendar Year
Preventive Care/Screening/Immunization You pay 0% – not subject to deductible
Prenatal and Postnatal Care You pay 20% after deductible
Imaging (CT/PET Scans, MRIs) You pay 0% after deductible
Laboratory Outpatient and Professional Services You pay 0% after deductible
Mental/Behavioral Health Inpatient Services You pay $500.00 after deductible
Delivery and All Inpatient Services for Maternity Care You pay $500.00 after deductible
Inpatient Physician and Surgical Services You pay 0% after deductible
Emergency Transportation/Ambulance You pay 0% after deductible
Allergy Testing You pay 0% after deductible
Durable Medical Equipment You pay 0% after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center) You pay 20% after deductible
Diabetes Care Management You pay 0% after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant) You pay $45.00 – not subject to deductible
Outpatient Rehabilitation Services Occupational Therapy: You pay 0% after deductible limited to 20 Visit(s) Per Year
Physical Therapy: You pay 20% after deductible limited to 20 Visit(s) Per Year
Speech Therapy: You pay 20% after deductible limited to 20 Visit(s) Per Year
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