Quick facts
Overall Deductible (In-Network, Per Person)
$1,500
Out-of-Pocket Limit (In-Network, Per Person)
$4,500
Primary Care Visit
Deductible + 20% Coinsurance
Specialist Visit
Deductible + 20% Coinsurance
Emergency Room Care
Deductible + 20% Coinsurance
Urgent Care
Deductible + 20% Coinsurance
General Coinsurance (after deductible)
20%
Generic Drugs
Deductible + $10 Copay per Prescription at retail, Deductible + $25 Copay per Prescription by mail
More details (12)
Preventive Care/Screening/Immunization
No Charge
Children's Dental Check-up
Not Covered
Children's Eye Exam
Not Covered
Children's Glasses
Not Covered
Diagnostic Test (x-ray, blood work)
Deductible + 20% Coinsurance
Home Health Care
Deductible + 20% Coinsurance
Hospital Facility Fee
Deductible + 20% Coinsurance
Imaging (CT/PET, MRI)
Deductible + 20% Coinsurance
Outpatient Facility Fee
Deductible + 20% Coinsurance
Preferred Brand Drugs
Deductible + $50 Copay per Prescription at retail, Deductible + $125 Copay per Prescription by mail
Non-Preferred Brand Drugs
Deductible + $80 Copay per Prescription at retail, Deductible + $200 Copay per Prescription by mail
Specialty Drugs
Specialty drugs are subject to the cost share based on applicable drug tier.
Carrier contact
1-800-352-2583 — 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.