| Key benefits | Bronze 60 | Silver 73 | Gold 80 | Platinum 90 |
|---|---|---|---|---|
| Benefits in Orange are Subject to Deductibles | Copays in Black are Not Subject to any Deductible and Count Toward the Anual Out-Of-Pocket Maximum | |||
| Individual Deductible | $6,300 medical $500 pharmacy |
$2,200 medical $250 pharmacy |
$0 | $0 |
| Family Deductible | $12,600 medical $1,000 pharmacy |
$4,400 medical $500 pharmacy |
$0 | $0 |
| Preventative Care | no cost1 | no cost1 | no cost1 | no cost1 |
| Primary Care Visit Copay | $752 | $30 | $30 | $15 |
| Urgent Care Visit Copay | $752 | $30 | $30 | $15 |
| Specialty Care Visit Copay | $1052 | $55 | $55 | $40 |
| Lab Testing Copay | $40 | $35 | $35 | $20 |
| X-Ray Copay | Full cost until Maximum Out-of-Pocket is met | $65 | $55 | $40 |
| Imaging Copay | Full cost until Maximum Out-of-Pocket is met | $300 | $275 or 20%3 | $150 or 10%3 |
| Outpatient services | Full cost until Maximum Out-of-Pocket is met | 20% | $600 or 20%3 | $250 or 10%3 |
| Emergency Room Copay | Full cost until Maximum Out-of-Pocket is met | $350 | $325 | $150 |
| Emergency Room Transportation Copay | Full cost until Maximum Out-of-Pocket is met | $250 | $250 | $150 |
| High cost and inpatient services (e.g. Hospital stay) | Full cost until Maximum Out-of-Pocket is met | 20% | $600 per day or 20%3 | $250 per day or 10%3 |
| Inpatient Hospital Physician services | Full cost until Maximum Out-of-Pocket is met | 20% | $55 or 20%3 | $40 or 10%3 |
| Tier 1 - Most Generic Drugs | Full cost until Maximum Out-of-Pocket is met. $500 Maximum Copay per prescription after pharmacy deductible is met | $15 | $15 | $5 |
| Tier 2 - Preferred Brand Drugs | $50 | $55 | $15 | |
| Tier 3 - Non-Preferred Brand Drugs | $75 | $75 | $25 | |
| Tier 4 - Specialty Drugs | 20% up to $250 maximum per prescription | 20% up to $250 maximum per prescription | 10% up to $250 maximum per prescription | |
| Maximum Out-Of-Pocket For One | $6,800 | $5,700 | $6,750 | $4,000 |
| Maximum Out-Of-Pocket For Family | $13,600 | $11,400 | $13,500 | $8,000 |
| 1 in-network only 2 Copay is limited to the first three visits in total. That includes any combination of Primary Care, Specialist or Urgent Care visits. After three visits, future visits will be at full cost until the out-of-pocket maximum is met. 3 See the plan's Summary of Benefits to determine if $ or % is due. |
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| Key benefits | Bronze 60 | Silver 73 | Gold 80 | Platinum 90 |