| Key benefits | Minimum Coverage (Must be under age 30 to purchase) |
|---|---|
| Benefits in Orange are Subject to Deductibles | |
| Individual Deductible | $7,150 integrated medical and pharmacy deductible |
| Family Deductible | $14,300 integrated medical and pharmacy deductible |
| Preventative Care | no cost1 |
| Primary Care Visit Copay | $02 |
| Urgent Care Visit Copay | $02 |
| Specialty Care Visit Copay | $02 |
| Lab Testing Copay | Full cost until Maximum Out-of-Pocket is met |
| X-Ray Copay | Full cost until Maximum Out-of-Pocket is met |
| Imaging Copay | Full cost until Maximum Out-of-Pocket is met |
| Outpatient services | Full cost until Maximum Out-of-Pocket is met |
| Emergency Room Copay | Full cost until Maximum Out-of-Pocket is met |
| Emergency Room Transportation Copay | Full cost until Maximum Out-of-Pocket is met |
| High cost and inpatient services (e.g. Hospital stay) | Full cost until Maximum Out-of-Pocket is met |
| Inpatient Hospital Physician services | Full cost until Maximum Out-of-Pocket is met |
| Tier 1 - Most Generic Drugs | Full cost until Maximum Out-of-Pocket is met |
| Tier 2 - Preferred Brand Drugs | Full cost until Maximum Out-of-Pocket is met |
| Tier 3 - Non-Preferred Brand Drugs | Full cost until Maximum Out-of-Pocket is met |
| Tier 4 - Specialty Drugs | Full cost until Maximum Out-of-Pocket is met |
| Maximum Out-Of-Pocket For One | $7,150 |
| Maximum Out-Of-Pocket For Family | $14,300 |
| 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. |
|
| Key benefits | Minimum Coverage (Must be under age 30 to purchase) |