Medical Benefits

Deductible
(Individual/Family)

$500/$1,000

Out-of-Pocket Max
(Individual/Family)

$1,500/$3,000

Member Coinsurance

20%

Primary Care Visit

$25 Copay

Preventive Care

Covered at 100%*

*If not coded as preventive, subject to coinsurance and deductible.

Specialist Visit

$25 copay

Inpatient Hospital

Deductible then 20%
Coinsurance

Outpatient Hospital

Deductible then 20%
Coinsurance

Urgent Care

$25 Copay

Emergency Room

$100 Copay then
Deductible and 20%
Coinsurance

Generic

$15 Copay

$37.50 Copay

Brand Formulary

$35 Copay

$87.50 Copay

Brand Non-Formulary

$50 Copay

$125 Copay

Employee Only

$51.25

Employee + Child(ren)

$151.90

Employee + Spouse or Domestic Partner

$162.15

Family

$262.05

Deductible
(Individual/Family)

$1,000/$2,000

Out-of-Pocket Max
(Individual/Family)

$2,000/$4,000

Member Coinsurance

20%

Primary Care Visit

$25 Copay

Preventive Care

Covered at 100%*

*If not coded as preventive, subject to coinsurance and deductible.

Specialist Visit

$25 Copay

Inpatient Hospital

Deductible then 20% Coinsurance

Outpatient Hospital

Deductible then 20% Coinsurance

Urgent Care

$25 Copay

Emergency Room

$100 Copay then
Deductible and 20%
Coinsurance

Generic

$15 Copay

$37.50 Copay

Brand Formulary

$35 Copay

$87.50 Copay

Brand Non-Formulary

$50 Copay

$125 Copay

Employee Only

$45.10

Employee + Child(ren)

$138.40

Employee + Spouse or Domestic Partner

$148.60

Family

$242.50

Deductible
(Individual/Family)

$1,500/$3,000

Out-of-Pocket Max
(Individual/Family)

$2,500/$5,000

Member Coinsurance

20%

Primary Care Visit

$25 Copay

Preventive Care

Covered at 100%*

*If not coded as preventive, subject to coinsurance and deductible.

Specialist Visit

$25 Copay

Inpatient Hospital

Deductible then 20% coinsurance

Outpatient Hospital

Deductible then 20% coinsurance

Urgent Care

$25 Copay

Emergency Room

$100 Copay then
deductible and 20%
coinsurance

Generic

$15 Copay

$37.50 Copay

Brand Formulary

$35 Copay

$87.50 Copay

Brand Non-Formulary

$50 Copay

$125 Copay

Employee Only

$40.25

Employee + Child(ren)

$128.55

Employee + Spouse or Domestic Partner

$137.65

Family

$225.30

Deductible
(Individual/Family)

$3,200/$6,400

Out-of-Pocket Max
(Individual/Family)

$3,200/$6,400

Member Coinsurance

0%

Primary Care Visit

Subject to Deductible

Preventive Care

Covered at 100%*

*If not coded as preventative, subject to coinsurance and deductible.

Specialist Visit

Subject to Deductible

Amwell Telehealth

$49 Billed Charge

Inpatient Hospital

Subject to Deductible

Outpatient Hospital

Subject to Deductible

Urgent Care

Subject to Deductible

Emergency Room

Subject to Deductible

Generic

Subject to Deductible

Brand Formulary

Subject to Deductible

Brand Non-Formulary

Subject to Deductible

Employee Only

$24.55

Employee + Child(ren)

$94.05

Employee + Spouse or Domestic Partner

$101.25

Family

$170.10