Member Cost Share

Deductibles
- $300 Individual Deductible
Applies to services rendered in an in-patient or out-patient hospital or ambulatory surgery centers.
- $600 Family Deductible
Applies to services rendered in an in-patient or out-patient hospital or ambulatory surgery centers.
Copays
- $25 Office Visit Copay
For medical, physical therapy, mental health, and chiropractic visits if services are rendered by a contracted provider.
- $40 Urgent Care Copay
- $200 Emergency Room Copay
If admitted to the hospital, the copay will be waived and/or applied to the deductible.
- Maximum of 50 Copays Per Person, Per Plan Year
Once the maximum is reached, no additional copay will be applied for the remainder of that Plan Year.
Out-of-Pocket (OOP) Maximums
- $1,550 Individual In-Network Medical OOP
- $3,100 Family In-Network Medical OOP
- $5,300 Individual Prescription OOP
- $10,600 Family Prescription OOP