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
$35 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
$2,050 Individual In-Network Medical OOP
$4,100 Family In-Network Medical OOP
$5,300 Individual Prescription OOP
$10,600 Family Prescription OOP