Medical & Prescription

Traditional HMO	Network Providers
Calendar Year Deductible: Single/Family	$0 / $0
Maximum Out of Pocket Limit: Single/Family	$1,500 / $3,000
PCP Office Visit	$15 copay
Specialist Office Visit	$15 copay
Urgent Care Visit	$15 copay
Emergency Room	$200 copay
Inpatient Services	$250 / admission
Outpatient Services	$15 / visit
Prescription Drugs (Retail/30-day Supply)
Generic	$10 copay
Preferred and Non-Preferred	$30 copay
Specialty	20% up to $250

Deductible HMO	Network Providers
Calendar Year Deductible: Single/Family	$750 / $1,500
Maximum Out of Pocket Limit: Single/Family	$3,000 / $6,000
PCP Office Visit	$30 copay
Specialist Office Visit	$40 copay
Urgent Care Visit	$30 copay
Emergency Room	20% coinsurance
Inpatient Services	20% coinsurance
Outpatient Services	20% coinsurance
Prescription Drugs (Retail/30-day Supply)
Generic	$10 copay
Preferred and Non-Preferred	$30 copay
Specialty	20% up to $20

Deductible HMO	Network Providers
Calendar Year Deductible: Single/Family	$1,500 / $3,000
Maximum Out of Pocket Limit: Single/Family	$4,000 / $8,000
PCP Office Visit	$40 copay
Specialist Office Visit	$50 copay
Urgent Care Visit	$40 copay
Emergency Room	30% coinsurance
Inpatient Services	30% coinsurance
Outpatient Services	30% coinsurance
Prescription Drugs (Retail/30-day Supply)
Generic	$10 copay
Preferred and Non-Preferred	$30 copay
Specialty	20% up to $250