Quick facts
Overall Deductible (In-Network, Individual)
$1,500 Per Person
Out-of-network: Not Applicable
Out-of-Pocket Limit (In-Network, Individual)
$4,500 Per Person
Out-of-network: Not Applicable
Primary Care Visit
Deductible + 20% Coinsurance
Out-of-network: Not Covered
Specialist Visit
Deductible + 20% Coinsurance
Out-of-network: Not Covered
Emergency Room Care
Deductible + 20% Coinsurance
Urgent Care
Deductible + 20% Coinsurance
Out-of-network: Not Covered
General Coinsurance (In-Network)
20%
Generic Drugs
Deductible + $10 Copay per Prescription at retail, Deductible + $25 Copay per Prescription by mail
More details (4)
Preventive Care/Screening/Immunization
No Charge
Preferred Brand Drugs
Deductible + $50 Copay per Prescription at retail, Deductible + $125 Copay per Prescription by mail
Non-Preferred Brand Drugs
Deductible + $80 Copay per Prescription at retail, Deductible + $200 Copay per Prescription by mail
Specialty Drugs
Specialty drugs are subject to the cost share based on applicable drug tier.
Amounts are in-network unless noted.
Carrier contact
1-800-352-2583 — member services
Your member ID card: check the carrier website or app, or ask HR for a copy.
Plan documents
Confirm details with your carrier for current plan information.