| Benefits | Participating Benefits |
Deductibles & Out-of-Pocket Maximums
(Deductible included in the out-of-pocket maximum) | Option 1:
Single: $1,300 deductible, $3,900 max
Family: $2,600 deductible, $7,800 max
Option 2:
Single: $1,500 deductible, $5,000 max
Family: $3,000 deductible, $10,000 max
Option 3:
Single: $2,500 deductible, $3,500 max
Family: $5,000 deductible, $7,000 max |
Preventive Care - Primary Care Provider
(deductible waived) |
Covered 100%
|
|
Preventive Care - Secondary Care Provider
(deductible waived)
|
Covered 100%
|
Office Visit - Primary Doctor | |
Office Visit - Secondary Care Provider | |
Prescription Drugs |
Tier 1: $10 after deductible
Tier 2: 25% after deductible
Tier 3: 50% after deductible
Tier 4: 20% after deductible
|
Emergency Room |
$250 after deductible participating/nonparticipating
|