Your medical benefit: to most, it’s the most important benefit we have available, but many of us don’t use our plan to the fullest. Medical benefits are not just for when you are sick… For example, if you use preventive benefits when you are well, you might actually be able to avoid getting sick!

Understanding your prescription drug benefit, and knowing how different types of medications will be covered, can help you save money and learn how to talk with your doctor about your options.

To learn more about some of the key plan details that are important to understand, like deductible and coinsurance, click here.

  • Deductible


    The amount of covered expenses you must pay before the Plan starts paying benefits.

    In-network:

    Individual: $2,000

    Family: $4,000

    Out-of-network:

    Individual: $2,000

    Family: $4,000

  • Coinsurance


    Cost-sharing between you and the company. This is applied after you meet your deductible.

    In-network:

    You pay 0% (after deductible)

    Plan pays 100%

    Out-of-network:

    You pay 30% (after deductible)

    Plan pays 70%

  • Out-of-Pocket Maximum


    The most you are required to pay out of your own pocket in a plan year. Some expenses may not apply.

    In-network:

    Individual: $5,000

    Family: $10,000

    Out-of-network:

    Individual: $10,000

    Family: $20,000

  • Doctor’s Office Visit


    Doctor’s Office Visit

    In-network:

    You pay 0% (after deductible)

    Plan pays 100%

    Out-of-network:

    You pay 30% (after deductible)

    Plan pays 70%

  • Specialist Office Visit


    Specialists include doctors trained in a specific area or function of the body, or a specific age group (cardiologist, pediatrician, orthopedic surgeon, neurologist, etc.).

    In-network:

    You pay 0% (after deductible)

    Plan pays 100%

    Out-of-network:

    You pay 30% (after deductible)

    Plan pays 70%

  • Preventive/Well Child Care


    Care focused on prevention or early detection of health conditions. Includes routine physical exam, immunizations, cancer screenings, vision and hearing exams, etc.

    In-network:

    You pay $0

    Plan pays 100%

    Out-of-network:

    You pay 30% (after deductible)

    Plan pays 70%

  • Diagnostic Test (x-ray, blood work)


    In-network:

    You pay $0
    Plan pays 100%

    Out-of-network:

    You pay 30% (after deductible)
    Plan pays 70%

  • Imaging (CT/PET scans, MRIs)


    In-network:

    You pay $0
    Plan pays 100%

    Out-of-network:

    You pay 30% (after deductible)
    Plan pays 70%

  • Emergency Room


    Provides accidental injury and medical emergency care. Note: Call your plan immediately if you are admitted to the hospital.

    In-network:

    You pay $0
    Plan pays 100%

    Out-of-network:

    You pay $0
    Plan pays 100%

  • Urgent Care


    Non-emergency care received from an urgent care clinic or other medical facility; typically used after hours or when your regular doctor is not available.

    In-network:

    You pay $0
    Plan pays 100%

    Out-of-network:

    You pay $0
    Plan pays 100%

  • Hospitalization


    Inpatient In-network:

    You pay 0% (after deductible)

    Plan pays 100%

    Inpatient Out-of-network:

    You pay 30% (after deductible)

    Plan pays 70%

    Outpatient In-network:

    You pay 0% (after deductible)

    Plan pays 100%

    Outpatient Out-of-network:

    You pay 30% (after deductible)

    Plan pays 70%

  • Are you required to use network providers?


    No (but your costs will be lower when you do)

  • Do you need a referral to a specialist?


    No.

  • Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)?


    A feature of high-deductible or consumer-driven medical plans, this is a tax-advantaged savings account you can use for medical expenses now or save for later.

    Yes (HSA) / Not applicable (HRA)

  • Can I use a Health Care Flexible Spending Account (FSA)?


    An account you contribute to before taxes, then use the money for qualified health-related expenses.

    No; you use your HSA instead. You can use a Limited Purpose FSA for dental and vision expenses.

  • Prescription Drug


    Deductible - See Deductible above

    Retail (Up to 31-day supply)

    In-network Only

    Tier 1: 30% coinsurance (after deductible)

    Tier 2: 30% coinsurance (after deductible)

    Tier 3: 30% coinsurance (after deductible)

    Mail Order (Up to 90-day supply)

    In-network Only

    Tier 1: 30% coinsurance (after deductible)

    Tier 2: 30% coinsurance (after deductible)

    Tier 3: 30% coinsurance (after deductible)

HSA Open Access Plan

Provider: Meritain Health

Phone: 888-324-5789

https://www.meritain.com/

Meritain Health  -Accessing the national Aetna Choice POS II network

Provider Search: www.aetna.com/docfind/custom/mymeritain,
Prescription Provider: RxBenefits – through Express-Scripts,
Phone: 800-334-8134, www.express-scripts.com

HSA Open Access Plan EPO In-Network Plan POS Open Access Plan

Deductible

In-network:
Individual: $2,000

Family: $4,000

Out-of-network:
Individual: $2,000

Family: $4,000

Deductible

In-network:
Individual: None

Family: None

Deductible

In-network:
Individual: None

Family: None

Out-of-network:
Individual: $500

Family: $1,000

Coinsurance

In-network:
You pay 0% (after deductible)

Plan pays 100%

Out-of-network:
You pay 30% (after deductible)

Plan pays 70%

Coinsurance

In-network:
You pay 0% (after deductible)

Plan pays 100%

Coinsurance

In-network:
You pay 0% (after deductible)

Plan pays 100%

Out-of-network:
You pay 20% (after deductible)

Plan pays 80%

Out-of-Pocket Maximum

In-network:
Individual: $5,000

Family: $10,000

Out-of-network:
Individual: $10,000

Family: $20,000

Out-of-Pocket Maximum

In-network:
Individual: $4,000

Family: $8,000

Out-of-Pocket Maximum

In-network:
Individual: $1,000

Family: $2,000

Out-of-network:
Individual: $2,000

Family: $4,000

Doctor’s Office Visit

In-network:
You pay 0% (after deductible)

Plan pays 100%

Out-of-network:
You pay 30% (after deductible)

Plan pays 70%

Doctor’s Office Visit

In-network:
You pay $20 copay

Doctor’s Office Visit

In-network:
You pay $15 copay

Out-of-network:
You pay 20% (after deductible)

Plan pays 80%

Specialist Office Visit

In-network:
You pay 0% (after deductible)

Plan pays 100%

Out-of-network:
You pay 30% (after deductible)

Plan pays 70%

Specialist Office Visit

In-network:
You pay $40 copay

Specialist Office Visit

In-network:
You pay $25 copay

Out-of-network:
You pay 20% (after deductible)

Plan pays 80%

Preventive/Well Child Care

In-network:
You pay $0

Plan pays 100%

Out-of-network:
You pay 30% (after deductible)

Plan pays 70%

Preventive/Well Child Care

In-network:
You pay $0

Plan pays 100%

Preventive/Well Child Care

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay 20% (after deductible)
Plan pays 80%

Diagnostic Test (x-ray, blood work)

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay 30% (after deductible)
Plan pays 70%

Diagnostic Test (x-ray, blood work)

In-network:
You pay $0
Plan pays 100%

Diagnostic Test (x-ray, blood work)

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay 20% (after deductible)
Plan pays 80%

Imaging (CT/PET scans, MRIs)

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay 30% (after deductible)
Plan pays 70%

Imaging (CT/PET scans, MRIs)

In-network:
You pay $0
Plan pays 100%

Imaging (CT/PET scans, MRIs)

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay 20% (after deductible)
Plan pays 80%

Emergency Room

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay $0
Plan pays 100%

Emergency Room

In-network:
You pay $200 copay waived if admitted

Emergency Room

In-network:
You pay $50 copay waived if admitted

Out-of-network:
You pay $50 copay waived if admitted

Urgent Care

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay $0
Plan pays 100%

Urgent Care

In-network:
You pay $40 copay

Urgent Care

In-network:
You pay $25 copay

Out-of-network:
You pay $25 copay

Hospitalization

Inpatient In-network:
You pay 0% (after deductible)

Plan pays 100%

Inpatient Out-of-network:
You pay 30% (after deductible)

Plan pays 70%

Outpatient In-network:
You pay 0% (after deductible)

Plan pays 100%

Outpatient Out-of-network:
You pay 30% (after deductible)

Plan pays 70%

Hospitalization

Inpatient In-network:
You pay $500 copay per admission

Outpatient In-network:
You pay $200 copay per admission

Hospitalization

Inpatient In-network:
You pay $500 copay per admission

Inpatient Out-of-network:
You pay 20% (after deductible)

Plan pays 80%

Outpatient In-network:
You pay $0

Plan pays 100%

Outpatient Out-of-network:
You pay 20% (after deductible)

Plan pays 80%

Are you required to use network providers?

No (but your costs will be lower when you do)

Are you required to use network providers?

Yes.

Are you required to use network providers?

No (but your costs will be lower when you do)

Do you need a referral to a specialist?

No.

Do you need a referral to a specialist?

No.

Do you need a referral to a specialist?

No.

Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)?

Yes (HSA) / Not applicable (HRA)

Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)?

No.

Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)?

No.

Can I use a Health Care Flexible Spending Account (FSA)?

No; you use your HSA instead. You can use a Limited Purpose FSA for dental and vision expenses.

Can I use a Health Care Flexible Spending Account (FSA)?

Yes.

Can I use a Health Care Flexible Spending Account (FSA)?

Yes.

Prescription Drug

Retail (Up to 31-day supply)
In-network Only

Tier 1: 30% coinsurance (after deductible)

Tier 2: 30% coinsurance (after deductible)

Tier 3: 30% coinsurance (after deductible)

Mail Order (Up to 90-day supply)
In-network Only

Tier 1: 30% coinsurance (after deductible)

Tier 2: 30% coinsurance (after deductible)

Tier 3: 30% coinsurance (after deductible)

Prescription Drug

Retail (Up to 31-day supply)
In-network Only

Tier 1: $10 copay

Tier 2: $20 copay

Tier 3: $35 copay

Mail Order (Up to 90-day supply)
In-network Only

Tier 1: $20 copay

Tier 2: $40 copay

Tier 3: $70 copay

Prescription Drug

Retail (Up to 31-day supply)
In-network Only

Tier 1: $10 copay
Tier 2: $20 copay
Tier 3: $35 copay

Mail Order (Up to 90-day supply)
In-network Only

Tier 1: $20 copay
Tier 2: $40 copay
Tier 3: $70 copay

  • Deductible


    The amount of covered expenses you must pay before the Plan starts paying benefits.

    In-network:

    Individual: None

    Family: None

  • Coinsurance


    Cost-sharing between you and the company. This is applied after you meet your deductible.

    In-network:

    You pay 0% (after deductible)

    Plan pays 100%

  • Out-of-Pocket Maximum


    The most you are required to pay out of your own pocket in a plan year. Some expenses may not apply.

    In-network:

    Individual: $4,000

    Family: $8,000

  • Doctor’s Office Visit


    In-network:

    You pay $20 copay

  • Specialist Office Visit


    Specialists include doctors trained in a specific area or function of the body, or a specific age group (cardiologist, pediatrician, orthopedic surgeon, neurologist, etc.).

    In-network:

    You pay $40 copay

  • Preventive/Well Child Care


    Care focused on prevention or early detection of health conditions. Includes routine physical exam, immunizations, cancer screenings, vision and hearing exams, etc.

    In-network:

    You pay $0

    Plan pays 100%

  • Diagnostic Test (x-ray, blood work)


    In-network:

    You pay $0
    Plan pays 100%

  • Imaging (CT/PET scans, MRIs)


    In-network:

    You pay $0
    Plan pays 100%

  • Emergency Room


    Provides accidental injury and medical emergency care. Note: Call your plan immediately if you are admitted to the hospital.

    In-network:

    You pay $200 copay waived if admitted

  • Urgent Care


    Non-emergency care received from an urgent care clinic or other medical facility; typically used after hours or when your regular doctor is not available.

    In-network:

    You pay $40 copay

  • Hospitalization


    Inpatient In-network:

    You pay $500 copay per admission

    Outpatient In-network:

    You pay $200 copay per admission

  • Are you required to use network providers?


    Yes.

  • Do you need a referral to a specialist?


    No.

  • Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)?


    A feature of high-deductible or consumer-driven medical plans, this is a tax-advantaged savings account you can use for medical expenses now or save for later.

    No.

  • Can I use a Health Care Flexible Spending Account (FSA)?


    An account you contribute to before taxes, then use the money for qualified health-related expenses.

    Yes.

  • Prescription Drug


    Deductible - See Deductible above

    Retail (Up to 31-day supply)

    In-network Only

    Tier 1: $10 copay

    Tier 2: $20 copay

    Tier 3: $35 copay

    Mail Order (Up to 90-day supply)

    In-network Only

    Tier 1: $20 copay

    Tier 2: $40 copay

    Tier 3: $70 copay

EPO In-Network Plan

Provider: Meritain Health

Phone: 888-324-5789

https://www.meritain.com/

Meritain Health -Accessing the national Aetna Choice POS II network

Provider Search: www.aetna.com/docfind/custom/mymeritain,
Prescription Provider: RxBenefits – through Express-Scripts,
Phone: 800-334-8134, www.express-scripts.com

EPO In-Network Plan HSA Open Access Plan POS Open Access Plan

Deductible

In-network:
Individual: None

Family: None

Deductible

In-network:
Individual: $2,000

Family: $4,000

Out-of-network:
Individual: $2,000

Family: $4,000

Deductible

In-network:
Individual: None

Family: None

Out-of-network:
Individual: $500

Family: $1,000

Coinsurance

In-network:
You pay 0% (after deductible)

Plan pays 100%

Coinsurance

In-network:
You pay 0% (after deductible)

Plan pays 100%

Out-of-network:
You pay 30% (after deductible)

Plan pays 70%

Coinsurance

In-network:
You pay 0% (after deductible)

Plan pays 100%

Out-of-network:
You pay 20% (after deductible)

Plan pays 80%

Out-of-Pocket Maximum

In-network:
Individual: $4,000

Family: $8,000

Out-of-Pocket Maximum

In-network:
Individual: $5,000

Family: $10,000

Out-of-network:
Individual: $10,000

Family: $20,000

Out-of-Pocket Maximum

In-network:
Individual: $1,000

Family: $2,000

Out-of-network:
Individual: $2,000

Family: $4,000

Doctor’s Office Visit

In-network:
You pay $20 copay

Doctor’s Office Visit

In-network:
You pay 0% (after deductible)

Plan pays 100%

Out-of-network:
You pay 30% (after deductible)

Plan pays 70%

Doctor’s Office Visit

In-network:
You pay $15 copay

Out-of-network:
You pay 20% (after deductible)

Plan pays 80%

Specialist Office Visit

In-network:
You pay $40 copay

Specialist Office Visit

In-network:
You pay 0% (after deductible)

Plan pays 100%

Out-of-network:
You pay 30% (after deductible)

Plan pays 70%

Specialist Office Visit

In-network:
You pay $25 copay

Out-of-network:
You pay 20% (after deductible)

Plan pays 80%

Preventive/Well Child Care

In-network:
You pay $0

Plan pays 100%

Preventive/Well Child Care

In-network:
You pay $0

Plan pays 100%

Out-of-network:
You pay 30% (after deductible)

Plan pays 70%

Preventive/Well Child Care

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay 20% (after deductible)
Plan pays 80%

Diagnostic Test (x-ray, blood work)

In-network:
You pay $0
Plan pays 100%

Diagnostic Test (x-ray, blood work)

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay 30% (after deductible)
Plan pays 70%

Diagnostic Test (x-ray, blood work)

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay 20% (after deductible)
Plan pays 80%

Imaging (CT/PET scans, MRIs)

In-network:
You pay $0
Plan pays 100%

Imaging (CT/PET scans, MRIs)

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay 30% (after deductible)
Plan pays 70%

Imaging (CT/PET scans, MRIs)

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay 20% (after deductible)
Plan pays 80%

Emergency Room

In-network:
You pay $200 copay waived if admitted

Emergency Room

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay $0
Plan pays 100%

Emergency Room

In-network:
You pay $50 copay waived if admitted

Out-of-network:
You pay $50 copay waived if admitted

Urgent Care

In-network:
You pay $40 copay

Urgent Care

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay $0
Plan pays 100%

Urgent Care

In-network:
You pay $25 copay

Out-of-network:
You pay $25 copay

Hospitalization

Inpatient In-network:
You pay $500 copay per admission

Outpatient In-network:
You pay $200 copay per admission

Hospitalization

Inpatient In-network:
You pay 0% (after deductible)

Plan pays 100%

Inpatient Out-of-network:
You pay 30% (after deductible)

Plan pays 70%

Outpatient In-network:
You pay 0% (after deductible)

Plan pays 100%

Outpatient Out-of-network:
You pay 30% (after deductible)

Plan pays 70%

Hospitalization

Inpatient In-network:
You pay $500 copay per admission

Inpatient Out-of-network:
You pay 20% (after deductible)

Plan pays 80%

Outpatient In-network:
You pay $0

Plan pays 100%

Outpatient Out-of-network:
You pay 20% (after deductible)

Plan pays 80%

Are you required to use network providers?

Yes.

Are you required to use network providers?

No (but your costs will be lower when you do)

Are you required to use network providers?

No (but your costs will be lower when you do)

Do you need a referral to a specialist?

No.

Do you need a referral to a specialist?

No.

Do you need a referral to a specialist?

No.

Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)?

No.

Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)?

Yes (HSA) / Not applicable (HRA)

Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)?

No.

Can I use a Health Care Flexible Spending Account (FSA)?

Yes.

Can I use a Health Care Flexible Spending Account (FSA)?

No; you use your HSA instead. You can use a Limited Purpose FSA for dental and vision expenses.

Can I use a Health Care Flexible Spending Account (FSA)?

Yes.

Prescription Drug

Retail (Up to 31-day supply)
In-network Only

Tier 1: $10 copay

Tier 2: $20 copay

Tier 3: $35 copay

Mail Order (Up to 90-day supply)
In-network Only

Tier 1: $20 copay

Tier 2: $40 copay

Tier 3: $70 copay

Prescription Drug

Retail (Up to 31-day supply)
In-network Only

Tier 1: 30% coinsurance (after deductible)

Tier 2: 30% coinsurance (after deductible)

Tier 3: 30% coinsurance (after deductible)

Mail Order (Up to 90-day supply)
In-network Only

Tier 1: 30% coinsurance (after deductible)

Tier 2: 30% coinsurance (after deductible)

Tier 3: 30% coinsurance (after deductible)

Prescription Drug

Retail (Up to 31-day supply)
In-network Only

Tier 1: $10 copay
Tier 2: $20 copay
Tier 3: $35 copay

Mail Order (Up to 90-day supply)
In-network Only

Tier 1: $20 copay
Tier 2: $40 copay
Tier 3: $70 copay

  • Deductible


    The amount of covered expenses you must pay before the Plan starts paying benefits.

    In-network:

    Individual: None

    Family: None

    Out-of-network:

    Individual: $500

    Family: $1,000

  • Coinsurance


    Cost-sharing between you and the company. This is applied after you meet your deductible.

    In-network:

    You pay 0% (after deductible)

    Plan pays 100%

    Out-of-network:

    You pay 20% (after deductible)

    Plan pays 80%

  • Out-of-Pocket Maximum


    The most you are required to pay out of your own pocket in a plan year. Some expenses may not apply.

    In-network:

    Individual: $1,000

    Family: $2,000

    Out-of-network:

    Individual: $2,000

    Family: $4,000

  • Doctor’s Office Visit


    In-network:

    You pay $15 copay

    Out-of-network:

    You pay 20% (after deductible)

    Plan pays 80%

  • Specialist Office Visit


    Specialists include doctors trained in a specific area or function of the body, or a specific age group (cardiologist, pediatrician, orthopedic surgeon, neurologist, etc.).

    In-network:

    You pay $25 copay

    Out-of-network:

    You pay 20% (after deductible)

    Plan pays 80%

  • Preventive/Well Child Care


    Care focused on prevention or early detection of health conditions. Includes routine physical exam, immunizations, cancer screenings, vision and hearing exams, etc.

    In-network:

    You pay $0
    Plan pays 100%

    Out-of-network:

    You pay 20% (after deductible)
    Plan pays 80%

  • Diagnostic Test (x-ray, blood work)


    In-network:

    You pay $0
    Plan pays 100%

    Out-of-network:

    You pay 20% (after deductible)
    Plan pays 80%

  • Imaging (CT/PET scans, MRIs)


    In-network:

    You pay $0
    Plan pays 100%

    Out-of-network:

    You pay 20% (after deductible)
    Plan pays 80%

  • Emergency Room


    Provides accidental injury and medical emergency care. Note: Call your plan immediately if you are admitted to the hospital.

    In-network:

    You pay $50 copay waived if admitted

    Out-of-network:

    You pay $50 copay waived if admitted

  • Urgent Care


    Non-emergency care received from an urgent care clinic or other medical facility; typically used after hours or when your regular doctor is not available.

    In-network:

    You pay $25 copay

    Out-of-network:

    You pay $25 copay

  • Hospitalization


    Inpatient In-network:

    You pay $500 copay per admission

    Inpatient Out-of-network:

    You pay 20% (after deductible)

    Plan pays 80%

    Outpatient In-network:

    You pay $0

    Plan pays 100%

    Outpatient Out-of-network:

    You pay 20% (after deductible)

    Plan pays 80%

  • Are you required to use network providers?


    No (but your costs will be lower when you do)

  • Do you need a referral to a specialist?


    No.

  • Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)?


    A feature of high-deductible or consumer-driven medical plans, this is a tax-advantaged savings account you can use for medical expenses now or save for later.

    No.

  • Can I use a Health Care Flexible Spending Account (FSA)?


    An account you contribute to before taxes, then use the money for qualified health-related expenses.

    Yes.

  • Prescription Drug


    Deductible – See Deductible above

    Retail (Up to 31-day supply)

    In-network Only

    Tier 1: $10 copay
    Tier 2: $20 copay
    Tier 3: $35 copay

    Mail Order (Up to 90-day supply)

    In-network Only

    Tier 1: $20 copay
    Tier 2: $40 copay
    Tier 3: $70 copay

POS Open Access Plan

Provider: Meritain Health

Phone: 888-324-5789

https://www.meritain.com/

Meritain Health  -Accessing the national Aetna Choice POS II network

Provider Search: www.aetna.com/docfind/custom/mymeritain,
Prescription Provider: RxBenefits – through Express-Scripts,
Phone: 800-334-8134, www.express-scripts.com

POS Open Access Plan HSA Open Access Plan EPO In-Network Plan

Deductible

In-network:
Individual: None

Family: None

Out-of-network:
Individual: $500

Family: $1,000

Deductible

In-network:
Individual: $2,000

Family: $4,000

Out-of-network:
Individual: $2,000

Family: $4,000

Deductible

In-network:
Individual: None

Family: None

Coinsurance

In-network:
You pay 0% (after deductible)

Plan pays 100%

Out-of-network:
You pay 20% (after deductible)

Plan pays 80%

Coinsurance

In-network:
You pay 0% (after deductible)

Plan pays 100%

Out-of-network:
You pay 30% (after deductible)

Plan pays 70%

Coinsurance

In-network:
You pay 0% (after deductible)

Plan pays 100%

Out-of-Pocket Maximum

In-network:
Individual: $1,000

Family: $2,000

Out-of-network:
Individual: $2,000

Family: $4,000

Out-of-Pocket Maximum

In-network:
Individual: $5,000

Family: $10,000

Out-of-network:
Individual: $10,000

Family: $20,000

Out-of-Pocket Maximum

In-network:
Individual: $4,000

Family: $8,000

Doctor’s Office Visit

In-network:
You pay $15 copay

Out-of-network:
You pay 20% (after deductible)

Plan pays 80%

Doctor’s Office Visit

In-network:
You pay 0% (after deductible)

Plan pays 100%

Out-of-network:
You pay 30% (after deductible)

Plan pays 70%

Doctor’s Office Visit

In-network:
You pay $20 copay

Specialist Office Visit

In-network:
You pay $25 copay

Out-of-network:
You pay 20% (after deductible)

Plan pays 80%

Specialist Office Visit

In-network:
You pay 0% (after deductible)

Plan pays 100%

Out-of-network:
You pay 30% (after deductible)

Plan pays 70%

Specialist Office Visit

In-network:
You pay $40 copay

Preventive/Well Child Care

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay 20% (after deductible)
Plan pays 80%

Preventive/Well Child Care

In-network:
You pay $0

Plan pays 100%

Out-of-network:
You pay 30% (after deductible)

Plan pays 70%

Preventive/Well Child Care

In-network:
You pay $0

Plan pays 100%

Diagnostic Test (x-ray, blood work)

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay 20% (after deductible)
Plan pays 80%

Diagnostic Test (x-ray, blood work)

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay 30% (after deductible)
Plan pays 70%

Diagnostic Test (x-ray, blood work)

In-network:
You pay $0
Plan pays 100%

Imaging (CT/PET scans, MRIs)

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay 20% (after deductible)
Plan pays 80%

Imaging (CT/PET scans, MRIs)

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay 30% (after deductible)
Plan pays 70%

Imaging (CT/PET scans, MRIs)

In-network:
You pay $0
Plan pays 100%

Emergency Room

In-network:
You pay $50 copay waived if admitted

Out-of-network:
You pay $50 copay waived if admitted

Emergency Room

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay $0
Plan pays 100%

Emergency Room

In-network:
You pay $200 copay waived if admitted

Urgent Care

In-network:
You pay $25 copay

Out-of-network:
You pay $25 copay

Urgent Care

In-network:
You pay $0
Plan pays 100%

Out-of-network:
You pay $0
Plan pays 100%

Urgent Care

In-network:
You pay $40 copay

Hospitalization

Inpatient In-network:
You pay $500 copay per admission

Inpatient Out-of-network:
You pay 20% (after deductible)

Plan pays 80%

Outpatient In-network:
You pay $0

Plan pays 100%

Outpatient Out-of-network:
You pay 20% (after deductible)

Plan pays 80%

Hospitalization

Inpatient In-network:
You pay 0% (after deductible)

Plan pays 100%

Inpatient Out-of-network:
You pay 30% (after deductible)

Plan pays 70%

Outpatient In-network:
You pay 0% (after deductible)

Plan pays 100%

Outpatient Out-of-network:
You pay 30% (after deductible)

Plan pays 70%

Hospitalization

Inpatient In-network:
You pay $500 copay per admission

Outpatient In-network:
You pay $200 copay per admission

Are you required to use network providers?

No (but your costs will be lower when you do)

Are you required to use network providers?

No (but your costs will be lower when you do)

Are you required to use network providers?

Yes.

Do you need a referral to a specialist?

No.

Do you need a referral to a specialist?

No.

Do you need a referral to a specialist?

No.

Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)?

No.

Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)?

Yes (HSA) / Not applicable (HRA)

Can I use a Health Savings Account (HSA) or Health Reimbursement Account (HRA)?

No.

Can I use a Health Care Flexible Spending Account (FSA)?

Yes.

Can I use a Health Care Flexible Spending Account (FSA)?

No; you use your HSA instead. You can use a Limited Purpose FSA for dental and vision expenses.

Can I use a Health Care Flexible Spending Account (FSA)?

Yes.

Prescription Drug

Retail (Up to 31-day supply)
In-network Only

Tier 1: $10 copay
Tier 2: $20 copay
Tier 3: $35 copay

Mail Order (Up to 90-day supply)
In-network Only

Tier 1: $20 copay
Tier 2: $40 copay
Tier 3: $70 copay

Prescription Drug

Retail (Up to 31-day supply)
In-network Only

Tier 1: 30% coinsurance (after deductible)

Tier 2: 30% coinsurance (after deductible)

Tier 3: 30% coinsurance (after deductible)

Mail Order (Up to 90-day supply)
In-network Only

Tier 1: 30% coinsurance (after deductible)

Tier 2: 30% coinsurance (after deductible)

Tier 3: 30% coinsurance (after deductible)

Prescription Drug

Retail (Up to 31-day supply)
In-network Only

Tier 1: $10 copay

Tier 2: $20 copay

Tier 3: $35 copay

Mail Order (Up to 90-day supply)
In-network Only

Tier 1: $20 copay

Tier 2: $40 copay

Tier 3: $70 copay