Benefit Details

Annual Deductible
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Combined
Medical Deductible	Individual: $4,000 Family: $8,000	--	Individual: $6,500 Family: $13,000	Individual: Not Applicable Family: Not Applicable
Drug Benefits Deductible	Individual: $300 Family: $600	--	Individual: Not Applicable Family: Not Applicable	Individual: Not Applicable Family: Not Applicable

Annual Out-of-Pocket
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Combined
Out of Pocket Max for Med and Drug EHB Benefits (Total)	Individual: $8,200 Family: $16,400	--	Individual: $20,000 Family: $40,000	Individual: Not Applicable Family: Not Applicable

Professional Services
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Other Practitioner Office Visit (Nurse, Physician Assistant)	$40	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Imaging (CT/PET Scans, MRIs)	$325	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
X-rays and Diagnostic Imaging	$85	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Specialist Visit	$80	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Laboratory Outpatient and Professional Services	$40	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Primary Care Visit to Treat an Injury or Illness	$40	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Prescription Drug Coverage
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Generic Drugs	$16 Copay after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Preferred Brand Drugs	$60 Copay after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Non-Preferred Brand Drugs	$90 Copay after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Specialty Drugs	20% Coinsurance after deductible, up to $250	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Preventative Care
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Well Baby Visits and Care	No Charge	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Preventive Care/Screening/Immunization	No Charge	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Emergency Health
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Urgent Care Centers or Facilities	$40	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Emergency Room Services	$400	--	$400	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Emergency Transportation/Ambulance	$255	--	$255	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Outpatient Services
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Outpatient Surgery Physician/Surgical Services	20%	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Outpatient Rehabilitation Services	$40	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Hospitalization Services
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Inpatient Physician and Surgical Services	20%	--	50% Coinsurance after deductible	Explanation: This Includes labor and delivery, mental health, and substance use disorder professional fee.
Habilitation Services	$40	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Inpatient Hospital Services (e.g., Hospital Stay)	20% Coinsurance after deductible	--	50% Coinsurance after deductible	Explanation: This includes labor and delivery, mental health, and substance use disorder facility fee.
Skilled Nursing Facility	20% Coinsurance after deductible	--	50% Coinsurance after deductible	Limit: 100 Days per Benefit Period Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Substance Abuse Disorder Outpatient Services	$40	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Substance Abuse Disorder Inpatient Services	20% Coinsurance after deductible	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Maternity Care
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Delivery and All Inpatient Services for Maternity Care	20% Coinsurance after deductible	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Prenatal and Postnatal Care	No Charge	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Home Health Care
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Home Health Care Services	$45	--	Not Covered	Limit: 100 Visit(s) per Year Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Other Services
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Mental/Behavioral Health Inpatient Services	20% Coinsurance after deductible	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Durable Medical Equipment	20%	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Routine Foot Care	$40	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Hospice Services	No Charge	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Bariatric Surgery	20% Coinsurance after deductible	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Mental/Behavioral Health Outpatient Services	$40	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Acupuncture	$40	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Rehabilitative Speech Therapy	$40	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Rehabilitative Occupational and Rehabilitative Physical Therapy	$40	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Abortion for Which Public Funding is Prohibited	20%	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Allergy Testing	$80	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Chemotherapy	20%	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Diabetes Education	No Charge	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Dialysis	20%	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Infusion Therapy	20%	--	Not Covered	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Prosthetic Devices	20%	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Radiation	20%	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Reconstructive Surgery	20% Coinsurance after deductible	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Transplant	20% Coinsurance after deductible	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Treatment for Temporomandibular Joint Disorders	20% Coinsurance after deductible	--	50% Coinsurance after deductible	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Additional Benefits	Outpatient Facility Fee (e.g., Ambulatory Surgery Center): 20% Outpatient Services Office Visit: 20% Mental/Behavioral Health Inpatient Professional Fee: 20% Delivery and all Inpatient Services Professional Fee: 20% Substance Use Disorder Inpatient Professional Fee: 20% Emergency Room Professional Fee: $0	--	Outpatient Facility Fee (e.g., Ambulatory Surgery Center): 50% after ded. Outpatient Services Office Visit: 50% after ded. Mental/Behavioral Health Inpatient Professional Fee: 50% after ded. Delivery and all Inpatient Services Professional Fee: 50% after ded. Substance Use Disorder Inpatient Professional Fee: 50% after ded. Emergency Room Professional Fee: $0	Outpatient Facility Fee (e.g., Ambulatory Surgery Center): Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. Outpatient Services Office Visit: Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. Mental/Behavioral Health Inpatient Professional Fee: Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. Delivery and all Inpatient Services Professional Fee: Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. Substance Use Disorder Inpatient Professional Fee: Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. Emergency Room Professional Fee: Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Dental
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Dental Check-Up for Children	No Charge	--	10%	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Major Dental Care – Child	50%	--	50%	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Basic Dental Care – Child	20%	--	30%	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Orthodontia – Child	50%	--	50%	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Vision
	Tier 1 - In Network	Tier 2 - In Network	Out of Network	Limits and Exclusions
Routine Eye Exam for Children	No Charge	--	No Charge	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Eye Glasses for Children	No Charge	--	No Charge	Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Additional Plan Information

NOTICE! Final rates and benefits are based on actual plan selection (including plan riders you may request) and the assignment of any rate adjustment factors due to the Health plan's underwriting guidelines.

IMPORTANT NOTICE: Coinsurance amounts represented with a "%" are payable after the plan deductibles are reached; Co-pay amounts represented with a "$" are not subject to plan deductibles (except where noted). Refer to contract for a detailed explanation of plan benefits, features, exclusions and limitations. Benefits subject to change without notice. Out of pocket maximum shown includes the plan deductible unless otherwise noted. Co-pays, Deductibles, and Coinsurance amounts listed above are your share of the costs for covered benefits.

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Additionally, information contained in this website is limited in scope, subject to change without notice, and does not contain all the terms, conditions, limitations, or exclusions of the referenced benefit plans. Only the insurance company Plan Documents and Policy contain the exact terms and conditions of coverage. Your grant of access to the rate and benefit summaries contained herein may not be relied upon as a guarantee of your eligibility or coverage under these benefit plans.

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Plan Details

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Additional Plan Information