This chart shows what you pay for health care services under each medical plan, assuming you see network providers.
| Classic Plan | Health Savings Plan | Premier Plan | |
|---|---|---|---|
| Deductibles | |||
| Individual | $1,250 | $2,700 | $650 |
| Family | $2,500 | $5,400 | $1,300 |
| Annual Out-of-Pocket Maximums | |||
| Individual | $5,250 | $6,650 | $3,000 |
| Family | $10,500 | $13,300 | $6,000 |
| Medical Services | |||
| Coinsurance | 25% | 10% | 20% |
| PCP Visit | $35 | 10% after deductible is met | $25 |
| Specialist Visit | $55 | 10% after deductible is met | $45 |
| Preventive Care | No cost | No cost | No cost |
| Diagnostic Lab In Office | 25% | 10% after deductible is met | No cost |
| Urgent Care | $55 | 10% after deductible is met | $50 |
| Emergency Room | 1st visit - $150 copay 2nd visit - $200 copay 3rd + visit(s) - $250 copay (waived if admitted) | 10% after deductible is met | 1st visit - $150 copay 2nd visit - $200 copay 3rd + visit(s) - $250 copay (waived if admitted) |
| Ambulance | $100 (waived if admitted) | 10% after deductible is met | $100 (waived if admitted) |
| Advanced Imaging* | 25% after deductible is met and $100 copay | 10% after deductible is met | 20% after deductible is met |
| Outpatient Surgery | 25% after deductible is met and $150 copay | 10% after deductible is met | 20% after deductible is met |
| Inpatient Services** | 25% after deductible is met and $300 copay | 10% after deductible is met | $300 copay |
| Speech, Occupational and Physical Therapy (30 visit combined maximum) | 25% after deductible is met and $35 copay | 10% after deductible is met | 25% after deductible is met and $25 copay |
| Routine Vision Exam | $35 | 10% after deductible is met | $25 |
| Prescription Drugs | |||
| Tier 1 | $15 | 10% after deductible is met | $10 |
| Tier 2 | $55 | 10% after deductible is met | $50 |
| Tier3 | $90 | 10% after deductible is met | $80 |
| Prescription Drug Out-of-Pocket Maximum | |||
| Individual | $1,600 | Combined with Medical Annual Out-of-Pocket Maximum | $1,600 |
| Family | $3,200 | $3,200 | |
| *Prior authorization required. **Includes semi-private room & board, intensive care room & board, ancillary charges and maternity inpatient charges. |
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