Deductible | |
---|---|
Individual | $1,600 |
Family | $3,200 |
Coinsurance Out-of-Pocket Maximum | |
Individual | $1,975 |
Family | $3,950 |
Total Out-of-Pocket Maximum | |
Individual | $3,575 |
Family | $7,150 |
HSA Seed Money | Individual/Family |
Band 1: Less than $45,000 | $800/$1,600 |
Band 2: $45,000.01 – $60,000 | $600/$1,200 |
Band 3: $60,000.01 – $90,000 | $400/$800 |
Band 4: Over $90,000 | $200/$400 |
Coinsurance | |
Percentage | 90% |
Services | |
Preventive Care | Covered at 100% |
Office Visit | Deductible and Coinsurance |
Specialist Visit | Deductible and Coinsurance |
Urgent Care | Deductible and Coinsurance |
Emergency Room (Waived if admitted) | Deductible and Coinsurance |
Pharmacy | |
Retail (30-day supply) | |
Generic Drugs | 10% coinsurance |
Formulary Brand Drugs | 20% coinsurance |
Non-Formulary Brand Drugs | 40% coinsurance |
Mail Order | |
Generic Drugs | 10% coinsurance |
Formulary Brand Drugs | 20% coinsurance |
Non-Formulary Brand Drugs | 40% coinsurance |
Specialty | |
Formulary Drugs | 20% and $65 Minimum |
Non-Formulary Brand Drugs | 40% and $100 Minimum |
Out-of-Pocket Maximum | Integrated with Medical |
More details and overview of coverage grid.