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Benefit Ultimate (platinum) Preferred (gold) Enhanced (silver) Enhanced 150 Subsidy1 (silver) Enhanced 200 Subsidy1 (silver) Enhanced 250 Subsidy1 (silver) Basic (bronze) Basic for HSA (bronze) Get Covered (catastrophic)
With participating providers, members pay2:
Office visit - primary care doctor $20* $30* $45* $3* $15* $40* $60 for 1st 3 visits before deductible, then $60 after deductible*3 40% $0 for 1st 3 visits before deductible, then $0 after deductible*3
Office visit - specialist doctor $40* $50* $65* $5* $20* $50* $70 40% 0%
Urgent care visit $40* $60* $90* $6* $30* $80* $120 for 1st 3 visits before deductible, then $120 after deductible*3 40% $0 for 1st 3 visits before deductible, then $0 after deductible*3
Preventive health benefits $0* $0* $0* $0* $0* $0* $0* $0* $0*
Inpatient hospitalization 10%* 20%* 20% 10%* 15% 20% 30% 40% 0%
Outpatient surgery 10%* 20%* 20%* 10%* 15%* 20%* 30% 40% 0%
Lab $20* $30* $45* $3* $15* $40* 30% 40% 0%
X-ray $40* $50* $65* $5* $20* $50* 30% 40% 0%
Emergency room services not resulting in admission $150* $250* $250 $25* $75 $250 $300 40% 0%
Maternity 10%* 20%* 20% 10%* 15% 20% 30% 40% 0%
Generic drugs $5* $19* $19* $3* $5* $19* $194 40%4 0%4
Preferred brand drugs $15* $50* $50 $5* $15 $30 $504 40%4 0%4
Non-preferred brand drugs $25* $70* $70 $10* $25 $50 $754 40%4 0%4
Chiropractic Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered
Acupuncture
(from a licensed acupuncturist)
$20* $30* $45* $3* $15* $40* $60 40% 0%
Pediatric eye exam $0* $0* $0* $0* $0* $0* $0* $0* $0*
Pediatric eyeglasses $0* $0* $0* $0* $0* $0* $0* $0* $0*
Calendar-year medical deductible5 $0 $0 $2,000 per individual
/ $4,000 per family
$0 $500 per individual
/ $1,000 per family
$1,500 per individual
/ $3,000 per family
$5,000 per individual
/ $10,000 per family
$4,500 per individual
/ $9,000 per family
$6,350 per individual
/ $12,700 per family
Calendar-year out-of-pocket maximum
(includes deductible)
$4,000 per individual
/ $8,000 per family
$6,350 per individual
/ $12,700 per family
$6,350 per individual
/ $12,700 per family
$2,250 per individual
/ $4,500 per family
$2,250 per individual
/ $4,500 per family
$5,200 per individual
/ $10,400 per family
$6,350 per individual
/ $12,700 per family
$6,350 per individual
/ $12,700 per family
$6,350 per individual
/ $12,700 per family
Calendar-year brand drug deductible $0 $0 $250 per individual
/ $500 per family
$0 $50 per individual
/ $100 per family
$250 per individual
/ $500 per family
$04 $04 $04

The chart above is designed to give an overview of our individual and family health plans, and contains benefits for participating providers only. For information on services received from non-participating providers, download the plan’s Benefit Summary, available on each product page. Unless otherwise noted, all benefits are subject to a deductible.

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