IN-NETWORK
BENEFITS |
Traditional Plan PPO |
Traditional Plan HMO |
HDHP with HSA PPO Plan |
HDHP with HSA HMO Plan |
Deductible |
$3,000 Single$6,000 Family |
$3,000 Single$6,000 Family |
$4,000 Single$8,000 Family |
$4,000 Single$8,000 Family |
Coinsurance |
You pay 20% (after deductible)Plan pays 80% |
You pay 20% (after deductible)Plan pays 80% |
You pay 0% (after deductible)Plan pays 100% |
You pay 0% (after deductible)Plan pays 100% |
Out of Pocket Maximum |
$6,000 Single$12,000 Family |
$6,000 Single$12,000 Family |
$4,000 Single$8,000 Family |
$4,000 Single$8,000 Family |
Office Visit Copay |
$25 PCP$50 Specialist
$25 Doctor on Demand
$25 Urgent Care
|
$25 PCP$50 Specialist$25 Doctor on Demand
$25 Urgent Care
|
Deductible then 0% coinsuranceDoctor on Demand offers reduced fees for various services. |
Deductible then 0% coinsuranceDoctor on Demand offers reduced fees for various services. |
Preventive Office Copay |
Covered at 100% |
Covered at 100% |
Covered at 100% |
Covered at 100% |
Emergency Room Copay |
You pay $300 copay followed by 20% coinsurance |
You pay $300 copay followed by 20% coinsurance |
0% coinsurance |
0% coinsurance |
Prescription DrugDeductibleCost Per Tier |
Tier 1: $10Tier 2: 25% coinsurance up to $100Tier 3: 35% coinsurance up to $100Specialty drugs: Same as cost-share above depending on drug category.
|
Tier 1: $10Tier 2: 25% coinsurance up to $100Tier 3: 35% coinsurance up to $100Specialty drugs: Same as cost-share above depending on drug category.
|
Tier 1: 0% coinsuranceTier 2: 0% coinsuranceTier 3: 0% coinsuranceSpecialty drugs: 0% coinsurance
|
Tier 1: 0% coinsuranceTier 2: 0% coinsuranceTier 3: 0% coinsuranceSpecialty drugs: 0% coinsurance
|