Medical
Medical coverage provides healthcare protection for you and your family. You can visit any provider, but in-network doctors offer the highest level of benefits and lower out-of-pocket costs by charging reduced, contracted rates. Out-of-network providers set their own fees, so you may be responsible for charges above the Reasonable and Customary (R&C) limits. Preventive care—such as physical exams, flu shots, and screenings—is covered at 100% when you use in-network providers. The main differences between plan options are how much you pay per paycheck and what you pay when you receive care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums– the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
HDHP with HSA
Benefit Highlights
In-Network
Deductible (Individual/Family)
$3,400/$6,800
Out-of-Pocket Max (Individual/Family)
$5,000/$10,000
Preventive Care
$0
Primary Care Visit
20%*
Specialist Visit
20%*
Urgent Care
20%*
Emergency Room
20%*
Retail Rx (Up to 31-Day Supply)
Generic
20%*
Preferred Brand
20%*
Non-Preferred Brand
20%*
Specialty
Refer to applicable prescription drug cost sharing
Mail-Order Rx (Up to 90-Day Supply)
Generic
20%*
Preferred Brand
20%*
Non-Preferred Brand
20%*
Specialty
Refer to applicable prescription drug cost sharing
*After deductible
Out-of-Network
Deductible (Individual/Family)
$6,000/$12,000
Out-of-Pocket Max (Individual/Family)
$12,000/$24,000
Preventive Care
$0 Child
40%* Adult
Primary Care Visit
40%*
Specialist Visit
40%*
Urgent Care
40%*
Emergency Room
20%*
Retail Rx (Up to 31-Day Supply)
Generic
40%*
Preferred Brand
40%*
Non-Preferred Brand
40%*
Specialty
Refer to applicable prescription drug cost sharing
Mail-Order Rx (Up to 90-Day Supply)
Generic
40%*
Preferred Brand
40%*
Non-Preferred Brand
40%*
Specialty
Not covered
Plan Cost Per Pay Period
Employee Only: $65
Employee and Spouse: $144
Employee and Child(ren): $116
Employee and Family: $213
Coupe
Benefit Highlights
In-Network
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$5,000/$10,000
Preventive Care
$0
Primary Care Visit
Tier 1: $25
Tier 2: $35
Tier 3: $60
Specialist Visit
Tier 1: $55
Tier 2: $70
Tier 3: $120
Urgent Care
Tier 1: $55
Tier 2: $70
Tier 3: $120
Emergency Room
$500
Retail Rx (Up to 30-Day Supply)
Except Walgreens/CVS
Generic (Tier 1): $10
Preferred: $40
Non-Preferred: $60
Specialty: Mail-order only
Walgreens
Generic(Tier 1): $15
Preferred: $50
Non-Preferred: $70
Specialty: Mail-order only
CVS (31-Day Supply)
Generic(Tier 1): $20
Preferred: $80
Non-Preferred: $120
Specialty: Mail-order only
Mail-Order Rx (Up to 90-Day Supply)
Generic: $20
Preferred: $80
Non-Preferred: $120
Specialty: $80
Out-of-Network
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
Unlimited
Preventive Care
$0
Primary Care Visit
Tier 4: $70
Specialist Visit
Tier 4: $145
Urgent Care
Tier 4: $145
Emergency Room
$500
Retail Rx (Up to 30-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Cost Per Pay Period
Employee Only: $74
Employee and Spouse: $185
Employee and Child(ren): $148
Employee and Family: $268
PPO Plan
Benefit Highlights
In-Network
Deductible (Individual/Family)
$1,500/$3,000
Out-of-Pocket Max (Individual/Family)
$5,000/$10,000
Preventive Care
$0
Primary Care Visit
$35
Specialist Visit
$50
Urgent Care
$35
Emergency Room
20%*
Retail Rx (Up to 31-Day Supply)
Tier 1
$15
Tier 2
$100
Tier 3
$50
Tier 4
$100
Specialty
20% up to $300
Mail-Order Rx (Up to 90-Day Supply)
Tier 1
$30
Tier 2
$200
Tier 3
$100
Tier 4
$200
Specialty
Not covered
*After deductible
Out-of-Network
Deductible (Individual/Family)
$2,250/$4,250
Out-of-Pocket Max (Individual/Family)
$5,000/$10,000
Preventive Care
40%*
Primary Care Visit
40%*
Specialist Visit
40%*
Urgent Care
40%*
Emergency Room
20%*
Retail Rx (Up to 31-Day Supply)
Tier 1
$15
Tier 2
$100
Tier 3
$50
Tier 4
$100
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Tier 1
Not covered
Tier 2
Not covered
Tier 3
Not covered
Tier 4
Not covered
Specialty
Not covered
Plan Cost Per Pay Period
Employee Only: $116
Employee and Spouse: $277
Employee and Child(ren): $227
Employee and Family: $402