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Medical deductible
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$500 / $1,000
|
|
Out-of-pocket maximum (includes medical, pharmacy, and behavioral health)
|
$5,000 / $10,000
|
|
Primary care provider office visit copay
|
$10 / $20 / $40
|
|
Specialist office visit copay
|
$30 / $60 / $75
|
|
Behavioral health office visit
|
$10 copay
|
|
Emergency room (emergency care covered at any hospital emergency room)
|
$100 copay then deductible (copay waived if admitted)
|
|
Inpatient acute medical care
|
$275 copay then deductible / $500 copay then deductible / $1,500 copay then deductible
|
|
Outpatient surgery at a freestanding ambulatory surgical center (for non-preventive colonoscopies, endoscopies, and eye surgeries)
|
$150 copay then deductible
|
|
Outpatient surgery (plus hospital based non-preventive colonoscopies, endoscopies, and eye surgeries)
|
$250 copay then deductible
|
|
High-tech imaging
|
$100 copay then deductible
|
|
Telemedicine through On Demand urgent care, PCP, or Specialist
|
$10 copay
|
|
Telemedicine for mental health care or substance use care
|
$10 copay (waived for first 3 visits)
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