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