In-Network

Annual Deductible: $750 per individual, $1,500 per family

Annual Out-of-Pocket Max: $3,500 per individual, $7,000 per family

Lifetime Max: unlimited

Primary Office Visit: $25 copay

Specialist: $40 copay

Preventive Services: $0

Urgent Care center services: $25/visit

Standard Services (not limited to): 20% coinsurance

• Allergy

• Inpatient/outpatient hospitalization

• Lab and x-Ray

Chiropractic Services: $25/visit, up to 20 visits per year

Advance Imaging: $100 copay + 20% coinsurance

Emergency Room: $150 copay + 20% coinsurance

OptumRx:

Pharmacy (Standard): supply limit 30 days

• Tier 1: $10 copay

• Tier 2: $35 copay

• Tier 3: $60 copay

• Tier 4: 30% coinsurance up to $200

• Contraceptive drugs and devices: $0

Pharmacy (Mail Order): supply limit 90 days

• Tier 1: $20 copay

• Tier 2: $70 copay

• Tier 3: $120 copay

• Tier 4: 30% coinsurance up to $400

Out-of-Network

Annual Deductible: $1,500 per individual, $3,000 per family

Annual Out-of-Pocket Max: $7,000 per individual, $14,000 per family

Lifetime Max: unlimited

Primary Office Visit: 40% coinsurance

Specialist: 40% coinsurance

Preventive Services: not covered

Urgent Care center services: 40% coinsurance

Standard Services (not limited to): 40% coinsurance

• Allergy

• Inpatient/outpatient hospitalization

• Lab and x-Ray

Chiropractic Services: 40% coinsurance

Advance Imaging: 40% coinsurance

Emergency Room: $150 copay + 20% coinsurance

OptumRx:

Pharmacy (Standard): supply limit 30 days

• Tier 1: 25% plus $10 copay

• Tier 2: 25% plus $35 copay

• Tier 3: 25% plus $60 copay

• Tier 4: 30% up to $200/prescription plus 25% of purchase price

• Contraceptive drugs and devices: Applicable Tier 1, 2 or 3 copay

Pharmacy (Mail Order): supply limit 90 days

• Tier 1: not covered

• Tier 2: not covered

• Tier 3: not covered

• Tier 4: not covered