In-Network

Annual Deductible: none

Annual Out-of-Pocket Max: $2,500 per individual, $5,000 per family

Lifetime Max: unlimited

Primary Office Visit: $20 copay

Specialist: $30 copay

Preventive Services: $0

Urgent Care center services: $20/visit

Standard Services (not limited to): 10% coinsurance

• Allergy

• Inpatient/outpatient hospitalization

• Lab and x-Ray

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

Advance Imaging: $100 copay + 10% coinsurance

Emergency Room: $150 copay + 10% coinsurance

OptumRx:

Pharmacy (Standard): supply limit 30 days

• Tier 1: $5 copay

• Tier 2: $30 copay

• Tier 3: $50 copay

• Tier 4: 30% coinsurance up to $200

• Contraceptive drugs and devices: $0

Pharmacy (Mail Order): supply limit 90 days

• Tier 1: $10 copay

• Tier 2: $60 copay

• Tier 3: $100 copay

• Tier 4: 30% coinsurance up to $400

Out-of-Network

Annual Deductible: $250 per individual, $500 per family

Annual Out-of-Pocket Max: $5,000 per individual, $10,000 per family

Lifetime Max: unlimited

Primary Office Visit: 40% coinsurance

Specialist: 40% coinsurance

Preventive Services: not covered

Urgent Care center services: 40%

Standard Services (not limited to): 40% coinsurance

• Allergy

• Inpatient/outpatient hospitalization

• Lab and x-Ray

Chiropractic Services: 40% coinsurance

Advance Imaging: $100 copay + 10% coinsurance

Emergency Room $150 copay + 10% coinsurance

OptumRx:

Pharmacy (Standard): supply limit 30 days

• Tier 1: 25% plus $5 copay

• Tier 2: 25% plus $30 copay

• Tier 3: 25% plus $50 copay

• Tier 4: 30% up to $200 copay 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