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| In-Network: |
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Individual / Family
$1,500 / $3000 |
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| Out-of-Network |
$4,500 / $9,000 |
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| Co-Insurance: |
In-Network: 10%
Out-of-Network: 40% |
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| Individual: |
In-Network: $2,500
Out-of-Network: $6,800 |
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| Family: |
In-Network: $5,500
Out-of-Network: $12,800 |
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| Office Visit: |
In-Network: $20 per visit
Out-of-Network: 40% after deductible |
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| Specialist Office Visit: |
In-Network: $40 per visit
Out-of-Network: 40% after deductible |
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| Chiropractic: |
In-Network: $40 per visit
Out-of-Network: 40% after deductible
20 visits per calendar year |
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| Emergency Room: |
In-Network: $150 per visit
Out-of-Network: $150 per visit
Waived if admitted |
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| Inpatient Care: |
In-Network: 10% after deductible
Out-of-Network: 40% after deductible |
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| Child Wellness: |
In-Network: $20 per visit
Out-of-Network: 40% |
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| Adult Routine Physicals: |
In-Network: $20 per visit
Out-of-Network: 40% after deductible |
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| Outpatient Surgery: |
In-Network: 10% after deductible
Out-of-Network: 40% after deductible |
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30 day supply (retail) |
| Level 1 |
$20 |
| Level 2 |
$45 |
| Level 3 |
$65 |
| Level 4 |
45%
Mail order prescriptions (90 day supply) is 2.5x copayment |
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| To Enroll: |
To enroll in this plan, use the "Medical Enrollment Form" located on the enrollment tab. |
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