MEDICAL

Resources

	In-Network	Out-of-Network
Deductible	$450/$900	$950/$1900
Maximum Out-of-pocket	$350/$700	$350/$700
Primary Care Visits	Ded + 20%	Ded + 40%
Preventive Care	No Charge	Ded + 40%
Specialist Visits	Ded + 20%	Ded + 40%
Emergency Room	Ded + 20%	Ded + 40%
Urgent Care	Ded + 20%	Ded + 40%
Rx Retail Copays
Generic	Ded + 20%	–
Preferred Brand	Ded + 20%	–
Non-Preferred Brand	Ded + 20%	–
Rx Mail Order
Generic	Ded + 20%	–
Preferred Brand	Ded + 20%	–
Non-Preferred Brand	Ded + 20%	–

Pharmacy Benefit
Options Notice

If you have a new or brand name medication, you may be able to utilize a manufacturer coupon. Please check the manufacturers website directly for more information and to obtain the coupon. If you need assistance, please reach out to [email protected]