Benefit Design

$1000 Base Plan

$500 Buy Up Plan

$1500 HSA Plan

Deductible (Plan Year):

$1,000

$500

$1,500

Individual

Family

$2,000

$1,000

$3,000

Coinsurance:

80%

90%

100%

Total Out of Pocket Max:

$3,000

$1,500

$3,000

Individual

Family

$6,000

$3,000

$6,000

Physician Office Visit:

$25

$25

$25 after Deductible

Specialist Office Visit:

$35

$35

$35 after Deductible

Emergency Room:

$100, then Ded / Coins

$100, then Ded / Coins

$100 after Deductible

Urgent Care:

$35, then Ded / Coins

$35, then Ded / Coins

$35 after Deductible

Inpatient Hospital:

$100, then Ded / Coins

$100, then Ded / Coins

$100 after Deductible

Outpatient Surgery:

Ded / Coins

Ded / Coins

Deductible

Prescription:

$10/30/50  

$10/30/50  

Deductible then $10/30/50   Specialty:  $75 or $125

Specialty:  $75 or $125

Specialty:  $75 or $125