Jefferson City School District

Benefit Design

$1000 Base Plan

$500 Buy Up Plan

$1600 HSA Plan

Deductible (Plan Year):

$1,000

$500

$1,600

Individual

Family

$2,000

$1,000

$3,200

Coinsurance:

80%

90%

100%

Total Out of Pocket Max:

$3,000

$1,500

$3,200

Individual

Family

$6,000

$3,000

$6,400

Physician Office Visit:

$25

$25

$25 after Deductible

Specialist Office Visit:

$35

$35

$35 after Deductible

Teladoc Visit:

$15

$15

$15 after Deductible

Emergency Room:

Deductible / Coinsurance

Deductible / Coinsurance

$100 after Deductible

Urgent Care:

$50

$50

$50 after Deductible

Inpatient Hospital:

$100, then Ded / Coins

$100, then Ded / Coins

$100 after Deductible

Outpatient Surgery:

Deductible / Coinsurance

Deductible / Coinsurance

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