Jefferson City School District

Benefit Design

Medical Base Plan

Deductible (Plan Year):

$1,250

Individual

Family

$2,500

Coinsurance:

80%

Total Out of Pocket Max:

$5,000 (deductible, copays, coinsurance)

Individual

Family

$10,000 (deductible, copays, coinsurance)

Physician Office Visit:

$25

Specialist Office Visit:

$50

Teladoc Visit:

$15

Emergency Room:

Deductible / Coinsurance

Urgent Care:

$50

Inpatient Hospital:

$100, then Ded / Coins

Outpatient Surgery:

Deductible / Coinsurance

Prescription:

Generic:  $10

Preferred brand:  20% up to $100 max

Non-preferred brand:  20% up to $200 max

Specialty:  20% up to $300 max

Employee Monthly Premiums: