Jefferson City School District

Benefit Design

Medical Buy Up Plan

Deductible (Plan Year):

$750

Individual

Family

$1,500

Coinsurance:

90%

Total Out of Pocket Max:

$3,000 (deductible, copays, coinsurance)

Individual

Family

$6,000 (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: