Medical Insurance

Benefit Design

Base Plan

Buy Up Plan

HSA Plan

Deductible (Plan Year):

$1,500

$1,000

$1,800

Individual

Family

$3,000

$2,000

$3,600

Coinsurance:

80%

90%

90%

Total Out of Pocket Max:(deductible, copays & coinsurance)

$7,500

$5,000

$4,500

Individual

Family

$15,000

$10,000

$9,000

Physician Office Visit:

$25

$25

$25 after Deductible

Specialist Office Visit:

$50

$50

$50 after Deductible

Teladoc Visit:

$15

$15

$15 

Emergency Room:

Deductible/Coinsurance

Deductible/Coinsurance

Deductible/Coinsurance

Urgent Care:

$50

$50

$50 after Deductible

Inpatient Hospital:

$100, then Deductible + Coinsurance

$100, then Deductible + Coinsurance

Deductible, then $100  + Coinsurance

Outpatient Surgery:

Deductible/Coinsurance

Deductible/Coinsurance

Deductible/Coinsurance

Prescription:

$10 copay generic

• Deductible then $10 copay generic; 
• preferred brand 20% up to $100;
• non-preferred brand 20% up to $200;
• specialty 20% up to $300

• preferred brand 20% up to $100;
• non-preferred brand 20% up to $200;
• specialty 20% up to $300

• preferred brand 20% up to $100;
• non-preferred brand 20% up to $200;
• specialty 20% up to $300