Medical Insurance

Benefit Design

Base Plan

Buy Up Plan

HSA Plan

Deductible (Plan Year):

$1,250

$750

$1,650

Individual

Family

$2,500

$1,500

$3,300

Coinsurance:

80%

90%

100%

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

$5,000

$3,000

$4,125

Individual

Family

$10,000

$6,000

$8,250

Physician Office Visit:

$25

$25

$25 after Deductible

Specialist Office Visit:

$50

$50

$50 after Deductible

Teladoc Visit:

$15

$15

$15 after Deductible

Emergency Room:

Deductible / Coinsurance

Deductible / Coinsurance

$200 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 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