Base Plan

Benefit Design

Medical Base Plan

Deductible (Plan Year):

$1,250

Individual

Family

$2,500

Coinsurance:

80%

Total Out of Pocket Max:

$5,000

Individual

Family

$10,000

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

Prescriptions:

Generic: $10 Copay

Preferred Brand:  20% up to $100 per script max

Employee Monthly Premiums: