Buy-Up Plan

Benefit Design

Medical Buy Up Plan

Deductible (Plan Year):

$1,000

Individual

Family

$2,000

Coinsurance:

90%

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

Prescription:

Generic:  $10 Copay  

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

Non-Preferred Brand:  20% up to $200 per script max

Specialty:  20% up to $300 per script max

Employee Monthly Premiums: