Jefferson City School District

Benefit Design

 HSA Plan

Deductible (Plan Year):

$1,650 

Individual

Family

$3,300

Coinsurance:

100%

Total Out of Pocket Max:

$4,125 (deductible, copays, coinsurance) 

Individual

Family

$8,250 (deductible, copays, coinsurance) 

Physician Office Visit:

$25 after Deductible

Specialist Office Visit:

$50 after Deductible

Teladoc Visit:

$15 after Deductible

Emergency Room:

$200 after Deductible

Urgent Care:

$50 after Deductible

Inpatient Hospital:

$100 after Deductible

Outpatient Surgery:

Deductible

Prescription:

Deductible then:

Generic $10

Preferred brand 20% up to $100

Non-preferred brand 20% up to $200

Specialty:  20% up to $300

 Employee Monthly Premiums: