The Premium and Standard plans pay in-network preventive care 100%, no deductible. For most other services, you pay the full cost until you meet the deductible. Then you pay coinsurance up to the annual out-of-pocket maximum.
At-A-Glance
| Premium and Standard Plans |
| Health Savings Account (HSA) | You are eligible to set up a Health Savings Account when you enroll in either plan. | |
| WHAT YOU PAY |
| In-Network* | Out-of-Network |
| Premiums | Your per pay period contribution for medical coverage. | |
| Annual Deductible |
Single: $1,500 Family: $3,000 |
Single: $3,000 Family: $6,000 |
| Out-of-Pocket Maximum |
Single: $2,500 Family: $5,000 |
Single: $5,000 Family: $10,000 |
COVERED SERVICES
| Preventive Services Well-Child Care, Routine Adult Physicals, Immunizations, Prenatal and Postnatal Care, Women’s Health |
$0; no deductible | 30% after deductible |
| Office Visits Primary Provider/Specialist |
10% after deductible | 30% after deductible |
| Inpatient Care | 10% after deductible | 30% after deductible (UCR) |
| Outpatient Care | 10% after deductible | 30% after deductible (UCR) |
| Urgent Care | 10% after deductible | 30% after deductible (UCR) |
| Other Services Ambulance Services, Chiropractic Services, Diagnostic Laboratory, Durable Medical Equipment, Home Health Care, Naturopathic Services, Skilled Nursing Care, X-ray & Imaging |
10% after deductible | 30% after deductible (UCR) |
| Acupuncture 25 visits per calendar year for treatments of headaches and acute pain |
10% after deductible | 30% after deductible (UCR) |
| Hearing Exam One exam per 24 months |
10% after deductible | 30% after deductible (UCR) |
| Private-duty nursing 70, eight-hour shifts per plan year |
10% after deductible | 30% after deductible (UCR) |
| Emergency Room |
Emergencies: 10% after deductible Non-Emergencies: 50% after deductible |
Emergencies: Same as in-network providers Non-Emergencies: 50% after deductible (UCR) |
| Mental Health and Substance Abuse Inpatient/Outpatient Care |
10% after deductible | 30% after deductible (UCR) |
| Prescription Drugs | The medical plans include prescription drug coverage through CVS Caremark. Most prescription drugs are subject to the medical plan deductible, then you pay the applicable copays. Learn More | |
*In some circumstances, you may go to an in-network provider, but receive services from an out-of-network provider. If that’s the case, generally you’ll pay 20% after the deductible for the out-of-network provider after you meet the in-network provider deductible.
UCR: Usual and customary rates
The amount paid for medical services in a geographic area based on what providers in the area usually charge for the same or similar service.