Medical Benefits

Deductible (Indiv./Fam.)

$1,500/$3,000

$2,000/$4,000

$1,000/$2,000

Out-of-Pocket Max (Indiv./Fam.)

$1,500/$3,000

$4,500/$9,000

$3,000/$6,000

Member Coinsurance

0%

0%

10%

Preventive Care

Covered at 100%

Covered at 100%

Covered at 100%

Primary Care Visit

Spira Care Facility: No Charge

All other physicians’ offices: Deductible

$30 Copay

$20 Copay

Specialist Visit

Spira Care Facility: No Charge

All other physicians’ offices: Deductible

$60 Copay

$30 Copay

Inpatient Hospitalization

Deductible

Deductible + Coinsurance

Deductible + Coinsurance

Physician Services

Deductible

Deductible + Coinsurance

Deductible + Coinsurance

Outpatient Surgery

Deductible

Deductible + Coinsurance

Deductible + Coinsurance

Outpatient Diagnostics

Deductible

Deductible + Coinsurance

Deductible + Coinsurance

Urgent Care

Spira Care No Charge

$50 Copay

$50 Copay

Emergency Room

Deductible

$300 Copay

$100 Copay, then Deductible + Coinsurance

Retail Prescriptions Tier 1/2/3

$15/$50/Deductible

$10/$35/$60

$10/$35/$60

Mail Order

$15/$125/Deductible

2.5 x Retail

2.5 x Retail

Employee

$0.00

$0.00

$102.96

$111.54

$115.97

$125.63

Employee + Spouse

$299.98

$324.98

$426.95

$462.53

$459.06

$497.32

Employee + Child(ren)

$217.13

$235.22

$321.27

$348.04

$344.16

$372.84

Employee + Family

$357.12

$386.88

$501.99

$543.82

$537.74

$582.55

Employee

$433.36

$469.47

$457.16

$495.26

$447.73

$485.04

Employee + Spouse

$770.41

$834.61

$956.56

$1,036.28

$933.27

$1,011.04

Employee + Child(ren)

$545.58

$591.05

$664.56

$719.94

$647.95

$701.95

Employee + Family

$834.61

$904.16

$1,038.36

$1,124.89

$1,012.43

$1,096.80

Employee

$938.94

$1,213.61

$1,221.33

Employee + Spouse

$2,319.18

$2,997.62

$3,016.72

Employee + Child(ren)

$1,652.55

$2,135.95

$2,149.57

Employee + Family

$2,582.08

$3,337.44

$3,358.70

Deductible (Indiv./Fam.)

$2,000/$4,000

$1,000/$2,000

Out-of-Pocket Max (Indiv./Fam.)

$4,500/$9,000

$3,000/$6,000

Member Coinsurance

0%

10%

Preventive Care

Covered at 100%

Covered at 100%

Primary Care Visit

$30 Copay

$20 Copay

Specialist Visit

$60 Copay

$30 Copay

Inpatient Hospitalization

Deductible + Coinsurance

Deductible + Coinsurance

Physician Services

Deductible + Coinsurance

Deductible + Coinsurance

Outpatient Surgery

Deductible + Coinsurance

Deductible + Coinsurance

Outpatient Diagnostics

Deductible + Coinsurance

Deductible + Coinsurance

Urgent Care

$50 Copay

$50 Copay

Emergency Room

$300 Copay

$100 Copay, then Deductible + Coinsurance

Retail Prescriptions Tier 1/2/3

$10/$35/$60

$10/$35/$60

Mail Order

2.5 x Retail

2.5 x Retail

Employee

$0.00

$0.00

$115.97

$125.63

Employee + Spouse

$337.33

$365.44

$459.06

$497.32

Employee + Child(ren)

$254.34

$275.53

$344.16

$372.84

Employee + Family

$405.45

$439.23

$537.74

$582.55

Employee

$560.13

$606.80

$447.73

$485.04

Employee + Spouse

$1,046.19

$1,133.37

$933.27

$1,011.04

Employee + Child(ren)

$731.48

$792.44

$647.95

$701.95

Employee + Family

$1,134.91

$1,229.48

$1,012.43

$1,096.80

Employee

$1,213.61

$1,221.33

Employee + Spouse

$2,997.62

$3,016.72

Employee + Child(ren)

$2,135.95

$2,149.57

Employee + Family

$3,337.44

$3,358.70