Quick facts
Overall Deductible (Family)
EDIT STICKS AFTER RELOAD
Out-of-Pocket Limit (Individual, Medical)
$5,000
Out-of-Pocket Limit (Family, Medical)
$10,000
Primary Care Visit Copay
$10 copay/visit
Specialist Visit Copay
$25 copay/visit
Emergency Room Care
$100 copay/visit
Urgent Care Copay
$30 copay/visit
Other Coinsurance (Coverage Example)
20% t
More details (21)
Generic Drugs
$3 copay/prescription (retail and mail order)
Preventive Care/Screening/Immunization
No charge
Children's Eye Exam
Not covered
Prescription Drug Out-of-Pocket Limit (Individual)
$1,600
Emergency Medical Transportation
$100 copay/trip
Hospital Facility Fee
$200 copay/day, up to $400/admission
Mental/Behavioral Health Outpatient Services
$10 copay/office visit; $30 copay/day, up to $400/episode of care for other outpatient services
Mental/Behavioral Health Inpatient Services
$200 copay/day, up to $400/admission
Prescription Drug Out-of-Pocket Limit (Family)
$3,200
Brand Name Drugs
$20 copay/prescription (retail and mail order)
Select Specialty Drugs and Select Biosimilars
Generic: $3 copay/prescription (mail order); Brand: 25% coinsurance (mail order)
Pregnancy Office Visits
$10 copay/visit
Home Health Care
$10 copay/visit (limited to 60 visits/year)
Rehabilitation Services
$15 copay/visit (non-hospital); $35 copay/visit (hospital)
Skilled Nursing Care
$50 copay/day, up to $400/admission (limited to 60 days/year)
Durable Medical Equipment
20% coinsurance
Hospice Services
No charge
Children's Dental Check-up
edit test
Diagnostic Test (x-ray, blood work)
testing
Imaging (CT/PET/MRI)
$100 copay/visit (non-hospital); $200 copay/visit (hospital)
Outpatient Surgery Facility Fee
$100 copay/visit (ambulatory surgery center); $200 copay/visit (hospital)
Carrier contact
1-866-686-0003 — member services
Group number: 176B
Your member ID card: check the carrier website or app, or ask HR for a copy.
Plan documents
Confirm details with your carrier for current plan information.