| Key benefits | Bronze 60 HDHP (HSA Compatible) |
|---|---|
| Benefits in Orange are Subject to Deductibles | |
| Individual Deductible | $4,800 integrated medical and pharmacy deductible |
| Family Deductible | $9,600 integrated medical and pharmacy deductible |
| Preventative Care | no cost1 |
| Primary Care Visit Copay | 40% |
| Urgent Care Visit Copay | 40% |
| Specialty Care Visit Copay | 40% |
| Mental Health & Substance Abuse Outpatient Office Visits | 40% |
| Lab Testing Copay | 40% |
| X-Ray Copay | 40% |
| Imaging Copay | 40% |
| Outpatient services | 40% |
| Emergency Room Copay | 40% |
| Emergency Room Transportation Copay | 40% |
| High cost and inpatient services (e.g. Hospital stay) | 40% |
| Inpatient Hospital Physician services | 40% |
| Tier 1 - Most Generic Drugs | 40% up to $500 maximum per prescription |
| Tier 2 - Preferred Brand Drugs | 40% up to $500 maximum per prescription |
| Tier 3 - Non-Preferred Brand Drugs | 40% up to $500 maximum per prescription |
| Tier 4 - Specialty Drugs | 40% up to $500 maximum per prescription |
| Maximum Out-Of-Pocket For One | $6,550 |
| Maximum Out-Of-Pocket For Family | $13,100 |
| 1 in-network only 2 Copay is limited to the first three visits in total. That includes any combination of Primary Care, Specialist, Mental Health, or Urgent Care visits. After three visits, future visits will be at full cost until the out-of-pocket maximum is met. 3 See the plan's Summary of Benefits to determine if $ or % is due. |
|
| Key benefits | Bronze 60 HDHP (HSA Compatible) |