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Premier PPO 1,250 – $1,250/$2,500

Network Single/Family

  • Office Copays- PCP $35, SPC $50
  • Hospital Copays- n/a
  • UC/ER/Major Diag Copay- UC $50, ER $150, MD n/a
  • Other- n/a
  • Deductible- $1,250/$2,500 (Emb)
  • Coinsurance- 70%
  • Out-of-pocket- $6,350/$12,700
  • Pharmacy- $10/$35/$60/$100 2.5x MO

Out of Network Single/Family

  • Deductible- $2,500/$5,000 (Emb)
  • Coinsurance- 50%
  • Out-of-pocket- $10,000/$20,000

HSA 2,600- $2,600/$5,200

Network Single/Family

  • Office Copays- n/a
  • Hospital Copays- n/a
  • UC/ER/Major Diag Copay- n/a
  • Other- n/a
  • Deductible- $2,600/$5,200 (Emb)
  • Coinsurance- 80%
  • Out-of-pocket- $5,000/$10,000
  • Pharmacy- $15/$40/$60 2x MO

Out of Network Single/Family

  • Deductible- $6,000/$12,000
  • Coinsurance- 60%
  • Out-of-pocket- $10,000/$20,000

Premier PPO 500 – $500/$1,000

Network Single/Family

  • Office Copays- PCP $20, SPC $40
  • Hospital Copays- n/a
  • UC/ER/Major Diag Copay- UC $50, ER $100, MD n/a
  • Other- n/a
  • Deductible- $500/$1,000
  • Coinsurance- 80%
  • Out-of-pocket- $4,500/$9,000
  • Pharmacy- $10/$35/$60/$100 2.5x MO

Out of Network Single/Family

  • Deductible- $1,000/$2,000
  • Coinsurance- 60%
  • Out-of-pocket- $9,000/$18,000

Select 2,000 – $2,000/$4,000

Network Single/Family

  • Office Copays- PCP $25, SPC $40
  • Hospital Copays- n/a
  • UC/ER/Major Diag Copay- UC $125, ER $250, MD n/a
  • Other- n/a
  • Deductible- $2,000/$4,000
  • Coinsurance- 80%
  • Out-of-pocket- $5,000/$10,000
  • Pharmacy- $10/$35/$60/$100 2x MO

Out of Network Single/Family

  • Deductible- n/a
  • Coinsurance- 0%
  • Out-of-pocket- n/a

Premier PPO 4,000 – $4,000/$8,000

Network Single/Family

  • Office Copays- PCP $40, SPC $40
  • Hospital Copays- OP n/a, IP $100 POD
  • UC/ER/Major Diag Copay- UC $40, ER $100, MD n/a
  • Other- n/a
  • Deductible- $4,000/$8,000
  • Coinsurance- 80%
  • Out-of-pocket- $6,350/$12,700
  • Pharmacy- $15/$35/$60/$100 2.5x MO

Out of Network Single/Family

  • Deductible- $4,000/$8,000
  • Coinsurance- 50%
  • Out-of-pocket- $14,000/$28,000

Navigate 1,000- $1,000/$2,000

Network Single/Family

  • Office Copays- PCP $30, SPC $50
  • Hospital Copays- n/a
  • UC/ER/Major Diag Copay- UC $125, ER $250, MD n/a
  • Other- n/a
  • Deductible- $1,000/$2,000
  • Coinsurance- 80%
  • Out-of-pocket- $3,000/$6,000
  • Pharmacy- $15/$40/30% (max $250) 2x MO

Out of Network Single/Family

  • Deductible- n/a
  • Coinsurance- n/a
  • Out-of-pocket- n/a

HSA 5,500 – $5,500/$11,000

  • Network Single/Family
  • Office Copays- PCP n/a, SPC n/a
  • Hospital Copays- n/a
  • UC/ER/Major Diag Copay- n/a
  • Other- n/a
  • Deductible- $5,500/$11,000 (Emb)
  • Coinsurance- 70%
  • Out-of-pocket- $6,350/$12,700
  • Pharmacy- $15/$40/$60 2x MO

Out of Network Single/Family

  • Deductible- $11,000/$22,000
  • Coinsurance- 50%
  • Out-of-pocket- $12,700/$25,400

 

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