In-Network Deductible
(Individual/Family)
$4,500/$9,000
In-Network Out-of-Pocket Maximum
(Individual/Family)
$6,500/$13,000
Office Visits (PCP/Specialist)
40% after deductible
Prescription Drugs - Medical Deductible Applies
Tier 1/Generic: 30% up to $50 after deductible
Tier 2/Brand: 40% up to $100 after deductible
Tier 3/Non-Preferred: 40% up to $100 after deductible
Tier 4/Specialty: 40% up to $250 after deductible