In-Network Deductible
(Individual/Family)
$2,000/$4,000
In-Network Out-of-Pocket Maximum
(Individual/Family)
$5,000/$10,000
Office Visits (PCP/Specialist)
$20/$40
Prescription Drugs
Tier 1/Generic: $5-$20
Tier 2/Brand: $40
Tier 3/Non-Preferred: $60
Tier 4/Specialty: 30% to $250