In-Network Deductible
(Individual/Family)
$5,000/$10,000
In-Network Out-of-Pocket Maximum
(Individual/Family)
$7,500/$15,000
Office Visits (PCP/Specialist)
20% after deductible
Prescription Drugs - Medical d Deductible Applies
Tier 1/Generic: $5-$15 after deductible
Tier 2/Brand: $40 after deductible
Tier 3/Non-Preferred: $60 after deductible
Tier 4/Specialty: 30% to $250 after deductible