In-Network Deductible
(Individual/Family)
$1,500/$3,000
In-Network Out-of-Pocket Maximum
(Individual/Family)
$4,000/$8,000
Office Visits (PCP/Specialist)
$40/$50
Prescription Drugs
Tier 1/Generic: $10
Tier 2/Brand: $30
Tier 3/Non-Preferred: $30
Tier 4/Specialty: 20% up to $250/script
