In-Network Deductible
(Individual/Family)
$0
In-Network Out-of-Pocket Maximum
(Individual/Family)
$1,500/$3,000
Office Visits (PCP/Specialist)
$30/$30
Prescription Drugs
Tier 1/Generic: $15
Tier 2/Brand: $35
Tier 3/Non-Preferred: $35
Tier 4/Specialty: 30% up to $250/script
