Preventive Care
- 100% Preventive Care Coverage
Preventive Care
- 100% Preventive Care Coverage
Preventive Care
- 100% Preventive Care Coverage
Deductible
- Network - $750 individual and $1,500 family
- Non-Network - $1,500 individual and $3,000 family
Deductible
- Network and Non-Network combined - $3,300 individual and $6,600 family
Deductible
- Network and Non-Network combined - $0 individual and $0 family
Out-of-Pocket Maximum
- Network - $4,500 individual and $9,000 family
- Non-Network - $9,000 individual and $18,000 family
Out-of-Pocket Maximum
- Network - $5,000 individual and $10,000 family
- Non-Network - $10,000 individual and $20,000 family
Out-of-Pocket Maximum
- Network - $4,000 individual and $8,000 family
- Non-Network - $8,000 individual and $16,000 family
Co-Pays
- In-network office visit - $30
- In-network Urgent Care visit - $75
- Emergency Room - $250 (in or out-of-network)
Co-Pays
- Plan does not have co-pays
Co-Pays
- Co-pay only plan - see app for details
- Office visit co-pays from $5 to $40
- In-network Urgent Care visit - $20
- Emergency room co-pay $180 (in or out-of-network)
Co-Insurance
- Network - 80% / 20%
- Non-Network - 60% / 40%
Co-Insurance
- Network - 80% / 20%
- Non-Network - 60% / 40%
Co-Insurance
- Plan does not have co-insurance
Prescription Benefits
- Retail Pharmacies (30-day supply):
- Tier 1 member pays $10
- Tier 2 member pays $40
- Tier 3 member pays $60
- Mail Order (90-day supply):
- Tier 1 member pays $20
- Tier 2 member pays $80
- Tier 3 member pays $120
- Specialty Tier 4 member pays 30%:
- Eligible for Specialty Copay Assistance Program
Prescription Benefits
- Retail Pharmacies (30-day supply):
- Tiers 1-3 member pays 20% after deductible
- Mail Order (90-day supply):
- Tiers 1-3 member pays 20% after deductible
- Specialty Tier 4 member pays 30%:
- Eligible for Specialty Copay Assistance Program
- Use or to find the best prices on prescriptions
Prescription Benefits
- Retail Pharmacies (30-day supply):
- Tier 1 member pays $5
- Tier 2 member pays $20
- Tier 3 member pays $40
- Mail Order (90-day supply):
- Tier 1 member pays $15
- Tier 2 member pays $50
- Tier 3 member pays $100
- Specialty Tier 4 member pays 30%:聽
- Eligible for Specialty Copay Assistance Program
No HSA Included
University HSA Contributions
- Individual - $750 (Initial funding of $282 and a monthly contribution of $39)
- Family - $1,500 (Initial funding of $564 and a monthly contribution of $78)