Plan Benefits
2023-2024 Highlights of Coverage
| In-Network | Out-of-Network | |
| Annual Deductible | $250 | $600 |
| Coinsurance | ||
| Preventive Care | Plan pays 100% | Maximum Non-Network Reimbursement Program (MNRP) after the Deductible |
| Other Care | Plan pays 90% after the Deductible |
Plan pays 70% of the MNRP after the Deductible |
| Copays | ||
| Physician Visit | $25 | |
| Urgent Care | $50 | |
| Emergency Care | $150 | |
| Out-of-Pocket Maximum | $6,350 individual $12,700 family |
None |
Prescription Drugs
- $10 Co-pay per prescription Tier 1
- $20 Co-pay per prescription Tier 2
- $40 Co-pay per prescription Tier 3
Medical Care
- Preventive care, including immunizations, physicals, and routine screenings
- Specialist care
- Hospitalization
- Surgery
- Telehealth Medical
Mental Health Care
- Individual and group counseling
- Inpatient and outpatient mental health treatment
- Substance use disorders
- Telehealth Behavioral