Plan Benefits

2022-2023 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
  • COVID-19

 

Mental Health Care

  • Individual and group counseling
  • Inpatient and outpatient mental health treatment
  • Substance use disorders
  • Telehealth Behavioral

 

Click here to access the 2022-23 Coverage Certificate, which lists all policy benefits, conditions, and exclusions.