Plan Benefits

2026-2027 Highlights of Coverage

The table below outlines highlights from the plan. Please see the 2026-27 Coverage Certificate, which lists all policy benefits, conditions, and exclusions.

	In-Network	Out-of-Network
Annual Deductible	$250	$600
Coinsurance
Preventive Care	Plan pays 100% of the Allowed Amount	Plan pays the Allowed Amount after the Deductible
Other Care	Plan pays 90% of the Allowed Amount for Covered Medical Expenses after the Deductible	Plan pays 70% of the Allowed Amount for Covered Medical Expenses after the Deductible
Copays
Physician Visit	$25
Urgent Care	$50
Emergency Care	$150
Prescription Drugs
Tier 1	$10 copay	$20 copay for generic drugs
Tier 2	$20 copay	$40 copay for brand name drugs
Tier 3	$40 copay
Out-of-Pocket Maximum	$6,350 individual $12,700 family	None