Quick facts
Deductible (Individual)
$3,000
Deductible (Family)
$6,000
Out-of-Pocket Max (Individual)
$6,000
Out-of-Pocket Max (Family)
$12,000
Primary Care Visit
10% coinsurance after deductible
Specialist Visit
10% coinsurance after deductible
Emergency Room Care
10% coinsurance after deductible
Urgent Care
10% coinsurance after deductible
More details (6)
Coinsurance
10% after deductible
Drugs - All Tiers
10% coinsurance after deductible
Preventive Care
No charge
HSA Employer Contribution
$750/year
Hospital Facility Fee
10% coinsurance after deductible
Telehealth Services
$49 per visit until deductible is met, then 10%
Carrier contact
1-800-555-0142 — member services
Group number: BSA-73212
Your member ID card: check the carrier website or app, or ask HR for a copy.
Confirm details with your carrier for current plan information.