Quick facts
Overall Deductible (Individual)
$500
Overall Deductible (Family)
$1,000
Out-of-Pocket Limit (Individual)
$4,000
Out-of-Pocket Limit (Family)
$8,000
Primary Care Visit Copay
$25 copay per visit
Specialist Visit Copay
$50 copay per visit
Emergency Room Care
$250 copay per visit (waived if admitted)
Urgent Care
$75 copay per visit
More details (10)
Facility Fee / Physician-Surgeon Fees (Hospital Stay)
20% coinsurance after deductible
Tier 1 - Generic Drugs
$10 copay (retail, 30-day supply)
Preventive Care / Screening / Immunization
No charge
Diagnostic Test (x-ray, blood work)
20% coinsurance after deductible
Imaging (CT/PET scans, MRIs)
20% coinsurance after deductible
Tier 2 - Preferred Brand Drugs
$35 copay
Tier 3 - Non-preferred Brand Drugs
$60 copay
Tier 4 - Specialty Drugs
25% coinsurance up to $250 per fill
Emergency Medical Transportation
20% coinsurance after deductible
Telehealth Services
$0 copay via TeleDoc Now
Carrier contact
1-800-555-0142 — member services
Group number: BSA-73211
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.