| Plan Specifics | You Pay (In-Network Costs) |
|---|---|
| Calendar-year deductible | Nothing |
| Benefit | You Pay |
| Preventive care, routine physicals, GYN, well child, routine hearing and vision exams, family planning | Nothing |
| Office visits (sick care and non-preventive) | $20 per visit |
| Office visits (specialists) | $20 per visit |
| Emergency room | $75 per visit (waived if admitted or for observation stay) |
| Inpatient hospital care | Nothing |
This plan covers dependents up to age 26, regardless of the dependent's financial dependency, student status, or employment status.
Your plan includes prescription drug coverage.
| Prescription Drug Benefit | You Pay (In-Network Costs) |
|---|---|
| Retail pharmacies | $10 for generic1 $20 for brand-name |
| Mail service pharmacy (up to a 90-day supply) | $20 for generic1 $40 for brand-name |
Active Employees
