In-Network Deductible (Individual/Family)
$250/$750
In-Network Out-of-Pocket Maximum (Individual/Family)
$3,700/$7,400
Office Visits (PCP/Specialist)
$15 copay/$30 copay
Prescription Drugs
| Tier 1 | $5-15 copay |
| Tier 2 | $30 copay |
| Tier 3 | $50 copay |
| Tier 4 | 30% coinsurance up to $250 |
