In-Network Deductible
(Individual/Family)
$500/$1,000
In-Network Out-of-Pocket Maximum
(Individual/Family)
$3,000/$6,000
Office Visits (PCP/Specialist)
$20/$20
Diagnostic Testing
Lab: 20% X-ray: 20%
Urgent Care:
$20
Prescription Drugs
Copays for 34 day supply (retail)
Generic: $10
Brand-Name: $30
Non- preferred brand: $50
Specialty: $10