Deductible
Out of pocket
In
$6,350
Out
$12,700
In
$12,700
Out
$25,400
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Coinsurance
In
80% Coinsurance
Out
60% Coinsurance
In
20% Coinsurance
Out
40% Coinsurance
Office visits
In
$40 Copay
Out
40% Coinsurance
In
Not Applicable
Out
Not Applicable
In
$55 Copay
Out
40% Coinsurance
In
$55 Copay
Out
40% Coinsurance
In
No Charge
Out
40% Coinsurance
In
20% Coinsurance
Out
40% Coinsurance
In
$40 Copay / office visit and 20% Coinsurance other outpatient services
Out
40% Coinsurance
If you have a test
In
20% Coinsurance
Out
40% Coinsurance
In
20% Coinsurance
Out
40% Coinsurance
Hospitalizations
In
20% Coinsurance
Out
40% Coinsurance
In
20% Coinsurance
Out
40% Coinsurance
In
20% Coinsurance
Out
20% Coinsurance
Prescription coverage
In
$250
Out
$250
In
$15 Copayment
Out
$15 Copayment
In
$40 Copayment
Out
$40 Copayment
In
$70 Copayment
Out
$70 Copayment
In
10% Coinsurance up to $150 per prescription
Out
10% Coinsurance up to $150 per prescription
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