Quick facts
Overall Deductible
$0
Overall Deductible (Family)
$0
Out-of-Pocket Limit (Individual)
$6,350
Out-of-Pocket Limit (Family)
$12,700
Primary Care Visit
No charge
Specialist Visit
No charge
Emergency Room Care
$25 copay/visit
Urgent Care
No charge
More details (17)
Generic Drugs
Copay/prescription: $5 (retail & mail order)
Preventive Care/Screening/Immunization
No charge
Children's Eye Exam
$15 copay/visit
Preferred Brand Drugs
Copay/prescription: $5 (retail & mail order)
Non-preferred Brand Drugs
100% coinsurance
Specialty Drugs
Copay/prescription: $5 (preferred), 100% coinsurance (non-preferred)
Diagnostic Test (x-ray, blood work)
No charge
Imaging (CT/PET scans, MRIs)
No charge
Outpatient Surgery Facility Fee
No charge
Hospital Stay Facility Fee
No charge
Mental/Behavioral Health Outpatient
Office & other outpatient services: no charge
Mental/Behavioral Health Inpatient
No charge
Rehabilitation Services
No charge (45 visits/plan year for PT, OT & Speech Therapy combined)
Skilled Nursing Care
No charge (100 days/plan year)
Chiropractic Care
20 visits/plan year
Children's Glasses
Not covered
Children's Dental Check-up
Not covered
Carrier contact
1-800-835-8742 — member services
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.