$173 Single
$505 Family
$164 Single
$477 Family
$156 Single
$453 Family
$148 Single
$431 Family
$139 Single
$405 Family
$131 Single
$382 Family
$126 Single
$367 Family
$121 Single
$353 Family
$103 Single
$300 Family
You want protection against hospital and doctor expenses, but don’t need coverage for certain types of medical care. Choose from single or family plans – coverage does not include pregnancy and maternity services or inpatient treatment for mental illness or substance abuse.
| In Network Single/Family* |
Out of Network Single/Family* |
|
|---|---|---|
| Deductible | $750/$1,500 | $1,500/$3,000 |
| Coinsurance Max | $1,500/$3,000 | $4,000/$8,000 |
| Total out-of-pocket (Deductible + coinsurance max; no copays) |
$2,250/$4,500 | $5,500/$11,000 |
| Coinsurance % for most covered services | 20% | 40% |
| Diagnostic office visit copay | N/A | |
| Maternity care/pregnancy service | No Coverage | |
| Inpatient Mental illness/substance abuse treatment | No Coverage | |
| Outpatient Mental illness/substance abuse treatment | 30% | 60% |
| Prescription Drug Coverage | $8 generic/ 30% ($35 minimum/$60 maximum) formulary brand name/ 50% ($60 minimum/$100 maximum) non-formulary brand name | |
| Mental illness/substance abuse treatment | $10,000 per covered person | |
| Total contract benefit maximum | $10 million per covered person | |
| In Network Single/Family* |
Out of Network Single/Family* |
|
|---|---|---|
| Deductible | $1,000/$2,000 | $2,000/$4,000 |
| Coinsurance Max | $2,000/$4,000 | $5,000/$10,000 |
| Total out-of-pocket (Deductible + coinsurance max; no copays) |
$3,000/$6,000 | $7,000/$14,000 |
| Coinsurance % for most covered services | 20% | 40% |
| Diagnostic office visit copay | $30 | N/A |
| Maternity care/pregnancy service | No Coverage | |
| Inpatient Mental illness/substance abuse treatment | No Coverage | |
| Outpatient Mental illness/substance abuse treatment | 30% | 60% |
| Prescription Drug Coverage | $8 generic/ 30% ($35 minimum/$60 maximum) formulary brand name/ 50% ($60 minimum/$100 maximum) non-formulary brand name | |
| Mental illness/substance abuse treatment | $10,000 per covered person | |
| Total contract benefit maximum | $10 million per covered person | |
| In Network Single/Family* |
Out of Network Single/Family* |
|
|---|---|---|
| Deductible | $1,250/$2,500 | $2,500/$5,000 |
| Coinsurance Max | $2,000/$4,000 | $5,000/$10,000 |
| Total out-of-pocket (Deductible + coinsurance max; no copays) |
$3,250/$6,500 | $7,500/$15,000 |
| Coinsurance % for most covered services | 20% | 40% |
| Diagnostic office visit copay | N/A | |
| Maternity care/pregnancy service | No Coverage | |
| Inpatient Mental illness/substance abuse treatment | No Coverage | |
| Outpatient Mental illness/substance abuse treatment | 30% | 60% |
| Prescription Drug Coverage | $8 generic/ 30% ($35 minimum/$60 maximum) formulary brand name/ 50% ($60 minimum/$100 maximum) non-formulary brand name | |
| Mental illness/substance abuse treatment | $10,000 per covered person | |
| Total contract benefit maximum | $10 million per covered person | |
| In Network Single/Family* |
Out of Network Single/Family* |
|
|---|---|---|
| Deductible | $1,500/$3,000 | $3,000/$6,000 |
| Coinsurance Max | $2,500/$5,000 | $6,000/$12,000 |
| Total out-of-pocket (Deductible + coinsurance max; no copays) |
$4,000/$8,000 | $9,000/$18,000 |
| Coinsurance % for most covered services | 20% | 40% |
| Diagnostic office visit copay | N/A | |
| Maternity care/pregnancy service | No Coverage | |
| Inpatient Mental illness/substance abuse treatment | No Coverage | |
| Outpatient Mental illness/substance abuse treatment | 30% | 60% |
| Prescription Drug Coverage | $8 generic/ 30% ($35 minimum/$60 maximum) formulary brand name/ 50% ($60 minimum/$100 maximum) non-formulary brand name | |
| Mental illness/substance abuse treatment | $10,000 per covered person | |
| Total contract benefit maximum | $10 million per covered person | |
| In Network Single/Family* |
Out of Network Single/Family* |
|
|---|---|---|
| Deductible | $2,000/$4,000 | $4,000/$8,000 |
| Coinsurance Max | $2,500/$5,000 | $6,000/$12,000 |
| Total out-of-pocket (Deductible + coinsurance max; no copays) |
$4,500/$9,000 | $10,000/$20,000 |
| Coinsurance % for most covered services | 20% | 40% |
| Diagnostic office visit copay | N/A | |
| Maternity care/pregnancy service | No Coverage | |
| Inpatient Mental illness/substance abuse treatment | No Coverage | |
| Outpatient Mental illness/substance abuse treatment | 30% | 60% |
| Prescription Drug Coverage | $8 generic/ 30% ($35 minimum/$60 maximum) formulary brand name/ 50% ($60 minimum/$100 maximum) non-formulary brand name | |
| Mental illness/substance abuse treatment | $10,000 per covered person | |
| Total contract benefit maximum | $10 million per covered person | |
| In Network Single/Family* |
Out of Network Single/Family* |
|
|---|---|---|
| Deductible | $2,500/$5,000 | $5,000/$10,000 |
| Coinsurance Max | $2,500/$5,000 | $6,000/$12,000 |
| Total out-of-pocket (Deductible + coinsurance max; no copays) |
$4,500/$9,000 | $10,000/$20,000 |
| Coinsurance % for most covered services | 20% | 40% |
| Diagnostic office visit copay | N/A | |
| Maternity care/pregnancy service | No Coverage | |
| Inpatient Mental illness/substance abuse treatment | No Coverage | |
| Outpatient Mental illness/substance abuse treatment | 30% | 60% |
| Prescription Drug Coverage | $8 generic/ 30% ($35 minimum/$60 maximum) formulary brand name/ 50% ($60 minimum/$100 maximum) non-formulary brand name | |
| Mental illness/substance abuse treatment | $10,000 per covered person | |
| Total contract benefit maximum | $10 million per covered person | |
| In Network Single/Family* |
Out of Network Single/Family* |
|
|---|---|---|
| Deductible | $3,000/$6,000 | $6,000/$12,000 |
| Coinsurance Max | $2,500/$5,000 | $6,000/$12,000 |
| Total out-of-pocket (Deductible + coinsurance max; no copays) |
$5,500/$11,000 | $12,000/$24,000 |
| Coinsurance % for most covered services | 20% | 40% |
| Diagnostic office visit copay | $30 | N/A |
| Maternity care/pregnancy service | No Coverage | |
| Inpatient Mental illness/substance abuse treatment | No Coverage | |
| Outpatient Mental illness/substance abuse treatment | 30% | 60% |
| Prescription Drug Coverage | $8 generic/ 30% ($35 minimum/$60 maximum) formulary brand name/ 50% ($60 minimum/$100 maximum) non-formulary brand name | |
| Mental illness/substance abuse treatment | $10,000 per covered person | |
| Total contract benefit maximum | $10 million per covered person | |
| In Network Single/Family* |
Out of Network Single/Family* |
|
|---|---|---|
| Deductible | $3,500/$7,000 | $7,000/$14,000 |
| Coinsurance Max | $2,500/$5,000 | $6,000/$12,000 |
| Total out-of-pocket (Deductible + coinsurance max; no copays) |
$6,000/$12,000 | $13,000/$26,000 |
| Coinsurance % for most covered services | 20% | 40% |
| Diagnostic office visit copay | N/A | |
| Maternity care/pregnancy service | No Coverage | |
| Inpatient Mental illness/substance abuse treatment | No Coverage | |
| Outpatient Mental illness/substance abuse treatment | 30% | 60% |
| Prescription Drug Coverage | $8 generic/ 30% ($35 minimum/$60 maximum) formulary brand name/ 50% ($60 minimum/$100 maximum) non-formulary brand name | |
| Mental illness/substance abuse treatment | $10,000 per covered person | |
| Total contract benefit maximum | $10 million per covered person | |
| In Network Single/Family* |
Out of Network Single/Family* |
|
|---|---|---|
| Deductible | $5,000/$10,000 | $10,000/$20,000 |
| Coinsurance Max | $2,500/$5,000 | $6,000/$12,000 |
| Total out-of-pocket (Deductible + coinsurance max; no copays) |
$7,500/$15,000 | $16,000/$32,000 |
| Coinsurance % for most covered services | 20% | 40% |
| Diagnostic office visit copay | N/A | |
| Maternity care/pregnancy service | No Coverage | |
| Inpatient Mental illness/substance abuse treatment | No Coverage | |
| Outpatient Mental illness/substance abuse treatment | 30% | 60% |
| Prescription Drug Coverage | Subject to deductible and coinsurance | |
| Mental illness/substance abuse treatment | $10,000 per covered person | |
| Total contract benefit maximum | $10 million per covered person | |