In-Network Deductible
(Individual/Family)
$1,000/$2,000
In-Network Out-of-Pocket Maximum
(Individual/Family)
$5,000/$10,000
Office Visits (PCP/Specialist)
$20/$40
Diagnostic Testing
Lab: 10% X-ray: 10%
Urgent Care:
$20
Prescription Drugs
Copays for 30 day supply (retail)
Generic: $10
Brand-Name: $30
Non- preferred brand: $60