Quick facts
Overall Deductible (Individual)
$2,000
Overall Deductible (Family)
$4,000
Out-of-Pocket Limit (Individual)
$3,500
Out-of-Pocket Limit (Family)
$7,000
Primary Care Visit
20% coinsurance after deductible
Specialist Visit
20% coinsurance after deductible
Emergency Room Care
20% coinsurance after deductible
Urgent Care
20% coinsurance after deductible
More details (7)
Facility Fee (Hospital Stay)
20% coinsurance after deductible
Formulary drugs
20% coinsurance after deductible
Preventive Care/Screening/Immunization
No charge
Children's Eye Exam
Not covered
Non-formulary drugs
50% coinsurance after deductible
Children's Glasses
Not covered
Children's Dental Check-up
Not covered
Carrier contact
1-800-555-0142 — member services
Group number: BSA-73212
Your member ID card: check the carrier website or app, or ask HR for a copy.