Quick facts
Overall Deductible (Individual)
$500
Overall Deductible (Family)
$1,000
Out-of-Pocket Limit (Individual)
$2,500
Out-of-Pocket Limit (Family)
$5,000
Primary Care Visit Copay
$35 copay per visit
Specialist Visit Copay
$50 copay per visit
Emergency Room Care
20% coinsurance
Urgent Care Copay
$30 copay per visit
More details (10)
Diagnostic Test / Imaging Coinsurance
20% coinsurance after deductible
Rx Tier 1 - Generic
$10 copay (retail, 30-day supply)
Preventive Care / Screening / Immunization
No charge
Telehealth Services
$0 copay via Teladoc Health
Physician/Surgeon Fees (Hospital Stay)
20% coinsurance after deductible
Hospital Facility Fee
20% coinsurance after deductible
Emergency Medical Transportation
20% coinsurance after deductible
Rx Tier 4 - Specialty
25% coinsurance up to $250 per fill
Rx Tier 3 - Non-Preferred Brand
40% coinsurance
Rx Tier 2 - Preferred Brand
$30 copay (retail & mail order)
Carrier contact
1-800-555-0142 — member services
Group number: BSA-73211
Your member ID card: check the carrier website or app, or ask HR for a copy.
Plan documents
Confirm details with your carrier for current plan information.