Quick facts
Overall Deductible (Individual)
$500
Overall Deductible (Family)
$1,000
Out-of-Pocket Limit (Individual)
$2,500
Out-of-network: $4,000
Out-of-Pocket Limit (Family)
$5,000
Out-of-network: $8,000
Primary Care Visit Copay
$35 copay/office visit and 20% coinsurance for other outpatient services; deductible does not apply
Out-of-network: 40% coinsurance
Specialist Visit Copay
$50 copay/visit
Out-of-network: 40% coinsurance
Emergency Room Care
20% coinsurance
Urgent Care Copay
$30 copay/visit
Out-of-network: 40% coinsurance
More details (27)
Coinsurance
20% coinsurance
Out-of-network: 40% coinsurance
Rx Tier 1 - Generic
$10 copay/prescription (retail & mail order)
Preventive Care / Screening / Immunization
No charge
Children's Eye Exam
$35 copay/visit
Rx Tier 2 - Preferred Brand
$30 copay/prescription (retail & mail order)
Rx Tier 3 - Non-Preferred Brand
40% coinsurance
Rx Tier 4 - Specialty
50% coinsurance
Prescription Drug Deductible
$300
Occupational Therapy Deductible
$300
Diagnostic Test (x-ray, blood work) Copay
$10 copay/test
Imaging (CT/PET/MRI) Copay
$50 copay/test
Outpatient Surgery Facility Fee
$100/day copay
Outpatient Surgery Physician/Surgeon Fees
20% coinsurance
Mental/Behavioral Health Outpatient Services
$35 copay/office visit and 20% coinsurance for other outpatient services
Mental/Behavioral Health Inpatient Services
20% coinsurance
Pregnancy Office Visits
20% coinsurance
Childbirth/Delivery Professional Services
20% coinsurance
Childbirth/Delivery Facility Services
20% coinsurance
Home Health Care
20% coinsurance
Rehabilitation Services
20% coinsurance
Habilitation Services
20% coinsurance
Skilled Nursing Care
20% coinsurance
Durable Medical Equipment
20% coinsurance
Hospice Services
20% coinsurance
Children's Glasses
20% coinsurance
Children's Dental Check-up
No charge
Emergency Medical Transportation
20% coinsurance after deductible
Amounts are in-network unless noted.
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.