• 

  $497/mo	(member)
  $894/mo	(plus child(ren))
  $1,043/mo	(plus spouse)
  $1,391/mo	(plus family)

  ---

  Dr. office visits
  Primary care	$25 copay
  Specialist	$50 copay
  Deductible / co-ins	$1,500 indiv ded, then 20%
  Out-of-pocket max	$6,000 indiv / $12,000 family
  Prescriptions
  Deductible	$200
  Generics	$15 copay
  Formulary	$50 copay
  Non-formulary	$100 copay
  Brand specialty	$100 copay
  Out-of-network services	$3,000 indiv ded, then 50%
  Out-of-pocket max	$15,000 indiv / $30,000 family
  Lab tests
  Office	$10 copay
  Freestanding lab	$10 copay
  Imaging tests	20% co-ins
  Mental health	$50 copay (30 visits / year)
  Surgery
  Office	Incl. in copay
  Facility	Ded applies, then 20%
  ER	$250 copay

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• 

  $381/mo	(member)
  $685/mo	(plus child(ren))
  $800/mo	(plus spouse)
  $1,066/mo	(plus family)

  ---

  Dr. office visits
  Primary care	$30 copay
  Specialist	$50 copay
  Deductible / co-ins	$2,500 indiv ded, then 25%
  Out-of-pocket max	$14,000 indiv / $28,000 family
  Prescriptions
  Deductible	$300
  Generics	$15 copay
  Formulary	$60 copay
  Non-formulary	Not covered
  Brand specialty	$150 copay
  Out-of-network services	$5,000 indiv ded, then 50%
  Out-of-pocket max	$20,000 indiv / $40,000 family
  Lab tests
  Office	$0 copay
  Freestanding lab	$0 copay
  Imaging tests	25% co-ins
  Mental health	$50 copay (20 visits / year)
  Surgery
  Office	Incl. in copay
  Facility	Ded applies, then 25%
  ER	$250 copay

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• 

  $285/mo	(member)
  $513/mo	(plus child(ren))
  $599/mo	(plus spouse)
  $798/mo	(plus family)

  ---

  Dr. office visits
  Primary care	$35 copay
  Specialist	$55 copay
  Deductible / co-ins	$3,500 indiv ded, then 30%
  Out-of-pocket max	$18,000 indiv / $36,000 family
  Prescriptions
  Deductible	$100
  Generics	$15 copay
  Formulary	Not covered
  Non-formulary	Not covered
  Brand specialty	Not covered
  Out-of-network services	$7,500 indiv ded, then 50%
  Out-of-pocket max	$30,000 indiv / $60,000 family
  Lab tests
  Office	$0 copay
  Freestanding lab	$0 copay
  Imaging tests	30% co-ins
  Mental health	$55 copay (20 visits / year)
  Surgery
  Office	Incl. in copay
  Facility	Ded applies, then 30%
  ER	$250 copay

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• 

  $324/mo	(member)
  $583/mo	(plus child(ren))
  $680/mo	(plus spouse)
  $907/mo	(plus family)

  ---

  Dr. office visits
  Primary care	ded applies
  Specialist	ded applies
  Deductible / co-ins	$5,000 indiv ded, then 0%
  Out-of-pocket max	$5,950 indiv / $11,900 family
  Prescriptions
  Deductible	$5,000
  Generics	30% co-ins
  Formulary	30% co-ins
  Non-formulary	30% co-ins
  Brand specialty	30% co-ins
  Out-of-network services	$10,000 indiv ded, then 50%
  Out-of-pocket max	Not applicable Not applicable
  Lab tests
  Office	Ded applies
  Freestanding lab	Ded applies
  Imaging tests	Ded applies
  Mental health	Ded applies
  Surgery
  Office	Ded applies
  Facility	Ded applies
  ER	Ded applies

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• 

  $196/mo	(member)
  $354/mo	(plus child(ren))
  $413/mo	(plus spouse)
  $550/mo	(plus family)

  ---

  Dr. office visits
  Primary care	ded applies
  Specialist	ded applies
  Deductible / co-ins	$10,000 indiv ded, then 0%
  Out-of-pocket max	Not applicable Not applicable
  Prescriptions
  Deductible	$10,000
  Generics	30% co-ins
  Formulary	30% co-ins
  Non-formulary	30% co-ins
  Brand specialty	30% co-ins
  Out-of-network services	$15,000 indiv ded, then 50%
  Out-of-pocket max	Not applicable Not applicable
  Lab tests
  Office	Ded applies
  Freestanding lab	Ded applies
  Imaging tests	Ded applies
  Mental health	Ded applies
  Surgery
  Office	Ded applies
  Facility	Ded applies
  ER	Ded applies

  Show Lessselect plan

* HSA Compatible