Consumer Driven

 

Consumer Driven Plan

Open Access+ Network

Out-of-Network

Office Visit

 

 

Primary Care Physician

Deductible + 0%

Deductible + 20%

Specialist

Deductible + 0%

Deductible + 20%

Consigilio Wellness Center

$10

 

Deductible

 

 

Individual

$2,700

$3,000

Individual + More

$5,400

$2,700/person

$6,000

Coinsurance

0%

20%

Out-of-Pocket Maximum

 

 

Individual

(includes deductible)

$2,700

$4,000

Individual + More

(includes deductible)

$5,400

$2,700/person

$8,000

$4,000/person

 

 

 

 

Consumer Driven Plan-Your Responsibility1

Prescription Drug

Preventive

Non-Preventive

Retail In-Network2

(34 day supply)

 

 

Generic

$0

Deductible + 0%

Preferred Brand

$0

Deductible + 0%

Non-Preferred Brand

$0

Deductible + 0%

Mail Order In-Network

(90 day supply)

 

 

Generic

$0

Deductible + 0%

Preferred Brand

$0

Deductible + 0%

Non-Preferred Brand

$0

Deductible + 0%

1There is no coverage for prescriptions obtained from an out-of-network mail order pharmacy for the SureFit and Consumer Driven plans.

2Prescriptions obtained at a non-network retail pharmacy are subject to the deductible + 50% coinsurance for all plans.