|
|
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
|
$2,800
|
$3,300
|
|
Individual + More
|
$5,600
$2,800/person
|
$6,600
|
|
Coinsurance
|
0%
|
20%
|
|
Out-of-Pocket Maximum
|
|
|
|
Individual
(includes deductible)
|
$3,000
|
$4,300
|
|
Individual + More
(includes deductible)
|
$6,000
$3,000/person
|
$8,600
$4,300/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.