This plan has a lower deductible and exclusively covers you for in-network doctors and facilities. Except in the case of an emergency, you’ll pay the full price for any out-of-network care.

Provider Network Extensive national network of contracted providers.
Primary Care Physician (PCP) to manage care Not required
Referrals needed to see a specialist Not required
Calendar Year Deductible $500 per individual/$1,000 per family1
Health Savings Account (HSA) No
Coinsurance (You Pay) After Meeting Deductible 20%
Calendar Year Out-of-Pocket Maximum $2,000 per individual/$4,000 per family
Preventive Care Covered in full (calendar year deductible waived)
Office Visit (You Pay) $30 copay
Hospitalization $500 copay2, then you pay 20%
Pharmacy Retail
(30-day supply)
Network pharmacy: specified preventive drugs—100% covered3; generic—$10 copay3; brand formulary—$25 copay3; brand non-formulary—$40 copay3
Pharmacy Mail Services
(up to 90-day supply)
Network pharmacy: specified preventive drugs—100% covered3; generic—$20 copay3; brand formulary—$50 copay3; brand non-formulary—$80 copay3
  1. The family deductible must be met before any person receives benefits.
  2. After calendar year deductible.
  3. Calendar year deductible waived.
  4. As specified in drug list.