IN-NETWORK
BENEFITS |
Plan 1 - OAP5 1000/0 |
Plan 2 - OAP5 1500/20 |
Plan 3 - OAP6 6000/30 |
Deductible |
$1,000 Single$3,000 Family |
$1,500 Single$4,500 Family |
$6,000 Single$12,000 Family |
Coinsurance |
You pay 0%Plan pays 100% |
You pay 20%Plan pays 80% |
You pay 30%Plan pays 70% |
Out of Pocket Maximum |
$7,900 Single$15,800 Family |
$7,900 Single$15,800 Family |
$7,900 Single$15,800 Family |
Office Visit Copay |
$30 PCP$60 Specialist$5 Telehealth, unlimited visits per year$75 Urgent Care |
$30 PCP$60 Specialist$5 Telehealth, unlimited visits per year$75 Urgent Care |
$30 PCP$60 Specialist$5 Telehealth, unlimited visits per year$75 Urgent Care |
Preventive Office Copay |
Covered at 100% |
Covered at 100% |
Covered at 100% |
Chiro Visit |
$30 copay |
$30 copay |
$30 copay |
Emergency Room Copay |
$350 copay |
$350 copay + 20% coinsurance |
$350 copay + 30% coinsurance |
Prescription DrugDeductible |
Combined with medical |
$300 Single /$600 Family
(waived for Tier 1) |
$300 Single /$600 Family
(waived for Tier 1) |
Prescription DrugCost Per Tier |
Generic 1a: $15
Generic 1b: $15Preferred Brand: $35 Non-Preferred Brand: $60 Specialty: 25% coinsurance up to $350 copay after deductible |
Generic 1a: $5
Generic 1b: $20Preferred Brand: $45 Non-Preferred Brand: $90 Specialty: 25% coinsurance up to $450 copay after deductible |
Generic 1a: $5
Generic 1b: $20Preferred Brand: $45 Non-Preferred Brand: $90 Specialty: 25% coinsurance up to $450 copay after deductible |