What your HMO plan covers

Compare the standard vs. the high option cost-sharing using the at-a-glance chart below. Both plans cover the same medical care.

2018 plan benefits

Deductible

$350 single/$700 family
Standard plan
$0 single/$0 family
High plan

Medical-only deductible

Primary care visits

$25 copayment
Standard plan
$20 copayment
High plan

Specialist visits

$45 copayment
Standard plan
$35 copayment
High plan

Urgent care facility

$75 copayment
Standard plan
$75 copayment
High plan

Allergy testing, serum & injections

Covered in full
Standard plan
Covered in full
High plan

Outpatient surgery professional services

20% coinsurance
Standard plan
0% coinsurance
High plan

Standard plan coinsurance applies after you meet your deductible.

Inpatient and outpatient labs & X-ray services

20% coinsurance
Standard plan
10% coinsurance
High plan

Standard plan coinsurance applies after you meet your deductible.

Emergency room

$150 copayment
Standard plan
$150 copayment
High plan

Copayment waived if admitted.
Standard plan copayment applies after you meet your deductible.

Ambulance services

$150 copayment
Standard plan
$150 copayment
High plan

Standard plan copayment applies after you meet your deductible.

Prescription drugs - Standard plan


Generic: $20 copayment
Preferred brand: $60 copayment
Non-preferred brand: $90 copayment
Preferred specialty: 20% coinsurance ($200 limit for 31-day supply)
Non-preferred specialty: 20% coinsurance ($400 limit for 31-day supply)

Use our online Approved Drug List to search by drug name, see what drugs your plan covers and check what your copayment will be.

Prescription drugs - High plan


Generic: $15 copayment
Preferred brand: $50 copayment
Non-preferred brand: $80 copayment
Preferred specialty: 20% coinsurance ($150 limit for 31-day supply)
Non-preferred specialty: 20% coinsurance ($300 limit for 31-day supply)

Use our online Approved Drug List to search by drug name, see what drugs your plan covers and check what your copayment will be.

Prior deductible carryover

Yes
Standard plan
N/A
High plan