4 MEDICAL Medical insurance helps you pay for preventive care, routine health needs, prescriptions, and advanced procedures by cost-sharing with your insurance provider. Hover over the insurance terms below to learn what they mean. Y O U R J O U R N E Y T O HEALTH HSA CO-PAY In Network In Network OFFICE VISITS Primary Care: Ded then 20% Specialist: Ded then 20% Urgent Care: Ded then 20% Primary Care: $30 Specialist: $75 Urgent Care: $75 PROCEDURES Inpatient: Ded then 20% Outpatient: Ded then 20% Emergency Room: Ded then 20% OP Lab & X-ray: Ded then $200 Radiology: Ded then 20% Inpatient: $1000 copay Outpatient: $1000 copay Emergency Room: $250 copay OP Lab & X-ray: $100 Copay Radiology: $1000 Copay COINSURANCE 20% N/A PRESCRIPTIONS Retail: Ded then 100% Mail Order: N/A Retail: $5/$40/$80/Rescrybe Mail Order: N/A ANNUAL DEDUCTIBLE Individual: $3,000 Family: $6,000 Individual: $0 Family: $0 OUT-OF-POCKET MAXIMUM Individual: $7,500 Family: $15,000 Individual: $5,000 Family: $10,000 RATES PER BI-WEEKLY PAY PERIOD Employee: $31.62 Employee + Spouse: $163.93 Employee + Children: $145.84 Family: $275.35 Employee: $28.22 Employee + Spouse: $155.24 Employee + Children: $134.07 Family: $262.49 *Deductible applies first. The benefits and rates in this guide are for illustrative purposes only. Please refer to the Summary of Benefits for specific benefits. To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlying insurance documents will govern in all cases. Out of Network Benefits Search