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 CARE+ COPAY IN-NETWORK ONLY DEDUCTIBLE Individual : $3,500 Family : $7,000 RX DEDUCTIBLE Individual : $1,000 Family : $2,000 COINSURANCE 30% OFFICE VISITS Primary Care : $50 copay Specialist : $100 copay Urgent Care : $100 copay PROCEDURES Inpatient : 20% coinsurance Outpatient : 20% coinsurance Emergency Room : $500 copay OP Lab & X-ray : Tier 1: $50 copay x-ray, $20 lab copay | Tier 2: $200 copay x-ray, $50 lab copay (Deductible does not apply) Radiology : Tier 1: $350 copay/test | Tier 2: $500 copay/test (Deductible does not apply) PRESCRIPTIONS Retail: $10 / $50 / $75 / 50% coinsurance Mail Order: $20 / $100 / $150 / 50% coinsurance RX OUT-OF-POCKET MAXIMUM Individual : $1,200 Family : $2,000 OUT-OF-POCKET MAXIMUM Individual : $7,100 Family : $2,100 EMPLOYEE MONTHLY CONTRIBUTIONS Employee : $511.30 Employee + Spouse : $954.17 Employee + Child(ren) : $954.17 Family : $1,485.62 *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. Review Plan Summary Care + Copay