Medical Plans HDHP*
Value Gold
Classic Silver
In Network
In Network
In Network
Lifetime Maximum
Unlimited
Unlimited
Unlimited
Calendar Year
Unlimited
Unlimited
Unlimited
Individual
$1,500
$750
$500
Family
$3,000**
$1,500
$1,000
Coinsurance
20%
25%
20%
Individual
$5,500
$5,000
$4,500
Family
$11,000
$10,000
$9,000
with Health Savings Account
Deductibles
Out-of-Pocket Maximum
Hospital Services Inpatient Hospital
$250 Copay, Deductible, then 20% $250 Copay, then 25%
$250 copay, then 20%
Outpatient Hospital
Deductible, then 20%
Deductible, then 25%
Deductible, then 20%
Emergency Room
Deductible, then 20%
Deductible, then 25%
Deductible, then 20%
Urgent Care
Deductible, then $45 Copay
$55 Copay
$50 copay
Office Visit
Deductible, then $25 Copay
$35 Copay
$30 copay
Specialist Visit
Deductible, then $35 Copay
$45 Copay
$40 copay
Preventive Care
Covered in Full
Covered in Full
Covered in Full
Lab & X-Ray
Deductible, then 20%
25% (deductible waived at a freestanding laboratory)
20% (deductible waived at a freestanding aboratory)
Chiropractic
Deductible, then $35 Copay
$45 Copay
$30 copay
Rehabilitation
Deductible, then $35 Copay
Deductible, then 25%
Deductible, then 20%
Tier 1
Deductible, then $15 Copay
$15 Copay
$15 Copay
Tier 2
Deductible, then 30% Copay ($25 min/$80 max)
30% Copay ($25 min/$80 max)
30% Copay ($25 min/$80 max)
Tier 3
Deductible, then 40% Copay ($40 min/$110 max)
40% Copay ($40 min/$110 max)
40% Copay ($40 min/$110 max)
Tier 4 Specialty
Deductible, then 20% Copay ($100 min/$150 max)
20% Copay ($100 min/$150 max)
20% Copay ($100 min/$150 max)
Mail-Order
Deductible, then $30 / 20% / 40%
$30 / 20% / 40%
$30 / 20% / 40%
Diabetic Medications
$5 Generic, $15 Brand
$5 Generic, $15 Brand
$5 Generic, $15 Brand
Routine Services
Prescription Drugs
**If you have Family coverage under the HDHP the Family Deductible must be satisfied before the Plan will pay any benefits.
6
