Group Medical Insurance

BLUE PLAN
Lifetime Maximum No Maximum
   
Calendar Year Deductible  
In-Network $500 (Individual) / $1,500 (Family)
Out-of-Network $750 (Individual) / $2,250 (Family)
   
Physician Office Visit Copay
$30
   
In-Network Specialist Copay $50
   
Coinsurance (Member Responsibility)
In-Network 20%
Out-of-Network 40%
   
Calendar Year Maximum Out of Pocket (Deductible & Your Share of Coinsurance) 
In-Network $5,000 (Individual) / $10,000 (Family)
Out-of-Network $10,000 (Individual) / $20,000 (Family)


Well Care Benefit
(PPO Network Only)

Adult annual preventive exam paid at 100%.

Prescription Drug Benefits
  • Deductible - $0
  • Preferred Generic Presciption Drugs - $15 Copayment ($30 Mail Order Copayment)
  • Preferred Brand Prescription Drugs - $30 Copayment ($60 Mail Order Copayment)
  • Non-Preferred Prescription Drugs - $50 Copayment ($100 Mail Order Copayment)
  • Specialty Drugs - Subject to cost share based on applicable drug tier

GREEN PLAN
Lifetime Maximum No Maximum
   
Calendar Year Deductible  
Per Person In-Network $1,500
Per Person Out-of Network $4,500
   
Family Physician Office Visit Copay
(PPO Network Only)
$35
   
In-Network Specialist Copay Deductible + 50% Coinsurance
   
Coinsurance (Member Responsibility)
In-Network 50%
Out-of-Network 50%
   
Calendar Year Maximum Out of Pocket (Deductible & Your Share of Coinsurance) 
In-Network $6,350 (Individual) / $10,000 (Family)
Out-of-Network $20,000 (Individual) / $20,000 (Family)


Well Care Benefit
(PPO Network Only)

Adult annual preventive exam paid at 100%.

   
Prescription Drug Benefits
(Mail Order Not Covered) 
  • Deductible - $500
  • Preferred Generic Prescription Drugs - $500 Pharmacy Deductible + $15 Copayment
  • Preferred Brand Prescription Drugs - $500 Pharmacy Deductible + 50% Coinsurance
  • Non-Preferred Prescription Drugs - $500 Pharmacy Deductible + 50% Coinsurance
  • Specialty Drugs - Subject to cost share based on applicable drug tier


YELLOW PLAN
Lifetime Maximum No Maximum
   
Calendar Year Deductible  
Per Person In-Network $1,500 (Individual Coverage) / $3,000 (Family Coverage)
Per Person Out-of Network $3,000 (Individual Coverage) / $6,000 (Family Coverage)
   
Physician Office Visit Copay
(PPO Network Only)
Deductible + 10% Coinsurance
   
In-Network Specialist CopayDeductible + 10% Coinsurance 
  
Coinsurance (Member Responsibility)
In-Network 10%
Out-of-Network 40%
   
Calendar Year Maximum Out of Pocket (Deductible & Your Share of Coinsurance) 
Individual: Utilizing the PPO Network $5,000
Individual: Non-PPO $10,000
Family: Utilizing the PPO Network $5,000
Family: Non-PPO $10,000
   
Well Care Benefit
(PPO Network Only)

Adult annual preventive exam paid at 100%.

   
Prescription Drug Benefits
  • Apply to deductible, then copays of:
  • Preferred Generic Presciption Drugs - $15 Copayment ($40 Mail Order Copayment)
  • Preferred Brand Prescription Drugs - $30 Copayment ($75 Mail Order Copayment)
  • Non-Preferred Prescription Drugs - $50 Copayment ($125 Mail Order Copayment)
  • Specialty Drugs - Subject to cost share based on applicable drug tier
  • Until out of pocket maximum is reached.