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Sample Plans
Bronze
Individual Deductible $5,000 deductible for medical & drugs
Family Deductible $10,000 deductible
Primary Care Visit Copay $60
Specialty Care Visit Copay $70
Urgent Care Visit Copay $120
Generic Medication Copay $15
Lab Testing Copay 30%
X-Ray Copay 30%
Emergency Room Copay $300
High cost and infrequent services (e.g. Hospital Stay) 30% of your plan’s negotiated rate
Preferred brand copay after Drug Deductible (if any) $50
Maximum Out-of-Pocket For One $6,250
Maximum Out-of-Pocket For Family $12,500
Silver
Individual Deductible $2,000 medical deductible
$250 brand drug deductible
Family Deductible $4,000 medical deductible
$500 brand drug deductible
Primary Care Visit Copay $45
Specialty Care Visit Copay $65
Urgent Care Visit Copay $90
Generic Medication Copay $15
Lab Testing Copay $45
X-Ray Copay $65
Emergency Room Copay $250
High cost and infrequent services (e.g. Hospital Stay) 20% of your plan’s
negotiated rate
Preferred brand copay after Drug Deductible (if any) $50
Maximum Out-of-Pocket For One $6,250
Maximum Out-of-Pocket For Family $12,500
Gold
Individual Deductible no deductible
Family Deductible no deductible
Primary Care Visit Copay $30
Specialty Care Visit Copay $50
Urgent Care Visit Copay $60
Generic Medication Copay $15
Lab Testing Copay $30
X-Ray Copay $50
Emergency Room Copay $250
High cost and infrequent services (e.g. Hospital Stay) HMO
Outpatient Surgery - $600
Hospital - $600/day up to 5 days
PPO - 20%
Preferred brand copay after Drug Deductible (if any) $50
Maximum Out-of-Pocket For One $6,250
Maximum Out-of-Pocket For Family $12,500
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