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| Your Benefits | Your Cost |
| Hospital (inpatient and outpatient) | No cost1 |
| Office visits (primary care physicians and specialist) | $15 per visit |
| Diagnostic x-ray and laboratory services | No cost |
| Ambulance | No cost |
| Urgent Care Virtual Visit/Urgent Care Center | $15/$15 per visit |
| Emergency room | $50 per visit2 |
| Chiropractic | $15 per visit3 |
| Acupuncture | $15 per visit3 |
|
1Except for $15/visit for physical, occupational, and speech therapy performed on an outpatient basis. 2Waived if hospitalized as an inpatient or for observation as an outpatient. 3Up to 20 combined visits in a calendar year. |
| Annual Out of Pocket Maximum | |
| Individual $1,500 | Family $3,000 |
Posted rates do not reflect employer contribution amounts.
| Single | 2-Party | Family |
| $914.27 | $1,828.54 | $2377.10 |
| Single | 2-Party | Family |
| $914.27 | $1,828.54 | $2377.10 |
