In-Network Deductible (Individual/Family)
None
In-Network Out-of-Pocket Maximum (Individual/Family)
$5,000/$10,000
Office Visits (PCP/Specialist)
$20 copay/$40 copay
Prescription Drugs
| Tier 1 | $10 copay |
| Tier 2 | $30 copay |
| Tier 3 | $50 copay |
| Tier 4 | 25% coinsurance up to $800 |