HDHP

Medical In-Network Out-of-Network
Your Responsibility
Plan Year (Dec 1 – Nov 30) Deductible (Individual / Family) $5,000 / $10,000 $7,500 / $15,000
Calendar Year Out-of-Pocket Max (Individual / Family) $6,650 / $13,300 $15,000 / $30,000
Preventive Care 0% 50%
Primary Care Physician Office Visits 0% * 50% *
Specialist Physician Office Visits 0% * 50% *
Urgent Care Center 0% * 50% *
Emergency Room 0% * 50% *
Hospital – Inpatient Stay 0% * 50% *
Surgery – Outpatient 0% * 50% *
Routine Lab/ Radiology 0% * 50% *
Complex Imaging (CT/PET scans, MRIs) 0% * 50% *
     

Prescription Drugs

In-Network Out-of-Network
Retail Your Responsibility (After Medical Deductible)
Low-Cost Generic $5 copay * 50% *
Generic $20 copay * 50% *
Preferred Brand $40 copay * 50% *
Non-Preferred $70 copay * 50% *
Self-Administered Specialty Drugs 1 50% to $500 per script * 50% *
       

* After deductible

Self-administered drugs are provided through the Specialty Pharmacy program. You have the option to choose any specialty pharmacy, however you will get the lowest cost if you use BriovaRx. You can contact BriovaRx at 855-427-4682.

Costs:

The example rates shown above are for employee only single coverage. If you intend to cover your children dependents as well under this health plan, you will be responsible for an additional $4,101 annually, $341.75 Per Month, $78.87 per week.

Enrollment Form Link— 2018 -2019 ACA Benefit Enrollment Form