Card Category: Medical
OPTION 1
Primary Only
Your Monthly Premium
$996.44
Individual Deductible
$6,000
Individual Out-of-Pocket Max
$6,000
Family Deductible
$12,000
Family Out-of-Pocket Max
$12,000
Office Visit
No charge
Specialist Visit
No charge
OPTION 1
Primary + Spouse
Your Monthly Premium
$2,092.58
Individual Deductible
$6,000
Individual Out-of-Pocket Max
$6,000
Family Deductible
$12,000
Family Out-of-Pocket Max
$12,000
Office Visit
No charge
Specialist Visit
No charge
OPTION 1
Primary + Child(ren)
Your Monthly Premium
$1,892.86
Individual Deductible
$6,000
Individual Out-of-Pocket Max
$6,000
Family Deductible
$12,000
Family Out-of-Pocket Max
$12,000
Office Visit
No charge
Specialist Visit
No charge
OPTION 1
Family
Your Monthly Premium
$2,988.65
Individual Deductible
$6,000
Individual Out-of-Pocket Max
$6,000
Family Deductible
$12,000
Family Out-of-Pocket Max
$12,000
Office Visit
No charge
Specialist Visit
No charge
OPTION 2
Primary Only
Your Monthly Premium
$960.04
Individual Deductible
$8,500
Individual Out-of-Pocket Max
$8,500
Family Deductible
$17,000
Family Out-of-Pocket Max
$17,000
Office Visit
No Charge
Specialist Visit
No Charge
OPTION 2
Primary + Spouse
Your Monthly Premium
$2,016.12
Individual Deductible
$8,500
Individual Out-of-Pocket Max
$8,500
Family Deductible
$17,000
Family Out-of-Pocket Max
$17,000
Office Visit
No Charge
Specialist Visit
No Charge
OPTION 2
Primary + Child(ren)
Your Monthly Premium
$1,823.73
Individual Deductible
$8,500
Individual Out-of-Pocket Max
$8,500
Family Deductible
$17,000
Family Out-of-Pocket Max
$17,000
Office Visit
No Charge
Specialist Visit
No Charge
OPTION 2
Family
Your Monthly Premium
$2,879.47
Individual Deductible
$8,500
Individual Out-of-Pocket Max
$8,500
Family Deductible
$17,000
Family Out-of-Pocket Max
$17,000
Office Visit
No Charge
Specialist Visit
No Charge
HSA Eligible
OPTION 3
Primary Only
Your Monthly Premium
$804.36
Individual Deductible
$5,000
Individual Out-of-Pocket Max
$6,500
Family Deductible
$10,000
Family Out-of-Pocket Max
$13,000
Office Visit
20% after deductible
Specialist Visit
20% after deductible
HSA Eligible
OPTION 3
Primary + Spouse
Your Monthly Premium
$1,689.20
Individual Deductible
$5,000
Individual Out-of-Pocket Max
$6,500
Family Deductible
$10,000
Family Out-of-Pocket Max
$13,000
Office Visit
20% after deductible
Specialist Visit
20% after deductible