Card Category: Medical

OPTION 1

Primary Only

Your Monthly Premium

$1,047.33

Individual Deductible
N/A for no cost services
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

$2,199.46

Individual Deductible
N/A for no cost services
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

$1,989.54

Individual Deductible
N/A for no cost services
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

$3,141.30

Individual Deductible
N/A for no cost services
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

$991.94

Individual Deductible
N/A for no cost services
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

$2,083.11

Individual Deductible
N/A for no cost services
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

$1,884.33

Individual Deductible
N/A for no cost services
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

$2,975.15

Individual Deductible
N/A for no cost services
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

$890.19

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

$1,869.45

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