Card Category: Medical
HSA Eligible
OPTION 3
Primary + Child(ren)
Your Monthly Premium
$1,691.05
Individual Deductible
$5,000
Individual Out-of-Pocket Max
$6,500
Family Deductible
$10,000
Family Out-of-Pocket Max
$13,000
Office Visit
$0 After Deductible
Specialist Visit
$0 After Deductible
HSA Eligible
OPTION 3
Family
Your Monthly Premium
$2,669.99
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 4
Primary Only
Your Monthly Premium
$817.83
Individual Deductible
$7,500
Individual Out-of-Pocket Max
$7,500
Family Deductible
$15,000
Family Out-of-Pocket Max
$15,000
Office Visit
$0 after deductible
Specialist Visit
$0 after deductible
HSA Eligible
OPTION 4
Primary + Spouse
Your Monthly Premium
$1,717.47
Individual Deductible
$7,500
Individual Out-of-Pocket Max
$7,500
Family Deductible
$15,000
Family Out-of-Pocket Max
$15,000
Office Visit
$0 after deductible
Specialist Visit
$0 after deductible
HSA Eligible
OPTION 4
Primary + Child(ren)
Your Monthly Premium
$1,553.57
Individual Deductible
$7,500
Individual Out-of-Pocket Max
$7,500
Family Deductible
$15,000
Family Out-of-Pocket Max
$15,000
Office Visit
$0 after deductible
Specialist Visit
$0 after deductible
HSA Eligible
OPTION 4
Family
Your Monthly Premium
$2,452.93
Individual Deductible
$7,500
Individual Out-of-Pocket Max
$7,500
Family Deductible
$15,000
Family Out-of-Pocket Max
$15,000
Office Visit
$0 after deductible
Specialist Visit
$0 after deductible