Silver Plans

In-Network Deductible

Individual: $3,500

Family: $7,000

Preventive Care²

$0

Office Visit

15%*

Doctor on Demand Visits

0%*

Specialist Visit

15%*

Prescriptions Filled at Preferred Pharmacies¹

Tier 1: $4*

Tier 2: 50%*

Tier 3: 50%*

Prescription Filled at Non-Preferred Pharmacies²

Tier 1: 50%*

Tier 2: 50%*

Tier 3: 50%*

Urgent Care

15%*

Emergency Room

15%*

Inpatient Hospital

15%*

Outpatient Surgery

15%*

Plan Documents

Summary of Benefits & Coverage

Health Plan Contract

In-Network Deductible

Individual: $2,500

Family: $5,000

Preventive Care²

$0

Office Visit

$25*

Doctor on Demand Visits

$0*

Specialist Visit

$50*

Prescriptions Filled at Preferred Pharmacies¹

Tier 1: $10*

Tier 2: $50*

Tier 3: $80*

Prescription Filled at Non-Preferred Pharmacies²

Tier 1: 50%*

Tier 2: 50%*

Tier 3: 50%*

Urgent Care

$75*

Emergency Room

$500*

Inpatient Hospital

$1,500*

Outpatient Surgery

$200*

Plan Documents

Summary of Benefits & Coverage

Health Plan Contract

In-Network Deductible

Individual: $2,100

Family: $4,200

Preventive Care²

$0

Office Visit

$30*

First visit to a PCP or Specialist is not subject to the deductible.

Doctor on Demand Visits

$30*

Specialist Visit

$65*

First visit to a PCP or Specialist is not subject to the deductible.

Prescriptions Filled at Preferred Pharmacies¹

Tier 1: $15

Tier 2: $40

Tier 3: $75

Prescription Filled at Non-Preferred Pharmacies²

Tier 1: $15

Tier 2: $40

Tier 3: $75

Urgent Care

$70*

Emergency Room

$500*

Inpatient Hospital

$1,500*

Outpatient Surgery

$150*

Plan Documents

Summary of Benefits & Coverage

Health Plan Contract