This plan has a lower deductible and exclusively covers you for in-network doctors and facilities. Except in the case of an emergency, you’ll pay the full price for any out-of-network care.

Provider Network Extensive national network of contracted providers.
Primary Care Physician (PCP) to manage care Not required
Referrals needed to see a specialist Not required
Calendar Year Deductible $500 per individual/$1,000 per family1
Health Savings Account (HSA) No
Coinsurance (You Pay) After Meeting Deductible 20%
Calendar Year Out-of-Pocket Maximum $2,000 per individual/$4,000 per family
Preventive Care Covered in full (calendar year deductible waived)
Office Visit (You Pay) $30 copay
Hospitalization $500 copay2, then you pay 20%
Pharmacy Retail
(30-day supply)
Network pharmacy: specified preventive drugs—100% covered3; generic—$10 copay3; brand formulary—$25 copay3; brand non-formulary—$40 copay3; specialty drugs-20%3,5 up to $125
Pharmacy Mail Services
(up to 90-day supply)
Network pharmacy: specified preventive drugs—100% covered3; generic—$20 copay3; brand formulary—$50 copay3; brand non-formulary—$80 copay3
  1. The family deductible must be met before any person receives benefits.
  2. After calendar year deductible.
  3. Calendar year deductible waived.
  4. As specified in drug list.
  5. May be available at CVS retail pharmacy or Pharmacy Mail Service if authorized. Note that any specialty drug discounts through copay cards or coupons will not apply towards the calendar year deductible our out-of-pocket maximum.