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 Access to Blue Cross Blue Shield 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 family
Health Savings Account (HSA) No
Coinsurance (You Pay) After Meeting Deductible In-network Only: 20%
Calendar Year Out-of-Pocket Maximum
$2,000 per individual/$4,000 per family
Preventive Care
In-network Only: Covered in full (calendar year deductible waived)
Office Visit (You Pay) PCP: $30 copay. Specialist: $50 copay
In-network Only: $500 copay1, then you pay 20%
Pharmacy Retail
(30-day supply)4
Network pharmacy: specified preventive drugs—100% covered2; generic—$10 copay2; brand formulary—$25 copay2; brand non-formulary—$40 copay2; specialty drugs-20%2,3 up to $125
Pharmacy Mail Services
(up to 90-day supply)
Network pharmacy: specified preventive drugs—100% covered2; generic—$20 copay2; brand formulary—$50 copay2; brand non-formulary—$80 copay2
  1. After calendar year deductible.
  2. Calendar year deductible waived.
  3. May be available at Cerpass 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.
  4. A $10 copay will be added to the cost for any prescriptions filled at Walgreens.