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Creditable Pharmacy Plan Designs

All Medicare-eligible employees and retirees will be eligible for a new prescription drug program. Employers are required by the Centers for Medicare and Medicaid Services (CMS) to notify their employees and retirees by October 15th, about whether their existing prescription drug plan is at least as good as Medicare’s standard prescription drug program, also referred to as providing “creditable coverage.”

1239 Pharmacy Plan Designs
Pharmacy Plan Designs Creditable Creditable/Non-Creditable Coverage Estimate
Copay Tiers: 
Deductible:$25 IND
Out-of-Pocket Maximum:  $2,000 IND/$4,000 FAM
Annual Max:N/A
Copay Tiers: 
Deductible:$25 IND
Out-of-Pocket Maximum:  $2,500 IND/$5,000 FAM
Annual Max:N/A
Copay Tiers: 
Deductible:$25 IND
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: 
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$1,250 IND (INC OON)
Out-of-Pocket Maximum:  $2,500 IND (INC OON)
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$1,300 IND (INC OON)
Out-of-Pocket Maximum:  $2,250 IND (INC OON)
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$1,500 IND
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$1,500 IND (INC OON)
Out-of-Pocket Maximum:  $3,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$1,500 IND (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$1,600 IND (INC OON)
Out-of-Pocket Maximum:  $3,200 IND (INC OON)
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$10,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $20,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$2,000 IND
Out-of-Pocket Maximum:  $4,000 IND
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  $2,000 IND
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  $3,000 IND
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  $4,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$2,500 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $5,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$2,500 IND
Out-of-Pocket Maximum:  $2,500 IND
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$2,500 IND (INC OON)
Out-of-Pocket Maximum:  $2,500 IND
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$2,500 IND (INC OON)
Out-of-Pocket Maximum:  $3,500 IND
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$2,500 IND (INC OON)
Out-of-Pocket Maximum:  $5,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$2,600 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $5,100 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$3,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$3,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $6,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$3,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$3,000 IND (INC OON)
Out-of-Pocket Maximum:  $5,500 IND (INC OON)
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$3,200 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $6,400 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$3,500 IND/$7,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $3,500 IND/$7,000 FAM
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $8,000 FAM
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $4,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $6,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $8,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$5,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $5,000 FAM
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$5,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $10,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$5,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $5,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$5,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $6,850 IND/$7,000 FAM
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$5,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$5,000 IND (INC OON)
Out-of-Pocket Maximum:  $10,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$5,000 IND (INC OON)
Out-of-Pocket Maximum:  $5,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:$6,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $11,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $0/$0/$0
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $0/$0/$0/$0
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $0/$0/$0/$0/$0/$0
Deductible:$6,500 IND/$13,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,500 IND/$13,000 FAM
Annual Max:N/A
No
Copay Tiers: $0/$15/$30
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  $5,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $0/$15/$30
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $10,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $0/$15/$30
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $6,850 IND/$10,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $0/$25/$50/50%
Deductible:$2,500 IND
Out-of-Pocket Maximum:  $5,000 IND
Annual Max:N/A
Copay Tiers: $0/$25/$50/50%
Deductible:$3,000 IND
Out-of-Pocket Maximum:  $6,000 IND
Annual Max:N/A
Copay Tiers: $0/$25/$50/50%
Deductible:$4,000 IND/$8,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $0/$25/$50/50%
Deductible:$5,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,850 IND/$10,000 FAM
Annual Max:N/A
Copay Tiers: $0/$25/$50/50%
Deductible:$5,000 IND/$10,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $0/$25/$50/50%
Deductible:$6,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,850 IND/$12,000 FAM
Annual Max:N/A
Copay Tiers: $0/$25/$50/50%
Deductible:N/A
Out-of-Pocket Maximum:  $3,000 IND/$6,000 FAM
Annual Max:N/A
Copay Tiers: $0/$25/$50/50%
Deductible:N/A
Out-of-Pocket Maximum:  $4,000 IND/$8,000 FAM
Annual Max:N/A
Copay Tiers: $0/$25/$50/50%
Deductible:N/A
Out-of-Pocket Maximum:  $5,000 IND/$10,000 FAM
Annual Max:N/A
Copay Tiers: $0/$25/$50/50%
Deductible:N/A
Out-of-Pocket Maximum:  $6,000 IND/$12,000 FAM
Annual Max:N/A
Copay Tiers: $0/$35/$50
Deductible:$100 IND/$300 FAM (RX Only)
Out-of-Pocket Maximum:  $3,425 IND/$6,850 FAM
Annual Max:N/A
Copay Tiers: $0/$35/$50/50%
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $10/$10/$20
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $10/$10/$20
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $10/$15/$20
Deductible:N/A
Out-of-Pocket Maximum:  $600 IND/$1,500 FAM
Annual Max:N/A
Copay Tiers: $10/$15/$20
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $10/$15/$25
Deductible:N/A
Out-of-Pocket Maximum:  $600 IND/$1,500 FAM
Annual Max:N/A
Copay Tiers: $10/$15/$25
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $10/$15/$30
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,500 FAM
Annual Max:N/A
Copay Tiers: $10/$15/$30
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $10/$15/50%/50%
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $10/$20
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
No
Copay Tiers: $10/$20/$25
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,500 FAM
Annual Max:$2,000
Copay Tiers: $10/$20/$25
Deductible:N/A
Out-of-Pocket Maximum:  $2,000 IND/$6,000 FAM
Annual Max:N/A
Copay Tiers: $10/$20/$30
Deductible:$1,500 IND (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $10/$20/$30
Deductible:$2,000 IND
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $10/$20/$30
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $10/$20/$30
Deductible:$3,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $10/$20/$30
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $10/$20/$30
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $10/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,500 FAM
Annual Max:N/A
Copay Tiers: $10/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $1,200 IND/$3,000 FAM
Annual Max:N/A
Copay Tiers: $10/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $1,200 IND/$3,600 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $10/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $1,500 IND/$4,500 FAM
Annual Max:N/A
Copay Tiers: $10/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $1,750 IND/$5,250 FAM
Annual Max:N/A
Copay Tiers: $10/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $2,000 IND/$6,000 FAM
Annual Max:N/A
Copay Tiers: $10/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $2,400 IND/$7,200 FAM
Annual Max:N/A
Copay Tiers: $10/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $2,500 IND/$5,000 FAM
Annual Max:N/A
Copay Tiers: $10/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $3,000 IND/$9,000 FAM
Annual Max:N/A
Copay Tiers: $10/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $4,000 IND/$10,000 FAM
Annual Max:N/A
Copay Tiers: $10/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $10/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $600 IND/$1,500 FAM
Annual Max:N/A
Copay Tiers: $10/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $800 IND/$2,000 FAM
Annual Max:N/A
Copay Tiers: $10/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $10/$20/$35
Deductible:$1,500 IND
Out-of-Pocket Maximum:  $3,000 IND
Annual Max:N/A
Copay Tiers: $10/$20/$35
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  $4,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $10/$20/$35
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $10/$20/$35
Deductible:$3,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,000 FAM
Annual Max:N/A
Copay Tiers: $10/$20/$35
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $8,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $10/$20/$35
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $10/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $2,250 IND/$6,750 FAM
Annual Max:N/A
Copay Tiers: $10/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $2,400 IND/$7,200 FAM
Annual Max:N/A
Copay Tiers: $10/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $3,500 IND/$8,750 FAM
Annual Max:N/A
Copay Tiers: $10/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $4,000 IND/$12,000 FAM
Annual Max:N/A
Copay Tiers: $10/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $5,000 IND/$10,000 FAM
Annual Max:N/A
Copay Tiers: $10/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $10/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $10/$20/$40
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  $5,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $10/$20/$40
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $10,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $10/$20/50%
Deductible:N/A
Out-of-Pocket Maximum:  $4,000 IND/$8,000 FAM
Annual Max:N/A
Copay Tiers: $10/$20/50%/50%
Deductible:$10,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,500 FAM
Annual Max:N/A
Copay Tiers: $10/$20/50%/50%
Deductible:$12,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,500 FAM
Annual Max:N/A
Copay Tiers: $10/$20/50%/50%
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $10/$20/50%/50%
Deductible:$5,000 IND
Out-of-Pocket Maximum:  $6,250 IND
Annual Max:N/A
Copay Tiers: $10/$20/50%/50%
Deductible:$6,000 IND
Out-of-Pocket Maximum:  $6,250 IND
Annual Max:N/A
Copay Tiers: $10/$25/$35
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $10/$25/$35
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$1,500 IND (INC OON)
Out-of-Pocket Maximum:  $3,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$1,500 IND (INC OON)
Out-of-Pocket Maximum:  $4,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$2,000 IND
Out-of-Pocket Maximum:  $3,000 IND
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  $4,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  $5,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$2,500 IND (INC OON)
Out-of-Pocket Maximum:  $3,500 IND (INC OON)
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$2,500 IND (INC OON)
Out-of-Pocket Maximum:  $4,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$2,500 IND (INC OON)
Out-of-Pocket Maximum:  $5,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$3,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $6,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$3,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $8,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$3,000 IND (INC OON)
Out-of-Pocket Maximum:  $4,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,000 FAM
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,850 IND/$8,000 FAM
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $8,000 FAM
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $10,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $8,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$400 IND/$800 FAM (RX Only)
Out-of-Pocket Maximum:  $6,250 IND/$12,500 FAM
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$5,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $10,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$5,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $7,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$5,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $8,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:$6,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $8,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $2,000 IND/$5,000 FAM
Annual Max:$1,500
Copay Tiers: $10/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:$1,500
Copay Tiers: $10/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:$5,000
Copay Tiers: $10/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,500 FAM
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $1,100 IND/$2,750 FAM
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $1,500 IND/$3,000 FAM
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $2,500 IND/$7,500 FAM
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $600 IND/$1,500 FAM
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $800 IND/$1,600 FAM
Annual Max:N/A
Copay Tiers: $10/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $10/$25/$40/$40
Deductible:$300 IND/$600 FAM (RX Only)
Out-of-Pocket Maximum:  $5,200 IND/$10,400 FAM
Annual Max:N/A
Copay Tiers: $10/$25/$40/30%
Deductible:$150 IND/$300 FAM (RX Only)
Out-of-Pocket Maximum:  $3,000 IND/$6,000 FAM
Annual Max:N/A
Copay Tiers: $10/$25/$45
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $10/$25/50%
Deductible:N/A
Out-of-Pocket Maximum:  $4,000 IND/$8,000 FAM
Annual Max:N/A
Copay Tiers: $10/$25/50%
Deductible:N/A
Out-of-Pocket Maximum:  $5,500 IND/$11,000 FAM
Annual Max:N/A
Copay Tiers: $10/$25/50%
Deductible:N/A
Out-of-Pocket Maximum:  $6,000 IND/$12,000 FAM
Annual Max:N/A
Copay Tiers: $10/$25/50%
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $10/$25/50%/50%
Deductible:$1,500 IND
Out-of-Pocket Maximum:  $5,000 IND
Annual Max:N/A
Copay Tiers: $10/$25/50%/50%
Deductible:$10,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,000 FAM
Annual Max:N/A
Copay Tiers: $10/$25/50%/50%
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $10/$25/50%/50%
Deductible:$3,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $10,000 FAM
Annual Max:N/A
Copay Tiers: $10/$25/50%/50%
Deductible:$5,000 IND
Out-of-Pocket Maximum:  $6,000 IND
Annual Max:N/A
Copay Tiers: $10/$30/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $10/$30/$40
Deductible:$2,500 IND
Out-of-Pocket Maximum:  $3,000 IND
Annual Max:N/A
Copay Tiers: $10/$30/$40
Deductible:$2,500 IND
Out-of-Pocket Maximum:  $3,500 IND
Annual Max:N/A
Copay Tiers: $10/$30/$40
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $10/$30/$40
Deductible:$3,500 IND
Out-of-Pocket Maximum:  $5,750 IND
Annual Max:N/A
Copay Tiers: $10/$30/$40
Deductible:$5,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,000 FAM
Annual Max:N/A
Copay Tiers: $10/$30/$40
Deductible:$5,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $7,000 FAM
Annual Max:N/A
Copay Tiers: $10/$30/$40
Deductible:$7,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $11,500 FAM
Annual Max:N/A
Copay Tiers: $10/$30/$40
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $10/$30/$40
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $10/$30/$50
Deductible:N/A
Out-of-Pocket Maximum:  $3,000 IND/$9,000 FAM
Annual Max:N/A
Copay Tiers: $10/$30/$50
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $10/$35/$40
Deductible:$2,000 IND
Out-of-Pocket Maximum:  $3,000 IND
Annual Max:N/A
Copay Tiers: $10/$35/$40
Deductible:$3,000 IND
Out-of-Pocket Maximum:  $5,000 IND
Annual Max:N/A
Copay Tiers: $10/$35/$40
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,000 FAM
Annual Max:N/A
Copay Tiers: $10/$35/$40
Deductible:$6,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $10,000 FAM
Annual Max:N/A
Copay Tiers: $10/$35/$40
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,000 FAM
Annual Max:N/A
Copay Tiers: $10/$40/50%
Deductible:$2,500 IND
Out-of-Pocket Maximum:  $3,500 IND
Annual Max:N/A
Copay Tiers: $10/$40/50%
Deductible:$3,500 IND
Out-of-Pocket Maximum:  $6,350 IND
Annual Max:N/A
Copay Tiers: $10/$40/50%
Deductible:$4,000 IND
Out-of-Pocket Maximum:  $6,350 IND
Annual Max:N/A
Copay Tiers: $10/$40/50%
Deductible:$5,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $7,000 FAM
Annual Max:N/A
Copay Tiers: $10/$40/50%
Deductible:$7,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,700 FAM
Annual Max:N/A
Copay Tiers: $10/$40/50%
Deductible:$8,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,700 FAM
Annual Max:N/A
Copay Tiers: $10/$40/50%
Deductible:N/A
Out-of-Pocket Maximum:  $3,000 IND/$6,000 FAM
Annual Max:N/A
Copay Tiers: $10/$40/50%
Deductible:N/A
Out-of-Pocket Maximum:  $5,500 IND/$11,000 FAM
Annual Max:N/A
Copay Tiers: $10/$40/50%
Deductible:N/A
Out-of-Pocket Maximum:  $6,000 IND/$12,000 FAM
Annual Max:N/A
Copay Tiers: $10/$40/50%
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $10/$40/50%/50%
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $10/40%/40%/40%
Deductible:$3,250 IND/$6,500 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,250 IND/$12,500 FAM
Annual Max:N/A
Copay Tiers: $10/50%/50%
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
No
Copay Tiers: $10/50%/50%/50%
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $5,500 IND/$11,000 FAM
Annual Max:N/A
Copay Tiers: $15/$15/$30
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,500 FAM
Annual Max:N/A
Copay Tiers: $15/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$1,250 IND
Out-of-Pocket Maximum:  $2,250 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$1,250 IND
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$1,500 IND
Out-of-Pocket Maximum:  $2,500 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$1,500 IND
Out-of-Pocket Maximum:  $3,000 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$1,500 IND
Out-of-Pocket Maximum:  $5,500 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$1,500 IND
Out-of-Pocket Maximum:  $6,350 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$1,500 IND
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$1,500 IND (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$10,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $10,000 FAM
Annual Max:N/A
No
Copay Tiers: $15/$25/$40
Deductible:$10,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,000 FAM
Annual Max:N/A
No
Copay Tiers: $15/$25/$40
Deductible:$10,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
No
Copay Tiers: $15/$25/$40
Deductible:$10,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $10,500 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$10,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$10,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,100 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$10,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,500 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$10,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,700 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$10,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$10,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
No
Copay Tiers: $15/$25/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $2,000 IND/$8,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,000 IND
Out-of-Pocket Maximum:  $2,000 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,000 IND
Out-of-Pocket Maximum:  $2,750 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,000 IND
Out-of-Pocket Maximum:  $3,000 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,000 IND
Out-of-Pocket Maximum:  $3,500 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,000 IND
Out-of-Pocket Maximum:  $4,000 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,000 IND
Out-of-Pocket Maximum:  $5,000 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,000 IND
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  $3,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  $4,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  $5,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,500 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $4,500 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,500 FAM (Combined with Medical)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,500 IND
Out-of-Pocket Maximum:  $3,500 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,500 IND
Out-of-Pocket Maximum:  $4,000 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,500 IND
Out-of-Pocket Maximum:  $4,500 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,500 IND
Out-of-Pocket Maximum:  $5,250 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,500 IND
Out-of-Pocket Maximum:  $6,050 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,500 IND
Out-of-Pocket Maximum:  $6,350 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,500 IND
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,500 IND (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$2,850 IND
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $4,000 IND/$8,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$3,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $10,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$3,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,700 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$3,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $5,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$3,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$3,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$3,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$3,000 IND
Out-of-Pocket Maximum:  $3,000 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$3,000 IND
Out-of-Pocket Maximum:  $4,000 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$3,000 IND
Out-of-Pocket Maximum:  $4,500 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$3,000 IND
Out-of-Pocket Maximum:  $5,000 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$3,000 IND
Out-of-Pocket Maximum:  $5,500 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$3,000 IND
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$3,000 IND (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$3,500 IND
Out-of-Pocket Maximum:  $4,500 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$3,500 IND
Out-of-Pocket Maximum:  $5,225 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$3,500 IND
Out-of-Pocket Maximum:  $5,500 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$3,500 IND
Out-of-Pocket Maximum:  $6,350 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$3,500 IND
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$3,500 IND (INC OON)
Out-of-Pocket Maximum:  $5,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$3,500 IND (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $10,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $4,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $5,500 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $7,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $8,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $10,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $6,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $8,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$4,000 IND
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
No
Copay Tiers: $15/$25/$40
Deductible:$4,000 IND
Out-of-Pocket Maximum:  $5,300 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$4,000 IND
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$4,000 IND (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
No
Copay Tiers: $15/$25/$40
Deductible:$5,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $10,500 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$5,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,100 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$5,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,700 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$5,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $7,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$5,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $8,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$5,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $9,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$5,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$5,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$5,000 IND
Out-of-Pocket Maximum:  $6,000 IND
Annual Max:N/A
No
Copay Tiers: $15/$25/$40
Deductible:$5,000 IND
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
No
Copay Tiers: $15/$25/$40
Deductible:$5,000 IND
Out-of-Pocket Maximum:  $5,250 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$5,000 IND
Out-of-Pocket Maximum:  $6,000 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$5,000 IND
Out-of-Pocket Maximum:  $6,050 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$5,000 IND
Out-of-Pocket Maximum:  $6,250 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$5,000 IND
Out-of-Pocket Maximum:  $6,350 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$5,000 IND
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$5,000 IND (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
No
Copay Tiers: $15/$25/$40
Deductible:$5,700 FAM (Combined with Medical)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$50 IND/$100 FAM (RX Only)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$6,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $10,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$6,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $11,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$6,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$6,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $8,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$6,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $9,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$6,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$6,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$7,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $10,450 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$7,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $11,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$7,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,700 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$7,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $9,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$7,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$7,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $10,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$7,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$8,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
No
Copay Tiers: $15/$25/$40
Deductible:$8,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $11,600 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$8,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:$8,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
No
Copay Tiers: $15/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:$1,000
No
Copay Tiers: $15/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:$3,000
No
Copay Tiers: $15/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,500 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $1,500 IND/$3,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $1,500 IND/$4,500 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $2,400 IND/$7,200 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $2,500 IND
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $2,500 IND/$5,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $3,000 IND/$9,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $3,500 IND/$12,500 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $4,000 IND/$12,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $4,000 IND/$8,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $4,500 IND/$9,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $5,000 IND/$10,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $5,500 IND/$11,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $5,500 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $6,000 IND/$12,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $15/$25/$40
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$25/50%
Deductible:$10,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,700 FAM
Annual Max:N/A
Copay Tiers: $15/$25/50%
Deductible:$4,000 IND
Out-of-Pocket Maximum:  $6,350 IND
Annual Max:N/A
Copay Tiers: $15/$25/50%
Deductible:$5,000 IND
Out-of-Pocket Maximum:  $6,350 IND
Annual Max:N/A
Copay Tiers: $15/$25/50%
Deductible:$8,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,700 FAM
Annual Max:N/A
Copay Tiers: $15/$25/50%
Deductible:N/A
Out-of-Pocket Maximum:  $5,500 IND/$11,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/50%/50%
Deductible:$10,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $12,700 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $15/$25/50%/50%
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $5,000 IND/$10,000 FAM
Annual Max:N/A
Copay Tiers: $15/$25/50%/50%
Deductible:$5,000 IND (INC OON)
Out-of-Pocket Maximum:  $6,350 IND (INC OON)
Annual Max:N/A
Copay Tiers: $15/$30/$30
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $15/$30/$30
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:$1,500 IND
Out-of-Pocket Maximum:  $2,500 IND
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:$1,500 IND
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $4,000 IND/$8,000 FAM
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $5,000 IND/$10,000 FAM
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:$2,000 IND
Out-of-Pocket Maximum:  $3,000 IND
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $2,400 IND/$7,200 FAM
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:$3,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $5,000 FAM
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:$3,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:$3,000 IND
Out-of-Pocket Maximum:  $4,000 IND
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,000 FAM
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:$6,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $8,000 FAM
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$3,000 FAM
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:N/A
Out-of-Pocket Maximum:  $3,500 IND/$7,000 FAM
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:N/A
Out-of-Pocket Maximum:  $3,750 IND/$12,500 FAM
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:N/A
Out-of-Pocket Maximum:  $5,000 IND/$10,000 FAM
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:N/A
Out-of-Pocket Maximum:  $600 IND/$1,500 FAM
Annual Max:N/A
Copay Tiers: $15/$30/$40
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/$30/50%
Deductible:$1,500 IND
Out-of-Pocket Maximum:  $4,000 IND
Annual Max:N/A
Copay Tiers: $15/$30/50%
Deductible:$3,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $8,000 FAM
Annual Max:N/A
Copay Tiers: $15/$30/50%
Deductible:$3,000 IND/$6,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $4,000 IND/$8,000 FAM
Annual Max:N/A
Copay Tiers: $15/$30/50%
Deductible:N/A
Out-of-Pocket Maximum:  $5,500 IND/$11,000 FAM
Annual Max:N/A
Copay Tiers: $15/$30/50%
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $15/$35/$60
Deductible:$1,500 IND
Out-of-Pocket Maximum:  $3,000 IND
Annual Max:N/A
Copay Tiers: $15/$35/$60
Deductible:$2,500 IND
Out-of-Pocket Maximum:  $5,000 IND
Annual Max:N/A
Copay Tiers: $15/$35/$60
Deductible:$3,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,000 FAM
Annual Max:N/A
Copay Tiers: $15/$35/$60
Deductible:$5,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $10,000 FAM
Annual Max:N/A
Copay Tiers: $15/$35/$60
Deductible:$5,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,850 IND/$10,000 FAM
Annual Max:N/A
Copay Tiers: $15/$35/$60
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $15/$40/50%/50%
Deductible:$1,500 IND
Out-of-Pocket Maximum:  $3,500 IND
Annual Max:N/A
Copay Tiers: $15/$40/50%/50%
Deductible:$3,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,850 IND/$7,000 FAM
Annual Max:N/A
Copay Tiers: $15/$40/50%/50%
Deductible:$3,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $7,000 FAM
Annual Max:N/A
Copay Tiers: $15/50%/50%
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $15/50%/50%/50%
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $5,000 IND/$10,000 FAM
Annual Max:N/A
Copay Tiers: $2/$7/$7
Deductible:N/A
Out-of-Pocket Maximum:  $500 IND/$1,200 FAM
Annual Max:$2,000
Copay Tiers: $2/$7/$7
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:$2,000
Copay Tiers: $2/$7/$7
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,300 FAM
Annual Max:$800
Copay Tiers: $2/$7/$7
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:$800
Copay Tiers: $2/$7/$7
Deductible:N/A
Out-of-Pocket Maximum:  $1,750 IND/$5,250 FAM
Annual Max:N/A
Copay Tiers: $2/$7/$7
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $2/$7/$7
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $20/$20/$40
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $20/$20/$40
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $20/$20/$40
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $20/$25/$35
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,500 FAM
Annual Max:N/A
Copay Tiers: $20/$25/$35
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$1,500 IND
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $5,000 IND/$10,000 FAM
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$2,000 IND
Out-of-Pocket Maximum:  $3,000 IND
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$2,000 IND
Out-of-Pocket Maximum:  $4,000 IND
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$2,000 IND
Out-of-Pocket Maximum:  $6,350 IND
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$2,000 IND
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $3,000 IND/$6,000 FAM
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $4,000 IND/$11,000 FAM
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $4,500 IND/$9,000 FAM
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $5,000 IND/$10,000 FAM
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $5,200 IND/$10,400 FAM
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$3,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$3,500 IND
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,700 FAM
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,000 FAM
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,850 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $8,000 FAM
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:$7,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:N/A
Out-of-Pocket Maximum:  $2,750 IND/$5,500 FAM
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:N/A
Out-of-Pocket Maximum:  $2,750 IND/$8,250 FAM
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:N/A
Out-of-Pocket Maximum:  $3,500 IND/$7,000 FAM
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:N/A
Out-of-Pocket Maximum:  $5,000 IND/$10,000 FAM
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $20/$30/$40
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $20/$30/50%
Deductible:$1,500 IND
Out-of-Pocket Maximum:  $4,500 IND
Annual Max:N/A
Copay Tiers: $20/$30/50%
Deductible:$2,000 IND
Out-of-Pocket Maximum:  $5,000 IND
Annual Max:N/A
Copay Tiers: $20/$30/50%
Deductible:$3,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $9,000 FAM
Annual Max:N/A
Copay Tiers: $20/$30/50%
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $10,000 FAM
Annual Max:N/A
Copay Tiers: $20/$30/50%
Deductible:$4,000 IND
Out-of-Pocket Maximum:  $6,350 IND
Annual Max:N/A
Copay Tiers: $20/$30/50%
Deductible:$8,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,700 FAM
Annual Max:N/A
Copay Tiers: $20/$30/50%
Deductible:N/A
Out-of-Pocket Maximum:  $5,250 IND/$10,500 FAM
Annual Max:N/A
Copay Tiers: $20/$30/50%
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $20/$30/50%/50%
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $20/$35/50%
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $20/$40/50%
Deductible:N/A
Out-of-Pocket Maximum:  $5,500 IND/$11,000 FAM
Annual Max:N/A
Copay Tiers: $20/50%/$30/50%/50%/50%
Deductible:N/A
Out-of-Pocket Maximum:  $5,500 IND/$11,000 FAM
Annual Max:N/A
Copay Tiers: $20/50%/$30/50%/50%/50%
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $20/50%/$40/50%/50%/50%
Deductible:$3,000 IND/$6,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $5,500 IND/$11,000 FAM
Annual Max:N/A
Copay Tiers: $25/$30/$40
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,500 FAM
Annual Max:N/A
Copay Tiers: $25/$30/50%/50%
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $25/$35/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $1,700 IND/$3,400 FAM
Annual Max:N/A
Copay Tiers: $25/$35/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $25/$35/50%
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $25/$35/50%/50%
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $4,500 IND/$9,000 FAM
Annual Max:N/A
Copay Tiers: $25/$35/50%/50%
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $25/$40/50%
Deductible:$3,500 IND
Out-of-Pocket Maximum:  $6,000 IND
Annual Max:N/A
Copay Tiers: $25/$40/50%
Deductible:$7,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,000 FAM
Annual Max:N/A
Copay Tiers: $25/$40/50%
Deductible:N/A
Out-of-Pocket Maximum:  $6,450 IND/$12,900 FAM
Annual Max:N/A
Copay Tiers: $25/50%/$40/50%/50%/50%
Deductible:N/A
Out-of-Pocket Maximum:  $6,000 IND/$12,000 FAM
Annual Max:N/A
Copay Tiers: $25/50%/$50/50%/50%/50%
Deductible:N/A
Out-of-Pocket Maximum:  $6,850 IND/$13,700 FAM
Annual Max:N/A
Copay Tiers: $3/$6/$6
Deductible:N/A
Out-of-Pocket Maximum:  $1,200 IND/$3,600 FAM
Annual Max:N/A
Copay Tiers: $3/$6/$6
Deductible:N/A
Out-of-Pocket Maximum:  $800 IND/$1,600 FAM
Annual Max:N/A
Copay Tiers: $30/$40/50%
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $30/$45/50%
Deductible:N/A
Out-of-Pocket Maximum:  $6,000 IND/$12,000 FAM
Annual Max:N/A
Copay Tiers: $30/50%/$50/50%/50%/50%
Deductible:N/A
Out-of-Pocket Maximum:  $6,500 IND/$13,000 FAM
Annual Max:N/A
Copay Tiers: $5/$10/$10
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,500 FAM
Annual Max:$1,000
Copay Tiers: $5/$10/$10
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:$1,000
Copay Tiers: $5/$10/$10
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,500 FAM
Annual Max:$2,000
Copay Tiers: $5/$10/$10
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:$2,000
Copay Tiers: $5/$10/$10
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,500 FAM
Annual Max:N/A
Copay Tiers: $5/$10/$10
Deductible:N/A
Out-of-Pocket Maximum:  $1,200 IND/$3,600 FAM
Annual Max:N/A
Copay Tiers: $5/$10/$10
Deductible:N/A
Out-of-Pocket Maximum:  $500 IND/$1,200 FAM
Annual Max:N/A
Copay Tiers: $5/$10/$10
Deductible:N/A
Out-of-Pocket Maximum:  $800 IND/$1,600 FAM
Annual Max:N/A
Copay Tiers: $5/$10/$10
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $5/$10/$15
Deductible:N/A
Out-of-Pocket Maximum:  $1,250 IND/$3,750 FAM
Annual Max:N/A
Copay Tiers: $5/$10/$15
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $5/$10/$20
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,500 FAM
Annual Max:$1,000
Copay Tiers: $5/$10/$20
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:$1,000
Copay Tiers: $5/$10/$20
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $5/$10/$20
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $5/$10/$25/50%
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $5/$10/$30/20%
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,000 FAM
Annual Max:N/A
Copay Tiers: $5/$10/$30/20%
Deductible:N/A
Out-of-Pocket Maximum:  $800 IND/$1,600 FAM
Annual Max:N/A
Copay Tiers: $5/$10/50%
Deductible:$2,500 IND
Out-of-Pocket Maximum:  $5,000 IND
Annual Max:N/A
Copay Tiers: $5/$10/50%
Deductible:$5,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $10,000 FAM
Annual Max:N/A
Copay Tiers: $5/$10/50%
Deductible:N/A
Out-of-Pocket Maximum:  $5,500 IND/$11,000 FAM
Annual Max:N/A
Copay Tiers: $5/$10/50%
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$20
Deductible:N/A
Out-of-Pocket Maximum:  $600 IND/$1,500 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$20/50%
Deductible:$100 IND/$200 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $750 IND/$1,500 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$25
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,500 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$25
Deductible:N/A
Out-of-Pocket Maximum:  $1,750 IND/$5,250 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$25
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$25
Deductible:N/A
Out-of-Pocket Maximum:  $600 IND/$1,500 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$25
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $5/$15/$25/50%
Deductible:$100 IND/$200 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $1,000 IND/$2,000 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$30
Deductible:$1,500 IND (INC OON)
Out-of-Pocket Maximum:  $2,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $5/$15/$30
Deductible:$3,000 IND
Out-of-Pocket Maximum:  $4,000 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$30
Deductible:$3,000 IND
Out-of-Pocket Maximum:  $4,000 IND
Annual Max:N/A
Copay Tiers: $5/$15/$30
Deductible:$6,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $8,000 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$30
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,000 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$30
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,500 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$30
Deductible:N/A
Out-of-Pocket Maximum:  $1,500 IND/$2,500 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$30
Deductible:N/A
Out-of-Pocket Maximum:  $1,500 IND/$4,500 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$30
Deductible:N/A
Out-of-Pocket Maximum:  $2,400 IND/$7,200 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$30
Deductible:N/A
Out-of-Pocket Maximum:  $4,000 IND/$12,000 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$30
Deductible:N/A
Out-of-Pocket Maximum:  $4,000 IND/$8,000 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$30
Deductible:N/A
Out-of-Pocket Maximum:  $5,000 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$30
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$30
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $5/$15/$30/$40
Deductible:N/A
Out-of-Pocket Maximum:  $2,000 IND/$4,000 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$30/$40
Deductible:N/A
Out-of-Pocket Maximum:  $2,250 IND/$4,500 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$30/20%
Deductible:N/A
Out-of-Pocket Maximum:  $2,000 IND/$4,000 FAM
Annual Max:N/A
Copay Tiers: $5/$15/$35
Deductible:$1,500 IND (INC OON)
Out-of-Pocket Maximum:  $2,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $5/$15/$35
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  $2,500 IND (INC OON)
Annual Max:N/A
Copay Tiers: $5/$15/$35
Deductible:$3,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $4,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $5/$15/$35
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $5,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $5/$15/$50/50%
Deductible:$3,500 IND/$7,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $5,000 IND/$10,000 FAM
Annual Max:N/A
Copay Tiers: $5/$15/50%
Deductible:N/A
Out-of-Pocket Maximum:  $6,000 IND/$12,000 FAM
Annual Max:N/A
Copay Tiers: $5/$15/50%/50%
Deductible:$150 IND/$300 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $600 IND/$1,200 FAM
Annual Max:N/A
Copay Tiers: $5/$15/50%/50%
Deductible:N/A
Out-of-Pocket Maximum:  $5,000 IND/$10,000 FAM
Annual Max:N/A
Copay Tiers: $5/$15/50%/50%
Deductible:N/A
Out-of-Pocket Maximum:  $6,000 IND/$12,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$25
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,500 FAM
Annual Max:$2,000
Copay Tiers: $5/$20/$25
Deductible:N/A
Out-of-Pocket Maximum:  $2,000 IND/$6,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:$1,500 IND (INC OON)
Out-of-Pocket Maximum:  $2,600 IND (INC OON)
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  $2,500 IND (INC OON)
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  $3,100 IND (INC OON)
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:$3,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $5,200 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $5,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $6,200 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:$4,500 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:$1,000
Copay Tiers: $5/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,500 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $1,200 IND/$3,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $1,200 IND/$3,600 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $1,500 IND/$4,500 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $1,750 IND/$5,250 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $2,000 IND/$5,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $2,400 IND/$7,200 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $2,500 IND/$5,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $3,000 IND/$9,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $6,050 IND/$12,100 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $6,600 IND/$13,200 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $600 IND/$1,500 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  $800 IND/$2,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$30
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $5/$20/$30/$50
Deductible:$5,000 IND/$10,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,000 IND/$12,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$30/50%
Deductible:$750 IND/$1,500 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $2,000 IND/$4,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:$1,500 IND
Out-of-Pocket Maximum:  $3,000 IND
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  $2,500 IND (INC OON)
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  $3,000 IND
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  $4,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  $5,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:$2,250 IND (INC OON)
Out-of-Pocket Maximum:  $5,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:$3,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $10,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $5,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $6,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $8,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:$4,500 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $10,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:$4,500 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $6,850 IND/$10,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:$1,000
No
Copay Tiers: $5/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:$2,000
No
Copay Tiers: $5/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:$2,000
Copay Tiers: $5/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:$3,000
No
Copay Tiers: $5/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,500 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $1,250 IND/$3,750 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $2,000 IND/$4,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $2,000 IND/$5,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $2,250 IND/$6,750 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $2,500 IND/$7,500 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $2,900 IND/$8,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $3,500 IND/$8,750 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $3,750 IND/$11,250 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $4,000 IND/$12,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $4,350 IND/$8,700 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $4,500 IND/$9,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $5,000 IND/$10,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$35
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $5/$20/$35/$50
Deductible:$25 IND/$50 FAM (RX Only)
Out-of-Pocket Maximum:  $1,750 IND/$3,500 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$35/$50
Deductible:N/A
Out-of-Pocket Maximum:  $600 IND/$1,200 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$35/20%
Deductible:$50 IND/$100 FAM (RX Only)
Out-of-Pocket Maximum:  $1,800 IND/$3,600 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$40
Deductible:$2,000 IND
Out-of-Pocket Maximum:  $4,000 IND
Annual Max:N/A
Copay Tiers: $5/$20/$40
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  $4,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $5/$20/$40
Deductible:$2,000 IND (INC OON)
Out-of-Pocket Maximum:  $5,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $5/$20/$40
Deductible:$4,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $8,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$40
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $10,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $5/$20/$40
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $6,850 IND/$10,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $5/$20/$40
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  $6,850 IND/$8,000 FAM (INC OON)
Annual Max:N/A
Copay Tiers: $5/$20/$40
Deductible:$4,000 FAM (Combined with Medical) (INC OON)
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $5/$20/$40
Deductible:N/A
Out-of-Pocket Maximum:  $5,000 IND/$10,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$40
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$40
Deductible:N/A
Out-of-Pocket Maximum:  $6,600 IND/$13,200 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$40
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $5/$20/$40/50%
Deductible:$200 IND/$400 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $1,000 IND/$2,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$40/50%
Deductible:$200 IND/$400 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $2,000 IND/$4,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$40/50%
Deductible:N/A
Out-of-Pocket Maximum:  $4,000 IND/$8,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$45/50%
Deductible:N/A
Out-of-Pocket Maximum:  $5,500 IND/$11,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$60/50%
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $5,500 IND/$11,000 FAM
Annual Max:N/A
Copay Tiers: $5/$20/$60/50%
Deductible:$200 IND/$400 FAM (RX Only)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $5/$20/50%/50%
Deductible:$2,500 IND
Out-of-Pocket Maximum:  $5,000 IND
Annual Max:N/A
Copay Tiers: $5/$20/50%/50%
Deductible:$5,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $6,850 IND/$10,000 FAM
Annual Max:N/A
Copay Tiers: $5/$25/$35
Deductible:N/A
Out-of-Pocket Maximum:  $1,000 IND/$2,500 FAM
Annual Max:N/A
Copay Tiers: $5/$25/$35
Deductible:N/A
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $5/$25/$35
Deductible:N/A
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$1,250 IND
Out-of-Pocket Maximum:  $2,250 IND
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$1,300 IND
Out-of-Pocket Maximum:  $2,600 IND
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$1,500 IND
Out-of-Pocket Maximum:  N/A
Annual Max:$3,000
No
Copay Tiers: $5/$25/$40
Deductible:$1,500 IND
Out-of-Pocket Maximum:  N/A
Annual Max:N/A
No
Copay Tiers: $5/$25/$40
Deductible:$1,500 IND
Out-of-Pocket Maximum:  $2,500 IND
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$1,500 IND
Out-of-Pocket Maximum:  $3,000 IND
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$1,500 IND
Out-of-Pocket Maximum:  $3,500 IND
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$1,500 IND
Out-of-Pocket Maximum:  $4,000 IND
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$1,500 IND
Out-of-Pocket Maximum:  $4,500 IND
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$1,500 IND
Out-of-Pocket Maximum:  $5,500 IND
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$1,500 IND (INC OON)
Out-of-Pocket Maximum:  $2,500 IND
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$1,500 IND (INC OON)
Out-of-Pocket Maximum:  $2,500 IND (INC OON)
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$1,500 IND (INC OON)
Out-of-Pocket Maximum:  $3,500 IND (INC OON)
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$1,500 IND (INC OON)
Out-of-Pocket Maximum:  $4,000 IND (INC OON)
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$1,500 IND (INC OON)
Out-of-Pocket Maximum:  $4,500 IND (INC OON)
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$10,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,000 FAM
Annual Max:N/A
No
Copay Tiers: $5/$25/$40
Deductible:$10,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $10,500 FAM
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$10,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,000 FAM
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$10,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,100 FAM
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$10,000 FAM (Combined with Medical)
Out-of-Pocket Maximum:  $12,700 FAM
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $2,000 IND/$8,000 FAM
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $2,500 IND/$5,000 FAM
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $3,000 IND/$6,000 FAM
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $3,750 IND/$12,500 FAM
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $4,000 IND/$12,000 FAM
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $5,000 IND/$10,000 FAM
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $5,000 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $5,200 IND/$10,400 FAM
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $5,500 IND/$11,000 FAM
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$100 IND/$200 FAM (RX Only)
Out-of-Pocket Maximum:  $6,350 IND/$12,700 FAM
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$2,000 IND
Out-of-Pocket Maximum:  $2,500 IND
Annual Max:N/A
Copay Tiers: $5/$25/$40
Deductible:$2,000 IND
Out-of-Pocket Maximum:  $2,750 IND
Annual Max:N/A