Medical Plans & Prescription Drug Coverage

Plan Options
Documents & Forms
You have four medical plan options to choose from. You can choose which plan is best for you depending on your healthcare needs.
$3,500 Deductible Choice+ PPO
Benefit Details
  • Individual Deductible: $3,500
  • Family Deductible: $7,000
  • Coinsurance (plan pays): 70%
  • Individual OOP Maximum: $8,550
  • Family OOP Maximum: $17,100
  • Urgent Care: Ded./coinsurance
  • ER (covered as in-network):
    $500 copay, 70% coinsurance
  • Office Visit PCP: Ded./coinsurance
  • Office Visit Specialist: Ded./coinsurance
  • Preventive: 100% covered
  • Virtual Visits: $5 copay
Prescription Drugs
  • Rx Retail: Generic: 70%/$25 max
  • Rx Retail: Preferred Brand: 70%/$80 max
  • Rx Retail: Non-preferred Brand: 55%/$130 max
  • Rx Mail: Generic(90 Day): 70%/$62.50 max
  • Rx Mail: Preferred Brand(90Day): 70%/$200 max
  • Rx Mail: Non-preferred Brand(90 Day): 55%/$325 max
  • Rx: Specialty:
    Applicable generic, preferred brand or
    non-preferred brand coinsurance
2022 Monthly Plan Costs
You Only: $280.95
You + Spouse: $1,001.55
You + Child(ren): $503.40
You + Family: $1,144.25
Tobacco Surcharge
If you or your spouse/domestic partner use or have used tobacco or tobacco-related products (including e-cigarettes) within the last six months, you will be assessed a $50 monthly surcharge per tobacco user.
BeneStream
Through our partnership with BeneStream, you can determine if you qualify for low-cost or zero-cost medical coverage through Medicaid or CHIP. If you qualify, BeneStream will help you through the enrollment and can also help with renewals. To get started, visit www.benestream.com or call 877-223-1432.
$4,500 Deductible Choice+ HDHP
Benefit Details
  • Individual Deductible: $4,500
  • Family Deductible: $9,000
  • Coinsurance (plan pays): 60%
  • Individual OOP Maximum: $7,000
  • Family OOP Maximum: $14,000
  • Urgent Care: Ded./coinsurance
  • ER (covered as in-network):
    $500 copay, 60% coinsurance
  • Office Visit PCP: Ded./coinsurance
  • Office Visit Specialist: Ded./coinsurance
  • Preventive: 100% covered
  • Virtual Visits: Ded./coinsurance
Prescription Drugs
  • Rx Retail: Generic: 60% after deductible
  • Rx Retail: Preferred Brand: 60% after deductible
  • Rx Retail: Non-preferred Brand: 60% after deductible
  • Rx Mail: Generic(90 Day): 60% after deductible
  • Rx Mail: Preferred Brand(90Day): 60% after deductible
  • Rx Mail: Non-preferred Brand(90 Day):
    60% after deductible
  • Rx: Specialty:
    60% after deductible
2022 Monthly Plan Costs
You Only: $169.57
You + Spouse: $858.12
You + Child(ren): $456.79
You + Family: $1,065.73
Tobacco Surcharge
If you or your spouse/domestic partner use or have used tobacco or tobacco-related products (including e-cigarettes) within the last six months, you will be assessed a $50 monthly surcharge per tobacco user.
BeneStream
Through our partnership with BeneStream, you can determine if you qualify for low-cost or zero-cost medical coverage through Medicaid or CHIP. If you qualify, BeneStream will help you through the enrollment and can also help with renewals. To get started, visit www.benestream.com or call 877-223-1432.
$3,500 Deductible Performance PPO
Benefit Details
  • Individual Deductible: $3,500
  • Family Deductible: $7,000
  • Coinsurance (plan pays): 70%
  • Individual OOP Maximum: $8,550
  • Family OOP Maximum: $17,100
  • Urgent Care: $50 copay
  • ER (covered as in-network):
    $500 copay, 70% coinsurance
  • Office Visit PCP: $25 copay
  • Office Visit Specialist: $50 copay
  • Preventive: 100% covered
  • Virtual Visits: $5 copay
Prescription Drugs
  • Rx Retail: Generic: 70%/$25 max
  • Rx Retail: Preferred Brand: 70%/$80 max
  • Rx Retail: Non-preferred Brand: 55%/$130 max
  • Rx Mail: Generic(90 Day): 70%/$62.50 max
  • Rx Mail: Preferred Brand(90Day): 70%/$200 max
  • Rx Mail: Non-preferred Brand(90 Day): 55%/$325 max
  • Rx: Specialty:
    Applicable generic, preferred brand or
    non-preferred brand coinsurance
2022 Monthly Plan Costs
You Only: $263.24
You + Spouse: $960.83
You + Child(ren): $469.75
You + Family: $1,087.59
Tobacco Surcharge
If you or your spouse/domestic partner use or have used tobacco or tobacco-related products (including e-cigarettes) within the last six months, you will be assessed a $50 monthly surcharge per tobacco user.
BeneStream
Through our partnership with BeneStream, you can determine if you qualify for low-cost or zero-cost medical coverage through Medicaid or CHIP. If you qualify, BeneStream will help you through the enrollment and can also help with renewals. To get started, visit www.benestream.com or call 877-223-1432.
$4,500 Deductible Performance HDHP
Benefit Details
  • Individual Deductible: $4,500
  • Family Deductible: $9,000
  • Coinsurance (plan pays): 70%
  • Individual OOP Maximum: $7,000
  • Family OOP Maximum: $14,000
  • Urgent Care: Ded./coinsurance
  • ER (covered as in-network):
    $500 copay, 70% coinsurance
  • Office Visit PCP: Ded./coinsurance
  • Office Visit Specialist: Ded./coinsurance
  • Preventive: 100% covered
  • Virtual Visits: Ded./coinsurance
Prescription Drugs
  • Rx Retail: Generic: 70% after deductible
  • Rx Retail: Preferred Brand: 70% after deductible
  • Rx Retail: Non-preferred Brand: 70% after deductible
  • Rx Mail: Generic(90 Day): 70% after deductible
  • Rx Mail: Preferred Brand(90Day):
    70% after deductible
  • Rx Mail: Non-preferred Brand(90 Day):
    70% after deductible
  • Rx: Specialty:
    70% after deductible
2022 Monthly Plan Costs
You Only < $20,000: $103.99
You Only: $149.98
You + Spouse: $813.07
You + Child(ren): $419.58
You + Family: $1,003.06
Tobacco Surcharge
If you or your spouse/domestic partner use or have used tobacco or tobacco-related products (including e-cigarettes) within the last six months, you will be assessed a $50 monthly surcharge per tobacco user.
BeneStream
Through our partnership with BeneStream, you can determine if you qualify for low-cost or zero-cost medical coverage through Medicaid or CHIP. If you qualify, BeneStream will help you through the enrollment and can also help with renewals. To get started, visit www.benestream.com or call 877-223-1432.
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