Plan Design Changes Effective January 1, 2024
The Basic and Premium plans have plan design changes that will take effect on January 1, 2024.
The calendar year deductible, out-of-pocket maximums and the emergency room copay will be changing.
Plan design changes are highlighted below in red.
Premium – $1,000 POS Plan Benefits (formerly $500)
| In-Network | Out-of-Network | |
| Deductible (Calendar Year) | ||
| Single | $1,000 | $6,000 |
| Family | $3,000 | $18,000 |
| Lifetime Maximum | Unlimited | Unlimited |
| Coinsurance (Plan/Member) | 90% / 10% | 60% / 40% |
| Max Out-of-Pocket (Including Deductible) | ||
| Single | $1,500 | $14,000 |
| Family | $4,500 | $42,000 |
| Physician Office Visits | ||
| Primary Care | $15 Copay | Plan Pays 40% after Deductible |
| Specialist | $25 Copay | Plan Pays 40% after Deductible |
| Urgent Care | $35 Copay | Plan Pays 40% after Deductible |
| Emergency Room | $250 Copay | $150 Copay |
| First-Choice Pharmacy* | ||
| Tier 1 Drugs | $15 Copay | Plan Pays 40% after Deductible |
| Tier 2 Drugs | $30 Copay | Plan Pays 40% after Deductible |
| Tier 3 Drugs | $60 Copay | Plan Pays 40% after Deductible |
| Specialty Tier 4 | 25% to $200 | Plan Pays 40% after Deductible |
| Mail Order | $25/$60/$120 | Not Covered |
| Non-First-Choice Pharmacy* | ||
| Tier 1 Drugs | $25 Copay | Plan Pays 40% after Deductible |
| Tier 2 Drugs | $40 Copay | Plan Pays 40% after Deductible |
| Tier 3 Drugs | $70 Copay | Plan Pays 40% after Deductible |
| Specialty Tier 4 | 25% to $250 | Plan Pays 40% after Deductible |
| Mail Order | $25/$60/$120 | Not Covered |
* Rx Out-of-Pocket Max (OOPM) is combined with Medical. Please refer to the benefit summary for Rx Tier descriptions
Basic – $2,000 POS Plan Benefits (formerly $1,500)
| In-Network | Out-of-Network | |
| Deductible (Calendar Year) | ||
| Single | $2,000 | $6,000 |
| Family | $6,000 | $18,000 |
| Lifetime Maximum | Unlimited | Unlimited |
| Coinsurance (Plan/Member) | 80% / 20% | 60% / 40% |
| Max Out-of-Pocket (Including Deductible) | ||
| Single | $3,000 | $14,000 |
| Family | $9,000 | $42,000 |
| Physician Office Visits | ||
| Primary Care | $25 Copay | Plan Pays 40% after Deductible |
| Specialist | $35 Copay | Plan Pays 40% after Deductible |
| Urgent Care | $35 Copay | Plan Pays 40% after Deductible |
| Emergency Room | $250 Copay | Plan Pays 40% after Deductible |
| First-Choice Pharmacy* | ||
| Tier 1 Drugs | $15 Copay | Plan Pays 40% after Deductible |
| Tier 2 Drugs | $30 Copay | Plan Pays 40% after Deductible |
| Tier 3 Drugs | $60 Copay | Plan Pays 40% after Deductible |
| Specialty Tier 4 | 25% to $250 | Plan Pays 40% after Deductible |
| Mail Order | $25/$60/$120 | Plan Pays 40% after Deductible |
| Non-First-Choice Pharmacy* | ||
| Tier 1 Drugs | $25 Copay | Plan Pays 40% after Deductible |
| Tier 2 Drugs | $40 Copay | Plan Pays 40% after Deductible |
| Tier 3 Drugs | $70 Copay | Plan Pays 40% after Deductible |
| Specialty Tier 4 | 25% to $250 | Plan Pays 40% after Deductible |
| Mail Order | $25/$60/$120 | Plan Pays 40% after Deductible |
* Rx Out-of-Pocket Max (OOPM) is combined with Medical. Please refer to the benefit summary for Rx Tier descriptions
High Deductible Health Plan – $1,500 HDHP Plan Benefits – NO PLAN CHANGES
| In-Network | Out-of-Network | |
| Deductible (Calendar Year) | ||
| Single | $1,500 | $6,000 |
| Family | $3,000 | $18,000 |
| Lifetime Maximum | Unlimited | Unlimited |
| Coinsurance (Plan/Member) | 90% / 10% | 60% / 40% |
| Max Out-of-Pocket (Including Deductible) | ||
| Single | $2,250 | $14,000 |
| Family | $4,500 | $42,000 |
| Hospital Facility Services | ||
| Inpatient | Plan Pays 90% after Deductible | Plan Pays 40% after Deductible |
| Outpatient | Plan Pays 90% after Deductible | Plan Pays 40% after Deductible |
| Emergency Room | Plan Pays 90% after Deductible | Plan Pays 90% after Deductible |
| Physician Office Visits | ||
| Primary Care | Plan Pays 90% after Deductible | Plan Pays 40% after Deductible |
| Specialist | Plan Pays 90% after Deductible | Plan Pays 40% after Deductible |
| First-Choice Pharmacy* | ||
| Tier 1 Drugs | Plan Pays 90% after Deductible | Plan Pays 40% after Deductible |
| Tier 2 Drugs | Plan Pays 90% after Deductible | Plan Pays 40% after Deductible |
| Tier 3 Drugs | Plan Pays 90% after Deductible | Plan Pays 40% after Deductible |
| Mail Order | Plan Pays 90% after Deductible | Plan Pays 40% after Deductible |
| Non-First-Choice Pharmacy* | ||
| Tier 1 Drugs | Plan Pays 90% after Deductible | Plan Pays 40% after Deductible |
| Tier 2 Drugs | Plan Pays 90% after Deductible | Plan Pays 40% after Deductible |
| Tier 3 Drugs | Plan Pays 90% after Deductible | Plan Pays 40% after Deductible |
| Mail Order | Plan Pays 90% after Deductible | Not Covered |
* Please refer to the benefit summary for Rx Tier descriptions
Basic Plan Summary 1-1-2024 thru 9-30-2024