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Deductible

The fixed dollar amount you must pay each calendar year before benefits subject to the annual deductible become available. You cannot pay the annual deductible amount to us in advance. You must meet the deductible on a claim by claim basis.

Coverage Amount
Individual $0
Family $0

Out-of-Pocket Maximum

The maximum deductible, copayment and coinsurance amounts you pay in a calendar year. Once you meet the coinsurance maximum you are no longer responsible for deductible, copayment, or coinsurance amounts.

Coverage Medical Prescription Drug and Supplies
Individual $2,500 $5,000
Family $7,500 $7,500

Please refer to your Description of Coverage (DOC) and Prescription Drug Plan Certificate (DRC) for additional information. In the case of a discrepancy between this website and the language contained within the DOC or DRC, the latter will take precedence.