Quick facts
Deductible (Individual)
$750
Deductible (Family)
$1,500
Out-of-Pocket Max (Individual)
$5,250
Out-of-Pocket Max (Family)
$10,500
Primary Care Visit Copay
$25 copay per visit
Specialist Visit Copay
$55 copay per visit
Emergency Room Care
$400 copay per visit, deductible applies
Inpatient Hospital Stay Coinsurance
20% coinsurance after deductible
More details (4)
Generic Drugs
$12 copay retail, $24 copay mail order
Preventive Care/Screening/Immunization
No charge
Outpatient Surgery
20% coinsurance after deductible
Preferred Brand Drugs
$45 copay retail
Carrier contact
1-800-555-0199 — member services
Group number: MHA-QA-4471
Your member ID card: check the carrier website or app, or ask HR for a copy.
Plan documents
Confirm details with your carrier for current plan information.