Health plan details

This is what your plan offers

Highlights


	N/A
Estimated yearly cost
Estimated yearly cost	Use Smart Planfinder for details
Annual deductible
Annual deductible
Plan metal level
Plan metal level	N/A
Plan type
Plan type	N/A
Quality rating
Quality rating
Primary care provider required
Primary care provider required	N/A
Specialist referrals required
Specialist referrals required	N/A
Providers and facilities
Providers and facilities	Use Smart Planfinder for details
Primary care visit other than preventive services
Primary care visit other than preventive services	N/A
Specialist visit
Specialist visit	N/A
Urgent care visit
Urgent care visit	N/A
Your prescriptions
Your prescriptions
Generic prescription drugs
Generic prescription drugs	N/A
Preferred brand drugs
Preferred brand drugs	N/A
Diabetes prescription drugs
Diabetes prescription drugs	Insulin prescription cost capped at $35 for a 30-day supply
Health savings account (HSA) eligible
Health savings account (HSA) eligible	N/A

Costs for medical care

Services covered before deductible
Services covered before deductible	In network: N/A Out of network: N/A
Annual deductible
Annual deductible	In network: Out of network:
Annual out-of-pocket maximum
Annual out-of-pocket maximum	In network: N/A Out of network: N/A
Preventive services with $0 co-pay
Preventive services with $0 co-pay	In network: N/A Out of network: N/A
Primary care visit other than preventive services
Primary care visit other than preventive services	In network: N/A Out of network: N/A
Specialist visit
Specialist visit	In network: N/A Out of network: N/A
Urgent care visit
Urgent care visit	In network: N/A Out of network: N/A
Emergency room visit
Emergency room visit	In network: N/A Out of network: N/A
Outpatient laboratory test
Outpatient laboratory test	In network: N/A Out of network: N/A
Imaging (CT/PET scans, MRIs)
Imaging (CT/PET scans, MRIs)	In network: Update soon. See Summary of Benefits and Coverage. Out of network: Benefit not covered
X-rays and diagnostic imaging
X-rays and diagnostic imaging	In network: N/A Out of network: N/A
Outpatient surgery (professional fees)
Outpatient surgery (professional fees)	In network: Update soon. See Summary of Benefits and Coverage. Out of network: Benefit not covered
Outpatient surgery (facility fees)
Outpatient surgery (facility fees)	In network: N/A Out of network: N/A
Hospitalization
Hospitalization	In network: N/A Out of network: N/A
Pre and postnatal visit
Pre and postnatal visit	In network: N/A Out of network: N/A
Labor and delivery hospital stay
Labor and delivery hospital stay	In network: N/A Out of network: N/A
Out-of-country coverage
Out-of-country coverage	In network: N/A Out of network: N/A
Chiropractic visit
Chiropractic visit	In network: N/A Out of network: N/A
Mental health visit
Mental health visit	In network: N/A Out of network: N/A
Substance use disorder visit
Substance use disorder visit	In network: N/A Out of network: N/A
Vision care
Vision care	In network: N/A Out of network: N/A

Prescription drug coverage

Generic prescription drugs
Generic prescription drugs	In network: N/A Out of network: N/A
Preferred brand drugs
Preferred brand drugs	In network: N/A Out of network: N/A
Non-preferred brand prescription drugs
Non-preferred brand prescription drugs	In network: N/A Out of network: N/A
Specialty prescription drugs
Specialty prescription drugs	In network: N/A Out of network: N/A

Cost and coverage examples

Having a Baby

Cost overview
Cost overview
Amount owed to providers
Amount owed to providers	N/A
Plan pays
Plan pays	N/A
Patient pays
Patient pays	N/A
Patient cost breakdown
Patient cost breakdown
Deductible
Deductible	N/A
Co-pays
Co-pays	N/A
Co-insurance
Co-insurance	N/A
Limits or exclusions
Limits or exclusions	N/A
Total
Total	N/A

Type-2 Diabetes

Cost overview
Cost overview
Amount owed to providers
Amount owed to providers	N/A
Plan pays
Plan pays	N/A
Patient pays
Patient pays	N/A
Patient cost breakdown
Patient cost breakdown
Deductible
Deductible	N/A
Co-pays
Co-pays	N/A
Co-insurance
Co-insurance	N/A
Limits or exclusions
Limits or exclusions	N/A
Total
Total	N/A

Simple Fracture

Cost overview
Cost overview
Amount owed to providers
Amount owed to providers	N/A
Plan pays
Plan pays	N/A
Patient pays
Patient pays	N/A
Patient cost breakdown
Patient cost breakdown
Deductible
Deductible	N/A
Co-pays
Co-pays	N/A
Co-insurance
Co-insurance	N/A
Limits or exclusions
Limits or exclusions	N/A
Total
Total	N/A

Additional resources

Resources and documents

Plan brochure
Plan brochure	N/A
Summary of benefits and coverage
Summary of benefits and coverage	N/A
More about this plan
More about this plan	N/A

This is a list of commonly used benefits. It is not all inclusive. Before selecting a plan, review the plan's Summary of Benefits and Coverage (SBC) for more information on benefits and exclusions.

Back to plan options