Medical
Medical coverage provides healthcare protection for you and your family. You can visit any provider, but in-network doctors offer the highest level of benefits and lower out-of-pocket costs by charging reduced, contracted rates. Out-of-network providers set their own fees, so you may be responsible for charges above the Reasonable and Customary (R&C) limits. Preventive care—such as physical exams, flu shots, and screenings—is covered at 100% when you use in-network providers. The main differences between plan options are how much you pay per paycheck and what you pay when you receive care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums– the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Providence Gold
Benefit Highlights
In-Network
Deductible (Individual/Family)
$1,000 / $2,000
Out-of-Pocket Max (Individual/Family)
$7,350 / $14,700
Preventive Care
$0 (deductible waived)
Primary Care Visit
1st 3 visits $5 copay, then $35 copay (deductible waived)
Specialist Visit
$45 copay (deductible waived)
Urgent Care
$45 copay (deductible waived)
Emergency Room
$250 copay
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay (deductible waived)
Preferred Brand
$15 copay (deductible waived)
Non-Preferred Brand
$45 copay (deductible waived)
Specialty
50% coinsurance, up to $200 (deductible waived)
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay (deductible waived)
Preferred Brand
$30 copay (deductible waived)
Non-Preferred Brand
$90 copay (deductible waived)
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$2,000 / $4,000
Out-of-Pocket Max (Individual/Family)
$14,700 / $29,400
Preventive Care
40% coinsurance
Primary Care Visit
40% coinsurance (deductible waived)
Specialist Visit
40% coinsurance (deductible waived)
Urgent Care
40% coinsurance (deductible waived)
Emergency Room
$250 copay
Retail Rx (Up to 30-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Providence Silver
Benefit Highlights
In-Network
Deductible (Individual/Family)
$2,500 / $5,000
Out-of-Pocket Max (Individual/Family)
$7,350 / $14,700
Preventive Care
$0 (deductible waived)
Primary Care Visit
1st 3 visits $5 copay, then $35 copay (deductible waived)
Specialist Visit
$45 copay (deductible waived)
Urgent Care
$45 copay (deductible waived)
Emergency Room
$250 copay
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay (deductible waived)
Preferred Brand
$15 copay (deductible waived)
Non-Preferred Brand
$45 copay (deductible waived)
Specialty
50% coinsurance, up to $200 (deductible waived)
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay (deductible waived)
Preferred Brand
$30 copay (deductible waived)
Non-Preferred Brand
$90 copay (deductible waived)
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$5,000 / $10,000
Out-of-Pocket Max (Individual/Family)
$14,700 / $29,400
Preventive Care
50% coinsurance
Primary Care Visit
50% coinsurance (deductible waived)
Specialist Visit
50% coinsurance (deductible waived)
Urgent Care
50% coinsurance (deductible waived)
Emergency Room
$250 copay
Retail Rx (Up to 30-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Providence HSA E 1700
Benefit Highlights
In-Network
Deductible (Individual/Family)
$1,700 / $3,400
Out-of-Pocket Max (Individual/Family)
$3,400 / $6,800
Preventive Care
$0 (deductible waived)
Primary Care Visit
20% coinsurance
Specialist Visit
20% coinsurance
Urgent Care
20% coinsurance
Emergency Room
20% coinsurance
Retail Rx (Up to 30-Day Supply)
Generic
20% coinsurance
Preferred Brand
20% coinsurance
Non-Preferred Brand
20% coinsurance
Specialty
20% coinsurance, up to $200
Mail-Order Rx (Up to 90-Day Supply)
Generic
20% coinsurance
Preferred Brand
20% coinsurance
Non-Preferred Brand
20% coinsurance
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$3,300 / $6,600
Out-of-Pocket Max (Individual/Family)
$6,600 / $13,200
Preventive Care
40% coinsurance
Primary Care Visit
40% coinsurance
Specialist Visit
40% coinsurance
Urgent Care
40% coinsurance
Emergency Room
40% coinsurance
Retail Rx (Up to 30-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Providence HSA 6650
Benefit Highlights
In-Network
Deductible (Individual/Family)
$6,650 / $13,300
Out-of-Pocket Max (Individual/Family)
$6,650 / $13,300
Preventive Care
$0 after deductible
Primary Care Visit
$0 after deductible
Specialist Visit
$0 after deductible
Urgent Care
$0 after deductible
Emergency Room
$0 after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$0 after deductible
Preferred Brand
$0 after deductible
Non-Preferred Brand
$0 after deductible
Specialty
$0 after deductible
Mail-Order Rx (Up to 90-Day Supply)
Generic
$0 after deductible
Preferred Brand
$0 after deductible
Non-Preferred Brand
$0 after deductible
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$13,300 / $26,600
Out-of-Pocket Max (Individual/Family)
$13,300 / $26,600
Preventive Care
$0 after deductible
Primary Care Visit
$0 after deductible
Specialist Visit
$0 after deductible
Urgent Care
$0 after deductible
Emergency Room
$0 after deductible
Retail Rx (Up to 30-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Providence Gold Extend PPO
Benefit Highlights
In-Network
Deductible (Individual/Family)
$1,000 / $2,000
Out-of-Pocket Max (Individual/Family)
$7,350 / $14,700
Preventive Care
$0 (deductible waived)
Primary Care Visit
1st 3 visits $5 copay, then $35 copay (deductible waived)
Specialist Visit
$45 copay (deductible waived)
Urgent Care
$45 copay (deductible waived)
Emergency Room
$250 copay
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay (deductible waived)
Preferred Brand
$15 copay (deductible waived)
Non-Preferred Brand
$45 copay (deductible waived)
Specialty
50% coinsurance, up to $200 (deductible waived)
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay (deductible waived)
Preferred Brand
$30 copay (deductible waived)
Non-Preferred Brand
$90 copay (deductible waived)
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$2,000 / $4,000
Out-of-Pocket Max (Individual/Family)
$14,700 / $29,400
Preventive Care
40% coinsurance
Primary Care Visit
40% coinsurance (deductible waived)
Specialist Visit
40% coinsurance (deductible waived)
Urgent Care
40% coinsurance (deductible waived)
Emergency Room
$250 copay
Retail Rx (Up to 30-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Providence Silver Extend PPO
Benefit Highlights
In-Network
Deductible (Individual/Family)
$2,500 / $5,000
Out-of-Pocket Max (Individual/Family)
$7,350 / $14,700
Preventive Care
$0 (deductible waived)
Primary Care Visit
1st 3 visits $5 copay, then $35 copay (deductible waived)
Specialist Visit
$45 copay (deductible waived)
Urgent Care
$45 copay (deductible waived)
Emergency Room
$250 copay
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay (deductible waived)
Preferred Brand
$15 copay (deductible waived)
Non-Preferred Brand
$45 copay (deductible waived)
Specialty
50% coinsurance, up to $200 (deductible waived)
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay (deductible waived)
Preferred Brand
$30 copay (deductible waived)
Non-Preferred Brand
$90 copay (deductible waived)
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$5,000 / $10,000
Out-of-Pocket Max (Individual/Family)
$14,700 / $29,400
Preventive Care
50% coinsurance
Primary Care Visit
50% coinsurance (deductible waived)
Specialist Visit
50% coinsurance (deductible waived)
Urgent Care
50% coinsurance (deductible waived)
Emergency Room
$250 copay
Retail Rx (Up to 30-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Providence Platinum Connect
Benefit Highlights
In-Network
Deductible (Individual/Family)
$500 / $1,000
Out-of-Pocket Max (Individual/Family)
$5,850 / $11,700
Preventive Care
$0 (deductible waived)
Primary Care Visit
1st 3 visits $5 copay, then $20 copay (deductible waived)
Specialist Visit
$40 copay (deductible waived)
Urgent Care
$40 copay (deductible waived)
Emergency Room
$250 copay
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay (deductible waived)
Preferred Brand
$15 copay (deductible waived)
Non-Preferred Brand
$45 copay (deductible waived)
Specialty
50% coinsurance, up to $200 (deductible waived)
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay (deductible waived)
Preferred Brand
$30 copay (deductible waived)
Non-Preferred Brand
$90 copay (deductible waived)
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$1,000 / $2,000
Out-of-Pocket Max (Individual/Family)
$11,700 / $23,400
Preventive Care
50% coinsurance
Primary Care Visit
50% coinsurance
Specialist Visit
50% coinsurance
Urgent Care
50% coinsurance
Emergency Room
$250 copay
Retail Rx (Up to 30-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Providence Gold Connect
Benefit Highlights
In-Network
Deductible (Individual/Family)
$1,500 / $3,000
Out-of-Pocket Max (Individual/Family)
$7,350 / $14,700
Preventive Care
$0 (deductible waived)
Primary Care Visit
1st 3 visits $5 copay, then $35 copay (deductible waived)
Specialist Visit
$70 copay (deductible waived)
Urgent Care
$70 copay (deductible waived)
Emergency Room
$250 copay
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay (deductible waived)
Preferred Brand
$15 copay (deductible waived)
Non-Preferred Brand
$45 copay (deductible waived)
Specialty
50% coinsurance, up to $200 (deductible waived)
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay (deductible waived)
Preferred Brand
$30 copay (deductible waived)
Non-Preferred Brand
$90 copay (deductible waived)
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$3,000 / $6,000
Out-of-Pocket Max (Individual/Family)
$14,700 / $29,400
Preventive Care
50% coinsurance
Primary Care Visit
50% coinsurance
Specialist Visit
50% coinsurance
Urgent Care
50% coinsurance
Emergency Room
$250 copay
Retail Rx (Up to 30-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Providence HSA 8500 Connect
Benefit Highlights
In-Network
Deductible (Individual/Family)
$8,500 / $17,000
Out-of-Pocket Max (Individual/Family)
$8,500 / $17,000
Preventive Care
$0 after deductible
Primary Care Visit
$0 after deductible
Specialist Visit
$0 after deductible
Urgent Care
$0 after deductible
Emergency Room
$0 after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$0 after deductible
Preferred Brand
$0 after deductible
Non-Preferred Brand
$0 after deductible
Specialty
$0 after deductible
Mail-Order Rx (Up to 90-Day Supply)
Generic
$0 after deductible
Preferred Brand
$0 after deductible
Non-Preferred Brand
$0 after deductible
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$17,000 / $34,000
Out-of-Pocket Max (Individual/Family)
$17,000 / $34,000
Preventive Care
$0 after deductible
Primary Care Visit
$0 after deductible
Specialist Visit
$0 after deductible
Urgent Care
$0 after deductible
Emergency Room
$0 after deductible
Retail Rx (Up to 30-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Providence Platinum Choice
Benefit Highlights
In-Network
Deductible (Individual/Family)
$500 / $1,000
Out-of-Pocket Max (Individual/Family)
$5,850 / $11,700
Preventive Care
$0 (deductible waived)
Primary Care Visit
1st 3 visits $5 copay, then $20 copay (deductible waived)
Specialist Visit
$40 copay (deductible waived)
Urgent Care
$40 copay (deductible waived)
Emergency Room
$250 copay
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay (deductible waived)
Preferred Brand
$15 copay (deductible waived)
Non-Preferred Brand
$45 copay (deductible waived)
Specialty
50% coinsurance, up to $200 (deductible waived)
Mail-Order Rx (Up to 90-Day Supply
Generic
$20 copay (deductible waived)
Preferred Brand
$30 copay (deductible waived)
Non-Preferred Brand
$90 copay (deductible waived)
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$1,000 / $2,000
Out-of-Pocket Max (Individual/Family)
$11,700 / $23,400
Preventive Care
50% coinsurance
Primary Care Visit
50% coinsurance
Specialist Visit
50% coinsurance
Urgent Care
50% coinsurance
Emergency Room
$250 copay
Retail Rx (Up to 30-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Providence Gold Choice 4000
Benefit Highlights
In-Network
Deductible (Individual/Family)
$4,000 / $8,000
Out-of-Pocket Max (Individual/Family)
$9,200 / $18,400
Preventive Care
$0 (deductible waived)
Primary Care Visit
$20 copay (deductible waived)
Specialist Visit
$40 copay (deductible waived)
Urgent Care
$40 copay (deductible waived)
Emergency Room
$250 copay
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay (deductible waived)
Preferred Brand
$15 copay (deductible waived)
Non-Preferred Brand
$45 copay (deductible waived)
Specialty
50% coinsurance, up to $200 (deductible waived)
Mail-Order Rx (Up to 90-Day Supply
Generic
$20 copay (deductible waived)
Preferred Brand
$30 copay (deductible waived)
Non-Preferred Brand
$90 copay (deductible waived)
Specialty
Not covered
Out-of-Network
Deductible (Individual/Family)
$8,000 / $16,000
Out-of-Pocket Max (Individual/Family)
$18,400 / $36,800
Preventive Care
50% coinsurance
Primary Care Visit
50% coinsurance
Specialist Visit
50% coinsurance
Urgent Care
50% coinsurance
Emergency Room
$250 copay
Retail Rx (Up to 30-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Kaiser Gold PPO
Benefit Highlights
In-Network
Deductible (Individual/Family)
$1,000 / $3,000
Out-of-Pocket Max (Individual/Family)
$4,000 / $8,000
Preventive Care
$0 (deductible waived)
Primary Care Visit
1st 3 visits $5 copay, then $25 copay (deductible waived)
Specialist Visit
$35 copay (deductible waived)
Urgent Care
$45 copay (deductible waived)
Emergency Room
$250 copay
Retail Rx (Up to 30-Day Supply)
Generic
$15 copay (deductible waived)
Preferred Brand
$30 copay (deductible waived)
Non-Preferred Brand
$50 copay (deductible waived)
Mail-Order Rx (Up to 90-Day Supply)
Generic
$30 copay (deductible waived)
Preferred Brand
$60 copay (deductible waived)
Non-Preferred Brand
$100 copay (deductible waived)
Vision Service
Routine Eye Exam
$25 copay
Vision Hardware (Lenses and Frames)
$150 allowance
PPO Provider
Deductible (Individual/Family)
$2,000 / $6,000
Out-of-Pocket Max (Individual/Family)
$6,000 / $12,000
Preventive Care
$0 (deductible waived)
Primary Care Visit
1st 3 visits $5 copay, then $35 copay (deductible waived)
Specialist Visit
$45 copay (deductible waived)
Urgent Care
$55 copay (deductible waived)
Emergency Room
$200 copay
Retail Rx (Up to 30-Day Supply)
Generic
$20 copay (deductible waived)
Preferred Brand
$40 copay (deductible waived)
Non-Preferred Brand
$60 copay (deductible waived)
Mail-Order Rx (Up to 90-Day Supply)
Generic
$60 copay (deductible waived)
Preferred Brand
$120 copay (deductible waived)
Non-Preferred Brand
$180 copay (deductible waived)
Vision Services
Routine Eye Exam
$35 copay
Vision Hardware (Lenses and Frames)
$150 allowance
Out-of-Network
Deductible (Individual/Family)
$3,000 / $9,000
Out-of-Pocket Max (Individual/Family)
$7,500 / $15,000
Preventive Care
40% coinsurance
Primary Care Visit
40% coinsurance
Specialist Visit
40% coinsurance
Urgent Care
40% coinsurance
Emergency Room
$200 copay
Retail Rx (Up to 30-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Plan Documents
Kaiser Gold
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$1,000 / $3,000
Out-of-Pocket Max (Individual/Family)
$4,000 / $12,000
Preventive Care
$0 (deductible waived)
Primary Care Visit
$25 copay (deductible waived)
Specialist Visit
$35 copay (deductible waived)
Urgent Care
$45 copay (deductible waived)
Emergency Room
20% coinsurance
Retail Rx (Up to 30-Day Supply)
Generic
$20 copay (deductible waived)
Preferred Brand
$40 copay (deductible waived)
Non-Preferred Brand
$60 copay (deductible waived)
Mail-Order Rx (Up to 90-Day Supply
Generic
$40 copay (deductible waived)
Preferred Brand
$80 copay (deductible waived)
Non-Preferred Brand
$120 copay (deductible waived)
Specialty
Not covered
Vision Services
Routine Eye Exam
$25 copay
Vision Hardware (Lenses and Frames)
$150 allowance
Plan Documents
Kaiser Silver
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$1,500 / $4,500
Out-of-Pocket Max (Individual/Family)
$4,000 / $12,000
Preventive Care
$0
Primary Care Visit
1st 3 visits $5 copay, then $20 copay (deductible waived)
Specialist Visit
$20 copay (deductible waived)
Urgent Care
$20 copay (deductible waived)
Emergency Room
$250 copay
Retail Rx (Up to 30-Day Supply)
Generic
$20 copay (deductible waived)
Preferred Brand
$40 copay (deductible waived)
Non-Preferred Brand
$60 copay (deductible waived)
Mail-Order Rx (Up to 90-Day Supply)
Generic
$40 copay (deductible waived)
Preferred Brand
$80 copay (deductible waived)
Non-Preferred Brand
$120 copay (deductible waived)
Vision Services
Routine Eye Exam
$20 copay
Vision Hardware (Lenses and Frames)
$150 allowance
Kaiser Bronze
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$3,000 / $9,000
Out-of-Pocket Max (Individual/Family)
$7,350 / $14,700
Preventive Care
$0 (deductible waived)
Primary Care Visit
1st 3 visits $5 copay, then $30 copay (deductible waived)
Specialist Visit
$40 copay (deductible waived)
Urgent Care
$50 copay (deductible waived)
Emergency Room
20% coinsurance
Retail Rx (Up to 30-Day Supply)
Generic
$20 copay
Preferred Brand
$40 copay
Non-Preferred Brand
$60 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$40 copay (deductible waived)
Preferred Brand
$80 copay (deductible waived)
Non-Preferred Brand
$120 copay (deductible waived)
Vision Services
Routine Eye Exam
$30 copay
Vision Hardware (Lenses and Frames)
$150 allowance
Kaiser HSA
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$5,000 / $10,000
Out-of-Pocket Max (Individual/Family)
$6,750 / $13,500
Preventive Care
$0 (deductible does not apply)
Primary Care Visit
1st 3 visits $5 copay, then 50% coinsurance
Specialist Visit
50% coinsurance
Urgent Care
50% coinsurance
Emergency Room
50% coinsurance
Retail Rx (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$50 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$30 copay (deductible waived)
Preferred Brand
$60 copay (deductible waived)
Non-Preferred Brand
$100 copay (deductible waived)
Vision Services
Routine Eye Exam
50% coinsurance
Vision Hardware (Lenses and Frames)
$150 allowance