| Medical Plan Benefits | Gold EPO | Silver EPO | Bronze EPO |
|---|---|---|---|
| Annual Deductible | $1,500 Individual | $3,000 Individual | 5,000 Individual |
| Coinsurance | 80% | 70% | 70% |
| Annual Out of Pocket Max | $7,000 Individual | $7,000 Individual | $7,000 Individual |
| Preventive Care Services | 100% | 100% | 100% |
| Accolade (Virtual Care) | $0 copay | $0 copay | $0 copay |
| Airrosti | $30 copay | $40 copay | 70% after deductible |
| Officie Visit: PCP | $10 copay | $20 copay | 70% after deductible |
| Office Visit: Specialist | $30 copay | $40 copay | 70% after deductible |
Hospital Services | 80% after deductible | 70% after deductible | 70% after deductible |
| Urgent Care | $40 copay | $40 copay | 70% after deductible |
| Emergency Room | $500 copay per visit; 20% Coinsurance | $500 copay per visit; 30% Coinsurance | 70% after deductible |
| Prescription Services | |||
| Rx: Retail (30 days) | |||
| Tier 1 | $5 copay | $5 copay | 70% after deductible |
| Tier 2 | $50 copay | $50 copay | |
| Tier 3 | $100 copay | $100 copay | |
| Tier 4 | $250 copay | $250 copay | |