| $500 PPO | $1,500 PPO | $250 ACO | $2,500 HDHP | $4,000 HDHP | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Providers | In-network | Out-of-network | In-network | Out-of-network | In-network | Out-of-network | In-network | Out-of-network | In-network | Out-of-network |
| Individual deductible | $500 | $1,000 | $1,500 | $3,000 | $250 | n/a | $2,500 | $5,000 | $4,000 | $8,000 |
| Family deductible | $1,000 | $2,000 | $3,000 | $6,000 | $500 | n/a | $5,000 | $10,000 | $4,000 individual in a family / $8,000 family | $8,000 individual in a family / $16,000 family |
| Coinsurance after deductible: Your share / insurance share | 10% / 90% | 50%/ 50% | 20% / 80% | 50%/ 50% | 0% / 100% | n/a | 20% / 80% | 50% / 50% | 20% / 80% | 50% / 50% |
| Individual out-of-pocket maximum | $1,500 | $3,000 | $2,500 | $5,000 | $1,250 | n/a | $4,000 | $8,000 | $5,500 | $11,000 |
| Family out-of-pocket maximum | $3,000 | $6,000 | $5,000 | $10,000 | $2,500 | n/a | $8,000 | $16,000 | $5500 individual in a family / $11,000 family | $11,000 individual in a family / $22,000 family |
| Primary care copay | $30 | 50% | 20% | 50% | $30 | n/a | 20% | 50% | 20% | 50% |
| Specialist copay | $40 | 50% | 20% | 50% | $60 | n/a | 20% | 50% | 20% | 50% |
| ER copay | $150 | $150 | 20% | 20% | $150 | n/a | 20% | 20% | 20% | 20% |
| Urgent care copay | $40 | 50% | 20% | 50% | $40 | n/a | 20% | 50% | 20% | 50% |