Compare your 2023 health plans
Use the chart below to compare plan benefits and costs.
| Compare your benefit choices | |||||
| Plan details | EPO* | HDHP PPO | PPO | ||
| In-network | In-network | Non-network | In-network | Non-network | |
| Calendar-year deductible | $500 Individual/ $1,500 Famiy | $5,000 Individual/ $10,000 Family | $5,000 Individual/ $10,000 Family | $500 Individual/ $1,000 Famiy | $500 Individual/ $1,000 Famiy |
| Medical out-of-pocket maximum | $3,500 Individual/ $7,000 Family | $6,000 Individual/ $12,000 Family | $6,000 Individual/ $12,000 Family | $2,500 Individual/ $5,000 Family | $3,500 Individual/ $7,000 Family |
| Hospital and Physician services | |||||
| Primary care physician | $25/visit | 20% Deductible applies | 50% Deductible applies | $25/visit | 50% Deductible applies |
| Specialist care office visit | $35/visit | 20% Deductible applies | 50% Deductible applies | $35/visit | 50% Deductible applies |
| Preventive health exam | $0 | $0 | Not covered | $0 | 50% Deductible applies |
| Outpatient x-ray, pathology and laboratory (non-hospital facilities) | $25/visit | 20% Deductible applies | 50% Deductible applies | $0 | $0 |
| Outpatient surgery in hospital | $250/surgery Deductible applies | 20% Deductible applies | 50% Subject to a Benefit maximum of $350/day Deductible applies | $0 Deductible applies | 50% Subject to a Benefit maximum of $2,000/day Deductible applies |
| Inpatient facility services | $500/admission plus 20% Deductible applies | $100/admission plus 20% Deductible applies | 50% Subject to a Benefit maximum of $600/day Deductible applies | $500/admission plus 20% Deductible applies | $500/admission plus 50% Subject to a Benefit maximum of $2,000/day Deductible applies |
| Virtual services | |||||
| Teladoc (virtual medical doctor visits) | $0 | $0 Deductible applies | Not covered | $0 | Not covered |
| Teladoc (mental health professional video or phone consultation) | $0 | 5 | Not covered | $0 | Not covered |
| Emergency care | |||||
| Urgent care center | $25/visit | 20% Deductible applies | 50% Deductible applies | $25/visit | 50% Deductible applies |
| Emergency room services facilities | $125/visit plus 20% | $150/visit plus 20% Deductible applies | $150/visit plus 20% Deductible applies | $125/visit plus 20% | $125/visit plus 20% |
| Ambulance services | 20% Deductible applies | 20% Deductible applies | 20% Deductible applies | 20% Deductible applies | 20% Deductible applies |
| Specialty services | |||||
| Pregnancy and maternity care (Prenatal and Postnatal) | $25/visit | 20% Deductible applies | 50% Deductible applies | $25/visit | 50% Deductible applies |
| Acupuncture services | $25/visit | 20% Deductible applies | 50% Deductible applies | $25/visit | 50% Deductible applies |
| Chiropractic services | $25/visit | 20% Deductible applies | 50% Deductible applies | $25/visit | 50% Deductible applies |
| Mental health office visit | $0 | 20% Deductible applies | 50% Deductible applies | $0 | 50% Deductible applies |
| Mental health inpatient services facilities | $500/admission plus 20% Deductible applies | $100/admission plus 20% Deductible applies | 50% Deductible applies | $500/admission plus 20% Deductible applies | 50% Deductible applies |
| Substance abuse (inpatient/outpatient facilities) | $500/admission plus 20% Deductible applies Inpatient/ $0 Outpatient |
$100/admission plus 20% Deductible applies Inpatient/ 20% Deductible applies Outpatient |
50% Deductible applies | $500/admission plus 20% Deductible applies Inpatient/ $0 Outpatient |
50% Deductible applies |
| Pharmacy benefits | |||||
| Retail prescription (30-day supply) | |||||
| Contraceptive Drugs and devices | $0/prescription | $0/prescription | Applicable Tier 1,Tier 2, or Tier 3 Copayment | $0/prescription | Applicable Tier 1, Tier 2, or Tier 3 Copayment |
| Value Based Tier Drugs or HDHP preventative Drugs | $0/prescription | $0/prescription | Not covered | $0/prescription | Not covered |
| Tier 1 Drugs | $10/prescription | $10/prescription Deductible applies | 25% plus $10/prescription Deductible applies | $10/prescription | 25% plus $10/prescription Deductible applies |
| Tier 2 Drugs | $25/prescription | $25/prescription Deductible applies | 25% plus $25/prescription Deductible applies | $25/prescription | 25% plus $25/prescription Deductible applies |
| Tier 3 Drugs | $40/prescription | $40/prescription Deductible applies | 25% plus $40/prescription Deductible applies | $40/prescription | 25% plus $40/prescription Deductible applies |
| Tier 4 Drugs | $40/prescription | $40/prescription Deductible applies | 25% plus $40/prescription Deductible applies | $40/prescription | 25% plus $40/prescription Deductible applies |
| Mail-service prescriptions (up to 90-day supply) | |||||
| Contraceptive Drugs and devices | $0/prescription | $0/prescription | Not covered | $0/prescription | Not covered |
| Value Based Tier Drugs or HDHP preventative Drugs | $0/prescription | $0/prescription | Not covered | $0/prescription | Not covered |
| Tier 1 Drugs | $20/prescription | $20/prescription Deductible applies | Not covered | $20/prescription | Not covered |
| Tier 2 Drugs | $50/prescription | $50/prescription Deductible applies | Not covered | $50/prescription | Not covered |
| Tier 3 Drugs | $80/prescription | $80/prescription Deductible applies | Not covered | $80/prescription | Not covered |
| Tier 4 Drugs | $80/prescription | $80/prescription Deductible applies | Not covered | $80/prescription | Not covered |
*Out-of-network services are not covered under the EPO plan.