| Deductible (individual, in-network) | $0 | $1,000 | $1,500 | $3,000 | $3,400 | $5,000 | $6,000 | $8,000 |
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| Deductible (family, in-network) | $0 | $2,000 | $3,000 | $6,000 | $6,800 | $10,000 | $12,000 | $16,000 |
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| Out-of-pocket max (individual) | $1,250 | $3,500 | $3,000 | $6,000 | $6,800 | $8,700 | $7,000 | $8,700 |
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| Out-of-pocket max (family) | $2,500 | $7,000 | $6,000 | $12,000 | $13,300 | $17,400 | $14,000 | $17,400 |
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| Primary care visit | $25 copay, deductible waived | $15 copay, deductible waived | $35 copay, deductible waived | $35 copay, deductible waived | 20% after deductible | $40 copay, deductible waived | 30% after deductible | $50 copay, deductible waived |
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| Specialist visit | $45 copay, deductible waived | $40 copay, deductible waived | $55 copay, deductible waived | $55 copay, deductible waived | 20% after deductible | $80 copay, deductible waived | 30% after deductible | $120 copay, deductible waived |
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| Urgent care | $45 copay, deductible waived | $40 copay, deductible waived | $55 copay, deductible waived | $55 copay, deductible waived | 20% after deductible | $60 copay, deductible waived | 30% after deductible | $100 copay, deductible waived |
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| Coinsurance (in-network) | 30% after deductible | 20% after deductible | 20% after deductible | 20% after deductible | 20% after deductible | 30% after deductible | 30% after deductible | 30% after deductible |
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| Generic drugs (retail) | $0 copay/Rx, deductible waived | $0 copay/Rx, deductible waived | $0 copay/Rx, deductible waived | $0 copay/Rx, deductible waived | 0% after deductible | $0 copay/Rx, deductible waived | 0% after deductible | $0 copay/Rx, deductible waived |
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| Preferred brand (retail) | $35 copay/Rx, deductible waived | $35 copay/Rx, deductible waived | $35 copay/Rx, deductible waived | $35 copay/Rx, deductible waived | 25% after deductible | $35 copay/Rx, deductible waived | 25% after deductible | $35 copay/Rx, deductible waived |
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