HSA Eligible

V2500

Family

Your Monthly Premium

$

Individual Deductible
$2,500
Individual Out-of-Pocket Max
$2,500
Family Deductible
$5,000
Family Out-of-Pocket Max
$5,000
Office Visit
100% after Deductible
Specialist Visit
100% after Deductible
Dental
Included
Vision
Included

Plan Summary Details

View Rx Formulary

HSA Eligible

V5000

Family

Your Monthly Premium

$

Individual Deductible
$5,000
Individual Out-of-Pocket Max
$5,000
Family Deductible
$10,000
Family Out-of-Pocket Max
$10,000
Office Visit
100% after Deductible
Specialist Visit
100% after Deductible
Dental
Included
Vision
Included

Plan Summary Details

View Rx Formulary

V10000

Family

Your Monthly Premium

$

Individual Deductible
$10,000
Individual Out-of-Pocket Max
$10,000
Family Deductible
$20,000
Family Out-of-Pocket Max
$20,000
Office Visit
100% after Deductible
Specialist Visit
100% after Deductible
Dental
Included
Vision
Included

Plan Summary Details

View Rx Formulary

HSA Eligible

V2500

Primary + Child(ren)

Your Monthly Premium

$

Individual Deductible
$2,500
Individual Out-of-Pocket Max
$2,500
Family Deductible
$5,000
Family Out-of-Pocket Max
$5,000
Office Visit
100% after Deductible
Specialist Visit
100% after Deductible
Dental
Included
Vision
Included

Plan Summary Details

View Rx Formulary

HSA Eligible

V5000

Primary + Child(ren)

Your Monthly Premium

$

Individual Deductible
$5,000
Individual Out-of-Pocket Max
$5,000
Family Deductible
$10,000
Family Out-of-Pocket Max
$10,000
Office Visit
100% after Deductible
Specialist Visit
100% after Deductible
Dental
Included
Vision
Included

Plan Summary Details

View Rx Formulary

V10000

Primary + Child(ren)

Your Monthly Premium

$

Individual Deductible
$10,000
Individual Out-of-Pocket Max
$10,000
Family Deductible
$20,000
Family Out-of-Pocket Max
$20,000
Office Visit
100% after Deductible
Specialist Visit
100% after Deductible
Dental
Included
Vision
Included

Plan Summary Details

View Rx Formulary

HSA Eligible

V2500

Primary + Spouse

Your Monthly Premium

$

Individual Deductible
$2,500
Individual Out-of-Pocket Max
$2,500
Family Deductible
$5,000
Family Out-of-Pocket Max
$5,000
Office Visit
100% after Deductible
Specialist Visit
100% after Deductible
Dental
Included
Vision
Included

Plan Summary Details

View Rx Formulary

HSA Eligible

V5000

Primary + Spouse

Your Monthly Premium

$

Individual Deductible
$5,000
Individual Out-of-Pocket Max
$5,000
Family Deductible
$10,000
Family Out-of-Pocket Max
$10,000
Office Visit
100% after Deductible
Specialist Visit
100% after Deductible
Dental
Included
Vision
Included

Plan Summary Details

View Rx Formulary

V10000

Primary + Spouse

Your Monthly Premium

$

Individual Deductible
$10,000
Individual Out-of-Pocket Max
$10,000
Family Deductible
$20,000
Family Out-of-Pocket Max
$20,000
Office Visit
100% after Deductible
Specialist Visit
100% after Deductible
Dental
Included
Vision
Included

Plan Summary Details

View Rx Formulary

HSA Eligible

V2500

Primary Only

Your Monthly Premium

$

Individual Deductible
$2,500
Individual Out-of-Pocket Max
$2,500
Family Deductible
$5,000
Family Out-of-Pocket Max
$5,000
Office Visit
100% after Deductible
Specialist Visit
100% after Deductible
Dental
Included
Vision
Included

Plan Summary Details

View Rx Formulary