Plan overview

Plan availability

County of residence

Available in Lehigh and Northampton counties

Exchange

On and off Pennie

Covered services


Plan details

You pay

Deductible (individual / family)

$2,150 / $4,300

Out-of-pocket max (individual / family)

$8,550 / $17,100

Coinsurance

10%


Doctor visits

You pay

Primary care office visit

$20 copay

Specialist office visit

$45 copay


Emergencies

You pay

Emergency room

$300 copay after deductible

Urgent care

$75 copay


Tests and lab work

You pay

Diagnostic lab services

Paid in full after deductible

Outpatient diagnostic test (X-ray)

10% coinsurance after deductible

Outpatient high tech imaging

25% coinsurance after deductible


Hospital services

You pay

Outpatient surgery service

10% coinsurance after deductible

Inpatient hospital admission

10% coinsurance after deductible


Prescriptions

You pay

Retail Rx

Preferred generic1: $10 
Nonpreferred generic1: 25% ($250 max) 
Preferred brand: $25 
Nonpreferred brand: $75

Home delivery Rx

Preferred generic1: $20 
Nonpreferred generic1: 25% ($500 max) 
Preferred brand: $50 
Nonpreferred brand: $150


Cost Share amounts listed in the chart are for service performed at in-network providers.

1 Deductible waived for generic drugs