Plan overview

Plan availability

County of residence

Exchange

HSA Eligible

Covered services


Plan details

You pay

Deductible (individual / family)

Combined medical and prescription drug

Out-of-pocket max

Coinsurance


Doctor visits

You pay

Primary care office visit

Specialist office visit

Virtual care PCP visit (Delivered via the Capital Blue Cross Virtual Care platform)


Emergencies

You pay

Emergency room

Urgent care


Tests and lab work

You pay

Diagnostic lab services

Outpatient diagnostic test (X-ray)

Outpatient high tech imaging


Hospital services

You pay

Outpatient surgery service

Inpatient hospital admission


Prescriptions

You pay

Retail Rx

Home delivery Rx

Formulary


Covered services


Plan details

You pay

Routine dental check-up adult

Routine dental check-up child

Deductible adult

Deductible child

Out-of-pocket max adult

Out-of-pocket max child

Plan details

Children

Adults

Diagnostic and preventative services

Basic services

Major services

Orthodontia services


Children- under age 19

Adults- age 19 and over

Covered services


Plan details

You pay

Routine eye exam

Frames

Contact Lenses

(Instead of glasses)

UV Coating

Solid Tint

Scratch Resistance

Polycarbonate

Anti-reflective

Standard Progressive

Other add-ons


1All other brand names, product names, or trademarks belong to their respective holders.

2Discounts are not insurance and create no liability for payment by the plan.