2023 Plan Breakdown
Plan details for HDHP Option 1
Deductible (In-Network)
$1,600 / $3,200
Coinsurance (In-Network)
0%
Max OOP (In-Network)
$1,600 / $3,200
Deductible (Out-Network)
$3,200 / $6,400
Coinsurance (Out-Network)
50%
Rx
Deductible
Doctor
Deductible
ER
Deductible
Plan details for HDHP Option 2
Deductible (In-Network)
$2500 / $5000
Coinsurance (In-Network)
10%
Max OOP (In-Network)
$3,750 / $7,500
Deductible (Out-Network)
$5,000 / $10,000
Coinsurance (Out-Network)
50%
Rx
Deductible
Doctor
Deductible
ER
Deductible
Plan details for HDHP Option 3
Deductible (In-Network)
$3,000 / $6,000
Coinsurance (In-Network)
10%
Max OOP (In-Network)
$4,500 / $9,000
Deductible (Out-Network)
$6,000 / $12,000
Coinsurance (Out-Network)
50%
Rx
Deductible
Doctor
Deductible
ER
Deductible
Plan details for HDHP Option 4
Deductible (In-Network)
$3,500 / $7,000
Coinsurance (In-Network)
10%
Max OOP (In-Network)
$5,250 / $10,500
Deductible (Out-Network)
$7,000 / $14,000
Coinsurance (Out-Network)
50%
Rx
Deductible
Doctor
Deductible
ER
Deductible
Plan details for HDHP Option 6
Deductible (In-Network)
$3,500 / $7,000
Coinsurance (In-Network)
30%
Max OOP (In-Network)
$7,000 / $12,000
Deductible (Out-Network)
$5,000 / $10,000
Coinsurance (Out-Network)
50%
Rx
30% after Deductible
Doctor (In-Network)
30% after Deductible
ER
30% after Deductible
Plan details for HDHP Option 7
Deductible (In-Network)
$5,000 / $10,000
Coinsurance (In-Network)
10%
Max OOP (In-Network)
$7,500 / $15,000
Deductible (Out-Network)
$10,000 / $30,000
Coinsurance (Out-Network)
50%
Rx
10% after Deductible
Doctor (In-Network)
10% after Deductible
ER
10% after Deductible
Plan details for HDHP Option 8
Deductible (In-Network)
$6,000 / $12,000
Coinsurance (In-Network)
10%
Max OOP (In-Network)
$7,500 / $15,000
Deductible (Out-Network)
$10,000 / $30,000
Coinsurance (Out-Network)
50%
Rx
10% after Deductible
Doctor (In-Network)
10% after Deductible
ER
10% after Deductible
Plan details for MM Choice Plus
Deductible (In-Network)
$500 / $1,500
Coinsurance (In-Network)
20%
Max OOP (In-Network)
$2,500 / $7,500
Deductible (Out-Network)
$1,000 / $3,000
Coinsurance (Out-Network)
50%
Rx
20% after Deductible
Doctor (In-Network)
20% after Deductible
ER
$100 + Coinsurance
Plan details for MM HD 1000
Deductible (In-Network)
$1,000 / $3,000
Coinsurance (In-Network)
20%
Max OOP (In-Network)
$3,000 / $9,000
Deductible (Out-Network)
$2,000 / $6,000
Coinsurance (Out-Network)
50%
Rx
20% after Deductible
Doctor (In-Network)
20% after Deductible
ER
$100 + Coinsurance
Plan details for MM HD 2000 Enhanced
Deductible (In-Network)
$2,000 / $6,000
Coinsurance (In-Network)
20%
Max OOP (In-Network)
$4,000 / $12,000
Deductible (Out-Network)
$4,000 / $12,000
Coinsurance (Out-Network)
50%
Rx
$5 / $35 / $60
Doctor (In-Network)
$30 / $50
ER
$100 + Coinsurance
Plan details for MM HD 5000
Deductible (In-Network)
$5,000 / $12,700
Coinsurance (In-Network)
20%
Max OOP (In-Network)
$9,100 / $18,200
Deductible (Out-Network)
$10,000 / $30,000
Coinsurance (Out-Network)
50%
Rx
20% after Deductible
Doctor (In-Network)
20% after Deductible
ER
$100 + Coinsurance
Plan details for Premier Plus
Deductible (In-Network)
$1,750 / $3,500
Coinsurance (In-Network)
30%
Max OOP (In-Network)
$5,000 / $10,000
Deductible (Out-Network)
$3,500 / $7000
Coinsurance (Out-Network)
50%
Rx
$12 / $80 / $200 / $250
Doctor (In-Network)
$30 / $60
ER
$300 + Coinsurance
Plan details for Prime Plus
Deductible (In-Network)
$3,000 / $6,000
Coinsurance (In-Network)
30%
Max OOP (In-Network)
$7,900 / $15,800
Deductible (Out- Network)
$5,000 / $10,000
Coinsurance (Out-Network)
50%
Rx
$12 / $80 / $200 / $250
Doctor (In-Network)
$30 / $60
ER
$300 + Coinsurance
Plan details for Select Plus
Deductible (In-Network)
$3,500 / $7,000
Coinsurance (In-Network)
30%
Max OOP (In-Network)
$7,900 / $15,800
Deductible (Out-Network)
$6,500 / $13,000
Coinsurance (Out-Network)
50%
Rx
$12 / $80 / $200 / $250
Doctor (In-Network)
$30 / $60
ER
$300 + Coinsurance
Plan details for Value Plus
Deductible (In-Network)
$9,100 / $18,200
Coinsurance (In-Network)
0%
Max OOP (In-Network)
$9,100 / $18,200
Deductible (Out-Network)
$10,000 / $30,000
Coinsurance (Out-Network)
50%
Rx
$12 / $80 / $100 / $250
Doctor (In-Network)
$30 / $60
ER
$300 + Coinsurance
Plan details for Basic
Calendar Deductible
Individual $50
Family 3 Individuals
Deductible Applies
Class II & III
Calendar Year Maximum Benefit
$1,000
Orthodontia
N/A
Highlights of Covered Services
Class I-Diagnostic & Preventative
Oral evaluations, routine cleanings, bitewing X-rays, fluoride treatments, sealants, intraoral complete series X-rays or panoramic film, other X-rays100%
Class II-Basic
Palliative treatment, fillings, simple extractions, space maintainers75%
Class III-Major
Crowns, crown buildup, stainless steel crowns, root canal therapy, periodontics, oral surgery, biopsy, general anesthesia and intravenous sedation, full and partial dentures, inlays, onlays bridges45%
Out of Network claims paid at the 80th percentile of usual and customary (UCR)
Plan details for Enhanced
Calendar Deductible
Individual $50
Family 3 Individuals
Deductible Applies
Class II & III
Calendar Year Maximum Benefit
$1,000 (Class I claims do NOT count against annual maximum)
Orthodontia
Adult & Child
Highlights of Covered Services
Class I-Diagnostic & Preventative
Oral evaluations, routine cleanings, bitewing X-rays, fluoride treatments, sealants, intraoral complete series X-rays or panoramic film, other X-rays100%
Class II-Basic
Palliative treatment, fillings, simple extractions, space maintainers, root canal therapy, periodontics, biopsy, general anesthesia and intravenous sedation80%
Class III-Major
Crowns, crown buildup, stainless steel crowns, oral surgery, full and partial dentures, inlays, onlays bridges50%
Class IV
Orthodontic extractions, full or partial bands, appliances (removable and fixed)50%
Family Tier
Employee Only$34.34
Employee + Spouse
$68.63
Employee + Children
$80.31
Family
$115.47
Out of Network claims paid at the 90th percentile of usual and customary (UCR)
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