Preventive | In Network | $0. Preventive is without cost share. | $0. Preventive is without cost share. |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Deductible | In Network | $2,500 person/$5,000 family | $3,000 person / $6,000 family |
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Out of Network | $5,000 person/$10,000 family | $6,000 person/$12,000 family |

Coinsurance | In Network | 20% | 20% |
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Out of Network | 50% | 50% |

Coinsurance maximum | In Network | N/A | N/A |
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Out of Network | $7,000 person/$14,000 family | $12,000 person/$24,000 family |

Annual out-of-pocket maximum | In Network | $5,200 person/$10,400 family | $6,000 person/$12,000 family |
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Out of Network | N/A | N/A |

Office visit - primary | In Network | $35 copay/visit, 5 visits per person at copay then subject to deductible and 20% coinsurance | $35 copay/visit |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Office visit - specialist | In Network | $70 copay/visit | $70 copay/visit |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Generic | In Network | $100 person/$200 family deductible then subject 50% coinsurance | $15 copay |
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Out of Network |

Brand | In Network | $100 person/$200 family deductible then subject to 50% coinsurance | $50 copay |
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Out of Network |

Non-formulary | In Network | $100 person/$200 family deductible then subject to 50% coinsurance | $75 copay |
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Out of Network |

Specialty | In Network | $100 person/$200 family deductible then subject to 50% coinsurance | $150 copay |
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Out of Network |

Mail order | In Network | $100 person/$200 family deductible then subject to 50% coinsurance | $37.50 generic/$125.00 preferred/$187.50 non-preferred/$375.00 specialty 3 month supply |
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Out of Network | $15 generic/$50 preferred/$75 non-preferred/$150 specialty 30 day supply |

Emergency room services | In Network | $300 copay then subject to deductible and 20% coinsurance | Deductible then 20% coinsurance |
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Out of Network |

Emergency medical transportation | In Network | Deductible then 20% coinsurance | Deductible then 20% coinsurance |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Inpatient surgery physician/surgical services | In Network | Deductible then 20% coinsurance | Deductible then 20% coinsurance |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Inpatient facility fee | In Network | Deductible then 20% coinsurance | Deductible then 20% coinsurance |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Outpatient facility fee/ASC | In Network | Deductible then 20% coinsurance | Deductible then 20% coinsurance |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Outpatient surgery physician/surgical services | In Network | Deductible then 20% coinsurance | Deductible then 20% coinsurance |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Outpatient lab and radiology | In Network | Deductible then 20% coinsurance | Deductible then 20% coinsurance |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Advanced imaging | In Network | $250 copay then 100% | Deductible then 20% coinsurance |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Injections | In Network | Deductible then 20% coinsurance | Deductible then 20% coinsurance |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Outpatient rehabilitation | In Network | $70 copay then 100% | Deductible then 20% coinsurance |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Outpatient habilitation | In Network | $70 copay then 100% | Deductible then 20% coinsurance |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Hospice | In Network | Deductible then 20% coinsurance | Deductible then 20% coinsurance |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Home health care | In Network | Deductible then 20% coinsurance | Deductible then 20% coinsurance |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Mental illness/substance use disorders inpatient services | In Network | Deductible then 20% coinsurance | Deductible then 20% coinsurance |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Mental illness/substance use disorders outpatient services | In Network | $35 copay/visit | $35 copay/visit |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Pre and postnatal office visit | In Network | Deductible then 20% coinsurance | Deductible then 20% coinsurance |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Labor and delivery hospital stay | In Network | Deductible then 20% coinsurance | Deductible then 20% coinsurance |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Pediatric dental (age 0-19) | In Network | Deductible then 20% coinsurance | Deductible then 20% coinsurance |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Pediatric vision (age 0-19) | In Network | Deductible then 20% coinsurance | Deductible then 20% coinsurance |
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Out of Network | Deductible then 50% coinsurance | Deductible then 50% coinsurance |

Adult dental (age 20+) | In Network | Not Covered | Not Covered |
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Out of Network |

Adult vision (age 20+) | In Network | Not Covered | Not Covered |
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Out of Network |

Lifetime maximum | Unlimited for each covered person | Unlimited for each covered person. |
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Eligible dependents | Covered to age 26 | Covered to age 26 |
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Diabetic education | $35 copay/visit | $35 copay/visit then 100% |
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HSA compliant | N/A | N/A |
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