2017 Patient-Centered Benefit Designs and Medical Cost Shares
Benefits in blue are NOT subject to a deductible. Benefits in light-blue are subject to a deductible after the first three visits.
Coverage Category | Minimum Coverage | Bronze | Silver | Enhanced Silver 73 | Enhanced Silver 87 | Enhanced Silver 94 | Gold | Platinum |
Percent of cost coverage | Covers 0% until out-of-pocket maximum is met | Covers 60% average annual cost | Covers 70% average annual cost | Covers 73% average annual cost | Covers 87% average annual cost | Covers 94% average annual cost | Covers 80% average annual cost | Covers 90% average annual cost |
Cost-sharing Reduction Single Income Range | N/A | N/A | N/A | $23,451 to $29,425 (>200% to <= 250% FPL) |
$17,656 to $23,450 (>150% to <= 200% FPL) |
up to $17,655 (>100% to <= 150% FPL) |
N/A | N/A |
Annual Wellness Exam | $0 | $0 | $0 | $0 | $0 | $0 | $0 | $0 |
Primary Care Visit | after first 3 non-preventive visits, pay negotiated carrier rate per instance until out-of-pocket maximum is met | $75* | $35 | $30 | $10 | $5 | $30 | $15 |
Urgent Care | $75* | $35 | $30 | $10 | $5 | $30 | $15 | |
Specialist Visit | pay negotiated carrier rate per service until out-of-pocket maximum is met | $105* | $70 | $55 | $25 | $8 | $55 | $40 |
Laboratory Tests | $40 | $35 | $35 | $15 | $8 | $35 | $20 | |
X-Rays and Diagnostics | Full cost until deductible is met | $70 | $65 | $25 | $8 | $55 | $40 | |
Imaging | $300 | $300 | $100 | $50 | $275 copay 20% coinsurance*** |
$150 copay 10% coinsurance*** |
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Tier 1 (Generic Drugs) | pay negotiated carrier rate per script until out-of-pocket maximum is met | Full cost up to $500 after drug deductible is met | $15 | $15 | $5 | $3 | $15 | $5 |
Tier 2 (Preferred Drugs) | $55** | $50** | $20** | $10 | $55 or less | $15 or less | ||
Tier 3 (Non-preferred Drugs) | $80** | $75** | $35** | $15 | $75 or less | $25 of less | ||
Tier 4 (Specialty Drugs) | 20% up to $250** per script |
20% up to $250** per script |
15% up to $150** per script |
10% up to $150 per script |
20% up to $250 per script |
10% up to $250 per script |
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Medical Deductible | N/A | Individual: $6,300 Family: $12,600 |
Individual: $2,500 Family: $5,000 |
Individual: $2,200 Family: $4,400 |
Individual: $650 Family: $1,300 |
Individual: $75 Family: $150 |
N/A | N/A |
Pharmacy Deductible | N/A | Individual: $500 Family: $1,000 |
Individual: $250 Family: $500 |
Individual: $250 Family: $500 |
Individual: $50 Family: $100 |
N/A | N/A | N/A |
Annual Out-of-Pocket Maximum | $7,150 individual only |
$6,800 individual $13,600 family |
$6,800 individual $13,600 family |
$5,700 individual $11,400 family |
$2,350 individual $4,700 family |
$2,350 individual $4,700 family |
$6,750 individual $13,500 family |
$4,000 individual $8,000 family |
Drug prices are for a 30 day supply.
* Copay is for any combination of services (primary care, specialist, urgent care) for the first three visits. After three visits, future visits will be at full cost until the medical deductible is met.
** Price is after pharmacy deductible is met.
*** See plan Evidence of Coverage for imaging cost share.