|Your Benefits||Your Cost|
|Hospital (inpatient and outpatient)||No cost1|
|Office visits (primary care physicians and specialist)||$15 per visit|
|Diagnostic x-ray and laboratory services||No cost|
|Urgent Care Virtual Visit/Urgent Care Center||$15/$15 per visit|
|Emergency room||$50 per visit2|
|Chiropractic||$15 per visit3|
|Acupuncture||$15 per visit3|
1Except for $15/visit for physical, occupational, and speech therapy performed on an outpatient basis. 2Waived if hospitalized as an inpatient or for observation as an outpatient. 3Up to 20 combined visits in a calendar year.
|Annual Out of Pocket Maximum|
|Individual $1,500||Family $3,000|
Posted rates do not reflect employer contribution amounts.