Begin Primary Care Cost-Sharing After Number Of Visits
0
Child-Only Offering
Allows Adult and Child-Only
Composite Rating Offered
No
Drug EHB Deductible, Combined In/Out of Network, Family Per Group
$0 per group
Drug EHB Deductible, Combined In/Out of Network, Family Per Person
$0 per person
Drug EHB Deductible, Combined In/Out of Network, Individual
$0
Drug EHB Deductible, In Network (Tier 1), Family Per Group
$0 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person
$0 per person
Drug EHB Deductible, In Network (Tier 1), Individual
$0
Drug EHB Deductible, Out of Network, Family Per Group
$0 per group
Drug EHB Deductible, Out of Network, Family Per Person
$0 per person
Drug EHB Deductible, Out of Network, Individual
$0
Design Type
Not Applicable
Disease Management Programs Offered
Asthma, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol
EHB Percent of Total Premium
1
First Tier Utilization
100%
Limited Cost Sharing Plan Variation - Estimated Advanced Payment
$0.00
Notice Required for Pregnancy
No
Is a Referral Required for Specialist?
No
Medical EHB Deductible, Combined In/Out of Network, Family Per Group
$0 per group
Medical EHB Deductible, Combined In/Out of Network, Family Per Person
$0 per person
Medical EHB Deductible, Combined In/Out of Network, Individual
$0
Medical EHB Deductible, In Network (Tier 1), Family Per Group
$0 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person
$0 per person
Medical EHB Deductible, In Network (Tier 1), Individual
$0
Medical EHB Deductible, Out of Network, Family Per Group
$0 per group
Medical EHB Deductible, Out of Network, Family Per Person
$0 per person
Medical EHB Deductible, Out of Network, Individual
$0
Plan Effective Date
1/1/2026
Plan Expiration Date
12/31/2026
Plan Level Exclusions
Abortion (except when the life of the mother is endangered), acupuncture, cosmetic surgery, dental care for adults, hearing aids, infertility treatment, long-term care, non-emergency care when traveling outside the United States, routine eye care for adults, and weight loss programs.
Wellness Program Offered
No