Medical Plan Costs
FY2022
Medical Plan In-Network
Medical Plan Out-of-Network *
$1,250/Person $2,500/Family
Separate $2,500/Person Separate $5,000/Family
$30 copay $50 copay
N/A N/A
30%
40%
$4,350/Person $8,700/Family
Separate $6,000/Person Separate $12,000/Family
Annual Deductible
Applies to all covered services, unless otherwise noted or copayment is indicated.
Copayment (outpatient office visits) Primary Care Physician Visit (PCP) Specialty Provider Visit
Coinsurance Percentages
(% of allowed charges member pays)
Annual Out-of-Pocket Maximum
(Maximum amount paid by member in a benefit plan year for covered services; includes deductibles, copays and coinsurance)
from an Out-of-Network provider have separate deductibles, % coinsurance, and Out-of-Pocket maximums. An Out-of* Services Network provider can balance bill the difference between the allowed amount and the billed charge.
Trail running in Bob Marshall, MT
Rounding Cattle, MT
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