Platinum Plans

Platinum Plans have the highest monthly premiums of the four metal levels, but the lower member cost-sharing.

For more information, contact us at 1-888-249-2583.





PPO 843 HMO 110 Plus
In-Network:

     Deductible (single/family) $500 / $1,000 $0
     Coinsurance 20% 0%
     Out-of-Pocket Maximum (single/family) $1,000 / $2,000 $5,000 / $10,000
Medical Services:

     PCP/Specialist Visit 20% after deductible $20 / $30
Hospital Services:

     Inpatient Hospital 20% after deductible $500
     Outpatient Surgery 20% after deductible $100
     Emergency Room Visit 20% after deductible $75
     Urgent Care 20% after deductible $40
Prescription Drugs*

     Generic/Formulary/Non-Formulary $10 / $30 / 50% $10 / $30 / 50% 
Rates (Single/Family):

     Single $586 $496
     Employee/Child $996 $843
     Employee/Spouse $1,172 $992
     Family $1,671 $1,413
     Pediatric Dental Rate $19 $19







*Generic oral contraceptives are covered in full.
*Mail order drugs are 2.5 copays / 90 day supply.
*Pediatric Dental is an essential health benefit required for dependents under the age of 19. Optional coverage is available with all plans.