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   $594.96   $503.31
     Employee/Child  $1011.44   $855.62
     Employee/Spouse $1189.92  $1006.62
     Family $1695.93 $1,434.43
     Pediatric Dental Rate     $14.61     $14.61
     
 
 

 

 

*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 independents under the age of 19.Optional coverage is available with all plans.