Silver Plans

2017
Plan Benefits
Access PPO
PPO
Silver
Coinsurance 3100
PPO
Silver
Coinsurance 
4500
PPO
Silver
HSA (100%)
Medical Deductible (if any)
Single/Family
$3,100/$6,200 $4,500/$9,000 $3,750/$7,500
Medication Deductible (if any) 
Single/Family
$0/$0 $0/$0 Integrated with Medical
Preventive Care Copay No Charge No Charge No Charge 
Adult Primary Care Visit Copay $25 $25 0%1
Pediatric Primary Care Visit Copay
(Ages 0-19)
No Charge No Charge 0%1
Specialty Care Visit Copay $50 $50 0%1
Inpatient Copay 20%1 20%1 0%1
Outpatient Copay 20%1 20%1 0%1
Emergency Room Copay $5001 $5001 0%1
Urgent Care Copay $50 $50 0%1
Routine Lab/X-Ray Copay No Charge No Charge 0%1
Imaging (MRI, CT, Scans) Copay $250 per test1 $250 per test1 0%1
Medication Copays:
Tier I
Tier II
Tier III
Tier IV
Tier V


$0
$20
$50
$100
40%


$0
$10
$50
$100
40%


0%1
0%1
0%1
0%1
0%1
Maximum Out-Of-Pocket
Single/Family
$7,150/$14,300 $6,000/$12,000 $3,750/$7,500
Plan ID 41549X0110001-00 41549X0110003-00 41549X0110002-00
Summary of Benefits & Coverage
(SBC)
Plan Documents
1After Medical Deductible
2017
Plan Benefits
FirstCare 
MyChoice™ PPO
PPO
Silver
Coinsurance 2700
PPO
Silver
Coinsurance 4500
PPO
Silver
HSA (100%)
Medical Deductible (if any)
Single/Family
$2,700/$5,400 $4,500/$9,000 $3,250/$6,500
Medication Deductible (if any) 
Single/Family
$0/$0 $0/$0 Integrated with Medical
Preventive Care Copay No Charge No Charge No Charge 
Adult Primary Care Visit Copay $25 $25 0%1
Pediatric Primary Care Visit Copay
(Ages 0-19)
No Charge No Charge 0%1
Specialty Care Visit Copay $50 $50
0%1
Inpatient Copay 20%1 20%1 0%1
Outpatient Copay 20%1 20%1 0%1
Emergency Room Copay $5001 $5001 0%1
Urgent Care Copay $50 $50 0%1
Routine Lab/X-Ray Copay No Charge No Charge 0%1
Imaging (MRI, CT, Scans) Copay $200 per test1 $200 per test1 0%1
Medication Copays:
Tier I
Tier II
Tier III
Tier IV
Tier V


$0
$20
$50
$100
40%


$0
$20
$50
$100
40%
 

0%1
0%1
0%1
0%1
0%1
Maximum Out-Of-Pocket
Single/Family
$7,150/$14,300 $6,000/$12,000
$3,250/$6,500
 
Plan ID 41549X0110004-00 41549TX0110005-00 41549TX0110006-00
Summary of Benefits & Coverage
(SBC)
Plan Documents
1After Medical Deductible

 



 

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