The Benefits Comparison Tool provides a side-by-side comparison of the medical and dental plans offered by Princeton University, including premium amounts and covered services. This is only an estimation of benefits; for more details about covered services, refer to the Summary Plan Descriptions.
Select plan type you want compare:
2019 Consumer Directed Health Plan
2019 Health Maintenance Organization (HMO) Plan
2019 J-1 Visa Plan
2019 Princeton Health Plan
2020 Consumer Directed Health Plan
2020 Health Maintenance Organization (HMO) Plan
2020 J-1 Visa Plan
2020 Princeton Health Plan
2019 Basic Option PPO Plan
2019 DMO Plan
2019 High Option PPO Plan
2020 Basic Option PPO Plan
2020 DMO Plan
2020 High Option PPO Plan
2019 Vision Plan
2020 Vision Plan
Annual Deductibles
In-Network
Individual: None
Family: None
Individual: None
Family: None
Out-of-Network
Individual: $50
Family: $150
Individual: $50
Family: $150
In-Network
Individual: $1,500.00
Family: $3,000.00
Individual: $1,500.00
Family: $3,000.00
Out-of-Network
Individual: $3,000.00
Family: $6,000.00
Individual: $3,000.00
Family: $6,000.00
In-Network
Individual: $0.00
Family: $0.00
Individual: $0.00
Family: $0.00
In-Network
Individual: $0
Family: $0
Individual: $0
Family: $0
In- or Out-of-Network
Individual: $50.00 (basic and major services)
Family: $150.00 (basic and major services)
Individual: $50.00 (basic and major services)
Family: $150.00 (basic and major services)
In- or Out-of-Network
Individual: $500.00
Family: $1,000.00
Individual: $500.00
Family: $1,000.00
In-Network
Individual: $200.00
Family: $400.00
Individual: $200.00
Family: $400.00
Out-of-Network
Individual: $750.00
Family: $1,500.00
Individual: $750.00
Family: $1,500.00
—
In-Network
Individual: None
Family: None
Individual: None
Family: None
Out-of-Network
Individual: $50
Family: $150
Individual: $50
Family: $150
In-Network
Individual: $1,500.00
Family: $3,000.00
Individual: $1,500.00
Family: $3,000.00
Out-of-Network
Individual: $3,000.00
Family: $6,000.00
Individual: $3,000.00
Family: $6,000.00
In-Network
Individual: $0.00
Family: $0.00
Individual: $0.00
Family: $0.00
In-Network
Individual: $0
Family: $0
Individual: $0
Family: $0
In- or Out-of-Network
Individual: $50.00 (basic and major services)
Family: $150.00 (basic and major services)
Individual: $50.00 (basic and major services)
Family: $150.00 (basic and major services)
In- or Out-of-Network
Individual: $500.00
Family: $1,000.00
Individual: $500.00
Family: $1,000.00
In-Network
Individual: $200.00
Family: $400.00
Individual: $200.00
Family: $400.00
Out-of-Network
Individual: $750.00
Family: $1,500.00
Individual: $750.00
Family: $1,500.00
—
Employee Monthly Contributions
Employee:
$20.69
Employee & Child: $48.16
Family: $72.62
Employee & Spouse: $44.19
Employee & Child: $48.16
Family: $72.62
Employee & Spouse: $44.19
Employee:
$20.00
Employee & Child: $60.00
Family: $120.00
Employee & Spouse: $80.00
Employee & Child: $60.00
Family: $120.00
Employee & Spouse: $80.00
Employee:
$25.15
Employee & Child: $49.05
Family: $70.09
Employee & Spouse: $50.72
Employee & Child: $49.05
Family: $70.09
Employee & Spouse: $50.72
Less than $75,000
Employee:
$73.00 Employee & Child: $212.00
Family: $437.00
Employee & Spouse: $284.00
$75,001–150,000
Employee:
$74.00 Employee & Child: $218.00
Family: $448.00
Employee & Spouse: $293.00
$150,001 and over
Employee:
$78.00 Employee & Child: $227.00
Family: $467.00
Employee & Spouse: $305.00
Employee:
$67.79
Employee & Child: $132.84
Family: $188.96
Employee & Spouse: $136.80
Employee & Child: $132.84
Family: $188.96
Employee & Spouse: $136.80
Employee:
$0.00
Employee & Child: $260.00
Family: $526.00
Employee & Spouse: $345.00
Employee & Child: $260.00
Family: $526.00
Employee & Spouse: $345.00
Employee:
$117.00
Employee & Child: $323.00
Family: $608.00
Employee & Spouse: $410.00
Employee & Child: $323.00
Family: $608.00
Employee & Spouse: $410.00
Employee:
$15.16
Employee & Child: $24.83
Family: $40.04
Employee & Spouse: $24.38
Employee & Child: $24.83
Family: $40.04
Employee & Spouse: $24.38
Employee:
$20.69
Employee & Child: $48.16
Family: $72.62
Employee & Spouse: $44.19
Employee & Child: $48.16
Family: $72.62
Employee & Spouse: $44.19
Employee:
$20.00
Employee & Child: $60.00
Family: $120.00
Employee & Spouse: $80.00
Employee & Child: $60.00
Family: $120.00
Employee & Spouse: $80.00
Employee:
$25.15
Employee & Child: $49.05
Family: $70.09
Employee & Spouse: $50.72
Employee & Child: $49.05
Family: $70.09
Employee & Spouse: $50.72
Less than $75,000
Employee:
$74.00 Employee & Child: $216.00
Family: $446.00
Employee & Spouse: $290.00
$75,001–150,000
Employee:
$77.00 Employee & Child: $226.00
Family: $464.00
Employee & Spouse: $303.00
$150,001 and over
Employee:
$81.00 Employee & Child: $235.00
Family: $483.00
Employee & Spouse: $316.00
Employee:
$67.79
Employee & Child: $132.84
Family: $188.96
Employee & Spouse: $136.80
Employee & Child: $132.84
Family: $188.96
Employee & Spouse: $136.80
Employee:
$0.00
Employee & Child: $269.00
Family: $544.00
Employee & Spouse: $357.00
Employee & Child: $269.00
Family: $544.00
Employee & Spouse: $357.00
Employee:
$121.00
Employee & Child: $334.00
Family: $629.00
Employee & Spouse: $424.00
Employee & Child: $334.00
Family: $629.00
Employee & Spouse: $424.00
Employee:
$15.16
Employee & Child: $24.83
Family: $40.04
Employee & Spouse: $24.38
Employee & Child: $24.83
Family: $40.04
Employee & Spouse: $24.38
Out-of-Pocket Maximum (OPM)
In- or Out-of-Network
Individual: $2,000.00
Family:
Individual: $2,000.00
Family:
In-Network
Individual: $3,000.00
Family: $6,000.00
Individual: $3,000.00
Family: $6,000.00
Out-of-Network
Individual: $6,000.00
Family: $12,000.00
Individual: $6,000.00
Family: $12,000.00
In-Network
Individual: None
Family:
Individual: None
Family:
In-Network
Individual: $2,500.00
Family: $5,000.00
Individual: $2,500.00
Family: $5,000.00
In-Network
Individual: $2,000.00
Family:
Individual: $2,000.00
Family:
Out-of-Network
Individual: $1,500.00
Family:
Individual: $1,500.00
Family:
In- or Out-of-Network
Individual: $2,500.00
Family: $5,000.00
Individual: $2,500.00
Family: $5,000.00
Less than $75,000
In-Network Individual: $1,550
Family: $3,100
$75,001–150,000
In-Network Individual: $2,350
Family: $4,700
$150,001 and over
In-Network Individual: $3,100
Family: $6,200
Less than $75,000
Out-of-Network Individual: $4,500
Family: $9,000
$75,001–150,000
Out-of-Network Individual: $4,700
Family: $9,400
$150,001 and over
Out-of-Network Individual: $6,200
Family: $12,400
—
In- or Out-of-Network
Individual: $2,000.00
Family:
Individual: $2,000.00
Family:
In-Network
Individual: $3,000.00
Family: $6,000.00
Individual: $3,000.00
Family: $6,000.00
Out-of-Network
Individual: $6,000.00
Family: $12,000.00
Individual: $6,000.00
Family: $12,000.00
In-Network
Individual: None
Family:
Individual: None
Family:
In-Network
Individual: $2,500.00
Family: $5,000.00
Individual: $2,500.00
Family: $5,000.00
In-Network
Individual: $2,000.00
Family:
Individual: $2,000.00
Family:
Out-of-Network
Individual: $1,500.00
Family:
Individual: $1,500.00
Family:
In- or Out-of-Network
Individual: $2,500.00
Family: $5,000.00
Individual: $2,500.00
Family: $5,000.00
Less than $75,000
In-Network Individual: $1,550
Family: $3,100
$75,001–150,000
In-Network Individual: $2,350
Family: $4,700
$150,001 and over
In-Network Individual: $3,100
Family: $6,200
Less than $75,000
Out-of-Network Individual: $4,500
Family: $9,000
$75,001–150,000
Out-of-Network Individual: $4,700
Family: $9,400
$150,001 and over
Out-of-Network Individual: $6,200
Family: $12,400
—
Services
Exam (Once every calendar year)
Comprehensive Vision Exam
—
—
—
—
—
—
—
In-Network
$10 copayment
Out-of-Network
100% with reimbursement up to $45
$10 copayment
Out-of-Network
100% with reimbursement up to $45
—
—
—
—
—
—
—
In-Network
$10 copayment
Out-of-Network
100% with reimbursement up to $45
$10 copayment
Out-of-Network
100% with reimbursement up to $45
Prescription Lenses (Once every calendar year)
Single Vision
—
—
—
—
—
—
—
In-Network
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $30
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $30
—
—
—
—
—
—
—
In-Network
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $30
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $30
Lined Bifocals
—
—
—
—
—
—
—
In-Network
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $50
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $50
—
—
—
—
—
—
—
In-Network
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $50
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $50
Progressives
—
—
—
—
—
—
—
In-Network
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $50
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $50
—
—
—
—
—
—
—
In-Network
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $50
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $50
Lined Trifocals
—
—
—
—
—
—
—
In-Network
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $65
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $65
—
—
—
—
—
—
—
In-Network
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $65
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $65
Lenticular
—
—
—
—
—
—
—
In-Network
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $100
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $100
—
—
—
—
—
—
—
In-Network
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $100
$10 copayment / Applied to lenses and frames / If purchasing lenses and frames together, one $10 copayment applies
Out-of-Network
100% with reimbursement up to $100
Frames (Once every calendar year)
All
—
—
—
—
—
—
—
In-Network
100% with coverage up to $155 after a $10 copayment / 100% with coverage up to $85 after a $10 copayment at Costco, Walmart, or Sam's Club / If purchasing lenses and frames together, on $10 copayment applies
Out-of-Network
100% with reimbursement up to $70
100% with coverage up to $155 after a $10 copayment / 100% with coverage up to $85 after a $10 copayment at Costco, Walmart, or Sam's Club / If purchasing lenses and frames together, on $10 copayment applies
Out-of-Network
100% with reimbursement up to $70
—
—
—
—
—
—
—
In-Network
100% with coverage up to $155 after a $10 copayment / 100% with coverage up to $85 after a $10 copayment at Costco, Walmart, or Sam's Club / If purchasing lenses and frames together, on $10 copayment applies
Out-of-Network
100% with reimbursement up to $70
100% with coverage up to $155 after a $10 copayment / 100% with coverage up to $85 after a $10 copayment at Costco, Walmart, or Sam's Club / If purchasing lenses and frames together, on $10 copayment applies
Out-of-Network
100% with reimbursement up to $70
Prescription Contact Lenses (Once every calendar year)
Evaluation Fees
—
—
—
—
—
—
—
In-Network
Copayment not to exceed $60
Out-of-Network
Not covered
Copayment not to exceed $60
Out-of-Network
Not covered
—
—
—
—
—
—
—
In-Network
Copayment not to exceed $60
Out-of-Network
Not covered
Copayment not to exceed $60
Out-of-Network
Not covered
Fitting Costs
—
—
—
—
—
—
—
In-Network
Copayment not to exceed $60
Out-of-Network
Not covered
Copayment not to exceed $60
Out-of-Network
Not covered
—
—
—
—
—
—
—
In-Network
Copayment not to exceed $60
Out-of-Network
Not covered
Copayment not to exceed $60
Out-of-Network
Not covered
Materials
—
—
—
—
—
—
—
In- or Out-of-Network
100% reimbursement up to $140
100% reimbursement up to $140
—
—
—
—
—
—
—
In- or Out-of-Network
100% reimbursement up to $140
100% reimbursement up to $140
Preventive & Diagnostic Services
Examinations & Visits
In- or Out-of-Network
Reimbursement based on 100% of in-network charge
Reimbursement based on 100% of in-network charge
—
In-Network
$0
$0
—
In-Network
$0
Out-of-Network
$0
$0
Out-of-Network
$0
—
—
—
In- or Out-of-Network
Reimbursement based on 100% of in-network charge
Reimbursement based on 100% of in-network charge
—
In-Network
$0
$0
—
In-Network
$0
Out-of-Network
$0
$0
Out-of-Network
$0
—
—
—
X-Ray Services
In- or Out-of-Network
Reimbursement based on 100% of in-network charge
Reimbursement based on 100% of in-network charge
—
In-Network
$0
$0
—
In-Network
$0
Out-of-Network
$0
$0
Out-of-Network
$0
—
—
—
In- or Out-of-Network
Reimbursement based on 100% of in-network charge
Reimbursement based on 100% of in-network charge
—
In-Network
$0
$0
—
In-Network
$0
Out-of-Network
$0
$0
Out-of-Network
$0
—
—
—
Cleanings
In- or Out-of-Network
Reimbursement based on 100% of in-network charge
Reimbursement based on 100% of in-network charge
—
In-Network
$0
$0
—
In-Network
$0
Out-of-Network
$0
$0
Out-of-Network
$0
—
—
—
In- or Out-of-Network
Reimbursement based on 100% of in-network charge
Reimbursement based on 100% of in-network charge
—
In-Network
$0
$0
—
In-Network
$0
Out-of-Network
$0
$0
Out-of-Network
$0
—
—
—
Flouride Treatments
In- or Out-of-Network
Reimbursement based on 100% of in-network charge
Reimbursement based on 100% of in-network charge
—
In-Network
$0
$0
—
In-Network
$0
Out-of-Network
$0
$0
Out-of-Network
$0
—
—
—
In- or Out-of-Network
Reimbursement based on 100% of in-network charge
Reimbursement based on 100% of in-network charge
—
In-Network
$0
$0
—
In-Network
$0
Out-of-Network
$0
$0
Out-of-Network
$0
—
—
—
Basic Services
Amalgam (Silver) Fillings
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
In-Network
$0
$0
—
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
In-Network
$0
$0
—
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
Root Canal Therapy (Anterior Teeth)
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
In-Network
$0
$0
—
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
In-Network
$0
$0
—
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
Root Canal Therapy (Molars)
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
—
—
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
—
—
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
Composite Fillings (Anterior Teeth)
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
In-Network
$0
$0
—
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
In-Network
$0
$0
—
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
Stainless Steel Crowns
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
In-Network
$0
$0
—
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
In-Network
$0
$0
—
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
Uncomplicated Extractions
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
In-Network
$0
$0
—
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Reimbursement based on 50% of in-network charge
—
In-Network
$0
$0
—
In-Network
20%
Out-of-Network
30%
20%
Out-of-Network
30%
—
—
—
Major Services
High Noble Metal & Porcelain Inlays
In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
—
In-Network
40%
40%
—
In-Network
40%
Out-of-Network
50%
40%
Out-of-Network
50%
—
—
—
In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
—
In-Network
40%
40%
—
In-Network
40%
Out-of-Network
50%
40%
Out-of-Network
50%
—
—
—
High Noble Metal Restorations
In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
—
In-Network
40%
40%
—
In-Network
40%
Out-of-Network
50%
40%
Out-of-Network
50%
—
—
—
In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
—
In-Network
40%
40%
—
In-Network
40%
Out-of-Network
50%
40%
Out-of-Network
50%
—
—
—
Crowns
In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
—
In-Network
40%
40%
—
In-Network
40%
Out-of-Network
50%
40%
Out-of-Network
50%
—
—
—
In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
—
In-Network
40%
40%
—
In-Network
40%
Out-of-Network
50%
40%
Out-of-Network
50%
—
—
—
Root Canal Therapy (Molars)
—
—
In-Network
40%
40%
—
—
—
—
—
—
—
In-Network
40%
40%
—
—
—
—
—
Implants
In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
—
In-Network
40%
40%
—
In-Network
40%
Out-of-Network
50%
40%
Out-of-Network
50%
—
—
—
In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
—
In-Network
40%
40%
—
In-Network
40%
Out-of-Network
50%
40%
Out-of-Network
50%
—
—
—
Orthodontia
Orthodontics
In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
—
In-Network
50% / No lifetime maximum / Covers children and adults
50% / No lifetime maximum / Covers children and adults
—
In-Network
50% / Lifetime maximum benefit of $2,000 / Covers children and adults
Out-of-Network
50% / Lifetime maximum benefit of $1,500 / Covers children and adults
50% / Lifetime maximum benefit of $2,000 / Covers children and adults
Out-of-Network
50% / Lifetime maximum benefit of $1,500 / Covers children and adults
—
—
—
In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
—
In-Network
50% / No lifetime maximum / Covers children and adults
50% / No lifetime maximum / Covers children and adults
—
In-Network
50% / Lifetime maximum benefit of $2,000 / Covers children and adults
Out-of-Network
50% / Lifetime maximum benefit of $1,500 / Covers children and adults
50% / Lifetime maximum benefit of $2,000 / Covers children and adults
Out-of-Network
50% / Lifetime maximum benefit of $1,500 / Covers children and adults
—
—
—
Basis of Reimbursement
Reimbursement
In- or Out-of-Network
Maximum allowable charge
Maximum allowable charge
—
In-Network
Negotiated fee
Negotiated fee
—
In-Network
Negotiated fee
Out-of-Network
80th percentile of reasonable and customary charges
Negotiated fee
Out-of-Network
80th percentile of reasonable and customary charges
—
—
—
In- or Out-of-Network
Maximum allowable charge
Maximum allowable charge
—
In-Network
Negotiated fee
Negotiated fee
—
In-Network
Negotiated fee
Out-of-Network
80th percentile of reasonable and customary charges
Negotiated fee
Out-of-Network
80th percentile of reasonable and customary charges
—
—
—
Physician Visits
Telemedicine (Offered through Teladoc)
—
In-Network
$40 until deductible is met, then 20% after deductible
Out-of-Network
NA
$40 until deductible is met, then 20% after deductible
Out-of-Network
NA
—
In-Network
$0
$0
—
In- or Out-of-Network
$40 until deductible is met, then 20% after deductible
$40 until deductible is met, then 20% after deductible
In-Network
$0
Out-of-Network
NA
$0
Out-of-Network
NA
—
—
In-Network
$40 until deductible is met, then 20% after deductible
Out-of-Network
NA
$40 until deductible is met, then 20% after deductible
Out-of-Network
NA
—
In-Network
$0
$0
—
In- or Out-of-Network
$40 until deductible is met, then 20% after deductible
$40 until deductible is met, then 20% after deductible
In-Network
$0
Out-of-Network
NA
$0
Out-of-Network
NA
—
Telemental Health (Offered through Teladoc)
—
In-Network
20% after deductible
Out-of-Network
NA
20% after deductible
Out-of-Network
NA
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
$30 copayment
Out-of-Network
NA
$30 copayment
Out-of-Network
NA
—
—
In-Network
20% after deductible
Out-of-Network
NA
20% after deductible
Out-of-Network
NA
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
$30 copayment
Out-of-Network
NA
$30 copayment
Out-of-Network
NA
—
Primary Care Physician (PCP)
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$20 copayment
$20 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
$20 copayment
Out-of-Network
40% after deductible
$20 copayment
Out-of-Network
40% after deductible
—
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$20 copayment
$20 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
$20 copayment
Out-of-Network
40% after deductible
$20 copayment
Out-of-Network
40% after deductible
—
Preventive Care & Immunizations
—
In-Network
$0
Out-of-Network
50% after deductible
$0
Out-of-Network
50% after deductible
—
In-Network
$0
$0
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
$0
Out-of-Network
40% after deductible
$0
Out-of-Network
40% after deductible
—
—
In-Network
$0
Out-of-Network
50% after deductible
$0
Out-of-Network
50% after deductible
—
In-Network
$0
$0
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
$0
Out-of-Network
40% after deductible
$0
Out-of-Network
40% after deductible
—
Specialists
—
—
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
—
—
—
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
—
—
Emergency & Urgent Care Services
Urgent Care Center
—
In-Network
$0 after deductible
Out-of-Network
50% after deductible
$0 after deductible
Out-of-Network
50% after deductible
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
—
—
In-Network
$0 after deductible
Out-of-Network
50% after deductible
$0 after deductible
Out-of-Network
50% after deductible
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
—
Emergency Room (No coverage for non-emergencies)
—
In- or Out-of-Network
$0 after deductible
$0 after deductible
—
In-Network
$175 copayment (waived if admitted)
$175 copayment (waived if admitted)
—
In- or Out-of-Network
20% after deductible
20% after deductible
In- or Out-of-Network
$175 copayment (waived if admitted)
$175 copayment (waived if admitted)
—
—
In- or Out-of-Network
$0 after deductible
$0 after deductible
—
In-Network
$175 copayment (waived if admitted)
$175 copayment (waived if admitted)
—
In- or Out-of-Network
20% after deductible
20% after deductible
In- or Out-of-Network
$175 copayment (waived if admitted)
$175 copayment (waived if admitted)
—
Inpatient Services
Medical & Surgical Procedures
—
In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$175 copayment
$175 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
40% after deductible
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
40% after deductible
—
—
In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$175 copayment
$175 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
40% after deductible
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
40% after deductible
—
Mental Health
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$175 copayment
$175 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
10% after deductible
Out-of-Network
40% after deductible
10% after deductible
Out-of-Network
40% after deductible
—
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$175 copayment
$175 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
10% after deductible
Out-of-Network
40% after deductible
10% after deductible
Out-of-Network
40% after deductible
—
Outpatient Services
Surgical Procedures
—
In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$0 (Independent Facility) / $75 copayment (Hospital)
$0 (Independent Facility) / $75 copayment (Hospital)
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network (Preferred)
10% after deductable
In-Network (Non-Preferred)
20% after deductable
Out-of-Network
40% after deductable
10% after deductable
In-Network (Non-Preferred)
20% after deductable
Out-of-Network
40% after deductable
—
—
In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$0 (Independent Facility) / $75 copayment (Hospital)
$0 (Independent Facility) / $75 copayment (Hospital)
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network (Preferred)
10% after deductable
In-Network (Non-Preferred)
20% after deductable
Out-of-Network
40% after deductable
10% after deductable
In-Network (Non-Preferred)
20% after deductable
Out-of-Network
40% after deductable
—
Laboratory
—
In-Network (Preferred)
$0 after deductible
In-Network (Non-Preferred)
40% after deductible
Out-of-Network
Not covered
$0 after deductible
In-Network (Non-Preferred)
40% after deductible
Out-of-Network
Not covered
—
In-Network
$0
$0
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network (Preferred)
$0
In-Network (Non-Preferred)
40%
Out-of-Network
Not covered
$0
In-Network (Non-Preferred)
40%
Out-of-Network
Not covered
—
—
In-Network (Preferred)
$0 after deductible
In-Network (Non-Preferred)
40% after deductible
Out-of-Network
Not covered
$0 after deductible
In-Network (Non-Preferred)
40% after deductible
Out-of-Network
Not covered
—
In-Network
$0
$0
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network (Preferred)
$0
In-Network (Non-Preferred)
40%
Out-of-Network
Not covered
$0
In-Network (Non-Preferred)
40%
Out-of-Network
Not covered
—
Radiology (X-Ray)
—
In-Network
$0 after deductible (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
$0 after deductible (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
—
In-Network
$0 (Independent Facility) / $50 copayment (Hospital)
$0 (Independent Facility) / $50 copayment (Hospital)
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
$0 (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
$0 (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
—
—
In-Network
$0 after deductible (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
$0 after deductible (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
—
In-Network
$0 (Independent Facility) / $50 copayment (Hospital)
$0 (Independent Facility) / $50 copayment (Hospital)
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
$0 (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
$0 (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
—
Hi-Tech Radiology (MRI, CAT, etc.)
—
In-Network
$0 after deductible (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
$0 after deductible (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
—
In-Network
$0 (Independent Facility) / $100 copayment (Hospital)
$0 (Independent Facility) / $100 copayment (Hospital)
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network (Preferred)
$0 (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
$0 (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
—
—
In-Network
$0 after deductible (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
$0 after deductible (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
—
In-Network
$0 (Independent Facility) / $100 copayment (Hospital)
$0 (Independent Facility) / $100 copayment (Hospital)
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network (Preferred)
$0 (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
$0 (Independent Facility) / 20% after deductible (Hospital)
Out-of-Network
Not covered
—
Mental Health
—
In-Network
20% after deductible
Out-of-Network
25% after deductible
20% after deductible
Out-of-Network
25% after deductible
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
$30 copayment
Out-of-Network
25% no deductible
$30 copayment
Out-of-Network
25% no deductible
—
—
In-Network
20% after deductible
Out-of-Network
25% after deductible
20% after deductible
Out-of-Network
25% after deductible
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
$30 copayment
Out-of-Network
25% no deductible
$30 copayment
Out-of-Network
25% no deductible
—
Annual Eye Exam
—
In- or Out-of-Network
Not covered
Not covered
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
Not covered
Not covered
In- or Out-of-Network
Not covered
Not covered
—
—
In- or Out-of-Network
Not covered
Not covered
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
Not covered
Not covered
In- or Out-of-Network
Not covered
Not covered
—
Prescription Eyeglasses and/or Contact Lenses
—
In- or Out-of-Network
Not covered
Not covered
—
In-Network
$70 reimbursement every 2 years
$70 reimbursement every 2 years
—
In- or Out-of-Network
Not covered
Not covered
In- or Out-of-Network
Not covered
Not covered
—
—
In- or Out-of-Network
Not covered
Not covered
—
In-Network
$70 reimbursement every 2 years
$70 reimbursement every 2 years
—
In- or Out-of-Network
Not covered
Not covered
In- or Out-of-Network
Not covered
Not covered
—
Physical Therapy (100 visits per calendar year)
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$15 copayment
$15 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
10% after deductible
Out-of-Network
50% after deductible
10% after deductible
Out-of-Network
50% after deductible
—
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$15 copayment
$15 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
10% after deductible
Out-of-Network
50% after deductible
10% after deductible
Out-of-Network
50% after deductible
—
Speech Therapy / Occupational Therapy / Pulmonary & Cardiac Rehabilitation (100 visits per calendar year)
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
10% after deductible
Out-of-Network
40% after deductible
10% after deductible
Out-of-Network
40% after deductible
—
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
10% after deductible
Out-of-Network
40% after deductible
10% after deductible
Out-of-Network
40% after deductible
—
Chiropractic Care (20 visits per calendar year)
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
—
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
—
Acupuncture (20 visits per calendar year)
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
—
—
In-Network
20% after deductible
Out-of-Network
50% after deductible
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network
$30 copayment
Out-of-Network
40% after deductible
$30 copayment
Out-of-Network
40% after deductible
—
Maternity
Prenatal Care Visits
—
In-Network (Preferred)
10% after deductible for the first visit, $0 for subsequent visits
In-Network (Non-Preferred)
20% after deductible for the first visit, $0 for subsequent visits
Out-of-Network
50% after deductible
10% after deductible for the first visit, $0 for subsequent visits
In-Network (Non-Preferred)
20% after deductible for the first visit, $0 for subsequent visits
Out-of-Network
50% after deductible
—
In-Network
$25 copayment for first visit, $0 for subsequent visits
$25 copayment for first visit, $0 for subsequent visits
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network (Preferred)
$30 copayment for the first visit, $0 for subsequent visits
In-Network (Non-Preferred)
$60 copayment for the first visit, $0 for subsequent visits
Out-of-Network
40% after deductible
$30 copayment for the first visit, $0 for subsequent visits
In-Network (Non-Preferred)
$60 copayment for the first visit, $0 for subsequent visits
Out-of-Network
40% after deductible
—
—
In-Network (Preferred)
10% after deductible for the first visit, $0 for subsequent visits
In-Network (Non-Preferred)
20% after deductible for the first visit, $0 for subsequent visits
Out-of-Network
50% after deductible
10% after deductible for the first visit, $0 for subsequent visits
In-Network (Non-Preferred)
20% after deductible for the first visit, $0 for subsequent visits
Out-of-Network
50% after deductible
—
In-Network
$25 copayment for first visit, $0 for subsequent visits
$25 copayment for first visit, $0 for subsequent visits
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network (Preferred)
$30 copayment for the first visit, $0 for subsequent visits
In-Network (Non-Preferred)
$60 copayment for the first visit, $0 for subsequent visits
Out-of-Network
40% after deductible
$30 copayment for the first visit, $0 for subsequent visits
In-Network (Non-Preferred)
$60 copayment for the first visit, $0 for subsequent visits
Out-of-Network
40% after deductible
—
Delivery
—
In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$175 copayment
$175 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
40% after deductible
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
40% after deductible
—
—
In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$175 copayment
$175 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
40% after deductible
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
40% after deductible
—
Post-Partum Visits
—
In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network (Preferred)
$30 copayment
In-Network (Non-Preferred)
$60 copayment
Out-of-Network
40% after deductible
$30 copayment
In-Network (Non-Preferred)
$60 copayment
Out-of-Network
40% after deductible
—
—
In-Network (Preferred)
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
10% after deductible
In-Network (Non-Preferred)
20% after deductible
Out-of-Network
50% after deductible
—
In-Network
$25 copayment
$25 copayment
—
In- or Out-of-Network
20% after deductible
20% after deductible
In-Network (Preferred)
$30 copayment
In-Network (Non-Preferred)
$60 copayment
Out-of-Network
40% after deductible
$30 copayment
In-Network (Non-Preferred)
$60 copayment
Out-of-Network
40% after deductible
—