2021 Platinum plan
Platinum plans provide the richest benefit offering. Because of this, employees will pay less out of pocket for medical
services. The benefits below apply to each employee.
Group Health Coverage - Metallic Plans [pdf]: Additional benefits available for individuals and families for these Small Group Plans.
Group Health Coverage - Dual Option Plans [pdf]: Additional benefits available for individuals and families for these Small Group Plans.
Platinum 250 ELITE
| Benefits | Platinum 250 ELITE |
|---|
| Deductible | $250 |
| Coinsurance | 20% |
| Out-of-Pocket Costs | $1,250 |
| Primary Care Physician Office Visit | $20 copay |
| Specialist Office Visit | $40 copay |
| Prescription Drugs | - $10 copay for generics
- $30 copay for preferred brand-name
- $50 copay for non-preferred brand-name
- $100 copay for preferred specialty
- $200 copay for specialty
|
| Deductible Type | Fulfillment |
Platinum 500 ELITE
| Benefits | Platinum 500 ELITE |
|---|
| Deductible | $500 |
| Coinsurance | 10% |
| Out-of-Pocket Costs | $1,500 |
| Primary Care Physician Office Visit | $20 copay |
| Specialist Office Visit | $40 copay |
| Prescription Drugs | - $10 copay for generics
- $30 copay for preferred brand-name
- $50 copay for non-preferred brand-name
- $100 copay for preferred specialty
- $200 copay for specialty
|
| Deductible Type | Fulfillment |
Platinum 500 ESSENTIAL
| Benefits | Platinum 500 ESSENTIAL |
|---|
| Deductible | $500 |
| Coinsurance | 20% |
| Out-of-Pocket Costs | $2,000 |
| Primary Care Physician Office Visit | $20 copay |
| Specialist Office Visit | $40 copay |
| Prescription Drugs | - $10 copay for generics
- $30 copay for preferred brand-name
- $50 copay for non-preferred brand-name
- $100 copay for preferred specialty
- $200 copay for specialty
|
| Deductible Type | Fulfillment |
Platinum 500 VALUE
| Benefits | Platinum 500 VALUE |
|---|
| Deductible | $500 |
| Coinsurance | 20% |
| Out-of-Pocket Costs | $3,250 |
| Primary Care Physician Office Visit | $30 copay |
| Specialist Office Visit | $50 copay |
| Prescription Drugs | - $10 copay for generics
- $30 copay for preferred brand-name
- $50 copay for non-preferred brand-name
- $100 copay for preferred specialty
- $200 copay for specialty
|
| Deductible Type | Fulfillment |
Platinum 1000 ELITE
| Benefits | Platinum 1000 ELITE |
|---|
| Deductible | $1,000 |
| Coinsurance | 20% |
| Out-of-Pocket Costs | $2,350 |
| Primary Care Physician Office Visit | $30 copay |
| Specialist Office Visit | $50 copay |
| Prescription Drugs | - $10 copay for generics
- $30 copay for preferred brand-name
- $50 copay for non-preferred brand-name
- $100 copay for preferred specialty
- $200 copay for specialty
|
| Deductible Type | Fulfillment |