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PRESCRIPTIONS Preferred Generic/Generic/ Preferred Brand
INDIVIDUAL COUNSELING + THERAPY
VIRTUAL CARE Amwell or Virtuwell
SPECIALTY CARE
PREVENTIVE CARE
$90
$0
$0
$35
$10/$20/$125
$160
$0
$0
$45
$15/$25/$200
$190
$0
$0
$25
$15/$25/$200
$15 (first 3 vistis)
$0
$0
$15 (first 3 vistis)
$10/$20/$150
25% coinsurance
$0 after deductible
$0
25% coinsurance
25% coinsurance
$15 (first 3 visits)
$0
$0
$15 (first 3 visits)
$15/$25/$200
$15 (first 3 visits)
$0
$0
$15 (first 3 visits)
$10/$20/$150
50% coinsurance
$0
$0
50% coinsurance
$15/$25/$200
$15 (first 3 visits)
$0
$0
$15 (first 3 visits)
$15/$25/$200
$90
$0
$0
$35
$10/$20/$125
5% coinsurance
$0 after deductible
$0
5% coinsurance
5% coinsurance
$160
$0
$0
$45
$15/$25/$200
Silver MODERATE PREMIUMS
Bronze LOWER PREMIUMS
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