Medical Plan Highlights Medical Plan Provisions Gold PPO Silver PPO Bronze HDHP/HSA In - Network Out - of - Network In - Network Out - of - Network In - Network Out - of - Network Aesop Contribution to HSA N/A N/A $600 annually RSI Front – Loaded Debit Card Funding (Individual/Family) $3,500 / $7,000 First Dollar Coverage $1,500 / $3,000 First Dollar Coverage Annual Deductible (Individual/Family) $4,000/ $8,000 $8,000/ $16,000 $4,000/ $8,000 $8,000/ $16,000 $4,000/ $8,000 $8,000/ $16,000 RSI Manual Expense Reimbursement (Individual/Family) In - Network Out of Pocket Expenses Above $6,500 / $13,000 In - Network Out of Pocket Expenses Above $6,500 / $13,000 Out - of - Pocket Maximum (Includes Deductible) $8,300/ $16,600 $16,600/ $33,200 $8,300/ $16,600 $16,600/ $33,200 $8,300/ $16,600 $16,600/ $33,200 Preventive Care Covered at 100% 5 0%* Covered at 100% 50%* Covered at 100% 50%* Primary Care Provider Office Visit 30%* 50%* 30%* 50%* 30%* 50%* Specialist Office Visit 30%* 50%* 30%* 50%* 30%* 50%* Telemedicine (PCP / UC) $0 Not Covered $0 Not Covered $0 Not Covered X - Ray and Lab 30%* 50%* 30%* 50%* 30%* 50%* Inpatient Hospital Services 30%* 50%* 30%* 50%* 30%* 50%* Outpatient Hospital Services 30%* 50%* 30%* 50%* 30%* 50%* Urgent Care 30%* 50%* 30%* 50%* 30%* 50%* Emergency Room 30%* 30%* 30%* Retail Pharmacy (up to a 30 - day supply) Tier 1 30%* 30%* 30%* 30%* 30%* 30%* Tier 2 30%* 30%* 30%* 30%* 30%* 30%* Tier 3 30%* 30%* 30%* 30%* 30%* 30%* Tier 4 30%* 30%* 30%* 30%* 30%* 30%* Mail Order Pharmacy (90 - day supply) is available Medical Gold PPO Silver PPO Bronze HDHP/HSA Employee Only $ 113.39 $ 72.52 $ 30.09 Employee + Spouse $ 364.51 $ 280.43 $ 167.19 Employee + Child(ren) $ 336.33 $ 258.76 $ 156.17 Family $ 570.43 $ 438.86 $ 247.76 Your bi - weekly payroll contributions for medical benefits are shown here.