Plan Benefits Configuration

Select Plan

Plan Year

Status

Active

Copayments

PCP Office Visit

$

Specialist Visit

$

Emergency Room Visit

$

Urgent Care

$

Telehealth Visit

$

Outpatient Surgery

$

Deductibles

Individual Deductible

$

Family Deductible

$

Deductible Type

Deductible Waived for Preventive

Coinsurance

In-Network Coinsurance (Member %)

Out-of-Network Coinsurance (Member %)

Out-of-Pocket Maximum

Individual OOP Max (In-Network)

$

Family OOP Max (In-Network)

$

Individual OOP Max (Out-of-Network)

$

Family OOP Max (Out-of-Network)

$

OOP Applies to Deductible

Additional Benefits

Inpatient Hospital (per day)

$

Max Hospital Days Covered

Skilled Nursing Facility (Days 1-20)

$

Ambulance (Ground)

$

Lab / Pathology

$

Radiology (X-ray)

$

Tier	Description	Preferred Retail	Non-Preferred Retail	Mail Order (90-day)
Tier 1	Generic Drugs	$	$	$
Tier 2	Preferred Brand	$	$	$
Tier 3	Non-Preferred Brand	$	$	$
Tier 4	Specialty Drugs	33% coinsurance	50% coinsurance	33% coinsurance
Tier 5	Select Insulins	$	$	$

Last saved: Today at 2:14 PM by Amy Lin

AI Assistant

Select a plan from the dropdown to view and configure its benefit structure. Changes are plan-year specific — always confirm the year before editing.

Medical — Copays, deductibles, coinsurance, OOP max
Pharmacy — Tier copays, formulary, specialty rules
Mental Health — Parity-compliant behavioral health benefits
Dental — Preventive, basic, major services
Vision — Exams, lenses, frames allowances

Use Save as Draft to preserve uncommitted changes. Save & Publish makes benefits effective and visible to member-facing systems. Publishing triggers EDI 834 update notification.

Mental Health Parity and Addiction Equity Act requires that MH/SUD benefits be no more restrictive than medical/surgical. System auto-checks parity compliance when you save Mental Health tab values.

ACA OOP max limits apply for non-grandfathered plans ($9,450 individual in 2025)
Pharmacy deductible applies before any drug coverage kicks in
Copy Plan feature clones all tabs to a new plan year

Copayments

Deductibles

Coinsurance

Out-of-Pocket Maximum

Additional Benefits

Pharmacy Tier Copays — Retail (30-Day Supply)

Pharmacy Benefits Settings

Coverage Restrictions

Mental Health & Substance Use Copays

Parity Compliance

Preventive & Basic Services

Major Services & Maximums

Vision Exam & Materials

Vision Network & Extras