Schedule of benefits
What members pay on 4500 Copay.
Deductibles & Limits
- Deductible — Individual (In/Out)
- $4,500 / $9,000
- Deductible — Family (In/Out)
- $9,000 / $18,000
- OOP Max — Individual (In/Out)
- $9,000 / $18,000
- OOP Max — Family (In/Out)
- $18,000 / $36,000
- Co-Insurance (Member Pays)
- 30% in / 50% out
Care & Visits
- Telemedicine
- $0 — Unlimited
- PCP Office Visit
- $40 Copay
- Specialist Office Visit
- $75 Copay
- Urgent Care
- $90 Copay
- Emergency Room
- Deductible + 30%
- Labs & X-Rays (Quest/LabCorp)
- $25 after deductible
- Advanced Imaging
- $200 after deductible
Hospital & Surgery
- Inpatient Hospital
- Deductible + 30%
- Outpatient Surgery
- Deductible + 30%
Pharmacy
- Pharmacy Deductible
- None
- Generic
- $20
- Preferred Brand
- $65
- Non-Preferred / Specialty
- $95 / $200
FCHP & PHCS networks available
All plans underwritten by Benefit Re Insurance, Inc. (NAIC #17459). FCHP and PHCS national networks — over 800,000 providers. Plans effective July 1, 2026. Premiums quoted on request.
Quote 4500 Copay for your group.
Premiums quoted on request — brokers can pre-qualify a group in 60 seconds with the Savings Estimator.