Plan Details
Plan Name	Geisinger CDHP
Effective Dates	Jan 01, 2024 to Jan 01, 2025
Benefits	In-Network	Out-of-Network
Annual Deductible/Individual	$1,600	$4,000
Annual Deductible/Family	$3,200	$8,000
Coinsurance	20%	40%
Office Visit/Exam	20% after deductible	40% after deductible
Outpatient Specialist Visit	20% after deductible	40% after deductible
Annual Out-of-Pocket Limit/Individual	$7,500	$8,000
Annual Out-of-Pocket Limit/Family	$15,000	$16,000
Preventive Care	0%	40% after deductible
Inpatient Hospitalization	20% after deductible	40% after deductible
Surgical Services Outpatient Facility Charge	20% after deductible	40% after deductible
Emergency Room	20% after deductible	20% after deductible
Urgent Care Facility	20% after deductible	20% after deductible
Prescription Drug Deductible	Combined with medical deductible	none
Prescription Drugs - Generic	$10 after deductible	Not covered
Prescription Drugs - Brand (Formulary/Preferred)	$50 after deductible	Not covered
Prescription Drugs - Brand (Non-Formulary/Non-preferred)	$90 after deductible	Not covered
Prescription Drugs - Specialty	Copayment varies by drug based on above	Not covered
Chiropractic Services	20% after deductible up to 15 visits per year	Services limited to a preferred providers
Acupuncture	Not covered	Not covered