INSURANCE CARRIER UNITED HEALTHCARE Gold Nexus ACO CEOO HMO Plan Name Rx K35Y Network Nexus HMO Network Calendar Year Deductible Individual $2,000 Gold Nexus Family $4,000 Out-of-Pocket Limit Individual $8,500 ACO CEOO Family $17,000 Office Visit Copay - Designated Network $30 PCP / $60 Spec HMO Plan Office Visit Copay - Non Desginated $60 PCP / $120 Spec Diagnostic Test (Lab/X-Ray) No Copay after ded Adv Imaging (MRI/PET/CT) No Copay after ded Hospitalization Inpatient Services $500 Copay, 80% after ded Outpatient Surgery $250 Copay, 80% after ded Urgent Care $50 Copay ER Copay (waived if admitted) $300 Copay after ded Chiropractic Care $60 Copay 35 visits per calendar year Durable Medical Equipment (DME) No Copay after ded Rx Ded: N/A $10 Tier 1 / $40 Tier 2 / Prescription Drugs $125 Tier 3 Tier 4: $300