Medical Plan Coverage Cost Chart
-
2025 Coverage Cost Comparison
2025
MEDICAL PLAN COMPARISONCharter Select Earn $35,00 orless Charter
BasicNexus
BasicChoice
HDHPCharter
PlusNexus
PlusChoice RATES Based on 24 pay periods Employee Only $2.75 $21.18 $23.30 $36.95 $42.67 $46.94 $74.39 Employee + Spouse $106.92 $119.03 $130.93 $207.52 $160.68 $176.75 $267.69 Employee + Child(ren) $97.24 $110.24 $121.28 $192.25 $148.83 $163.71 $248.79 Employee + Family $176.55 $203.93 $224.33 $355.60 $275.30 $302.84 $430.11 PLAN LIMITS Annual Deductible Individual $500 $2,500 $2,500 $3,300 $1,750 $1,750 $1,750 Family $1000 $5,000 $5,000 $6,600 $3,500 $3,500 $3,500 Annual out-of-pocket max (includes all medical and pharmacy deductibles, copays, and coinsurance) Individual $4,900 $7,900 $7,900 $7,900 $6,150 $6,150 $6,150 Family $9,800 $15,800 $15,800 $15,800 $12,300 $12,300 $12,300 Preventive CARE Exams Free Free Free Free Not Available Free Free COST FOR COVERED SERVICES AFTER DEDUCTIBLE HAS BEEN MET Office Visits Primary Care (PCP) $30 copay1 $30 copay1 25%/45%4 20% $30 copay1 20%/40%4 20% Specialists $65 copay1 $65 copay1 25%/45%4 20% $65 copay1 20%/40%4 20% HISD Onsite Clinics & PRIME1 Free Free Free Not available Free Free Free Inpatient-Hospital3 30% 25% 25%/45%4 20% 20% 20%/40%4 20% Outpatient - Hospital3 30% 25% 25%/45%4 20% 20% 20%/40%4 20% Outpatient - Freestanding and Surgical Centers3 30% 25% 25%/45%4 20% 20% 20%/40%4 20% Emergency Room 30% +
$750 copay25% +
$750
copay25% + $750
copay20%+ $750 copay 20% + $750
copay20% + $750
copay20% + $750
copayUrgent Care Facility 100 copay1 100 copay1 100 copay1 20% 100 copay1 100 copay1 100 copay1 Lab, X-Ray, Diagnostic and Mammograms 30% 25% 25% 20% 20% 20% 20% Diagnostic Scans (MRI, MRA, CAT, PET) 30% 25% 25% 20% 20% 20% 20% Maternity - Delivery (Hospital) 30% 25% 25%/45%4 20% 20% 20%/40%4 20% Mental Health and Substance Abuse - Inpatient 30% 25% 25% 20% 20% 20% 20% Mental Health and Substance Abuse - Outpatient $65 copay1 $65 copay1 25% $20 $65 copay1 20% 20% PRESCRIPTION DRUG COMPARISON Annual pharmacy deductible $50 per person $100
per person$100
per personIntegrated with medical $100
per person$100
per person$100
per personPrescription drugs (30-day retail)5
Tier 1 Generally Genetic $20 $20 20% 20% $20 $20 $20 Tier 2 Generally preferferd brand $60 $75 $75 20% $75 $75 $75 Tier 3 Generally Non-preferferd brand generic $100 25%
(min. $100 copay/max. $250 copay)25%
(min. $100 copay/max. $250 copay)20% 25%
(min. $100 copay/max. $250 copay)25%
(min. $100 copay/max. $250 copay)25%
(min. $100 copay/max. $250 copay)Specialty Drugs $150 25%
(min. $100 copay/max. $250 copay)25%
(min. $100 copay/max. $250 copay)20% 25%
(min. $100 copay/max. $250 copay)25%
(min. $100 copay/max. $250 copay)25%
(min. $100 copay/max. $250 copayPrescription drugs (90-day or retail)5 Tier 1 Generally Genetic $50 $50 $50 20% $50 $50 $50 Tier 2 Generally Genetic $150
$187.50$187.50 20% $187.50 $187.50 $187.50 Tier 3 Generally Non-preferred brand generic $250 25%
(min. $250 copay/max. $500 copay)25%
(min. $250 copay/max. $500 copay)20% 25%
(min. $250 copay/max. $500 copay)25%
(min. $100 copay/max. $500 copay)25%
(min. $250 copay/max. $500 copay)1 - Charter PCP and specialist copays do not count towards the annual deductible; but, do apply towards the annual out-of-pocket maximum.
2 - Free if you are enrolled in an HISD medical plan (not available to Choice HDHP members).
3 - Pre-certification may be required.
4 - Services are tiered under Nexus Basic and Nexus Plus.
5 - Separate pharmacy copay applies after separate pharmacy deductible has been met (except Choice HDHP). -
2024 Coverage Cost Comparison
For additional information, view The 2024 Benefits Guide.
- Kelsey ACO PCP and specialist copays do not count toward the annual deductible but do apply toward the annual out-of-pocket maximum.
- Free if you are enrolled in an HISD medical plan
- Pre-certification may be required
- OBGYN specialists are tiered
- Copay applies after the pharmacy deductible has been met
- >Preventive services are not subject to the deductible
- The copays in the Kelsey plans are not subject to deductible
