my Direct Blue EPO Gold 1700 HSA

Health Insurance Plan Details (2026 Plan)

EPO

HSA

Gold

Deductible (per individual)	$1,700 /yr
Deductible (per family)	$3,400 /yr
Max Out-of-Pocket (per individual)	$7,500 /yr
Max Out-of-Pocket (per family)	$15,000 /yr
Plan Type	EPO
Includes Child Dental?	Yes
Includes Adult Dental?	No

Medical Services
Preventive Care	No Charge
Primary Care Visit	$15 Copay after deductible
Specialist Visit	$15 Copay after deductible
Emergency Room	$250 Copay after deductible
Inpatient Facility	$450 Copay per Stay after deductible
Inpatient Physician	No Charge after deductible

Drug Costs
Generic Drugs	$0 Copay after deductible
Preferred Brand Drugs	$30 Copay after deductible
Non-preferred Brand Drugs	$150 Copay after deductible
Specialty Drugs	50.00% Coinsurance after deductible

Summary of Benefits and Coverage	SBC doc
Provider Directory	Doctor lookup
Drug Formulary List	n/a

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible

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