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Sibley DPC Plan — 2023

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EHP Preferred Network Provider EHP Network Provider Out of Network Provider
Calendar Year Deductible
Individual $150 (under $50K) / $200 ($50K to $119,999K) / $300 ($120K and over) $150 (under $50K) / $200 ($50K to $119,999K) / $300 ($120K and over) $750
Family $300 (under $50K) / $400 ($50K to $119,999K) / $600 ($120K and over) $300 (under $50K) / $400 ($50K to $119,999K) / $600 ($120K and over) $1500
Co-Insurance Out of Pocket
Individual $1500 (under $50K) / $2000 ($50K to $119,999K) / $3000 ($120K and over) $1500 (under $50K) / $2000 ($50K to $119,999K) / $3000 ($120K and over) $3500
Family $3000 (under $50K) / $4000 ($50K to $119,999K) / $6000 ($120K and over) $3000 (under $50K) / $4000 ($50K to $119,999K) / $6000 ($120K and over) $7000
Lifetime Maximum
Individual Unlimited Unlimited Unlimited
Family Unlimited Unlimited Unlimited
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