Page 7 - Benefits Guide

Plan Details
Choice Care PPO/Choice POS
Base Plan Buy-Up Plan
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible Embedded Embedded
Individual $4,500 $13,500 $2,800 $8,400
Family $9,000 $27,000 $5,600 $16,800
Out-of-Pocket Maximum
Individual $6,350 $19,050 $5,000 $15,000
Family $12,700 $38,100 $10,000 $30,000
Physician Ofice Visits
Primary Care 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Specialist 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Preventive 100% no deductible 50% after deductible 100% no deductible 50% after deductible
Urgent Care 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Hospital Services
Inpatient 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Outpatient 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Emergency Room 70% after deductible 80% after deductible
Therapy 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Limitations 60 visits combined 10 visits combined 60 visits combined 10 visits combined
Prescription Drugs
Retail—Supply Limit 30 days 30 days
Preventive Medications Limited to Listed Medications
Tier 1 $10 copay* 50% after deductible $10 copay* 50% after deductible
Tier 2 $35 copay* 50% after deductible $35 copay* 50% after deductible
Tier 3 $60 copay* 50% after deductible $60 copay* 50% after deductible
Tier 4 $60 copay* 50% after deductible $60 copay* 50% after deductible
Non-Preventive Medications
Tier 1 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Tier 2 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Tier 3 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Tier 4 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Mail Order—Supply Limit 90 Days 90 Days
Tier 1 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Tier 2 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Tier 3 70% after deductible 50% after deductible 80% after deductible 50% after deductible
Tier 4 70% after deductible 50% after deductible 80% after deductible 50% after deductible

* Mail order preventive drugs available in 90-day quantities and subject to 2 monthly copayments .
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In the event there
is a discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your SPD will prevail.

Family Coverage and Embedded Deductibles
Embedded deductibles means your plan has an individual deductible for each family member as well as a maximum family
deductible . When a family member meets his or her deductible, the plan will begin sharing healthcare costs for this family
member . The rest of the family still has to satisfy their individual deductible . However, all individual expenses for each family
member count toward the family deductible . Once the family deductible is met (by more than one family member) the plan will
share costs for all family members for the rest of the plan year .

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