Page 7 - Guide

Medical/Prescription Drug Benefits
PPO Plan HSA Plan
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible 3 Month Deductible Carryover Non-Embedded Deductible*
Individual $1,000 $2,000 $1,500 $1,500
Family $2,000 $4,000 $3,000 $3,000
Coinsurance (Member Responsibility Shown)
20% after deductible 40% after deductible 10% after deductible 30% after deductible
Out-of-Pocket Maximum Includes Deductibles and All Copays Non-Embedded Maximum, Includes Deductibles*
Individual $3,250 $6,500 $3,000 $6,000
Family $6,500 $13,000 $6,000 $12,000
Physician Ofice Visits
Primary Care $25 copay 40% after deductible 10% after deductible 30% after deductible
Specialist $35 copay 40% after deductible 10% after deductible 30% after deductible
Wellness/Preventive
Immunizations Covered at 100% 40% after deductible Covered at 100% 30% after deductible
Routine Exams Covered at 100% 40% after deductible Covered at 100% 30% after deductible
Mammograms Covered at 100% 40% after deductible Covered at 100% 30% after deductible
Pap Smears Covered at 100% 40% after deductible Covered at 100% 30% after deductible
PSA Exams Covered at 100% 40% after deductible Covered at 100% 30% after deductible
Colonoscopy Exams Covered at 100% 40% after deductible Covered at 100% 30% after deductible
Hospital Services
Inpatient 20% after deductible 40% after deductible 10% after deductible 30% after deductible
Outpatient 20% after deductible 40% after deductible 10% after deductible 30% after deductible
Emergency Room $200 copay $200 copay 10% after deductible 10% after deductible
Prescription Drugs
Per Person Deductible $100 for tiers 2 and 3 drugs combined Medical deductible applies
Retail (30-day supply)
Tier 1 $8 copay 50% coinsurance 10% after deductible 30% after deductible
(min. $45)
Tier 2 $30 copay 50% coinsurance 10% after deductible 30% after deductible
(min. $45)
Tier 3 $50 copay 50% coinsurance 10% after deductible 30% after deductible
(min. $45)
Mail Order (90-day supply)
Tier 1 $16 copay Not covered 10% after deductible Not covered
Tier 2 $60 copay Not covered 10% after deductible Not covered
Tier 3 $100 copay Not covered 10% after deductible Not covered

* Deductibles and out-of-pocket maximums are non-embedded, meaning no individual family member’s deductible or out-of-pocket is satisied until
the full family deductible or out-of-pocket maximum is satisied. One member of the family can meet the full family deductible or out-of-pocket
maximum.

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