Page 3 - LBC 2020 Benefit Guide

Lansing Brewing Company Medical Benefits

Effective October 1, 2020

Current Renewal

BCN Classic HMO BCN Classic HMO

Single $338.38 $361.59
Two Person $812.11 $867.80
Family $1,015.14 $1,084.75

Benefits
Deductible
In network $1000/$2000 $1000/$2000
Out Network No Benefit No Benefit

Prescription drug copay $4/$15/$40/$80/20%/20% $4/$15/$40/$80/20%/20%

Office visit copay $20 PCP/$40 Spec $20 PCP/$40 Spec

Urgent care copay $50 $50

Emergency Room Copay $250 after deductible $250 after deductible

Hospitalization
In patient 80% after deductible 80% after deductible
Out patient 80% after deductible 80% after deductible

Lab & X-ray 80% after deductible 80% after deductible

Embedded Coinsurance Max. $2500/$5000 $2500/$5000

Maximum copayment
In network $6600/$13,200 $6600/$13,200
Out network No Benefit No Benefit

Employee Cost Per Pay

Single $46.73
Two Person $112.15
Family $140.18