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Enrollment
Guide

Classic PPO Plan Premier PPO Plan CDHP
Out-of-
Out-of-
Out-of-
In-Network Network In-Network Network In-Network Network
Calendar Year Deductible
Employee $750 $3,000 $500 $2,000 $1,500 $5,000
Employee + 1 $1,000 $4,000 $750 $3,000 $2,500 $7,500

Family $1,350 $5,400 $1,000 $4,000 $3,000 $10,000
Out-of-Pocket Maximum
Employee $3,000 $7,500 $2,000 $5,000 $3,000 $10,000
Employee + 1 $4,000 $10,000 $3,000 $7,500 $4,500 $15,000
Family $5,400 $13,500 $4,000 $10,000 $6,000 $20,000

Physician Ofice Visits
Primary Care $20 Copay 40% after $20 Copay 40% after 80% after 40% after
deductible deductible deductible deductible
Specialist $20 Copay 40% after $20 Copay 40% after 80% after 40% after
deductible deductible deductible deductible
Preventive Care
Coverage 100% no 40% after 100% no 40% after 100% no 40% after
level deductible deductible deductible deductible deductible deductible
Hospital Services
Inpatient 80% after 40% after 80% after 40% after 80% after 40% after
deductible deductible deductible deductible deductible deductible
Outpatient 80% after 40% after 80% after 40% after 80% after 40% after
deductible deductible deductible deductible deductible deductible
Emergency $200 (waived $200 (waived $200 (waived $200 (waived $200 (waived $200 (waived
Room if admitted) if admitted) if admitted) if admitted) if admitted) if admitted)
Urgent Care $25 copay 40% after $25 copay 40% after 80% after 40% after
deductible deductible deductible deductible

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