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EnrollmEnt InformatIon

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annual Deductible
Individual $1,500 $750 $1,500
*Family $1,500/Member $750/Member $3,000
coinsurance (You Pay) 25% 25% 20%
Physician office Visits
Primary Care Physician $25 Copay $25 Copay $20 Copay
Specialist $40 Copay $40 Copay $20 Copay
lab & X-Ray No Charge, Out Hosp: 25% No Charge, Out Hosp: 25% Deductible, $10 Copay
Complex $100 Copay, Out Hosp: 25% $100 Copay, Out Hosp: 25% Deductible, $50 Copay
out-of-Pocket Maximum
Individual $3,000 $3,000 $4,000
*Family $6,000 $6,000 $8,000
Hospitalization
Inpatient Deductible, 25% Deductible, 25% Deductible, 20%
Outpatient Deductible, 25% Deductible, 25% Deductible, 20%

emergency services $150 Copay, Ded, 25% $150 Copay, Ded, 25% Deductible, 20%
urgent care $25 Copay $25 Copay $20 Copay
Preventive care No Charge No Charge No Charge
Prescription Drugs
Retail (30 Day Supply)
Tier 1a - 1b $5 or $20 Copay $5 or $20 Copay $10 Copay
Tier 2 $30 Copay $40 Copay $30 Copay
Tier 3 $50 Copay $75 Copay N/A
Tier 4 30% Max $250 30% Max $250 20% Max $150
Mail Order (90 Day Supply)
Tier 1a - 1b $12.50 or $50 Copay $12.50 or $50 Copay $20 Copay
Tier 2 $90 Copay $120 Copay $60 Copay
Tier 3 $150 Copay $225 Copay N/A
Tier 4 30% Max $250 30% Max $250 N/A

EMPloyEE ratE PEr PayChECK
(based on 26 pay periods)
Employee Only $34.26 $85.13 $56.92
Employee + Spouse $205.55 $355.84 $252.06
Employee + Child(ren) $148.45 $265.59 $221.17
Employee + Family $334.01 $558.88 $382.17

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