Option A CORE
Option B BUY‐UP
OUT‐OF‐NETWORK 1 Deductible
$3,000 / $6,000 $6,000 / $12,000
$4,000/$8,000 $12,700/$25,400 60%
Maximum Out‐of‐Pocket
Coinsurance
30%
PERSONAL HEALTH FUND
$500/ Single (after $1,500 deductible) $1,000/ Family (after $3,000 Deductible) Rx costs are excluded
$500/ Single (after $1,000 Deductible) $1,000/ Family (after $2,000 Deductible) Rx costs are excluded
Cost for coverage (per paycheck)
Option A CORE $ 61.11 $242.71 $219.71 $371.54
Option B BUY‐UP $110.77 $323.61 $291.64 $488.15
Employee only
Employee + Spouse Employee + Child(ren) Employee + Family
The chart below provides a brief overview of the medical plans. This chart is intended only to highlight the benefits available and should not be relied upon to fully determine your coverage. If the below illustration of benefits conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your exact description of services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
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