MEDICAL PLAN
SUMMARY OF COVERAGE
Plan 1 (HSA)
Plan 2 (HSA)
Plan 3 (PPO)
Plan 4 (PPO)
In Network
Deductible (Single / Family)
$1,600 / $3,200 $2,250 / $4,500
$500 / $1,000 $7,350 / $14,700
Out of Pocket Maximum (Single / Family)
$3,450 / $6,900 $3,450 / $6,900
$3,500 / $7,000 $8,150 / $16,300
Coinsurance
N/A
N/A
N/A
N/A
Preventive Care
100% Covered 100% Covered 100% Covered 100% Covered
Primary Care
Deductible + $25
Deductible + $25
$25 (no deductible)
$40 (no deductible)
Specialist Visit
Deductible + $75
Deductible + $75
$75 (no deductible)
Deductible + $80
Inpatient Hospital
Deductible + $250 Deductible + $250 Deductible + 0% Deductible + $500
Emergency Room (copay waived if admitted)
Deductible + $500 Deductible + $500
$500 Copay
Deductible + $500
Rx Copays (Retail)
$10 / $50 / $80
$10 / $50 / $80 $10 / $45 /0 $75 $10 / $50 / $80
Rx Copays (Mail Order)
2X Retail
2X Retail
2X Retail
2X Retail
Out of Network
Deductible
$10,000 / $30,000 $10,000 / $30,000 $2,000 / $6,000 $22,060 / $66,150
Coinsurance
50%
50%
50%
50%
Max Out of Pocket
2x Deductible 2x Deductible 5x Deductible $42,050/$126,150
Employee Contributions (Monthly)
Coverage
Plan 1
Plan 2
Plan 3
Plan 4
Employee Only
$97.50
$61.08
$243.76
$17.53
Employee + Spouse
$411.66
$308.01
$835.52
$37.12
Employee + Child(ren)
$327.74
$245.41
$663.57
$29.14
Employee + Family
$566.37
$423.41
$1,152.50
$50.36
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CAMPBELL & COMPANY BENEFITS GUIDE
MEDICAL PLAN I
8
* For illustrative purposes only. Please refer to your plan documents for all plan details
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