SUMMARY OF COVERAGE MEDICAL PLAN
Option 1 Bronze Plan $5,000 - 100% - H.S.A.
Option 2 Gold Plan $5,000 - 100%
Option 3 Silver Plan $5,000 - 80%
In-Network
In-Network
In-Network
BlueCross BlueShield
Annual Deductible Individual | Family Out-of-Pocket Max Individual | Family
$5,000 | $10,000
$5,000 | $10,000
$5,000 | $14,700
$5,000 | $10,000
$8,150 | $16,300
$7,350 | $14,700
Primary Care Specialty Care
$35 copay $70 copay
$45 copay $90 copay
0% after deductible
Preventive Care
No Charge
No Charge
No Charge
Diagnostic Lab and X-ray
0% after deductible
0% after deductible
20% after deductible
Complex Radiology
0% after deductible
0% after deductible
20% after deductible
Urgent Care
0% after deductible
$75 copay
$75 copay
0% after deductible
$500 copay
$500 copay
Emergency Room
Hospital Inpatient & Outpatient
0% after deductible
0% after deductible
20% after deductible
Retail Drugs (30 day supply)
Preferred Pharmacy / Non Preferred In-network Pharmacy
Preferred Pharmacy / Non Preferred In-network Pharmacy
Preferred Pharmacy / Non Preferred In-network Pharmacy
$0 / $10
$0 / $10
0% after deductible
Generic Drug
$50 / $70
$50 / $70
0% after deductible
Preferred Brand
$100 / $120
$100 / $120
0% after deductible
Non-Preferred
$150 or 250
$150 or 250
0% after deductible
Specialty Drug
Out of Network Coverage
Annual Deductible Individual | Family
$10,000 / $20,000
$10,000 / $20,000
$10,000 / $29,400
30%
50%
Coinsurance
40%
Out-of-Pocket Max Individual | Family
Unlimited
Unlimited
Unlimited
Bi-Weekly Contribution
$46.38
$57.63
$49.21
Employee Only
Employee and Spouse
$195.64
$246.77
$212.83
$187.92
$237.05
$208.22
Employee and Child
$317.63
$400.06
$351.42
Family
4
Any dependents that are a domestic partner imputed income and after-tax contributions may apply
MEDICAL PLAN I
4
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