Medical Plans

Lifetime Maximum Calendar Year

Deductibles

Individual Family Coinsurance

Out-of-Pocket Maximum

Individual Family

Hospital Services

Inpatient Hospital Outpatient Hospital Emergency Room Urgent Care

Routine Services

Office Visit Specialist Visit Preventive Care Lab & X-Ray Chiropractic Rehabilitation

Prescription Drugs

Tier 1 Tier 2 Tier 3 Tier 4 Specialty Mail-Order

HDHP with Health Savings Account PPO Plan In Network In Network

Unlimited Unlimited Unlimited Unlimited

$2,800 $5,600 20% $1000 $3,000 20%

$6,350 $12,700 $6,350 $12,700

Deductible, then 20% Deductible, then 20% Deductible, then 20% Deductible, then 20%

Deductible, then 20% Deductible, then 20% Covered in Full Deductible, then 20% Deductible, then 20% Deductible, then 20% Deductible, then 20% Deductible, then 20% $250 Copay $50 Copay

$30 Copay $40 Copay Covered in Full Deductible, then 20% $40 Copay Deductible, then 20%

Deductible, then $15 Copay Deductible, then $40 Copay Deductible, then $70 Copay

$15 Copay $40 Copay $70 Copay Deductible, then cost varies by drug** No Charge** Deductible, then $37.50 / $100 / $175 $37.50 / $100 / $175

**Contact specialty pharmacy, Vivio Health for cost details by drug.