Medical Plans

Lifetime Maximum Calendar Year HDHP* with Health Savings Account Value Gold Classic Silver

In Network In Network In Network

Unlimited Unlimited Unlimited Unlimited Unlimited Unlimited

Deductibles

Individual Family Coinsurance $1,500 $3,000** 20% $750 $1,500 25% $500 $1,000 20%

Out-of-Pocket Maximum

Individual Family $5,500 $11,000 $5,000 $10,000

Hospital Services

Inpatient Hospital

$250 Copay, Deductible, then 20% $250 Copay, then 25% Outpatient Hospital Deductible, then 20% Deductible, then 25%

Emergency Room Urgent Care Deductible, then 20% Deductible, then 20% Deductible, then 25% $55 Copay

Routine Services

Office Visit Specialist Visit Preventive Care Lab & X-Ray

Chiropractic Rehabilitation Deductible, then 20% Deductible, then 20% Covered in Full Deductible, then 20%

Deductible, then 20% Deductible, then 20% $35 Copay $45 Copay Covered in Full 25% (deductible waived at a freestanding laboratory) $45 Copay Deductible, then 25% $4,500 $9,000

$250 copay, then 20% Deductible, then 20% Deductible, then 20% $50 copay

$30 copay $40 copay Covered in Full 20% (deductible waived at a freestanding aboratory) $30 copay Deductible, then 20%

Prescription Drugs

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

Deductible, then 20% Deductible, then 20% Deductible, then 20% Deductible, then 20% Deductible, then 20% Diabetic Medications Deductible, then 20% $15 Copay

$15 copay 20% Copay ($25 min/$80 max) 30% Copay ($25 min/$80 max) 40% Copay ($40 min/$110 max) 40% Copay ($40 min/$110 max) 20% Copay ($100 min/$150 max) 20% Copay ($100 min/$150 max) $30 / 20% / 40% $30 / 20% / 40% $5 Generic, $15 Brand $5 Generic, $15 Brand

**If you have Family coverage under the HDHP the Family Deductible must be satisfied before the Plan will pay any benefits. $5 Generic, $15 Brand