Medical Plans

HDHP*

with Health Savings Account

Value Gold Classic Silver

In Network In Network In Network

Lifetime Maximum Calendar Year

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 $4,500 $9,000

Hospital Services

Inpatient Hospital Outpatient Hospital Emergency Room Urgent Care

$250 Copay, Deductible, then 20% $250 Copay, then 25% $250 copay, then 20% Deductible, then 20% Deductible, then 25% Deductible, then 20%

Deductible, then 20%

Deductible, then 25% Deductible, then 20% Deductible, then $45 Copay $55 Copay $50 copay

Routine Services

Office Visit Specialist Visit Preventive Care Lab & X-Ray

Chiropractic Rehabilitation

Deductible, then $25 Copay $35 Copay Deductible, then $35 Copay $45 Copay Covered in Full Covered in Full

Deductible, then 20% 25% (deductible waived at a freestanding laboratory) $30 copay $40 copay Covered in Full 20% (deductible waived at a freestanding aboratory)

Deductible, then $35 Copay $45 Copay

$30 copay Deductible, then $35 Copay Deductible, then 25% Deductible, then 20%

Prescription Drugs

Tier 1 Tier 2

Tier 3

Deductible, then $15 Copay $15 Copay $15 Copay

Deductible, then 30% Copay ($25 min/$80 max) 30% Copay ($25 min/$80 max) 30% Copay ($25 min/$80 max)

Deductible, then 40% Copay ($40 min/$110 max) 40% Copay ($40 min/$110 max) 40% Copay ($40 min/$110 max)

Tier 4 Specialty

Deductible, then 20% Copay ($100 min/$150 max) 20% Copay ($100 min/$150 max) 20% Copay ($100 min/$150 max)

Mail-Order

Deductible, then $30 / 20% / 40% $30 / 20% / 40% $30 / 20% / 40%

Diabetic Medications $5 Generic, $15 Brand $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.