MEDICAL Y O U R J O U R N E Y T O HEALTH Medical insurance helps you pay for preventive care, routine health needs, prescriptions, and advanced procedures by cost-sharing with your insurance provider. Hoverovertheinsurancetermsbelowtolearnwhattheymean! PLAN 1 PLAN 2 PLAN 3 Individual: $2,000 Individual: $1,500 Individual: $3,500 DEDUCTIBLE Family: $4,000 Individual with Family: $2,800 Family: $7,000 Family: $3,000 Primary Care: $30 Primary Care: *30% Coinsurance Primary Care: *30% Coinsurance OFFICE VISITS Specialist: $50 Specialist: *30% Coinsurance Specialist: *30% Coinsurance REVIEW Urgent Care: $50 Urgent Care: *30% Coinsurance Urgent Care: *30% Coinsurance Inpatient: *30% Coinsurance Inpatient: *30% Coinsurance Inpatient: *30% Coinsurance PLAN SBC’S PROCEDURES Outpatient: *30% Coinsurance Outpatient: *30% Coinsurance Outpatient: *30% Coinsurance Emergency Room: $200 Emergency Room: *30% Coinsurance Emergency Room: *30% Coinsurance Tier 1: $10 Tier 1: $10 after deductible Tier 1: $15 after deductible PRESCRIPTIONS Tier 2: $35 Tier 2: $35 after deductible Tier 2: $35 after deductible Tier 3: 60 Tier 3: $60 after deductible Tier 3: $60 after deductible OUT-OF-POCKET Individual: $4,000 Individual: $4,000 Individual: $5,000 MAXIMUM Family: $8,000 Family: $8,000 Family: $10,000 RATES PER Employee: $10.00 Employee: $10.00 Employee: $10.00 BIWEEKLY Employee + Spouse: $20.00 Employee + Spouse: $20.00 Employee + Spouse: $20.00 PAY PERIOD Employee + Children: $30.00 Employee + Children: $30.00 Employee + Children: $30.00 Family: $40.00 Family: $40.00 Family: $40.00 *Deductible applies first. The benefits and rates in this guide are for illustrative purposes only. Please refer to the Summary of Benefits and Coverage for specific benefits. To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlying insurance documents will govern in all cases.