MEDICAL Medical insurance helps you pay for preventive care, routine health needs, prescriptions, and advanced procedures by cost-sharing with your insurance provider. Hover over the insurance terms below to learn what they mean. DOUBLE CHEESE IN-NETWORK DEDUCTIBLE Individual : $8,000 Family : $16,000 COINSURANCE 0% once the individual out-of-pocket maximum is met OFFICE VISITS Primary Care : $100 copay Specialist : $100 copay Urgent Care : $100 copay PROCEDURES Inpatient : N/A Outpatient : $2,000 copay Emergency Room : $500 copay OP Lab & X-ray : $200 copay Radiology : $200 copay PRESCRIPTIONS Retail : After deductible is met - $5/$40/$80/$250 OUT-OF-POCKET MAXIMUM Individual : $9,100 Family : $18,200 EMPLOYEE BIWEEKLY CONTRIBUTIONS Medical rates are age-banded 50 & Under Employee: $148.78 Employee + Spouse: $723.75 Employee + Children: $1,523.75 Family: $2,123.75 51-59 Employee: $280.00 Employee + Spouse: $1,280.00 Employee + Children: $1,880.00 Family: $2,480.00 Over 60 Employee: $455.00 Employee + Spouse: $1,155.00 Employee + Children: $1,755.00 Family: $2,355.00 *Deductible applies first. The benefits and rates in this guide are for illustrative purposes only. Please refer to the Summary of Benefits 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. Review Plan SBC Double Cheese