Medical Plans Comparison

In-Network Benefits

Plan Features$1,500 PPO$4,000 HDHP
Deductible
(Calendar year)		$1,500 individual /
$3,000 family		$4,000 individual /
$8,000 family
Out-of-Pocket Maximum
(Calendar year)		$3,000 individual /
$6,000 family		$5,000 individual /
$10,000 family
Coinsurance
(Plan pays/You pay)		80% / 20%90% / 10%
Primary Care Physician Office Visits$25 copayDeductible, then 10% coinsurance
Specialist Office Visits$50 copayDeductible, then 10% coinsurance
Preventive Care100%100%
Urgent Care$50 copayDeductible, then 10% coinsurance
Emergency Room$300 Copay, then deductible, then 20% coinsuranceIn-Network deductible, then 10% coinsurance
Inpatient ServicesDeductible, then 20% coinsuranceDeductible, then 10% coinsurance
Outpatient ServicesDeductible, then 20% coinsuranceDeductible, then 10% coinsurance
Retail Prescription Drug Coverage
(up to 34-day supply)		Tier 1: $10 copay
Tier 2: $35 copay
Tier 3: $60 copay		Deductible, then
Tier 1: $10 copay
Tier 2: $35 copay
Tier 3: $60 copay
Mail Order
(up to 102-day supply)		Tier 1: $25 copay
Tier 2: $87.50 copay
Tier 3: $150 copay		Deductible, then
Tier 1: $25 copay
Tier 2: $87.50 copay
Tier 3: $150 copay

Monthly Premium$1,500 PPO$4,000 HDHP
    Employee only
$199.00$0.00
    Employee + Spouse
$694.80$377.70
    Employee + Child(ren)
$628.60$341.70
    Family
$959.50$521.60

Out-Of-Network Benefits

Plan Features$1,500 PPO$4,000 HDHP
Deductible
(Calendar year)		$3,000 individual /
$6,000 family		$4,000 individual /
$8,000 family
Out-of-Pocket Maximum
(Calendar year)		$15,000 individual /
$30,000 family		$10,000 individual /
$20,000 family
Coinsurance
(Plan pays/You pay)		50% / 50%70% / 30%
Primary Care Physician Office VisitsDeductible, then 50% coinsuranceDeductible, then 30% coinsurance
Specialist Office VisitsDeductible, then 50% coinsuranceDeductible, then 30% coinsurance
Preventive CareDeductible, then 50% coinsuranceDeductible, then 30% coinsurance
Urgent CareDeductible, then 50% coinsuranceDeductible, then 30% coinsurance
Emergency Room$300 copay, then in-network deductible, then 20% coinsurance In-network deductible, then 10% coinsurance
Inpatient ServicesDeductible, then 50% coinsuranceDeductible, then 30% coinsurance
Outpatient ServicesDeductible, then 50% coinsuranceDeductible, then 30% coinsurance
Retail Prescription Drug Coverage
(up to 34-day supply)		Copay + 50% coinsuranceDeductible, then copay, then 50% coinsurance
Mail Order
(up to 102-day supply)		Copay + 50% coinsuranceDeductible, then copay, then 50% coninsurance