Medical Insurance Overview
Cost per pay period per coverage level:
Employee Only: $25.00 (Without Wellness: $63.00)
Employee + Spouse: $266.50 (Without Wellness: $273)
Employee + Child(ren): $137.50 (Without Wellness: $144)
Employee + Family: $382.00 (Without Wellness: $388.50)
Deductible and Out-of-Pocket Maximum:
Deductible: $1,250 Individual and $3,750 Family
Out-of-Pocket-Maximum $4,890 Individual and $14,670 Family
Office Visits:
PCP: $20 Copay
Specialist: $30 Copay
Preventative Services: $20 Copay
(Colonoscopy/Mammogram $0)
Hospital Related Cost
Hospital Inpatient: 20% after deductible has been met.
Hospital Outpatient: 20% after deductible has been met.
Emergency Room Visit: $200 Copay Then Subject to Co-Insurance after Deductible is Met.
Urgent Care Visit: $30 Copay
Prescription Drugs
Retail 31 Day or Mail Order 90 Day Supply
$10 Copay- Tier 1
$30 Copay- Tier 2
$45 Copay- Tier 3
25% up to $100 Max- Tier 4