PLAN

PLAN #1    

HMO PLAN 20E

PLAN #2

HMO LOW PLAN 25

 PLAN #3

HMO LOW PLAN 25 LIMITED RX

 PLAN #4

POS PLAN F

MONTHLY PREMIUM 

 Single: $382.99

 2 Person: $749.98

 Family: $1077.81

 Single: $307.23

 2 Person: $598.46

 Family: $858.62

 Single: $285.25

 2 Person: $554.50

 Family: $795.02

 Single: $333.34

 2 Person: $650.68

 Family:  $934.16

 
OFFICE VISITS

 
$20 Copay

 
$25 PCP & $40 Specialist Copay

 
$25 PCP & $40 Specialist Copay

 
$25 PCP & $40 Specialist Copay

 
EMERGENCY ROOM

 
$50 Copay

 
$50 Copay

 
$50 Copay

 
$50 Copay

 
HOSPITAL

 
$0 Copay

 
$500  per Admission

 
$500  per Admission

 
$500 per Admission

OUT-OF-NETWORK

N/A

 
N/A

 
N/A

 
$2000 per individual /
$4000 Family deductable

70%/30% co insurance
to max out of pocket of
$5000 individual /
$10,000 family

 
Rx DRUG

CARD

$20 Generic

$30 Name Brand

$40 Non-formulary
Name Brand

$20 Generic

$30 Name Brand

$40 Non-formulary
Name Brand

 
Mandatory Generic
$10
Generic

$25 Name Brand
after $250 deductable

Annual max benefit
of $500 per member
for covered name
brand drugs

-unlimited generic

$20 Generic

$30 Name Brand

$40 Non-formulary
Name Brand

 
DEPENDENT CHILDREN

 
Covered up to
age 19  unless
full time Student

 
Covered up to
age 19  unless
full time Student

 
Covered up to
age 19  unless
full time Student

 
Covered up to
age 19  unless
full time Student