Insured by the “NEW” HIP!
Premiums Effective 9/1/07 through 8/31/08

PLAN	PLAN #1 Select EPO Prime	PLAN #2 HMO Medium Prime	PLAN #3 HMO High Prime	PLAN #4 PPO Select Prime
MONTHLY PREMIUM (Domestic Partners Not Covered)	SINGLE: $357.41 Two Person: $640.53 FAMILY: $1009.34	SINGLE: $488.63 Two Person: $919.64 FAMILY: $1453.20	SINGLE: $557.73 Two Person: $1045.92 FAMILY: $1654.14	SINGLE: $379.08 Two Person: $680.14 FAMILY: $1072.40
OFFICE VISITS	$25 Primary & Specialist Copay NO REFERRALS REQUIRED	$20 Primary & Specialist Copay REFERRALS REQUIRED	$0 Primary & Specialist Copay REFERRALS REQUIRED	$30 Primary & Specialist Copay NO REFERRALS REQUIRED
EMERGENCY ROOM	$50 Copay	$50 Copay	$0 Copay	$75 Copay
HOSPITAL: In Patient, Ambulatory Surgery, & Outpatient Facilities Services	$1000/$2000 Deductible. Then 90% Co-Insurance $500/$1000	$0 Copay	$0 Copay	$1000/$2000 Deductible. Then 90% Co-Insurance $2500/$5000
OUT-OF-NETWORK	N/A	N/A	N/A	$2000/$4000 Deductible. Then 70% Co-Insurance $5000/$10000
Rx DRUG CARD	$20 Generic $30 Formulary $50 Non-Formulary	$7 Generic $30 Formulary $50 Non-Formulary	$5 Generic $10 Formulary **FORMULARY REQUIRED***	$7 Generic $30 Formulary $50 Non-Formulary
PREVENTIVE DENTAL	Included	Included	Included	Included
DEPENDENT CHILDREN	Covered to EOM 19^th birthday, unless dependant student, then EOY 23	Covered to EOM 19^th birthday, unless dependant student, then EOY 23	Covered to EOM 19^th birthday, unless dependant student, then EOY 23	Covered to EOM 19^th birthday, unless dependant student, then EOY 23