Medical

High Deductible Health Plans (HDHP)AG-X7AG-YD* BM-C4 (HMO)
Deductible (per calendar year)
Individual Family
$3,000
$6,000
$5,000
$10,000
$5,000
$10,000
Out of pocket Maximum
Individual Family
$4,000
$8,000
$6,550
$13,100
$6,900
$13,800
Coinsurance Amounts
Primary Care (PCP)
Primary Care (PCP) if child age is; 19
Specialty Care
Urgent Care
Convenience Care Clinic
Virtual Visit Copay
100% after deductible
80% after deductible
70% after deductible
Preventive CarePlan pays 100%Plan pays 100%Plan Pays 100%
-Diagnostic Testing and Procedures

-Simple Diagnostics Complex Imaging
100% after deductible

100% after deductible
80% after deductible

80% after deductible
70% after deductible

70% after deductible
Inpatient Hospital100% after deductible80% after deductible70% after deductible
Emergency Room
(accidental injury & emergency care)
100% after deductible80% after deductible70% after deductible
Prescription Drug Deductible

Tier 1
Tier 2
Tier 3 Mail Order
Rx copays AFTER deductible
$10 copay
$35 copay
$60 copay 2.5X
Rx copays AFTER deductible
$10 copay
$35 copay
$60 copay 2.5X
Rx copays AFTER deductible
$10 copay
$35 copay
$60 copay 2.5X
*BM-C4 HDHP (HMO) Must designate a primary care physician (requires referrals for specialists each plan year)
HDHP Plans
Monthly Deductions
Coverage TierAG-X7AG-YDBM-C4 (HMO)
Employee Only$298.50$129.50$55.40
Employee + Spouse$900.20$575.60$433.30
Employee + Child(ren)$754.00$467.30$341.50
Family$1,228.00$818.60$639.10
HDHP Plans
Biweekly
Deductions
Coverage TierAG-X7AG-YDBM-C4 (HMO)
Employee Only$149.25$64.75$27.70
Employee + Spouse$450.10$287.80$216.65
Employee + Child(ren)$377.50$233.65$170.75
Family$614.00$409.30$319.55
Copay PlansAN-DOAX-KY
Benefits
Deductible (per calendar year)
Individual$1,000$5,000
Family$2,000$10,000
Out of pocket Maximum
Individual$6,500$7,150
Family$13,000$14,300
Copayment Amounts
Primary Care (PCP)
Primary Care (PCP) if child age is; 19
Specialty Care
Urgent Care
Convenience Care Clinic
Virtual Visit Copay

$0 copay
$0 copay
$100 copay
$50 copay
$0 copay
$0 copay

$15 copay
$0 copay
$50/$100 copay
$25 copay
$15 copay
$0 copay
Preventive CarePlan pays 100%Plan Pays 100%
Diagnostic Testing and Procedures
Simple Diagnostics Complex Imaging
80% after deductible
80% after deductible
80% after deductible
80% after deductible
Inpatient Hospital80% after deductible80% after deductible
Emergency Room
(accidental injury & emergency care)
$250 copay + Deductible
+ 20% coinsurance
$300 copay + Deductible
+ 20% coinsurance
Prescription Drug Deductible$ 250/$500 (Tier 3 & 4 only)None
Tier 1$5 copay$20 copay
Tier 2$50 copay$50 copay
Tier 3$100 copay$85 copay
Tier 4$250 copayN/A
Mail Order2.5X2.5X
Copay Plans
Monthly Deductions
Coverage Tier AN-DO / AX-KY
Employee Only$329.50$195.30
Employee + Spouse$959.80$702.00
Employee + Child(ren)$806.60$578.90
Family$1,303.10$978.10
Copay Plans
Biweekly Deductions
Coverage Tier AN-DO / AX-KY
Employee Only$164.75$97.65
Employee + Spouse$479.90$351.00
Employee + Child(ren)$403.30$289.45
Family$651.55$489.05