Medical

Premier Silver 1250 PPODeductible: $1,250 Individual / $2,500 Family
Out-of-Pocket: $6,350 Individual / $12,700 
Office Visit: Primary Care Physician $35 / Specialist $50
Inpatient Hospital: 30% once medical deductible is satisfied 
UC / ER/ Major Diag Copay: UC $50 / ER $150 / MD N/A 
Pharmacy: Tier 1 $10 / Tier 2 $35 / Tier 3 $60 / Tier 4 $100 / Mail Order 2.5x
Premier Bronze 5900 PPODeductible: $5,900 Individual / $11,000 Family
Out-of-Pocket: $6,350 Individual / $12,700 
Office Visit: Primary Care Physician $35 for first 3 visits / Specialist $35 for first 3 visits
Inpatient Hospital: 0% once medical deductible is satisfied 
UC / ER/ Major Diag Copay: 0% once medical deductible is satisfied
Pharmacy: Tier 1 $15 / Tier 2 $40 / Tier 3 $60 / 2x Mail Order
Select Plus Silver 2700 HSADeductible: $2,700 Individual / $5,400 Family
Out-of-Pocket: $5,000 Individual / $10,000 Family 
Office Visit: 20% once medical deductible is satisfied 
Inpatient Hospital: 20% once medical deductible is satisfied 
UC / ER/ Major Diag Copay: 20% once medical deductible is satisfied
Pharmacy: Tier 1 $15 / Tier 2 $40 / Tier 3 $60 / 2x Mail Order
Select Plus Bronze 5500 HSADeductible: $5,500 Individual / $11,000 Family
Out-of-Pocket: $6,350 Individual / $12,700 
Office Visit: 30% once medical deductible is satisfied 
Inpatient Hospital: 30% once medical deductible is satisfied 
UC / ER/ Major Diag Copay: 30% once medical deductible is satisfied  
Pharmacy: Tier 1 $15 / Tier 2 $40 / Tier 3 $60 / 2x Mail Order
Core Silver 2000 PPODeductible: $2,000 Individual / $4,000 Family
Out-of-Pocket: $5,000 Individual / $10,000 
Office Visit: Primary Care Physician $25 / Specialist $40
Inpatient Hospital: 30% once medical deductible is satisfied 
UC / ER/ Major Diag Copay: UC $125 / ER $250 / MD N/A 
Pharmacy: Tier 1 $10 / Tier 2 $30 / Tier 3 $50 / Mail Order 2.5x
Core Bronze 5500 HSADeductible: $5,500 Individual / $11,000 Family
Out-of-Pocket: $6,350 Individual / $12,700 
Office Visit: 30% once medical deductible is satisfied 
Inpatient Hospital: 30% once medical deductible is satisfied 
UC / ER/ Major Diag Copay: 30% once medical deductible is satisfied  
Pharmacy: Tier 1 $10 / Tier 2 $30 / Tier 3 $50 / Mail Order 2.5x

Dental

Dental Incentive PPO (Network)Diagnostic Services: Covered
Preventative Services: Covered
Basic Services: 10%
Major Services: 60%
Orthodontic Services: 50%
Deductible: $0
Annual Max: $1500
Dental Passive PPO (Network)Diagnostic Services: Covered
Preventative Services: Covered
Basic Services: 20%
Major Services: 50%
Orthodontic Services: 50%
Annual Max: $1500
Dental DMOCall for schedule of discount rates

Vision/HIPP/Life

VisionExam Co-pays: $10
Eye Examination: 100%
Retail Frame Allowance: Up to $130
Discount on Frame Overage: 30%
Hospital Indemnity Plan (Network)Hospital and ICU
Admission: $1,500
Confinement: $200 per day
Dep Lodging: $200 per day
Dep Transportation: $200

Group Life Insurance$50,000
$20,000