MEDICAL * D e d u ct i b l e A p p l i e s Fi r st The rates and benefit plan information shown in this guide are illustrative only. To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlying insurance documents will govern in all cases. The insurance carrier will determine the actual rates based upon the final member enrollment, plan selection, funding, type, and eligibility criteria. Until that time, and the carrier's final communication, the rates will be subject to change. Medical insurance helps you pay for preventive care, routine health needs, prescriptions, and advanced procedures by cost-sharing with your insurance provider. Hover over the insurance terms below to learn what they mean! REVIEW PLAN SBC & SUMMARY OAP HSA $1,500 HSA $3,500 Save on Prescription HEALTH YOUR JOURNEY TO DEDUCTIBLE Individual: $2,000 Family: $4,000 Individual: $1,500 Individual with Family: $2,800 Family: $3,000 Individual: $1,500 Individual with Family: $2,800 Family: $3,000 OFFICE VISITS Primary Care: $30 Specialist: $50 Urgent Care: $50 Primary Care: *30% Coinsurance Specialist: *30% Coinsurance Urgent Care: *30% Primary Care: *30% Coinsurance Specialist: *30% Coinsurance Urgent Care: *30% PROCEDURES Inpatient: *30% Coinsurance Outpatient: *30% Coinsurance Emergency Room: $200 Individual: $4,000 Family: $8,000 Individual: $4,000 Family: $8,000 OUT-OF-POCKET MAXIMUM Individual: $4,000 Family: $8,000 Individual: $4,000 Family: $8,000 Individual: $4,000 Family: $8,000 RATES PER BIWEEKLY PAY PERIOD Employee: $132.24 Employee + Spouse: $268.31 Employee + Children: $253.64 Family: $389.71 Employee: $92.96 Employee + Spouse: $188.61 Employee + Children: $178.29 Family: $273.94 Employee: $92.96 Employee + Spouse: $188.61 Employee + Children: $178.29 Family: $273.94