| Monthly Premiums |
Co-Pays |
Prescription Benefit |
| $225.40 - Single |
$20-Specialist |
$10 Copay for 30 Day Supply Tier I Drugs |
| $507.15 -Two Person |
$50 - ER |
$25 Copay for 30 Day Supply Tier II Drugs |
| $586.02 - Family |
$250 In Patient Hospitalization |
$40 Copay for 30 Day Supply TierIII Drugs |
| $20 Primary Care Physician |
$0 Well Child Office Visits |
$1000 Annual/Person Maximum for all 3 Tiers |
| |
20% discount on Eyeware Annualy |
|
