Medical Plan Benefits

Medical Plan Benefits	Gold EPO	Silver EPO	Bronze EPO
Annual Deductible	$1,500 Individual $3,000 Family	$3,000 Individual $6,000 Family	5,000 Individual $10,000 Family
Coinsurance	80%	70%	70%
Annual Out of Pocket Max	$9,450 Individual $18,900 Family	$9,450 Individual $18,900 Family	$9,450 Individual $18,900 Family
Preventive Care Services	100%	100%	100%
Accolade (Virtual Care)	$0 copay	$0 copay	$0 copay
Airrosti	$35 copay	$35 copay	70% after deductible
Officie Visit: PCP	$10 copay	$20 copay	70% after deductible
Office Visit: Specialist	$30 copay	$40 copay	70% after deductible
Hospital Services Inpatient/Outpatient	80% after deductible	70% after deductible	70% after deductible
Urgent Care	$40 copay	$40 copay	70% after deductible
Emergency Room	$500 copay per visit; 20% Coinsurance	$500 copay per visit; 30% Coinsurance	70% after deductible
Prescription Services
Rx: Retail (30 days)
Tier 1	$5 copay	$5 copay	70% after deductible
Tier 2	$50 copay	$50 copay
Tier 3	$100 copay	$100 copay
Tier 4	$250 copay	$250 copay