| Deductible Ranges | $500-$10,000*** | $250-$10,000*** | $250-$10,000*** |
| Office Visit Copays | None, toward deductible & coinsurance | $25 Consultation only | $25 (includes same day lab/X-ray up to $750) |
| Emergency Room Copay | None, Toward deductible & coinsurance | None, Toward deductible & coinsurance | $100 (facility charges only)* |
| Out-of-Pocket Maximum** | $3,000 Individual / $9,000 Family | $3,000 Individual / $6,000 Family | $3,000 Individual / $6,000 Family |
| Coinsurance | 75% of allowable amount | 80% of allowable amount | 85% of allowable amount |
| Prescription Drug Program Deductible | $200 Per Person | $200 Per Person | No Deductible |
| Prescription Drug Program Copays | 3-tier open formulary $10/$40 / $55 | 3-tier open formulary $10/$30 /$45 | 3-tier open formulary $10/$30 /$45 |
| Prescription Drug Calendar Year Maximum (including mail order) | $3,000 Per Participant | $3,000 Per Participant | $3,000 Per Participant |
| Preventative Care | 75% allowable amount subject to deductible and coinsurance up to $300 calendar year maximum per participant | 100% allowable amount subject to office visit copay up to $300 calendar year maximum per participant | 100% allowable amount subject to office visit copay up to $300 calendar year maximum per participant |
| Well-Child Care (through age 7) | Routine physical exams and developmental assessment, subject to deductible and coinsurance, up to a $300 calendar year maximum per participant. Immunizations through age 7, paid at 100%. | Routine physical exams and developmental assessment, subject to office visit copay up to a $300 calendar year maximum per participant. Immunizations through age 7, paid at 100%. | Routine physical exams and developmental assessment, covered at 100% of allowable, subject to office visit copay up to $300 calendar year maximum per participant. Immunizations through age 7, paid at 100%. |
| Lifetime Maximum | $5 million per person | $5 million per person | $5 million per person |
| Pre-Existing Condition Clause | 12 months | 12 months | 18 months |
