| Basic |
|---|
| Employee Only | $699.00 |
| Employee and One Dependent | $1,467.00 |
| Employee and Two or more Dependent(s) | $1,876.00 |
| Supplement to Medicare |
|---|
| Employee Only | $464.00 |
| Employee and One Dependent | $924.00 |
| Employee and Two or more Dependent(s) | $1,477.00 |
Maximum Out-of-Pocket Expense $4,500 per person/ $9,000 for a family.
Prescription Drugs
| Retail |
|---|
| Generic | $10.00 copay |
| Brand Formulary | $25.00 copay |
| Brand Non-Formulary | $45.00 copay |
| Mail Order |
|---|
| Generic | $20.00 copay |
| Brand Formulary | $40.00 copay |
| Brand Non-Formulary | $75.00 |
Benefit Changes effective 2015: Body Scans will be subject to a maximum $1,000 coverage limit every 36 months.
