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.