| Basic | |
|---|---|
| Employee Only | $ 774.00 |
| Employee and One Dependent | $1,623.00 |
| Employee and Two or more Dependent(s) | $2,076.00 |
| Supplement to Medicare | |
|---|---|
| Employee Only | $ 513.00 |
| Employee and One Dependent | $1022.00 |
| Employee and Two or more Dependent(s) | $1,635.00 |
Maximum Out-of-Pocket Expense $3,000 per person/ $6,000 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 copay |
Body Scans are subject to a maximum $1,000 coverage limit every 36 months.