OPEN ACCESS CORE PLAN

Core Plan Booklet

Individual annual deductible: $750.00

Family annual deductible: $1,500.00

Coinsurance: 20%

Payment Limit: Individual: $5,000  Family: $10,000

Office visit co-pay: Primary:$30  Specialist: $55

Prescription co-pay: Generic: $10  Preferred: $35  Non-Preferred: $55

MONTHLY RATES

EE: $187.00

EE/S: $760.00

EE/C: $658.00

EE/F: $1,354.00

BOTH EE: $626.00