ACO 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: $135.00

EE/S: $686.00

EE/C: $596.00

EE/F: $1,211.00

Both EE: $539.00