Lpn nurse

TiWvN

Deductible

Office Visit

Inpatient

Outpatient

Emergency Room

Rx

Lab & X-Ray

Out-of-Network

Out-of-Pocket Maximum

Page 1

TiWvN

Choice Plus HSA BC-OD RX 0I "Bronze","Choice Plus Premier AX-PG RX 0I "Silver","Choice Plus Premier BC-OP RX 0I "Go

"Per Pay Period (Weekly)

$3,500 Single / $7,000 Family

PCP: Ded. then $25 Copay; SP: Ded. then $50 Copay

Ded. then 0%

Ded. then 0%

UC: Ded. then $75 Copay; ER: Ded. then $250 Copay

Retail: Ded. then $10/$35/$70; Mail Order: Ded. then $25/$87.50/$175

Ded. then 0%

See SBC

$6,650 Single / $13,300 Family

Page 2

TiWvN

$29.81

$3,000 Single / $6,000 Family

PCP: $15 Copay / Tier 1SP: $50 Copay / SP: $100 Copay

Ded. then 20%

Ded. then 20%

UC: $25 Copay; ER: $300 Copay, Ded. then 20%

Retail: $10/$35/$70; Mail Order: $25/$87.50/$175

Ded. then 20%

See SBC

$7,150 Single / $14,300 Family

Page 3

TiWvN

$31.61 $78.36

$1,500 Single / $3,000 Family

PCP: $25 Copay / Tier 1SP: $25 Copay / SP: $50 Copay

Ded. then 0%

Ded. then 0%

$300 Copay

Retail: $10/$35/$70; Mail Order: $25/$87.50/$175

Covered in full

See SBC

$3,000 Single / $6,000 Family

Page 4

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