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<br />In Network/Participating <br />Deductible EE/Fam <br />Coinsurance EE/Fam <br />Office Visit Copay <br />Specialist Copay <br />Hospital Admission <br />ER <br />Referral Needed? <br />Urgent Care <br />Outpatient Surgical Facility <br />MRI-CAT-PET-ETC. <br />Max out of pocket <br />Prescription <br />Mail Order Prescription <br />Lifetime Maximum <br />Out of Network/Non- <br />Participating <br />Deductible EE/Fam N/A N/A $750/$1500 <br />Coinsurance EE/Fam N/A N/A 30% <br />Office Visit Copay N/A N/A 30% <br />Specialist Copay N/A N/A 30% <br />Hospital Admission N/A N/A 30% <br />ER N/A N/A 30% <br />Urgent Care N/A N/A 30% <br />Outpatient Surgical Facility N/A N/A 30% <br />MRI-CAT-PET-ETC. N/A N/A 30% <br />Max out of pocket N/A N/A $5000 <br />Prescription N/A N/A N/A <br />Mail Order Prescription N/A N/A N/A <br />Lifetime Maximum N/A N/A 1 M <br />Min Employer Contribution 99% 99% 99% <br />Min Employee Participation 75% 75% 75% <br />Monthly Rates Current Renewal Current Renewal Current Renewal <br />EE $299.42 $417.99 $430.26 $600.64 $453.17 $632.63 <br />ES $664.71 4927.94 $955.18 $1333.43 $1006.05 $1404.45 <br />EC $559.92 $781.65 4804.59 $1123.21 $847.44 $1183.03 <br />Family $874.32 $1220.55 $1256.38 $1753.91 $1323.29 $1847.31 <br />Actual Rates subject to Final Medical Underwriting and group under 50 may range +/- <br /> <br />15% <br /> <br />CARRIER <br />AM BEST RATING <br />PLAN NAME <br />PRODUCT TYPE <br /> <br />Employee Benefit Summary <br />Effective Period - 3/1/09 -3/1/10 <br />NHP United <br />A- A- <br />EVG 5C <br />HMO HMO <br /> <br />United <br />A- <br />52C+ <br />POS <br /> <br />$500/$1000 <br />N/A <br />$25 <br />$45 <br />$0 <br />$0 <br />$50 <br />$50 <br />$0 <br />$100 <br />$3,000 <br />$20/$40/$60/20% <br />Available <br />2M <br /> <br />N/A <br />N/A <br />$15 <br />$15 <br />$0 <br />$75 <br />$35 <br />$35 <br />$0 <br />$0 <br />$1,500 <br />$8/$25/$40 <br />Available <br />Unlimited <br /> <br />N/A <br />N/A <br />$15 <br />$15 <br />$500/Adm <br />$150 <br />$50 <br />$50 <br />$250 <br />$250 <br />$2500 <br />$8/$25/$40 <br />Available <br />Unlimited <br />