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<br /> Employee Benefit Summary <br /> Effective Period <br />CARRIER AvMed AvMed AvMed AvMed A vMed AvMed <br />AM BEST RATING B+ B+ B+ B+ B+ B+ <br />PLAN NAME 3422 3424 5228 5076 5077 CH-5011 <br />PRODUCT TYPE HMO-OA HMO-OA HMO-OA HMO-OA HMO-OA POS-OA <br /> <br />In <br />Network/Participating <br />Deductible EE/Fam <br />Coinsurance EE/Fam <br />Office Visit Copay <br />Specialist Co pay <br />Hospital Admission <br />ER <br />Urgent Care <br />Outpatient Surgical <br />Facility <br />MRI-CAT-PET-ETC. <br />Max out of pocket <br />Prescription <br />Mail Order <br />Prescription <br />Lifetime Maximum <br />Out of Network/Non- <br />Participating <br />Deductible EE/Fam <br />Coinsurance EE/Fam <br />Office Visit Copay <br />Specialist Co pay <br />Hospital Admission <br />ER <br />Urgent Care <br />Outpatient Surgical <br />Facility <br />MRI-CAT-PET-ETC. <br />Max out of pocket <br />Prescription <br />Mail Order <br />Prescription <br />Lifetime Maximum <br />Min Employer <br />Contribution <br />Min Employee <br />Participation <br />Monthly Rates <br />EE $457.21 $480.22 $420.12 $362.85 $339.85 $451.60 <br />ES $1015.00 $1066.09 $932.66 $805.53 $754.46 $1002.55 <br />EC $854.84 $897.87 $785.49 $678.42 $635.41 $844.35 <br />Family $1293.63 $1358.74 $1188.68 $1026.66 $961.57 $1277.75 <br /> <br />Actual Rates subject to Final Medical Underwriting and group under 50 may range +/- <br /> <br />15% <br /> <br />None <br />N/A <br />$15 <br />$25 <br />250/Adm <br />$75 <br />$40 <br />$250 <br /> <br />$25 <br />$1500/$3000 <br />$10/$20/$30/$75 <br />2x's <br /> <br />$5M <br /> <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br /> <br />N/A <br />N/A <br />N/A <br />N/A <br /> <br />N/A <br />50% <br /> <br />75% <br /> <br />None <br />N/A <br />$15 <br />$25 <br />$0 <br />$75 <br />$40 <br />$0 <br /> <br />$0 <br />$1500/$3000 <br />$10/$20/$30/$75 <br />2x's <br /> <br />$5M <br /> <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br /> <br />N/A <br />N/A <br />N/A <br />N/A <br /> <br />N/A <br />50% <br /> <br />75% <br /> <br />$250/$750 <br />N/A <br />$10 <br />$20 <br />$150/Adm <br />$75 <br />$40 <br />$150 <br /> <br />10% after ded <br />$1500/$3000 <br />$1 0/$20/$30/$75 <br />2x's <br /> <br />$5M <br /> <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br /> <br />N/A <br />N/A <br />N/A <br />N/A <br /> <br />N/A <br />50% <br /> <br />75% <br /> <br />$1 000/$2000 <br />N/A <br />$25 <br />$50 <br />0% after ded <br />0% after ded <br />$50 <br /> <br />$1500/$3000 <br />N/A <br />$25 <br />$50 <br />0% after ded <br />0% after ded <br />$50 <br /> <br />0% after ded <br /> <br />0% after ded <br /> <br />0% after ded <br />$1500/$3000 <br />$10/$20/$30/$75 <br />2x's <br /> <br />0% after ded <br />$2000/$4000 <br />$10/$20/$30/$75 <br />2x's <br /> <br />$5M <br /> <br />$5M <br /> <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br /> <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br />N/A <br /> <br />N/A <br />N/A <br />N/A <br />N/A <br /> <br />N/A <br />N/A <br />N/A <br />N/A <br /> <br />N/A <br />50% <br /> <br />N/A <br />50% <br /> <br />75% <br /> <br />75% <br /> <br />$500/$1000 <br />20% <br />$20 <br />$40 <br />$250/Days 1-5 <br />$100 <br />$40 <br />20% after ded <br /> <br />20% after ded <br />$2500/$5000 <br />$10/$30/$50/$75 <br />2x's <br /> <br />$5M <br /> <br />$1 000/$2000 <br />40% <br />40% <br />40% <br />40% <br />40% <br />40% <br />40% <br /> <br />40% <br />$5000/$10000 <br />N/A <br />N/A <br /> <br />N/A <br />50% <br /> <br />75% <br /> <br />13 <br />