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I3 <br />Attachment 4 <br />HEALTH INSURANCE PLAN DESIGN DESCRIPTIONS <br />Current, Renewal* and N_o__c_ h_a__nge __ <br />Option 1 (Buy Up)** PPO HMO <br />Primary Care Provider Copay $15 $15 <br />Specialist Copay $30 $30 <br />Emergency Room Copay $150 $150 <br />Individual Deductible (IN / OON) $250 /$500 $250 <br />Coinsurance Maximum (IN / OON) $1,000 / $2,000 $0 <br />Family Maximums 3 times 3 times <br />Coinsurance (IN / OON) 90% / 70% 100% <br />OP Lab & Mammograms (IN / OON) 100% 100% <br />Preventive Care Program (IN / OON) 100% / 0% 100% <br />Retail Drug Copay (30 Day Supply) $5-15-30 $5-15-30 <br />Mail Order Drug Copay (90 Day Supply) $13-26-60 $13-26-60 <br />Vision - E e Exam Deductible $15 $15 <br />* Costs for HMO dependent coverage will increase more than PPO <br />dependent coverage. <br />** Employees will pay part of the premium for employee coverage <br />(plus dependent coverage). <br />Option 2 One Plan PPO <br />Primar Care Provider Co a $15 <br />S ecialist Co a $30 <br />Emer enc Room Co a $150 <br />Individual Deductible IN / OON $250/$500 <br />Coinsurance Maximum IN / OON $500/$1000 <br />Famil Maximums 3 times <br />Coinsurance (IN / OON) 95%/75% <br />OP Lab & Mammo rams IN / OON 100%/75% <br />Preventive Care Pro ram IN / OON 100%/0% <br />Retail Dru Co a 30 Da Su I $5-15-30 <br />Mail Order Dru Co a 90 Da Su I $13-26-60 <br />Vision - E e Exam Deductible $15 <br />