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Health Insurance - General Benefit Plan <br />Plan 1 PPO Plan <br />Plan 2 HRA Plan <br />Deductible — Single <br />$1,000 <br />$2,500 <br />Deductible — Family <br />$3,000 <br />$5,000 <br />HRA Funds — Single <br />N/A <br />$500 <br />HRA Funds— Family <br />N/A <br />$1,000 <br />Coinsurance (Plan Pays) <br />80x/0 <br />80% <br />Out of Pocket Maximum — Single (including deductible) <br />$4,000 <br />$5,000 <br />Out of Pocket Maximum — Family (including deductible) <br />$8,000 <br />$10,000 Family <br />Office Visit for Primary Care Provider <br />$30 <br />Deductible & Coinsurance Apply <br />Office Visit for Non - Primary Care Provider <br />$60 <br />Deductible & Coinsurance Apply <br />Preventive Care <br />100% <br />100% <br />Emergency Room <br />$200 Copayment + 20% <br />Deductible & Coinsurance Apply <br />Urgent Care Center <br />$75 Copayment <br />Deductible & Coinsurance Apply <br />Outpatient Facility Services <br />Deductible + 20% <br />Deductible & Coinsurance Apply <br />RX- Retail <br />20 %, 30%,40% <br />Deductible & Coinsurance Apply <br />Employee Cost (Bi- Monthly) <br />2016 <br />2017 <br />Employee & <br />Employee <br />Spouse <br />PPOPP� <br />Employee Cost <br />Employee <br />Cost with <br />Wellness <br />_ <br />Employee Cost <br />with Wellness <br />Cost <br />Wellness <br />Rate <br />Employee Only <br />$ 70.93 <br />$ 30.20 <br />$ 73.77 <br />S 31.77 <br />NA <br />EE & Spouse <br />Only <br />$ 187.30 <br />S 97.97 <br />$ 194.79 <br />$ 152.79 <br />$ 110.79 <br />Employee & <br />Child(ren) Only <br />$ 102.30 <br />$ 60.43 <br />106.39 <br />$ 64.39 <br />NA <br />Employee & <br />Family <br />$ 194.81 <br />$ 108.18 <br />202.60 <br />$ 160.60 <br />$ 118.60 <br />Employee & <br />Spouse <br />Surcharge <br />$ 217.30 <br />$ 127.97 <br />229.79 <br />$ 187.79 <br />$ 145.79 <br />Employee & <br />Family <br />Surcharge <br />$ 224.81 <br />$ 138.18 <br />237.60 <br />S 195.60 <br />$ 153.60 <br />