Laserfiche WebLink
HRA Funds—Single N/A <br /> $500 <br /> HRA Funds—Family N/A $1,000 <br /> Coinsurance(Plan Pays) 80% 80% <br /> Out of Pocket Maximum—Single(including deductible) $4,000 $5,000 <br /> Out of Pocket Maximum—Family(including deductible) $8,000 $10,000 Family <br /> Office Visit for Primary Care Provider $30 Deductible&Coinsurance Apply <br /> Office Visit for Non-Primary Care Provider $60 Deductible&Coinsurance Apply <br /> Preventive Care 100% 100% <br /> Emergency Room $200 Copayment+209%/. Deductible&Coinsurance Apply <br /> Urgent Care Center $75 Copayment Deductible&Coinsurance Apply <br /> Outpatient Facility Services Deductible+20% Deductible&Coinsurance Apply <br /> RX-Retail 20%,300/( 40% Deductible&Coinsurance Apply <br /> Employee Cost (Bi-Monthly) <br /> 2016 2017 <br /> Employee& <br /> Employee Spouse <br /> PPS E Employee Cost Employee Cost with Wellness <br /> m loyee Cost with Wellness Cost Wellness Rate <br /> Employee Only S 70.93 S 30.20 S 73.77 S 31.77 NA <br /> EE& Spouse <br /> Only S 187.30 S 97.97 S 194.79 S 152.79 S 110.79 <br /> Employee& <br /> Child(ren)Only S 102.30 S 60.43 106.39 S 64.39 NA <br /> Employee& <br /> Family S 194.81 S 108.18 202.60 S 160.60 S 118.60 <br /> Employee& <br /> Spouse <br /> Surcharge S 217.30 S 127.97 229.79 S 187.79 S 145.79 <br /> Employee& <br /> Family <br /> Surcharge S 224.81 S 138.18 237.60 S 195.60 S 153.60 <br />