Plan Comparison for TEST EMPLOYEE Ran on 4/21/2018 2:44:49 PM

Effective Date Coverage Wellness
Average Visits Per Year
Primary Care Office Visit Specialist Office Visit Emergency Room Visit
Outpatient Lab & Diagnostics Outpatient Surgery Inpatient Hospital Admission
Perscriptions Per Year
Generic Prescriptions Brand Name Prescriptions 90 Day Supply Prescriptions

Plan Comparison Table (In Network Only)

Yearly rate
Rate Per Pay Period
Employer Offset
Family deductible
Out of Pocket
Family Out of Pocket
Co-Insurance level
Primary Care Office Visit Copay
Specialist Office Visit Copay
Emergency Room Visit Copay
Outpatient Surgery
Inpatient Hospital Admission Copay
Outpatient Lab & Diagnostics Copay
RX Deductible
RX Family Deductible
RX Out Of Pocket
RX Family Out Of Pocket
RX Co-Insurance
 Generic Prescriptions Copay
 Brand Name Prescriptions Copay
90 Day Supply Prescriptions Copay
RX Plan Maximum

*All figures are estimates and are not meant to be taken as exact*