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|
INSURANCE CARRIER
Plan Type |
HIP
Prime HMO |
| In Network |
| Physician copay |
$20 |
| Deductible |
$0 |
| Coinsurance |
100% |
| Out of Pocket Maximum |
$0 |
| Hospital IP copay |
$500 |
| Emergency Room copay |
$50 |
| Lifetime Maximum |
Unlimited |
Out of Network |
| Deductible |
N/A |
| Coinsurance |
N/A |
| Out of Pocket Maximum |
N/A |
| Reasonable & Customary Level |
N/A |
| Lifetime Maximum |
N/A |
Prescription Drug |
| Deductible |
$0 |
| Preferred Generic copay |
$15 |
| Preferred Brand copay |
$25 |
| Non Preferred copay |
$40 |
Rate Exhibit - Costs |
| Employee |
$419.91 |
| Employee + Spouse |
$839.76 |
| Employee + Child(ren) |
$780.99 |
| Employee + Family |
$1,284.45 |
Summary of Cigna PPO Dental and VSP Vision Premiums
Effective February 1, 2006 through December 31, 2006
|
| Cigna Dental PPO |
| Single |
$46.70 |
| Two Party |
$87.71 |
| Family |
$105.53 |
VSP Vision Plan |
| Single |
$8.74 |
| Two Party |
$12.60 |
| Family |
$22.57 |
Subtotal Benefits |
| Single |
$55.44 |
| Two Party |
$100.31 |
| Family |
$128.10 |
Billing Fee - Third Party Administrator (AIA) |
| Single |
$5.85 |
| Two Party |
$5.85 |
| Family |
$5.85 |
Administrative Fee - NWU |
| Single |
$3.75 |
| Two Party |
$3.75 |
| Family |
$3.75 |
Subtotal Billing Fees |
| Single |
$9.60 |
| Two Party |
$9.60 |
| Family |
$9.60 |
Total Cost of Premium |
| Single |
$65.04 |
| Two Party |
$109.91 |
| Family |
$137.70 |
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