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4. Plan Benefit Summary History
A. January 1, 2016 through December 31, 2016
Premium
Base
HDHP
In network
In network
In network
Deductible
$500 2x
$650 2x
$2600 2x
Coinsurance
100%
90%
100%
Out of pocket maximum
$1500 2x
$2000 2x
$2600 2x
Primary office visit
$20
$25
Ded, then 100%
Specialist office visit
$30
$50
Ded, then 100%
Urgent care visit
$50
$75
Ded, then 100%
Emergency room visit
$150
$200
Ded, then 100%
Pharmacy
$12/$35/$55
$12/$40/$60
Ded, then 100%
Actuarial plan value
0.881
0.845
0.766
B. January 1, 2015 through December 31, 2015
Premium
Base
HDHP
In network
In network
In network
Deductible
$300 2x
$500 2x
$2500 2x
Coinsurance
100%
90%
100%
Out of pocket maximum
$900 2x
$1500 2x
$2500 2x
Primary office visit
$20
$25
Ded, then 100%
Specialist office visit
$30
$40
Ded, then 100%
Urgent care visit
$50
$75
Ded, then 100%
Emergency room visit
$150
$200
Ded, then 100%
Pharmacy
$12/$35/$55
$12/$40/$60
Ded, then 100%
Actuarial plan value
0.909
0.867
0.772
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