Option One  (0501) Option Two (0502) Option Three (0505) Option Four (0506)
  PPO Providers NonPPO Providers PPO Providers NonPPO Providers PPO Providers NonPPO Providers PPO Providers NonPPO Providers
Deductible/Out-of-Pocket                
Lifetime Maximum Benefit Unlimited No Coverage Unlimited $2,000,000 $2,000,000
Per Confinement Deductible ----- No Coverage None $200        
Plan Year Deductible None No Coverage $200 $500 ($1000 Family) $1000 ($2000 Family) $500 ($1500 Family) $1000 ($3000 Family)
Out-of-Pocket Maximum                
     Individual None No Coverage $800 $3,000 $2,000 $4,000 $2,000 $4,000
     Family None No Coverage $2,000 $7,000 $4,000 $8,000 $6,000 $12,000
Special Coverages                
Second Surgical Opinion 100% after a $10 co-pay No Coverage     80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
     Voluntary -----   80% No Deductible -----   -----  
     Required -----   100% No Deductible -----   -----  
Well Child Care (through age 6)                
     Office Visits 100% after a $10 co-pay No Coverage 80% No Deductible 100% after a $20 copay 60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
     Immunizations/Routine Lab Work 100% No Coverage 100% No Deductible 100% after a $20 copay 60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
School Health Exams  (grades 5 and 8)                
     Office Visits 100% after a $10 co-pay No Coverage 80% No Deductible 100% after a $20 copay 60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
     Immunizations/Routine Lab Work 100% No Coverage 100% No Deductible 100% after a $20 copay 60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Adult Physicals  (age 19 and over)                
     Office Visits 100% after a $10 co-pay No Coverage 80% No Deductible 100% after a $20 copay 60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
     Immunizations/Routine Lab Work 100% No Coverage 100% No Deductible 100% No Deductible  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Pap Smear 100% No Coverage 100% No Deductible 100% No Deductible  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
     Related Exam 100% after a $10 co-pay No Coverage 80% No Deductible 100% No Deductible  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
     Related Professional charges 100% No Coverage 80% No Deductible 100% No Deductible  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Mammograms 100% No Coverage 100% No Deductible 100% No Deductible  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
     Related Professional charges 100% No Coverage 80% No Deductible 100% No Deductible  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Sigmoidscopy 100% No Coverage 80% No Deductible 100% No Deductible  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
     Fecal Occult Blood Testing 100% No Coverage 100% No Deductible 100% No Deductible  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
     Related Professional charges 100% No Coverage 80% No Deductible 100% No Deductible  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
PSA Test 100% No Coverage 100% No Deductible 100% No Deductible  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
     Related Exam 100% after a $10 co-pay No Coverage 80% No Deductible 100% No Deductible  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
     Related Professional charges 100% No Coverage 80% No Deductible 100% No Deductible  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Physician and Office Services                
Office Visits 100% after a $10 co-pay No Coverage 80% Deductible Applies 100% after a $20 copay 60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Surgeon 100% No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Diagnostic X-ray & Lab 100% No Coverage 100% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Independent Lab, Radiologist & Pathologist 100% No Coverage 100% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Allergy Injections 100% No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Allergy Testing 100% No Coverage 100% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Acupuncture for treatment of chronic pain 100% after a $10 co-pay No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Christian Science Practitioner 100% after a $10 co-pay No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Nurse Practitioner 100% after a $10 co-pay No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Dietician Services/Consultation 100% No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Chemotherapy 100% No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Physical, Occupational & Speech Therapy 100% No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Chiropractic Services 100% after a $10 co-pay No Coverage 80% Deductible Applies 50% up to $500 per year (after deductible) 50% up to $500 per year (after deductible)
Podiatric Services                
     Office Visits 100% after a $10 co-pay No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
     Surgery 100% No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
     X-ray & Lab 100% No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
     Orthotics 100% No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Infertility Services                
     Physician Charges 100% after a $10 co-pay No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
     Lab/X-ray 100% No Coverage 100% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Other Covered Services     80% Deductible Applies        
Outpatient Hospital & Ambulatory Surgical Center                
Facility 100% No Coverage 90% Deductible Applies 65% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Surgi-Center/Ambulatory Surgicenter (Facility Fee Only) -----   90% Deductible and Network OOP Applies -----   -----  
Emergency Room 100% after a $150 co-pay No Coverage 80% after a $200 per visit co-pay, Deductible Applies 100% after a $150 co-pay 100% after a $150 co-pay 80% ($50 penalty for non-emergencies) 60% ($50 penalty for non-emergencies)
Urgent Care Facility 100% after a $10 co-pay No Coverage     100% after a $150 co-pay 100% after a $150 co-pay 80% Deductible Applies  60% Deductible Applies 
     Non-Emergency Care -----   80% Deductible Applies -----   -----  
     Emergency Care -----   100% Deductible Applies -----   -----  
     Lab/X-ray -----   100% Deductible Applies -----   -----  
Diagnostic X-ray & Lab 100% No Coverage 100% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Pre-Admission Testing 100% No Coverage 90% Deductible Applies 65% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Surgeon 100% No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Physical, Occupational & Speech Therapy 100% No Coverage 90% Deductible Applies 65% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Chemotherapy & Radiation Therapy 100% No Coverage 90% Deductible Applies 65% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Assistant Surgeon, Anesthesiologist, & Consulting Physician 100% No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Pathologist, Radiologist 100% No Coverage 100% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Other Covered Services 100% No Coverage 90% Deductible Applies 65% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Inpatient Hospital                
Room, Board & Miscellaneous 100% after a $150 co-pay No Coverage 90% Deductible Applies 65% Deductible Applies 80% after a $150 co-pay 60% after a $150 co-pay 80% Deductible Applies  60% Deductible Applies 
Nursery 100% after a $150 co-pay No Coverage 90% Deductible Applies 65% Deductible Applies 80% after a $150 co-pay 60% after a $150 co-pay 80% Deductible Applies  60% Deductible Applies 
Diagnostic X-ray & Lab 100% No Coverage 90% Deductible Applies 65% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Surgeon 100% after a $10 co-pay No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Physician Visits 100% after a $10 co-pay No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Private Duty Nursing 100% No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Assistant Surgeon, Anesthesiologist, & Consulting Physician 100% No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Other Covered Services 100% No Coverage 90% Deductible Applies   80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Other Covered Services                
Extended Care Facility 100% after a $150 co-pay No Coverage 80% Deductible Applies 80% after a $150 co-pay 60% after a $150 co-pay 80% Deductible Applies  60% Deductible Applies 
Home Health Care 100% No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Hospice Care 100% No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Rbereavement Counseling 100% No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Ambulance 100% No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Durable Medical Equipment 80% No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Prosthetic Appliances 80% No Coverage 80% Deductible Applies 80% Deductible Applies  60% Deductible Applies  80% Deductible Applies  60% Deductible Applies 
Smoking Cessation Program 100% up to $50 No Coverage 100% up to $50 80% up to $150 60% up to $150 80% Deductible Applies  60% Deductible Applies 
Psychiatric & Substance Abuse Care                
Inpatient Care 100% after a $150 co-pay No Coverage $50 per day co-pay up to $275 per admission, 100% co-insurance $50 per day copay up to $250 per admission, 60% co-insurance 80% after a $150 co-pay 60% after a $150 co-pay 80% Deductible Applies  60% Deductible Applies 
Inpatient Physicians 100% after a $20 co-pay No Coverage 100% after a $15 per day co-pay 50% limted to $35 per visit 80% after a $20 co-pay 60% after a $20 co-pay 80% Deductible Applies  60% Deductible Applies 
Outpatient Care/Physician Visits 100% after a $20 co-pay No Coverage 100% after a $15 per visit 50% limted to $35 per visit 80% after a $20 co-pay 60% after a $20 co-pay 80% Deductible Applies  60% Deductible Applies 
Prescription Drug Plan                
Retail Prescription Plan                
     Brand 100% after a $10 co-pay No Coverage $24 100% after a $40 co-pay No Coverage 100% after a $40 co-pay No Coverage
     Formulary 100% after a $10 co-pay No Coverage $12 100% after a $20 co-pay No Coverage 100% after a $20 co-pay No Coverage
     Generic 100% after a $5 co-pay No Coverage $6 100% after a $10 co-pay No Coverage 100% after a $10 co-pay No Coverage
Mail Order Prescripiton Plan                
     Brand 100% after a $20 co-pay No Coverage $48 100% after a $80 co-pay No Coverage 100% after a $80 co-pay No Coverage
     Formulary 100% after a $20 co-pay No Coverage $24 100% after a $40 co-pay No Coverage 100% after a $40 co-pay No Coverage
     Generic 100% after a $10 co-pay No Coverage $12 100% after a $20 co-pay No Coverage 100% after a $20 co-pay No Coverage
Purchased Outside the Plan No Coverage No Coverage 100% of the discounted amount minus the appropriate co-pay No Coverage No Coverage No Coverage No Coverage
Dental Benefits                
Plan Year Maximum Benefit $1,200 $1,200 No coverage $1,200
Prosthetic, Periodontic, Surgical Extraction & Related Anesthesia $2,000 $2,000 No Coverage $2,000
Orthodontia Lifetime Maximum $1,500 $1,500 No Coverage $1,500
Plan Year Deductible $50 per person $50 per person No Coverage $50 per person
VSP                
Eye Care Wellness                
     Exam Covered in Full up to $25 every 24 months Covered in Full up to $25 every 24 months No coverage Covered in Full up to $25 every 24 months
     Lenses Single Vision, Lined Bifocal, Lined Trifocal lenses are coverd in full up to $30 ($35 bifocal & $45 trifocal) every 24 months Single Vision, Lined Bifocal, Lined Trifocal lenses are coverd in full up to $30 ($35 bifocal & $45 trifocal) every 24 months No Coverage Single Vision, Lined Bifocal, Lined Trifocal lenses are coverd in full up to $30 ($35 bifocal & $45 trifocal) every 24 months
     Frames VSP fully covers a wide selection of frames up to $45 VSP fully covers a wide selection of frames up to $45 No Coverage VSP fully covers a wide selection of frames up to $45
     Contact Lenses Covered in Full after a $50 co-pay up to $250 after a $50 co-pay every 24 months Covered in Full after a $50 co-pay up to $250 after a $50 co-pay every 24 months No Coverage Covered in Full after a $50 co-pay up to $250 after a $50 co-pay every 24 months
2007-2008                
     Single $705.00 $800.00 $548.00 $546.00
     Employee + One $1,376.00 $1,558.00 $1,100.00 $1,096.00
     Family $1,781.00 $2,038.00 $1,236.00 $1,228.00
                 
                 
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[1]
Dental and Vision benefits are available optional coverages.  Rates for Dental benefits are $19 for Single, $33 for Employee + One, and $63 for Family coverage.  Rates for Vision benefits are $10 for Single, $15 for Employee + One, and $26 for Family coverage.