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a,yfield Village ?
<br />Deductible
<br />Single
<br />Family
<br />Coinsurance
<br />Out of Pocket Max
<br />Single
<br />Family
<br />Lifetime Maximum
<br />Office Visit
<br />Preventive
<br />Specialist Visit
<br />Emergency Services
<br />Urgent Care
<br />Emergency Room
<br />Hospital
<br />Inpatient
<br />Outpatient
<br />Diagnostic Lab/X-Ray
<br />Vision - Exam Only
<br />Prescriptions
<br />Retail
<br />Mail-Order
<br />Employee 10
<br />EE/Spouse 1s
<br />EE/Child(ren) 5
<br />Family so
<br />TOTAL sa
<br />Monthly Premium
<br />Annual Premium
<br />Increase/ Savings
<br />$ +/- Current (Mos./Yr)
<br />$ +/- Renewal (Mos./Yr)
<br />MedicaURx Benefit & Cost Comparison . : - .
<br />. , Aprillst,2009EffectiveDate ONG-th dB@ -? ?urren eaIMedicuaumma niacaex Card cess [aaged Choc S17iPlus OD/80 PlCad
<br />
<br />
<br />,Non V?'etwor?k lVetwo?k Non Network Networ•k 11-Fn Netw?ork Network on-1Vehv?rk etwork Nop;?,:etwur•k
<br />$0 $300 $0 $300 $0 $300 $0 $500 $0 $300
<br />$0 $900 $0 $900 $0 $900 $0 $1,000 $0 $900
<br />100% 80% 100% 80% 100% 80% 100% 70% 100% 80%
<br />$0 $2,000 $0 $2,000 $0 $2,000 $0 $3,000 $0 $2,300
<br />$0 $4,000 $0 $4,000 $0 $4,000 $0 $6,000 $0 $4,600
<br />$5,000,000 Combined $5,000,000 Combined $5,000,000 Combined $0,000,000 Combined $5,000,000 Combined
<br />$10 Copay 80% after ded $10 Copay 80% after ded $10 Copay 80% after ded $10 Copay 70% after ded $15 Copay 80% after ded
<br />$10 Copay 80% after ded $10 Copay 80% after ded $10 Copay 80% after ded $10 Copay 70% after ded $15 Copay 80% after ded
<br />$10 Copay 80% afterded $10 Copay 80% a8erded $10 Copay 80% afterded $10 Copay 70% afterded $15 Copay 80% afterded
<br />$50 Copay $50 Copay $50 Copay $35 Copay 70% after ded $35 Copay
<br />$150 Copay (Waived ifAdmitted) $150 Copay (Waived ifAdmitted) $150 Copay (Waived ifAdmitted) $75 Copay (Waived ifAdmitted) $75 Copay (Waived ifAdmitted)
<br />100% 80% afterded 100% 80% afterded 100% 80% afterded $250 Copay 70% afterded 100% 80% afterded
<br />100% 80% afterded 100% 80% afterded 100% 80% afterded 100% 70% afterded 100% 80% afterded
<br />100% 80% afterded 100% 80% afterded 100% 80% afterded 100% 70% afterded 100% 80% afterded
<br />$10 Copay 80% after ded $10 Copay 80% after ded $10 Copay 80% after ded $10 Copay 70% after ded $15 Copay 80% after ded
<br />$8/$15/$25 $10/$20/$35 _ $8/$15/$25 $8/$15/$30 $10/$20/$30
<br />$16/$30/$50 - 90 Day Supply $20/$40/$70 - 90 Day Supply $16/$30/$50 - 90 Day Supply $16/$30/$60 - 90 day Supply $20/$40/$60 - 90 Day Supply
<br />R?'e?`sed
<br />
<br />A
<br />CurrenEi I ` ,
<br />? Rates'- S1r.ee Rutes,e ...
<br />Rate`s - P,rescr,ecned
<br />ates - Yrescr,eene`
<br />RaCes - S`tr,ee Rales'`
<br />ice ewal
<br />$481.53 $529.68 $380.41 $533.76 $563.68 $351.17
<br />$1,150.63 S1,265.69 $909.00 $19323.22 $1,161.18 $839.06
<br />$883.93 $972.32 $698.30 $1,016.52 $19090.73 $644.64
<br />$1,616.53 $1,778.18 $1,277.06 $1,859.01 $1,758.68 519178.91
<br />$72,689 $79,958 $57,424 $83,392 5789946 $53,010
<br />$872 268 $959 493 $689,092 $19000,708 $947,354 $636,120
<br />' 10.00% -21.00% 14.72% 8.61% -27.07%
<br /> -$15,265 -$183,176 $10,703 $128,440 $6,257 $75,086 -$199679 4236,149
<br /> -$22 533 -$270 401 $3 435 $41 215 41,012 -$12 139 -$26 948 -$323 373
<br />*- These carriers require ii:dividual medica[ underwriting. Each eligible employee would need lo complete tka[ carrier s Medica! Hea1[h Questionnaire in order to secure firm' rates.
<br />Thrs illustration rs intended to o:rtline the basic plan and is not intended to describe the contract provision. Each employee will receive a plan bookJet which will outline in detail the plar: provisions and limitations. Shou(d there
<br />be a discrepancy between this out/rne and the plan document, the plar: document prevails.
<br />- Medical Rx - 1
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