Coverage Tier

2007-2008 Premium

Employee Only

$266.00

Employee & Spouse

$606.00

Employee & Child(ren)

$424.00

Employee & Family

$667.00

Individual Deductible

$1,100

Coverage Tier

2007-2008 Premium

Employee Only

$354.00

Employee & Spouse

$806.00

Employee & Child(ren)

$564.00

Employee & Family

$886.00

Outpatient Surgery Copay *

$100

Emergency Room Copay *

$100

Waived if admitted

Inpatient Copay *

$100 per day with $500 per admission maximum and $1,500 plan year maximum

Coverage Tier

2007-2008 Premiums

Employee Only

$477.00

Employee & Spouse

$1,085.00

Employee & Child(ren)

$760.00

Employee & Family

$1,193.00

Coverage Tier

2007-2008 Plan Year

Employee Only

$359.00

Employee & Spouse

$890.00

Employee & Child(ren)

$571.00

Employee & Family

$893.00

Benefit

2007-2008 Plan Year

Emergency Room Copay

$100

Ambulance Copay

$100

Minor Emergency Copay

$40

Generic/Preferred Brand/Non-preferred Brand prescription retail copays

$15/$30/$50

Maximum Prescription Benefit per Plan Year

$10,000

Coverage Tier

2007-2008 Plan Year

Employee Only

$351.48

Employee & Spouse

$827.76

Employee & Child(ren)

$555.28

Employee & Family

$862.10

Benefit

2007-2008 Plan Year

Outpatient Specialty Drugs copay:

Level 1

Level 2 (preferred)

Level 3 (premium preferred)

Level 4 (non-preferred)

$50

$100

$250

50% **

**Does not count toward out-of-pocket maximum

Prescription drug copays:

Preferred brand retail

Preferred brand mail

$25

$50

Non-formulary retail

Greater of $50 or 50%

Coverage Tier

2007-2008 Plan Year

Employee Only

$370.07

Employee & Spouse

$834.80

Employee & Child(ren)

$585.46

Employee & Family

$918.40

Coverage Tier

2007-2008 Plan Year

Employee Only

$553.30

Employee & Spouse

$1,101.58

Employee & Child(ren)

$1,041.29

Employee & Family

$1,792.45

Coverage Tier

2007-2008 Plan Year

Employee Only

$357.30

Employee & Spouse

$800.30

Employee & Child(ren)

$563.02

Employee & Family

$879.02