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Comparison of Plans <br />y <br />afore Premier <br />ilver Plan � <br />Buy Pre ier <br />� � �� aPl <br />d ni <br />Individual/Family Deductible <br />$800/$1,600 <br />$400/$800 <br />Individual/Family OOP Max (includes Deductible, copays, <br />coinsurance) <br />$6,000/$12,000 <br />$3,000/$6,000 <br />Coinsurance <br />30% <br />20% <br />Inpatient Hospital Copay (Per Admission) + Deductible & Co- <br />insurance <br />$500 <br />$200 <br />ER Copay (Waived if Admitted) + Deductible & Co-insurance <br />$500 <br />$250 <br />PCP Office Visit/Urgent Care <br />$35 - <br />$25 <br />Specialist Office Visit <br />$60 <br />$45 <br />Advancing Imaging (in any setting) <br />30% <br />$200 <br />Rx Deductible (per person) <br />$100 <br />$0 <br />Rx Retail Generic <br />$5 <br />$10 <br />Formulary Brand <br />$50 <br />$35 <br />Non -Formulary Brand <br />$70 <br />$50 <br />Do Rx Copays Accumulate to OOP Max? <br />Yes <br />Yes <br />Out of Network Coinsurance (includes Deductible, copays, <br />coinsurance) <br />40% <br />30% <br />Out of Network Individual/Family Deductible <br />$1,600/$3,200 <br />$800/$1,600 <br />Out of Network OOP Max (includes Deductible, copays, coinsurance) <br />$8,000/$16,000 <br />$4,000/$8 0 <br />