| Plan Selection |
| Custom Choice Fund 500,
Employee + Family |
| Benefit Description
|
|
Your Benefits |
|
| |
| Deductible |
|
|
|
|
| Coinsurance |
|
|
|
|
| OOP Maximum |
|
|
|
|
| Medical Total |
|
|
$130.93 |
|
|
| |
| For Medical |
|
|
Monthly |
| Total Plan Cost |
|
|
$630.93 |
|
| Employer Contribution |
|
|
$500.00 |
|
| Employee Contribution |
|
|
$130.93 |
|
|