| Coverage Type Employee |
Total Premium $400.00 |
Your Premium Share 10% |
| |
Individual |
Family |
| You Pay |
|
|
Employee Deductible
(before spending account pays) |
$0.00 |
$0.00 |
Bridge
(after spending account pays) |
$2,000.00 |
$4,000.00 |
| Employer Pays |
|
|
| Spending Account |
$1,000.00 |
$2,000.00 |
| Prevention Benefit |
$250.00 |
$500.00 |
| Maintenance Benefit |
$500.00 |
$1,000.00 |
| Plan Coverage |
|
|
| Begin when you have met |
$2,000.00 |
$4,000.00 |
| Coinsurance Applies |
20% In Network |
20% In Network |
| Max Out of Pocket Expense |
$5,000.00 In Network |
$10,000.00 In Network |
| Lifetime Maximum Benefit |
$1,000,000.00 |
$1,000,000.00 |
|
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