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County of Albemarle |
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Attachment A |
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Proposed Medical Plan Options Effective October 1, 2004 -- Triple Option
Plans |
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CURRENT (10/02 - 9/03) |
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POS - High Plan |
POS - Middle Plan |
POS - Low Plan |
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Coinsurance Paid By Plan |
100% |
90% |
80% |
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Maximum Out-of-Pocket (Individual/Family) |
$1,000/$2,000 |
$2,000/$4,000 |
$2,500/$5,000 |
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Inpatient Hospital |
$100/admission |
10% coinsurance |
20% coinsurance |
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Physician Services |
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PCP office visit |
$15 |
$15 |
$20 |
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Specialist visit |
$25 |
$25 |
$35 |
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Preventive Services |
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Physical Exams |
$15 |
$15 |
$20 |
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Well Child Care |
$15 |
$15 |
$20 |
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Outpatient Services |
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Outpatient Surgery |
0% facility, $15/$25 physician |
10% facility, $15/$25 physician |
20% facility, $20/$35 physician |
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Urgent Care Center |
$15 |
$35 |
$35 |
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Emergency Room |
$75 |
$100 |
20% coinsurance |
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X-rays, MRIs and Lab Services |
100% covered after applicable copay |
10% coinsurance |
20% coinsurance |
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Prescription Drugs |
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Retail |
$8/$18/$33, 30-day supply |
$10/$20/$35, 30-day supply |
$10/$30/$50, 30-day supply |
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OUT OF NETWORK |
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Deductible: $500/$1,000
Coinsurance: 70%/30% |
Deductible: $750/$1,500
Coinsurance: 70%/30% |
Deductible: $1,000/$2,000
Coinsurance: 70%/30% |
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