INSURANCE CARRIER UNITED HEALTHCARE Silver Choice Plus CECY PPO Plan Name Rx K35Y - HSA Network Full Network Non PPO PPO (Neg Fee) Calendar Year Deductible Silver Choice Individual $5,000 $10,000 Family $10,000 $30,000 Out-of-Pocket Limit Plus CECY Individual $6,000 $20,000 Family $12,000 $60,000 PPO Plan Coinsurance 100% 70% Lifetime Maximum Unlimited Desg. Office Visits 100% 70% PPO Diagnostic Test (Lab/X-Ray) Office 100% 70% Adv Imaging (MRI/PET/CT) Hospital 100% 70% Hospitalization Inpatient Services 100% 70% ER Services (waived if admitted) 100% Chiropractic Care 100% 70% 35 visits per year Durable Medical Equipment (DME) 100% 70% After Medical Deductible is Met Prescription Drugs $10 Tier 1 / $40 Tier 2 / (In-Network Only; please refer to full summary for Out of $125 Tier 3 Network coverage) Tier 4: $300