INSURANCE CARRIER UNITED HEALTHCARE Gold Choice Plus CEFZ PPO Plan Name Rx K35Y Network Full Network Non PPO PPO Base Plan: (Neg Fee) Calendar Year Deductible Individual $3,500 $5,000 Gold Choice Family $7,000 $15,000 Out-of-Pocket Limit Individual $8,500 $10,000 Plus CEFZ Family $17,000 $30,000 Coinsurance 80% 50% Lifetime Maximum Unlimited PPO Plan Desg. $15 / $50 Office Visits 50% PPO $15 / $100 Diagnostic Test (Lab/X-Ray) Office 80% 50% Adv Imaging (MRI/PET/CT) Hospital 80% 50% Hospitalization Inpatient Services 80% 50% ER Services (waived if admitted) $300 Copay, 80% Chiropractic Care $15 Copay 50% 35 visits per year Durable Medical Equipment (DME) 80% 50% Rx Ded: N/A 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