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VA-22 PPO $20/$40 100/80 Rx1 Out-of-state employees

VA 22 IH PPO $20/$40 100/80 Rx 1 Local employees

IN NETWORK* Doctor CoPay (PCP/Spec.) Deductible (Ind/Fam) Coinsurance (Insurance) Inpatient Hospital Out of Pocket Max (Ind/Fam) OUT OF NETWORK* Deductible (Ind/Fam) Coinsurance (Insurance) Inpatient Hospital Out of Pocket Max (Ind/Fam) EMERGENCY SERVICES Emergency Room PRESCRIPTIONS Retail EMPLOYEE MONTHLY DEDUCTIONS

$20 / $40

$20/$40

$0

$0

100% $500

100% $500

$2,500/$5 000

$2,500/$5,000

$0

$0

80% 80%

80% 80%

$5,000/$10,000

$5,000/$10,000

$250

$250

$5/$10/$45/$85/20% to $150/$250 $5/$10/$45/$85/20% to $150/$250

$202.16 $510.20 $406.18 $701.49

$197.67 $498.91 $397.30 $685.89

Employee Employee/Spouse Employee/Child(ren) Family