953 Back   2003 Health Benefit Agreement
NRC/UTU Plan Design
Basic PPO Design
    Basic PPO
 

Medical / MHSA

In-network   Out-Network
     Annual Deductible      
        individual   $300  
        family   $900  
    Office Visits, ER, Urgent Care 70%   50%
    Coinsurance 70%   50%
  Annual Out-of-pocket Max      
    individual   $2,500  
    family   $5,000  
  Prescription Drugs      
    Retail      
      - - generic 70%*   50%
      - - brand on formulary 65%*   50%
      - - off formulary 60%*   50%
    Mail Order      
      - - generic 70%*   50%
      - - brand on formulary 65%*   50%
      - - off formulary 60%*   50%
  Monthly Contributions      
    Nov 2003 - June 2004 $0.00 (eff. 1/1/2004)
    July 2004 - June 2005   $0.00  
    Note: Deductibles do not apply toward Annual Out-of-pocket Max
  * Basic PPO prescription drug benefit has an annual out-of-pocket maximum of $2,000 per individual and $4,000 per family.