Health Care Expenses

	Service and Cost	Cost with Health Choice Plan	Cost With Super Health Plan
1.	Doctors ofce visit for a sore throat and cough (in network) $95	Answer	Answer
2.	Emergency room for stitches (in network) $115	Answer	Answer
	Deductible Now Met for items 4-10
3.	Appendectomy (in Network)
	. Two Night Hospital Stay $2,000	Answer	Answer
	. Surgery $14,000	Answer	Answer
	. Prescription (brand) $185	Answer	Answer
4.	Eye Exam (in network) $45	Answer	Answer
5.	Urgent care (out of network) $85	Answer	Answer
6.	Prescription (generic) $85	Answer	Answer
7.	Prescription (brand, out of network) $225	Answer	Answer
8.	Annual physical (in network) $95	Answer	Answer
9.	Emergency Room for snow board accident (concussion, broken leg, x-rays, etc) $6,500	Answer	Answer
10.	Urgent Care (in network) $105	Answer	Answer

Health Plan Comparison Sheet SERVICE AND COST HEALTH CHOICE SUPER HEALTH Emergency Room $25 co-pay 90% of approved amount after deductible 100% of approved amount for accidental injury Urgent Care 90% of approved amount after deductible IN NETWORK: $10 co-pay: 100% for initial exam for accident/medical emergency OUT OF NETWORK: 80% of approved amount after deductible, 100% of approved amount for initial exam for accident/medical emergency Surgery 100% of approved amount IN NETWORK: 100% of approved amount OUT OF NETWORK: 80% of approved amount after deductible Hospital Care IN NETWORK: 100% of approved amount 100% of approved amount plus $5 per OUT OF NETWORK: 80% of approved amount day for private room after deductible Prescriptions IN NETWORK: Co-pay $5 generic/$10 brand OUT OF NETWORK: 75% of approved amount Co-pay $5 generic/brand Physician Office Visit 90% of approved amount after deductible; 100% for accidental injury IN NETWORK: $5 co-pay: 100% approved amount for initial exam for injury/medical emergency OUT OF NETWORK: 80% of approved amount after deductible: 100% approved amount for initial exam for injury/medical emergency Vision 90% of approved amount after deductible IN NETWORK: $10 co-pay for one exam per calendar year OUT OF NETWORK: 80% of approved amount after deductible Deductible $250 per calendar year IN NETWORK: None OUT OF NETWORK: $250 individual per calendar year Maximum Out of Pocket 100% after payments reach $1,000 IN NETWORK: None OUT OF NETWORK: 100% after payments reach $2,500 Health Plan Comparison Sheet SERVICE AND COST HEALTH CHOICE SUPER HEALTH Emergency Room $25 co-pay 90% of approved amount after deductible 100% of approved amount for accidental injury Urgent Care 90% of approved amount after deductible IN NETWORK: $10 co-pay: 100% for initial exam for accident/medical emergency OUT OF NETWORK: 80% of approved amount after deductible, 100% of approved amount for initial exam for accident/medical emergency Surgery 100% of approved amount IN NETWORK: 100% of approved amount OUT OF NETWORK: 80% of approved amount after deductible Hospital Care IN NETWORK: 100% of approved amount 100% of approved amount plus $5 per OUT OF NETWORK: 80% of approved amount day for private room after deductible Prescriptions IN NETWORK: Co-pay $5 generic/$10 brand OUT OF NETWORK: 75% of approved amount Co-pay $5 generic/brand Physician Office Visit 90% of approved amount after deductible; 100% for accidental injury IN NETWORK: $5 co-pay: 100% approved amount for initial exam for injury/medical emergency OUT OF NETWORK: 80% of approved amount after deductible: 100% approved amount for initial exam for injury/medical emergency Vision 90% of approved amount after deductible IN NETWORK: $10 co-pay for one exam per calendar year OUT OF NETWORK: 80% of approved amount after deductible Deductible $250 per calendar year IN NETWORK: None OUT OF NETWORK: $250 individual per calendar year Maximum Out of Pocket 100% after payments reach $1,000 IN NETWORK: None OUT OF NETWORK: 100% after payments reach $2,500