Triple Option Health Plan - Full Time
7/1/2008 - 6/30/2009

Benefits

PREMIUM

CORE

BASIC

In Network

Out of Network

In Network

Out of Network

In Network

Out of Network

Office Visit (Primary/Specialist)
$0 copay for preventive care - all levels

$15/$30

80% after deductible

$20/$40

70% after deductible

$25/$50

60% after deductible

Vision Exams - Spectera

$15 copay

Varies

$15 copay

varies

$15 copay

varies

Vision Hardware - Spectera

$15 copay

Varies

$15 copay

varies

$15 copay

varies

*NOTE: Spectera hardware copayment is subject to plan price guidelines. Please refer to Spectera Vision Benefits Summary for additional information.

Urgent Care

$15 copay

$20 copay

$25 copay

Emergency Room

$150 copay

Hospital Facility Inpatient / Outpatient

Deductible (Ind. / Family)

$250/$500

$500/$1,000

$1,000/$2,000

$2,000/$4,000

Co-Insurance
(Plan pays this% after deductible)

100% after ded

80% after ded

90% after ded

70% after ded

80% after ded

60% after ded

Out of Pocket Max (Ind. / Family)
after deductible

N/A

$2,000/$4,000

$3,000/$6,000

$6,000/$12,000

Prescription Drugs
Free Generic/Formulary/Non-formulary

$0/$20/$35

$0/$25/$50

$0/$30/$50

Mail Order

$0/$50/$87.50

$0/$62.50/$125

$0/$75/$125

PER PAYCHECK DEDUCTIONS

PREMIUM

CORE

BASIC**

Individual

$20.00

$0.00

$0.00 ($360)

Employee+Spouse

$134.50

$93.00

$64.25 ($552)

Employee+Child(ren)

$114.00

$76.00

$50.00 ($516)

Family

$215.25

$158.50

$119.00 ($696)

**Amount in parenthese ( ) indicates Town contribution to Employee Flexible Spending Account - For new employees throughout the year, this amount will be prorated according to the month of the effective date of the new employee's coverage

This summary is for purposes of comparing the three plan options and is not a complete summary of all plan provisions.