Plan Options LivingWell CDHP LivingWell PPO LivingWell Basic CDHP LivingWell HDHP

In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Lifetime Maximum Unlimited

HRA Single 500; Family 1,000 No HRA Single 250; Family 500 No HRA. Can use a non-KEHP HSA with this plan.

Annual Maximum Out-of-Pocket Applies to Medical and Pharmacy Applies to Medical Applies to Medical and Pharmacy Applies to Medical and Pharmacy

Annual Deductible Single 1,500 Family 2,750 Single 2,750 Family 5,250 Single 1,000 Family 1,750 Single 1,750 Family 3,250 Single 2,000 Family 3,750 Single 3,250 Family 6,250 Single 2,000*\nFamily 4,000* Single 4,000 Family 8,000

Single 3,000 Family 5,750 Single 5,750 Family 11,250 Single 3,000 Family 5,750 Single 5,750 Family 11,250 Single 4,000 Family 7,750 Single 7,750 Family 11,250 Single 8,050 Family 16,100 Single 16,100 Family 32,200

Deductibles and Maximum Out-of-Pocket for In-Network and Out-of-Network providers accumulate separately and do not cross-apply

Co-Insurance Plan: 80% Member: 20% Plan: 50% Member: 50% Plan: 75% Member: 25% Plan: 50% Member: 50% Plan: 70% Member: 30% Plan: 50% Member: 50% Plan: 70% Member: 30% Plan: 50% Member: 50%

Doctor's Office Visit Deductible, then 20% Deductible, then 50% Co-pay: 25 PCP 50 Specialist Deductible, then 50% Deductible, then 30% Deductible, then 50% Deductible, then 30% Deductible, then 50%

Annual Prescription Drug Maximum Out-of-Pocket Combined with Medical Single 2,500 Family 5,000 Single 5,000 Family 10,000 Combined with Medical Combined with Medical

30-Day Supply Tier 1 - Generic Tier 2 - Formulary Deductible, then 20% Deductible, then 50% 20 40 40 80 Deductible, then 30% Deductible, then 50% Deductible, then 30% Deductible, then 50%

90-Day Supply (Retail or Mail Order) Deductible, then 20% Not Covered 40 80 Not Covered Deductible, then 30% Not Covered Deductible, then 30% Not Covered

Covered Services

Well-baby, well-child visits, as recommended 100% Deductible, then 50% 100% Deductible, then 50% 100% Deductible, then 50% 100% Deductible, then 50%

Adult annual physical exam 100% Deductible, then 50% 100% Deductible, then 50% 100% Deductible, then 50% 100% Deductible, then 50%

Immunizations, as recommended 100% Deductible, then 50% 100% Deductible, then 50% 100% Deductible, then 50% 100% Deductible, then 50%

Screenings including Pap smears, and labs, as part of the preventive office visit 100% Deductible, then 50% 100% Deductible, then 50% 100% Deductible, then 50% 100% Deductible, then 50%

Primary Care and Specialist Office Visits Deductible, then 20% Deductible, then 50% Co-pay 25 PCP 50 Specialist Deductible, then 50% Deductible, then 30% Deductible, then 50% Deductible, then 30% Deductible, then 50%

Outpatient Services

LiveHealth Online telehealth for Medical and Behavioral Health 100% N/A 100% N/A 100% N/A N/A N/A

Telehealth with provider other than LiveHealth Online Deductible, then 20% Deductible, then 50% Co-pay 25 PCP 50 Specialist Deductible, then 50% Deductible, then 30% Deductible, then 50% Deductible, then 30% Deductible, then 50%

Preventive Care Office Visits