Gold	Silver	Bronze
$15 Office visit Co-Pay	$20 Office Visit Co-Pay	$25 Office Visit Co-Pay
Co-pay applies to physician’s office visit charges, including; lab, x-ray and other charges billed by the physician during the office visit or on the same day of the visit.
$35 Urgent Care Co-Pay *	$35 Urgent Care Co-Pay *	$35 Urgent Care Co-Pay *
$50 Emerg. Room Co-Pay *	$50 Emerg. Room Co-Pay *	$50 Emerg. Room Co-Pay *
ER co-pay is waived if admitted as a result. ER benefit is paid at In-Network rates regardless of where treatment is received.
$250 Individual Deductible	$500 Individual Deductible	$1,000 Individual Deductible
$500 Family Deductible	$1,000 Family Deductible	$2,000 Family Deductible
One member of the family must meet the individual deductible amount, then a combination of covered individuals can collectively meet the family deductible.
$1,000 Individual out of pocket	$1,500 Individual out of pocket	$2,000 Individual out of pocket
$2,000 Family out of pocket	$3,000 Family out of pocket	$4,000 Family out of pocket
Co-insurance will be applied, but deductibles and co-pays do not apply to maximum out-of-pocket.

Coverage for Hospital-Based Services*

• Services billed by PCRMC…100% no deductible applies
• Services billed by Network Providers…80% after deductible has been met
• Services billed byNon-Network Providers…50% after deductible has been met

Full-time employees may enroll in one of three health plans; Gold, Silver, or Bronze. Part-time employees may enroll in the Bronze health plan. Coverage marked with an asterisk (*) is the same rate, regardless of plan.