SPIRA $500 Plan	In-Network	Out-of-Network
Deductible Individual/ Family	$500 / $1,000	N/A
Out-of-pocket maximum	$6,600 / $13,200	N/A
Coinsurance	100%	N/A
Preventative Care	$0	N/A
Primary care office visit	$0 Copay at Spira	N/A
Specialty offcie visit	Deductible	N/A
Urgent Care Visit	Deductible	N/A
Inpatient hospital service / Outpatient surgery	Deductible	N/A
Lab services	Deductible	N/A
MRI, MRA, CT and PET scans	Deductible	N/A
Emergency room	Deductible	Paid as In-Network
X-rays	Deductible	N/A
Prescription drugs Tier 1 / Tier2 / Tier 3	$15 / $50 / Deductible	N/A
Lifetime maximum	Unlimited	Unlimited

Bi-Weekly Cost	$20 AHY DISCOUNT	$10 AHY DISCOUNT	$5 AHY DISCOUNT	NO AHY DISCOUNT
EMPLOYEE	$53.23	$63.23	$68.23	$73.23
EMPLOYEE + CHILD(REN)	$200.90	$205.90	$215.90	$210.90
EMPLOYEE + SPOUSE	$146.11	$151.11	$156.11	$161.11
FAMILY	$283.78	$288.78	$293.78	$298.78