HDHP PLANS
BPL#	MEDICAL DEDUCTIBLE	PREVENTATIVE HEALTH SERVICES	CO-INSURANCE AFTER DEDUCTIBLE	OUT-OF-POCKET MAXIMUM	RX COVERAGE AFTER DEDUCTIBLE
K / 41920 / JHD00900	$1250/$2500	0%	0%	$2500/$5000	100%
I / 41908 / JHD00700	$1250/$2500	0%	0%	$2500/$5000	$10/$25/$50
B / 41901 / JHD00100	$2000/$4000	0%	0%	$4000/$8000	$10/$25/$50
C / 41902 / JHD00200	$5000/$10000	0%	0%	$5000/$10000	$10/$25/$50
J / 41909 / JHD00800	$1250/$2500	0%	20%	$2500/$5000	$10/$25/$50
E / 41904 / JHD00300	$2000/$4000	0%	20%	$4000/$8000	$10/$25/$50
F / 41905 / JHD00400	$4000/$8000	0%	20%	$5000/$10000	$10/$25/$50
HDHP Prescription Drug Rider

HDHP PLUS PLANS
BPL#	MEDICAL DEDUCTIBLE	PREVENTATIVE HEALTH SERVICES	CO-INSURANCE AFTER DEDUCTIBLE	OUT-OF-POCKET MAXIMUM	RX COVERAGE AFTER DEDUCTIBLE
K / 94970 / JHP00900	$1250/$2500	0%	0%	$2500/$5000	100%
I / 94966 / JHP00700	$1250/$2500	0%	0%	$2500/5000	$10/$25/$50
B / 94951 / JHP00100	$2000/$4000	0%	0%	$4000/$8000	$10/$25/$50
C / 94952 / JHP00200	$5000/$10000	0%	0%	$5000/$10000	$10/$25/$50
J / 94968 / JHP00800	$1250/$2500	0%	20%	$2500/$5000	$10/$25/$50
E / 94954 / JHP00300	$2000/$4000	0%	20%	$4000/$8000	$10/$25/$50
F / 94955 / JHP00400	$4000/$8000	0%	20%	$5000/$10000	$10/$25/$50
HDHP Prescription Drug Rider

HDHP PLANS, OUT-OF-NETWORK
BPL#	MEDICAL DEDUCTIBLE	PREVENTATIVE HEALTH SERVICES	CO-INSURANCE AFTER DEDUCTIBLE	OUT-OF-POCKET MAXIMUM	RX COVERAGE AFTER DEDUCTIBLE
K / 94970 / JHP00900	$2500/$5000	N/C	30%	$5000/$10000	100%
I / 94966 / JHP00700	$2500/$5000	N/C	30%	$5000/$10000	$10/$25/$50
B / 94951 / JHP00100	$4000/$8000	N/C	30%	$8000/$16000	$10/$25/$50
C / 94952 / JHP00200	$5000/$10000	N/C	30%	$10000/$20000	$10/$25/$50
J / 94968 / JHP00800	$2500/$5000	N/C	40%	$5000/$10000	$10/$25/$50
E / 94954 / JHP00300	$4000/$8000	N/C	40%	$8000/$16000	$10/$25/$50
F / 94955 / JHP00400	$5000/$10000	N/C	40%	$10000/$20000	$10/$25/$50
HDHP Prescription Drug Rider