North Smithfield Public Schools

Benefit Exhibit

Group Number

#0001A840*0003

Account Name

North Smithfield School Teachers

Benefit Component

Office Visits

PCP

$20

Spec

$30

Allergy/Derm

$30

Vision

$30

Chiro

$30

Urgi

$50

In Network Coinsurance

100%/0%

In Network Deductible

$1,000/$2,000

In Network OOP Max

$6,350/$12,700

ER Copay

$150

Rx-Pharmacy

$7/$25/$40/$40, 2.5x Mail Order

MHCD copays

$30 Ind/$30 Group

Out of Network Coinsurance

80%/20%

Out of Network Deductible

$2,000/$4,000

Out of Network OOP Max

$6,350/$12,700

Health Matters Wellness Program

Yes

Vision Eyewear Program

$100 Vision Allowance Plan 2