Comparison Chart - RF | Human Resources

Description	RF Traditional PPO (Empire BlueCross Blue Shield)	RF Deductible PPO
DescriptionCo-Pay	RF Traditional PPO (Empire BlueCross Blue Shield) $20.00	RF Deductible PPO $30
DescriptionIn-Network Deductible	RF Traditional PPO (Empire BlueCross Blue Shield) None	RF Deductible PPO $500 Individual / $1,250 Family
DescriptionIn-Network Co-Insurance	RF Traditional PPO (Empire BlueCross Blue Shield) None	RF Deductible PPO 90/10 coinsurance
DescriptionOut of Network Deductible	RF Traditional PPO (Empire BlueCross Blue Shield) Yes ($1000 Individual/ $2500 Family deductible)	RF Deductible PPO Yes ($1500 Individual/ $3750 Family deductible)
DescriptionOut of Network Co-Insurance	RF Traditional PPO (Empire BlueCross Blue Shield) 80/20 coinsurance	RF Deductible PPO 40/60 coinsurance
DescriptionPreventive Care	RF Traditional PPO (Empire BlueCross Blue Shield) $0 (up to $300 gym reimbursement)	RF Deductible PPO $0 (up to $300 gym reimbursement)
DescriptionHospital	RF Traditional PPO (Empire BlueCross Blue Shield) $100	RF Deductible PPO Deductible and Coinsurance
DescriptionER Visit	RF Traditional PPO (Empire BlueCross Blue Shield) $50	RF Deductible PPO $50
DescriptionLab or X-rays	RF Traditional PPO (Empire BlueCross Blue Shield) $20	RF Deductible PPO Deductible and Coinsurance
DescriptionPrescriptions	RF Traditional PPO (Empire BlueCross Blue Shield) $10/$25/$45	RF Deductible PPO $10/$25/$45

COVERAGE TYPE		RF Traditional PPO (Empire BlueCross Blue Shield)	RF Deductible PPO
In Network	Individual Coverage	$4,224	$1,500
In Network	Family Coverage	$10,560	$3,750
Out of Network	Individual Coverage	$4,000	$5,500
Out of Network	Family Coverage	$10,000	$13,750