HSA PLAN G

Plan Rates Subject to Taxes and Admin Fees

COVERAGES

Co-Pays:

. Primary Care: Covered 100% after deductible

. Specialist: Covered 100% after deductible

. Urgent Care: Covered 100% after deductible

Deductible:

In-Network: $8,000 Individual/$16,000 Family

Out of Pocket Maximum:

In-Network: $8,000 Individual/$16,000 Family

THIS PLAN INCLUDES

Unlimited Telehealth Services

Benefit Support and Administration

*Pay Period: 1st and 15th of each month

** This plan is underwritten by Group Management Services Inc, NAICS 541612, and not Cigna