Revised: 1/07

Medical Plan Information
Physician Services The plan utilizes the Primary Physician Care network. Preferred providers can be found on Primary Physician Care's website (www.primarypc.com) Primary Care Physician Definition A primary care physician is a family physician, general internist, pediatrician, or gynecologist. Selecting A Primary Care Physician Your Plan requires that you select a primary care physician a minimum of 30 days prior to your first scheduled appointment with your primary care physician. If a primary care physician is not selected within this time frame, the participant will pay 20% after a $200 deductible. Hospital Services The plan utilizes the services of Catawba Valley Medical Center and other preferred hospitals in Primary Physician Care's network Third Party Administrator Primary Physician Care Post Office Box 11088 Charlotte, NC 28220-1088 Customer Service: (800) 446-5439 Website: www.primarypc.com (Group Number – 039) Internet Instructions Go to www.primarypc.com. Select the Search Providers button in the middle of the webpage. Search by provider name or look at the entire preferred provider list by selecting the appropriate directory in the upper right hand corner.
Healthcare Provider Services
Primary Care Physician	Benefit
Preferred Providers Primary PhysicianCare network	$15 Employee Co-Pay Per Visit
Non-Preferred Providers Other Providers	$200 Deductible Per Calendar Year 20% Employee Co-Pay Per Visit
Specialist Physician	Benefit
Preferred Providers Primary PhysicianCare network	$200 Deductible Per Calendar Year 20% Employee Co-Pay Per Visit
Non-Preferred Providers Other Providers	$200 Deductible Per Calendar Year 40% Employee Co-Pay Per Visit

Hospital Services
Facility	Benefit
Preferred Provider Catawba Valley Medical Center	$0 Deductible 10% Employee Co-Pay $1,000 Maximum Out of Pocket
Preferred Providers Primary PhysicianCare network	$200 Deductible Per Occurrence 20% Employee Co-Pay $1,500 Maximum Out of Pocket
Non-Preferred Providers Other Hospitals	2,000 Deductible Per Occurrence 40% Employee Co-Pay Unlimited Out of Pocket
Non-Preferred Providers Frye Regional Medical Center	No Benefit Coverage Exception: Open Heart Surgery 20% Employee Co-Pay $1,500 Maximum Out of Pocket

Emergency and Urgent Care Services
Facility	Benefit
Preferred Provider Catawba Valley Medical Center	$0 Deductible Per Occurrence 10% Employee Co-Pay Per Occurrence $1,000 Maximum Out of Pocket Per Visit
Non-Preferred Provider Other Hospitals	$50 Per Visit Deductible Per Occurrence (Waived if Admitted) 20% Employee Co-Pay Per Occurrence $1,500 Maximum Out of Pocket
Non-Preferred Provider Frye Regional Medical Center	No Benefit Coverage Exception: If admitted to FRMC as an Inpatient after receiving treatment in the Emergency Room, the benefit coverage is:     $50 Deductible Per Occurrence     40% Employee Co-Pay Per Occurrence     Unlimited Out of Pocket

Prescription Benefit for Medical Plan Participants** **Oral contraceptives are only covered through mail order.
Category	Employee Pharmacy Co-Pay Rate			Express Scripts-Retail Co-Pay Rate			Express Scripts Mail Co-Pay Rate
	30-Day	60-Day	90-Day	30-Day	60-Day	90-Day	30-Day	60-Day	90-Day
Generic	$5.00	$10.00	$15.00	$15.00	N/A	N/A	$5.00	$10.00	$15.00
Formulary	$15.00	$30.00	$45.00	$25.00	N/A	N/A	$15.00	$30.00	$45.00
Name Brand	$25.00	$50.00	$75.00	$45.00	N/A	N/A	$25.00	$50.00	$75.00

Health Insurance Premium Rates
Plan Category	Premium Rates Per Pay Period Full-Time Employees	Premium Rates Per Pay Period Part-Time Employees	Premium Rates COBRA (Monthly)
Employee Only	$10.30	$53.00	$315.10
Employee + Child	$38.00	$84.00	$504.04
Employee + Children	$54.00	$108.00	$661.79
Family	$69.00	$123.00	$661.79

Dental Insurance Premium Rates
Plan Category	Premium Rates Per Pay Period for Full-Time Employees	Premium Rates Per Pay Period for Part-Time Employees	Premium Rates COBRA (Monthly)
Employee Only	$4.25	$7.46	$18.48
Employee + Dependent	$7.00	$13.62	$33.26
Employee + Dependents	$13.00	$20.93	$51.31

Form Revision Dates

3/1/02 - 5/24/02 - 3/1/03 - 4/7/03 - 6/17/03 - 7/1/04 - 3/1/05 - 1/1/07

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