Acousti Engineering Co. of Florida

BLUE PLAN
Lifetime Maximum	No Maximum

Calendar Year Deductible
Individual	$500
Family	$1500

Physician Office Visit Copay (PPO Network Only)	$20

In-Network Specialist Copay	$40

Coinsurance (Blue Cross Share)
Preferred Providers	80% of PPO Schedule
Non-Preferred Providers	60% of Allowance

Calendar Year Maximum Out of Pocket (Deductible & Your Share of Coinsurance)
Individual: Utilizing the PPO Network	$2,500
Individual: Non-PPO	$5,000
Family: Utilizing the PPO Network	$5,000
Family: Non-PPO	$10,000

Well Care Benefit (PPO Network Only)	Adult annual preventive exam paid at 100%.

Prescription Drug Benefits	Deductible - $0 Preferred Generic Presciption Drugs - $15 Copayment ($30 Mail Order Copayment) Preferred Brand Name Prescription Drugs - $30 Copayment ($60 Mail Order Copayment) Non-Preferred Prescription Drugs - $50 Copayment ($100 Mail Order Copayment)

PAYROLL RECOVERY (Your Cost Before Flex Discount)
Individual Employee	$200.00 month / $46.15 week
Family	$550.00 Month / $126.92 week

GREEN PLAN
Lifetime Maximum	No Maximum

Calendar Year Deductible
Per Person In-Network	$1,500
Per Person Out-of Network	$4,500

Family Physician Office Visit Copay (PPO Network Only)	$35

Coinsurance (Blue Cross Share)
Preferred Providers	50% of PPO Schedule
Non-Preferred Providers	50% of Allowance

Calendar Year Maximum Out of Pocket (Deductible & Your Share of Coinsurance)
Individual: Utilizing the PPO Network	$10,000
Individual: Non-PPO	$10,000
Family: Utilizing the PPO Network	$20,000
Family: Non-PPO	$20,000

Well Care Benefit (PPO Network Only)	Adult annual preventive exam paid are $35 at participants family physician.

Prescription Drug Benefits	$15 Copay Plan for Generics- $500 Prescription Deductible and 50% Coinsurance for Brand Name Drugs.

PAYROLL RECOVERY (Your Cost Before Flex Discount)
Individual Employee	$0.00 month/$0.00 week
Family	$275.00 month / $63.46 week

YELLOW PLAN
Lifetime Maximum	No Maximum

Calendar Year Deductible
Per Person In-Network	$1,500
Per Person Out-of Network	$3,000

Physician Office Visit Copay (PPO Network Only)	DED + 10%

Coinsurance (Blue Cross Share)
Preferred Providers	10% of PPO Schedule
Non-Preferred Providers	40% of Allowance

Calendar Year Maximum Out of Pocket (Deductible & Your Share of Coinsurance)
Individual: Utilizing the PPO Network	$5,000
Individual: Non-PPO	$10,000
Family: Utilizing the PPO Network	$5,000
Family: Non-PPO	$10,000

Well Care Benefit (PPO Network Only)	Adult annual preventive exam paid at 90%.

Prescription Drug Benefits	Apply to deductible, then copays of: Preferred Generic Presciption Drugs - $15 Copayment ($40 Mail Order Copayment) Preferred Brand Name Prescription Drugs - $30 Copayment ($75 Mail Order Copayment) Non-Preferred Prescription Drugs - $50 Copayment ($125 Mail Order Copayment) Until out of pocket maximum is reached.

PAYROLL RECOVERY (Your Cost Before Flex Discount)
Individual Employee	$95.00 month / $21.92 week
Family	$320.00 month / $73.84 week

Acousti Engineering Company of Florida
4656 34th Street, S. W.
Orlando, Florida 32811

E-mail: info@acousti.com
Phone: (407) 425-3467
Fax: (407) 422-6502