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Benchmarking Medical Plan Benefits <br />Public BenchmarkCity of La Porte <br />63 <br />Number of Benchmark Cities <br />393 <br />Number of Enrolled Employees <br />Non HDHPHDHP <br />3 <br />Plans Offered <br />Aetna <br />Current Carrier <br />20212021 <br />Plan Year <br />PPO 500HF 1000HF 1500 <br />Plan Type <br />15697140 <br />Subscriber Enrollment <br />40%25%36% <br />% of Subscriber Enrollment <br />$1,066 EE$500 EE $500 EE <br />n/an/a <br />$1,829 Fam$1,000 FAM$1,000 FAM <br />HSA or HRA Contribution <br />$500$1,000$1,500 <br />$1,775$3,149 <br />Individual Deductible <br />$1,500$3,000$4,500 <br />$3,865$6,216 <br />Family Deductible <br />$3,500$3,500$4,200 <br />$4,413$4,824 <br />Individual Out of Pocket <br />$10,500$10,500$12,600 <br />$9,379$10,778 <br />Family Out of Pocket <br />20%20%20% <br />19%14% <br />Coinsurance <br />$26 PCP Copay / $50 $25 PCP Copay / $40 <br />Ded./14%Ded./20%Ded./20% <br />Specialist CopaySpecialist Copay <br />Office Visits/Specialist <br />$64 CopayDed./14%$40 CopayDed./20%Ded./20% <br />Urgent Care <br />$239 Copay + <br />Ded./14%$150 Copay$150 Copay$150 Copay <br />Coinsurance <br />Emergency Room <br />Ded./20%Ded./14%Ded./20%Ded./20%Ded./20% <br />Inpatient Surgery <br />Tier 1- $10 <br />Tier 1 - $10Tier 1 - $10Tier 1 - $10 <br />Tier 2- $41 <br />Ded./14%Tier 2 - $30Tier 2 - $30Tier 2 - $30 <br />Pharmacy - Retail Only <br />Tier 3- $77 <br />© 2018 HUB International Limited. <br />34 <br />Tier 3 - $60Tier 3 - $60Tier 3 - $60 <br />Tier 4 - $144 <br /> <br />