Employee Cost Acknowledgement Form

Receive a $25 wellness incentive added to your PCA for each family member who completes a yearly checkup or recommended screening.

15% coinsurance: The percentage of costs you pay after you pay the deductible.

A Copay is a fixed amount you pay for a covered healthcare service, usually at the time you receive the service.

Plan allowance is the maximum amount a plan will pay for a covered healthcare service