Tier | Indemnity with PPO People First Plan Code 4031 |
Standard PPO People First Plan Code 4032 |
Preventive PPO People First Plan Code 4033 |
Employee Only |
$45.50 |
$32.08 | $21.98 |
Employee + Spouse |
$84.16 |
$59.34 | $40.64 |
Employee + Child(ren) |
$94.04 |
$66.32 | $45.42 |
Employee + Spouse + Child(ren) |
$136.52 |
$96.28 | $65.92 |