| Co-Pay for Physician Office Visit |
$0 for children;
 $3.65 for adults
|
$3.65 for children |
$5 for children |
$10 for children |
| Monthly Premium |
None |
None |
$15 - 1 person
$25 - 2 persons
$5 each add'l
|
$40 per child |
| Max Monthly Premium |
N/A |
N/A |
$40 for 5 or more persons |
$80 for 2 or more children |
| Max Co-Payments per Year |
N/A |
$100 per family |
$100 per family |
$125 per child per calendar quarter |
