MedSave Management Cash Back Medical Plan

Tier 1               Cash Card                                                           100% to $4,000

Tier 2               Virtual Primary Care                                        100%

Tier 3 *             Deductible                                                          $8,000

Tier 4               Plan Pays                                                             100%

□ Plan Allowed Amount is based on Reference Based Pricing metrics.

□ Rx limited to $640 for a 30-day supply.

□ All specialty & facility care must be pre-certified

□ Plan is excess coverage to IRC501r

□ Plan members participate in year-end plan surplus

□ * Compassionate Care Plan™ option for those plan members who qualify

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