Effective Date: 06/21/2026
Broker: Jack Gordman
Prepared by: Morgan White Group
502 Court Street, Suite 241 • Utica, New York 13502
Deductible: $500 / Coinsurance: 90%/10% to $2,500
| Current MM Rates | # on Plan | Total Monthly Premium | |
|---|---|---|---|
| Employee | $0.00 | 30 | $0.00 |
| E + Spouse | $0.00 | 0 | $0.00 |
| E + Child(ren) | $0.00 | 0 | $0.00 |
| Family | $0.00 | 0 | $0.00 |
| Total | $21,579.59 | ||
Deductible: $1,000 / Coinsurance: 80%/20% to $2,000
| Renewal MM Rates | # on Plan | Total Monthly Premium | |
|---|---|---|---|
| Employee | $0.00 | 30 | $0.00 |
| E + Spouse | $0.00 | 0 | $0.00 |
| E + Child(ren) | $0.00 | 0 | $0.00 |
| Family | $0.00 | 0 | $0.00 |
| Total | $21,579.59 | ||
Deductible: $5,000 / Coinsurance: 100/0% to $1,250
|
Deductible: $500 per person Coinsurance: 50% to $1,000 |
Benefit: $4,750 Office Copay: $30 |
Outpatient RX Benefit: (see attached plan description) |
| Alternate Plan MM Rates | Premium Saver Rates | Total w/PS | # on Plan | Total New Monthly Premium | |
|---|---|---|---|---|---|
| Employee | $0.00 | + $142.12 | $142.12 | 30 | $4,263.60 |
| E + Spouse | $0.00 | + $278.89 | $278.89 | 0 | $0.00 |
| E + Child(ren) | $0.00 | + $263.15 | $263.15 | 0 | $0.00 |
| Family | $0.00 | $404.96 | $404.96 | 30 | $0.00 |
| Monthly Totals | $16,422.22 | $4,263.60 | $20,685.82 | ||
Total Monthly Savings
Total Annual Savings
1st Month PS Premium
Alternate major medical rates could be an estimate. Actual rates are based on the major medical carrier's actual quote.
Each insured person has a $500 annual deductible. After the deductible is met the insured person pays 50% until they pay $1,000 coinsurance. This plan wraps around your high deductible health plan and pays the amount applied to your major medical plan's Deductible, Coinsurance and Copayment until our payments reach the Maximum Benefit Amount.
This plan covers all eligible expenses covered by your major medical plan.
After the insured person pays a $30 copay per office visit for the professional fee of a primary care physician or specialist in a doctor's office or medical clinic, this plan will cover the balance in full up to 6 visits per person per benefit year. The supplemental plan deductible and coinsurance described above apply to all charges except professional fee of a primary care physician or specialist in a doctor's office or medical clinic.
$4,750 is the maximum benefit amount payable for benefits described on this page during a benefit year for each Insured Person. The Prescription Drug Benefit described on attached page has a separate benefit amount.
| Employee | $142.12 |
|---|---|
| E + Spouse | $278.89 |
| E + Child(ren) | $263.15 |
| Family | $404.96 |
* Monthly rates include a non-commissionable $1.00 association fee for prescription drugs.
Participation requirements: All persons covered by the group major medical or comprehensive health plan must be covered by the Premium Saver Plan except when the HSA is funded.
This is a brief description of coverage, see policy for complete details.
The Premium Saver Plan pays the benefits directly to the provider. Paying the provider directly saves the insured time and it is the quickest way for the provider to receive payment.
Please note: Always give your Premium Saver insurance card to the provider.
This is the easiest and best method to submit a claim.
Claims can be filed electronically by the provider. This means no paperwork and quick payment of your claim to the provider. We are contracted with some of the largest claims clearinghouses in the country.
Providers can email, mail or fax your claim information to us if they are not contracted with our clearinghouses. We will be glad to contact providers that want to contract with our clearinghouses.
If the insured files the claim, they need to submit the two forms described below:
The Explanation of Benefits is a form provided by your major medical carrier that describes the procedures covered, facility used, benefit paid and the amount applied to the insured's deductible or coinsurance.
These forms describe the procedures codes, provides us with the address and the provider's federal identification number so we can pay the claim for you.
Administered by:
Underwritten by: