North State Bank 2024 Benefits Guide

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NORTH STATE BANK | 2025 BENEFITS GUIDE

Health Care

Plan details below are based on in-network services and providers.

PPO 70

HDHP 1750

HDHP 3250

Deductible

Individual

$2,000

$1,750

$3,250

Family

$4,000

$3,500

$6,500

Coinsurance

70%

80%

100%

Coinsurance Maximum Individual

$3,250 $6,500

$3,500 $7,000

n/a n/a

Family

Out-of-Pocket Maximum Individual

$5,250

$5,250

$3,250 $6,500

Family

$10,500

$10,500

Preventative/Wellness

100%

100%

100%

Office Visits

Primary Office Visits Specialist Office Visits

$30 copay $50 copay

80%, after ded. 80%, after ded.

100%, after ded. 100%, after ded.

Prenatal Care

$200 copay

80%, after ded.

100%, after ded.

Hospitalization

100%, after ded. 100%, after ded.

Emergency Room

$250 copay $50 copay 30 day supply: $9/$35/$65/ 25% up to $150 90 day supply mail order: $27/$105/$195

80%, after ded. 80%, after ded.

Urgent Care

Rx

80%, after ded.

100%, after ded.

Monthly Employee Deduction

Employee & Spouse

Employee & Child(ren)

Employee & Family

Plans

Employee

PPO 70

$0.00 $0.00 $0.00

$489.48 $447.50 $433.96

$231.39 $211.55 $205.14

$734.21 $671.25 $650.94

HD 1750 HD 3250