Page 6 - Yaskawa 2022 Open Enrollment Guide
P. 6
Prescription Drug Plan For Medical Plan Participants
2022 Plan Design PPO Silver Plan CDHP Plan Yaskawa America, Inc. has a mail-order prescription
Prescription Out-of-Pocket Maximums drug program, OptumRx Mail Service, which will
Individual $4,100 Combined with medical deliver a three-month supply (90-day supply) of
Family $8,200 out-of-pocket routine maintenance drugs to your home for 2/3
Prescription Drug Retail (31-day supply) of the cost of illing at a retail pharmacy. To enroll
Tier 1 $10 in the mail order program for the irst time, you
Tier 2 $25 Medical deductible and should request a new 12-month supply prescription
out-of-pocket apply
Tier 3 $45
Prescription Drug Mail Order (90-day supply) from your physician and submit it with the mail
Tier 1 $20 order form available on www.optumrx.com or call
Tier 2 $50 Medical deductible and 855.856.0541.
out-of-pocket apply
Tier 3 $90
Bi-Weekly Employee Contributions
Silver PPO Plan CDHP Plan
Wellvibe Participant Non-Wellvibe Participant Wellvibe Participant Non-Wellvibe Participant
Employee $63.52 $75.06 $31.24 $42.78
Employee + Spouse $138.59 $150.13 $74.03 $85.56
Employee + Child(ren) $133.33 $144.87 $71.03 $82.57
Family $221.91 $233.45 $121.51 $133.05
* Note 26 annual pay periods
For more information on the Wellvibe wellness program and how to participate, please see page 11 or contact your HR
department.
New Hires will be eligible for the Wellvibe Participant discount the calendar year following year of hire.
Opt Out Credit
If an Associate chooses to opt out of Yaskawa’s Medical and/or Dental plans, he/she will receive an annual
credit in the following amount (paid on a per pay period basis). Associates must be active to receive opt out
credits. Opt out credits will be suspended if an associate is not actively at work. These credits will be paid
retroactively to any associate that returns to active employment from an approved leave of absence.
Medical Dental
■ Employee Only: $1,320 ■ All tiers: $120
■ Employee + Spouse: $1,800
■ Employee + Child(ren): $1,800
■ Family: $2,400
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2022 Plan Design PPO Silver Plan CDHP Plan Yaskawa America, Inc. has a mail-order prescription
Prescription Out-of-Pocket Maximums drug program, OptumRx Mail Service, which will
Individual $4,100 Combined with medical deliver a three-month supply (90-day supply) of
Family $8,200 out-of-pocket routine maintenance drugs to your home for 2/3
Prescription Drug Retail (31-day supply) of the cost of illing at a retail pharmacy. To enroll
Tier 1 $10 in the mail order program for the irst time, you
Tier 2 $25 Medical deductible and should request a new 12-month supply prescription
out-of-pocket apply
Tier 3 $45
Prescription Drug Mail Order (90-day supply) from your physician and submit it with the mail
Tier 1 $20 order form available on www.optumrx.com or call
Tier 2 $50 Medical deductible and 855.856.0541.
out-of-pocket apply
Tier 3 $90
Bi-Weekly Employee Contributions
Silver PPO Plan CDHP Plan
Wellvibe Participant Non-Wellvibe Participant Wellvibe Participant Non-Wellvibe Participant
Employee $63.52 $75.06 $31.24 $42.78
Employee + Spouse $138.59 $150.13 $74.03 $85.56
Employee + Child(ren) $133.33 $144.87 $71.03 $82.57
Family $221.91 $233.45 $121.51 $133.05
* Note 26 annual pay periods
For more information on the Wellvibe wellness program and how to participate, please see page 11 or contact your HR
department.
New Hires will be eligible for the Wellvibe Participant discount the calendar year following year of hire.
Opt Out Credit
If an Associate chooses to opt out of Yaskawa’s Medical and/or Dental plans, he/she will receive an annual
credit in the following amount (paid on a per pay period basis). Associates must be active to receive opt out
credits. Opt out credits will be suspended if an associate is not actively at work. These credits will be paid
retroactively to any associate that returns to active employment from an approved leave of absence.
Medical Dental
■ Employee Only: $1,320 ■ All tiers: $120
■ Employee + Spouse: $1,800
■ Employee + Child(ren): $1,800
■ Family: $2,400
6
