Page 7 - WJ Bradley Annual Enrollment

W.J. Bradley

2015 Health Plan Summary

Beneit Plans $1,500 $2,500
Deductible Plan Deductible Plan
Network Non-Network Network Non-Network
Deductible
Individual $1,500 $4,500 $2,500 $7,500
Family $4,500 $13,500 $7,500 $22,500
Out-of-Pocket Maximum (Includes Deductible)
Individual $4,000 $12,000 $6,350 $22,500
Family $12,000 $36,000 $12,700 $67,500
Ofice Visit Copay
Primary Care $35 Ded/50% $40 Ded/50%
Specialist $50 Ded/50% $60 Ded/50%
Hospital
Inpatient $500 Copay Ded/50% $500 Copay Ded/50%
Outpatient Ded/20% Ded/50% Ded/30% Ded/50%
Emergency Room $250 Copay $250 Copay $300 Copay $300 Copay
Prescription Drug—Pharmacy
Tier I $15 $15 30% coinsurance 30% coinsurance
($20 min/$60 max) ($20 min/$60 max)
Tier II $45 $45 40% coinsurance ($45 40% coinsurance
min/$135 max) ($45 min/$135 max)
Tier III $60 $60 50% coinsurance 50% coinsurance
($80 min/$240 max) ($80 min/$240 max)
Prescription Drug—Mail Order (90 day supply)
Tier I $37.50 Not Covered 30% coinsurance Not Covered
($50 min/$150 max)
Tier II $112.50 Not Covered 40% coinsurance Not Covered
($112.50 min/$337.50
max)
Tier III $150.00 Not Covered 50% coinsurance ($200 Not Covered
min/$600 max)

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