Page 8 - WJ Bradley Annual Enrollment
P. 8
Beneits Guide
2015 Health Plan Summary—Continued
$1,500 Deductible Plan In-network preventive care is covered at 100% for both
$2,500 Deductible Plan
In-network preventive care is covered at 100% for
Preventive Care both children and adult services with no deductible. children and adult services with no deductible.
X Go to any doctor or hospital; however, receive X Go to any doctor or hospital; however, receive higher
higher beneits if you use an in-network provider.
beneits if you use an in-network provider. No referrals
Network X 80%/20% coinsurance in-network vs. 50%/50% X 70%/30% coinsurance in-network vs. 50%/50% out-of-
No referrals needed to see a specialist.
needed to see a specialist.
out-of-network. network.
Ofice Visit No deductible applies for in-network ofice visits. No deductible applies for in-network ofice visits. These
These require a $35 copay for primary care physicians require a $40 copay for primary care physicians and a $60
and a $50 copay for specialists.
Retail prescription for In and Out-of-Network are copay for specialists.
Retail prescriptions for in- and out-of-network are covered as
covered as follows: follows:
X Tier 1 $15 copay X Tier 1 30% coinsurance
($20 min/$60 max)
X Tier 2 $45 copay X Tier 2 40% coinsurance
X
Tier 3 $60 copay
Prescription Drugs Mail Order prescription drugs are covered as follows: X Tier 3 50% coinsurance
($45 min/$135 max)
Tier 1 $37.50 copay
X
($80 min/$240 max)
X
Tier 2 $112.50 copay
Mail order prescriptions drugs are covered as follows:
X
Tier 3 $150 copay
Tier 1 30% coinsurance
X
($50 min/$150 max)
X Tier 2 40% coinsurance
($112.50 min/$337.50 max)
X Tier 3 50% coinsurance
($200 min/$600 max)
Other service/care requires a deductible per family member
Other service/care requires a deductible per family
Deductible member or per family. You pay the deductible, then the or per family. You pay the deductible, then the plan pays most
expenses while you pay a coinsurance percentage. The family
plan pays most expenses while you pay a coinsurance
percentage. The family deductibles for in-network and deductibles for in-network and out-of-network are $7,500 and
out-of-network are $4,500 and $13,500 respectively.
$22,500 respectively.
Out-of-Pocket Maximum You are protected from large expenses by an out- You are protected from large expenses by an out-of-pocket
maximum. Once your covered expenses reach this limit, the
of-pocket maximum. Once your covered expenses
reach this limit, the plan pays the rest of your covered plan pays the rest of your covered expenses. The in-network
expenses. The in-network out-of-pocket maximums
out-of-pocket maximums (which include the deductible) are
(which include the deductible) are $4,000 for an
$6,350 for an individual and $12,700 for family.
individual and $12,000 for family.
8
2015 Health Plan Summary—Continued
$1,500 Deductible Plan In-network preventive care is covered at 100% for both
$2,500 Deductible Plan
In-network preventive care is covered at 100% for
Preventive Care both children and adult services with no deductible. children and adult services with no deductible.
X Go to any doctor or hospital; however, receive X Go to any doctor or hospital; however, receive higher
higher beneits if you use an in-network provider.
beneits if you use an in-network provider. No referrals
Network X 80%/20% coinsurance in-network vs. 50%/50% X 70%/30% coinsurance in-network vs. 50%/50% out-of-
No referrals needed to see a specialist.
needed to see a specialist.
out-of-network. network.
Ofice Visit No deductible applies for in-network ofice visits. No deductible applies for in-network ofice visits. These
These require a $35 copay for primary care physicians require a $40 copay for primary care physicians and a $60
and a $50 copay for specialists.
Retail prescription for In and Out-of-Network are copay for specialists.
Retail prescriptions for in- and out-of-network are covered as
covered as follows: follows:
X Tier 1 $15 copay X Tier 1 30% coinsurance
($20 min/$60 max)
X Tier 2 $45 copay X Tier 2 40% coinsurance
X
Tier 3 $60 copay
Prescription Drugs Mail Order prescription drugs are covered as follows: X Tier 3 50% coinsurance
($45 min/$135 max)
Tier 1 $37.50 copay
X
($80 min/$240 max)
X
Tier 2 $112.50 copay
Mail order prescriptions drugs are covered as follows:
X
Tier 3 $150 copay
Tier 1 30% coinsurance
X
($50 min/$150 max)
X Tier 2 40% coinsurance
($112.50 min/$337.50 max)
X Tier 3 50% coinsurance
($200 min/$600 max)
Other service/care requires a deductible per family member
Other service/care requires a deductible per family
Deductible member or per family. You pay the deductible, then the or per family. You pay the deductible, then the plan pays most
expenses while you pay a coinsurance percentage. The family
plan pays most expenses while you pay a coinsurance
percentage. The family deductibles for in-network and deductibles for in-network and out-of-network are $7,500 and
out-of-network are $4,500 and $13,500 respectively.
$22,500 respectively.
Out-of-Pocket Maximum You are protected from large expenses by an out- You are protected from large expenses by an out-of-pocket
maximum. Once your covered expenses reach this limit, the
of-pocket maximum. Once your covered expenses
reach this limit, the plan pays the rest of your covered plan pays the rest of your covered expenses. The in-network
expenses. The in-network out-of-pocket maximums
out-of-pocket maximums (which include the deductible) are
(which include the deductible) are $4,000 for an
$6,350 for an individual and $12,700 for family.
individual and $12,000 for family.
8
