Page 7 - Fontbonne 2021 New Hire Guide
P. 7
2021
Fontbonne University Enrollment Guide
Wellness Program
Fontbonne offers the opportunity to receive a discount on your monthly medical premium by participating in the
Wellness Program. In order to be eligible for the Program, you must complete a biometric screening and health
risk assessment each year. Information regarding these requirements can be acquired through Human Resources
and will also be distributed each year during open enrollment.
Medical Contributions—Monthly
Premium Plan HSA Plan
Wellness Non-Wellness Wellness Non-Wellness
Employee Only $170 $200 $52 $88
Employee + Spouse $910 $949 $492 $538
Employee + Child(ren) $814 $843 $450 $481
Family $1,037 $1,073 $580 $629
Medical Benefits
Premium Plan HSA Plan
UHC Choice Plus
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $750 $1,500 $1,500 $3,000
Family $1,500* $3,000 $3,000 $6,000
Preventive Care
Covered Service 100% covered 50% after deductible 100% covered 30% after deductible
Out-of-Pocket Maximum
Individual $3,500 $7,000 $3,500 $7,000
Family $7,000* $14,000 $7,000* $14,000
Physician Oice Visits
Primary/Specialist Visit $25 copay 50% after deductible 10% after deductible 30% after deductible
Teledoc $10 copay Not covered 10% after deductible Not covered
Hospital Services
Urgent Care $50 copay 50% after deductible 10% after deductible 30% after deductible
Emergency Room $200 copay $200 copay 10% after deductible 10% after deductible
Inpatient Services 20% after deductible 50% after deductible 10% after deductible 30% after deductible
Outpatient Services 20% after deductible 50% after deductible 10% after deductible 30% after deductible
* Embedded structure (see page 7 for more information on embedded versus non-embedded plan designs)
Please refer to the Summary Plan Description for detailed information on covered beneits
7
Fontbonne University Enrollment Guide
Wellness Program
Fontbonne offers the opportunity to receive a discount on your monthly medical premium by participating in the
Wellness Program. In order to be eligible for the Program, you must complete a biometric screening and health
risk assessment each year. Information regarding these requirements can be acquired through Human Resources
and will also be distributed each year during open enrollment.
Medical Contributions—Monthly
Premium Plan HSA Plan
Wellness Non-Wellness Wellness Non-Wellness
Employee Only $170 $200 $52 $88
Employee + Spouse $910 $949 $492 $538
Employee + Child(ren) $814 $843 $450 $481
Family $1,037 $1,073 $580 $629
Medical Benefits
Premium Plan HSA Plan
UHC Choice Plus
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $750 $1,500 $1,500 $3,000
Family $1,500* $3,000 $3,000 $6,000
Preventive Care
Covered Service 100% covered 50% after deductible 100% covered 30% after deductible
Out-of-Pocket Maximum
Individual $3,500 $7,000 $3,500 $7,000
Family $7,000* $14,000 $7,000* $14,000
Physician Oice Visits
Primary/Specialist Visit $25 copay 50% after deductible 10% after deductible 30% after deductible
Teledoc $10 copay Not covered 10% after deductible Not covered
Hospital Services
Urgent Care $50 copay 50% after deductible 10% after deductible 30% after deductible
Emergency Room $200 copay $200 copay 10% after deductible 10% after deductible
Inpatient Services 20% after deductible 50% after deductible 10% after deductible 30% after deductible
Outpatient Services 20% after deductible 50% after deductible 10% after deductible 30% after deductible
* Embedded structure (see page 7 for more information on embedded versus non-embedded plan designs)
Please refer to the Summary Plan Description for detailed information on covered beneits
7
