Page 8 - Fontbonne University 2022 Benefits Guide
P. 8
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
Teladoc $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
Prescription Drugs
Deductible, then the
following copays:
no deductible
on maintenance
medications
Generic $10 copay 50% after deductible $10 copay 50% after deductible
Preferred Brand $40 copay 50% after deductible $30 copay 50% after deductible
Non-Preferred Brand $60 copay 50% after deductible $50 copay 50% after deductible
Mail Order
Generic $20 copay Not covered $20 copay Not covered
Preferred Brand $80 copay Not covered $60 copay Not covered
Non-Preferred Brand $120 copay Not covered $100 copay Not covered
* Embedded structure (see page 7 for more information on embedded versus non-embedded plan designs)
Note: If you purchase a prescription drug from a non-network pharmacy, you are responsible for any diference between what the non-network
pharmacy charges and the amount which would have been paid for the same prescription drug dispensed by a network pharmacy.
Please refer to the Summary Plan Description for detailed information on covered beneits
Medical Contributions—Monthly
Premium Plan HSA Plan
Employee Only $170 $52
Employee + Spouse $910 $492
Employee + Child(ren) $814 $450
Family $1,037 $580
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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
Teladoc $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
Prescription Drugs
Deductible, then the
following copays:
no deductible
on maintenance
medications
Generic $10 copay 50% after deductible $10 copay 50% after deductible
Preferred Brand $40 copay 50% after deductible $30 copay 50% after deductible
Non-Preferred Brand $60 copay 50% after deductible $50 copay 50% after deductible
Mail Order
Generic $20 copay Not covered $20 copay Not covered
Preferred Brand $80 copay Not covered $60 copay Not covered
Non-Preferred Brand $120 copay Not covered $100 copay Not covered
* Embedded structure (see page 7 for more information on embedded versus non-embedded plan designs)
Note: If you purchase a prescription drug from a non-network pharmacy, you are responsible for any diference between what the non-network
pharmacy charges and the amount which would have been paid for the same prescription drug dispensed by a network pharmacy.
Please refer to the Summary Plan Description for detailed information on covered beneits
Medical Contributions—Monthly
Premium Plan HSA Plan
Employee Only $170 $52
Employee + Spouse $910 $492
Employee + Child(ren) $814 $450
Family $1,037 $580
8
