Page 6 - Waterjet Holdings- OE Guide 2015
P. 6
Medical Plan Summary
HRA Plan HSA Plan
In-Network Out-of-Network In-Network Out-of-Network
Health Account Employer Funding
Individual $250 $250 $250 $250
Employee + Spouse or
Child(ren) $750 $750 $750 $750
Family $1,250 $1,250 $1,250 $1,250
Calendar Year Deductible
Individual $1,500 $1,500 $1,500 $3,000
Employee + Spouse or
Child(ren) $2,500 $2,500
Family $3,500 $3,500 $3,500 $7,000
Out-of-Pocket Maximum
Individual $4,250 $7,750 $4,000 $8,000
Employee + Spouse or
Child(ren) $5,500 $10,000
Family $7,500 $14,500 $8,000 $16,000
Physician Ofice Visits
Primary Care 80% after deductible 60% after deductible 80% after deductible 50% after deductible
Specialist 80% after deductible 60% after deductible 80% after deductible 50% after deductible
Wellness/Preventive
100% no deductible 60% after deductible 100% covered 50% after deductible
Lab Services
80% after deductible 60% after deductible 80% after deductible 50% after deductible
X-Ray/Radiology Services
80% after deductible 60% after deductible 80% after deductible 50% after deductible
Hospital Services
Inpatient 80% after deductible 60% after deductible 80% after deductible 50% after deductible
Outpatient 80% after deductible 60% after deductible 80% after deductible 50% after deductible
80% after deductible
50% after deductible
Non-Emergency ER
Emergency Room for non-emergency ER visits are not covered 80% after deductible
visits
Prescription Drugs (In-
Network Coverage Only)
HRA Plan HSA Plan
Retail—Supply Limit 30 day supply 30 day supply
Tier 1 $15 copay 80% after deductible 50% after deductible
Tier 2 $35 copay 80% after deductible 50% after deductible
Tier 3 $60 copay 80% after deductible 50% after deductible
Mail Order—Supply
Limit 90 day supply 90 day supply
Tier 1 $30 copay Not Covered 80% after deductible No Coverage
Tier 2 $70 copay Not Covered 80% after deductible No Coverage
Tier 3 $120 copay Not Covered 80% after deductible No Coverage
Note: Under the HRA plan, prescription copays are not eligible for payment through the HRA fund.
Waterjet Holdings 6
HRA Plan HSA Plan
In-Network Out-of-Network In-Network Out-of-Network
Health Account Employer Funding
Individual $250 $250 $250 $250
Employee + Spouse or
Child(ren) $750 $750 $750 $750
Family $1,250 $1,250 $1,250 $1,250
Calendar Year Deductible
Individual $1,500 $1,500 $1,500 $3,000
Employee + Spouse or
Child(ren) $2,500 $2,500
Family $3,500 $3,500 $3,500 $7,000
Out-of-Pocket Maximum
Individual $4,250 $7,750 $4,000 $8,000
Employee + Spouse or
Child(ren) $5,500 $10,000
Family $7,500 $14,500 $8,000 $16,000
Physician Ofice Visits
Primary Care 80% after deductible 60% after deductible 80% after deductible 50% after deductible
Specialist 80% after deductible 60% after deductible 80% after deductible 50% after deductible
Wellness/Preventive
100% no deductible 60% after deductible 100% covered 50% after deductible
Lab Services
80% after deductible 60% after deductible 80% after deductible 50% after deductible
X-Ray/Radiology Services
80% after deductible 60% after deductible 80% after deductible 50% after deductible
Hospital Services
Inpatient 80% after deductible 60% after deductible 80% after deductible 50% after deductible
Outpatient 80% after deductible 60% after deductible 80% after deductible 50% after deductible
80% after deductible
50% after deductible
Non-Emergency ER
Emergency Room for non-emergency ER visits are not covered 80% after deductible
visits
Prescription Drugs (In-
Network Coverage Only)
HRA Plan HSA Plan
Retail—Supply Limit 30 day supply 30 day supply
Tier 1 $15 copay 80% after deductible 50% after deductible
Tier 2 $35 copay 80% after deductible 50% after deductible
Tier 3 $60 copay 80% after deductible 50% after deductible
Mail Order—Supply
Limit 90 day supply 90 day supply
Tier 1 $30 copay Not Covered 80% after deductible No Coverage
Tier 2 $70 copay Not Covered 80% after deductible No Coverage
Tier 3 $120 copay Not Covered 80% after deductible No Coverage
Note: Under the HRA plan, prescription copays are not eligible for payment through the HRA fund.
Waterjet Holdings 6
