Page 7 - 2015 BRP Benefits Guide

2015 Annual Enrollment

CDHP
In-Network Out-of-Network
Plan Maximum
Per Lifetime Unlimited
Deductible per Calendar Year
Per Individual $1,500 $5,000
Per Family $3,000 $10,000
Maximum Out-of-Pocket Exposure per Calendar Year (Includes Deductible)
Per Individual $3,000 $10,000
Per Family $6,000 $20,000
Plan Cost Sharing
Coinsurance 80% after deductible 60% after deductible
Covered Services
Hospital Services
Inpatient 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible
Emergency Room 80% after deductible 60% after deductible
Urgent Care Center 80% after deductible 60% after deductible
Physician Services
Ofice Visit 80% after deductible 60% after deductible
Other Covered Services
Preventive Care 100% covered 60% after deductible
Prescription Drug Beneit
Retail Pharmacy
Tier 1 Deductible, then a $10 copay
Tier 2 Deductible, then 80%, not less than a $25 copay, not more than a $50 copay
Tier 3 Deductible, then 70%, not less than a $45 copay, not more than a $90 copay
Mail Order Pharmacy
Tier 1 Annual deductible then $25 copay
Tier 2 Annual deductible then 80% of the prescription drug cost, but not less than a $62.50 copay
and not more than a $125 copay
Tier 3 Annual deductible then 70% of the prescription drug cost, but not less than a $112.50 copay
and not more than a $225 copay

Bi-Weekly Medical and Rx Coverage Cost

Coverage Tier Non-Tobacco Tobacco
Employee $25.57 $91.01
Employee + Spouse $71.60 $131.96
Employee + Child $62.82 $128.95
Employee + Children $97.87 $163.65
Employee + Family $115.39 $181.01

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