Page 5 - 2017-18 TechLab Benefits Guide
P. 5
In-Network Plan Details
Lumenos HSA
Key Care 25 Key Care 30 High Deductible Health Plan
Traditional PPO Plan Traditional PPO Plan (HDHP)
Calendar Year Deductible
Individual $500 $1,000 $3,000
Family $1,000 $2,000 $6,000
Out-of-Pocket Maximum
Individual $4,000 $4,500 $4,000
Family $8,000 $9,000 $8,000
Physician Ofice Visits
Primary Care $25 copay $30 copay 100% after deductible
Specialist $50 copay $50 copay 100% after deductible
Preventive Covered at 100% Covered at 100% Covered at 100%
Urgent Care $25 copay $30 copay 100% after deductible
Hospital Services
Inpatient 80% after deductible 80% after deductible 100% after deductible
Outpatient 80% after deductible 80% after deductible 100% after deductible
Emergency Room 80% after deductible 80% after deductible 100% after deductible
Prescription Drugs**
Retail—Supply Limit 30 days 30 days
Tier 1—Typically Generic $10 copay $10 copay $10 copay after deductible
Tier 2—Typically Preferred/Brand $30 copay $30 copay $30 copay after deductible
Tier 3—Typically Non-Preferred/Specialty $50 copay $50 copay $50 copay after deductible
Tier 4—Typically Specialty (brand and 80% coinsurance up to 80% coinsurance up to 80% coinsurance up to $200
generic) $200 $200 after deductible
Mail Order—Supply Limit 90 days 90 days
Tier 1—Typically Generic $25 copay $25 copay $25 copay after deductible
Tier 2—Typically Preferred/Brand $75 copay $75 copay $75 copay after deductible
Tier 3—Typically Non-Preferred/Specialty $125 copay $125 copay $125 copay after deductible
Tier 4—Typically Specialty (brand and 80% coinsurance up to 80% coinsurance up to 80% coinsurance up to $200
generic) $200 $200 after deductible
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In the event there
is a discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your SPD will prevail.
Your Monthly Cost In all three plans, you will have
KeyCare 25 Plan Key Care 30 Plan Lumenos HSA access to both in and out-of-network
Plan* beneits. However, you will receive
Employee Only $69.00 $0.00 $0.00 the deepest discounts when choosing
Employee and Spouse $994.64 $840.06 $492.55 in-network providers. Your in-network
Employee and Child $342.21 $247.95 $36.03 beneits in each plan are shown in the
Employee and Children $840.12 $699.83 $384.43 table above. For details on out-of-
Family $1,625.42 $1,412.53 $933.93 network coverage, please reference
your Summary Plan Description (SPD)
* If you elect the HSA plan, you will be given a monthly credit of $142.79 for employee from Anthem.
only coverage. If you are covering yourself and at least one dependent, you will be given
a monthly credit of $155.14. The monthly credit of $142.79 for electing employee only
coverage will be deposited into your HSA. The monthly credit of $155.14 for electing
coverage for yourself and your dependents will be credited to you.
** Generic drugs are mandatory when available. If you choose to take a brand name drug when
a generic is available, you will be charged the difference in cost between the two.
TechLab 5
Lumenos HSA
Key Care 25 Key Care 30 High Deductible Health Plan
Traditional PPO Plan Traditional PPO Plan (HDHP)
Calendar Year Deductible
Individual $500 $1,000 $3,000
Family $1,000 $2,000 $6,000
Out-of-Pocket Maximum
Individual $4,000 $4,500 $4,000
Family $8,000 $9,000 $8,000
Physician Ofice Visits
Primary Care $25 copay $30 copay 100% after deductible
Specialist $50 copay $50 copay 100% after deductible
Preventive Covered at 100% Covered at 100% Covered at 100%
Urgent Care $25 copay $30 copay 100% after deductible
Hospital Services
Inpatient 80% after deductible 80% after deductible 100% after deductible
Outpatient 80% after deductible 80% after deductible 100% after deductible
Emergency Room 80% after deductible 80% after deductible 100% after deductible
Prescription Drugs**
Retail—Supply Limit 30 days 30 days
Tier 1—Typically Generic $10 copay $10 copay $10 copay after deductible
Tier 2—Typically Preferred/Brand $30 copay $30 copay $30 copay after deductible
Tier 3—Typically Non-Preferred/Specialty $50 copay $50 copay $50 copay after deductible
Tier 4—Typically Specialty (brand and 80% coinsurance up to 80% coinsurance up to 80% coinsurance up to $200
generic) $200 $200 after deductible
Mail Order—Supply Limit 90 days 90 days
Tier 1—Typically Generic $25 copay $25 copay $25 copay after deductible
Tier 2—Typically Preferred/Brand $75 copay $75 copay $75 copay after deductible
Tier 3—Typically Non-Preferred/Specialty $125 copay $125 copay $125 copay after deductible
Tier 4—Typically Specialty (brand and 80% coinsurance up to 80% coinsurance up to 80% coinsurance up to $200
generic) $200 $200 after deductible
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In the event there
is a discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your SPD will prevail.
Your Monthly Cost In all three plans, you will have
KeyCare 25 Plan Key Care 30 Plan Lumenos HSA access to both in and out-of-network
Plan* beneits. However, you will receive
Employee Only $69.00 $0.00 $0.00 the deepest discounts when choosing
Employee and Spouse $994.64 $840.06 $492.55 in-network providers. Your in-network
Employee and Child $342.21 $247.95 $36.03 beneits in each plan are shown in the
Employee and Children $840.12 $699.83 $384.43 table above. For details on out-of-
Family $1,625.42 $1,412.53 $933.93 network coverage, please reference
your Summary Plan Description (SPD)
* If you elect the HSA plan, you will be given a monthly credit of $142.79 for employee from Anthem.
only coverage. If you are covering yourself and at least one dependent, you will be given
a monthly credit of $155.14. The monthly credit of $142.79 for electing employee only
coverage will be deposited into your HSA. The monthly credit of $155.14 for electing
coverage for yourself and your dependents will be credited to you.
** Generic drugs are mandatory when available. If you choose to take a brand name drug when
a generic is available, you will be charged the difference in cost between the two.
TechLab 5
