Page 5 - Guide

Medical Benefits 2016–2017 Beneits Enrollment

PPO Out-of-Network
Employee Eligibility
Class 1 All other full-time employees working a minimum of 30 hours per week
Class 2 All full-time managers and supervisors working a minimum of 30 hours per week
Eligibility Waiting Period
Class 1 First of month following 60 days
Class 2 First of month following date of hire
Calendar Year Deductible
Individual $2,000
Family $4,000
Out-of-Pocket Maximum
Individual $3,500 $5,000
Family $7,000 $10,000
Physician Office Visits
Primary Care $30 copay 40% after deductible
Specialist $30 copay 40% after deductible
Urgent Care $30 copay 40% after deductible
Wellness/Preventive 100% 40% after deductible
Lab Services
Physician Office 20% after deductible 40% after deductible
Outpatient Facility 20% after deductible 40% after deductible
Outpatient Hospital 20% after deductible 40% after deductible
X-Ray/Radiology Services
Physician Office 20% after deductible 40% after deductible
Outpatient Facility 20% after deductible 40% after deductible
Outpatient Hospital 20% after deductible 40% after deductible
Hospital Services
Inpatient 20% after deductible 40% after deductible
Outpatient 20% after deductible 40% after deductible
Emergency Room $100 copay then 20% after deductible $100 copay then 40% after deductible
Mental Health
Inpatient Facility 20% after deductible 40% after deductible
Outpatient Facility 20% after deductible 40% after deductible
Office Visits $30 copay 40% after deductible
Substance Abuse
Inpatient Facility 20% after deductible 40% after deductible
Outpatient Facility 20% after deductible 40% after deductible
Office Visits $30 copay 40% after deductible
Chiropractic Care
20% after deductible 50% after deductible
Limitations 18 visits combined per insured per benefit period
Prescription Rx Out-of-Pocket Maximum: $3,000 Single/$6,000 Family
Retail—Supply Limit 30 days
Generic $15 copay $15 copay
Preferred Brand $30 copay $30 copay
Non-Preferred and Specialty $45 copay $45 copay
Mail Order—Supply Limit 90 days 90 days
Generic $15 copay $15 copay
Preferred Brand $30 copay $30 copay
Non-Preferred and Specialty $45 copay $45 copay

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