Page 14 - Open Enrollment Guide Sample

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2015 Medical/Rx Benefit Summary

PPO HSA
In-Network Out-of-Network In-Network Out-of-Network
Deductible (1)
Individual $500 $1,350 $1,300 $2,600
Family $1,000 $2,700 $2,600 $5,200
Out-of-Pocket Maximum (1)
Individual $2,000 None $2,550 $5,100
Family $4,000 None $5,100 $10,200
Physician Ofice Visits
Primary Care Physician $20 copay 50% after deductible 80% after deductible 60% after deductible
Specialist $40 copay 50% after deductible 80% after deductible 60% after deductible
Wellness Care
Pap smears, routine physicals, Covered 100%, no 50% (no deductible), Covered 100%, no 60% after deductible
lu shots, immunizations, copay no copay copay
Mammograms, prostate exams,
women’s contraceptives, other age
appropriate testing
LiveHealth Online (Telemedicine)
$10 copay N/A 80% after deductible N/A
Hospital
Inpatient 90% after deductible 50% after deductible 80% after deductible 60% after deductible
Outpatient 90% after deductible 50% after deductible 80% after deductible 60% after deductible
Urgent Care Facility $50 copay, 90% $50 copay, 50% 80% after deductible 60% after deductible
after deductible
after deductible
Emergency Room (copay waived if $175 copay, 90% $175 copay, 50% 80% after deductible 60% after deductible
admitted) after deductible after deductible
Ambulance 80% after deductible 80% after deductible 80% after deductible 60% after deductible
Lab Fees: Stand-alone Facility, and 90% after deductible 50% after deductible 80% after deductible 60% after deductible
Outpatient at Hospital
Radiology/Pathology (MRI, PET, and 90% after deductible 50% after deductible 80% after deductible 60% after deductible
CAT scans) (pre-certiication (pre-certiication
required) required)
Retail Pharmacy (up to a 30-day supply)
Pharmacy Out-of-Pocket Maximum
Individual $1,500 N/A Not applicable
Family $3,000 N/A
Generic $10 copay 80% after deductible 60% after deductible
Preferred Brand Name $40 copay (2)
Non-Preferred Brand Name $60 copay (2)
Mail Order Pharmacy (up to a 90-day supply)
Generic $25 copay 80% after deductible Not Available
Preferred Brand Name $100 copay (2)
Non-Preferred Brand Name $150 copay (2)

(1) Separate deductibles and maximums apply to network and out-of-network PPO providers
(2) Copay applies when no generic equivalent exists; otherwise, mandatory generic drug policy applies

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