Page 7 - Fontbonne 2020 Benefits

2020
Fontbonne University Enrollment Guide

Wellness Program

Fontbonne offers the opportunity to receive a discount on your monthly
medical by participating in the Wellness Program. In order to be eligible
for the Program, you must complete a biometric screening and health risk
assessment each year.

Medical Contributions—Monthly
Premium Plan HSA Plan
Non-
Non-
Wellness Wellness Wellness Wellness
Employee Only $170 $200 $52 $88
Employee + Spouse $910 $949 $492 $538
Employee + Child(ren) $814 $843 $450 $481
Family $1,037 $1,073 $580 $629

Medical Benefits

Premium Plan HSA Plan
UHC Choice Plus
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $750 $1,500 $1,500 $3,000
Family $1,500* $3,000 $3,000 $6,000
Preventive Care
Covered Service 100% covered 50% after deductible 100% covered 30% after deductible
Out-of-Pocket Maximum
Individual $3,500 $7,000 $3,500 $7,000
Family $7,000* $14,000 $7,000* $14,000
Physician Oice Visits
Primary/Specialist Visit $25 copay 50% after deductible 10% after deductible 30% after deductible
Teledoc $10 copay Not covered 10% after deductible Not covered
Hospital Services
Urgent Care $50 copay 50% after deductible 10% after deductible 30% after deductible
Emergency Room $200 copay $200 copay 10% after deductible 10% after deductible
Inpatient Services 20% after deductible 50% after deductible 10% after deductible 30% after deductible
Outpatient Services 20% after deductible 50% after deductible 10% after deductible 30% after deductible

* Embedded structure (see page 7 for more information on embedded versus non-embedded plan designs)
Please refer to the Summary Plan Description for detailed information on covered beneits

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