Page 6 - Guide

6

Medical Rates and Beneits

Medical Benefits Summary

PPO HDHP with HSA
PPO Out-of-Network PPO Out-of-Network
Calendar Year Deductible
Individual $3,000 $6,000 $2,000 $2,000
Family $9,000 $18,000 $4,000 $4,000
Out-of-Pocket Maximum
Individual $6,000 $12,000 $2,000 $4,000
Family $12,700 $25,400 $4,000 $8,000
Coinsurance 70% after 50% after 100% after 70% after
deductible deductible deductible deductible
Physician Ofice Visits
Primary $30 copay 50% after 100% after 70% after
Care deductible deductible deductible
Specialist $60 copay 50% after 100% after 70% after
deductible deductible deductible
Prescription Drugs
Retail—Supply Limit (30 Days)
Tier 1 $15 copay 100% after 70% after
deductible deductible
Tier 2 $40 copay 100% after 70% after
deductible deductible
Tier 3 $60 copay N/A 100% after 70% after
deductible deductible
Tier 4 30% copay 100% after 70% after
($250 deductible deductible
maximum)

NOTE: The mail order copays are now 2.5 times the amount of the

retail copays.

Bi-Weekly Premium Rates

PPO Plan HDHP with HSA
Employee only $12.50 $50.00
Employee and spouse $72.50 $135.44
Employee and child(ren) $59.50 $114.42
Family $132.00 $186.31

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