Page 6 - Enrollment Guide Example
P. 6
2016 Benefits Enrollment
Medical Benefits
You have the option of choosing between two traditional PPO plans and two HSA qualiied high deductible
health plans (HDHPs).
[Carrier] [Carrier] [Carrier] [Carrier]
[Plan 1] [Plan 2] [Plan 3] [Plan 4]
In-Network In-Network In-Network In-Network
Dependent eligibility Children covered up to age 26 regardless of marital, student, or dependency status
Lifetime maximum Unlimited
Calendar year Embedded—no one Embedded—no one Not embedded—family Embedded—no one
deductible individual must meet individual must meet ded applies if one or individual must meet
more than the individual more than the individual more dependents are more than the individual
limit limit covered limit
Individual $750 $1,500 $1,500 $3,000
Family $1,500 $3,000 $3,000 $6,000
Out-of-pocket Embedded—out-of- Embedded—out-of- Not embedded—family Embedded—out-of-
maximum pocket maximum pocket maximum out-of-pocket maximum pocket maximum
includes deductible, includes deductible, applies if one or more includes deductible and
coinsurance, and medical coinsurance, and medical dependents are covered coinsurance
copays copays Out-of-pocket maximum
includes deductible,
coinsurance, and
prescription drug copays
Individual $3,000 $4,000 $2,500 $3,000
Family $6,000 $8,000 $5,000 $6,000
Physician Ofice Visits
Primary care $20 copay* $25 copay* 90% after ded 100% after ded
Specialist $40 copay* $50 copay* 90% after ded 100% after ded
Urgent care If billed as ofice visit, If billed as ofice visit, 90% after ded t100% after ded
ofice visit copay; ofice visit copay;
otherwise 80% after ded otherwise 80% after ded
Wellness/preventive Covered at 100% Covered at 100% Covered at 100% Covered at 100%
Lab Services
Physicians ofice Covered at 100%** Covered at 100%** 90% after ded 100% after ded
Outpatient facility Covered at 100%** Covered at 100%** 90% after ded 100% after ded
Outpatient hospital Covered at 100%** Covered at 100%** 90% after ded 100% after ded
X-Ray/Radiology Services
Physicians ofice Covered at 100%** Covered at 100%** 90% after ded 100% after ded
Outpatient facility Covered at 100%** Covered at 100%** 90% after ded 100% after ded
Outpatient hospital Covered at 100%** Covered at 100%* 90% after ded 100% after ded
Hospital Services
Inpatient 80% after ded 80% after ded 90% after ded 100% after ded
Outpatient 80% after ded 80% after ded 90% after ded 100% after ded
Emergency room $150 copay $250 copay 90% after ded 100% after ded
Ambulance 80% after ded 80% after ded 90% after ded 100% after ded
* The ofice visit copay applies when the physician bills for an ofice visit. Labs and non-major diagnostics are covered at 100 percent. All other
services are subject to ded/ coinsurance. Examples of these other services include but are not limited to major diagnostics (CT, PET, MRI scans,
etc.), nuclear medicine, therapeutic scopic procedures, surgery, therapeutic treatments, allergy injections, etc.
** Exceptions: major diagnostics (CT, PET, MRI nuclear medicine, etc.) which are deductible/coinsurance
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Medical Benefits
You have the option of choosing between two traditional PPO plans and two HSA qualiied high deductible
health plans (HDHPs).
[Carrier] [Carrier] [Carrier] [Carrier]
[Plan 1] [Plan 2] [Plan 3] [Plan 4]
In-Network In-Network In-Network In-Network
Dependent eligibility Children covered up to age 26 regardless of marital, student, or dependency status
Lifetime maximum Unlimited
Calendar year Embedded—no one Embedded—no one Not embedded—family Embedded—no one
deductible individual must meet individual must meet ded applies if one or individual must meet
more than the individual more than the individual more dependents are more than the individual
limit limit covered limit
Individual $750 $1,500 $1,500 $3,000
Family $1,500 $3,000 $3,000 $6,000
Out-of-pocket Embedded—out-of- Embedded—out-of- Not embedded—family Embedded—out-of-
maximum pocket maximum pocket maximum out-of-pocket maximum pocket maximum
includes deductible, includes deductible, applies if one or more includes deductible and
coinsurance, and medical coinsurance, and medical dependents are covered coinsurance
copays copays Out-of-pocket maximum
includes deductible,
coinsurance, and
prescription drug copays
Individual $3,000 $4,000 $2,500 $3,000
Family $6,000 $8,000 $5,000 $6,000
Physician Ofice Visits
Primary care $20 copay* $25 copay* 90% after ded 100% after ded
Specialist $40 copay* $50 copay* 90% after ded 100% after ded
Urgent care If billed as ofice visit, If billed as ofice visit, 90% after ded t100% after ded
ofice visit copay; ofice visit copay;
otherwise 80% after ded otherwise 80% after ded
Wellness/preventive Covered at 100% Covered at 100% Covered at 100% Covered at 100%
Lab Services
Physicians ofice Covered at 100%** Covered at 100%** 90% after ded 100% after ded
Outpatient facility Covered at 100%** Covered at 100%** 90% after ded 100% after ded
Outpatient hospital Covered at 100%** Covered at 100%** 90% after ded 100% after ded
X-Ray/Radiology Services
Physicians ofice Covered at 100%** Covered at 100%** 90% after ded 100% after ded
Outpatient facility Covered at 100%** Covered at 100%** 90% after ded 100% after ded
Outpatient hospital Covered at 100%** Covered at 100%* 90% after ded 100% after ded
Hospital Services
Inpatient 80% after ded 80% after ded 90% after ded 100% after ded
Outpatient 80% after ded 80% after ded 90% after ded 100% after ded
Emergency room $150 copay $250 copay 90% after ded 100% after ded
Ambulance 80% after ded 80% after ded 90% after ded 100% after ded
* The ofice visit copay applies when the physician bills for an ofice visit. Labs and non-major diagnostics are covered at 100 percent. All other
services are subject to ded/ coinsurance. Examples of these other services include but are not limited to major diagnostics (CT, PET, MRI scans,
etc.), nuclear medicine, therapeutic scopic procedures, surgery, therapeutic treatments, allergy injections, etc.
** Exceptions: major diagnostics (CT, PET, MRI nuclear medicine, etc.) which are deductible/coinsurance
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