Page 6 - 2019 Fontbonne

2019 Benefits 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
Cigna Open
Out-of-
Out-of-
Access Plus In-Network Network In-Network Network
Deductible
Individual $750 $1,500 $1,500 $3,000
Family $1,500 $3,000 $3,000 $6,000
Coinsurance 20% 50% 10% 30%
Out-of-Pocket Maximum
Individual $3,500 $7,000 $3,500 $7,000
Family $7,000* $14,000 $7,000* $14,000
Oice visit copay $25** 50% after 10% after 30% after
deductible deductible** deductible
Urgent care copay $50 $50 10% after 30% after
deductible deductible
ER copay $200 $200 10% after 10% after
deductible deductible
Inpatient/ 20% after 50% after 10% after 30% after
outpatient services deductible deductible deductible deductible

* Embedded structure (see page 7 for more information on embedded versus non-embedded
plan designs)
** Routine preventive services covered at 100%
Please refer to the Summary Plan Description for detailed information on covered beneits

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