Page 4 - 2016 WFF Guide 3

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Medical/Prescription Drugs Plan Summary

A brief summary of the plan details are outlined below.

In-Network Out-of-Network
Plan Maximum
Per lifetime Unlimited
Deductible per Calendar Year
Per individual $1,500 $3,000
Per family $3,000 $6,000
Maximum Out-of-Pocket Exposure per Calendar Year (Includes Deductible)
Per individual $5,000 $10,000
Per family $10,000 $20.000
Plan Cost Sharing
Coinsurance 100% 60% after deductible
Covered Services
Hospital Services
Inpatient 80% Covered 60% after deductible
Outpatient 80% Covered 60% after deductible
Emergency room $250 copay $250 copay
Urgent care center $75 copay 60% after deductible
Physician Services
Ofice visit PCP: $50 copay 60% after deductible
Specialist: $75 copay
All other lab/x-ray 100% covered 60% after deductible
Other Covered Services
Preventive care * 100% covered 60% after deductible
Prescription Drug Beneit **
Retail Pharmacy Mail Order Pharmacy
Generic $7 copay $21 copay
Preferred brands $35 copay $105 copay
Non-preferred brands $70 copay $210 copay
Multi-source brands $65 copay $195 copay

This summary of beneits is intended to be a brief outline of coverage. The entire provisions of beneits and exclusions are contained in the Summary
Plan Description (SPD). In the event of a conlict between the SPD and this description, the terms of the SPD will prevail.
* As deined by the US Preventive Services Task Force
** If brand is dispensed when generic is available, the employee will be responsible for the difference in cost between brand and generic