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Plan Details 2016–17 Beneits Enrollment
In-Network Out-of-Network
Calendar Year Deductible Embedded*
Individual $1,500 $4,500
Family $3,000 $9,000
Out-of-Pocket Maximum Embedded*
(includes deductibles)
Individual $5,000 $10,000
Family $10,000 $20,000
Physician Office Visits
Primary Care** $30 copay; 20% after deductible 50% after deductible
Virtual Visits $20 copay; 20% after deductible 50% after deductible
Specialist** $60 copay; 20% after deductible 50% after deductible
Preventive $0; deductible does not apply 50% after deductible
Urgent Care** $75 copay; 20% after deductible 50% after deductible
Hospital Services
Inpatient 20% after deductible 50% after deductible
Outpatient 20% after deductible 50% after deductible
Emergency Room 20% after deductible 20% after deductible
Chiropractic Care 50% no deductible 50% no deductible
Prescription Drugs
Retail—Supply Limit 31 days
Tier 1 $10 copay
Tier 2 $35 copay
Tier 3 $70 copay
Mail Order—Supply Limit 90 days
Tier 1 $25 copay Not covered
Tier 2 $87.50 copay Not covered
Tier 3 $175 copay Not covered
This is a high level summary of your beneit coverage. Full coverage details are
available in your summary plan description (SPD). In the event there is a discrepancy
between what is relected in this guide and what is communicated in your SPD, the
terms of your SPD will prevail.
* Family Coverage and Embedded Deductibles
Embedded deductibles mean your plan has individual deductibles for each family member and the family
deductible. When a family member meets his or her deductible, the plan will begin sharing healthcare costs
for that family member. The rest of the family still has to satisfy their individual deductible. However, all
individual expenses for each family member count toward the family deductible. Once the family deductible
is met (by more than one family member) the plan will share costs for all family members for the rest of the
plan year.
** Copays only apply for the irst 4 ofice visits per calendar year; primary care physician and specialist
visits are combined. After 4 visits, the copay doesn’t apply and members are responsible for meeting the
applicable deductible and 20% coinsurance.
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In-Network Out-of-Network
Calendar Year Deductible Embedded*
Individual $1,500 $4,500
Family $3,000 $9,000
Out-of-Pocket Maximum Embedded*
(includes deductibles)
Individual $5,000 $10,000
Family $10,000 $20,000
Physician Office Visits
Primary Care** $30 copay; 20% after deductible 50% after deductible
Virtual Visits $20 copay; 20% after deductible 50% after deductible
Specialist** $60 copay; 20% after deductible 50% after deductible
Preventive $0; deductible does not apply 50% after deductible
Urgent Care** $75 copay; 20% after deductible 50% after deductible
Hospital Services
Inpatient 20% after deductible 50% after deductible
Outpatient 20% after deductible 50% after deductible
Emergency Room 20% after deductible 20% after deductible
Chiropractic Care 50% no deductible 50% no deductible
Prescription Drugs
Retail—Supply Limit 31 days
Tier 1 $10 copay
Tier 2 $35 copay
Tier 3 $70 copay
Mail Order—Supply Limit 90 days
Tier 1 $25 copay Not covered
Tier 2 $87.50 copay Not covered
Tier 3 $175 copay Not covered
This is a high level summary of your beneit coverage. Full coverage details are
available in your summary plan description (SPD). In the event there is a discrepancy
between what is relected in this guide and what is communicated in your SPD, the
terms of your SPD will prevail.
* Family Coverage and Embedded Deductibles
Embedded deductibles mean your plan has individual deductibles for each family member and the family
deductible. When a family member meets his or her deductible, the plan will begin sharing healthcare costs
for that family member. The rest of the family still has to satisfy their individual deductible. However, all
individual expenses for each family member count toward the family deductible. Once the family deductible
is met (by more than one family member) the plan will share costs for all family members for the rest of the
plan year.
** Copays only apply for the irst 4 ofice visits per calendar year; primary care physician and specialist
visits are combined. After 4 visits, the copay doesn’t apply and members are responsible for meeting the
applicable deductible and 20% coinsurance.
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