Page 4 - The Polyclinic New Hire Guide

Medical Benefits Overview

Medical Benefits Overview

The Polyclinic offers an IRS-qualiied High Deductible Health Plan (HDHP) offers
an IRS-qualiied High Deductible Health Plan (HDHP) from First Choice Health
with a Health Savings Account (HSA) from Optum Health Financial. The plan
covers preventive care services and screenings at 100 percent with no cost-sharing
for adults and children.

Key Features of a HDHP
X You pay lower premiums but higher annual deductibles

X Employees who enroll in a High Deductible Health Plan are eligible to open the
Health Savings Account (HSA) offered at The Polyclinic

X A three-tiered prescription drug beneit through ClearScript is available after
you have met the annual deductible

In-Network Out-of-Network
Calendar Year Deductible
Individual $2,500 $5,000
Family $5,000 $10,000
Out-of-Pocket Maximum (OOP)
The deductible, coinsurance and copays apply to the OOP maximum; once the entire individual
or family maximum is met (depending on which tier you elect), the plan will pay 100%; beneit
maximums still apply
Individual $5,000 $10,000
Family $10,000 $20,000
Common Services
Preventive care 100% (deductible waived) Not covered
100% (deductible waived)
Eye exam limit one exam per calendar Not covered
year
Physician ofice visits 80% after deductible 60% after deductible
Inpatient services 80% after deductible 60% after deductible
Outpatient services 80% after deductible 60% after deductible
Emergency room 80% after deductible 80% after deductible
Urgent care 80% after deductible 80% after deductible

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2015 New Employee Benefit Guide