Page 7 - 2015 First Busey Enrollment Guide

First Busey Corporation

Medical

Choosing the right health plan is probably one of the most important decisions you can make for yourself and
your family members. Please carefully consider the plan information provided in this document.

Busey offers three plans: A traditional POS 1000 plan, a POS 2600 CDHP, and a POS 5000 CDHP. Only associates
hired in February or March 2015, or associates who currently are enrolled in the POS 1000 plan are eligible for the POS 1000
plan, effective April 1, 2015.

POS 1000 POS 2600 CDHP POS 5000 CDHP
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $1,500 $5,000 $2,600 $10,000 $5,000 $10,000
Family $3,000 $10,000 $5,200 $20,000 $10,000 $20,000
Out-of-Pocket Maximum
Individual $5,000 $10,000 $5,000 $15,000 $5,000 $15,000
Family $10,000 $20,000 $10,000 $30,000 $10,000 $30,000
Physician Ofice Visits
Primary Care $25 copay 50% coinsurance 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Specialist $50 copay 50% coinsurance 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Wellness/Preventive
$0 50% coinsurance $0 50% coinsurance $0 50% coinsurance
Urgent Care
$50 copay 50% coinsurance 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Lab Services/X-Ray
Physician Ofice 30% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Outpatient 30% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Facility
Outpatient 30% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Hospital
Hospital Services
Inpatient 30% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
after $1,000
copay
Outpatient 30% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
after $1,000
copay
Emergency Room $200 copay $200 copay 20% coinsurance 20% coinsurance 0% coinsurance 0% coinsurance
Mental Health/Substance Abuse
Inpatient 30% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
after $1,000
copay
Outpatient $25 copay 50% coinsurance 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Ofice Visits $25 copay 50% coinsurance 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Chiropractic Care
50% after 50% coinsurance 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
deductible

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