Page 8 - 2015 First Busey Enrollment Guide
P. 8
Beneits
Enrollment
POS 1000 POS 2600 CDHP POS 5000 CDHP
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Prescription Drugs
Retail Supply 30 days 30 days 30 days 30 days 30 days 30 days
Limit
X Tier 1 $20 copay 50% coinsurance 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
X Tier 2 $40 copay 50% coinsurance 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
X Tier 3 $50 copay 50% coinsurance 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
X Tier 4 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Mail Order 90 days 90 Days 90 days
Supply Limit
X Tier 1 $55 copay 20% coinsurance 0% coinsurance
X Tier 2 $110 copay 20% coinsurance 0% coinsurance
X Tier 3 $137.50 copay 20% coinsurance 0% coinsurance
Benefit Compensation < $92,500
Bi-Weekly Rates POS 1000 POS 2600 CDHP POS 5000 CDHP
Associate Only $73.69 $31.24 $17.30
Associate + Spouse $254.14 $196.06 $167.45
Associate + Child(ren) $185.73 $135.42 $110.68
Family $330.95 $250.89 $211.85
Benefit Compensation ≥ $92,500
Bi-Weekly Rates POS 1000 POS 2600 CDHP POS 5000 CDHP
Associate Only $113.62 $85.02 $71.08
Associate + Spouse $320.69 $262.62 $234.00
Associate + Child(ren) $252.29 $201.97 $177.23
Family $426.03 $345.97 $306.92
Visit www.healthalliance.org.
Please note: In prior years, the CDHP family deductible was non-embedded, meaning one family member (or
a combination of family members) had to reach the full family deductible before coinsurance applied. To make
the CDHP plans more affordable for families, Busey has implemented an embedded deductible, meaning as
soon as one family member reaches the individual deductible, coinsurance will apply for that family member. The
remaining family members would need to satisfy the rest of the family deductible (since family deductibles are
two times the individual deductible) for coinsurance to apply for the entire family.
8
Enrollment
POS 1000 POS 2600 CDHP POS 5000 CDHP
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Prescription Drugs
Retail Supply 30 days 30 days 30 days 30 days 30 days 30 days
Limit
X Tier 1 $20 copay 50% coinsurance 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
X Tier 2 $40 copay 50% coinsurance 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
X Tier 3 $50 copay 50% coinsurance 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
X Tier 4 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Mail Order 90 days 90 Days 90 days
Supply Limit
X Tier 1 $55 copay 20% coinsurance 0% coinsurance
X Tier 2 $110 copay 20% coinsurance 0% coinsurance
X Tier 3 $137.50 copay 20% coinsurance 0% coinsurance
Benefit Compensation < $92,500
Bi-Weekly Rates POS 1000 POS 2600 CDHP POS 5000 CDHP
Associate Only $73.69 $31.24 $17.30
Associate + Spouse $254.14 $196.06 $167.45
Associate + Child(ren) $185.73 $135.42 $110.68
Family $330.95 $250.89 $211.85
Benefit Compensation ≥ $92,500
Bi-Weekly Rates POS 1000 POS 2600 CDHP POS 5000 CDHP
Associate Only $113.62 $85.02 $71.08
Associate + Spouse $320.69 $262.62 $234.00
Associate + Child(ren) $252.29 $201.97 $177.23
Family $426.03 $345.97 $306.92
Visit www.healthalliance.org.
Please note: In prior years, the CDHP family deductible was non-embedded, meaning one family member (or
a combination of family members) had to reach the full family deductible before coinsurance applied. To make
the CDHP plans more affordable for families, Busey has implemented an embedded deductible, meaning as
soon as one family member reaches the individual deductible, coinsurance will apply for that family member. The
remaining family members would need to satisfy the rest of the family deductible (since family deductibles are
two times the individual deductible) for coinsurance to apply for the entire family.
8
