Page 6 - 2015 Reznor Union Enrollment Guide

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Enrollment

Let’s take a look at the key features of each plan.

PPO Plan
In-Network Out-of-Network
Calendar Year Deductible
Individual $500 $1,000
Family $1,000 $2,000
Out-of-Pocket Maximum
Individual $1,500 $4,000
Family $3,000 $8,000
Physician Ofice Visits
Primary Care 80% after deductible
Specialist 80% after deductible
Preventive Care
Coverage level 100% covered 80% after deductible
Hospital Services
Inpatient 80% after deductible
Outpatient 80% after deductible
Emergency Room 80% after deductible
Urgent Care 80% after deductible
Lab Services/X-Ray
Physician Ofice 80% after deductible
Outpatient 80% after deductible
Prescription Drugs
Retail Supply Limit 30 days
Tier 1 $15 copay $15 copay *
Tier 2 $30 copay $30 copay *
Tier 3 $60 copay $60 copay *
Retail Supply Limit 90 days
Tier 1 $20 copay Not covered
Tier 2 $60 copay Not covered
Tier 3 $120 copay Not covered
Out-of-Pocket Maximum
Individual $5,100 N/A
Family $10,200 N/A

* Reimbursement rate less applicable copay
Please refer to your Summary Plan Description (SPD) for complete details of plan beneits,
limitations, and exclusions. In the event of a conlict between the SPD and this description,
the terms of the SPD will prevail.

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