Page 7 - WJ Bradley 2015 Annual Enrollment

W.J. Bradley

2015 Health Plan Summary

Beneit $500 $1,500 $2,500
Plans Deductible Plan Deductible Plan Deductible Plan
Network Non-Network Network Non-Network Network Non-Network
Deductible
Individual $500 $1,500 $1,500 $4,500 $2,500 $7,500
Family $1,500 $4,500 $4,500 $13,500 $7,500 $22,500
Out-of-Pocket Maximum (Includes Deductible)
Individual $1,500 $4,500 $4,000 $12,000 $6,350 $22,500
Family $4,500 $13,500 $12,000 $36,000 $12,700 $67,500
Ofice Visit Copay
Primary $20 Ded/50% $35 Ded/50% $40 Ded/50%
Care
Specialist $40 Ded/50% $50 Ded/50% $60 Ded/50%
Hospital
Inpatient $250 Copay Ded/50% $500 Copay Ded/50% $500 Copay Ded/50%
Outpatient Ded/20% Ded/50% Ded/20% Ded/50% Ded/30% Ded/50%
Emergency $150 Copay $150 Copay $250 Copay $250 Copay $300 Copay $300 Copay
Room
Prescription Drug—Pharmacy
Tier I $10 $10 $15 $15 30% coinsurance 30% coinsurance
($20 min/$60 ($20 min/$60
max) max)
Tier II $25 $25 $45 $45 40% coinsurance 40% coinsurance
($45 min/$135 ($45 min/$135
max) max)
Tier III $50 $50 $60 $60 50% coinsurance 50% coinsurance
($80 min/$240 ($80 min/$240
max) max)
Prescription Drug—Mail Order (90 day supply)
Tier I $25 Not Covered $37.50 Not Covered 30% coinsurance Not Covered
($50 min/$150
max)
Tier II $62.50 Not Covered $112.50 Not Covered 40% coinsurance Not Covered
($112.50
min/$337.50
max)
Tier III $125 Not Covered $150.00 Not Covered 50% coinsurance Not Covered
($200 min/$600
max)

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