Page 8 - WJ Bradley 2015 Annual Enrollment
P. 8
Beneits Guide
2015 Health Plan Summary—Continued
$1,500 Deductible Plan
$500 Deductible Plan In-network preventive care is covered In-network preventive care is covered at
$2,500 Deductible Plan
In-network preventive care is
Preventive Care covered at 100% for both children at 100% for both children and adult 100% for both children and adult services
and adult services with no
services with no deductible.
with no deductible.
deductible.
X Go to any doctor or hospital; X Go to any doctor or hospital; X Go to any doctor or hospital; however,
however, receive higher beneits however, receive higher beneits receive higher beneits if you use an
if you use an in-network
in-network provider. No referrals
if you use an in-network provider.
Network provider. No referrals needed to No referrals needed to see a X 70%/30% coinsurance in-network vs.
needed to see a specialist.
see a specialist.
specialist.
X
80%/20% coinsurance in-
network vs. 50%/50% out-of-
network vs. 50%/50% out-of- X 80%/20% coinsurance in- 50%/50% out-of-network.
network. network.
Ofice Visit No deductible applies for in-network No deductible applies for in-network No deductible applies for in-network
ofice visits. These require a $20
ofice visits. These require a $35 copay ofice visits. These require a $40 copay for
for primary care physicians and a $50 primary care physicians and a $60 copay
copay for primary care physicians
and a $40 copay for specialists. copay for specialists. for specialists.
Retail prescription for In and Out- Retail prescription for In and Out-of- Retail prescriptions for in- and out-of-
of-Network are covered as follows: Network are covered as follows: network are covered as follows:
X Tier 1 $10 copay X Tier 1 $15 copay X Tier 1 30% coinsurance
X Tier 2 $25 copay X Tier 2 $45 copay ($20 min/$60 max)
X Tier 3 $50 copay X Tier 3 $60 copay X Tier 2 40% coinsurance
($45 min/$135 max)
Prescription Drugs covered as follows: covered as follows: X Tier 3 50% coinsurance
Mail Order prescription drugs are
Mail Order prescription drugs are
($80 min/$240 max)
X
Tier 1 $37.50 copay
X
Tier 1 $25 copay
Mail order prescriptions drugs are covered
X
X
Tier 2 $112.50 copay
Tier 2 $62.50 copay
as follows:
X
X
Tier 3 $150 copay
Tier 3 $125 copay
X
Tier 1 30% coinsurance
($50 min/$150 max)
X Tier 2 40% coinsurance
($112.50 min/$337.50 max)
X Tier 3 50% coinsurance
($200 min/$600 max)
Other service/care requires a Other service/care requires a Other service/care requires a deductible
Deductible deductible per family member or per deductible per family member or per per family member or per family. You pay
family. You pay the deductible, then family. You pay the deductible, then
the deductible, then the plan pays most
the plan pays most expenses while
the plan pays most expenses while
expenses while you pay a coinsurance
percentage. The family deductibles for in-
you pay a coinsurance percentage.
you pay a coinsurance percentage.
The family deductibles for in-
and out-of-network are $4,500 and
network and out-of-network are The family deductibles for in-network network and out-of-network are $7,500 and
$22,500 respectively.
$1,500 and $4,500 respectively. $13,500 respectively.
You are protected from large You are protected from large expenses You are protected from large expenses by
by an out-of-pocket maximum. Once an out-of-pocket maximum. Once your
expenses by an out-of-pocket
Out-of-Pocket Maximum maximum. Once your covered your covered expenses reach this limit, covered expenses reach this limit, the plan
expenses reach this limit, the plan
the plan pays the rest of your covered pays the rest of your covered expenses.
expenses. The in-network out-of-
pays the rest of your covered
The in-network out-of-pocket maximums
pocket maximums (which include
expenses. The in-network out-of-
(which include the deductible) are $6,350
pocket maximums (which include
individual and $12,000 for family.
the deductible) are $1,500 for an the deductible) are $4,000 for an for an individual and $12,700 for family.
individual and $4,500 for family.
8
2015 Health Plan Summary—Continued
$1,500 Deductible Plan
$500 Deductible Plan In-network preventive care is covered In-network preventive care is covered at
$2,500 Deductible Plan
In-network preventive care is
Preventive Care covered at 100% for both children at 100% for both children and adult 100% for both children and adult services
and adult services with no
services with no deductible.
with no deductible.
deductible.
X Go to any doctor or hospital; X Go to any doctor or hospital; X Go to any doctor or hospital; however,
however, receive higher beneits however, receive higher beneits receive higher beneits if you use an
if you use an in-network
in-network provider. No referrals
if you use an in-network provider.
Network provider. No referrals needed to No referrals needed to see a X 70%/30% coinsurance in-network vs.
needed to see a specialist.
see a specialist.
specialist.
X
80%/20% coinsurance in-
network vs. 50%/50% out-of-
network vs. 50%/50% out-of- X 80%/20% coinsurance in- 50%/50% out-of-network.
network. network.
Ofice Visit No deductible applies for in-network No deductible applies for in-network No deductible applies for in-network
ofice visits. These require a $20
ofice visits. These require a $35 copay ofice visits. These require a $40 copay for
for primary care physicians and a $50 primary care physicians and a $60 copay
copay for primary care physicians
and a $40 copay for specialists. copay for specialists. for specialists.
Retail prescription for In and Out- Retail prescription for In and Out-of- Retail prescriptions for in- and out-of-
of-Network are covered as follows: Network are covered as follows: network are covered as follows:
X Tier 1 $10 copay X Tier 1 $15 copay X Tier 1 30% coinsurance
X Tier 2 $25 copay X Tier 2 $45 copay ($20 min/$60 max)
X Tier 3 $50 copay X Tier 3 $60 copay X Tier 2 40% coinsurance
($45 min/$135 max)
Prescription Drugs covered as follows: covered as follows: X Tier 3 50% coinsurance
Mail Order prescription drugs are
Mail Order prescription drugs are
($80 min/$240 max)
X
Tier 1 $37.50 copay
X
Tier 1 $25 copay
Mail order prescriptions drugs are covered
X
X
Tier 2 $112.50 copay
Tier 2 $62.50 copay
as follows:
X
X
Tier 3 $150 copay
Tier 3 $125 copay
X
Tier 1 30% coinsurance
($50 min/$150 max)
X Tier 2 40% coinsurance
($112.50 min/$337.50 max)
X Tier 3 50% coinsurance
($200 min/$600 max)
Other service/care requires a Other service/care requires a Other service/care requires a deductible
Deductible deductible per family member or per deductible per family member or per per family member or per family. You pay
family. You pay the deductible, then family. You pay the deductible, then
the deductible, then the plan pays most
the plan pays most expenses while
the plan pays most expenses while
expenses while you pay a coinsurance
percentage. The family deductibles for in-
you pay a coinsurance percentage.
you pay a coinsurance percentage.
The family deductibles for in-
and out-of-network are $4,500 and
network and out-of-network are The family deductibles for in-network network and out-of-network are $7,500 and
$22,500 respectively.
$1,500 and $4,500 respectively. $13,500 respectively.
You are protected from large You are protected from large expenses You are protected from large expenses by
by an out-of-pocket maximum. Once an out-of-pocket maximum. Once your
expenses by an out-of-pocket
Out-of-Pocket Maximum maximum. Once your covered your covered expenses reach this limit, covered expenses reach this limit, the plan
expenses reach this limit, the plan
the plan pays the rest of your covered pays the rest of your covered expenses.
expenses. The in-network out-of-
pays the rest of your covered
The in-network out-of-pocket maximums
pocket maximums (which include
expenses. The in-network out-of-
(which include the deductible) are $6,350
pocket maximums (which include
individual and $12,000 for family.
the deductible) are $1,500 for an the deductible) are $4,000 for an for an individual and $12,700 for family.
individual and $4,500 for family.
8
