Page 8 - Dentsu 2021 Benefit Guide
P. 8
Medical Plan Highlights
Enhanced PPO Standard PPO Classic HDHP Value HDHP
Out-of-
Out-of-
Out-of-
Out-of-
Plan Feature* In-Network Network In-Network Network In-Network Network In-Network Network
Contributions Per Semi Monthly Pay Period
Employee $110.00 $72.00 $43.50 $31.00
Employee + $253.50 $184.00 $125.50 $96.00
Spouse/DP
Employee + $214.50 $140.50 $95.50 $73.00
Child(ren)
Family $394.50 $284.50 $192.50 $138.00
Deductible
Individual $500 $2,000 $1,000 $2,000 $2,000 $4,000 $4,000 $8,000
Family $1,000 $4,000 $2,000 $4,000 $4,000 $8,000 $8,000 $16,000
Company HSA Contribution
Individual/Family N/A N/A $500/$1,000 $750/$1,500
Out of Pocket Maximum
Individual $4,500 $9,000 $4,500 $9,000 $4,500 $9,000 $6,900 $12,000
Family $9,000 $18,000 $9,000 $18,000 $7,000 $18,000 $13,800 $24,000
Plan Feature
Plan Coinsurance 90% 70% 80% 60% 80% 60% 80% 60%
Preventive 100% Ded & Coin 100% Ded & Coin 100% Ded & Coin 100% Ded & Coin
Not
Not
Not
Not
Virtual Visits $0 Covered $0 Covered $0 after Ded Covered $0 after Ded Covered
Primary Care $30 Ded & Coin $30 Ded & Coin Ded & Coin Ded & Coin Ded & Coin Ded & Coin
Specialist $50 Ded & Coin $50 Ded & Coin Ded & Coin Ded & Coin Ded & Coin Ded & Coin
Inpatient Ded & Coin Ded & Coin Ded & Coin Ded & Coin Ded & Coin Ded & Coin Ded & Coin Ded & Coin
Outpatient Ded & Coin Ded & Coin Ded & Coin Ded & Coin Ded & Coin Ded & Coin Ded & Coin Ded & Coin
Emergency Room $250 $250 Ded & Coin Ded & Coin
Copay
8 2021 Benefits Enrollment
Enhanced PPO Standard PPO Classic HDHP Value HDHP
Out-of-
Out-of-
Out-of-
Out-of-
Plan Feature* In-Network Network In-Network Network In-Network Network In-Network Network
Contributions Per Semi Monthly Pay Period
Employee $110.00 $72.00 $43.50 $31.00
Employee + $253.50 $184.00 $125.50 $96.00
Spouse/DP
Employee + $214.50 $140.50 $95.50 $73.00
Child(ren)
Family $394.50 $284.50 $192.50 $138.00
Deductible
Individual $500 $2,000 $1,000 $2,000 $2,000 $4,000 $4,000 $8,000
Family $1,000 $4,000 $2,000 $4,000 $4,000 $8,000 $8,000 $16,000
Company HSA Contribution
Individual/Family N/A N/A $500/$1,000 $750/$1,500
Out of Pocket Maximum
Individual $4,500 $9,000 $4,500 $9,000 $4,500 $9,000 $6,900 $12,000
Family $9,000 $18,000 $9,000 $18,000 $7,000 $18,000 $13,800 $24,000
Plan Feature
Plan Coinsurance 90% 70% 80% 60% 80% 60% 80% 60%
Preventive 100% Ded & Coin 100% Ded & Coin 100% Ded & Coin 100% Ded & Coin
Not
Not
Not
Not
Virtual Visits $0 Covered $0 Covered $0 after Ded Covered $0 after Ded Covered
Primary Care $30 Ded & Coin $30 Ded & Coin Ded & Coin Ded & Coin Ded & Coin Ded & Coin
Specialist $50 Ded & Coin $50 Ded & Coin Ded & Coin Ded & Coin Ded & Coin Ded & Coin
Inpatient Ded & Coin Ded & Coin Ded & Coin Ded & Coin Ded & Coin Ded & Coin Ded & Coin Ded & Coin
Outpatient Ded & Coin Ded & Coin Ded & Coin Ded & Coin Ded & Coin Ded & Coin Ded & Coin Ded & Coin
Emergency Room $250 $250 Ded & Coin Ded & Coin
Copay
8 2021 Benefits Enrollment
