Page 7 - 2015 Enrollment Guide
P. 7
American Air Filter
Making a Choice
To determine the best plan for you, we have provided a side-by-side comparison of your choices in the following
chart.
Summary of Medical Plan Beneits
Beneits National PPO Consumer PPO Lumenos HDHP
In-network In-network In-network
Deductible $750 Single $1,500 Single $2,000 Single
$1,500 Family $3,000 Family $4,000 Family
Coinsurance 20% 20% 10%
Out-of-Pocket Limit Medical Medical Medical/Rx
$3,250 Single $5,100 Single $6,000 Single
$9,000 Family $10,200 Family $12,000 Family
(Includes deductible, coinsurance, and (Includes deductible, coinsurance, and (Includes deductible and
copayments) copayments) coinsurance)
Preventive Beneits Plan pays 100% Plan pays 100% Plan pays 100%
Ofice Visits $25 copay $35 copayment 10% after deductible
(non-preventive) ($35 copay for specialist) ($45 copay for specialist)
Emergency Room $200 copay, 20% coinsurance after $200 copay, then 20% coinsurance after 10% after deductible
deductible deductible
Chiropractic Care $35 copay $45 copay 10% after deductible
(maximum 20 visits per calendar year)
Outpatient Surgery $50 copayment, 20% coinsurance after $100 copayment, 20% coinsurance after 10% after deductible
deductible deductible
Inpatient Services $250 copayment, 20% coinsurance after $350 copayment, 20% coinsurance after 10% after deductible
deductible deductible
Ambulance 20% after deductible 20% after deductible 10% after deductible
Mental Health/ Inpatient: $250 copay, 20% coinsurance Inpatient: $350 copay, 20% coinsurance 10% after deductible
Chemical Dependency after deductible after deductible
Outpatient: $25 copay Outpatient: $35 copay
($35 copay for specialist) ($45 copay for specialist)
Prescription Drugs— $10 Generic $15 Generic 10% after deductible
Retail $35 Brand Formulary $40 Brand Formulary
$55 Brand Non-Formulary $60 Brand Non Formulary
Prescription Drugs— $20 Generic $30 Generic 10% after deductible
Mail Order $70 Brand Formulary $80 Brand Formulary
$110 Brand Non-Formulary $120 Brand Non-Formulary
Pharmacy Out-of-Pocket Limit
$1,500 Single $1,500 Single Combined with medical out-of-
$3,000 Family $3,000 Family pocket limit
This is only a guide of plan beneits. The Summary Plan Description includes complete details of what is and is not covered and out-of-network
beneits. Amounts shown are your out-of-pocket cost unless otherwise noted that the plan pays.
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Making a Choice
To determine the best plan for you, we have provided a side-by-side comparison of your choices in the following
chart.
Summary of Medical Plan Beneits
Beneits National PPO Consumer PPO Lumenos HDHP
In-network In-network In-network
Deductible $750 Single $1,500 Single $2,000 Single
$1,500 Family $3,000 Family $4,000 Family
Coinsurance 20% 20% 10%
Out-of-Pocket Limit Medical Medical Medical/Rx
$3,250 Single $5,100 Single $6,000 Single
$9,000 Family $10,200 Family $12,000 Family
(Includes deductible, coinsurance, and (Includes deductible, coinsurance, and (Includes deductible and
copayments) copayments) coinsurance)
Preventive Beneits Plan pays 100% Plan pays 100% Plan pays 100%
Ofice Visits $25 copay $35 copayment 10% after deductible
(non-preventive) ($35 copay for specialist) ($45 copay for specialist)
Emergency Room $200 copay, 20% coinsurance after $200 copay, then 20% coinsurance after 10% after deductible
deductible deductible
Chiropractic Care $35 copay $45 copay 10% after deductible
(maximum 20 visits per calendar year)
Outpatient Surgery $50 copayment, 20% coinsurance after $100 copayment, 20% coinsurance after 10% after deductible
deductible deductible
Inpatient Services $250 copayment, 20% coinsurance after $350 copayment, 20% coinsurance after 10% after deductible
deductible deductible
Ambulance 20% after deductible 20% after deductible 10% after deductible
Mental Health/ Inpatient: $250 copay, 20% coinsurance Inpatient: $350 copay, 20% coinsurance 10% after deductible
Chemical Dependency after deductible after deductible
Outpatient: $25 copay Outpatient: $35 copay
($35 copay for specialist) ($45 copay for specialist)
Prescription Drugs— $10 Generic $15 Generic 10% after deductible
Retail $35 Brand Formulary $40 Brand Formulary
$55 Brand Non-Formulary $60 Brand Non Formulary
Prescription Drugs— $20 Generic $30 Generic 10% after deductible
Mail Order $70 Brand Formulary $80 Brand Formulary
$110 Brand Non-Formulary $120 Brand Non-Formulary
Pharmacy Out-of-Pocket Limit
$1,500 Single $1,500 Single Combined with medical out-of-
$3,000 Family $3,000 Family pocket limit
This is only a guide of plan beneits. The Summary Plan Description includes complete details of what is and is not covered and out-of-network
beneits. Amounts shown are your out-of-pocket cost unless otherwise noted that the plan pays.
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