Page 13 - ABC Company 2018 Open Enrollment Guide

Medical Benefits
Employee Contributions: (Semi-Monthly)
Basic HSA Plan Summary
$13
Employee
Employee and Spouse
Employee and Children
$32
$26
Family
$64
Medical Plan Benefits
In-Network
Out-of-Network**
Health Savings Account (HSA)
Qualified Tax Advantage Plan
Referral Required
N/A
Deductible (Annual)
$2,500 Individual / $5,000 Family *
$4,500 Individual / $9,000 Family*
Coinsurance (You Pay)
30% After deductible
50% After deductible
Out-of-Pocket Maximum (Inc. Deductibles, Co-ins., and Copays)
$4,500 Individual /
$6,850 Family*
$9,000 Individual / $18,000 Family*
Preventive Care Services
Covered 100%
Primary Care Office Visit
Specialist Care Office Visit
Hospital – Inpatient
50% After deductible
Hospital – Outpatient Surgery
30% After deductible
Emergency Room
Telehealth
Virtual Office Visit
Subject to Deductible and Co-insurance
Not Covered
Prescription Drugs (Copay)
Retail (30 day supply)
Deductible then
$15 / $35 / $75
Mail Order (2.5 x retail for 90 day supply)
Deductible then
$37.50 / $87.50 / $187.50
Deductible and copay waived for approved preventive medication
N/A
Lifetime Maximum
Unlimited
Preventive Drugs (Complete list on ABC Company Intranet site)
* Family includes employee + spouse, employee + children, and employee + family coverage tiers. Each individual covered under the family plan is responsible for satisfying the family deductible and maximum out-of-pocket.
* *Eligible charges are subject to reasonable and customary limitations as deemed by the carrier based upon geographic area, the nature and complexity of the service, and the amounts paid by other professionals for similar services.
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