Page 14 - ABC Company 2018 Open Enrollment Guide

Medical Benefits
Preferred HRA Plan Summary
Employee Contributions: (Semi-Monthly)
Employee
$64
THIS PLAN INCLUDES A HEALTH REIMBURSEMENT ACCOUNT (HRA)
A HRA is an account funded by your employer to help you pay for covered healthcare services. Your HRA will automatically pay for covered services first and you won’t pay as long as you have money in your HRA. When you have money in your HRA, that’s less you have to pay out of your pocket for covered services.
Your HRA fund rolls over each year! The maximum HRA
fund roll over is: $2,500 Individual / $4,500 Family*
as long as you continue to participate in the plan.
Qualified HRA expenses:
You can use an HRA for many expenses, including: Doctor office visits Non-preventive tests (lab work, X-rays, etc.)
Employee and Spouse
$139
Employee and Children
$134
Family
$186
Benefit Plan Details
In-Network
Out-of-Network**
Health Reimbursement Account (HRA)
$1,000 Individual / $2000 Family
Deductible (Annual)
$2,000 Individual / $4,000 Family*
$3,000 Individual / $6,000 Family*
Coinsurance (You Pay)
20% After deductible
40% After deductible*
Out-of-Pocket Maximum
(Inc. Deductibles, Co-ins., and Copays)
$2,500 Individual / $4,500 Family*
$6,000 Individual / $10,000 Family*
Preventive Care Services
Covered 100%
40% After deductible
Primary Care Office Visit
20% After deductible
Specialist Care Office Visit
Hospital - Inpatient
Hospital - Outpatient Surgery
Emergency Room
Telehealth
Virtual Office Visit
No Copay
Not Covered
Prescription Drugs (Copay)
Retail (30 day supply)
$10 / $25 / $50
N/A
Mail Order (2.5 x retail for 90 day supply)
$25 / $62.50 / $125
Lifetime Maximum
Unlimited
* Family includes employee + spouse, employee + children, and employee + family coverage tiers.
* *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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