Page 9 - 2018 Franke Enrollment
P. 9
Franke
OAP Plan Choice Fund HSA Plan
In-Network Out-of-Network In-Network Out-of-Network
Plan Maximum
Per Lifetime Unlimited Unlimited
Deductible per Calendar Year
Per Individual $1,100 $2,200 $2,500 $5,000
Per Family $2,750 $5,500 $5,000 $10,000
Maximum Out-of-Pocket Exposure per Calendar Year (Includes Deductible)
Per Individual $3,000 $10,000 $3,500 $14,000
Per Family $7,500 $25,000 $6,850 $28,000
Coinsurance 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Covered Services
Hospital Services
Inpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Emergency Room 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Urgent Care Center 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Physician Services
Ofice Visit PCP—$25 copay 60% after deductible 80% after deductible 60% after deductible
Specialist—$50 copay
Other Covered Services
Preventive Care 100% covered 60% after deductible 100% covered 60% after deductible
Telemedicine $25 copay N/A $42 applied to N/A
deductible
Prescription Drug Benefit*
OAP Plan Choice Fund HSA Plan
Retail Pharmacy Mail Order Pharmacy Retail Pharmacy Mail Order Pharmacy
Generic $8 copay $16 copay 80% after deductible
Preferred Brands $40 copay $80 copay HSA preventive generic drug list—100%
Non-Preferred Brands $70 copay $140 copay covered
Listed No Cost Preventive Medications 100% 100%
* All specialty medications must be illed through the CIGNA Specialty Pharmacy network; if you select a brand name drug when a generic
equivalent is available, the plan will only pay the cost of the generic drug; the plan will not cover medications for which there is an equivalent
over-the-counter alternative, all listed maintenance medications must be illed through home delivery or 90 Now network pharmacies.
Bi-Weekly Medical Contributions—Paid By You on a Pre-Tax Basis
Employee Premiums** With Tobacco Surcharge With Tobacco Surcharge
1 User
2 Users
OAP Plan Bi-weekly Rates
Employee Only $52.92 $76.00 $76.00
Employee + Spouse $147.09 $170.17 $193.25
Employee + Child(ren) $110.53 $133.61 $133.61
Family $191.41 $214.49 $237.56
HSA Plan Bi-weekly Rates
Employee Only $44.43 $67.51 $67.51
Employee + Spouse $112.74 $135.81 $158.89
Employee + Child(ren) $83.46 $106.54 $106.54
Family $143.96 $167.04 $190.12
** If you completed all wellness requirements, you will receive a bi-weekly incentive payment of $30.77.
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OAP Plan Choice Fund HSA Plan
In-Network Out-of-Network In-Network Out-of-Network
Plan Maximum
Per Lifetime Unlimited Unlimited
Deductible per Calendar Year
Per Individual $1,100 $2,200 $2,500 $5,000
Per Family $2,750 $5,500 $5,000 $10,000
Maximum Out-of-Pocket Exposure per Calendar Year (Includes Deductible)
Per Individual $3,000 $10,000 $3,500 $14,000
Per Family $7,500 $25,000 $6,850 $28,000
Coinsurance 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Covered Services
Hospital Services
Inpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Emergency Room 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Urgent Care Center 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Physician Services
Ofice Visit PCP—$25 copay 60% after deductible 80% after deductible 60% after deductible
Specialist—$50 copay
Other Covered Services
Preventive Care 100% covered 60% after deductible 100% covered 60% after deductible
Telemedicine $25 copay N/A $42 applied to N/A
deductible
Prescription Drug Benefit*
OAP Plan Choice Fund HSA Plan
Retail Pharmacy Mail Order Pharmacy Retail Pharmacy Mail Order Pharmacy
Generic $8 copay $16 copay 80% after deductible
Preferred Brands $40 copay $80 copay HSA preventive generic drug list—100%
Non-Preferred Brands $70 copay $140 copay covered
Listed No Cost Preventive Medications 100% 100%
* All specialty medications must be illed through the CIGNA Specialty Pharmacy network; if you select a brand name drug when a generic
equivalent is available, the plan will only pay the cost of the generic drug; the plan will not cover medications for which there is an equivalent
over-the-counter alternative, all listed maintenance medications must be illed through home delivery or 90 Now network pharmacies.
Bi-Weekly Medical Contributions—Paid By You on a Pre-Tax Basis
Employee Premiums** With Tobacco Surcharge With Tobacco Surcharge
1 User
2 Users
OAP Plan Bi-weekly Rates
Employee Only $52.92 $76.00 $76.00
Employee + Spouse $147.09 $170.17 $193.25
Employee + Child(ren) $110.53 $133.61 $133.61
Family $191.41 $214.49 $237.56
HSA Plan Bi-weekly Rates
Employee Only $44.43 $67.51 $67.51
Employee + Spouse $112.74 $135.81 $158.89
Employee + Child(ren) $83.46 $106.54 $106.54
Family $143.96 $167.04 $190.12
** If you completed all wellness requirements, you will receive a bi-weekly incentive payment of $30.77.
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