Page 5 - 2015 New Hire Guide

Olshan Properties

Medical/Prescription Drug Benefit Summary
Standard Plan Buy-Up Plan High Deductible Plan
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $250 $5,000 $0 $1,000 $2,500 $5,000
Family $500 $10,000 $0 $2,000 $5,000 $10,000
Out-of-Pocket Maximum (includes deductibles and copays)
Individual $2,250 $15,000 $1,000 $5,000 $6,350 $10,000
Family $4,500 $30,000 $2,000 $10,000 $12,700 $20,000
Physician Ofice Visits
Primary Care/Specialist $30 copay 40% after $20 copay 30% after $25 copay 50% after
deductible deductible deductible
Wellness/Preventive Covered at 40% after Covered at 30% after Covered at 50% after
100% deductible 100% deductible 100% deductible
Urgent Care
$50 copay 40% after $50 copay 30% after $50 copay 50% after
deductible deductible deductible
Emergency Room
$100 copay $100 copay $100 copay $100 copay $150 copay $150 copay
Hospital Services
Inpatient 20% after 40% after $250 copay per 30% after 30% after 50% after
deductible deductible coninement deductible deductible deductible
Outpatient 20% after 40% after 0% no 30% after 30% after 50% after
deductible deductible deductible deductible deductible deductible
Chiropractic Care or Outpatient Therapies
$30 copay 40% after $20 copay 30% after $25 copay 50% after
deductible deductible deductible
Prescription Drugs
Retail—31 days
Tier 1 $10 copay $10 copay $10 copay $10 copay $10 copay $10 copay
Tier 2 $30 copay $30 copay $30 copay $30 copay $30 copay $30 copay
Tier 3 $50 copay $50 copay $50 copay $50 copay $50 copay $50 copay
Mail Order—90 days
Tier 1/2/3 2.5x retail Not covered 2.5x retail Not covered 2.5x retail Not covered
copay copay copay
Medical Plan Bi-Weekly Employee Contributions
Employee (Ee) $75.06 $105.85 $56.67
Ee/Spouse $210.16 $274.81 $158.67
Ee/Child(ren) $190.14 $248.64 $143.56
Family $300.22 $392.59 $226.67

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