Page 4 - 2016 WFF Guide 2
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4
M ed ical/ P rescription D rugs P lan S ummary
A brief summary of the plan details are outlined below.
I n- N etw ork O ut- of- N etw ork
P lan M ax imum
P er lifetime U nlimited
D ed uctible per C alend ar Y ear
P er ind iv id ual $ 1 , 0 0 0 $ 2 , 0 0 0
P er family $ 3 , 0 0 0 $ 6 , 0 0 0
M ax imum O ut- of- P ock et E x posure per C alend ar Y ear ( I nclud es D ed uctible)
P er ind iv id ual $ 3 , 0 0 0 $ 7 , 0 0 0
P er family $ 9 , 0 0 0 $ 1 7 , 0 0 0
P lan C ost S haring
C oinsurance 8 0 % after d ed uctible 6 0 % after d ed uctible
C ov ered S erv ices
H ospital S erv ices
I npatient 8 0 % after d ed uctible 6 0 % after d ed uctible
O utpatient 8 0 % after d ed uctible 6 0 % after d ed uctible
E mergency room $ 1 0 0 copay $ 1 0 0 copay
U rgent care center $ 7 5 copay 6 0 % after d ed uctible
P hysician S erv ices
Ofice visit P C P : $ 2 5 copay 6 0 % after d ed uctible
S pecialist: $ 3 5 copay
A ll other lab/ x - ray 8 0 % after d ed uctible 6 0 % after d ed uctible
O ther C ov ered S erv ices
P rev entiv e care * 1 0 0 % cov ered 6 0 % after d ed uctible
Prescription Drug Beneit **
R etail P harmacy M ail O rd er P harmacy
G eneric $ 7 copay $ 2 1 copay
P referred brand s $ 3 5 copay $ 1 0 5 copay
N on- preferred brand s $ 7 0 copay $ 2 1 0 copay
This summary of beneits is intended to be a brief outline of coverage. The entire provisions of beneits and exclusions are contained in the Summary
Plan Description (SPD). In the event of a conlict between the SPD and this description, the terms of the SPD will prevail.
* As deined by the US Preventive Services Task Force.
* * I f brand is d ispensed w hen generic is av ailable, the employee w ill be responsible for the d ifference in cost betw een brand and generic.
M ed ical/ P rescription D rugs P lan S ummary
A brief summary of the plan details are outlined below.
I n- N etw ork O ut- of- N etw ork
P lan M ax imum
P er lifetime U nlimited
D ed uctible per C alend ar Y ear
P er ind iv id ual $ 1 , 0 0 0 $ 2 , 0 0 0
P er family $ 3 , 0 0 0 $ 6 , 0 0 0
M ax imum O ut- of- P ock et E x posure per C alend ar Y ear ( I nclud es D ed uctible)
P er ind iv id ual $ 3 , 0 0 0 $ 7 , 0 0 0
P er family $ 9 , 0 0 0 $ 1 7 , 0 0 0
P lan C ost S haring
C oinsurance 8 0 % after d ed uctible 6 0 % after d ed uctible
C ov ered S erv ices
H ospital S erv ices
I npatient 8 0 % after d ed uctible 6 0 % after d ed uctible
O utpatient 8 0 % after d ed uctible 6 0 % after d ed uctible
E mergency room $ 1 0 0 copay $ 1 0 0 copay
U rgent care center $ 7 5 copay 6 0 % after d ed uctible
P hysician S erv ices
Ofice visit P C P : $ 2 5 copay 6 0 % after d ed uctible
S pecialist: $ 3 5 copay
A ll other lab/ x - ray 8 0 % after d ed uctible 6 0 % after d ed uctible
O ther C ov ered S erv ices
P rev entiv e care * 1 0 0 % cov ered 6 0 % after d ed uctible
Prescription Drug Beneit **
R etail P harmacy M ail O rd er P harmacy
G eneric $ 7 copay $ 2 1 copay
P referred brand s $ 3 5 copay $ 1 0 5 copay
N on- preferred brand s $ 7 0 copay $ 2 1 0 copay
This summary of beneits is intended to be a brief outline of coverage. The entire provisions of beneits and exclusions are contained in the Summary
Plan Description (SPD). In the event of a conlict between the SPD and this description, the terms of the SPD will prevail.
* As deined by the US Preventive Services Task Force.
* * I f brand is d ispensed w hen generic is av ailable, the employee w ill be responsible for the d ifference in cost betw een brand and generic.
