Page 4 - 2016 WFF Guide 1
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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. Note: the plan includes “non-embedded” deductibles. A
non-embedded deductible requires satisfaction of the full family deductible before the plan will be begin paying
coinsurance. The deductible is capped at the individual level only if there are no dependents covered under the
plan.
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 ( N on- E mbed d ed )
P er ind iv id ual $ 3 , 5 0 0 $ 7 , 0 0 0
P er family $ 7 , 0 0 0 $ 1 4 , 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 $ 6 , 3 5 0 $ 1 2 , 7 0 0
P er family $ 1 2 , 7 0 0 $ 2 5 , 4 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 8 0 % after d ed uctible 8 0 % after d ed uctible
U rgent care center 8 0 % after d ed uctible 6 0 % after d ed uctible
P hysician S erv ices
Ofice visit 8 0 % after d ed uctible 6 0 % after d ed uctible
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 3 0 % 3 0 %
P referred brand s 4 0 % 4 0 %
N on- preferred brand s 5 0 % 5 0 %
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. Note: the plan includes “non-embedded” deductibles. A
non-embedded deductible requires satisfaction of the full family deductible before the plan will be begin paying
coinsurance. The deductible is capped at the individual level only if there are no dependents covered under the
plan.
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 ( N on- E mbed d ed )
P er ind iv id ual $ 3 , 5 0 0 $ 7 , 0 0 0
P er family $ 7 , 0 0 0 $ 1 4 , 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 $ 6 , 3 5 0 $ 1 2 , 7 0 0
P er family $ 1 2 , 7 0 0 $ 2 5 , 4 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 8 0 % after d ed uctible 8 0 % after d ed uctible
U rgent care center 8 0 % after d ed uctible 6 0 % after d ed uctible
P hysician S erv ices
Ofice visit 8 0 % after d ed uctible 6 0 % after d ed uctible
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 3 0 % 3 0 %
P referred brand s 4 0 % 4 0 %
N on- preferred brand s 5 0 % 5 0 %
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.
