Page 14 - 2015 DAN Benefits Guide
P. 14
Open
Enrollment
Moderate Utilizer
Jill, age 42, covers herself and her spouse on the plan and seeks healthcare services
moderately. Her 2015 medical expenses might look like this.
Premium PPO Enhanced PPO Standard PPO HSA PPO
Total Cost (In-Network) 1 Out-of-Pocket Expenses by Plan
Well woman & male oice Free Free Free Free
visits: $572
Four Primary Care Visits ($120/ $30 copay $30 copay $30 copay $480
visit) ($120 total) ($120 total) ($120 total) (deducible)
One Brand Rx/Month: $30/ $30 monthly $30 monthly $30 monthly $3,520
Month copay ($360) copay ($360) copay ($360) to saisfy
deducible;
then 20% of
remaining $80
Outpaient service for spouse : $250 to saisfy $500 to saisfy $1,000 20% of
2
$2,500 deducible; deducible; to saisfy remaining
then 0% of then 10% of deducible; $2,500
$2,250 remaining then 20% of
Notes: $2,000 remaining
1 Please note the costs for the various services $1,500
used to create the preceding scenarios are for Total Employee Responsibility
illustraive purposes only. Actual costs may difer
the type of care or services provided. Total Out-of-Pocket Expenses $730 $1,180 $1,780 $4,516
Annual Payroll Deducion $6,577 $4,554 $2,680 $1,712
2 Outpaient Services—cost assumed as total of (EE + Sp)
all outpaient expenses; therefore, applying Company HSA Contribuion N/A N/A N/A ($1,000)
directly to deducible and coinsurance for all
modeled plans. Jill’s Total Cost $7,307 $5,734 $4,460 $5,228
The best opion for Jill is the Standard Plan.
14
Enrollment
Moderate Utilizer
Jill, age 42, covers herself and her spouse on the plan and seeks healthcare services
moderately. Her 2015 medical expenses might look like this.
Premium PPO Enhanced PPO Standard PPO HSA PPO
Total Cost (In-Network) 1 Out-of-Pocket Expenses by Plan
Well woman & male oice Free Free Free Free
visits: $572
Four Primary Care Visits ($120/ $30 copay $30 copay $30 copay $480
visit) ($120 total) ($120 total) ($120 total) (deducible)
One Brand Rx/Month: $30/ $30 monthly $30 monthly $30 monthly $3,520
Month copay ($360) copay ($360) copay ($360) to saisfy
deducible;
then 20% of
remaining $80
Outpaient service for spouse : $250 to saisfy $500 to saisfy $1,000 20% of
2
$2,500 deducible; deducible; to saisfy remaining
then 0% of then 10% of deducible; $2,500
$2,250 remaining then 20% of
Notes: $2,000 remaining
1 Please note the costs for the various services $1,500
used to create the preceding scenarios are for Total Employee Responsibility
illustraive purposes only. Actual costs may difer
the type of care or services provided. Total Out-of-Pocket Expenses $730 $1,180 $1,780 $4,516
Annual Payroll Deducion $6,577 $4,554 $2,680 $1,712
2 Outpaient Services—cost assumed as total of (EE + Sp)
all outpaient expenses; therefore, applying Company HSA Contribuion N/A N/A N/A ($1,000)
directly to deducible and coinsurance for all
modeled plans. Jill’s Total Cost $7,307 $5,734 $4,460 $5,228
The best opion for Jill is the Standard Plan.
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