Page 8 - 2016 Enrollment
P. 8
HMO Plan
Did You Know? Calendar Year Deductible: Your Cost HMO-POS Plan
Your pharmacy plan Employee $0 $0
covers many tobacco Family
cessation drugs at 100 Out of Pocket Maximum: Your Cost
percent when received in- Employee $2,500 $2,000
network. Some common Family $7,500 $6,000
Medical: Your Cost For Care
examples of covered Preventive $0 no deductible
drugs include Bupropion Ofice Visits $20 copay
HCL, Chantix, Nicotrol, Emergency Room $100
Nicotine Patch, Nicorelief. Inpatient Services 10% of applicable charges per day (including
Talk to your pharmacist maternity)
about your coverage and Rx Drugs: Your Cost
$5 copay, per 30 day supply
take advantage of this Generic Maintenance $10 copay, per 30 day supply
Other Generic
opportunity to start living Brand Name $45 copay, per 30 day supply
tobacco free. Dental: Your Cost
Annual Exam (1 per year) 0% of allowed amount
Bitewing X-rays (2 per 0% of allowed amount
year)
Cleaning (2 per year) 0% of allowed amount
Restorative 30% of allowed amount
Crowns 50% of allowed amount
Your Contributions For Healthcare
Employee $86.72 $101.27
Employee + 1 $173.45 $202.53
Family $260.05 $303.66
8
New Hire Enrollment
Did You Know? Calendar Year Deductible: Your Cost HMO-POS Plan
Your pharmacy plan Employee $0 $0
covers many tobacco Family
cessation drugs at 100 Out of Pocket Maximum: Your Cost
percent when received in- Employee $2,500 $2,000
network. Some common Family $7,500 $6,000
Medical: Your Cost For Care
examples of covered Preventive $0 no deductible
drugs include Bupropion Ofice Visits $20 copay
HCL, Chantix, Nicotrol, Emergency Room $100
Nicotine Patch, Nicorelief. Inpatient Services 10% of applicable charges per day (including
Talk to your pharmacist maternity)
about your coverage and Rx Drugs: Your Cost
$5 copay, per 30 day supply
take advantage of this Generic Maintenance $10 copay, per 30 day supply
Other Generic
opportunity to start living Brand Name $45 copay, per 30 day supply
tobacco free. Dental: Your Cost
Annual Exam (1 per year) 0% of allowed amount
Bitewing X-rays (2 per 0% of allowed amount
year)
Cleaning (2 per year) 0% of allowed amount
Restorative 30% of allowed amount
Crowns 50% of allowed amount
Your Contributions For Healthcare
Employee $86.72 $101.27
Employee + 1 $173.45 $202.53
Family $260.05 $303.66
8
New Hire Enrollment
