Page 6 - 2015 New Hire Guide
P. 6
Open
Enrollment
Wellness Program
Employees will have the opportunity to complete various wellness-
related tasks and receive a reduction in their premiums.
Medical Contributions—Monthly
Wellness Non-Wellness
Premium HSA Plan Premium HSA Plan
Plan Plan
Employee Only $121 $41 $144 $64
Employee + Spouse $658 $415 $687 $438
Employee + $589 $374 $612 $392
Child(ren)
Family $750 $479 $779 $503
Medical Benefits
Premium Plan HSA Plan
Cigna Open
Access Plus In-Network Out-of- In-Network Out-of-
Network Network
Deductible
Individual $750 $1,500 $1,500 $3,000
Family $1,500 $3,000 $3,000 $6,000
Coinsurance 10% 30% 10% 30%
Out-of-Pocket Maximum
Individual $2,000 $6,000 $3,000 $5,000
Family $4,000 $12,000 $6,000 $10,000
Ofice Visit Copay $20 * 30% after 10% after 30% after
deductible deductible * deductible
Specialist Copay $20 30% after 10% after 30% after
deductible deductible deductible
Urgent Care $50 $50 10% after 30% after
Copay deductible deductible
ER Copay $150 $150 10% after 10% after
deductible deductible
Inpatient/ 10% after 30% after 10% after 30% after
outpatient deductible deductible deductible deductible
services
* Routine preventive services covered at 100%
Please refer to the Summary Plan Description for detailed information on covered beneits
6
Enrollment
Wellness Program
Employees will have the opportunity to complete various wellness-
related tasks and receive a reduction in their premiums.
Medical Contributions—Monthly
Wellness Non-Wellness
Premium HSA Plan Premium HSA Plan
Plan Plan
Employee Only $121 $41 $144 $64
Employee + Spouse $658 $415 $687 $438
Employee + $589 $374 $612 $392
Child(ren)
Family $750 $479 $779 $503
Medical Benefits
Premium Plan HSA Plan
Cigna Open
Access Plus In-Network Out-of- In-Network Out-of-
Network Network
Deductible
Individual $750 $1,500 $1,500 $3,000
Family $1,500 $3,000 $3,000 $6,000
Coinsurance 10% 30% 10% 30%
Out-of-Pocket Maximum
Individual $2,000 $6,000 $3,000 $5,000
Family $4,000 $12,000 $6,000 $10,000
Ofice Visit Copay $20 * 30% after 10% after 30% after
deductible deductible * deductible
Specialist Copay $20 30% after 10% after 30% after
deductible deductible deductible
Urgent Care $50 $50 10% after 30% after
Copay deductible deductible
ER Copay $150 $150 10% after 10% after
deductible deductible
Inpatient/ 10% after 30% after 10% after 30% after
outpatient deductible deductible deductible deductible
services
* Routine preventive services covered at 100%
Please refer to the Summary Plan Description for detailed information on covered beneits
6
