Page 10 - 2015 CBRY Enrollment Guide
P. 10
2015 Beneit Guide
Case Study— Option 1—HRA Plan
Susan Susan elects the HRA Plan and completes all four of the speciic
wellness activities to earn $750 in HRA incentives.
Susan is a healthy 26 year old who Allowed Member
participates in itness classes at least 3 Expenses Cost
days a week. Each year she has a well Well Women Check Up (Preventive 100%) $100 $0
woman check up with her OB/Gyn and Doctor's Ofice Visit—Sinus Infection $85 $20 Copay
follow up visit with her Endocrinologist Endocrinologist Specialist Ofice Visit $125 $50 Copay
for hypothyroidism and takes a generic Endocrinologist Lab Tests $225 $225 Deductible
prescription drug each month to Prescription Drugs (12 generic) $150 $120
regulate her thyroid. She also had a Total Medical Expenses $415
doctor ofice visit for a sinus infection. Total Copays $190
Let’s take a look at the coverage and Total Deductible $225
costs of each plan. Total Coinsurance $0
Less Deductible & Coinsurance expenses paid from HRA -$225
Annual Premium Cost ($23.08 per pay period) $600
Total Annual Member Cost $790
Susan is responsible for copays. Since she did not spend all of her
HRA money, the unused money will rollover to next year to use in
future years when needed.
HRA Rollover to next year $525
Option 2—PPO Plan
Allowed Member
Expenses Cost
Well Women Check Up (Preventive 100%) $100 $0
Doctor's Ofice Visit—Sinus Infection $85 $85 Deductible
Endocrinologist Specialist Ofice Visit $125 $125 Deductible
Endocrinologist Lab Tests $225 $225 Deductible
Prescription Drugs (12 generic) $150 $120 Copay
Total Medical Expenses $555
Total Copays $120
Total Deductible $435
Total Coinsurance $0
Annual Premium Cost ($44.77 per pay period) $1,164
Total Annual Member Cost $1,719
This is an example. Your actual experience may
vary. All expenses assume the use of in-network
providers. The medical copays, deductible, and
coinsurance expenses will apply towards the
medical out-of-pocket maximum. The prescription
drug copays will apply towards the prescription
out-of-pocket maximum. Refer to the Summary
Plan Description for the individual and family
deductibles and out-of-pocket maximums.
10
Case Study— Option 1—HRA Plan
Susan Susan elects the HRA Plan and completes all four of the speciic
wellness activities to earn $750 in HRA incentives.
Susan is a healthy 26 year old who Allowed Member
participates in itness classes at least 3 Expenses Cost
days a week. Each year she has a well Well Women Check Up (Preventive 100%) $100 $0
woman check up with her OB/Gyn and Doctor's Ofice Visit—Sinus Infection $85 $20 Copay
follow up visit with her Endocrinologist Endocrinologist Specialist Ofice Visit $125 $50 Copay
for hypothyroidism and takes a generic Endocrinologist Lab Tests $225 $225 Deductible
prescription drug each month to Prescription Drugs (12 generic) $150 $120
regulate her thyroid. She also had a Total Medical Expenses $415
doctor ofice visit for a sinus infection. Total Copays $190
Let’s take a look at the coverage and Total Deductible $225
costs of each plan. Total Coinsurance $0
Less Deductible & Coinsurance expenses paid from HRA -$225
Annual Premium Cost ($23.08 per pay period) $600
Total Annual Member Cost $790
Susan is responsible for copays. Since she did not spend all of her
HRA money, the unused money will rollover to next year to use in
future years when needed.
HRA Rollover to next year $525
Option 2—PPO Plan
Allowed Member
Expenses Cost
Well Women Check Up (Preventive 100%) $100 $0
Doctor's Ofice Visit—Sinus Infection $85 $85 Deductible
Endocrinologist Specialist Ofice Visit $125 $125 Deductible
Endocrinologist Lab Tests $225 $225 Deductible
Prescription Drugs (12 generic) $150 $120 Copay
Total Medical Expenses $555
Total Copays $120
Total Deductible $435
Total Coinsurance $0
Annual Premium Cost ($44.77 per pay period) $1,164
Total Annual Member Cost $1,719
This is an example. Your actual experience may
vary. All expenses assume the use of in-network
providers. The medical copays, deductible, and
coinsurance expenses will apply towards the
medical out-of-pocket maximum. The prescription
drug copays will apply towards the prescription
out-of-pocket maximum. Refer to the Summary
Plan Description for the individual and family
deductibles and out-of-pocket maximums.
10
