Page 12 - 2015 CBRY Enrollment Guide
P. 12
2015 Beneit Guide
Case Study— Option 1—HRA Plan
Ochoa Family The Ochoa family elects the HRA Plan and they both complete all four
of the speciic wellness activities to earn $1,500 in HRA incentives.
As a whole, the Ochoas are all in Allowed Member
good health, however, their son Jim, Expenses Cost
suffers from asthma. Other than Jim’s Annual Physicals (Preventive 100%) $400 $0
monthly prescription for his inhaler, Doctor's Ofice Visit—Strep Throat $85 $20 Copay
their daughter Maria got sick with strep Prescription Drug (1 generic) $38 $10 Copay
throat and had to get an antibiotic. All Prescription Drugs (12 generic) $175 $120 Copay
four of them go in each year for an Total Medical Expenses $150
annual physical. Let’s take a look at the Total Copays $150
coverage and costs of each plan. Total Deductible $0
Total Coinsurance $0
Less Deductible & Coinsurance expenses paid from HRA $0
Annual Premium Cost ($71.54 per pay period) $1,860
Total Annual Member Cost $2,010
The Ochoa family is responsible for copays. Since they did not spend all
of the HRA, the medical copays on the HRA plan will accumulate towards
the out of pocket maximum.
HRA Rollover to next year $1,500
Option 2—PPO Plan
Allowed Member
Expenses Cost
Annual Physicals (Preventive 100%) $400 $0
Doctor's Ofice Visit—Strep Throat $85 $85 Deductible
Prescription Drug (1 generic) $38 $10 Copay
Prescription Drugs (12 generic) $175 $120 Copay
Total Medical Expenses $215
Total Copays $130
Total Deductible $85
Total Coinsurance $0
Annual Premium Cost ($149.54 per pay period) $3,888
Total Annual Member Cost $4,103
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.
12
Case Study— Option 1—HRA Plan
Ochoa Family The Ochoa family elects the HRA Plan and they both complete all four
of the speciic wellness activities to earn $1,500 in HRA incentives.
As a whole, the Ochoas are all in Allowed Member
good health, however, their son Jim, Expenses Cost
suffers from asthma. Other than Jim’s Annual Physicals (Preventive 100%) $400 $0
monthly prescription for his inhaler, Doctor's Ofice Visit—Strep Throat $85 $20 Copay
their daughter Maria got sick with strep Prescription Drug (1 generic) $38 $10 Copay
throat and had to get an antibiotic. All Prescription Drugs (12 generic) $175 $120 Copay
four of them go in each year for an Total Medical Expenses $150
annual physical. Let’s take a look at the Total Copays $150
coverage and costs of each plan. Total Deductible $0
Total Coinsurance $0
Less Deductible & Coinsurance expenses paid from HRA $0
Annual Premium Cost ($71.54 per pay period) $1,860
Total Annual Member Cost $2,010
The Ochoa family is responsible for copays. Since they did not spend all
of the HRA, the medical copays on the HRA plan will accumulate towards
the out of pocket maximum.
HRA Rollover to next year $1,500
Option 2—PPO Plan
Allowed Member
Expenses Cost
Annual Physicals (Preventive 100%) $400 $0
Doctor's Ofice Visit—Strep Throat $85 $85 Deductible
Prescription Drug (1 generic) $38 $10 Copay
Prescription Drugs (12 generic) $175 $120 Copay
Total Medical Expenses $215
Total Copays $130
Total Deductible $85
Total Coinsurance $0
Annual Premium Cost ($149.54 per pay period) $3,888
Total Annual Member Cost $4,103
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.
12
