Page 7 - 2016 Enrollment

7

Medical Plan Summary

HRA Plan HSA Plan
Medical In-Network Out-of-Network In-Network Out-of-Network
Health Account Employer Funding
Individual $250 $250
Employee + spouse or $750 $750
child(ren)
Family $1,250 $1,250
Calendar Year Deductible
Individual $1,500 Shared with in-network $1,500 $3,000
Employee + spouse or
child(ren) $2,500 Shared with in-network $3,500 $7,000
Family $3,500 Shared with in-network $3,500 $7,000
Out-of-Pocket Maximum*
Individual $4,250 $7,750 $4,000 $8,000
Employee + spouse or $5,500 $10,000 $8,000 $16,000
child(ren)
Family $7,500 $14,500 $8,000 $16,000
Physician Ofice Visits
Primary care 80% after deductible 60% after deductible 80% after deductible 50% after deductible
Specialist 80% after deductible 60% after deductible 80% after deductible 50% after deductible
Wellness/Preventive
100% covered 60% after deductible 100% covered 50% after deductible
Lab Services
80% after deductible 60% after deductible 80% after deductible 50% after deductible
X-Ray/Radiology Services
80% after deductible 60% after deductible 80% after deductible 50% after deductible
Hospital Services
Inpatient 80% after deductible 60% after deductible 80% after deductible 50% after deductible
Outpatient 80% after deductible 60% after deductible 80% after deductible 50% after deductible
Emergency room 80% after deductible 80% after deductible
50% after deductible for non-emergency ER visits
Prescription Drugs
Retail—supply limit 30 day supply 30 day supply
Tier 1 $15 copay 80% after deductible
Tier 2 $35 copay 80% after deductible
Tier 3 $60 copay 80% after deductible
Mail order—supply limit 90 day supply 90 day supply
Tier 1 $30 copay Not covered 80% after deductible Not covered
Tier 2 $70 copay Not covered 80% after deductible Not covered
Tier 3 $120 copay Not covered 80% after deductible Not covered

* An embedded individual out-of-pocket (OOP) maximum is included within the family-level OOP limits. No single family member will be required
to expense more than the Individual OOP maximum amount during the 2016 plan year. The family-level OOP maximum limits are shared
arrangements between all members of the family which are covered.

Note: Under the HRA plan, prescription copays are not eligible for payment through the HRA fund.

2016 Benefits Guide