Page 6 - 2018 Fontbonne Benefit Guide
P. 6
Wellness Program
Employees will have the opportunity to complete various wellness-related
tasks and receive a reduction in their premiums.
Medical Contributions—Monthly
Premium Plan HSA Plan
Non- Non-
Wellness Wellness Wellness Wellness
Employee only $160 $187 $49 $82
Employee + spouse $854 $890 $462 $504
Employee + child(ren) $764 $791 $421 $451
Family $973 $1,007 $544 $590
Medical Benefits
Premium Plan HSA Plan
Cigna Open
Out-of-
Out-of-
Access Plus In-Network Network In-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 $2,500* $7,500 $3,500 $5,900
Family $5,000* $15,000 $7,000* $11,800
Ofice visit copay $20** 30% after 10% after 30% after
deductible deductible** deductible
Urgent care copay $50 $50 10% after 30% after
deductible deductible
ER copay $150 $150 10% after 10% after
deductible deductible
Inpatient/ 10% after 30% after 10% after 30% after
outpatient services deductible deductible deductible deductible
* Embedded structure (see page 7 for more information on embedded versus non-embedded
plan designs)
** Routine preventive services covered at 100%
Please refer to the Summary Plan Description for detailed information on covered beneits
6 2018 Benefits Enrollment
Employees will have the opportunity to complete various wellness-related
tasks and receive a reduction in their premiums.
Medical Contributions—Monthly
Premium Plan HSA Plan
Non- Non-
Wellness Wellness Wellness Wellness
Employee only $160 $187 $49 $82
Employee + spouse $854 $890 $462 $504
Employee + child(ren) $764 $791 $421 $451
Family $973 $1,007 $544 $590
Medical Benefits
Premium Plan HSA Plan
Cigna Open
Out-of-
Out-of-
Access Plus In-Network Network In-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 $2,500* $7,500 $3,500 $5,900
Family $5,000* $15,000 $7,000* $11,800
Ofice visit copay $20** 30% after 10% after 30% after
deductible deductible** deductible
Urgent care copay $50 $50 10% after 30% after
deductible deductible
ER copay $150 $150 10% after 10% after
deductible deductible
Inpatient/ 10% after 30% after 10% after 30% after
outpatient services deductible deductible deductible deductible
* Embedded structure (see page 7 for more information on embedded versus non-embedded
plan designs)
** Routine preventive services covered at 100%
Please refer to the Summary Plan Description for detailed information on covered beneits
6 2018 Benefits Enrollment
