Page 5 - 2017 Benefits Enrollment Busey Pulaski

2017 BENEFITS ENROLLMENT

Medical

Choosing the right health plan is probably one of the most important decisions you can make for yourself and
your family members. Please carefully consider the plan information provided in this document.

This year, Busey will offer 2 plans through Aetna: the 2600 CDHP and the 5000 CDHP. Your plan options will
remain the same as last year but your carrier will change to Aetna. We understand paying for the full cost of
coverage up front under a CDHP may be overwhelming. To help associates with this cost, Busey is providing
two items which will be discussed later in this guide: HSA seed money through B Well and a concierge vendor—
Compass. Visit www.aetna.com.

POS 2600 CDHP POS 5000 CDHP
In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Deductible
Individual $2,600 $10,000 $5,000 $10,000
Family $5,200 $20,000 $10,000 $20,000
Out-of-Pocket Maximum
Individual $5,000 $15,000 $5,000 $15,000
Family $10,000 $30,000 $10,000 $30,000
Physician Ofice Visits
Primary care 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Specialist 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Wellness/Preventive
$0 50% coinsurance $0 50% coinsurance
Urgent Care
20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Lab Services/X-Ray
Physician ofice 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Outpatient facility 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Outpatient hospital 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Hospital Services
Inpatient 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Outpatient 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Emergency room 20% coinsurance 20% coinsurance 0% coinsurance 0% coinsurance
Mental Health/Substance Abuse
Inpatient 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Outpatient 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Ofice visits 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Chiropractic Care
20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Prescription Drugs
Retail supply limit 30 days 30 days 30 days 30 days
ƒ Tier 1 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
ƒ Tier 2 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
ƒ Tier 3 20% coinsurance 50% coinsurance 0% coinsurance 50% coinsurance
Mail order supply limit 90 days 90 days
ƒ Tier 1 20% coinsurance 0% coinsurance
ƒ Tier 2 20% coinsurance 0% coinsurance
ƒ Tier 3 20% coinsurance 0% coinsurance

FIRST BUSEY CORPORATION 5