Page 8 - 2017 Benefits Enrollment Busey Pulaski

2017 BENEFITS ENROLLMENT

Medical—Grandfathered PPO

Associates currently enrolled in the PPO plan have the option to renew
their coverage through Aetna for 1 year, through December 31, 2017.

This plan is not open for enrollment for the 2017 plan year.

PPO 1500
In-Network Out-of-Network
Calendar Year Deductible
Individual $1,500 $2,000
Family $3,000 $4,000
Out-of-Pocket Maximum
Individual $4,000 $4,000
Family $8,000 $8,000
Physician Ofice Visits
Primary care $20 copay 30% coinsurance
Specialist $40 copay 30% coinsurance
Wellness/Preventive
$0 30% coinsurance
Urgent Care
$75 copay 30% coinsurance
Lab Services/X-Ray
Physician ofice 100% after deductible 30% coinsurance
Outpatient facility 100% after deductible 30% coinsurance
Outpatient hospital 100% after deductible 30% coinsurance
Hospital Services
Inpatient 100% after deductible 30% coinsurance
Outpatient 100% after deductible 30% coinsurance
Emergency room $200 copay $200 copay
PPO
Bi-weekly Rates 1500 Mental Health/Substance Abuse 30% coinsurance
Inpatient
100% after deductible
Beneit Compensation < $92,500 Outpatient $20 copay 30% coinsurance
ƒ Associate only $63.48 Prescription Drugs
ƒ Associate + spouse $267.33 Retail supply limit 31 days 30% after copay
Tier 1
$10
ƒ Associate + child(ren) $210.92 ƒ ƒ Tier 2 $35 30% after copay
ƒ Family $341.47 Tier 3 $60 30% after copay
ƒ
Beneit Compensation ≥ $92,500 Mail order supply limit 90 days
ƒ Associate only $119.18 ƒ Tier 1 $25
ƒ Associate + spouse $335.11 ƒ Tier 2 $87.50
ƒ Associate + child(ren) $280.88 ƒ Tier 3 $150
ƒ Family $442.14

8 FIRST BUSEY CORPORATION