Page 6 - 2015/2016 Benefits Guide
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Premium Health Highlights Basic Health Highlights HSA Highlights
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Ded. Non-Embedded
Individual $350 $1,050 $900 $2,700 $1,300 $2,600
Family $700 $2,100 $1,800 $5,400 $2,600 $5,200
Coinsurance
90% 60% 80% 50% 80% 60%
Out-of-Pocket Maximum
Individual $1,650 $3,300 $2,150 $4,300 $6,450 $12,900
Family $3,300 $6,600 $4,300 $8,600 $12,900 $25,800
Hospital
Inpatient 90% after ded. 60% after ded. 80% after ded. 50% after ded. 80% after ded. 60% after ded.
Outpatient surgery 90% after ded. 60% after ded. 80% after ded. 50% after ded. 80% after ded. 60% after ded.
Outpatient other 90% after ded. 60% after ded. 80% after ded. 50% after ded. 80% after ded. 60% after ded.
Emergency room $100 copay; $100 copay; $100 copay; $100 copay; 80% after ded. 80% after ded.
90% after ded. 90% after ded. 80% after ded. 80% after ded.
Physician Ofice Visit
General $20 copay 60% after ded. $25 copay 50% after ded. 80% after ded. 60% after ded.
practitioners,
pediatricians
Specialist $40 copay 60% after ded. $50 copay 50% after ded. 80% after ded. 60% after ded.
Urgent Care
$40 copay 60% after ded. $50 copay 50% after ded. 80% after ded. 60% after ded.
Physician Surgery
90% after ded. 60% after ded. 80% after ded. 50% after ded. 80% after ded. 60% after ded.
Speciied Preventative Care, Physicals, and Wellchild Care
100%, no ded. Not covered 100%, no ded. Not covered 100% no ded. 60% after ded.
Telemedicine
Teladoc $10 copay 60% after $10 copay 50% after 80% after 60% after
deductible deductible deductible deductible
Chiropractic
90% after ded. 60% after ded. 80% after ded. 50% after ded. 80% after ded. 60% after ded.
Mental/Substance
Inpatient 90% after ded. 60% after ded. 80% after ded. 50% after ded. 80% after ded. 60% after ded.
Outpatient Ded./coinsurance 60% after ded. Ded./coinsurance 50% after ded. 80% after ded. 60% after ded.
or copay or copay
Pharmacy
Retail 80% after ded. 60% after ded.
Mail 80% after ded. Not available
Out-of-pocket See page 8 for plan details See page 8 for plan details Pharmacy expenses are included
maximum in your medical out-of-pocket
maximum
7/1/15 to 6/30/16 Medical Plans
Semi-Monthly Premium
Premium Basic HSA
Employee only $24.81 $7.55 $5.81
Employee + spouse $228.07 $140.68 $135.32
Employee + child(ren) $156.39 $104.50 $96.67
Employee + family $332.09 $214.36 $206.21
TheBANK of Edwardsville
Premium Health Highlights Basic Health Highlights HSA Highlights
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Calendar Year Ded. Non-Embedded
Individual $350 $1,050 $900 $2,700 $1,300 $2,600
Family $700 $2,100 $1,800 $5,400 $2,600 $5,200
Coinsurance
90% 60% 80% 50% 80% 60%
Out-of-Pocket Maximum
Individual $1,650 $3,300 $2,150 $4,300 $6,450 $12,900
Family $3,300 $6,600 $4,300 $8,600 $12,900 $25,800
Hospital
Inpatient 90% after ded. 60% after ded. 80% after ded. 50% after ded. 80% after ded. 60% after ded.
Outpatient surgery 90% after ded. 60% after ded. 80% after ded. 50% after ded. 80% after ded. 60% after ded.
Outpatient other 90% after ded. 60% after ded. 80% after ded. 50% after ded. 80% after ded. 60% after ded.
Emergency room $100 copay; $100 copay; $100 copay; $100 copay; 80% after ded. 80% after ded.
90% after ded. 90% after ded. 80% after ded. 80% after ded.
Physician Ofice Visit
General $20 copay 60% after ded. $25 copay 50% after ded. 80% after ded. 60% after ded.
practitioners,
pediatricians
Specialist $40 copay 60% after ded. $50 copay 50% after ded. 80% after ded. 60% after ded.
Urgent Care
$40 copay 60% after ded. $50 copay 50% after ded. 80% after ded. 60% after ded.
Physician Surgery
90% after ded. 60% after ded. 80% after ded. 50% after ded. 80% after ded. 60% after ded.
Speciied Preventative Care, Physicals, and Wellchild Care
100%, no ded. Not covered 100%, no ded. Not covered 100% no ded. 60% after ded.
Telemedicine
Teladoc $10 copay 60% after $10 copay 50% after 80% after 60% after
deductible deductible deductible deductible
Chiropractic
90% after ded. 60% after ded. 80% after ded. 50% after ded. 80% after ded. 60% after ded.
Mental/Substance
Inpatient 90% after ded. 60% after ded. 80% after ded. 50% after ded. 80% after ded. 60% after ded.
Outpatient Ded./coinsurance 60% after ded. Ded./coinsurance 50% after ded. 80% after ded. 60% after ded.
or copay or copay
Pharmacy
Retail 80% after ded. 60% after ded.
Mail 80% after ded. Not available
Out-of-pocket See page 8 for plan details See page 8 for plan details Pharmacy expenses are included
maximum in your medical out-of-pocket
maximum
7/1/15 to 6/30/16 Medical Plans
Semi-Monthly Premium
Premium Basic HSA
Employee only $24.81 $7.55 $5.81
Employee + spouse $228.07 $140.68 $135.32
Employee + child(ren) $156.39 $104.50 $96.67
Employee + family $332.09 $214.36 $206.21
TheBANK of Edwardsville
