Page 7 - Enrollment Guide
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Low Deductible Plan (PPO) High Deductible Plan (HDHP)
PPO Out-of-Network PPO Out-of-Network
Calendar Year Deductible
Employee $1,000 $2,000 $2,000 $4,000
Family $2,000 $4,000 $4,000 $8,000
Out of Pocket Maximum
Employee $2,500 $5,000 $4,000 $8,000
Family $5,000 $10,000 $6,850 $16,000
Wellness/preventive care 100% no ded. Not covered 100% no ded. Not covered
Physician/Hospital Services
Primary care $30 copay 60% after ded. 80% after ded. 60% after ded.
Specialist $60 copay 60% after ded. 80% after ded. 60% after ded.
Hospital services 80% after ded. 60% after ded. 80% after ded. 60% after ded.
Emergency room services $250 copay 80% after ded. 80% after ded.
Urgent care $50 copay 60% after ded. 80% after ded.
Lifetime maximum Unlimited Unlimited Unlimited Unlimited
Low Deductible Plan (PPO) High Deductible Plan (HDHP)
PPO Out-of-Network PPO Out-of-Network
Retail Pharmacy Plan (30 day supply)
Tier 1—generic $10 copay Not covered 80% after ded * Not covered
Tier 2—preferred $35 copay Not covered 80% after ded * Not covered
Tier 3—non-preferred $60 copay Not covered 80% after ded * Not covered
Tier 4—specialty Rx $100 copay Not covered 80% after ded * Not covered
Retail or Mail Order Pharmacy Plan (90 day supply)
Tier 1—generic $20 copay Not covered 80% after ded * Not covered
Tier 2—preferred $70 copay Not covered 80% after ded * Not covered
Tier 3—non-preferred $120 copay Not covered 80% after ded * Not covered
Preventive Drugs
Generic/preferred/non-preferred Same copays as Not covered $5/$25/$50 Not covered
above
* Preventive medications are covered under the high deductible plan (HDHP) through the following copay structure: $5 copay (Tier 1, 30-day),
$25 copay (Tier 2, 30-day), and $50 copay (Tier 3, 30-day); 90-day supply are available at 2x the corresponding 30-day copay listed.
All members taking brand name medications may be required to pay the difference in the cost between the brand
name medication and its generic equivalent, if purchased.
2016 Medical/Rx Monthly Contributions
Low Deductible Plan High Deductible Plan
Employee $88.91 $55.41
Employee + spouse $188.72 $118.35
Employee + child(ren) $176.04 $115.73
Family $308.52 $187.89
Benefit Guide 2016
Low Deductible Plan (PPO) High Deductible Plan (HDHP)
PPO Out-of-Network PPO Out-of-Network
Calendar Year Deductible
Employee $1,000 $2,000 $2,000 $4,000
Family $2,000 $4,000 $4,000 $8,000
Out of Pocket Maximum
Employee $2,500 $5,000 $4,000 $8,000
Family $5,000 $10,000 $6,850 $16,000
Wellness/preventive care 100% no ded. Not covered 100% no ded. Not covered
Physician/Hospital Services
Primary care $30 copay 60% after ded. 80% after ded. 60% after ded.
Specialist $60 copay 60% after ded. 80% after ded. 60% after ded.
Hospital services 80% after ded. 60% after ded. 80% after ded. 60% after ded.
Emergency room services $250 copay 80% after ded. 80% after ded.
Urgent care $50 copay 60% after ded. 80% after ded.
Lifetime maximum Unlimited Unlimited Unlimited Unlimited
Low Deductible Plan (PPO) High Deductible Plan (HDHP)
PPO Out-of-Network PPO Out-of-Network
Retail Pharmacy Plan (30 day supply)
Tier 1—generic $10 copay Not covered 80% after ded * Not covered
Tier 2—preferred $35 copay Not covered 80% after ded * Not covered
Tier 3—non-preferred $60 copay Not covered 80% after ded * Not covered
Tier 4—specialty Rx $100 copay Not covered 80% after ded * Not covered
Retail or Mail Order Pharmacy Plan (90 day supply)
Tier 1—generic $20 copay Not covered 80% after ded * Not covered
Tier 2—preferred $70 copay Not covered 80% after ded * Not covered
Tier 3—non-preferred $120 copay Not covered 80% after ded * Not covered
Preventive Drugs
Generic/preferred/non-preferred Same copays as Not covered $5/$25/$50 Not covered
above
* Preventive medications are covered under the high deductible plan (HDHP) through the following copay structure: $5 copay (Tier 1, 30-day),
$25 copay (Tier 2, 30-day), and $50 copay (Tier 3, 30-day); 90-day supply are available at 2x the corresponding 30-day copay listed.
All members taking brand name medications may be required to pay the difference in the cost between the brand
name medication and its generic equivalent, if purchased.
2016 Medical/Rx Monthly Contributions
Low Deductible Plan High Deductible Plan
Employee $88.91 $55.41
Employee + spouse $188.72 $118.35
Employee + child(ren) $176.04 $115.73
Family $308.52 $187.89
Benefit Guide 2016
