Page 7 - 2015 Reznor Union Enrollment Guide
P. 7
Nortek
CDHP with HRA
In-Network Out-of-Network HRA Plan Basics
Calendar Year Deductible Your company contributes to your
Individual $1,200 $2,400 HRA and you use those funds
Individual + Spouse $1,800 $3,600
Individual + Child(ren) $2,400 $4,800 to pay for qualiied healthcare
Family $2,400 $4,800 expenses during the year
Out-of-Pocket Maximum
Individual $4,500 $9,000 Once you’ve used the dollars
Individual + Spouse $6,750 $10,000 in your HRA, you pay for your
Individual + Child(ren) $9,000 $14,000 expenses up to deductible
Family $9,000 $14,000
HRA Contribution from Company After your deductible is met, you
Individual $750 pay a coinsurance amount for your
Individual + Spouse $1,125 services up to the out-of-pocket
Individual + Child(ren) $1,500 maximum
Family $1,500
Physician Ofice Visits Money left over at the end of the year
Primary Care 80% after deductible 60% after deductible rolls over to your active HRA to use
Specialist 80% after deductible 60% after deductible
Preventive Care next year .
Coverage level 100% covered Not covered
Hospital Services
Inpatient 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible
Emergency Room 80% after deductible 80% after deductible
Urgent Care 80% after deductible 60% after deductible
Lab Services/X-Ray
Physician Ofice 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible
Prescription Drugs
Retail Supply Limit 30 days
Tier 1 25% per prescription 50% per prescription*
Min. $10 copay
Max. $15 copay
Tier 2 25% per prescription 50% per prescription*
Min. $30 copay
Max. $40 copay
Tier 3 25% per prescription 50% per prescription*
Min. $60 copay
Max. $70 copay
Retail Supply Limit 90 days
Tier 1 25% per prescription Not covered
Min. $20 copay
Max. $30 copay
Tier 2 25% per prescription Not covered
Min. $60 copay
Max. $80 copay
Tier 3 25% per prescription Not covered
Min. $120 copay
Max. $140 copay
Out-of-Pocket Maximum
Individual $2,100 N/A
Family $4,200 N/A
* Reimbursements less the applicable coinsurance
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CDHP with HRA
In-Network Out-of-Network HRA Plan Basics
Calendar Year Deductible Your company contributes to your
Individual $1,200 $2,400 HRA and you use those funds
Individual + Spouse $1,800 $3,600
Individual + Child(ren) $2,400 $4,800 to pay for qualiied healthcare
Family $2,400 $4,800 expenses during the year
Out-of-Pocket Maximum
Individual $4,500 $9,000 Once you’ve used the dollars
Individual + Spouse $6,750 $10,000 in your HRA, you pay for your
Individual + Child(ren) $9,000 $14,000 expenses up to deductible
Family $9,000 $14,000
HRA Contribution from Company After your deductible is met, you
Individual $750 pay a coinsurance amount for your
Individual + Spouse $1,125 services up to the out-of-pocket
Individual + Child(ren) $1,500 maximum
Family $1,500
Physician Ofice Visits Money left over at the end of the year
Primary Care 80% after deductible 60% after deductible rolls over to your active HRA to use
Specialist 80% after deductible 60% after deductible
Preventive Care next year .
Coverage level 100% covered Not covered
Hospital Services
Inpatient 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible
Emergency Room 80% after deductible 80% after deductible
Urgent Care 80% after deductible 60% after deductible
Lab Services/X-Ray
Physician Ofice 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible
Prescription Drugs
Retail Supply Limit 30 days
Tier 1 25% per prescription 50% per prescription*
Min. $10 copay
Max. $15 copay
Tier 2 25% per prescription 50% per prescription*
Min. $30 copay
Max. $40 copay
Tier 3 25% per prescription 50% per prescription*
Min. $60 copay
Max. $70 copay
Retail Supply Limit 90 days
Tier 1 25% per prescription Not covered
Min. $20 copay
Max. $30 copay
Tier 2 25% per prescription Not covered
Min. $60 copay
Max. $80 copay
Tier 3 25% per prescription Not covered
Min. $120 copay
Max. $140 copay
Out-of-Pocket Maximum
Individual $2,100 N/A
Family $4,200 N/A
* Reimbursements less the applicable coinsurance
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