Page 10 - 2019 Franke Enrollment Guide
P. 10
2019 BENEFITS ENROLLMENT
OAP Plan Choice Fund HSA Plan
In-Network Out-of-Network In-Network Out-of-Network
Plan Maximum
Per Lifetime Unlimited Unlimited
Deductible per Calendar Year
Per Individual $1,100 $2,200 $2,500 $5,000
Per Family $2,750 $5,500 $5,000 $10,000
Maximum Out-of-Pocket Exposure per Calendar Year (Includes Deductible)
Per Individual $3,000 $10,000 $3,500 $14,000
Per Family $7,500 $25,000 $6,850 $28,000
Coinsurance 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Covered Services
Hospital Services
Inpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Emergency Room 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Urgent Care Center 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Physician Services
Office Visit PCP—$25 copay 60% after deductible 80% after deductible 60% after deductible
Specialist—$50 copay
Other Covered Services
Preventive Care 100% covered 60% after deductible 100% covered 60% after deductible
Telemedicine $25 copay N/A $45 MD Live/$49 N/A
Amwell - applied to
deductible
Prescription Drug Benefit*
OAP Plan Choice Fund HSA Plan
Mail Order Mail Order
Retail Pharmacy Pharmacy Retail Pharmacy Pharmacy
Generic $8 copay $16 copay 80% after deductible
Preferred Brands $40 copay $80 copay HSA Generic Preventive drug
Non-Preferred Brands $70 copay $140 copay list—100% covered
Listed No Cost Preventive Medications 100% 100%
* All specialty medications must be filled through the CIGNA Specialty Pharmacy network; if you select a brand name drug when
a generic equivalent is available, the plan will only pay the cost of the generic drug; the plan will not cover medications for which
there is an equivalent over-the-counter alternative, all listed maintenance medications must be filled through home delivery or 90
Now network pharmacies.
Bi-Weekly Medical Contributions—Paid By You on a Pre-Tax Basis
Employee Premiums** With 1 Wellness Discount With 2 Wellness Discounts
OAP Plan Bi-Weekly Rates
Employee Only $68.06 $37.29 $37.29
Employee + Spouse $218.14 $187.37 $156.60
Employee + Child(ren) $142.63 $111.86 $111.86
Family $277.80 $247.03 $216.26
HSA Plan Bi-Weekly Rates
Employee Only $46.46 $15.69 $15.69
Employee + Spouse $155.70 $124.93 $94.16
Employee + Child(ren) $91.30 $60.53 $60.53
Family $191.57 $160.80 $130.03
** Each tobacco user will pay an additional $23.08 per pay period for either of the medical plan options. If both you and your
covered spouse are tobacco users, you will pay an additional $46.16 per pay period for either of the medical plan options.
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OAP Plan Choice Fund HSA Plan
In-Network Out-of-Network In-Network Out-of-Network
Plan Maximum
Per Lifetime Unlimited Unlimited
Deductible per Calendar Year
Per Individual $1,100 $2,200 $2,500 $5,000
Per Family $2,750 $5,500 $5,000 $10,000
Maximum Out-of-Pocket Exposure per Calendar Year (Includes Deductible)
Per Individual $3,000 $10,000 $3,500 $14,000
Per Family $7,500 $25,000 $6,850 $28,000
Coinsurance 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Covered Services
Hospital Services
Inpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Outpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Emergency Room 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Urgent Care Center 80% after deductible 60% after deductible 80% after deductible 60% after deductible
Physician Services
Office Visit PCP—$25 copay 60% after deductible 80% after deductible 60% after deductible
Specialist—$50 copay
Other Covered Services
Preventive Care 100% covered 60% after deductible 100% covered 60% after deductible
Telemedicine $25 copay N/A $45 MD Live/$49 N/A
Amwell - applied to
deductible
Prescription Drug Benefit*
OAP Plan Choice Fund HSA Plan
Mail Order Mail Order
Retail Pharmacy Pharmacy Retail Pharmacy Pharmacy
Generic $8 copay $16 copay 80% after deductible
Preferred Brands $40 copay $80 copay HSA Generic Preventive drug
Non-Preferred Brands $70 copay $140 copay list—100% covered
Listed No Cost Preventive Medications 100% 100%
* All specialty medications must be filled through the CIGNA Specialty Pharmacy network; if you select a brand name drug when
a generic equivalent is available, the plan will only pay the cost of the generic drug; the plan will not cover medications for which
there is an equivalent over-the-counter alternative, all listed maintenance medications must be filled through home delivery or 90
Now network pharmacies.
Bi-Weekly Medical Contributions—Paid By You on a Pre-Tax Basis
Employee Premiums** With 1 Wellness Discount With 2 Wellness Discounts
OAP Plan Bi-Weekly Rates
Employee Only $68.06 $37.29 $37.29
Employee + Spouse $218.14 $187.37 $156.60
Employee + Child(ren) $142.63 $111.86 $111.86
Family $277.80 $247.03 $216.26
HSA Plan Bi-Weekly Rates
Employee Only $46.46 $15.69 $15.69
Employee + Spouse $155.70 $124.93 $94.16
Employee + Child(ren) $91.30 $60.53 $60.53
Family $191.57 $160.80 $130.03
** Each tobacco user will pay an additional $23.08 per pay period for either of the medical plan options. If both you and your
covered spouse are tobacco users, you will pay an additional $46.16 per pay period for either of the medical plan options.
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