Page 7 - 2018 VER Benefit Guide
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Medical Options Comparison Chart
Option 1 Option 2
PPO Plan HSA Plan
Network Non-Network Network Non-Network
Account Funding
Individual None $750
Family None $1,500
Calendar Year Deductible Embedded Non-Embedded
Individual $250 $3,500 $2,000 $4,000
Family $500 $7,000 $4,000 $8,000
Out-of-Pocket Maximum Embedded Embedded
Individual $3,000 $10,000 $4,000 $8,000
Family $6,000 $20,000 $8,000 $16,000
Physician Ofice Visits
Primary Care $30 copay 50% after deductible 90% after deductible 70% after deductible
Specialist $30 copay 50% after deductible 90% after deductible 70% after deductible
Wellness/Preventive 100%, no cost share 50% after deductible 100%, no cost share 70% after deductible
Services
Hospital Services
Inpatient $500 copay 50% after deductible 90% after deductible 70% after deductible
Outpatient $250 copay 50% after deductible 90% after deductible 70% after deductible
Emergency Room 90% after deductible 90% after deductible 90% after deductible 90% after deductible
Urgent Care Facility $30 copay $30 copay 90% after deductible 90% after deductible
Prescription Medications
Retail
Tier 1–Generic $10 copay 50% no deductible 10% after deductible 30% after deductible
Tier 2–Preferred Brand $30 copay 50% no deductible 10% after deductible 30% after deductible
Tier 3–Non–Preferred Brand $50 copay 50% no deductible 10% after deductible 30% after deductible
Tier 4–Specialty 30% to $150 max 50% no deductible 10% to $150 max* 30% after deductible
Home Delivery
Tier 1–Generic $10 copay Not covered 10% after deductible Not covered
Tier 2–Preferred Brand $60 copay Not covered 10% after deductible Not covered
Tier 3–Non–Preferred Brand $100 copay Not covered 10% after deductible Not covered
Tier 4–Specialty 30% to $150 max Not covered 10% to $150 max* Not covered
* Applies after deductible has been met.
Preventive care is an integral part of a comprehensive healthcare plan which includes preventive drug therapies. Preventive
medications are those used for the prevention of conditions such as high blood pressure, high cholesterol, asthma, and stroke.
VER covers preventive medications at 100% under both plan options.
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Option 1 Option 2
PPO Plan HSA Plan
Network Non-Network Network Non-Network
Account Funding
Individual None $750
Family None $1,500
Calendar Year Deductible Embedded Non-Embedded
Individual $250 $3,500 $2,000 $4,000
Family $500 $7,000 $4,000 $8,000
Out-of-Pocket Maximum Embedded Embedded
Individual $3,000 $10,000 $4,000 $8,000
Family $6,000 $20,000 $8,000 $16,000
Physician Ofice Visits
Primary Care $30 copay 50% after deductible 90% after deductible 70% after deductible
Specialist $30 copay 50% after deductible 90% after deductible 70% after deductible
Wellness/Preventive 100%, no cost share 50% after deductible 100%, no cost share 70% after deductible
Services
Hospital Services
Inpatient $500 copay 50% after deductible 90% after deductible 70% after deductible
Outpatient $250 copay 50% after deductible 90% after deductible 70% after deductible
Emergency Room 90% after deductible 90% after deductible 90% after deductible 90% after deductible
Urgent Care Facility $30 copay $30 copay 90% after deductible 90% after deductible
Prescription Medications
Retail
Tier 1–Generic $10 copay 50% no deductible 10% after deductible 30% after deductible
Tier 2–Preferred Brand $30 copay 50% no deductible 10% after deductible 30% after deductible
Tier 3–Non–Preferred Brand $50 copay 50% no deductible 10% after deductible 30% after deductible
Tier 4–Specialty 30% to $150 max 50% no deductible 10% to $150 max* 30% after deductible
Home Delivery
Tier 1–Generic $10 copay Not covered 10% after deductible Not covered
Tier 2–Preferred Brand $60 copay Not covered 10% after deductible Not covered
Tier 3–Non–Preferred Brand $100 copay Not covered 10% after deductible Not covered
Tier 4–Specialty 30% to $150 max Not covered 10% to $150 max* Not covered
* Applies after deductible has been met.
Preventive care is an integral part of a comprehensive healthcare plan which includes preventive drug therapies. Preventive
medications are those used for the prevention of conditions such as high blood pressure, high cholesterol, asthma, and stroke.
VER covers preventive medications at 100% under both plan options.
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