Page 6 - 2016 Enrollment
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Wellness Program
Employees will have the opportunity to complete various wellness-related
tasks and receive a reduction in their premiums.
Medical Contributions—Monthly
Wellness Non-Wellness
Premium Premium
Plan HSA Plan Plan HSA Plan
Employee only $121 $37 $144 $57
Employee + spouse $658 $372 $687 $393
Employee + $589 $335 $612 $352
child(ren)
Family $750 $430 $779 $451
Medical Benefits
Premium Plan HSA Plan
Cigna Open
Out-of-
Out-of-
Access Plus In-Network Network In-Network Network
Deductible
Individual $750 $1,500 $1,500 $3,000
Family $1,500 $3,000 $3,000 $6,000
Coinsurance 10% 30% 10% 30%
Out-of-Pocket Maximum
Individual $2,500 $7,500 $3,500 $5,900
Family $5,000 $15,000 $7,000** $11,800
Ofice visit copay $20* 30% after 10% after 30% after
deductible deductible* deductible
Specialist copay $20 30% after 10% after 30% after
deductible deductible deductible
Urgent care copay $50 $50 10% after 30% after
deductible deductible
ER copay $150 $150 10% after 10% after
deductible deductible
Inpatient/ 10% after 30% after 10% after 30% after
outpatient services deductible deductible deductible deductible
* Routine preventive services covered at 100 percent
** Due to ACA, the out of pocket maximum for HSA Plan is now embedded, while the HSA
deductible continues to be non-embedded. (The PPO plan continues to have an embedded
deductible and out of pocket maximum)
Please refer to the Summary Plan Description for detailed information on covered beneits
Fontbonne University
Wellness Program
Employees will have the opportunity to complete various wellness-related
tasks and receive a reduction in their premiums.
Medical Contributions—Monthly
Wellness Non-Wellness
Premium Premium
Plan HSA Plan Plan HSA Plan
Employee only $121 $37 $144 $57
Employee + spouse $658 $372 $687 $393
Employee + $589 $335 $612 $352
child(ren)
Family $750 $430 $779 $451
Medical Benefits
Premium Plan HSA Plan
Cigna Open
Out-of-
Out-of-
Access Plus In-Network Network In-Network Network
Deductible
Individual $750 $1,500 $1,500 $3,000
Family $1,500 $3,000 $3,000 $6,000
Coinsurance 10% 30% 10% 30%
Out-of-Pocket Maximum
Individual $2,500 $7,500 $3,500 $5,900
Family $5,000 $15,000 $7,000** $11,800
Ofice visit copay $20* 30% after 10% after 30% after
deductible deductible* deductible
Specialist copay $20 30% after 10% after 30% after
deductible deductible deductible
Urgent care copay $50 $50 10% after 30% after
deductible deductible
ER copay $150 $150 10% after 10% after
deductible deductible
Inpatient/ 10% after 30% after 10% after 30% after
outpatient services deductible deductible deductible deductible
* Routine preventive services covered at 100 percent
** Due to ACA, the out of pocket maximum for HSA Plan is now embedded, while the HSA
deductible continues to be non-embedded. (The PPO plan continues to have an embedded
deductible and out of pocket maximum)
Please refer to the Summary Plan Description for detailed information on covered beneits
Fontbonne University
