Page 7 - 2018 Roquette Benefit Guide
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Roquette America Inc.
Medical Options Comparison Chart
Low Deductible Plan High Deductible Health Plan
Network Non-Network Network Non-Network
HSA Company Contribution
Individual Not applicable $250
Family Not applicable $250
Calendar Year
Deductible Non-Embedded Non-Embedded
Individual $750 $1,500 $1,350 $2,700
Family $1,500 $3,000 $2,700 $5,400
Out-of-Pocket Maximum Non-Embedded Non-Embedded
Individual $2,500 $4,500 $2,700 $5,400
Family $4,500 $9,000 $5,400 $10,800
Physician Ofice Visits
Primary Care $40 copay 30% after deductible 20% after deductible 40% after deductible
Specialist 20% after deductible 30% after deductible 20% after deductible 40% after deductible
Doctor-on-Demand/ $30 copay 30% after deductible 20% after deductible 40% after deductible
Telemedicine
Wellness/Preventive 100%, no cost share 30% after deductible 100%, no cost share 40% after deductible
Services
Hospital Services
Inpatient 20% after deductible 30% after deductible 20% after deductible 40% after deductible
Outpatient 20% after deductible 30% after deductible 20% after deductible 40% after deductible
Emergency Room 20% after deductible 20% after deductible 20% after deductible 20% after deductible
Urgent Care Facility $50 copay 30% after deductible 20% after deductible 40% after deductible
Prescription Medications
Retail
Tier 1 $12 copay $12 copay 20% after deductible 20% after deductible
Tier 2 $30 copay $30 copay 20% after deductible 20% after deductible
Tier 3 $75 copay $75 copay 20% after deductible 20% after deductible
Specialty $100 copay Not covered 20% after deductible Not covered
Home Delivery
Tier 1 $24 copay Not covered 20% after deductible Not covered
Tier 2 $60 copay Not covered 20% after deductible Not covered
Tier 3 $150 copay Not covered 20% after deductible Not covered
Specialty $200 copay Not covered 20% after deductible Not covered
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. Roquette provides coverage at 100% for IRS-approved preventive medications for
those enrolled in the high deductible health plan.
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Medical Options Comparison Chart
Low Deductible Plan High Deductible Health Plan
Network Non-Network Network Non-Network
HSA Company Contribution
Individual Not applicable $250
Family Not applicable $250
Calendar Year
Deductible Non-Embedded Non-Embedded
Individual $750 $1,500 $1,350 $2,700
Family $1,500 $3,000 $2,700 $5,400
Out-of-Pocket Maximum Non-Embedded Non-Embedded
Individual $2,500 $4,500 $2,700 $5,400
Family $4,500 $9,000 $5,400 $10,800
Physician Ofice Visits
Primary Care $40 copay 30% after deductible 20% after deductible 40% after deductible
Specialist 20% after deductible 30% after deductible 20% after deductible 40% after deductible
Doctor-on-Demand/ $30 copay 30% after deductible 20% after deductible 40% after deductible
Telemedicine
Wellness/Preventive 100%, no cost share 30% after deductible 100%, no cost share 40% after deductible
Services
Hospital Services
Inpatient 20% after deductible 30% after deductible 20% after deductible 40% after deductible
Outpatient 20% after deductible 30% after deductible 20% after deductible 40% after deductible
Emergency Room 20% after deductible 20% after deductible 20% after deductible 20% after deductible
Urgent Care Facility $50 copay 30% after deductible 20% after deductible 40% after deductible
Prescription Medications
Retail
Tier 1 $12 copay $12 copay 20% after deductible 20% after deductible
Tier 2 $30 copay $30 copay 20% after deductible 20% after deductible
Tier 3 $75 copay $75 copay 20% after deductible 20% after deductible
Specialty $100 copay Not covered 20% after deductible Not covered
Home Delivery
Tier 1 $24 copay Not covered 20% after deductible Not covered
Tier 2 $60 copay Not covered 20% after deductible Not covered
Tier 3 $150 copay Not covered 20% after deductible Not covered
Specialty $200 copay Not covered 20% after deductible Not covered
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. Roquette provides coverage at 100% for IRS-approved preventive medications for
those enrolled in the high deductible health plan.
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