Page 7 - CPSS Benefit Guide Class 3 Employee

Medical and Pharmacy Coverage

Our medical plan is offered through Meritain, and prescription drugs are through Express Scripts.

HSA $2,300 PPO $1,500
Medical Plan
Provisions In-Network Out-of-Network In-Network Out-of-Network

Company contribution to HSA Match up to $800 a year at year end N/A – You may only enroll in an HSA if you
(Individual/Family) select the HSA $2,300 plan
Annual Deductible
(Individual/Family) $2,300/$4,600 $4,600/$9,200 $1,500/$3,000 $3,000/$6,000

Out-of-Pocket Maximum (Includes
Deductible) $6,750/$13,500 $13,500/$27,000 $5,000/$10,000 $10,000/$20,000
Coveredat 50% coinsurance after 50% coinsurance after
Preventive Care 100% deductible Covered at 100% deductible

Amount you pay after deductible
Primary Care Provider Office
Visit 20% coinsurance 50% coinsurance $30 copay 50% coinsurance
Specialist Office Visit 20% coinsurance 50% coinsurance $50 copay 50% coinsurance
X-Ray and Lab 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance
Inpatient Hospital Services 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance
Outpatient Hospital Services 20% coinsurance 50% coinsurance 20% coinsurance 50% coinsurance
Urgent Care 20% coinsurance 50% coinsurance $50 copay 50% coinsurance

Emergency Room 20% coinsurance $400 copay 50% coinsurance
Pharmacy Provisions In-Network Out-of-Network In-Network Out-of-Network

Retail pharmacy Amount you pay after deductible Amount you pay after deductible
(up to a 30-day supply)

Preventive Maintenance Generic $0 copay Member would need $0 copay Not covered
to submit claim for
Generic 20% coinsurance reimbursement. $10 copay Not covered
Reimbursement
Brand Preferred 20% coinsurance $35 copay Not covered
amount is equal to the
Brand Non-Preferred 20% coinsurance in-network cost share. $60 copay Not covered
Specialty 20% coinsurance $250 copay Not covered
Mail Order Pharmacy (90-day Amount you pay after deductible Amount you pay after deductible
supply)
Preventive Maintenance Generic $0 copay Member would need $0 copay Not covered
to submit claim for
Generic 20% coinsurance reimbursement. $25 copay Not covered
Reimbursement
Brand Preferred 20% coinsurance amount is equal to $87.50 copay Not covered
the in-network cost
share.
Brand Non-Preferred 20% coinsurance $150 copay Not covered
Note: This is a summary only of your coverage. In-network services are based on negotiated charges; out-of-network services are based on
reasonable and customary (R&C) charges.
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