Page 10 - Success Academy | 21-22 Benefits Summary
P. 10
Employee + Child(ren)
Copay Value Plan
HSA Plan
Copay Plus Plan
8
In-Network Only
In-Network Only
In-Network
Out-of-Network
$3,000
$3,000
$1,000
$5,000
N/A
$2,400
N/A
N/A
Preventive: $0 Primary: $30 Specialist/ Urgent Care: $50
N/A
Preventive: $0 Primary: $15 Specialist: $30 Urgent Care: $35
N/A
20%
10%
10%
30%
$15|$40|$80
$15|$30|$60
$15|$30|$60
N/A
$6,000
$4,000
$4,000
$10,000
$13,640.52
$13,522.80
$15,459.24
$2,220.60
$2,575.80
$5,153.04
Deductible
SA Contribution to Account
Coinsurance (% of medical costs employee pays for after meeting deductible)
Pharmacy
Out-of-Pocket Maximum
SA Pays (Annual)
Employee Pays (Annual)
Employee + Family (Spouse + Child(ren))
Copay Value Plan
HSA Plan
Copay Plus Plan
In-Network Only
In-Network Only
In-Network
Out-of-Network
$3,000
$3,000
$1,000
$5,000
N/A
$2,400
N/A
N/A
Preventive: $0 Primary: $30 Specialist/ Urgent Care: $50
Preventive: $0; fees vary
Preventive: $0 Primary: $15 Specialist: $30
N/A
20%
10%
10%
30%
$15|$40|$80
$15|$30|$60
$15|$30|$60
N/A
$6,000
$4,000
$4,000
$10,000
$21,261.24
$20,231.76
$24,176.40
$5,315.28
$6,743.88
$10,361.28
Deductible
SA Contribution to Account
Coinsurance (% of medical costs employee pays for after meeting deductible)
Pharmacy
Out-of-Pocket Maximum
SA Pays (Annual)
Employee Pays (Annual)
