Page 9 - Success Academy | 21-22 Benefits Summary
P. 9
Employee Only
Copay Value Plan
HSA Plan
Copay Plus Plan
7
In-Network Only
In-Network Only
In-Network
Out-of-Network
$1,500
$1,500
$500
$2,500
N/A
$1,200
$0
$0
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 After deductible
$15|$30|$60
N/A
$3,000
$2,000
$2,000
$5,000
$7,287.72
$7,135.44
$8,245.32
$1,286.04
$1,566.36
$2,897.04
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 + Spouse
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
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
$15,460.56
$14,735.64
$17,396.52
$3,393.84
$4,401.48
$7,105.68
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)
