Page 2 - QSC Action Guide 2019 San Luis Obispo
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SUMMARY OF PLAN CHANGES

         Below is a list of plan design changes effective July 1, 2019. Please review these before making your benefit
         elections for the July 1, 2019 plan year. Your next opportunity to make benefit changes will be for January 1, 2020.

                                                                Current Benefit              Effective 7/1/2019
         Medical HMO (Full)                                                                 Through 12/31/2020

           Office Visit Copay                                $20 PCP / $40 Specialist     $30 PCP / $50 Specialist
           Out-of-Pocket Maximum                               $2,000 / $4,000              $3,000 / $6,000
           Outpatient Surgery                                     $40 Copay                   $250 Copay
           Urgent Care Copay                                      $35 Copay                   $50 Copay
           Advanced Imaging Copay                                 $40 Copay                   $100 Copay
           Pharmacy Copays (Retail/Mail Order)           $10/$25/$50 (2x Mail Order)  $15/$30/$50 (2x Mail Order)
         Medical OAP (PPO)
           Deductible (In-Network) (Ind. /Ind. in Fam/Fam)     $750 / $750 / $1,500     $1,000 / $1,000 / $2,000
           Deductible (Out-of-Network)                       $750 / $750 / $1,500       $2,000 / $2,000 / $4,000
           Out-of-Pocket Maximum (In-Network)                  $3,500 / $7,000              $4,000 / $8,000
           Out-of-Pocket Maximum (Out-of-Network)              $3,500 / $7,000              $6,000 / $12,000
           Coinsurance (You Pay)                                  20% / 40%                   20% / 50%
           Office Visit Copay                                $25 PCP / $40 Specialist     $30 PCP / $50 Specialist
           Urgent Care Copay                                      $35 Copay                   $50 Copay
           Pharmacy Copays (Retail/Mail Order)           $10/$25/$50 (2x Mail Order)  $15/$30/$50 (2x Mail Order)
         Health Savings Account

         Employer Funding - Individual / Family              $46.16 / $92.31 biweekly       $45 / $90 biweekly


                                                                Current Benefit              Effective 7/1/2019
         Flexible Spending Account                                                          Through 12/31/2019

           Health Care FSA                                    $2,650 Maximum               $1,350 Maximum
           Dependent Care FSA                                 $5,000 Maximum               $2,500 Maximum
         Flexible Spending Account                                                       Effec ve 1/1 ‐ 12/31/2020

           Health Care FSA                                           N/A                   $2,700 Maximum
           Dependent Care FSA                                                              $5,000 Maximum

                    Health Advocate

                    QSC is excited to offer our employees access to Health Advocate. Health Advocate is a program that
                    provides you with experienced help when dealing with benefit related issues. Their team includes highly
                    trained registered nurses, backed by a staff of medical directors and administrative experts. When you
                    call Health Advocate for assistance, you are assigned a Personal Health Advocate who takes
                    responsibility for helping you to resolve problems.

                      Contacting Health Advocate

                      Telephone: If you need assistance dealing with benefit-related issues, you can speak
                      directly with a highly trained Personal Health Advocate by calling (866) 799-2731

                      Email: answers@healthadvocate.com

                      Web: www.healthadvocate.com/members

                      Mobile App:  Available for free at the Apple App Store or Google Play Store



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