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N/A = Not Applicable| HRA Wellness Plan | HRA Standard Plan | High Deductible Wellness Plan | High Deductible Standard Plan | Choice HMO Wellness Plan | Choice HMO Standard Plan | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Medical | Network | Non-network | Network | Non-network | Network | Non-network | Network | Non-network | Network | Non-network | Network | Non-network |
| Deductible | ||||||||||||
| Employee | $1,300 | $1,300 | $1,500 | $3,000 | $1,750 | $3,500 | $1,000 | N/A | $1,000 | |||
| Employee + Spouse | $2,250 | $2,250 | $3,000 | $6,000 | $3,500 | $7,000 | $1,500 | N/A | $1,500 | |||
| Employee + Child(ren) | $2,250 | $2,250 | $3,000 | $6,000 | $3,500 | $7,000 | $1,500 | N/A | $1,500 | |||
| Employee + Family | $3,250 | $3,250 | $3,000 | $6,000 | $3,500 | $7,000 | $2,000 | N/A | $2,000 | |||
| Out-of-pocket maximum | ||||||||||||
| Employee | $3,000 | $3,000 | $2,400 | $5,300 | $2,650 | $5,800 | $3,000 + copays | N/A | $3,000 + copays | |||
| Employee + Spouse | $5,000 | $5,000 | $4,100 | $9,800 | $4,600 | $10,800 | $4,500 + copays | N/A | $4,500 + copays | |||
| Employee + Child(ren) | $5,000 | $5,000 | $4,100 | $9,800 | $4,600 | $10,800 | $4,500 + copays | N/A | $4,500 + copays | |||
| Employee + Family | $7,000 | $7,000 | $4,100 | $9,800 | $4,600 | $10,800 | $6,000 + copays | N/A | $6,000 + copays | |||
| HRA Credit Dollars | ||||||||||||
| Employee | $500 | $375 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | |||
| Employee + Spouse | $1,000 | $650 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | |||
| Employee + Child(ren) | $1,000 | $650 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | |||
| Employee + Family | $1,500 | $1,000 | N/A | N/A | N/A | N/A | N/A | N/A | N/A | |||
| Ambulance (emergency only) | 85% * | 85% * | 90% * | 80% * | 100% | N/A | 100% | |||||
| Chiropractic Visit (20 Visits per Plan year) | 85% * | 60% * | 85% * | 60% * | 90% * | 60% * | 80% * | 60% * | $45 copay | N/A | $55 copay | |
| Emergency room | 85% * | 85% * | 90% * | 80% * | $150 copay (waived if admited), 100% | N/A | $150 copay (waived if admitted), 100% | |||||
| Eye Exam - Routine (limited to one exam every 24 months; no non-network coverage) | 100% | 100% | 100% | 100% | 100% | N/A | 100% | |||||
| Hospital stay (inpatient / outpatient) | 85% * | 60% * | 85% * | 60% * | 90% * | 60% * | 80% * | 60% * | 80%* | N/A | 80% * | |
| Maternity Care (physician only) | 85% * | 60% * | 85% * | 60% * | 90% * | 60% * | 80% * | 60% * |
$35 copay (initial visit only, 100%) |
N/A | $45 copay (initial visit only, 100%) | |
| Outpatient Rehabilitation - Physical, Speech, Occupational, Cardiac, Pulmonary Therapy (40 visits per therapy per Plan year) | 85% * | 60% * | 85% * | 60% * | 90% * | 60% * | 80% * | 60% * | $25 copay | N/A | $25 copay | |
| Physician Office Services (illness/injury) | 85% * | 60% * | 85% * | 60% * | 90% * | 60% * | 80% * | 60% * |
$35 copay-PCP $45 copay - Specialist |
N/A | $45 copay – PCP $55 copay – Specialist | |
| Physician Office Services (preventive; no non-network coverage) | 100% | N/A | 100% | 100% | 100% | 100% | N/A | 100% | ||||
| Professional fees for surgical and medical | 85% * | 60% * | 85% * | 60% * | 90% * | 60% * | 80% * | 60% * | 80%* | N/A | 80% * | |
| Urgent care visit | 85% * | 60% * | 85% * | 60% * | 90% * | 60% * | 80% * | 60% * | $35 copay | N/A | $35 copay | |
| Mental Health/Substance Abuse-Inpatient (prior notification required, Visits unlimited) | 85% * | 60% * | 85% * | 60% * | 90% * | 60% * | 80% * | 60% * | 80%* | N/A | 80% * | |
| Mental Health/Substance Abuse-Outpatient (prior notification required, Visits unlimited) | 85% * | 60% * | 85% * | 60% * | 90% * | 60% * | 80% * | 60% * | $45 copay | N/A | $55 copay – Specialist 80% * – Facility | |
| Retail Pharmacy |
Tier 1 — 85% ($20 min/$50 max) Tier 2 — 75% ($50 min/$80 max) Tier 3 — 75% ($80 min/$125 max) Does not apply to deductible or out-of-pocket |
40% |
Tier 1 — 85% ($20 min/$50 max) Tier 2 — 75% ($50 min/$80 max) Tier 3 — 75% ($80 min/$125 max) Does not apply to deductible or out-of-pocket |
80% * ($10 min/ $100 max) No non-network coverage |
80% * ($10 min/ $100 max) No non-network coverage |
Tier 1 - $20 Tier 2 - $50 Tier 3 - $90 (up to a 31-day supply) |
Tier 1 – $20 Tier 2 – $50 Tier 3 – $90 (up to a 31-day supply) |
|||||
| 90-Day Mail Order |
Tier 1 — 85% ($50 min/$125 max) Tier 2 — 75% ($125 min/$200 max) Tier 3 — 75% ($200 min/$312.50 max) Does not apply to deductible or out-of-pocket |
Tier 1 — 85% ($50 min/$125 max) Tier 2 — 75% ($125 min/$200 max) Tier 3 — 75% ($200 min/$312.50 max) Does not apply to deductible or out-of-pocket |
80% * ($25 min / $250 max) No Non-network Coverage |
80% * ($25 min / $250 max) No Non-network Coverage |
Tier 1 — $50 Tier 2 — $125 Tier 3 — $225 |
Tier 1 — $50 Tier 2 — $125 Tier 3 — $225 |
||||||
* Subject to deductible