Medical insurance helps you pay for preventive care, routine health needs, prescriptions, and advanced procedures by cost-sharing with your insurance provider.
BASE(with HRA) | BUY UP 1 (HMO) | BUY UP 2 (HMO) |
|
|---|---|---|---|
| IN-NETWORK ONLY | IN-NETWORK ONLY | IN-NETWORK ONLY | |
| Individual: $5,800 Family: $11,600 | Individual: $2,000 Family: $4,000 | Individual: $1,500 Family: $3,000 | |
| Primary Care: $40 copay Specialist: $40 - $50 copay Urgent Care: $40 copay | Primary Care: $30 copay Specialist: $30 - $45 copay Urgent Care: $30 copay | Primary Care: $20 copay Specialist: $20 - $35 copay Urgent Care: $20 copay | |
| Inpatient: 40%* - 30% coinsurance* Outpatient: 40%* - 30% coinsurance* Emergency Room (In/Out of-Network): $350 copay | Inpatient: 30% coinsurance* Outpatient: 30%* - 30% coinsurance* Emergency Room (In/Out of-Network): $150 copay | Inpatient: 20% coinsurance* Outpatient: 30%* - 25% coinsurance* Emergency Room (In/Out of-Network): $150 copay |
|
| Retail: $10 / $30 / $50 / 20% up to $250 Mail Order: $20 / $60 / $100 / 20% up to $250 | Retail: $10 / $30 / $50 / 20% up to $250 Mail Order: $20 / $60 / $100 / 30% up to $250 | Retail: $10 / $30 / $50 / 20% up to $250 Mail Order: $20 / $60 / $100 / 20% up to $250 |
|
| Individual: $7,000 Family: $14,000 | Individual: $3,500 Family: $7,000 | Individual: $3,000 Family: $6,000 |
|
| Employee: $122.79 Employee + 1 dependent: $555.99 Employee + 2 dependents: $912.20 | Employee: $261.21 Employee + 1 dependent: $776.59 Employee + 2 dependents: $1,298.67 | Employee: $351.52 Employee + 1 dependent: $966.61 Employee + 2 dependents: $1,575.02 |
Medical insurance helps you pay for preventive care, routine health needs, prescriptions, and advanced procedures by cost-sharing with your insurance provider.
PPO |
||
|---|---|---|
| IN-NETWORK | OUT-OF-NETWORK | |
| DEDUCTIBLE | Individual: $1,000 Family: $3,000 | Individual: $3,000Family: $9,000 |
| OFFICE VISITS | Primary Care: $35 copay Specialist: $40 copay Urgent Care: $35 copay | Primary Care: 40% coinsurance* Specialist: 40% coinsurance* Urgent Care: 40% coinsurance* |
| PROCEDURES | Inpatient: 20% coinsurance* Outpatient: 25%* - 10% coinsurance* Emergency Room: $150 + 20% coinsurance* | Inpatient: 40% coinsurance* Outpatient: 40% coinsurance* Emergency Room: $150 + 20% coinsurance |
| PRESCRIPTIONS | Retail: $10 / $30 / $50 / 30% up to $250 Mail Order: $20 / $60 / $100 / 30% up to $250 | Retail: 25% + ($10 / $30 / $50 / $250) Mail Order: Not Covered |
| OUT-OF-POCKET MAXIMUM | Individual: $5,500 Family: $11,000 | Individual: $10,000 Family: $20,000 |
| EMPLOYEE MONTHLY CONTRIBUTIONS | Employee: $441.67 Employee + 1 dependent: $1,243.81 Employee + 2 dependents: $1,961.09 | |
*Deductible applies first.
The benefits and rates in this guide are for illustrative purposes only. Please refer to the Summary of Benefits for specific benefits. To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlying insurance documents will govern in all cases.