Medical Benefits
Effective October 1, 2020 Here is a snapshot of the coverage offered through the 2020-2021 medical plans.
BENEFITS – Kelsey & Cigna
Kelsey 90
Kelsey 80
HSA Plan
$2,800 Individual / $5,000 Family $5,000 Individual / $10,000 Family Includes Deductible $4,000 Individual / $8,000 Family $8,000 Individual / $16,000 Family
Deductible
Network
None
None
Non-Network
N/A
N/A
Out-of-Pocket Maximum
$2,000 Individual / $4,000 Family
$3,000 Individual / $6,000 Family
Network
Non-Network
N/A 90% N/A
N/A 80% N/A
Co-insurance
Network
80% 60%
Non-Network
Lifetime Maximum
Unlimited You Pay
Unlimited You Pay
Unlimited You Pay
Office Visit
Network
$25 PCP / $50 Spec
$25 PCP / $50 Spec
Deductible/ 20% Deductible/ 40%
Non-Network
N/A
N/A
Wellness Visit
Network
$0 Copay
$0 Copay
$0 Copay
Non-Network
N/A
N/A
Deductible/ 40%
In-Patient & Out-Patient Hospital
Network
10% N/A
20% N/A
Deductible/ 20% Deductible/ 40% Deductible/ 20% Deductible/ 40% Deductible/ 20% Deductible/ 40% Deductible Then $10/$40/$80/$150 Deductible Then $20/$80/$160/$300 Open Access PPO
Non-Network
Urgent Care
Network
$75 Copay
$75 Copay
Non-Network
N/A
N/A
Emergency Room
Network
$200 Copay
$200 Copay
Non-Network Generic/Brand/ Non-Formulary
N/A
N/A
Prescriptions
$10/$40/$80/$150
$10/$40/$80/$150
Mail Order (90 Days)
$20/$80/$160/$300
$20/$80/$160/$300
Network
Kelsey Care Network
Kelsey Care Network
NOTE: This is a brief summary and not intended to be a contract.
Medical Costs Per Pay Period Employee Only
Kelsey 90
Kelsey 80
HSA Plan
Wellness $11.00 $148.50 $111.00 $237.00
Non-Wellness
Wellness
Non-Wellness
Wellness $19.50 $166.00 $131.00 $245.00
Non-Wellness
$36.00 $173.50 $136.00 $262.00
$0.00
$25.00 $151.00 $116.50 $231.00
$44.50 $191.00 $156.00 $270.00
Employee & Spouse Employee & Children Employee & Family
$126.00 $91.50 $206.00
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