MEDICAL INSURANCE
MEDICAL PLAN INFORMATION
65%+ FTE FACULTY 75%+ FTE STAFF
ELIGIBILITY
PLAN INFORMATION
HSA
PPO
BLUE ACCESS PPO CARE NETWORK
IN NETWORK
OUT OF NETWORK
IN NETWORK
OUT OF NETWORK
$2,750 Individual $5,500 Family $4,750 Individual* $9,500 Family* (Includes in-network medical and pharmacy expenses) $4,750 Individual $9,500 Family (non- embedded deductible) (includes in network medical and pharmacy expenses)
$5,500 Per Person $11,000 Family $9,500 Individual* $19,000 Family* (includes out of network medical and pharmacy expenses) $9,500 Individual* $19,000 Family* (includes in network medical and pharmacy expenses)
$1,100 Individual $2,200 Family $3,000 Individual $6,000 Family (Medical services only excludes copays; does NOT include deductible) $10,600 Individual $21,200 Family (Includes copays – medical and pharmacy)
$2,200 Per Person $4,400 Family
ANNUAL DEDUCTIBLE
$6,000 Individual $12,000 Family (Medical services excludes copays; does NOT include deductible)
ANNUAL OUT-OF- POCKET MAXIMUM**
Not Applicable (No limit on your out-of- pocket expenses)
PLAN MAXIMUM OUT-OF-POCKET***
65% After Deductible 65% After Deductible
65% After Deductible 65% After Deductible
PREVENTIVE CARE*
Covered 100%
Covered 100%
80% After Deductible
80% After Deductible
COVERED SERVICES
Retail/Mail Generic: 30% ($20 min, $30 max retail/$40 min, $60 max mail order) Formulary: 30% ($35 min, $55 max retail/$80 min, $110 max mail order) Non- Formulary: 30% ($55 min, $75 max retail/$110 min, $150 max mail order) Specialty: 30% ($250 max) 90-Day maintenance medications now available at retail pharmacies. Pharmacy copays apply to Plan Out-of-Pocket Maximum. *Out-of-network subject to co-insurance and deductible
PHARMACY 80% After Deductible
EMPLOYEE CONTRIBUTION PLAN ADMINISTRATOR
Rates vary based on plan selection. See page 7 for details.
* As recommended by the American Medical Association **The Annual Out-of-Pocket Maximum includes medical services only, excluding copays and the deductible. This is the maximum amount you will pay in co-insurance (e.g., 20% after deductible). ***The Plan Maximum Out-of-Pocket is the most you could pay in a calendar year for covered services, including deductible, co-insurance, and co- pays for both medical and pharmacy expenses.
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