MEDICAL INSURANCE
MEDICAL PLAN INFORMATION
65%+ FTE FACULTY 75%+ FTE STAFF
ELIGIBILITY
PLAN INFORMATION
PPO
HSA
BLUE ACCESS PPO CARE NETWORK
IN NETWORK
OUT OF NETWORK
IN NETWORK
OUT OF NETWORK
$1,000 Individual $2,000 Family $2,750 Individual $5,500 Family $9,200 Individual $18,400 Family (includes copays – medical and pharmacy)
$2,000 Individual $4,000 Family $5,500 Individual $11,000 Family
$2,250 Individual $4,500 Family $4,500 Individual $9,000 Family $4,500 Individual $9,000 Family (non- embedded deductible) (includes in network medical and pharmacy expenses)
$5,000 Per Person $9,000 Family $9,000 Individual $18,000 Family $9,000 Individual $18,000 Family (includes in network medical and pharmacy expenses)
ANNUAL DEDUCTIBLE
ANNUAL OUT-OF- POCKET MAXIMUM**
Not Applicable (no limit on your out- of- pocket expenses)
PLAN MAXIMUM OUT-OF-POCKET***
ANNUAL HEALTH SAVINGS ACCOUNT FUNDING (UC)
$325 – $825 EE $650 - $1,650 Family
$325 – $825 EE $650 - $1,650 Family
Not Applicable
Not Applicable
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.
80% After Deductible
PHARMACY
EMPLOYEE CONTRIBUTION
Rates vary based on plan selection. See page 7 for details.
PLAN ADMINISTRATOR
* 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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