|
HDHP |
||
| Medical | In-Network | Out-of-Network |
| Your Responsibility | ||
| Plan Year (Dec 1 – Nov 30) Deductible (Individual / Family) | $5,000 / $10,000 | $7,500 / $15,000 |
| Calendar Year Out-of-Pocket Max (Individual / Family) | $6,650 / $13,300 | $15,000 / $30,000 |
| Preventive Care | 0% | 50% |
| Primary Care Physician Office Visits | 0% * | 50% * |
| Specialist Physician Office Visits | 0% * | 50% * |
| Urgent Care Center | 0% * | 50% * |
| Emergency Room | 0% * | 50% * |
| Hospital – Inpatient Stay | 0% * | 50% * |
| Surgery – Outpatient | 0% * | 50% * |
| Routine Lab/ Radiology | 0% * | 50% * |
| Complex Imaging (CT/PET scans, MRIs) | 0% * | 50% * |
Prescription Drugs
| In-Network | Out-of-Network | ||
| Retail | Your Responsibility (After Medical Deductible) | ||
| Low-Cost Generic | $5 copay * | 50% * | |
| Generic | $20 copay * | 50% * | |
| Preferred Brand | $40 copay * | 50% * | |
| Non-Preferred | $70 copay * | 50% * | |
| Self-Administered Specialty Drugs 1 | 50% to $500 per script * | 50% * | |
* After deductible
Self-administered drugs are provided through the Specialty Pharmacy program. You have the option to choose any specialty pharmacy, however you will get the lowest cost if you use BriovaRx. You can contact BriovaRx at 855-427-4682.
Costs:
Example:
| Hours Worked | Per Hour | Total Paycheck | Total Insurance Cost (9.5%) |
| 40 | $ 10.00 | $ 400.00 | $ 38.00 |
| 40 | $ 12.00 | $ 480.00 | $ 45.60 |
| 40 | $ 14.00 | $ 560.00 | $ 53.20 |
| 40 | $ 15.00 | $ 600.00 | $ 57.00 |
The example rates shown above are for employee only single coverage. If you intend to cover your children dependents as well under this health plan, you will be responsible for an additional $70.49/wk, $305.48/month and $3,665.76/yr.
Enrollment Form Link— 2019-2020 ACA Benefit Enrollment Form
Notices We Are Required to Send to Associates- Packet of Compliance & 2019-2010 Benefit Guide
