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3 Table of Contents
4 About SIHO
5 Fully Insured Products
6 Product Components
8 Precertification Information
9 Eligibility Guidelines
10 HRA & HSA Overview
11 Information Available on the SIHO Website
12 How To Get A Quote
14 3 Tier Plan Designs
24 2 Tier Plan Designs
30 Voluntary Dental Option
31 Voluntary Vision Option
For questions about plan
information in this brochure,
please contact our Account
Coordinator.
4
SIHO Insurance Services, headquartered in Columbus, Indiana, was established in 1987
through the cooperative efforts of local physicians, hospitals, and employers who were
concerned about the rising cost of health care.
SIHO was formed with a vision to provide affordable health care benefits by partnering with
local medical providers and employers. One of the fastest growing Health Plan
Administrators in the Midwest, SIHO strives to raise the standard of health care and the
quality of life in its communities.
SIHO’s promise to its customers is very simple: provide them with the sophistication of a
national carrier while keeping the focus on flexibility and cost-effectiveness as a top priority.
SIHO provides friendly and professional customer
service with a personal touch to all our clients. SIHO's Member
Service Representatives are trained to answer questions pertaining
to the health plans, including benefit coverage and claim inquiries.
With offices located in Columbus and Seymour Indiana, SIHO is
able to provide local, reliable customer service to all of our
members. SIHO’s employees are highly trained with access to the
latest technology to provide fast and accurate administration of
claims payment, issuance of ID cards and policies.
How can I help
you today?
5
SIHO provides a wide range of health plans specifically designed for your
business. Working with insurance agents and benefit consultants, SIHO is
dedicated to servicing all aspects of an employer’s group health plan. Managing
complex administrative requirements while simultaneously providing first-class
service to our customers is the SIHO advantage.
PPO (Choice) Plans
In addition to our comprehensive health plans, SIHO also provides other
employee benefit programs:
HSA Plans
HRA Plans
Flexible Spending
Administration
COBRA
Administration Dental Plans Vision Plans Life Insurance
SIHO has a solution to your
network needs. We offer both two
tier and three tier network plans.
The employer’s location will
determine network options.
6
SIHO’s staff of Physicians, Nurse Practitioners and Registered Nurses
ensure medical services are clinically appropriate, meet the standards
of care in the community and are done in the most cost-effective
manner. SIHO’s medical staff provides expert medical opinions and
information to improve the quality of care for SIHO members. SIHO
also provides follow-up contacts, when needed, to ensure proper care
is being followed.
Preventive care is covered for all members with zero cost
sharing. Check www.siho.org for the latest version of our
Preventive Health Benefit.
SIHO uses many national health care guidelines to create our
Preventive Health Benefit standards and recommendations.
Our Quality Management Committee reviews preventive care
services quarterly and updates the benefits as needed.
SIHO provides coverage to expecting mothers
before and after delivery. Covered services include:
office visits, services prior to birth, delivery and
follow-up care. Newborns receive coverage for the
first 30 days after birth. Parents must notify SIHO
of the new addition to the family within those 30
days to ensure continued coverage.
SIHO’s prescription drug coverage is managed by
Caremark. Members can purchase prescription
medications at a local retail pharmacies, as well as
through the mail order service.
Members can review their prescription drug
activity and cost, learn about various health
conditions and access self-care centers.
Members can also check drug prices at any
participating pharmacy.
SIHO offers a diabetes care management
program in partnership with Livongo.
• Voluntary program with zero cost for the member
• Advanced blood glucose meter, unlimited test strips
and lancets mailed to members home
• 24/7 monitoring and support, coaching by certified
diabetic educators, personalized member portal at
www.livongo.com
7
Plans cover emergency and urgent care services. If
hospital admission is required, SIHO must be notified
within 48 hours or as soon as reasonably possible.
Copays are waived if you are admitted to the hospital
directly from the Emergency Department.
SIHO encourages members to establish a relationship with a primary care physician (family practice, pediatrics and
internal medicine). When members see their primary care physician, they pay an office copay (or deductible and
coinsurance on HRA and HSA Plans) and the physician then files the claim directly with SIHO. We make the process
simple for you and your employees.
When members need to see a specialist physician, they pay an office copay (or deductible and coinsurance on HRA
and HSA Plans) to cover the office visit. Any ancillary services provided during the visit, such as radiology or
laboratory tests, are subject to coinsurance.
To find a participating provider, go to www.siho.org and click on “Member” tab. You can also call SIHO Member
Services at 812.378.7070 or toll-free 800.443.2980.
Group life insurance coverage is offered as an option for groups over 50 employees. The standard benefit is $15,000
for each employee plus $15,000 AD&D coverage. Dependent life insurance is available upon the employer’s request.
Members on Choice or HRA plans pay a $5 copay for
allergy injections from an in-network provider. This
benefit will help control out-of-pocket expenses for
members. HSA plan members pay deductible
and coinsurance.
SIHO has included mental health and substance abuse
benefits in our plans through the SOLUTIONS network.
SOLUTIONS is a service of Quinco Behavioral Health
Systems, which is a private, not-for-profit behavioral
health organization.
The enhanced mental health and substance abuse benefit
offers behavioral health care assistance in the identification
and resolution of problems that members face in their
everyday lives, including marital, family, drug abuse, work
and school-related issues, depression, stress, and anxiety
(HRA and HSA plans use the SIHO Network, instead of the
Solutions Network, for Mental Health Benefits).
If you are traveling and require emergency care
outside of the plan’s network, covered services are
paid at in-network levels. If you are traveling or
attend school outside of the plan’s network and are
in need of routine medical care, covered services are
paid at out-of-network levels; in most cases, you
would benefit from a network discount.
8
Members are responsible for obtaining precertification for services from network or non-network
providers. Failure to obtain precertification could result in a reduction of benefits for that service or
procedure up to a penalty of fifty percent (50%) of the Prevailing Rate.
1. All inpatient admission including but not limited to long term acute/sub-acute/rehab
2. Skilled nursing facilities
3. Inpatient Mental Health and Substance Abuse and residential treatment (RES for Mental
Health/Substance Abuse)
4. Home health care
5. Durable Medical Equipment and prosthetics (purchase over $750 and all rentals)
6. Hospice care
7. Transplant evaluations and procedures
8. Specialty medications (excluding insulin)
9. Oncology services (chemotherapy and radiation)
10. Applied Behavioral Analysis (ABA Therapy)
11. Dialysis
12. Speech therapy
13. Implantation of Cardiac Defibrillator
14. Genetic Testing
15. Neurological Implants and implanted nerve stimulator devices including but not limited
to spinal cord stimulators and vague nerve stimulators (VNS)
9
All medical and pharmacy quotes are issued contingent upon SIHO being the only medical coverage being offered
by the employer unless prior agreement is granted by SIHO.
For all groups, participation must be 75% of total eligible population excluding spousal waivers and waivers for
other coverage. If an employer is paying 100% of premium for employees, all eligible employees must be on the
medical plan.
Employees who are full-time, working a minimum of
30 hours per week in the regular business of the
employer, are eligible for coverage. Working owners
must be working a minimum of 20 hours per week or
80 hours per month to be on the medical plan.
The employer must contribute a minimum of 50%
of the employee only monthly premium.
An eligible dependent is a spouse or a child who is under
the age of 26 and is a natural born or legally adopted son,
daughter or stepchild.
Initial Enrollees
Coverage will take effect on the participating employer group’s effective date. Following the initial open enrollment
period, an annual open enrollment shall be held each year starting 45 days prior to the anniversary date of the
policy. Anyone wishing to join the plan at a time other than the effective date of the group is considered a late
enrollee and must meet the criteria below to be covered under the employer’s health plan. Anyone choosing not to
enroll during the initial enrollment period must wait until the next open enrollment period to do so. Coverage will
take effect on the participating employer’s anniversary date.
Late Enrollees
A member may be added as a late enrollee effective on a date other than the anniversary date if the member
experiences a qualifying event. Qualifying events include (but are not limited to) marriage, birth, adoption or spousal
loss of coverage.
10
The HRA consists of two parts:
A Health Reimbursement Arrangement starts out as a financial commitment from the employer to the employee; i.e., the employer will
pay the first $750 of medical expenses for the employee each year. If the employee incurs no claims, the employer does not make any
payment. However, this obligation generally carries over to the next year and is added to another $750 commitment for year two. HRAs
are generally paired with a higher deductible health plan whose structure can be very flexible, including co-payments for certain services.
HRAs are not portable; any balances are forfeited if an employee leaves the organization. Although HRAs can be used to cover the very
broad list of IRS qualified medical expenses, most employers limit their use to only services covered by the higher deductible health plan.
Claims must be submitted and substantiated to be paid from the HRA.
SIHO offers several HRA design variations to meet the needs of most employers. They each have differences in deductibles, coinsurance, co-pays and suggested HRA funding amounts.
An affordable health plan that provides comprehensive coverage for office visits, preventive care, prescription drugs, hospital costs and physician services.
A Health Reimbursement Account funded by the employer
which can be used to pay for services that are the
responsibility of the member, i.e., subject to deductible and
coinsurance. If the member does not use any or all of their
dollars, they roll over to the next year and will accumulate to
provide greater financial protection! The HRA cannot be used
to cover co-payments.
A Health Savings Account (HSA) can be viewed much like a medical IRA. It is a tax advantaged savings account that individuals
can use to pay for qualified health care expenses, both now and in the future. As employers continue to migrate to ever higher
deductible plans, it makes sense to consider structuring the High Deductible Health Plan (HDHP) so that employees can benefit
from the advantages of an HSA.
HSAs are physical accounts established at a bank, credit union or insurance company. In order to establish the HSA, the
consumer must be covered by a federally qualified HDHP. The structure of the HDHP is set by the U.S. Treasury with minimum
deductibles and limits on out-of-pocket maximums.
Employees and/or employers can contribute to the HSA, subject to an annual maximum. The accounts are portable and remain
with the employee, even if they change jobs. Withdrawals from the HSA can be made for any IRS qualified medical expense, the
list can be found at the web address below. The member does not need to submit claims or receipts to make a withdrawal. The
member should keep all receipts should they be audited by the IRS.
SIHO offers several HSA design variations to meet the needs of most employers. These designs can vary in: deductible,
coinsurance, and suggested HSA funding amounts by the employer. An employer may choose to offer their employees only an
HSA plan design. Alternatively, the employer may offer an HSA plan together with a more traditional plan to better meet the
needs of all employees.
https://www.irs.gov/pub/irs-pdf/p502.pdf
11
http://www.siho.org
Member Employer Provider Chamber Plans Social
Members Can:
• Log in to the Member Portal
• Search the Provider Directory
• Access Member Forms
• View Pharmacy Information
• Find Answers to FAQs
Employers Can:
• Log in to the Employer Portal
• Learn more about our Fully Insured Plans
• Access Health Links
• View Additional Wellness Information
Providers Can:
• Log in to the Provider Portal
• View Medical Forms
• Learn more about Provider Services
• Access and Submit Authorization Requests
and Check Eligibility
Login
We have a Mobile App!
Just search for SIHO in
the app store.
12
Name, Address, SIC code
EE, Spouse, Dependents, DOB, Zip Code, Gender
Medical Paid Claims by Month, RX Paid Claims by Month, High Cost
Member Paid Claims together with Diagnosis and Prognosis
If claims data is not available applications are required.
Signed within 60 days
Telephone 812.378.7071
Email [email protected]
13
To view participating providers visit siho.org or contact Carolyn Dailey.
St. Joseph, Marshall Select Health Network
Cass Logansport Memorial with
Sagamore
Boone, Hancock,
Hamilton, Hendricks,
Henry, Johnson, Rush
Suburban Health
Organization (SHO)
Shelby Suburban Health
Organization (SHO)
Bartholomew, Brown,
Jackson, Jennings SIHO with EncoreCombined
Clark, Dearborn, Floyd,
Harrison, Jefferson, Ohio,
Scott, Switzerland,
SIHO
Dubois
Patoka Valley Health Care
Cooperative with
EncoreCombined/Encore
Gibson, Knox, Perry, Pike,
Posey, Spencer,
Vanderburgh, Warrick
OneCare Network OneCare Network with
EncoreCombined
Allen, Crawford, Daviess,
Decatur, Dekalb, Elkhart,
Franklin, Greene,
Kosciusko, LaGrange,
Lawrence, Madison,
Marion, Martin, Monroe,
Morgan, Noble, Orange,
Owen, Ripley, Steuben,
EncoreCombined Encore Combined with
Encore
Note: The SIHO Proprietary Network is available in all of our licensed Counties, as is EncoreCombined and EncoreCombined with Encore. SIHO will work with the Agent and Employer to recommend the best network solution.
14
Prime Care Choice $500/20% Price Care Choice $1000/20%
Tier 1
Network Tier 2
Network
Tier 3
Out-of-
Network
Tier 1
Network Tier 2
Network
Tier 3 Out-of-Network
Annual Single Deductible $500 $1,000 $2,000
$1,000 $2,000 $3,000
Annual Family Deductible $1,000 $2,000 $4,000
$2,000 $4,000 $6,000
Annual OOP Max - Single
(incl Deductible, copay, and coinsurance) $5,000 $6,500 $9,000
$6,000 $7,500 $10,000
Annual OOP Max - Family
(incl Deductible, copay, and coinsurance) $10,000 $13,000 $18,000
$12,000 $15,000 $20,000
PCP Office Visit $20 $20 Ded, 50%
$25 $25 Ded, 50%
Specialist Office Visit
(20% for Ancillary Services) $30 $30 Ded, 50%
$40 $40 Ded, 50%
Preventive Care 0% 0% Not Covered
0% 0% Not Covered
Inpatient Hospital Services Ded, 20% Ded, 30% Ded, 50%
Ded, 20% Ded, 30% Ded, 50%
Outpatient Hospital Services Ded, 20% Ded, 30% Ded, 50%
Ded, 20% Ded, 30% Ded, 50%
Professional Services (In & Out) Ded, 20% Ded, 30% Ded, 50%
Ded, 20% Ded, 30% Ded, 50%
Emergency Room $250 $250 $250
$250 $250 $250
Urgent Care Facility $30 $30 Ded, 50%
$40 $40 Ded, 50%
Ambulance Ded, 20% Ded, 20% Ded, 20%
Ded, 20% Ded, 20% Ded, 20%
PT/OT/Speech Therapy
(20 visit annual max each) Ded, 20% Ded, 30% Ded, 50%
Ded, 20% Ded, 30% Ded, 50%
Chiropractic Services
(15 visit annual max) $30 $30 Ded, 50%
$40 $40 Ded, 50%
DME/Orthotics & Prosthetic Devices Ded, 20% Ded, 30% Ded, 50%
Ded, 20% Ded, 30% Ded, 50%
Inpatient Behavioral Health Ded, 20% Ded, 30% Ded, 50%
Ded, 20% Ded, 30% Ded, 50%
Outpatient Behavioral Health (4 free visits) $20 $20 Ded, 50%
$25 $25 Ded, 50%
Skilled Nursing Facility/LTACH (45 day max) Ded, 20% Ded, 30% Ded, 50%
Ded, 20% Ded, 30% Ded, 50%
Acute Inpatient Rehabilitation (45 day max) Ded, 20% Ded, 30% Ded, 50%
Ded, 20% Ded, 30% Ded, 50%
Home Health (60 day annual max) Ded, 20% Ded, 30% Ded, 50%
Ded, 20% Ded, 30% Ded, 50%
Hospice Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Pharmacy:
Generic Drug $10 $10 Ded, 50%
$10 $10 Ded, 50%
Brand Name Formulary $30 $30 Ded, 50%
$30 $30 Ded, 50%
Brand Name Non-Formulary $45 $45 Ded, 50%
$45 $45 Ded, 50%
Specialty Drugs** ($500 maximum) Ded, 25% Ded, 25% Mail Order
Only Ded, 50%
Ded, 25% Ded, 25% Mail Order
Only Ded, 50%
Mail Order 2.5x 2.5x N/A
2.5x 2.5x N/A
OON Coinsurance applies to all services, except Emergency Room services, which are legally require d to be that of INN **Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by
15
Prime Care Choice $1500/20% Prime Care Choice $2000/20%
Tier 1 Network
Tier 2 Network
Tier 3 Out-of-Network
Tier 1
Network Tier 2
Network Tier 3
Out-of-Network
$1,500 $2,500 $4,000 $2,000 $3,000 $5,000 Annual Single Deductible
$3,000 $5,000 $8,000 $4,000 $6,000 $10,000 Annual Family Deductible
$7,000 $7,900 $11,000 $7,900 $7,900 $12,000 Annual OOP Max - Single
(incl Deductible, copay, and coinsurance)
$14,000 $15,800 $22,000 $15,800 $15,800 $24,000 Annual OOP Max - Family
(incl Deductible, copay, and coinsurance)
$25 $25 Ded, 50% $25 $25 Ded, 50% PCP Office Visit
$40 $40 Ded, 50% $40 $40 Ded, 50% Specialist Office Visit
(20% for Ancillary Services)
0% 0% Not Covered 0% 0% Not Covered Preventive Care
Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Inpatient Hospital Services
Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Outpatient Hospital Services
Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Professional Services (In & Out)
$250 $250 $250 $250 $250 $250 Emergency Room
$40 $40 Ded, 50% $40 $40 Ded, 50% Urgent Care Facility
Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ambulance
Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% PT/OT/Speech Therapy
(20 visit annual max each)
$40 $40 Ded, 50% $40 $40 Ded, 50% Chiropractic Services
(15 visit annual max)
Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% DME/Orthotics & Prosthetic Devices
Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Inpatient Behavioral Health
$25 $25 Ded, 50% $25 $25 Ded, 50% Outpatient Behavioral Health (4 free visits)
Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Skilled Nursing Facility/LTACH (45 day max)
Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Acute Inpatient Rehabilitation (45 day max)
Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Home Health (60 day annual max)
Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Hospice
Pharmacy:
$10 $10 Ded, 50% $10 $10 Ded, 50% Generic Drug
$40 $40 Ded, 50% $40 $40 Ded, 50% Brand Name Formulary
$60 $60 Ded, 50% $60 $60 Ded, 50% Brand Name Non-Formulary
Ded, 25% Ded, 25% Mail Order
Only Ded, 50% Ded, 25% Ded, 25%
Mail Order Only
Ded, 50%
Specialty Drugs** ($500 maximum)
2.5x 2.5x N/A 2.5x 2.5x N/A Mail Order
OON Coinsurance applies to all services, except Emergency Room services, which are legally require d to be that of INN **Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by
16
Prime Care Choice
$2500
Prime Care Choice
$2500/50%
Prime Care Choice
$3000/20%
Prime Care Choice
$3500 /20%
Tier 1
Network Tier 2
Network
Tier 3 Out-of-Network
Tier 1 Network
Tier 2 Network
Tier 3 Out-of-Network
Tier 1
Network Tier 2
Network
Tier 3 Out-of-Network
Tier 1
Network Tier 2
Network
Tier 3 Out-of-Network
Annual Single Deductible $2,500 $3,500 $6,000 $2,500 $5,000 $10,000 $3,000 $4,000 $7,000 $3,500 $4,500 $8,000
Annual Family Deductible $5,000 $7,000 $12,000 $5,000 $10,000 $20,000 $6,000 $8,000 $14,000 $7,000 $9,000 $16,000
Annual OOP Max - Single
(incl Deductible, copay, and
coinsurance)
$7,900 $7,900 $13,000 $7,900 $7,900 $24,450 $7,900 $7,900 $14,000 $7,900 $7,900 $14,000
Annual OOP Max - Family
(incl Deductible, copay, and
coinsurance)
$15,800 $15,800 $26,000 $15,800 $15,800 $48,900 $15,800 $15,800 $28,000 $15,800 $15,800 $28,000
PCP Office Visit $30 $30 Ded, 50% $35 $35 Ded, 50% $30 $30 Ded, 50% $30 $30 Ded, 50%
Specialist Office Visit
(20% for Ancillary Services) $50 $50 Ded, 50% $80 $80 Ded, 50% $50 $50 Ded, 50% $50 $50 Ded, 50%
Preventive Care 0% 0% Not
Covered 0% 0%
Not
Covered 0% 0%
Not
Covered 0% 0%
Not
Covered
Inpatient Hospital Services Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Outpatient Hospital Services Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Professional Services
(In & Out) Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Emergency Room $350 $350 $350 $500, 50% $500, 50% $500, 50% $350 $350 $350 $350 $350 $350
Urgent Care Facility $50 $50 Ded, 50% $100 $100 Ded, 50% $50 $50 Ded, 50% $50 $50 Ded, 50%
Ambulance Ded, 20% Ded, 20% Ded, 20% Ded, 50% Ded, 50% Ded, 50% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20%
PT/OT/Speech Therapy
(20 visit annual maximum
each)
Ded, 20% Ded, 30% Ded, 50% $80 $80 Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Chiropractic Services
(15 visit annual maximum) $50 $50 Ded, 50% $80 $80 Ded, 50% $50 $50 Ded, 50% $50 $50 Ded, 50%
DME/Orthotics & Prosthetic
Devices Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Inpatient Behavioral Health Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Outpatient Behavioral
Health (4 free visits) $30 $30 Ded, 50% $35 $35 Ded, 50% $30 $30 Ded, 50% $30 $30 Ded, 50%
Skilled Nursing Facility/
LTACH
(45 day maximum)
Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Acute Inpatient
Rehabilitation
(45 day maximum)
Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Home Health
(60 visit annual maximum) Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Hospice Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Pharmacy:
Generic Drug $15 $15 Ded, 50% $15 $15 Ded, 50% $15 $15 Ded, 50% $15 $15 Ded, 50%
Brand Name Formulary $45 $45 Ded, 50% $45 $45 Ded, 50% $45 $45 Ded, 50% $45 $45 Ded, 50%
Brand Name
Non-Formulary $70 $70 Ded, 50% $70 $70 Ded, 50% $70 $70 Ded, 50% $70 $70 Ded, 50%
Specialty Drugs** Ded, 25% Ded, 25%
Mail Order
Only
Ded, 50%
Ded, 25% Ded, 25%
Mail Order
Only
Ded, 50%
Ded, 25% Ded, 25%
Mail Order
Only
Ded, 50%
Ded, 25% Ded, 25%
Mail Order
Only
Ded, 50%
Mail Order 2.5x 2.5x N/A 2.5x 2.5x N/A 2.5x 2.5x N/A 2.5x 2.5x N/A
OON Coinsurance applies to all services, except Emergency Room services, which are legally require d to be that of INN **Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by
17
Prime Care Choice
$4000/20%
Prime Care Choice
$5000 /20%
Prime Care Choice
$5000/50%
Tier 1
Network Tier 2
Network
Tier 3 Out-of-Network
Tier 1
Network Tier 2
Network
Tier 3 Out-of-Network
Tier 1
Network Tier 2
Network
Tier 3 Out-of-Network
Annual Single Deductible $4,000 $5,000 $9,500 $5,000 $6,000 $11,000 $5,000 $7,900 $15,800
Annual Family Deductible $8,000 $10,000 $19,000 $10,000 $12,000 $22,000 $10,000 $15,800 $31,600
Annual OOP Max - Single
(incl Deductible, copay, and
coinsurance)
$7,900 $7,900 $16,000 $7,900 $7,900 $19,000 $7,900 $7,900 $24,450
Annual OOP Max - Family
(incl Deductible, copay, and
coinsurance)
$15,800 $15,800 $32,000 $15,800 $15,800 $38,000 $15,800 $15,800 $48,900
PCP Office Visit $30 $30 Ded, 50% $30 $30 Ded, 50% $45 $45 Ded, 50%
Specialist Office Visit
(20% for Ancillary Services) $50 $50 Ded, 50% $50 $50 Ded, 50% $90 $90 Ded, 50%
Preventive Care 0% 0% Not
Covered 0% 0%
Not
Covered 0% 0%
Not
Covered
Inpatient Hospital Services Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50%
Outpatient Hospital Services Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50%
Professional Services
(In & Out) Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50%
Emergency Room $350 $350 $350 $350 $350 $350 $500, 50% $500, 50% $500, 50%
Urgent Care Facility $50 $50 Ded, 50% $50 $50 Ded, 50% $100 $100 Ded, 50%
Ambulance Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 50% Ded, 50% Ded, 50%
PT/OT/Speech Therapy
(20 visit annual maximum
each)
Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% $90 $90 Ded, 50%
Chiropractic Services
(15 visit annual maximum) $50 $50 Ded, 50% $50 $50 Ded, 50% $90 $90 Ded, 50%
DME/Orthotics & Prosthetic
Devices Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50%
Inpatient Behavioral Health Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50%
Outpatient Behavioral Health
(4 free visits) $30 $30 Ded, 50% $30 $30 Ded, 50% $45 $45 Ded, 50%
Skilled Nursing Facility/LTACH
(45 day maximum) Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50%
Acute Inpatient
Rehabilitation
(45 day maximum)
Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50%
Home Health
(60 visit annual maximum) Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50%
Hospice Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50%
Pharmacy:
Generic Drug $15 $15 Ded, 50% $15 $15 Ded, 50% $15 $15 Ded, 50%
Brand Name Formulary $45 $45 Ded, 50% $45 $45 Ded, 50% $45 $45 Ded, 50%
Brand Name
Non-Formulary $70 $70 Ded, 50% $70 $70 Ded, 50% $70 $70 Ded, 50%
Only Specialty Drugs** Ded, 25% Ded, 25%
Mail Order
Only
Ded, 50%
Ded, 25% Ded, 25%
Mail Order
Only
Ded, 50%
Ded, 25% Ded, 25%
Mail Order
Only
Ded, 50%
Mail Order 2.5x 2.5x N/A 2.5x 2.5x N/A 2.5x 2.5x N/A
OON Coinsurance applies to all services, except Emergency Room services, which are legally require d to be that of INN **Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by
18
HSA Plan $2800/0% HSA Plan $2800/20%
Tier 1
Network Tier 2
Network Tier 3
Out-of-Network Tier 1
Network Tier 2
Network Tier 3
Out-of-Network
Annual Single Deductible $2,800 $3,800 $5,000 $2,800 $3,800 $5,000
Annual Family Deductible $5,600 $7,600 $10,000 $5,600 $7,600 $10,000
Annual OOP Max - Single (incl Deductible, and coinsurance)
$2,800 $3,800 $12,000 $6,750 $6,750 $12,000
Annual OOP Max - Family (incl Deductible, and coinsurance)
$5,600 $7,600 $24,000 $13,500 $13,500 $24,000
Family Deductible / OOP Max Embedded Embedded
PCP Office Visit Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%
Specialist Office Visit Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%
Preventive Care 0% 0% Not Covered 0% 0% Not Covered
Inpatient Hospital Services Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Outpatient Hospital Services Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Professional Services (In & Out) Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Emergency Room Ded, 0% Ded, 0% Ded, 20% Ded, 20% Ded, 20% Ded, 20%
Urgent Care Facility Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%
Ambulance Ded, 0% Ded, 0% Ded, 0% Ded, 20% Ded, 20% Ded, 20%
PT/OT/Speech Therapy (20 visit annual maximum each)
Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Chiropractic Services (15 visit annual maximum)
Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%
DME/Orthotics & Prosthetic Devices Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Inpatient Behavioral Health Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Outpatient Behavioral Health Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%
Skilled Nursing Facility/LTACH (45 day maximum)
Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Acute Inpatient Rehabilitation (45 day maximum)
Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Home Health (60 visit annual maximum)
Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Hospice Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Pharmacy:
Generic Drug Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%
Brand Name Formulary Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%
Brand Name Non-Formulary Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%
Specialty Drugs** Ded, 0% Ded, 0% Mail Order Only
Ded, 50% Ded, 20% Ded, 20%
Mail Order Only
Ded, 50%
OON Coinsurance applies to all services, except Emergency Room services, which are legally require d to be that of INN **Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by
19
HSA Plan $3500/0% HSA Plan $3500/20%
Tier 1
Network Tier 2
Network Tier 3
Out-of-Network Tier 1
Network Tier 2
Network Tier 3
Out-of-Network
Annual Single Deductible $3,500 $4,500 $8,000 $3,500 $4,500 $8,000
Annual Family Deductible $7,000 $9,000 $16,000 $7,000 $9,000 $16,000
Annual OOP Max - Single (incl Deductible, and coinsurance)
$3,500 $4,500 $14,000 $6,750 $6,750 $14,000
Annual OOP Max - Family (incl Deductible, and coinsurance)
$7,000 $9,000 $28,000 $13,500 $13,500 $28,000
Family Deductible / OOP Max Embedded Embedded
PCP Office Visit Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%
Specialist Office Visit Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%
Preventive Care 0% 0% Not Covered 0% 0% Not Covered
Inpatient Hospital Services Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Outpatient Hospital Services Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Professional Services (In & Out) Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Emergency Room Ded, 0% Ded, 0% Ded, 0% Ded, 20% Ded, 20% Ded, 20%
Urgent Care Facility Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%
Ambulance Ded, 0% Ded, 0% Ded, 0% Ded, 20% Ded, 20% Ded, 20%
PT/OT/Speech Therapy (20 visit annual maximum each)
Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Chiropractic Services (15 visit annual maximum)
Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%
DME/Orthotics & Prosthetic Devices Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Inpatient Behavioral Health Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Outpatient Behavioral Health Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%
Skilled Nursing Facility/LTACH (45 day maximum)
Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Acute Inpatient Rehabilitation (45 day maximum)
Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Home Health (60 visit annual maximum)
Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Hospice Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%
Pharmacy:
Generic Drug Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%
Brand Name Formulary Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%
Brand Name Non-Formulary Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%
Specialty Drugs** Ded, 0% Ded, 0% Mail Order Only
Ded, 50% Ded, 20% Ded, 20%
Mail Order Only
Ded, 50%
OON Coinsurance applies to all services, except Emergency Room services, which are legally require d to be that of INN **Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by
20
HSA Plan $5000/0% HSA Plan $5000/20% HSA Plan $6500/0%
Tier 1
Network Tier 2
Network
Tier 3 Out-of-Network
Tier 1 Network
Tier 2 Network
Tier 3 Out-of-Network
Tier 1 Network
Tier 2 Network
Tier 3 Out-of-Network
Annual Single Deductible $5,000 $6,000 $11,000 $5,000 $6,000 $11,000 $6,500 $6,750 $19,500
Annual Family Deductible $10,000 $12,000 $22,000 $10,000 $12,000 $22,000 $13,000 $13,500 $39,000
Annual OOP Max - Single
(incl Deductible, coinsurance) $5,000 $6,000 $22,000 $6,750 $6,750 $22,000 $6,750 $6,750 $20,700
Annual OOP Max - Family
(incl Deductible, coinsurance) $10,000 $12,000 $44,000 $13,500 $13,500 $44,000 $13,500 $13,500 $41,400
Family Deductible / OOP Max Embedded Embedded Embedded
PCP Office Visit Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Specialist Office Visit Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Preventive Care 0% 0% Not Covered 0% 0% Not Covered 0% 0% Not Covered
Inpatient Hospital Services Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Outpatient Hospital Services Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Professional Services (In & Out) Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Emergency Room Ded, 0% Ded, 0% Ded, 0% Ded, 20% Ded, 20% Ded, 20% Ded, 0% Ded, 0% Ded, 0%
Urgent Care Facility Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Ambulance Ded, 0% Ded, 0% Ded, 0% Ded, 20% Ded, 20% Ded, 20% Ded, 0% Ded, 0% Ded, 0%
PT/OT/Speech Therapy
(20 visit annual maximum each) Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Chiropractic Services
(15 visit annual maximum) Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
DME/Orthotics & Prosthetic
Devices Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Inpatient Behavioral Health Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Outpatient Behavioral Health Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Skilled Nursing Facility/LTACH
(45 day maximum) Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Acute Inpatient Rehabilitation
(45 day maximum) Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Home Health (60 day maximum) Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Hospice Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Pharmacy:
Generic Drug Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, $10 Ded, $10 Ded, $10
Brand Name Formulary Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, $50 Ded, $50 Ded, $50
Brand Name Non-Formulary Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, $100 Ded, $100 Ded, $100
Specialty Drugs** Ded, 0% Ded, 0%
Mail Order
Only
Ded, 50%
Ded, 20% Ded, 20%
Mail Order
Only
Ded, 50%
Ded, 25% Ded, 25%
Mail Order
Only
Ded, 50%
OON Coinsurance applies to all services, except Emergency Room services, which are legally require d to be that of INN **Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by
21
HRA Plan $2800/20% HRA Plan $2800/0%
Tier 3
Tier 1 Network
Tier 2 Network
Tier 3 Out-of-Network
Tier 1 Network
Tier 2 Network
Tier 3 Out-of-Network
$2,800 $3,800 $5,000 $2,800 $3,800 $5,000 Annual Single Deductible
$5,600 $7,600 $10,000 $5,600 $7,600 $10,000 Annual Family Deductible
$6,750 $6,750 $12,000 $2,800 $3,800 $12,000 Annual OOP Max - Single (incl Deductible, and coinsurance)
$13,500 $13,500 $24,000 $5,600 $7,600 $24,000 Annual OOP Max - Family (incl Deductible, and coinsurance)
Embedded Embedded Family Deductible / OOP Max
Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% PCP Office Visit
Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Specialist Office Visit
0% 0% Not Covered 0% 0% Not Covered Preventive Care
Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Inpatient Hospital Services
Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Outpatient Hospital Services
Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Professional Services (In & Out)
Ded, 20% Ded, 20% Ded, 20% Ded, 0% Ded, 0% Ded, 0% Emergency Room
Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Urgent Care Facility
Ded, 20% Ded, 20% Ded, 20% Ded, 0% Ded, 0% Ded, 0% Ambulance
Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% PT/OT/Speech Therapy (20 visit annual maximum each)
Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Chiropractic Services (15 visit annual maximum)
Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% DME/Orthotics & Prosthetic Devices
Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Inpatient Behavioral Health
Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Outpatient Behavioral Health
Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Skilled Nursing Facility/LTACH (45 day maximum)
Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Acute Inpatient Rehabilitation (45 day maximum)
Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Home Health (60 visit annual maximum)
Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Hospice
Pharmacy:
$15 $15 Ded, 50% $15 $15 Ded, 50% Generic Drug
$45 $45 Ded, 50% $45 $45 Ded, 50% Brand Name Formulary
$70 $70 Ded, 50% $70 $70 Ded, 50% Brand Name Non-Formulary
Only Ded, 25% Ded, 25%
Mail Order
Only
Ded, 50%
Ded, 0% Ded, 0%
Mail Order
Only
Ded, 50%
Specialty Drugs**
OON Coinsurance applies to all services, except Emergency Room services, which are legally require d to be that of INN **Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by
22
HRA Plan $3500/20% HRA Plan $3500/0%
Tier 1
Network Tier 2
Network Tier 3
Out-of-Network Tier 1
Network Tier 2
Network Tier 3
Out-of-Network
Annual Single Deductible $3,500 $4,500 $8,000 $3,500 $4,500 $8,000
Annual Family Deductible $7,000 $9,000 $16,000 $7,000 $9,000 $16,000
Annual OOP Max - Single (incl Deductible, and coinsurance)
$6,750 $6,750 $14,000 $3,500 $4,500 $14,000
Annual OOP Max - Family (incl Deductible, and coinsurance)
$13,500 $13,500 $28,000 $7,000 $9,000 $28,000
Family Deductible / OOP Max Embedded Embedded
PCP Office Visit Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Specialist Office Visit Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Preventive Care 0% 0% Not Covered 0% 0% Not Covered
Inpatient Hospital Services Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Outpatient Hospital Services Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Professional Services (In & Out) Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Emergency Room Ded, 20% Ded, 20% Ded, 20% Ded, 0% Ded, 0% Ded, 0%
Urgent Care Facility Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Ambulance Ded, 20% Ded, 20% Ded, 20% Ded, 0% Ded, 0% Ded, 0%
PT/OT/Speech Therapy (20 visit annual maximum each)
Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Chiropractic Services (15 visit annual maximum)
Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
DME/Orthotics & Prosthetic Devices Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Inpatient Behavioral Health Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Outpatient Behavioral Health Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Skilled Nursing Facility/LTACH (45 day maximum)
Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Acute Inpatient Rehabilitation (45 day maximum)
Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Home Health (60 visit annual maximum)
Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Hospice Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Pharmacy:
Generic Drug $15 $15 Ded, 50% $15 $15 Ded, 50%
Brand Name Formulary $45 $45 Ded, 50% $45 $45 Ded, 50%
Brand Name Non-Formulary $70 $70 Ded, 50% $70 $70 Ded, 50%
Specialty Drugs** Ded, 25% Ded, 25% Mail Order Only
Ded, 50% Ded, 0% Ded, 0%
Mail Order Only Ded, 50%
Mail Order 2.5x 2.5x N/A 2.5x 2.5x N/A
OON Coinsurance applies to all services, except Emergency Room services, which are legally require d to be that of INN **Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by
23
HRA Plan $5000/20% HRA Plan $5000/0% HRA Plan $6500/0%
Tier 1
Network Tier 2
Network
Tier 3 Out-of-Network
Tier 1 Network
Tier 2 Network
Tier 3 Out-of-Network
Tier 1 Network
Tier 2 Network
Tier 3 Out-of-Network
Annual Single Deductible $5,000 $6,000 $11,000 $5,000 $6,000 $11,000 $6,500 $6,750 $19,500
Annual Family Deductible $10,000 $12,000 $22,000 $10,000 $12,000 $22,000 $13,500 $13,500 $39,000
Annual OOP Max - Single (incl Deductible, and coinsurance)
$6,750 $6,750 $22,000 $5,000 $6,000 $22,000 $6,750 $6,750 $20,700
Annual OOP Max - Family (incl Deductible, and coinsurance)
$13,500 $13,500 $44,000 $10,000 $12,000 $44,000 $13,500 $13,500 $41,400
Family Deductible / OOP Max Embedded Embedded Embedded
PCP Office Visit Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Specialist Office Visit Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Preventive Care 0% 0% Not Covered 0% 0% Not Covered 0% 0% Not Covered
Inpatient Hospital Services Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Outpatient Hospital Services Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Professional Services (In & Out) Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Emergency Room Ded, 20% Ded, 20% Ded, 20% Ded, 0% Ded, 0% Ded, 0% Ded, 0% Ded, 0% Ded, 0%
Urgent Care Facility Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Ambulance Ded, 20% Ded, 20% Ded, 20% Ded, 0% Ded, 0% Ded, 0% Ded, 0% Ded, 0% Ded, 0%
PT/OT/Speech Therapy (20 visit annual maximum each)
Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Chiropractic Services (15 visit annual maximum)
Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
DME/Orthotics & Prosthetic Devices Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Inpatient Behavioral Health Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Outpatient Behavioral Health Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Skilled Nursing Facility/LTACH (45 day maximum)
Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Acute Inpatient Rehabilitation (45 day maximum)
Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Home Health (60 visit annual maximum)
Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Hospice Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%
Pharmacy:
Generic Drug $10 $10 Ded, 50% $10 $10 Ded, 50% $10 $10 Ded, 50%
Brand Name Formulary $50 $50 Ded, 50% $50 $50 Ded, 50% $50 $50 Ded, 50%
Brand Name Non-Formulary $100 $100 Ded, 50% $100 $100 Ded, 50% $100 $100 Ded, 50%
Specialty Drugs** Ded, 30% Ded, 30% Mail Order
Only Ded, 50%
Ded, 0% Ded, 0% Mail Order
Only Ded, 50%
Ded, 0% Ded, 0% Mail Order
Only Ded, 50%
Mail Order 2.5x 2.5x N/A 2.5x 2.5x N/A 2.5x 2.5x N/A
OON Coinsurance applies to all services, except Emergency Room services, which are legally require d to be that of INN **Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by
24
PC Choice $500/20%
PC Choice $1000/20%
PC Choice $1500/20%
PC Choice $2000/20%
PC Choice $2500/20%
PC Choice $2500/50%
Annual Single Deductible $500 $1,000 $1,500 $2,000 $2,500 $2,500
Annual Family Deductible $1,000 $2,000 $3,000 $4,000 $5,000 $5,000
Annual OOP Max - Single
(incl Deductible, copay, and coinsurance) $5,000
$6,000
$7,000
$7,900
$7,900 $7,900
Annual OOP Max - Family
(incl Deductible, copay, and coinsurance) $10,000
$12,000
$14,000
$15,800
$15,800 $15,800
PCP Office Visit $20 $25 $25 $25 $30 $35
Specialist Office Visit
(20% for Ancillary Services) $30
$40
$40
$40
$50 $80
Preventive Care 0% 0% 0% 0% 0% 0%
Inpatient Hospital Services Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 50%
Outpatient Hospital Services Ded, 20%
Ded, 20%
Ded, 20%
Ded, 20%
Ded, 20% Ded, 50%
Professional Services (In & Out) Ded, 20%
Ded, 20%
Ded, 20%
Ded, 20%
Ded, 20% Ded, 50%
Emergency Room $250 $250 $250 $250 $350 $500,50%
Urgent Care Facility $30 $40 $40 $40 $50 $100
Ambulance Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 50%
PT/OT/Speech Therapy
(20 visits) Ded, 20%
Ded, 20%
Ded, 20%
Ded, 20%
Ded, 20% $80
Chiropractic Services
(15 visits) $30
$40
$40
$40
$50 $80
DME/Orthotics & Prosthetic Devices Ded, 20%
Ded, 20%
Ded, 20%
Ded, 20%
Ded, 20% Ded, 50%
Inpatient Behavioral Health Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 50%
Outpatient Behavioral Health
(4 free visits) $20
$25
$25
$25
$30 $35
Skilled Nursing Facility/LTACH
(45 days) Ded, 20%
Ded, 20%
Ded, 20%
Ded, 20%
Ded, 20% Ded, 50%
Acute Inpatient Rehabilitation
(45 days) Ded, 20%
Ded, 20%
Ded, 20%
Ded, 20%
Ded, 20% Ded, 50%
Home Health
(60 max) Ded, 20%
Ded, 20%
Ded, 20%
Ded, 20%
Ded, 20% Ded, 50%
Hospice Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 50%
Out of Network:
Annual Single Deductible $2,000 $3,000 $4,000 $5,000 $6,000 $10,000
Annual Family Deductible $4,000 $6,000 $8,000 $10,000 $12,000 $20,000
Coinsurance for All Services* 50%
50%
50%
50%
50% 50%
Annual OOP Max - Single $9,000 $10,000 $11,000 $12,000 $13,000 $24,450
Annual OOP Max - Family $18,000 $20,000 $22,000 $24,000 $26,000 $48,900
Pharmacy:
Generic Drug $10 $10 $10 $10 $15 $15
Brand Name Formulary $30 $30 $40 $40 $45 $45
Brand Name Non-Formulary $45
$45
$60
$60
$70 $70
Specialty Drugs ** (max $500) Ded, 25%
Ded, 25%
Ded, 25%
Ded, 25%
Ded, 25% Ded, 25%
Mail Order 2.5x 2.5x 2.5x 2.5x 2.5x 2.5x
OON Coinsurance applies to all services, except Emergency Room services, which are legally required to be that of INN **Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by
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PC Choice $3000/20%
PC Choice $3500/20%
PC Choice $4,000/20%
PC Choice $5000/20%
PC Choice $5000/50%
Annual Single Deductible $3,000 $3,500 $4,000 $5,000 $5,000
Annual Family Deductible $6,000 $7,000 $8,000 $10,000 $10,000
Annual OOP Max - Single
(incl Deductible, copay, and coinsurance) $7,900
$7,900 $7,900 $7,900 $7,900
Annual OOP Max - Family
(incl Deductible, copay, and coinsurance) $15,800
$15,800 $15,800 $15,800 $15,800
PCP Office Visit $30 $30 $30 $30 $45
Specialist Office Visit
(20% for Ancillary Services) $50
$50 $50 $50 $90
Preventive Care 0% 0% 0% 0% 0%
Inpatient Hospital Services Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 50%
Outpatient Hospital Services Ded, 20%
Ded, 20% Ded, 20% Ded, 20% Ded, 50%
Professional Services (In & Out) Ded, 20%
Ded, 20% Ded, 20% Ded, 20% Ded, 50%
Emergency Room $350 $350 $350 $350 $500,50%
Urgent Care Facility $50 $50 $50 $50 $100
Ambulance Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 50%
PT/OT/Speech Therapy
(20 visits) Ded, 20%
Ded, 20% Ded, 20% Ded, 20% Ded, 50%
Chiropractic Services
(15 visits) $50
$50 $50 $50 $90
DME/Orthotics & Prosthetic Devices Ded, 20%
Ded, 20% Ded, 20% Ded, 20% Ded, 50%
Inpatient Behavioral Health Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 50%
Outpatient Behavioral Health
(4 free visits) $30
$30 $30 $30 $45
Skilled Nursing Facility/LTACH
(45 days) Ded, 20%
Ded, 20% Ded, 20% Ded, 20% Ded, 50%
Acute Inpatient Rehabilitation
(45 days) Ded, 20%
Ded, 20% Ded, 20% Ded, 20% Ded, 50%
Home Health
(60 max) Ded, 20%
Ded, 20% Ded, 20% Ded, 20% Ded, 50%
Hospice Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 50%
Out of Network:
Annual Single Deductible $7,000 $8,000 $9,500 $11,000 $15,800
Annual Family Deductible $14,000 $16,000 $19,000 $22,000 $31,600
Coinsurance for All Services* 50%
50% 50% 50% 50%
Annual OOP Max - Single $14,000 $14,000 $16,000 $19,000 $24,450
Annual OOP Max - Family $28,000 $28,000 $32,000 $38,000 $48,900
Pharmacy:
Generic Drug $15 $15 $15 $15 $15
Brand Name Formulary $45 $45 $45 $45 $45
Brand Name Non-Formulary $70
$70 $70 $70 $70
Specialty Drugs ** (max $500) Ded, 25%
Ded, 25% Ded, 25% Ded, 25% Ded, 25%
Mail Order 2.5x 2.5x 2.5x 2.5x 2.5x
OON Coinsurance applies to all services, except Emergency Room services, which are legally required to be that of INN **Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by
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Care Plus $500/30%
Care Plus $1000/30%
Care Plus $2500/30%
Care Plus $5000/30%
Annual Single Deductible $500 $1,000 $2,500 $5,000
Annual Family Deductible $1,000 $2,000 $5,000 $10,000
Annual OOP Max - Single (incl Deductible, copay, and coinsurance) $5,000
$6,000 $7,900
$7,900
Annual OOP Max - Family (incl Deductible, copay, and coinsurance) $10,000
$12,000 $15,800
$15,800
PCP Office Visit $20 $25 $30 $30
Specialist Office Visit (20% for Ancillary Services) $40
$50 $50
$50
Preventive Care 0% 0% 0% 0%
Inpatient Hospital Services Ded, 30% Ded, 30% Ded, 30% Ded, 30%
Outpatient Hospital Services Ded, 30% Ded, 30% Ded, 30% Ded, 30%
Professional Services (In & Out) Ded, 30% Ded, 30% Ded, 30% Ded, 30%
Emergency Room $150 $200 $250 $300
Urgent Care Facility $40 $50 $50 $50
Ambulance Ded, 30% Ded, 30% Ded, 30% Ded, 30%
PT/OT/Speech Therapy (20 visits) $40 $50 $50 $50
Chiropractic Services (15 visits) $40 $50 $50 $50
DME/Orthotics & Prosthetic Devices Ded, 30% Ded, 30% Ded, 30% Ded, 30%
Inpatient Behavioral Health Ded, 30% Ded, 30% Ded, 30% Ded, 30%
Outpatient Behavioral Health (4 free visits) $20 $25 $30 $30
Skilled Nursing Facility/LTACH (45 days) Ded, 30% Ded, 30% Ded, 30% Ded, 30%
Acute Inpatient Rehabilitation (45 days) Ded, 30% Ded, 30% Ded, 30% Ded, 30%
Home Health (60 max) Ded, 30% Ded, 30% Ded, 30% Ded, 30%
Hospice Ded, 30%
Ded, 30% Ded, 30%
Ded, 30%
Out of Network:
Annual Single Deductible $2,000 $3,000 $6,000 $11,000
Annual Family Deductible $4,000 $6,000 $12,000 $22,000
Coinsurance for All Services* 50% 50% 50% 50%
Annual OOP Max - Single $9,000 $10,000 $13,000 $19,000
Annual OOP Max - Family $18,000 $20,000 $26,000 $38,000
Pharmacy:
Generic Drug $10 $10 $10 $10
Brand Name Formulary $40 $40 $40 $40
Brand Name Non-Formulary $60 $60 $60 $60
Specialty Drugs ** (max $500) Ded, 25% Ded, 25% Ded, 25% Ded, 25%
Mail Order 2.5x 2.5x 2.5x 2.5x
OON Coinsurance applies to all services, except Emergency Room services, which are legally required to be that of INN **Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by
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HSA
$2800/0%
HSA $2800/20%
HSA
$3500/20%
HSA $3500/0%
HSA
$5000/20%
HSA $5000/0%
HSA $6500/0%
Annual Single Deductible $2,800 $2,800 $3,500 $3,500 $5,000 $5,000 $6,500
Annual Family Deductible $5,600 $5,600 $7,000 $7,000 $10,000 $10,000 $13,000
Annual OOP Max - Single Single (incl Deductible and coinsurance)
$6,750 $2,800 $6,750 $3,500 $6,750 $5,000 $6,750
Annual OOP Max - Family (incl Deductible and coinsurance)
$13,500 $5,600 $13,500 $7,000 $13,500 $10,000 $13,500
Family Deductible / OOP Max Embedded Embedded Embedded Embedded Embedded Embedded Embedded
PCP Office Visit Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%
Specialist Office Visit Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%
Preventive Care 0% 0% 0% 0% 0% 0% 0%
Inpatient Hospital Services Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%
Outpatient Hospital Services Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%
Professional Services (In & Out) Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%
Emergency Room Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%
Urgent Care Facility Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%
Ambulance Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%
PT/OT/Speech Therapy
(20 visits) Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%
Chiropractic Services (15 visits)
Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%
DME/Orthotics & Prosthetic Devices Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%
Inpatient Behavioral Health Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%
Outpatient Behavioral Health Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%
Skilled Nursing Facility/LTACH
(45 days) Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%
Acute Inpatient Rehabilitation
(45 days) Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%
Home Health (60 max) Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%
Hospice Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%
Out of Network:
Annual Single Deductible $5,000 $5,000 $8,000 $8,000 $11,000 $11,000 $19,500
Annual Family Deductible $10,000 $10,000 $16,000 $16,000 $22,000 $22,000 $39,000
Coinsurance for All Services* 50% 50% 50% 50% 50% 50% 50%
Annual OOP Max - Single $12,000 $12,000 $14,000 $14,000 $22,000 $22,000 $20,700
Annual OOP Max - Family $264,000 $264,000 $28,000 $28,000 $44,000 $44,000 $41,400
Pharmacy:
Generic Drug Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, $10
Brand Name Formulary Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, $50
Brand Name Non-Formulary Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, $100
Specialty Drugs ** (max $500) Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 25%
Mail Order 2.5x 2.5x 2.5x 2.5x 2.5x 2.5x 2.5x
OON Coinsurance applies to all services, except Emergency Room services, which are legally required to be that of INN **Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by
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* OON Coinsurance applies to all services, except for Emergency Room services, which are legally required to be that of INN. ** Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by injection. Additionally the Specialty Drug Benefit has a coinsurance maximum of $500.
HRA $2800/20%
HRA $2800/0%
HRA $3500/20%
HRA $3500/0%
Annual Single Deductible $2,800 $2,800 $3,500 $3,500
Annual Family Deductible $5,600 $5,600 $7,000 $7,000
Annual OOP Max - Single
(incl Deductible, copay, coinsurance) $6,750 $2,800 $6,750 $3,500
Annual OOP Max - Family
(incl Deductible, copay, coinsurance) $13,500 $5,400 $13,500 $7,000
Family Deductible / OOP Max Embedded Embedded Embedded Embedded
PCP Office Visit Ded, 20% Ded, 0% Ded, 20% Ded, 0%
Specialist Office Visit Ded, 20% Ded, 0% Ded, 20% Ded, 0%
Preventive Care 0% 0% 0% 0%
Inpatient Hospital Services Ded, 20% Ded, 0% Ded, 20% Ded, 0%
Outpatient Hospital Services Ded, 20% Ded, 0% Ded, 20% Ded, 0%
Professional Services (In & Out) Ded, 20% Ded, 0% Ded, 20% Ded, 0%
Emergency Room Ded, 20% Ded, 0% Ded, 20% Ded, 0%
Urgent Care Facility Ded, 20% Ded, 0% Ded, 20% Ded, 0%
Ambulance Ded, 20% Ded, 0% Ded, 20% Ded, 0%
PT/OT/Speech Therapy (20 visits) Ded, 20% Ded, 0% Ded, 20% Ded, 0%
Chiropractic Services (15 visits) Ded, 20% Ded, 0% Ded, 20% Ded, 0%
DME/Orthotics & Prosthetic Devices Ded, 20% Ded, 0% Ded, 20% Ded, 0%
Inpatient Behavioral Health Ded, 20% Ded, 0% Ded, 20% Ded, 0%
Outpatient Behavioral Health Ded, 20% Ded, 0% Ded, 20% Ded, 0%
Skilled Nursing Facility/LTACH
(45 days) Ded, 20% Ded, 0% Ded, 20% Ded, 0%
Acute Inpatient Rehabilitation
(45 days) Ded, 20% Ded, 0% Ded, 20% Ded, 0%
Home Health (60 max) Ded, 20% Ded, 0% Ded, 20% Ded, 0%
Hospice Ded, 20% Ded, 0% Ded, 20% Ded, 0%
Out of Network:
Annual Single Deductible $5,000 $5,000 $8,000 $8,000
Annual Family Deductible $10,000 $10,000 $16,000 $16,000
Coinsurance for All Services* 50% 50% 50% 50%
Annual OOP Max - Single $12,000 $12,000 $14,000 $14,000
Annual OOP Max - Family $24,000 $24,000 $28,000 $28,000
Pharmacy:
Generic Drug $15 $15 $15 $15
Brand Name Formulary $45 $45 $45 $45
Brand Name Non-Formulary $70 $70 $70 $70
Specialty Drugs ** (max $500) Ded, 25% Ded, 0% Ded, 25% Ded, 0%
Mail Order 2.5x 2.5x 2.5x 2.5x
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HRA $5000/20%
HRA $5000/0%
HRA $6500/0%
Annual Single Deductible $5,000 $5,000 $6,500
Annual Family Deductible $10,000 $10,000 $13,000
Annual OOP Max - Single
(incl Deductible, copay, coinsurance) $6,750 $5,000 $6,500
Annual OOP Max - Family
(incl Deductible, copay, coinsurance) $13,500 $10,000 $13,000
Family Deductible / OOP Max Embedded Embedded Embedded
PCP Office Visit Ded, 20% Ded, 0% Ded, 0%
Specialist Office Visit Ded, 20% Ded, 0% Ded, 0%
Preventive Care 0% 0% 0%
Inpatient Hospital Services Ded, 20% Ded, 0% Ded, 0%
Outpatient Hospital Services Ded, 20% Ded, 0% Ded, 0%
Professional Services (In & Out) Ded, 20% Ded, 0% Ded, 0%
Emergency Room Ded, 20% Ded, 0% Ded, 0%
Urgent Care Facility Ded, 20% Ded, 0% Ded, 0%
Ambulance Ded, 20% Ded, 0% Ded, 0%
PT/OT/Speech Therapy (20 visits) Ded, 20% Ded, 0% Ded, 0%
Chiropractic Services (15 visits) Ded, 20% Ded, 0% Ded, 0%
DME/Orthotics & Prosthetic Devices Ded, 20% Ded, 0% Ded, 0%
Inpatient Behavioral Health Ded, 20% Ded, 0% Ded, 0%
Outpatient Behavioral Health Ded, 20% Ded, 0% Ded, 0%
Skilled Nursing Facility/LTACH
(45 days) Ded, 20% Ded, 0% Ded, 0%
Acute Inpatient Rehabilitation
(45 days) Ded, 20% Ded, 0% Ded, 0%
Home Health (60 max) Ded, 20% Ded, 0% Ded, 0%
Hospice Ded, 20% Ded, 0% Ded, 0%
Out of Network:
Annual Single Deductible $11,000 $11,000 $19,500
Annual Family Deductible $22,000 $22,000 $39,000
Coinsurance for All Services* 50% 50% 50%
Annual OOP Max - Single $22,000 $22,000 $20,700
Annual OOP Max - Family $44,000 $44,000 $41,400
Pharmacy:
Generic Drug $10 $10 $10
Brand Name Formulary $50 $50 $50
Brand Name Non-Formulary $100 $100 $100
Specialty Drugs ** (max $500) Ded, 30% Ded, 0% Ded, 0%
Mail Order 2.5x 2.5x 2.5x
* OON Coinsurance applies to all services, except for Emergency Room services, which are legally required to be that of INN. ** Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by injection. Additionally the Specialty Drug Benefit has a coinsurance maximum of $500.
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Services
Value Plan
Calendar Year Deductible NONE NONE NONE NONE
Plan Year Benefit $1,500 $1,250 $1,000 $750
Lifetime Orthodontia Maximum $1,000 $1,250 $1,000 N/A
Preventive Services
• Oral Exam (once every 6 months) • Routine Cleanings (once every 6 months)
Fluoride Treatment for Children up to age 14 (once every 6 months)
• Space Maintainers for Children • Topical Sealants for Children up to age 15
100% 100% 100% 100%
Diagnostic Services
• Bitewing X-Rays (once every year) • Full Mouth (one every 4 years)
100% 100% 80% 60%
Basic
• Amalgam, Silicate & Composite Fillings
• Simple Extractions
• Repairs of dentures, bridgework, and crowns
• Endodontic Therapy (Paramount and Preferred Plans only)
80% 80% 60% 50%
Major Services
• Oral Surgery & Complex Extractions • Periodontal Therapy • Endodontic Therapy (Standard and Value Plans only)
• Full & Partial Dentures • Implants as an Alternate Procedure (Covered at 50% on all plans)
• Crowns
• Bridges
50% 80% 50% 50%
(for children under age 19) 50% 50% 50% Not Covered
Employee Only: $33.29 $34.15 $29.04 $26.29
Employee + Spouse: $69.91 $71.73 $60.96 $55.20
Employee + Child(ren): $87.35 $89.58 $76.15 $68.94
Employee + Family: $122.81 $126.04 $107.14 $97.00
Minimum of 2 employees to offer. For more information on the dental plan including OON benefits, please contact [email protected].
Offered through Health Resources Inc. | HRI Network
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Minimum of 2 employees to offer. For more information on the vision plan including OON benefits, please contact [email protected].
Offered through EyeMed Vision I Insight Network
EyeMed Vision
In-Network Benefits 12/12 Plan 12/24 Plan
Eye Exam Frequency Once every 12 Months Once every 12 Months
Eye Exam Copay $10 $10
Eyeglass Lens Frequency Once every 12 Months Once every 12 Months
Eyeglass Lens Copay $25 Additional charge for Progressive $25 Additional charge for Progressive
Eyeglass Frame Frequency Once every 12 Months Once every 24 Months
Eyeglass Frame Allowance $180 – 20% off balance over the $180 $150 – 20% off balance over the $150
Eyeglass Frame Copay $0 $0
Contact Lens Frequency Once every 12 Months Once every 12 Months
Contact Lens Allowance $180 $150
Contact Lens Copay $0 – 15% off balance over the $180 $0 – 15% off balance over the $150
Network EyeMed EyeMed
Employee: $9.62 $6.30
Employee + Spouse: $18.28 $11.97
Employee + Child(ren): $19.24 $12.60
Employee + Family: $28.28 $18.52
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The plans illustrated in this brochure are representative examples.
Because plan details change from time to time, your plan may have
different benefits. Refer to your Certificate of Coverage for the specific
benefits available to you. For more information on these plans, contact
your authorized SIHO agent/broker or SIHO account coordinator.
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