Sample Enrollment Guide
Medical and prescription drug plan summary Side-by-side Medical Enhanced HDHP plan Basic HDHP plan
Medical and prescription bi-weekly employee payroll contributions (effective Jan. 1, 2018)
Out-of- network
Out-of- network
Enhanced plan
Basic plan
In-network
In-network
Employee
$
$
Deductible
Employee only Family coverage
$ $
$ $
$ $
$ $
Employee + spouse
$
$
Employee + child(ren)
$
$
Coinsurance (what the plan pays after deductible is reached)
%
%
%
%
Family
$
$
Out-of-pocket maximum (includes deductible) Employee only Family coverage
Employees can elect the medical and prescription drug plan without enrolling in the dental or vision plans.
$ $
$ $
$ $
$ $
Preventive care
% % % % % %
% % % % % %
% % % % % %
% % % % % %
Office visit (PCP and specialist)
Emergency room
Urgent care
Inpatient care Outpatient care Prescription drugs
Employee Pays
Retail (30-day supply) Tier 1 — generics
$ $ $ $ $ $
$ $ $ $ $ $
$ $ $ $ $ $
$ $ $ $ $ $
Tier 2 — preferred
Tier 3 — nonpreferred
Mail order (90-day supply) Tier 1 — generics
Tier 2 — preferred
Tier 3 — nonpreferred
Prescription drugs—100% coverage for preventive generics before the deductible applies.
Preventive brand and non-preferred brand (second and third tier) drugs are covered at the plan’s coinsurance maximum amounts as outlined in the chart. A deductible does not apply.
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