Choice Plan vs. Kelsey Charter Plan Choice (plan to be eliminated)

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Blaze Bond
5 years ago
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1 Choice Plan vs. Kelsey Charter Plan Kelsey UHC Charter Kelsey-Sebold Providers ONLY. Exceptions allowed for emergency care, dependent out of area and untreatable conditions. St. Lukes is the affiliated hospital. Premiums (per pay period) Employee Only $ $80.23 Employee + Spouse $ $ Employee + Child(ren) $ $ Employee + Family $ $ Employee Only $ $96.28 Employee + Spouse $ $ Employee + Child(ren) $ $ Employee + Family $ $ Individual $1,500 $750 Family $3,000 $1,500 Individual $5,000 $3,750 Family $10,000 $7,500 Preventive PCP $35 copay $25 copay Specialists $35 copay Vitual Visits $35 per visit $25 per visit Inpatient - hospital Surgery Plus** $300 copay then 20% Urgent Care Facility Airrosti Muscle/Joint $35 copay Routine Lab, X-Ray Advanced Imaging (MRI, MRA, CT Scan, PET) Mental health and substance abuse (inpatient) Generic 30% 30% Preferred brand 40% 40% Non preferred brand 50% 50% Generic 25% 25% Preferred brand 35% 35% Non preferred brand

2 Choice Plan vs. Choice Premium Tier Plan Choice Premium Tier Premiums (per pay period) Employee Only $ Employee + Spouse $ Employee + Child(ren) $ Employee + Family $ Employee Only $ Employee + Spouse $ Employee + Child(ren) $ Employee + Family $ Tier 1 (Methodist Hospital System and UHC Premium Tier1 Providers) Tier 2 (All UHC Choice Network Providers and Hospitals) $88.67 $ $ $ $ $ $ $ Individual $1,500 $1,500 $2,000 Family $3,000 $3,000 $4,000 Individual $5,000 $5,000 $6,000 Family $10,000 $10,000 $12,000 Preventive PCP $35 copay $30 $50 Specialists $45 $75 Vitual Visits $35 per visit $25 per Visit Inpatient - hospital Surgery Plus** $300 copay then 20% Urgent Care Facility Airrosti Muscle/Joint Routine Lab, X-Ray Advanced Imaging (MRI, MRA, CT Scan, PET) Mental health and substance abuse (inpatient) Generic 30% Preferred brand 40% Non preferred brand 50% Specialty Generic 25% Preferred brand 35% Non preferred brand Specialty 30% 40% 50% 25% 35%

3 Choice Plan vs. Nexus Plan Nexus Premiums (per pay period) Employee Only $ Employee + Spouse $ Employee + Child(ren) $ Employee + Family $ Employee Only $ Employee + Spouse $ Employee + Child(ren) $ Employee + Family $ Tier 1 (Memorial Herman Hospital System) Tier 2 (All UHC Choice Network Providers and Hospitals) $88.67 $ $ $ $ $ $ $ Individual $1,500 $1,500 $2,000 Family $3,000 $3,000 $4,000 Individual $5,000 $5,000 $6,000 Family $10,000 $10,000 $12,000 Preventive PCP $35 copay $25 $50 Specialists $40 $75 Vitual Visits $35 per visit $25 per Visit Inpatient - hospital Surgery Plus** Urgent Care Facility Airrosti Muscle/Joint Routine Lab, X-Ray Advanced Imaging (MRI, MRA, CT Scan, PET) Mental health and substance abuse (inpatient) $300 copay then 20% $40 copay Generic 30% 30% 30% Preferred brand 40% 40% 40% Non preferred brand 50% 50% 50% Generic 25% 25% 25% Preferred brand 35% 35% 35% Non preferred brand

4 Choice Plan vs. Choice HRA Plan Choice HRA (FBISD HRA Contribution: $500 individual/$1,000 family) Premiums (per pay period) Employee Only $ $52.92 Employee + Spouse $ $ Employee + Child(ren) $ $ Employee + Family $ $ Employee Only $ $63.50 Employee + Spouse $ $ Employee + Child(ren) $ $ Employee + Family $ $ Individual $1,500 $2,500 Family $3,000 $5,000 Individual $5,000 $6,000 Family $10,000 $12,000 Preventive PCP $35 copay 30% after Deductible Specialists 30% after Deductible Vitual Visits $35 per visit 30% after Deductible Inpatient - hospital 30% after Deductible Surgery Plus** 30% after Deductible Urgent Care Facility 30% after Deductible Airrosti Muscle/Joint 30% after Deductible Routine Lab, X-Ray 30% after Deductible Advanced Imaging (MRI, MRA, CT Scan, PET) 30% after Deductible Mental health and substance abuse (inpatient) 30% after Deductible Generic 30% 30% Preferred brand 40% 40% Non preferred brand 50% 50% Generic 25% 25% Preferred brand 35% 35% Non preferred brand

5 Choice Plan vs. Choice High Deductible Plan Choice High Deductible Premiums (per pay period) Employee Only $ $31.05 Employee + Spouse $ N/A Employee + Child(ren) $ $ Employee + Family $ N/A Employee Only $ $37.26 Employee + Spouse $ N/A Employee + Child(ren) $ $ Employee + Family $ N/A Individual $1,500 $6,500 Family $3,000 $13,000 Individual $5,000 $6,500 Family $10,000 $13,000 Preventive PCP $35 copay 0% after Deductible Specialists 0% after Deductible Vitual Visits $35 per visit 0% after Deductible Inpatient - hospital 0% after Deductible Surgery Plus** 0% after Deductible 0% after Deductible Urgent Care Facility 0% after Deductible Airrosti Muscle/Joint 0% after Deductible Routine Lab, X-Ray 0% after Deductible Advanced Imaging (MRI, MRA, CT Scan, PET) 0% after Deductible Mental health and substance abuse (inpatient) 0% after Deductible Generic 30% 0% after Deductible Preferred brand 40% 0% after Deductible Non preferred brand 50% 0% after Deductible Specialty 0% after Deductible Generic 25% 0% after Deductible Preferred brand 35% 0% after Deductible Non preferred brand 0% after Deductible Specialty 0% after Deductible

Medical Plan Summary: PPO Core Plan

Medical Plan Summary: PPO Core Plan Healthcare is one of the most important and necessary parts of your benefit package. The following is a summary of our benefit plan. For a more detailed explanation