2015 Health Plan Coverage Tool
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1 2015 Health Plan Coverage Tool
2 Annual Deductible 1/1/15 12/31/15 Combined Network and Out-of-Network: $1,300 for employee coverage. $3,000 for employee + 1 and family coverage. Health Savings Account Contributions HSA Contributions from North Memorial Maximum Employee Contribution* Employee: $750 Employee + 1: $1,800 Family: $1,800 Employee: $2,600 Employee + 1: $4,850 Family: $4,850 *Additional contributions of $1,000 may be allowed for individuals 55 years and older. Annual Out-of-Pocket Maximum 1/1/15 12/31/15 Network: $3,500 for employee coverage, $8,000 for employee + 1 and family coverage (includes prescription costs) Out-of-Network: $5,000 for employee coverage. $10,000 for employee + 1 and family coverage. Please see the Benefits Enrollment Guide online for definitions of the Tier 1, Network, and Out-of-Network benefits. Additional information about coverage is available by calling PreferredOne at (800) or by visiting 1
3 Preventive Care Received in the s Office Routine Physical Exam (includes lab and screenings) - 1 per year Tier 1 and Network: 100% Out-of-network: No coverage Immunizations Tier 1 and Network: 100% Well Child Care Tier 1 and Network: 100% Routine Eye Exam Tier 1 and Network: 100% Out-of-network: No coverage Prenatal Services Tier 1 and Network: 100% Counseling Alcohol misuse BRCA screening Healthy Diet Obesity Tobacco Use Contraceptive Methods and Counseling for Women Tier 1 and Network: 100% Tier 1 and Network: 100% Out-of-network: 40% Wellness Reimbursements Employee: up to $400 Employee + 1: up to $800 Family: up to $2,000 Contact the North Memorial Employee Health Center for more Information. Gym Memberships The Fitness Advantage Program is available through PreferredOne. If you work out at least 6 times per month (this includes workouts at the onsite fitness center),you and one covered adult qualify for a $20 per month reimbursement in the form of reduced monthly membership dues at your club. Visit preferredone.com/fitnessadvantage for a list of qualifying fitness facilities. Chiropractic Care Network: 80% after deductible is met. Coverage is limited to 15 visits per year. 2
4 Services Received in the s Office Office Visits for Illness or Injury* Allery Testing Allergy Shots Lab and X-ray Surgical Services Infertility Services Tier 1: 80% after deductible is met. Out-of-network: N/A ($5,000 lifetime max) *Includes mental health and substance abuse care. Maternity - Received in the s Office or Hospital Delivery Services Facility Postnatal Services** **If you use a Tier 1 or Network Provider, one postnatal visit is 100% covered with no deductible. 3
5 Physical Therapy - Facility Tier 1: If billed by Institute of Athletic Medicine: 100% after deductible is met. Occupational Therapy, Speech Therapy Received in the Provider s Office of Hospital Inpatient Hospital Services Received in a Hospital or Surgi-Center Facility Out-of-network: 40% of eligible charges after deductible is met for up to 120 days per year. Outpatient Hospital Facility Lab and X-ray Facility (does not include enhanced radiology. Example - MRI Enhanced radiology covered under Outpatient Hospital). 4
6 Durable Medial Equipment and Prosthetics (includes coverage for hearing aids*) Network: 90% after deductible is met. Out-of-network: 70% of eligible charges after deductible is met. *Age 18 and under, benefits limited to one hearing aid every three years; age 19 and over, benefits subject to $4,000 lifetime maximum. Prescription Medications North Memorial Employee Pharmacy (30-day supply*) North Memorial Employee Pharmacy- Mail-order** (90- day/3-month supply*) Network Pharmacy Retail and Mail-order(30-day supply*) Out-of-network Pharmacy (30-day supply*) Women s Birth Control: 100% Generic: $15 copay after deductible is met. Formulary: $30 copay after deductible is met. Nonformulary: 50% after deductible is met; $30 minimum, $200 maximum. Women s Birth Control: 100% Generic: $45 copay after deductible is met. Formulary: $90 copay after deductible is met. Nonformulary: 50% after deductible is met; $90 minimum, $600 maximum. Women s Birth Control: 100% Generic: $50 copay after deductible is met. Formulary: $90 copay after deductible is met. Nonformulary: 50% after deductible is met; $60 minimum, $300 maximum. 60% of eligible charges after deductible is met. *Medications dispensed according to the plan s formulary **Restrictions apply See your Summary Plan Description for specialty drug coverage details 5
7 Emergency Department Facility Network: 100% after deductible is met. Out-of-network: 100% of eligible charges after deductible is met. Urgent Care Center Network: 100% after deductible is met. Ambulance Network: 80% after deductible is met. Out-of-network: 80% of eligible charges after deductible is met. 6
(30- to 34-day supply) 100% after $40 copay; significant or new therapeutic class drugs: 50%
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Anthem BlueCross BlueShield Lumenos Health Savings Account Option 56 Rx9 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 12/01/2013-11/30/2014 Coverage For: Individual/Family
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Medical Plan Comparison 2018 ATTENTION: This Medical Plan Comparison is considered a summary of material modifications (SMM) to one or more of the WHOI benefit plans. It contains a summary of important
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