Medical Plan 2019 Coverage Options

Transcription

1 Medical Plan 2019 Coverage Options These documents provide a convenient overview of your health care insurance rates and coverage (medical, including pharmacy; dental; vision) and your contribution limits for your health savings account (HSA). For detailed information about the plans, read the summary plan description (SPD) for each plan. The SPD summarizes what the plan provides and how it operates. Each plan also provides a summary of benefits and coverage or other overview document that may help you understand your benefits. These documents are available at the MyBenefitsSource site on MySolutionSource (our HCM portal), at tcfbank.com/benefits, or from your Human Capital Management team at or HCMSC@tcfbank.com. Choice Plus HSA Option 1 Network Nonnetwork DEDUCTIBLE $ 1,500 $3,000 $ 2,500 $ 5,000 + spouse $ 2,700 $5,400 $ 3,700 $ 7,400 + child(ren) $ 2,700 $5,400 $ 3,700 $ 7,400 Family $3,000 $6,000 $5,000 $10,000 OUT-OF-POCKET MAXIMUM $4,000 $ 8,000 $ 6,000 $ 12,000 + spouse $6,000 $12,000 $ 9,000 (embedded) $ 18,000 + child(ren) $6,000 $12,000 $ 9,000 (embedded) $ 18,000 Family $8,000 (embedded) $16,000 $12,000 (embedded) $24,000 COINSURANCE Choice Plus HSA Option 2 Network Nonnetwork Preventive care 100% no deductible You pay full price 100% no deductible You pay full price Emergency room visit 80% after deductible 80% after deductible 80% after deductible 80% after deductible Virtual visit 80% after deductible In-network care only 80% after deductible In-network care only Primary care physician office visit 80% after deductible 60% after deductible 80% after deductible 60% after deductible Specialist office visit 80% after deductible 60% after deductible 80% after deductible 60% after deductible Urgent care visit 80% after deductible 60% after deductible 80% after deductible 60% after deductible Inpatient hospital/doctor Outpatient hospital/doctor 80% after deductible 60% after deductible 80% after deductible 60% after deductible Maternity care prenatal 80% after deductible 60% after deductible 80% after deductible 60% after deductible Maternity care delivery 80% after deductible 60% after deductible 80% after deductible 60% after deductible Mental health and substance abuse inpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible Mental health and substance abuse outpatient 80% after deductible 60% after deductible 80% after deductible 60% after deductible Choice Plus HSA Option 1 Choice Plus HSA Option 2 TCF ANNUAL CONTRIBUTION TO HSA We will contribute to your HSA each pay period in 2019 if you are an eligible employee enrolled in the Choice Plus HSA Option 1 plan, based on the coverage you elect. $400 None $600 + Spouse None $600 + Child(ren) None $800 Family None TCF Financial Corporation, October 2018

2 Health Care Plans 2019 Premiums and HSA Contributions Coverage level + spouse + child(ren) Family UHC CHOICE PLUS HSA OPTION 1 annual cost $1, $3, $3, $5, cost per pay period $66.51 $ $ $ UHC CHOICE PLUS HSA OPTION 2 annual cost $ $2, $1, $2, cost per pay period $36.58 $81.41 $73.16 $ HEALTH SAVINGS ACCOUNT (HSA) Maximum annual contribution $3, $7, $7, $7, Additional catchup (age 55 or older by 12/31/19) $1, $1, $1, $1, TCF ANNUAL CONTRIBUTION TO HSA Choice Plus HSA Option 1 $ $ $ $ Choice Plus HSA Option 1 per pay period $15.39 $23.08 $23.08 $30.77 Choice Plus HSA Option 2 N/A N/A N/A N/A DENTAL PLAN annual cost $ $1, cost per pay period $18.83 $41.69 VISION PLAN annual cost $78.52 $ $ $ cost per pay period $3.02 $5.75 $6.02 $ TCF Financial Corporation, October 2018

3 Pharmacy Benefits 2019 Coinsurance and Copayment Levels Some preventive drugs are available at no cost to you. Other preventive drugs require only a copay or coinsurance and are not subject to the deductible. For details, visit MyBenefitsSource on the MySolutionCenter portal or consult the summary plan description. Your Costs After You Pay the Deductible Drug tier Retail 30-day supply Home delivery 90-day supply Generic $15 copay $30 copay Brand name preferred/formulary minimum $40; maximum $80 minimum $80; maximum $160 Brand name nonpreferred/nonformulary minimum $55; maximum $110 minimum $110; maximum $220 Specialty drug dispensed through Accredo Coinsurance and minimum/maximum 1- to 30-day supply $100 minimum; $350 maximum 31- to 60-day supply $100 minimum; $525 maximum 61- to 90-day supply $100 minimum/$700 maximum TCF Financial Corporation, October 2018

4 Health Savings Account 2019 Contribution Limits + spouse / + child(ren) Family IRS annual maximum contribution $3,500 $7,000 $7,000 Annual catch-up contribution if you are 55 or older (as of 12/31/2019) $1,000 $1,000 $1,000 IF YOU ENROLL IN CHOICE PLUS HSA OPTION 1 TCF will contribute $400 $600 $800 You can contribute up to (age 54 or younger as of 12/31/2019) $3,100 $6,400 $6,200 You can contribute up to (age 55 or older as of 12/31/2019) $4,100 $7,400 $7, TCF Financial Corporation, October 2018

5 Dental Plan 2019 Coinsurance Levels Service & description Delta Dental preferred provider organization (PPO) & premier provider networks Out-of-network providers Deductible Per person/per family Calendar year No deductible for diagnostic preventive services or orthodontics $25/$75 $25/$75 Calendar year plan maximum Per person $1,500 $1,500 Orthodontia Per eligible child (ages 8-18) 60% $1,500 lifetime maximum 60% of maximum allowable fee $1,500 lifetime maximum Diagnostics & preventive care Exams and cleanings, X-rays, fluoride treatments, space maintainers, sealants 100% 100% of maximum allowable fee Basic services Emergency treatment for relief of pain, amalgam restorations (silver fillings) and composite resin restorations (white fillings) on anterior (front) teeth 80% 80% of maximum allowable fee Endodontics, periodontics & oral surgery Pulpotomies on primary teeth for dependent children, root canal therapy on permanent teeth, surgical and nonsurgical extractions 80% 80% of maximum allowable fee Major restorative Crowns and composite resin restorations (white fillings) on posterior (back) teeth 60% 60% of maximum allowable fee Prosthetic Dentures, bridges, adjustments and repairs 60% 60% of maximum allowable fee TCF Financial Corporation, October 2018

6 Vision Plan 2019 Coinsurance Levels Service In-network Out-of-network maximum reimbursement Vision exam Once every 12 months 100% after $10 copay Up to $40 Prescription lenses Once every 12 months 100% after $25 copay Single copayment if frames and lenses are purchased at the same time Single up to $40 Bifocal up to $60 Trifocal up to $80 Lenticular up to $80 Frame Once every 24 months 100% up to $130 frame allowance after $25 copay Up to $45 Contact lenses Once every 12 months in lieu of glasses/frames 100% up to $150 retail after $25 copay (up to 6 boxes of disposable lenses) Up to $150 elective Up to $210 necessary Laser vision correction Discounted price at contracted providers Not covered TCF Financial Corporation, October 2018

7 Life Insurance 2019 Rates Basic Life Insurance We pay the full cost of life insurance equal to your annual earnings (gross pay) for full-time employees. This is called basic life insurance. Optional life insurance You may choose to purchase additional (supplemental) life insurance at increments up to four times your annual earnings (1x, 2x, 3x, or 4x). You must provide evidence of insurability if you increase your coverage. Rates for Optional (Supplemental) Life Insurance The amount you pay for optional (supplemental) life insurance is based on your age and your annual gross pay. It is calculated per $1,000 of coverage. Note: This table will help you estimate your premiums. When you view your enrollment options in Oracle, you will see exact calculations based on your age, rounded-up gross pay, and rounded premiums (e.g., if your annual gross pay is $35,200, your coverage will be based on $33,000 and premiums will be rounded to two decimal points.) Your age on January 1, 2019 Rates for Optional (Supplemental) Life Insurance Your premium per Annual premium per pay period, per $1,000 of coverage $1,000 of coverage 24 or younger $0.624 $ $0.728 $ $0.962 $ $1.092 $ $1.456 $ $2.392 $ $4.030 $ $6.214 $ $9.750 $ $ $ $ $ and older $ $1.337 Rates for Spouse Life Insurance Annual cost by coverage level Cost per pay period by coverage level $25, $50, $75, $100, $25, $50, $75, $100, coverage at these levels coverage at these levels Age requires evidence of insurability requires evidence of insurability Less than 25 $15.30 $30.60 $45.90 $61.20 $0.59 $1.18 $1.77 $ $18.00 $36.00 $54.00 $72.00 $0.69 $1.38 $2.08 $ $24.00 $48.00 $72.00 $96.00 $0.92 $1.85 $2.77 $ $27.00 $54.00 $81.00 $ $1.04 $2.08 $3.12 $ $36.30 $72.60 $ $ $1.40 $2.79 $4.19 $ $59.70 $ $ $ $2.30 $4.59 $6.89 $ $ $ $ $ $3.88 $7.75 $11.63 $ $ $ $ $ $5.98 $11.95 $17.93 $ $ $ $ $ $9.37 $18.74 $28.11 $ $ $ $1, $1, $16.74 $33.48 $50.23 $ and older $ $1, $2, $3, $33.43 $66.85 $ $ Rates for Child Life Insurance (per child) Annual cost by coverage level Cost per pay period by coverage level $5, $10, $15, $5, $10, $15, $3.24 $6.48 $9.72 $0.12 $0.25 $ TCF Financial Corporation, October 2018