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.

3