Community Partners, Inc. Benefits Book 2017

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DESCRIPTION OF COVERAGE HIGH DEDUCTIBLE HEALTH PLAN - IN NETWORK
Deductible/Per Plan Year - Individual/Family (Embedded Deductible*) $2,600/$5,200
Coinsurance Per Plan Year 20%
Maximum Out-of-Pocket/Per Plan Year - Individual/Family
(Includes deductible and coinsurance) $5,000/$10,000
Office Visit 20% after deductible. Preventive - covered 100%
Hospitalization 20% after deductible
Routine Diagnostic - Lab/X-ray 20% after deductible. Preventive - covered 100%
Complex Diagnostic Testing - MRI/CT/PET 20% after deductible
Eye Exam - Every Other Plan Year 20% after deductible
Emergency Room 20% after deductible
Urgent Care 20% after deductible
PHARMACY BENEFITS RETAIL - UP TO 30 DAY SUPPLY MAIL ORDER - UP TO 90 DAY SUPPLY
Deductible DeductibleWaivedforCertainPreventiveDrugs.SeePreventiveDrugListforConsumerDrivenHealthPlansExpandedList.
Generic $10 after deductible $25 after deductible
Brand $30 after deductible $75 after deductible
Non-Preferred Brand $50 after deductible $125 after deductible
Specialty 30 day supply, $50 after deductible
Rates - HIGH DEDUCTIBLE HEALTH PLAN (HDHP)
Employee per month Employee per paycheck**
Employee Only $0 $0
Employee + Spouse/Partner $460.04 $230.02
Employee + Child(ren) $418.22 $209.11
Employee + Family $920.10 $460.05
UMR HIGH DEDUCTIBLE HEALTH PLAN (HDHP) - UHC CHOICE PLUS NETWORK
PREVENTIVE CARE
Preventive Care – covered 100% without deductible (Well-women, Well-men, Well-baby Care, Blood Pressure Screening,
Cholesterol Check) For Example: If the physician charge is $300, insurance pays 100% of the bill, leaving you with a $0 balance.
HEALTH SAVINGS ACCOUNT (HSA)
• If you are enrolled in the high deductible health plan, you are eligible to establish an HSA. Each calendar year the IRS
sets the contribution limits for single and family amounts that can be contributed to your HSA. Your contribution is
tax free, earns interest and can be invested.
• The maximum contribution for 2017 is $3,400 for a single and $6,750 for family coverage. Individuals age 55 and
older can also make additional “catch up” contributions. The maximum annual catch-up contribution for 2017 is $1,000.
• CPI will contribute $50 per pay period (up to 24 pays annually), to a health savings account opened at Optum
Bank or Arizona Central Credit Union for employee or employee plus spouse/child(ren)/family coverage in
the high deductible health plan. (HDHP). This contribution may be utilized for all services/products eligible for
reimbursement through a Health Savings Account.
• You may choose to use the funds in your HSA for current qualified medical expenses or save it for future qualified
medical expenses for yourself, your spouse or eligible dependents. (Domestic Partners are not eligible dependents
as defined by IRS thus HSA contributions are not allowed as reimbursable for Domestic Partner expenses).
• Your balance, carried over from year-to-year, IS NOT “USE IT or LOSE IT” if unused.
• You are ineligible to enroll in the HDHP and contribute or have contributions made to an HSA if you have medical
coverage elsewhere (i.e. with a spouse’s plan).
Additional information on HSA can be found by using the U.S. Treasury web link:
** Deductions based on 24 pay-periods. Community Partners, Inc’s (CPI) $68 benefit dollar contributions are not reflected in these premiums.
* An Embedded Deductible means that one person in a family can meet their individual deductible at which point the health plan will begin paying. The
remainder of the family can make up the remaining portion of the family deductible. The deductible year is January 1, 2017 - December 31, 2017.