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2015—2016 Benefits Guide
6
Benefit Plan
In-Network
Member Responsibility (after
Morgan White payment)
Out-of-Network
Deductible
(calendar year)
Single
$3,000
$500
$9,000
Family
$6,000
$1,000
$18,000
Coinsurance
(plan pays/you pay)
80% / 20%
20%
50% / 50%
Out-of-Pocket Limit
(including the deductible + coinsurance + copayments)
Single
$6,250
$3,750
$12,500
Family
$6,000
$7,500
$25,000
Copayments
Office Visits
(Preventive—100% in-
network
$35 / Primary Care Physician
$70 / Specialist
$35 / Primary Care Physician
$70 / Specialist
50% after deductible
Emergency Room Visit
$300 co-pay, then 80%
$300 co-pay, then 80%
$300 co-pay, then 80%
Urgent Care Center Visit
$100 co-pay
$100 co-pay
50% after deductible
Prescription Drug Coverage
Retail Pharmacy
$10/30/50
$10/30/50
$10/30/50
Mail Order Pharmacy
$25/75/125
$25/75/125
$25/75/125
Outpatient Surgery
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
Inpatient Hospital
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
Major Diagnostics (MRI,
MRA, CT, PET…)
$400 Copay
$400 Copay
50% After Deductible
2015—2016 Employee
Medical Plan
Contributions
MEDICAL INSURANCE—UNITED HEALTHCARE—OXZ, Rx H9
Employee Monthly Cost
2015 Employee
Monthly Cost
Employee
$222.14
Employee & Spouse
$726.55
Employee & Child(ren)
$618.65
Employee & Family
$1,089.95
2015 Employee
Per Paycheck
$111.07
$363.28
$309.33
$544.98