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City of O’Fallon
7
MEDICAL INSURANCE
Benefit Plan—PLAN B BASE
PLAN
In Network
Out of Network
Deductible
(calendar year)
Single
$500
$1,000
Family
$1,500
$3,000
Coinsurance
(plan pays/you pay)
80% / 20%
60% / 40%
Out of Pocket Limit
(including the deductible + coinsurance + copayments with the exception of
prescription copays)
Single
$2,500
$5,000
Family
$5,000
$10,000
Copayments
Primary Physician Visit
$25 co-pay
Deductible & Coinsurance
Specialist Physician Visit
$50 co-pay
Deductible & Coinsurance
Preventive Care
Plan pays 100%
Deductible & Coinsurance
Emergency Room Visit
$300 co-pay
$300 co-pay
Urgent Care Center Visit
$50 co-pay
Deductible & Coinsurance
Prescription Drug Coverage ($2,000 out of pocket maximum)
Retail Pharmacy
$10/35/60
Not Covered
Mail Order Pharmacy
2.5 co-pays for a 90 day supply
Not Covered
Inpatient Hospital
Deductible & Coinsurance
Deductible & Coinsurance
Outpatient Surgery
Deductible & Coinsurance
Deductible & Coinsurance
2016 Employee Plan B Base Plan Medical Contributions
Employee Deduction
Per Month
Employee
$53.50
Employee & Spouse
$114.00
Employee & Child(ren)
$96.50
Employee & Family
$158.00
Per Pay
Period
$26.75
$57.00
$48.25
$79.00