O'Fallon 2016 Benefits Guide1

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2016 Benefits Guide
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MEDICAL INSURANCE
Benefit Plan—QHDHP PLAN In Network Out of Network
Deductible (calendar year, embedded)
Single $2,600 $5,00
Family $7,800 $15,000
Coinsurance (plan pays/you pay)
100% / 0% 60% / 40%
Out of Pocket Limit (including the deductible + coinsurance)
Single $2,600 $9,000
Family $7,800 $18,000
Copayments
Primary Physician Visit Deductible & Coinsurance Deductible & Coinsurance
Specialist Physician Visit Deductible & Coinsurance Deductible & Coinsurance
Preventive Care Plan pays 100% Deductible & Coinsurance
Emergency Room Visit Deductible & Coinsurance Same as Network Benefit
Urgent Care Center Visit Deductible & Coinsurance Deductible & Coinsurance
Prescription Drug Coverage
Retail Pharmacy Deductible & Coinsurance Deductible & Coinsurance
Mail Order Pharmacy Deductible & Coinsurance Deductible & Coinsurance
Inpatient Hospital Deductible & Coinsurance Deductible & Coinsurance
Outpatient Surgery Deductible & Coinsurance Deductible & Coinsurance
2016 Employee QHDHP Plan Medical Contributions
Employee Deduction Per Month
Employee $0
Employee & Spouse $0
Employee & Child(ren) $0
Employee & Family $0
Per Pay
Period
$0
$0
$0
$0
*Embedded” means that when one person in a family meets the deducƟble, the plan starts paying at the coinsurance level.