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2016 Benefits Guide
6
MEDICAL INSURANCE
Benefit Plan—PLAN A HIGH
PLAN
In Network
Out of Network
Deductible
(calendar year)
Single
$200
$500
Family
$600
$1,000
Coinsurance
(plan pays/you pay)
90% / 10%
70% / 30%
Out of Pocket Limit
(including the deductible + coinsurance + copayments with the exception of
prescription copays)
Single
$1,700
$5,000
Family
$3,400
$10,000
Copayments
Primary Physician Visit
$20 co-pay
Deductible & Coinsurance
Specialist Physician Visit
$40 co-pay
Deductible & Coinsurance
Preventive Care
Plan pays 100%
Deductible & Coinsurance
Emergency Room Visit
$150 co-pay
$150 co-pay
Urgent Care Center Visit
$50 co-pay
Deductible & Coinsurance
Prescription Drug Coverage ($2,000 out of pocket maximum)
Retail Pharmacy
$5/25/40
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 A High Plan Medical Contributions
Employee Deduction
Per Month
Employee
$140.50
Employee & Spouse
$299.00
Employee & Child(ren)
$246.50
Employee & Family
$407.00
Per Pay
Period
$70.25
$149.50
$123.25
$203.50