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School District of University City
6
MEDICAL INSURANCE
Plan Highlights
In-Network
Out-of-Network
Deductible
(per calendar year)
Individual
Family
$750
$1,500
$1,500
$3,000
Out-of-Pocket Maximum
(per calendar year)
(includes deductibles & copays)
Individual
Family
$2,500
$5,000
$4,500
$9,000
Coinsurance
(the amount the plan pays)
90%
60%
Office Visits
(Preventive—100% in-network)
$30 Primary Care Physician
$60 Specialist
Deductible & Coinsurance
Inpatient Hospital
Deductible & Coinsurance
Deductible & Coinsurance
Outpatient Surgery
Deductible & Coinsurance
Deductible & Coinsurance
Urgent Care
$50 Copay
$50 Copay
Emergency Room
$250 Copay
$250 Copay
Prescription Drug
Retail Pharmacy
Mail Order Pharmacy
Tier 1 / Tier 2 / Tier 3 / Tier 4
$10 / $50 / $70 / $150
$20 / $100 / $140 / NA
Not Covered
BASE PLAN
The District
contributes the
cost of the
employee’s
coverage under
this plan. If you
elect dependent
coverage you will
be required to pay
the cost of your
elected coverage
BASE PLAN EMPLOYEE MONTHLY CONTRIBUTIONS
Type of Coverage
Employee
Monthly Cost
Employee
$0
Employee & Spouse
$335
Employee & Child(ren)
$225
Employee & Family
$550
Base Plan
Annual Salary
Less than $30,000
Type of Coverage
Employee
Monthly Cost
Employee
$0
Employee & Spouse
$348
Employee & Child
(ren)
$238
Employee & Family
$563
Base Plan
Annual Salary
$30,000 to $95,000
Type of Coverage
Employee
Monthly Cost
Employee
$0
Employee & Spouse
$360
Employee & Child(ren)
$250
Employee & Family
$575
Base Plan
Annual Salary
Over $95,000
Below are the employee cost for the Base Plan option. The employee contribution is based upon your annual income.