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2016 Benefits Guide
4
Benefit Plan
QHDHP Option
In-Network
QHDHP Option
Out-of-Network
Deductible
(plan year)
Single
$3,000
$6,000
Family
$6,000
$12,000
Coinsurance
(plan pays/you pay)
100% / 0%
80% / 20%
Out-of-Pocket Limit
(including the deductible + coinsurance)
Single
$3,000
$12,000
Family
$6,000
$24,000
Copayments
Primary Physician Visit
Deductible, then you pay 0%
Deductible, then you pay 20%
Specialist Physician Visit
Deductible, then you pay 0%
Deductible, then you pay 20%
Preventive Care
Plan pays 100%
Deductible, then you pay 20%
Major Diagnostic Lab
Deductible, then you pay 0%
Deductible, then you pay 20%
Emergency Room Visit
Deductible, then you pay 0%
In Network Ded., then you pay 0%
Urgent Care Center Visit
Deductible, then you pay 0%
Deductible, then you pay 20%
Prescription Drug Coverage
Retail Pharmacy
Deductible, then you pay 0%
Deductible, then you pay 20%
Mail Order Pharmacy
Deductible, then you pay 0%
Not Covered
2016 Employee QHDHP Option Medical Contributions
Employee Semi-Monthly
Cost
Previous
2015
Cost
New
2016
Cost
Employee
$46.15
$45.89
Employee & Spouse
$216.41
$243.16
Employee & Child(ren)
$199.66
$203.49
Employee & Family
$294.04
$300.62
MEDICAL INSURANCE—QHDHP Option ($3,000 Ded)