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2016-2017 Benefits Guide
4
Health Savings Account (HSA)
Anthem HSA Plan Summary
(E3,AH)
Benefit/Service
In-Network
Out-of-Network
Deductible
(Individual/family)
$5,000 / $10,000
$10,000 / $20,000
Coinsurance
100%
70%
Out-of-Pocket Max.
(Individual/family)
$6,050 / $12,100
$20,000 / $40,000
Office Visit
$25/50 Co-Pay After Deductible
70% after Deductible
Virtual Visits
Office Visit Co-Pay
after deductible
50% after Deductible
Well care Benefits
100%
70% after Deductible
Lab & X-ray/Diagnostics
100% after Deductible
70% after Deductible
Inpatient Hospital
100% after Deductible
70% after Deductible
Outpatient Surgery
100% after Deductible
70% after Deductible
Emergency Room
$250 Co-Pay After In Network Deductible
Urgent Care
$75 Co-Pay After Deductible
70% After Deductible
Prescription:
Retail
Mail Order
Deductible, then
:
$10 / $35 / $60 / 25% to $200 max
$10 / $90 / $180 / 25% to $200 max
Type of
Coverage
Employee
Bi-Weekly Cost
Employee
$47.21
Employee & Spouse
$175.19
Employee & Child(ren)
$143.20
Employee & Family
$271.18
Upon establishing an HSA Account through Optum Bank,
RAFCO will contribute $100 to each employee’s account.
Thereafter, RAFCO will match, dollar for dollar, up to $900
for each employee who continues to contribute to their
HSA. For example, if an employee chooses to contribute
$25 per pay period to their HSA, then RAFCO will
contribute $25 per pay period until the total contribution
from RAFCO reaches $900 ($1,000 total for the year).