Medical Benefits

PPO (Blue Choice) or Traditional (CAP). Maximum benefits are available when services are received from Blue Choice providers. Non-Blue Choice & Non-CAP: The difference between the payment allowance and provider charge, additional 20% non-PPO network coinsurance amount*, deductible, coinsurance or copay amount. CAP (Non-Blue Choice): Additional 20% non-PPO network coinsurance amount*, deductible, coinsurance or copay amount.
Blue Choice: Deductible, coinsurance or copay amount.
*Non-PPO Coinsurance limited to a combined $2,000 per person, $4,000 two-or more persons each benefit period.

In-Network	Option 1	Option 2	Option 3
Deductible (Individual/Two or more)	$500/$1,000	$1,000 / $2,000	$1,500 / $3,000
Out-of-Pocket Max (Individual/Two or more)	$5,000/$10,000	$5,000/$10,000	$5,000/$10,000
Member Coinsurance (Member portion for most services)	20% of allowed amounts after deductible.	20% of allowed amounts after deductible.	20% of allowed amounts after deductible.
Doctor's Office Visits
Home and office visits	$35 Copay/Visit	$35 Copay/Visit	$35 Copay/Visit
Telemedicine Visits	Paid at 100% of the allowable charge. All other services provided via Telemed are subject to same Cost Sharing as Non-Telemed.	Paid at 100% of the allowable charge. All other services provided via Telemed are subject to same Cost Sharing as Non-Telemed.	Paid at 100% of the allowable charge. All other services provided via Telemed are subject to same Cost Sharing as Non-Telemed.
Preventive care as defined by the Affordable Care Act	Paid at 100% of the allowable charge. Some of the services include: Routine screenings / Preventive immunizations / Well-women visits / screenings / contraception	Paid at 100% of the allowable charge. Some of the services include: Routine screenings / Preventive immunizations / Well-women visits / screenings / contraception	Paid at 100% of the allowable charge. Some of the services include: Routine screenings / Preventive immunizations / Well-women visits / screenings / contraception
Specialist Visit	$70 Copay/Visit	$70 Copay/Visit	$70 Copay/Visit
Medical Services
Emergency medical transportation Inpatient surgery physician/surgical Inpatient facility fee Outpatient surgery physician/surgical Outpatient lab and radiology (Includes Advanced Imaging) Accidental Injury Services	Subject to deductible/coinsurance	Subject to deductible/coinsurance	Subject to deductible/coinsurance
Emergency Room	$250 Copay then subject to deductible/coinsurance	$250 Copay then subject to deductible/coinsurance	$250 Copay then subject to deductible/coinsurance
Recovery/Special Needs
Outpatient rehabilitation Hospice Home Social Work Visits	Subject to deductible/coinsurance	Subject to deductible/coinsurance	Subject to deductible/coinsurance
Mental Health
Mental Illness & Substance Use Disorders Inpatient & Outpatient Services Requires pre-admission certification from New Directions Behavioral Health at 1-800-952-5906	Subject to deductible/coinsurance	Subject to deductible/coinsurance	Subject to deductible/coinsurance
Mental Illness & Substance Use Disorders Outpatient Services	$35 Copay per visit	$35 Copay per visit	$35 Copay per visit
Other
Maximum Lifetime Benefit	Unlimited	Unlimited	Unlimited

Prescription Drugs	Retail Prescriptions 30-day supply	Mail Order Prescriptions 90-day supply through the Extended Supply Network
Generic/Preferred Brand/Non-preferred Brand	BlueRx Card Retail: $15/$50/$75 Copay	2.5x Retail Copay with ResultsRx formulary
Specialty: Preferred/Nonpreferred	$150/20% up to $250. Designated Specialty Pharmacy	2.5x Retail Copay with ResultsRx formulary

Semi-Monthly Rate	Employee	Employer	Total
Option 1
Employee Only	$56.38	$302.73	$359.10
Employee + Child(ren)	$178.37	$592.75	$771.12
Employee + Spouse or Domestic Partner*	$167.09	$559.71	$726.80
Family	$288.26	$850.56	$1,138.82
Option 2
Employee Only	$49.61	$302.56	$352.17
Employee + Child(ren)	$163.46	$592.75	$756.21
Employee + Spouse or Domestic Partner*	$152.24	$560.51	$712.75
Family	$266.70	$850.09	$1,116.79
Option 3
Employee Only	$44.28	$302.36	$346.63
Employee + Child(ren)	$151.42	$592.89	$744.31
Employee + Spouse or Domestic Partner*	$141.41	$560.12	$701.52
Family	$247.83	$851.37	$1,099.20

*A portion of the health care premium contributions for domestic partners are deducted on an aftertax
basis unless the domestic partner qualifies as the employee’s dependent under federal tax laws.
Even though domestic partner premiums are not deducted on a pre-tax basis, the same restrictions
for adding or dropping coverage still apply to domestic partners when a qualifying change in status
occurs. If you wish to cover your domestic partner, contact the HR department to obtain additional information.

Downloads

Summary Plan Description-Option 1

Summary of Benefits-Option 1

Summary Plan Description-Option 2

Summary of Benefits-Option 2

Summary Plan Description-Option 3

Summary of Benefits-Option 3

Maximum benefits are available when services are received from Blue Choice providers. Non-Blue Choice & Non-CAP: The difference between the payment allowance and provider charge, additional 20% non-PPO network coinsurance amount*, deductible, coinsurance or copay amount. CAP (Non-Blue Choice): Additional 20% non-PPO network coinsurance amount*, deductible, coinsurance or copay amount.
Blue Choice: Deductible, coinsurance or copay amount.
*Non-PPO Coinsurance limited to a combined $2,000 per person, $4,000 two-or more persons each benefit period.

	In-Network
Deductible (Individual/Two-or-more)	$3,400/$6,800
Out-of-Pocket Max (Individual/Two-or-more)	$6,350/$12,700
Member Coinsurance (Member portion for most services)	0%
Doctor's Office Visits
Home and office visits	Subject to Deductible
Telemedicine Visits	Subject to the same Cost Sharing provisions as a non-Telemedicine service
Preventive care as defined by the Affordable Care Act	Paid at 100% of the allowable charge. Some of the services include: Routine screenings / Preventive immunizations / Well-women visits / screenings / contraception
Specialist Visit	Subject to Deductible
Medical Services
Emergency medical transportation Inpatient surgery physician/surgical Inpatient facility fee Outpatient surgery physician/surgical Outpatient lab and radiology (Includes Advanced Imaging) Accidental Injury Services	Subject to Deductible
Emergency Room	Subject to Deductible
Accidental Injury Services	Subject to Deductible
Recovery/Special Needs
Outpatient rehabilitation Hospice Home Social Work Visits	Subject to deductible/coinsurance
Mental Health
Mental Illness & Substance Use Disorders Inpatient & Outpatient Services Requires pre-admission certification from New Directions Behavioral Health at 1-800-952-5906	Subject to deductible
Other
Maximum Lifetime Benefit	Unlimited

Prescription Drugs	Retail Prescriptions	Mail Order Prescriptions
Tier 1	$15 Copay	2.5x Retail
Tier 2	$50 Copay	2.5x Retail
Tier 3	$75 Copay	2.5x Retail
Tier 4	Preferred: $150 Copay Non-Preferred: 20% Coinsurance up to $250 Copay	2.5x Retail

Semi-Monthly Rate	Employee	Employer	Total
Employee Only	$27.01	$296.96	$323.96
Employee + Child(ren)	$111.38	$584.19	$695.57
Employee + Spouse or Domestic Partner	$103.46	$552.14	$655.59
Family	$187.11	$840.09	$1,027.20