Health Savings Account PPO Plan
The Health Savings Account – PPO lets you control your healthcare expenses. This option combines the features of a Health Savings Account for your day-to-day medical expenses and the required high deductible plan to cover catastrophic expenses. This option is available only to employees not covered by a collective bargaining agreement.
Deductible applies to all network and non-network services. |
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Company Contribution Employee Contribution
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$500 Individual / $1,000 Family up to $2,800 Individual / $5,550 Family
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| Summary of Benefits | Network Provider | Non-Network Provider |
|
Physician Services Specialists |
80% |
60% of MNRP* |
|
Preventive Care |
$25 co-payment (deductible does not apply) |
None |
|
Well Baby Care |
Included in Preventive Care (deductible does not apply) |
None |
|
Hospital Inpatient |
80% |
60% of MNRP* |
|
Hospital Outpatient |
80% |
60% of MNRP* |
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Emergency Room |
80% for emergencies 60% for non-emergencies |
80% of MNRP* for emergencies 60% of MNRP* for non-emergencies |
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Urgent Care Centers |
80% |
60% MNRP* |
|
Surgery |
80% |
60% MNRP* |
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X-ray & laboratory |
80% |
60% MNRP* |
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Prescription Drugs (one month supply) |
Tier 1: 80% ($25 min/$45 max) Tier 2: 60% ($45 min/$70 max) Tier 3: 50% ($70 min/$95 max) |
Not covered
|
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Mail Order Prescription (3 month Supply) |
Tier 1: 80% ($45 min/$90 max) Tier 2: 60% ($90 min/$140 max) Tier 3: 50% ($140min/$190 max) |
Not covered |
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Mental Health & Chemical Dependency |
Inpatient 50% Outpatient 50%
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Inpatient 50% Outpatient 50% |
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Deductible ** |
$1,550/person $3,100/family |
$3,100/person $6,200/family |
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Co-insurance maximum |
$4,300/person $8,600/ family |
$6,200/person $12,4000/ family |
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Life time maximum |
none |
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* Maximum Non-network Reimbursement Program (MNRP) as determined by United Health Care
** Deductible does not apply to network providers except where noted. The deductible applies in most situation when using a non-network provider.
Employee Bi-Weekly Cost (Effective January 1, 2015)
|
Employee Only |
$47.29/bi-weekly |
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Employee & Child(ren) |
$82.23/bi-weekly |
Employee & Spouse |
$99.49/bi-weekly |
|
Employee, Spouse & Child(ren) |
$147.49/bi-weekly |
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