2024-BenefitsGuide-V14-Final

Medical Benefits Plan Feature Comparison

What type of expenses does an HSA cover? You can use your HSA to pay for medical expenses that are not covered by a health plan and meet the IRS definition of a qualified medical expense for you, your spouse, and dependents. See IRS Publications 969 and 502 at www.irs. gov. Many medical and health expenses are covered by an HSA: • Health plan deductibles and coinsurance • Prescription drugs and insulin • Medical care and services • Dental and vision care (after deductible has been met) Understanding the Reliance Saver Plan The Saver Plan requires you to pay more of your medical expenses upfront before the plan begins to pay. Below is an example of how the Saver Plan would work compared to the High and Low PPO Plans. Note: In-network medical expenses include discounts and negotiated rates. Out-of-network medical expenses can cost you much more than the examples below.

HIGH PPO PLAN

LOW PPO PLAN

SAVER PLAN

Coverage

In-Network

Out-of-Network

In-Network

Out-of-Network

In-Network Out-of-Network

Applies to Medical Expenses AND Prescription Drugs

Deductible

Applies to Medical Expenses

Single

$300

$800

$850

$2,000

$1,600

$3,200

Family

$600

$1,600

$1,700

$4,000

$3,200

$6,400

Out-of-Pocket Maximums

Non-Copay Amounts Apply to Medical Expenses After Deductible

Single

$1,500

$5,000

$4,500

$8,000

$4,500

$8,000

Family

$3,000

$9,500

$9,000

$15,500

$9,000

$15,500

LOW PPO PLAN You Pay 20% In-Network $850 Individual Deductible

SAVER PLAN You Pay 20% In-Network $1,600 Individual Deductible

HIGH PPO PLAN You Pay 10% In-Network $300 Individual Deductible

Applies to Medical AND Prescription Drug Expenses after Deductible

Coinsurance

Applies to Medical Expenses after Deductible

Physician Office Visits

$25 Copay

You Pay 30%

$40 Copay

You Pay 40% You Pay 20% You Pay 40%

Medical Expense (In-Network) $100 Specialist Office Visit

Specialist Office Visits

$35 Copay

You Pay 30%

$40 Copay

You Pay 40% You Pay 20% You Pay 40%

Plan Pays

You Pay

Plan Pays

You Pay

Plan Pays

You Pay

Most Covered Services

You Pay 10% You Pay 30% You Pay 20% You Pay 40% You Pay 20% You Pay 40%

$35 Copay No Deductible

$40 Copay No Deductible

$100 towards Deductible

Preventive No Cost to You

You Pay 30% No Cost to You

You Pay 40% No Cost to You

You Pay 40%

$65

$60

$0

Inpatient Hospital

You Pay 10% You Pay 30% You Pay 20% You Pay 40% You Pay 20% You Pay 40%

$200 Generic Preventive Rx

No Copay No Deductible

No Copay No Deductible

Outpatient Surgery

You Pay 10% You Pay 30% You Pay 20% You Pay 40% You Pay 20% You Pay 40%

$200

$200

$200

$0

Emergency Room (Max. 25 non-admission visits per calendar year)

You Pay 10% after $150 Copay

You Pay 20% after $150 Copay

You Pay 20%

$125 Generic Non-Preventive Rx

$10 Copay No Deductible $300 towards Deductible + $50 (10% Coinsurance)

$10 Copay No Deductible

$125 towards Deductible

$115

$115

$0

Urgent Care You Pay 10% You Pay 30% You Pay 20% You Pay 40% You Pay 20% You Pay 40%

Mental Health/Substance Abuse – Inpatient

$800 Outpatient Surgery

$450 (90% Coinsurance)

$800 towards Deductible

$800 towards Deductible

You Pay 10% You Pay 30% You Pay 20% You Pay 40% You Pay 20% You Pay 40%

$0

$0

Mental Health/Substance Abuse – Outpatient

$35 Copay

You Pay 30%

$40 Copay

You Pay 40% You Pay 20% You Pay 40%

$50 towards Deductible + $130 (20% Coinsurance)

$575 towards Deductible + $25 (20% Coinsurance)

$700 Physician Fees (Non- Office Visit)

$630 (90% Coinsurance)

$70 (10% Coinsurance)

$100 (80% Coinsurance)

$520

Chiropractic Care (30 visits max per calendar year)

$35 Copay

You Pay 30%

$40 Copay

You Pay 40% You Pay 20% You Pay 40%

Subtotal

$1,460

$465

$895

$1,030

$300

$1,625

Prescription Drugs

Rx Copays Apply Some Preventive at No Cost to You

Rx Copays Apply Some Preventive at No Cost to You

Waive Deductible Some Preventive at No Cost to You

Preventive

LIVEHEALTH ONLINE Save time andmoney with LiveHealth Online. All you need is amobile phone/ tablet or a computer (with video camera) with an internet connection. You or your covered dependent may see a LiveHealth Online doctor for a $15 copay for PPO enrollees and $59 for Saver Plan enrollees. Inmost cases, a doctor can send a non-controlled substance prescription electronically to your local pharmacy.

Generic / Preferred / Non-preferred

Retail: $10 Copay / 25% / 40%Mail Order*: $20 Copay / 20% / 35%

Retail: $10 Copay / 25% / 40% Mail Order*: $20 Copay / 20% / 35%

Subject to the Deductible & You Pay 20% / 40% Coinsurance

PrudentRx Specialty Medication

With PrudentRx: $0 Copay Without PrudentRx: You Pay 30%

With PrudentRx: $0 Copay Without PrudentRx: You Pay 30%

HSA Calendar Year Maximum for Employee and Employer Contributions (Saver Plan Only)

Employer

$250**

Employee Only

$4,150*** + $1,000 Age 55+

Common concerns include: flu, minor rashes, sore throat, pink eye, allergies, fever, skin infections, headache, cold, diarrhea, anxiety, depression, andmuchmore.

Family

$8,300*** + $1,000 Age 55+

FSA Calendar Year Maximum for Employee Contributions

Healthcare FSA

$3,050

$3,050

$3,050 LPFSA****

DOCTOR VISITS

With your Employee Assistance Program (EAP), you can schedule a video visit with a licensed counselor when you need support. Use your phone, tablet, or computer with a camera to have a secure visit on LiveHealth Online fromhome.

Dependent Day Care FSA

$2,500 Single / $5,000 Family

$2,500 Single / $5,000 Family

$2,500 Single / $5,000 Family

* Discounted pricing for mail order prescriptions is not allowed in OK or MN **Saver Plan employer contribution reduces to $125 for those effective after June 30 ***Includes employer contribution ****Limited Purpose FSA – covers dental and vision expenses only; available only to those enrolled in the Saver Plan

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