2024-BenefitsGuide-V16-Final

Medical Benefits Plan Feature Comparison

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

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%

Specialist Office Visits

$35 Copay

You Pay 30%

$40 Copay

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

Most Covered Services

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

Preventive No Cost to You

You Pay 30% No Cost to You

You Pay 40% No Cost to You

You Pay 40%

Inpatient Hospital

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

Outpatient Surgery

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

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%

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

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

Mental Health/Substance Abuse – Outpatient

$35 Copay

You Pay 30%

$40 Copay

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

Chiropractic Care (30 visits max per calendar year)

$35 Copay

You Pay 30%

$40 Copay

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

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

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+

Family

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

FSA Calendar Year Maximum for Employee Contributions

Healthcare FSA

$3,050

$3,050

$3,050 LPFSA****

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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