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My Benefits Plan 2015

2015 Medical Plan Choices – A Review

PHA Completion Required
Some plans have additional eligibility requirements
No PHA Completed

Prime Care Advantage1

Prime Care Choice1,4

Prime Care Connect9

Out-of-Area Plan2,10

Basic PPO Plan4,7

Basic Out-of-Area Plan10

Network

Network

Out-of-Network

Network

Non-Network

Network

Out-of-Network

Non-Network

Annual Deductible3

Individual: $200

Family: $600

for most services

Individual: $600

Family: $1,800

for most services

Individual: $1200

Family: $3,600

for most services

None for most services

None for most services

Individual: $800

Family: $2,400

for most services

Individual: $1,600

Family: $4,800

for most services

Individual: $800

Family: $2,400

for most services

Coinsurance

Plan pays 85% for most services6

Plan pays 80% for most services6

Plan pays 60% of UCR for most services6

Plan pays 100% for most services

Plan pays 80% of UCR for most services

Plan pays 75% for most services6

Plan pays 55% of UCR for most services6

Plan pays 75% of UCR for most services6

Annual Out-of-Pocket Maximum4

Individual: $2,000

Family: $4,000

Individual: $3,000

Family: $6,000

Individual: $6,000

Family: $12,000

Individual: $1,000

Family: $3,000

Individual: $2,000

Family: $4,000

Individual: $3,500

Family: $7,000

Individual: $7,000

Family: $14,000

Individual: $3,500

Family: $7,000

Preventive Care

Plan pays 100%

Plan pays 100%

Plan pays 60%6

Plan pays 100%

Plan pays 100%

Plan pays 100%

Plan pays 55%6

Plan pays 100%

Office Visits:

  • Primary Care Provider11

Plan pays 100%11

Plan pays 100%11

Plan pays 60%6

Plan pays 100%11

Plan pays 100%11

Plan pays 75%6

Plan pays 55%6

Plan pays 75%6

  • Other Practitioners

You pay $25/copay5

Plan pays 80%6

Plan pays 60%6

You pay $10/copay5

Plan pays 80%

Plan pays 75%6

Plan pays 55%6

Plan pays 75%6

  • Specialist

You pay $35/copay

Plan pays 80%6

Plan pays 60%6

You pay $10/copay

Plan pays 80%

Plan pays 75%6

Plan pays 55%6

Plan pays 75%6

  • Behavioral Health

Plan pays 85%8

Plan pays 80%6

Plan pays 60%6

Plan pays 100%

Plan pays 80%

Plan pays 75%6

Plan pays 55%6

Plan pays 75%6

Emergency Care

You pay $150/copay

Plan pays 80%6

Plan pays 80%6

You pay $50/copay

You pay $150/copay

Plan pays 75%6

Plan pays 75%6

Plan pays 75%6

Urgent Care

You pay $35/copay

Plan pays 80%6

Plan pays 60%6

You pay $10/copay

Plan pays 80%

Plan pays 75%6

Plan pays 55%6

Plan pays 75%6

Inpatient

Hospitalization

Plan pays 85%6

Plan pays 80%6

Plan pays 60%6

You pay $100/copay

Plan pays 80%

Plan pays 75%6

Plan pays 55%6

Plan pays 75%6

Outpatient Surgery

Plan pays 85%6

Plan pays 80%6

Plan pays 60%6

You pay $100/copay

Plan pays 80%

Plan pays 75%6

Plan pays 55%6

Plan pays 75%6

Lab and X-ray

Plan pays 85%8

Plan pays 80%6

Plan pays 60%6

Plan pays 100%

Plan pays 80%

Plan pays 75%6

Plan pays 55%6

Plan pays 75%6

2015 Medical Plans Contribution Rates for Employee, Spouse, and Dependent Children

The following FULL-TIME RATES are for eligible regular and term appointments of 75% – 100% FTE; includes faculty, A&P, Sr. A&P, CCS, auxiliary faculty, clinical instructor, intern, postdoctoral fellow, postdoctoral researcher, and visiting faculty.

Completion of PHA Required for Enrollment No PHA Completed
  Rates reflect the NET premium, which includes the PHA Medical Plan Premium Credit of up to $360 annually ($30/monthly pay; $13.85/biweekly pay) when the Your Plan for Health (YP4H) Personal Health & Well-Being Assessment (PHA) is completed. Basic PPO and Basic Out-of-Area rates do not include the PHA credit.
Biweekly Monthly Biweekly Monthly Biweekly Monthly Biweekly Monthly Biweekly Monthly Biweekly Monthly
Coverage Level Prime Care Advantage Prime Care Choice Prime Care Connect1 Out-of-Area Plan1 Basic PPO Plan Basic Out-of-Area Plan
Employee Only $36.56 $79.23 $17.79 $38.55 $36.56 $79.23 $36.56 $79.23 $45.38 $98.33 $45.38 $98.33
Employee + Children $74.01 $160.37 $39.28 $85.11 $74.01 $160.37 $74.01 $160.37 $93.60 $202.80 $93.60 $202.80
Employee + Spouse $95.35 $206.59 $55.92 $121.17 $95.35 $206.59 $95.35 $206.59 $112.40 $243.53 $112.40 $243.53
Family $140.51 $304.44 $81.84 $177.32 $140.51 $304.44 $140.51 $304.44 $170.55 $369.52 $170.55 $369.52

The following PART-TIME RATES are for regular and term appointments of 50% – 74% FTE; includes faculty, A&P, Sr. A&P, CCS, auxiliary faculty, clinical instructor, intern, postdoctoral researcher, and visiting faculty.

Completion of PHA Required for Enrollment No PHA Completed
  Rates reflect the NET premium, which includes the PHA Medical Plan Premium Credit of up to $360 annually ($30/monthly pay; $13.85/biweekly pay) when the Your Plan for Health (YP4H) Personal Health & Well-Being Assessment (PHA) is completed. Basic PPO and Basic Out-of-Area rates do not include the PHA credit.
Biweekly Monthly Biweekly Monthly Biweekly Monthly Biweekly Monthly Biweekly Monthly Biweekly Monthly
Coverage Level Prime Care Advantage Prime Care Choice Prime Care Connect1 Out-of-Area Plan1 Basic PPO Plan Basic Out-of-Area Plan
Employee Only $101.36 $219.62 $82.58 $178.94 N/A N/A $101.36 $219.62 $90.77 $196.66 $90.77 $196.66
Employee + Children $189.48 $410.54 $154.74 $335.28 N/A N/A $189.48 $410.54 $167.92 $363.82 $167.92 $363.82
Employee + Spouse $220.01 $476.69 $180.58 $391.27 N/A N/A $220.01 $476.69 $195.23 $422.99 $195.23 $422.99
Family $326.27 $706.92 $267.60 $579.80 N/A N/A $326.27 $706.92 $288.26 $624.56 $288.26 $624.56

The following FULL COST RATES are for regular and term appointments of 0.1% – 49% FTE; includes clinical instructor; and temporary appointments of 75% - 100% FTE; includes faculty, A&P, Sr. A&P, CCS, auxiliary faculty, intern, postdoctoral researcher, visiting faculty, and ONA members with appointments of .1% – 49% FTE.

  Completion of PHA Required for Enrollment No PHA Completed
  Rates reflect the NET premium, which includes the PHA Medical Plan Premium Credit of up to $360 annually ($30/monthly pay; $13.85/biweekly pay) when the Your Plan for Health (YP4H) Personal Health & Well-Being Assessment (PHA) is completed. Basic PPO and Basic Out-of-Area rates do not include the PHA credit.
Biweekly Monthly Biweekly Monthly Biweekly Monthly Biweekly Monthly Biweekly Monthly Biweekly Monthly
Coverage Level Prime Care Advantage Prime Care Choice Prime Care Connect1 Out-of-Area Plan1 Basic PPO Plan Basic Out-of-Area Plan
Employee Only $245.32 $531.54 $226.55 $490.86 N/A N/A $245.32 $531.54 $226.92 $491.65 $226.92 $491.65
Employee + Children $465.62 $1,008.85 $430.88 $933.59 N/A N/A $465.62 $1,008.85 $419.79 $909.55 $419.79 $909.55
Employee + Spouse $530.41 $1,149.23 $490.99 $1,063.81 N/A N/A $530.41 $1,149.23 $476.52 $1,032.47 $476.52 $1,032.47
Family $796.06 $1,724.81 $737.39 $1,597.69 N/A N/A $796.06 $1,724.81 $709.11 $1,536.41 $709.11 $1,536.41