Medical Plan Options

Renewal Period:
11/01/16 - 10/31/17

PLAN DESIGN

POS 15/0/NY1

POS 20/0/NY11

POS 30/0/NY12

POS 20/750/NY3

EPO 30/0/NY6

EPO 45/0/NY7

EPO 25/1000/NY10

IN-NETWORK
Preventative / Primary Care / Specialist

$0 / $15 / $20

$0 / $20 / $30

$0 / $30 / $50

$0 / $20 / $30

$0 / $30 / $50

$0 / $45 / $65

$0 / $25 / $40

$0

$0

$0

$750 / 2.5x

$0

$0

$1,000 / 2.5x

100%

100%

100%

90%

100%

100%

80%

$2,500 / 2.5x

$3,000 / 2.5x

$4,000 / 2.5x

$5,000 / 2.5x

$3,500 / 2.5x

$4,000 / 2.5x

$4,000/ 2.5x

$250 per day (3

days max)

$350 per day (3

days max)

$500 per day (3

days max)

90% after Ded.

$750 per admission

$500 per day (5

days max)

80% after Ded.

$150

$150

$150

$150

$200

$200

$200

$75
Covered at 100%

$75
Covered at 100%

$75
Covered at 100%

90% after Ded.

90% after Ded.

$0
Covered at 100%

$0
Covered at 100%

80% after Ded.

80% after Ded.

80%

80%

80%

140%

Not covered

Not covered

Not covered

Deductible

$2,500 / 2.5x

$2,500 / 2.5x

$3,000 / 2.5x

$2,500 / 2.5x

Not covered

Not covered

Not covered

MOOP (Copays RX, Deduct. and Coinsurance)

$5,000 / 2.5x

$5,000 / 2.5x

$5,000 / 2.5x

$8,000 / 2.5x

Not covered

Not covered

Not covered

70%

70%

70%

70%

Not covered

Not covered

Not covered

Deductible
Coinsurance (Carrier Pays)
MOOP*

Hospitalization

Hospital Emergency Room

Outpatient Surgery
Lab Services / X-rays & Complex Imaging
OUT-OF-NETWORK
Reimbursement Rate

Coinsurance (Carrier Pays)

PRESCRIPTION AND MAIL ORDER
Copay - Generic/Brand/Non-Formulary

$10 / $30 / $50

$10 / $30 / $50

$10 / $30 / $50

$10 / $30 / $50

$10 / $30 / $50 after

$100/$300 Ded.

Mail Order - Multiple for 90-Day Supply

2x

2x

2x

2x

2x

MONTHLY RATES

$10 / $30 / $50

$10 / $30 / $50
after $100/$300
after $100/$300 Ded.
Ded.
2x
2x

Enrolled

Employee

23

1,006.00

932.00

757.00

675.00

597.00

544.00

517.00

Employee / Spouse

2,164.00

2,002.00

1,626.00

1,452.00

1,284.00

1,168.00

1,113.00

Employee / Child(ren)

1,962.00

1,816.00

1,476.00

1,316.00

1,166.00

1,059.00

1,009.00

Employee / Family

3,119.00

2,886.00

2,346.00

2,094.00

1,852.00

1,683.00

1,605.00

* Copay, RX, Ded. and Coinsurance

** Applies to single coverage only. All other levels of coverage must meet full family deductible

Medical Plan Options

Renewal Period:
11/01/16 - 10/31/17

PLAN DESIGN

10

11

12

EPO 30/2000/NY9

HSA 2600/NY5

EPO 30/3000/NY8

EPO HSA/5000/NY13

IN-NETWORK
Preventative / Primary Care / Specialist

$0 / $30 / $50

$0 / 90% after Ded.

$0 / $30 / $60

$0 / 100% after Ded.

$2,000 / 2.5x

$2,600 / 2x

$3,000 / 2.5x

$5,000 / 2x

80%

90%

80%

100%

$5,000 / 2.5x

$4,500 / 2x

$6,350/ 2x

$5,500 / 2x

80% after Ded.

90% after Ded.

80% after Ded.

100% after Ded.

$200

90% after Ded.

$200

100% after Ded.

80% after Ded.

80% after Ded.

90% after Ded.

90% after Ded.

80% after Ded.

80% after Ded.

100% after Ded.

Covered at 100%

Reimbursement Rate

Not covered

140%

Not covered

N/A

Deductible

Not covered

$4,000 / 2x

Not covered

N/A

MOOP (Copays RX, Deduct. and Coinsurance)

Not covered

$8,000 / 2x

Not covered

N/A

Coinsurance (Carrier Pays)

Not covered

70%

Not covered

N/A

Copay - Generic/Brand/Non-Formulary

$10 / $30 / $50 after

$100/$300 Ded.

$10 / $30 / $50

after deductible

Mail Order - Multiple for 90-Day Supply

2x

2x

Deductible
Coinsurance (Carrier Pays)
MOOP*

Hospitalization

Hospital Emergency Room

Outpatient Surgery
Lab Services / X-rays & Complex Imaging
OUT-OF-NETWORK

PRESCRIPTION AND MAIL ORDER

$10 / $30 / $50
after $100/$300
Ded.
2x

$10 / $30 / $50 after

deductible
2x

MONTHLY RATES
Employee
Employee / Spouse
Employee / Child(ren)
Employee / Family
* Copay, RX, Ded. and Coinsurance
** Applies to single coverage only. All other levels of coverage must meet full family deductible

465.00

454.00

424.00

399.00

1,000.00

977.00

909.00

859.00

907.00

886.00

825.00

778.00

1,443.00

1,409.00

1,311.00

1,238.00

13