|
Plan Design |
PPO Plan |
Blue Edge $2,500 HDHP Plan* |
Blue Edge $5,000 HDHP Plan* |
|||
|
|
In-Network |
Out-of-Network |
In-Network |
Out-of-Network |
In-Network |
Out-of-Network |
|
Deductible Single Family |
$1,500 $4,500 |
$3,000 $9,000 |
$2,500 $5,000 |
$5,000 $10,000 |
$5,000 $10,000 |
$10,000 $20,000 |
|
Coinsurance |
80% |
60% |
80% |
70% |
80% |
50% |
|
Out-of-Pocket Max Single Family |
$6,500 $15,000 |
$13,000 $31,000 |
$7,500 $15,000 |
$14,000 $30,000 |
$8,500 $17,000 |
$20,000 $40,000 |
|
Preventive Care |
100% |
60% after deductible |
100% |
70% after deductible |
100% |
50% after deductible |
|
Doctors Office Visit |
$30 copay then 100%—PCP $50 copay then 100%—SPC |
60% after deductible |
80% after deductible |
70% after deductible |
80% after deductible |
50% after deductible |
|
Medical/Surgical Services |
80% after deductible |
60% after deductible |
80% after deductible |
70% after deductible |
80% after deductible |
50% after deductible |
|
Emergency Room (copay waived if admitted to hospital) |
$300 copay then 100% |
$300 copay then 100% |
80% after deductible |
80% after deductible |
80% after deductible |
80% after deductible |
|
Inpatient Services |
80% after deductible |
$300 per admission then 60% after deductible |
80% after deductible |
$300 per admission then 70% after deductible |
80% after deductible |
$300 per admission then 50% after deductible |
|
Outpatient Services |
80% after deductible |
60% after deductible |
80% after deductible |
70% after deductible |
80% after deductible |
50% after deductible |
|
Prescription Drugs (Retail) Generic Formulary Non-Formulary Specialty |
$10 copay $40 copay $60 copay 20% to $250 |
$10 copay $40 copay $60 copay 20% to $250 |
80% after deductible |
80% after deductible |
80% after deductible |
80% after deductible |
|
Prescription Drugs (Mail Order) Generic Formulary Non-Formulary Specialty |
$20 copay $80 copay $120 copay N/A |
Not Covered |
80% after deductible |
Not Covered |
80% after deductible |
Not Covered |
|
* Shorr Packaging Corp. provides HDHP matching contributions up to $500 for employee only coverage tiers and $1,000 for employee plus one and family coverage tiers per year. In the chart above, PCP refers to primary care provider and SPC refers to a specialist. Note: This is a summary of benefits, please see Shorr Packaging Corp. Human Resources for a detailed plan description. Member pays coinsurance after deductible is met. |
||||||













