for questions about plan - siho · information in this brochure, please contact our account...

3

3 Table of Contents

4 About SIHO

5 Fully Insured Products

6 Product Components

8 Precertification Information

9 Eligibility Guidelines

10 HRA & HSA Overview

11 Information Available on the SIHO Website

12 How To Get A Quote

14 3 Tier Plan Designs

24 2 Tier Plan Designs

30 Voluntary Dental Option

31 Voluntary Vision Option

For questions about plan

information in this brochure,

please contact our Account

Coordinator.

4

SIHO Insurance Services, headquartered in Columbus, Indiana, was established in 1987

through the cooperative efforts of local physicians, hospitals, and employers who were

concerned about the rising cost of health care.

SIHO was formed with a vision to provide affordable health care benefits by partnering with

local medical providers and employers. One of the fastest growing Health Plan

Administrators in the Midwest, SIHO strives to raise the standard of health care and the

quality of life in its communities.

SIHO’s promise to its customers is very simple: provide them with the sophistication of a

national carrier while keeping the focus on flexibility and cost-effectiveness as a top priority.

SIHO provides friendly and professional customer

service with a personal touch to all our clients. SIHO's Member

Service Representatives are trained to answer questions pertaining

to the health plans, including benefit coverage and claim inquiries.

With offices located in Columbus and Seymour Indiana, SIHO is

able to provide local, reliable customer service to all of our

members. SIHO’s employees are highly trained with access to the

latest technology to provide fast and accurate administration of

claims payment, issuance of ID cards and policies.

How can I help

you today?

5

SIHO provides a wide range of health plans specifically designed for your

business. Working with insurance agents and benefit consultants, SIHO is

dedicated to servicing all aspects of an employer’s group health plan. Managing

complex administrative requirements while simultaneously providing first-class

service to our customers is the SIHO advantage.

PPO (Choice) Plans

In addition to our comprehensive health plans, SIHO also provides other

employee benefit programs:

HSA Plans

HRA Plans

Flexible Spending

Administration

COBRA

Administration Dental Plans Vision Plans Life Insurance

SIHO has a solution to your

network needs. We offer both two

tier and three tier network plans.

The employer’s location will

determine network options.

6

SIHO’s staff of Physicians, Nurse Practitioners and Registered Nurses

ensure medical services are clinically appropriate, meet the standards

of care in the community and are done in the most cost-effective

manner. SIHO’s medical staff provides expert medical opinions and

information to improve the quality of care for SIHO members. SIHO

also provides follow-up contacts, when needed, to ensure proper care

is being followed.

Preventive care is covered for all members with zero cost

sharing. Check www.siho.org for the latest version of our

Preventive Health Benefit.

SIHO uses many national health care guidelines to create our

Preventive Health Benefit standards and recommendations.

Our Quality Management Committee reviews preventive care

services quarterly and updates the benefits as needed.

SIHO provides coverage to expecting mothers

before and after delivery. Covered services include:

office visits, services prior to birth, delivery and

follow-up care. Newborns receive coverage for the

first 30 days after birth. Parents must notify SIHO

of the new addition to the family within those 30

days to ensure continued coverage.

SIHO’s prescription drug coverage is managed by

Caremark. Members can purchase prescription

medications at a local retail pharmacies, as well as

through the mail order service.

Members can review their prescription drug

activity and cost, learn about various health

conditions and access self-care centers.

Members can also check drug prices at any

participating pharmacy.

SIHO offers a diabetes care management

program in partnership with Livongo.

• Voluntary program with zero cost for the member

• Advanced blood glucose meter, unlimited test strips

and lancets mailed to members home

• 24/7 monitoring and support, coaching by certified

diabetic educators, personalized member portal at

www.livongo.com

7

Plans cover emergency and urgent care services. If

hospital admission is required, SIHO must be notified

within 48 hours or as soon as reasonably possible.

Copays are waived if you are admitted to the hospital

directly from the Emergency Department.

SIHO encourages members to establish a relationship with a primary care physician (family practice, pediatrics and

internal medicine). When members see their primary care physician, they pay an office copay (or deductible and

coinsurance on HRA and HSA Plans) and the physician then files the claim directly with SIHO. We make the process

simple for you and your employees.

When members need to see a specialist physician, they pay an office copay (or deductible and coinsurance on HRA

and HSA Plans) to cover the office visit. Any ancillary services provided during the visit, such as radiology or

laboratory tests, are subject to coinsurance.

To find a participating provider, go to www.siho.org and click on “Member” tab. You can also call SIHO Member

Services at 812.378.7070 or toll-free 800.443.2980.

Group life insurance coverage is offered as an option for groups over 50 employees. The standard benefit is $15,000

for each employee plus $15,000 AD&D coverage. Dependent life insurance is available upon the employer’s request.

Members on Choice or HRA plans pay a $5 copay for

allergy injections from an in-network provider. This

benefit will help control out-of-pocket expenses for

members. HSA plan members pay deductible

and coinsurance.

SIHO has included mental health and substance abuse

benefits in our plans through the SOLUTIONS network.

SOLUTIONS is a service of Quinco Behavioral Health

Systems, which is a private, not-for-profit behavioral

health organization.

The enhanced mental health and substance abuse benefit

offers behavioral health care assistance in the identification

and resolution of problems that members face in their

everyday lives, including marital, family, drug abuse, work

and school-related issues, depression, stress, and anxiety

(HRA and HSA plans use the SIHO Network, instead of the

Solutions Network, for Mental Health Benefits).

If you are traveling and require emergency care

outside of the plan’s network, covered services are

paid at in-network levels. If you are traveling or

attend school outside of the plan’s network and are

in need of routine medical care, covered services are

paid at out-of-network levels; in most cases, you

would benefit from a network discount.

8

Members are responsible for obtaining precertification for services from network or non-network

providers. Failure to obtain precertification could result in a reduction of benefits for that service or

procedure up to a penalty of fifty percent (50%) of the Prevailing Rate.

1. All inpatient admission including but not limited to long term acute/sub-acute/rehab

2. Skilled nursing facilities

3. Inpatient Mental Health and Substance Abuse and residential treatment (RES for Mental

Health/Substance Abuse)

4. Home health care

5. Durable Medical Equipment and prosthetics (purchase over $750 and all rentals)

6. Hospice care

7. Transplant evaluations and procedures

8. Specialty medications (excluding insulin)

9. Oncology services (chemotherapy and radiation)

10. Applied Behavioral Analysis (ABA Therapy)

11. Dialysis

12. Speech therapy

13. Implantation of Cardiac Defibrillator

14. Genetic Testing

15. Neurological Implants and implanted nerve stimulator devices including but not limited

to spinal cord stimulators and vague nerve stimulators (VNS)

9

All medical and pharmacy quotes are issued contingent upon SIHO being the only medical coverage being offered

by the employer unless prior agreement is granted by SIHO.

For all groups, participation must be 75% of total eligible population excluding spousal waivers and waivers for

other coverage. If an employer is paying 100% of premium for employees, all eligible employees must be on the

medical plan.

Employees who are full-time, working a minimum of

30 hours per week in the regular business of the

employer, are eligible for coverage. Working owners

must be working a minimum of 20 hours per week or

80 hours per month to be on the medical plan.

The employer must contribute a minimum of 50%

of the employee only monthly premium.

An eligible dependent is a spouse or a child who is under

the age of 26 and is a natural born or legally adopted son,

daughter or stepchild.

Initial Enrollees

Coverage will take effect on the participating employer group’s effective date. Following the initial open enrollment

period, an annual open enrollment shall be held each year starting 45 days prior to the anniversary date of the

policy. Anyone wishing to join the plan at a time other than the effective date of the group is considered a late

enrollee and must meet the criteria below to be covered under the employer’s health plan. Anyone choosing not to

enroll during the initial enrollment period must wait until the next open enrollment period to do so. Coverage will

take effect on the participating employer’s anniversary date.

Late Enrollees

A member may be added as a late enrollee effective on a date other than the anniversary date if the member

experiences a qualifying event. Qualifying events include (but are not limited to) marriage, birth, adoption or spousal

loss of coverage.

10

The HRA consists of two parts:

A Health Reimbursement Arrangement starts out as a financial commitment from the employer to the employee; i.e., the employer will

pay the first $750 of medical expenses for the employee each year. If the employee incurs no claims, the employer does not make any

payment. However, this obligation generally carries over to the next year and is added to another $750 commitment for year two. HRAs

are generally paired with a higher deductible health plan whose structure can be very flexible, including co-payments for certain services.

HRAs are not portable; any balances are forfeited if an employee leaves the organization. Although HRAs can be used to cover the very

broad list of IRS qualified medical expenses, most employers limit their use to only services covered by the higher deductible health plan.

Claims must be submitted and substantiated to be paid from the HRA.

SIHO offers several HRA design variations to meet the needs of most employers. They each have differences in deductibles, coinsurance, co-pays and suggested HRA funding amounts.

An affordable health plan that provides comprehensive coverage for office visits, preventive care, prescription drugs, hospital costs and physician services.

A Health Reimbursement Account funded by the employer

which can be used to pay for services that are the

responsibility of the member, i.e., subject to deductible and

coinsurance. If the member does not use any or all of their

dollars, they roll over to the next year and will accumulate to

provide greater financial protection! The HRA cannot be used

to cover co-payments.

A Health Savings Account (HSA) can be viewed much like a medical IRA. It is a tax advantaged savings account that individuals

can use to pay for qualified health care expenses, both now and in the future. As employers continue to migrate to ever higher

deductible plans, it makes sense to consider structuring the High Deductible Health Plan (HDHP) so that employees can benefit

from the advantages of an HSA.

HSAs are physical accounts established at a bank, credit union or insurance company. In order to establish the HSA, the

consumer must be covered by a federally qualified HDHP. The structure of the HDHP is set by the U.S. Treasury with minimum

deductibles and limits on out-of-pocket maximums.

Employees and/or employers can contribute to the HSA, subject to an annual maximum. The accounts are portable and remain

with the employee, even if they change jobs. Withdrawals from the HSA can be made for any IRS qualified medical expense, the

list can be found at the web address below. The member does not need to submit claims or receipts to make a withdrawal. The

member should keep all receipts should they be audited by the IRS.

SIHO offers several HSA design variations to meet the needs of most employers. These designs can vary in: deductible,

coinsurance, and suggested HSA funding amounts by the employer. An employer may choose to offer their employees only an

HSA plan design. Alternatively, the employer may offer an HSA plan together with a more traditional plan to better meet the

needs of all employees.

https://www.irs.gov/pub/irs-pdf/p502.pdf

11

http://www.siho.org

Member Employer Provider Chamber Plans Social

Members Can:

• Log in to the Member Portal

• Search the Provider Directory

• Access Member Forms

• View Pharmacy Information

• Find Answers to FAQs

Employers Can:

• Log in to the Employer Portal

• Learn more about our Fully Insured Plans

• Access Health Links

• View Additional Wellness Information

Providers Can:

• Log in to the Provider Portal

• View Medical Forms

• Learn more about Provider Services

• Access and Submit Authorization Requests

and Check Eligibility

Login

We have a Mobile App!

Just search for SIHO in

the app store.

12

Name, Address, SIC code

EE, Spouse, Dependents, DOB, Zip Code, Gender

Medical Paid Claims by Month, RX Paid Claims by Month, High Cost

Member Paid Claims together with Diagnosis and Prognosis

If claims data is not available applications are required.

Signed within 60 days

Telephone 812.378.7071

Email [email protected]

13

To view participating providers visit siho.org or contact Carolyn Dailey.

St. Joseph, Marshall Select Health Network

Cass Logansport Memorial with

Sagamore

Boone, Hancock,

Hamilton, Hendricks,

Henry, Johnson, Rush

Suburban Health

Organization (SHO)

Shelby Suburban Health

Organization (SHO)

Bartholomew, Brown,

Jackson, Jennings SIHO with EncoreCombined

Clark, Dearborn, Floyd,

Harrison, Jefferson, Ohio,

Scott, Switzerland,

SIHO

Dubois

Patoka Valley Health Care

Cooperative with

EncoreCombined/Encore

Gibson, Knox, Perry, Pike,

Posey, Spencer,

Vanderburgh, Warrick

OneCare Network OneCare Network with

EncoreCombined

Allen, Crawford, Daviess,

Decatur, Dekalb, Elkhart,

Franklin, Greene,

Kosciusko, LaGrange,

Lawrence, Madison,

Marion, Martin, Monroe,

Morgan, Noble, Orange,

Owen, Ripley, Steuben,

EncoreCombined Encore Combined with

Encore

Note: The SIHO Proprietary Network is available in all of our licensed Counties, as is EncoreCombined and EncoreCombined with Encore. SIHO will work with the Agent and Employer to recommend the best network solution.

14

Prime Care Choice $500/20% Price Care Choice $1000/20%

Tier 1

Network Tier 2

Network

Tier 3

Out-of-

Network

Tier 1

Network Tier 2

Network

Tier 3 Out-of-Network

Annual Single Deductible $500 $1,000 $2,000

$1,000 $2,000 $3,000

Annual Family Deductible $1,000 $2,000 $4,000

$2,000 $4,000 $6,000

Annual OOP Max - Single

(incl Deductible, copay, and coinsurance) $5,000 $6,500 $9,000

$6,000 $7,500 $10,000

Annual OOP Max - Family

(incl Deductible, copay, and coinsurance) $10,000 $13,000 $18,000

$12,000 $15,000 $20,000

PCP Office Visit $20 $20 Ded, 50%

$25 $25 Ded, 50%

Specialist Office Visit

(20% for Ancillary Services) $30 $30 Ded, 50%

$40 $40 Ded, 50%

Preventive Care 0% 0% Not Covered

0% 0% Not Covered

Inpatient Hospital Services Ded, 20% Ded, 30% Ded, 50%

Ded, 20% Ded, 30% Ded, 50%

Outpatient Hospital Services Ded, 20% Ded, 30% Ded, 50%

Ded, 20% Ded, 30% Ded, 50%

Professional Services (In & Out) Ded, 20% Ded, 30% Ded, 50%

Ded, 20% Ded, 30% Ded, 50%

Emergency Room $250 $250 $250

$250 $250 $250

Urgent Care Facility $30 $30 Ded, 50%

$40 $40 Ded, 50%

Ambulance Ded, 20% Ded, 20% Ded, 20%

Ded, 20% Ded, 20% Ded, 20%

PT/OT/Speech Therapy

(20 visit annual max each) Ded, 20% Ded, 30% Ded, 50%

Ded, 20% Ded, 30% Ded, 50%

Chiropractic Services

(15 visit annual max) $30 $30 Ded, 50%

$40 $40 Ded, 50%

DME/Orthotics & Prosthetic Devices Ded, 20% Ded, 30% Ded, 50%

Ded, 20% Ded, 30% Ded, 50%

Inpatient Behavioral Health Ded, 20% Ded, 30% Ded, 50%

Ded, 20% Ded, 30% Ded, 50%

Outpatient Behavioral Health (4 free visits) $20 $20 Ded, 50%

$25 $25 Ded, 50%

Skilled Nursing Facility/LTACH (45 day max) Ded, 20% Ded, 30% Ded, 50%

Ded, 20% Ded, 30% Ded, 50%

Acute Inpatient Rehabilitation (45 day max) Ded, 20% Ded, 30% Ded, 50%

Ded, 20% Ded, 30% Ded, 50%

Home Health (60 day annual max) Ded, 20% Ded, 30% Ded, 50%

Ded, 20% Ded, 30% Ded, 50%

Hospice Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%

Pharmacy:

Generic Drug $10 $10 Ded, 50%

$10 $10 Ded, 50%

Brand Name Formulary $30 $30 Ded, 50%

$30 $30 Ded, 50%

Brand Name Non-Formulary $45 $45 Ded, 50%

$45 $45 Ded, 50%

Specialty Drugs** ($500 maximum) Ded, 25% Ded, 25% Mail Order

Only Ded, 50%

Ded, 25% Ded, 25% Mail Order

Only Ded, 50%

Mail Order 2.5x 2.5x N/A

2.5x 2.5x N/A

OON Coinsurance applies to all services, except Emergency Room services, which are legally require d to be that of INN **Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by

15

Prime Care Choice $1500/20% Prime Care Choice $2000/20%

Tier 1 Network

Tier 2 Network


Tier 1

Network Tier 2

Network Tier 3

Out-of-Network

$1,500 $2,500 $4,000 $2,000 $3,000 $5,000 Annual Single Deductible

$3,000 $5,000 $8,000 $4,000 $6,000 $10,000 Annual Family Deductible

$7,000 $7,900 $11,000 $7,900 $7,900 $12,000 Annual OOP Max - Single

(incl Deductible, copay, and coinsurance)

$14,000 $15,800 $22,000 $15,800 $15,800 $24,000 Annual OOP Max - Family

(incl Deductible, copay, and coinsurance)

$25 $25 Ded, 50% $25 $25 Ded, 50% PCP Office Visit

$40 $40 Ded, 50% $40 $40 Ded, 50% Specialist Office Visit

(20% for Ancillary Services)

0% 0% Not Covered 0% 0% Not Covered Preventive Care

Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Inpatient Hospital Services

Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Outpatient Hospital Services

Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Professional Services (In & Out)

$250 $250 $250 $250 $250 $250 Emergency Room

$40 $40 Ded, 50% $40 $40 Ded, 50% Urgent Care Facility

Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ambulance

Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% PT/OT/Speech Therapy

(20 visit annual max each)

$40 $40 Ded, 50% $40 $40 Ded, 50% Chiropractic Services

(15 visit annual max)

Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% DME/Orthotics & Prosthetic Devices

Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Inpatient Behavioral Health

$25 $25 Ded, 50% $25 $25 Ded, 50% Outpatient Behavioral Health (4 free visits)

Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Skilled Nursing Facility/LTACH (45 day max)

Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Acute Inpatient Rehabilitation (45 day max)

Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Home Health (60 day annual max)

Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Hospice

Pharmacy:

$10 $10 Ded, 50% $10 $10 Ded, 50% Generic Drug

$40 $40 Ded, 50% $40 $40 Ded, 50% Brand Name Formulary

$60 $60 Ded, 50% $60 $60 Ded, 50% Brand Name Non-Formulary


Only Ded, 50% Ded, 25% Ded, 25%

Mail Order Only

Ded, 50%

Specialty Drugs** ($500 maximum)

2.5x 2.5x N/A 2.5x 2.5x N/A Mail Order


16

Prime Care Choice

$2500

Prime Care Choice

$2500/50%

Prime Care Choice

$3000/20%

Prime Care Choice

$3500 /20%

Tier 1

Network Tier 2

Network


Tier 1 Network

Tier 2 Network


Tier 1

Network Tier 2

Network


Tier 1

Network Tier 2

Network


Annual Single Deductible $2,500 $3,500 $6,000 $2,500 $5,000 $10,000 $3,000 $4,000 $7,000 $3,500 $4,500 $8,000

Annual Family Deductible $5,000 $7,000 $12,000 $5,000 $10,000 $20,000 $6,000 $8,000 $14,000 $7,000 $9,000 $16,000


(incl Deductible, copay, and

coinsurance)

$7,900 $7,900 $13,000 $7,900 $7,900 $24,450 $7,900 $7,900 $14,000 $7,900 $7,900 $14,000



coinsurance)

$15,800 $15,800 $26,000 $15,800 $15,800 $48,900 $15,800 $15,800 $28,000 $15,800 $15,800 $28,000

PCP Office Visit $30 $30 Ded, 50% $35 $35 Ded, 50% $30 $30 Ded, 50% $30 $30 Ded, 50%


(20% for Ancillary Services) $50 $50 Ded, 50% $80 $80 Ded, 50% $50 $50 Ded, 50% $50 $50 Ded, 50%

Preventive Care 0% 0% Not

Covered 0% 0%

Not

Covered 0% 0%

Not

Covered 0% 0%

Not

Covered

Inpatient Hospital Services Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%

Outpatient Hospital Services Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%

Professional Services

(In & Out) Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%

Emergency Room $350 $350 $350 $500, 50% $500, 50% $500, 50% $350 $350 $350 $350 $350 $350

Urgent Care Facility $50 $50 Ded, 50% $100 $100 Ded, 50% $50 $50 Ded, 50% $50 $50 Ded, 50%

Ambulance Ded, 20% Ded, 20% Ded, 20% Ded, 50% Ded, 50% Ded, 50% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20%


(20 visit annual maximum

each)

Ded, 20% Ded, 30% Ded, 50% $80 $80 Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%


(15 visit annual maximum) $50 $50 Ded, 50% $80 $80 Ded, 50% $50 $50 Ded, 50% $50 $50 Ded, 50%

DME/Orthotics & Prosthetic

Devices Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%

Inpatient Behavioral Health Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%

Outpatient Behavioral

Health (4 free visits) $30 $30 Ded, 50% $35 $35 Ded, 50% $30 $30 Ded, 50% $30 $30 Ded, 50%

Skilled Nursing Facility/

LTACH

(45 day maximum)

Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%

Acute Inpatient

Rehabilitation

(45 day maximum)

Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%

Home Health

(60 visit annual maximum) Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%

Hospice Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50%

Pharmacy:

Generic Drug $15 $15 Ded, 50% $15 $15 Ded, 50% $15 $15 Ded, 50% $15 $15 Ded, 50%

Brand Name Formulary $45 $45 Ded, 50% $45 $45 Ded, 50% $45 $45 Ded, 50% $45 $45 Ded, 50%

Brand Name

Non-Formulary $70 $70 Ded, 50% $70 $70 Ded, 50% $70 $70 Ded, 50% $70 $70 Ded, 50%

Specialty Drugs** Ded, 25% Ded, 25%

Mail Order

Only

Ded, 50%

Ded, 25% Ded, 25%

Mail Order

Only

Ded, 50%

Ded, 25% Ded, 25%

Mail Order

Only

Ded, 50%

Ded, 25% Ded, 25%

Mail Order

Only

Ded, 50%

Mail Order 2.5x 2.5x N/A 2.5x 2.5x N/A 2.5x 2.5x N/A 2.5x 2.5x N/A


17

Prime Care Choice

$4000/20%

Prime Care Choice

$5000 /20%

Prime Care Choice

$5000/50%

Tier 1

Network Tier 2

Network


Tier 1

Network Tier 2

Network


Tier 1

Network Tier 2

Network


Annual Single Deductible $4,000 $5,000 $9,500 $5,000 $6,000 $11,000 $5,000 $7,900 $15,800

Annual Family Deductible $8,000 $10,000 $19,000 $10,000 $12,000 $22,000 $10,000 $15,800 $31,600



coinsurance)

$7,900 $7,900 $16,000 $7,900 $7,900 $19,000 $7,900 $7,900 $24,450



coinsurance)

$15,800 $15,800 $32,000 $15,800 $15,800 $38,000 $15,800 $15,800 $48,900

PCP Office Visit $30 $30 Ded, 50% $30 $30 Ded, 50% $45 $45 Ded, 50%


(20% for Ancillary Services) $50 $50 Ded, 50% $50 $50 Ded, 50% $90 $90 Ded, 50%

Preventive Care 0% 0% Not

Covered 0% 0%

Not

Covered 0% 0%

Not

Covered

Inpatient Hospital Services Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50%

Outpatient Hospital Services Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50%

Professional Services

(In & Out) Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50%

Emergency Room $350 $350 $350 $350 $350 $350 $500, 50% $500, 50% $500, 50%

Urgent Care Facility $50 $50 Ded, 50% $50 $50 Ded, 50% $100 $100 Ded, 50%

Ambulance Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 50% Ded, 50% Ded, 50%


(20 visit annual maximum

each)

Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% $90 $90 Ded, 50%


(15 visit annual maximum) $50 $50 Ded, 50% $50 $50 Ded, 50% $90 $90 Ded, 50%


Devices Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50%

Inpatient Behavioral Health Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50%

Outpatient Behavioral Health

(4 free visits) $30 $30 Ded, 50% $30 $30 Ded, 50% $45 $45 Ded, 50%

Skilled Nursing Facility/LTACH

(45 day maximum) Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50%

Acute Inpatient

Rehabilitation

(45 day maximum)

Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50%

Home Health

(60 visit annual maximum) Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50%

Hospice Ded, 20% Ded, 30% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 50% Ded, 50% Ded, 50%

Pharmacy:

Generic Drug $15 $15 Ded, 50% $15 $15 Ded, 50% $15 $15 Ded, 50%

Brand Name Formulary $45 $45 Ded, 50% $45 $45 Ded, 50% $45 $45 Ded, 50%

Brand Name

Non-Formulary $70 $70 Ded, 50% $70 $70 Ded, 50% $70 $70 Ded, 50%

Only Specialty Drugs** Ded, 25% Ded, 25%

Mail Order

Only

Ded, 50%

Ded, 25% Ded, 25%

Mail Order

Only

Ded, 50%

Ded, 25% Ded, 25%

Mail Order

Only

Ded, 50%

Mail Order 2.5x 2.5x N/A 2.5x 2.5x N/A 2.5x 2.5x N/A


18

HSA Plan $2800/0% HSA Plan $2800/20%

Tier 1

Network Tier 2

Network Tier 3

Out-of-Network Tier 1

Network Tier 2

Network Tier 3

Out-of-Network

Annual Single Deductible $2,800 $3,800 $5,000 $2,800 $3,800 $5,000

Annual Family Deductible $5,600 $7,600 $10,000 $5,600 $7,600 $10,000

Annual OOP Max - Single (incl Deductible, and coinsurance)

$2,800 $3,800 $12,000 $6,750 $6,750 $12,000

Annual OOP Max - Family (incl Deductible, and coinsurance)

$5,600 $7,600 $24,000 $13,500 $13,500 $24,000

Family Deductible / OOP Max Embedded Embedded

PCP Office Visit Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%

Specialist Office Visit Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%

Preventive Care 0% 0% Not Covered 0% 0% Not Covered

Inpatient Hospital Services Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%

Outpatient Hospital Services Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%

Professional Services (In & Out) Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%

Emergency Room Ded, 0% Ded, 0% Ded, 20% Ded, 20% Ded, 20% Ded, 20%

Urgent Care Facility Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%

Ambulance Ded, 0% Ded, 0% Ded, 0% Ded, 20% Ded, 20% Ded, 20%

PT/OT/Speech Therapy (20 visit annual maximum each)

Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%

Chiropractic Services (15 visit annual maximum)


DME/Orthotics & Prosthetic Devices Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%

Inpatient Behavioral Health Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50%

Outpatient Behavioral Health Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%

Skilled Nursing Facility/LTACH (45 day maximum)


Acute Inpatient Rehabilitation (45 day maximum)


Home Health (60 visit annual maximum)



Pharmacy:

Generic Drug Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%

Brand Name Formulary Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%

Brand Name Non-Formulary Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%

Specialty Drugs** Ded, 0% Ded, 0% Mail Order Only

Ded, 50% Ded, 20% Ded, 20%

Mail Order Only

Ded, 50%


19

HSA Plan $3500/0% HSA Plan $3500/20%

Tier 1

Network Tier 2

Network Tier 3


Network Tier 2

Network Tier 3

Out-of-Network




$3,500 $4,500 $14,000 $6,750 $6,750 $14,000


$7,000 $9,000 $28,000 $13,500 $13,500 $28,000

























Pharmacy:

Generic Drug Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%

Brand Name Formulary Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%

Brand Name Non-Formulary Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50%


Ded, 50% Ded, 20% Ded, 20%

Mail Order Only

Ded, 50%


20

HSA Plan $5000/0% HSA Plan $5000/20% HSA Plan $6500/0%

Tier 1

Network Tier 2

Network


Tier 1 Network

Tier 2 Network


Tier 1 Network

Tier 2 Network





(incl Deductible, coinsurance) $5,000 $6,000 $22,000 $6,750 $6,750 $22,000 $6,750 $6,750 $20,700


(incl Deductible, coinsurance) $10,000 $12,000 $44,000 $13,500 $13,500 $44,000 $13,500 $13,500 $41,400

Family Deductible / OOP Max Embedded Embedded Embedded

PCP Office Visit Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50%

Specialist Office Visit Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50%

Preventive Care 0% 0% Not Covered 0% 0% Not Covered 0% 0% Not Covered



Professional Services (In & Out) Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%

Emergency Room Ded, 0% Ded, 0% Ded, 0% Ded, 20% Ded, 20% Ded, 20% Ded, 0% Ded, 0% Ded, 0%

Urgent Care Facility Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50%



(20 visit annual maximum each) Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%


(15 visit annual maximum) Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50%


Devices Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%


Outpatient Behavioral Health Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50%



Acute Inpatient Rehabilitation


Home Health (60 day maximum) Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50%


Pharmacy:

Generic Drug Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, $10 Ded, $10 Ded, $10

Brand Name Formulary Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, $50 Ded, $50 Ded, $50

Brand Name Non-Formulary Ded, 0% Ded, 0% Ded, 50% Ded, 20% Ded, 20% Ded, 50% Ded, $100 Ded, $100 Ded, $100

Specialty Drugs** Ded, 0% Ded, 0%

Mail Order

Only

Ded, 50%

Ded, 20% Ded, 20%

Mail Order

Only

Ded, 50%

Ded, 25% Ded, 25%

Mail Order

Only

Ded, 50%


21

HRA Plan $2800/20% HRA Plan $2800/0%

Tier 3

Tier 1 Network

Tier 2 Network


Tier 1 Network

Tier 2 Network


$2,800 $3,800 $5,000 $2,800 $3,800 $5,000 Annual Single Deductible

$5,600 $7,600 $10,000 $5,600 $7,600 $10,000 Annual Family Deductible

$6,750 $6,750 $12,000 $2,800 $3,800 $12,000 Annual OOP Max - Single (incl Deductible, and coinsurance)

$13,500 $13,500 $24,000 $5,600 $7,600 $24,000 Annual OOP Max - Family (incl Deductible, and coinsurance)

Embedded Embedded Family Deductible / OOP Max

Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% PCP Office Visit

Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Specialist Office Visit

0% 0% Not Covered 0% 0% Not Covered Preventive Care

Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Inpatient Hospital Services

Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Outpatient Hospital Services

Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Professional Services (In & Out)

Ded, 20% Ded, 20% Ded, 20% Ded, 0% Ded, 0% Ded, 0% Emergency Room

Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Urgent Care Facility

Ded, 20% Ded, 20% Ded, 20% Ded, 0% Ded, 0% Ded, 0% Ambulance

Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% PT/OT/Speech Therapy (20 visit annual maximum each)

Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Chiropractic Services (15 visit annual maximum)

Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% DME/Orthotics & Prosthetic Devices

Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Inpatient Behavioral Health

Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Outpatient Behavioral Health

Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Skilled Nursing Facility/LTACH (45 day maximum)

Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Acute Inpatient Rehabilitation (45 day maximum)

Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Home Health (60 visit annual maximum)

Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Hospice

Pharmacy:

$15 $15 Ded, 50% $15 $15 Ded, 50% Generic Drug

$45 $45 Ded, 50% $45 $45 Ded, 50% Brand Name Formulary

$70 $70 Ded, 50% $70 $70 Ded, 50% Brand Name Non-Formulary

Only Ded, 25% Ded, 25%

Mail Order

Only

Ded, 50%

Ded, 0% Ded, 0%

Mail Order

Only

Ded, 50%

Specialty Drugs**


22

HRA Plan $3500/20% HRA Plan $3500/0%

Tier 1

Network Tier 2

Network Tier 3


Network Tier 2

Network Tier 3

Out-of-Network




$6,750 $6,750 $14,000 $3,500 $4,500 $14,000


$13,500 $13,500 $28,000 $7,000 $9,000 $28,000

























Pharmacy:

Generic Drug $15 $15 Ded, 50% $15 $15 Ded, 50%

Brand Name Formulary $45 $45 Ded, 50% $45 $45 Ded, 50%

Brand Name Non-Formulary $70 $70 Ded, 50% $70 $70 Ded, 50%


Ded, 50% Ded, 0% Ded, 0%

Mail Order Only Ded, 50%

Mail Order 2.5x 2.5x N/A 2.5x 2.5x N/A


23

HRA Plan $5000/20% HRA Plan $5000/0% HRA Plan $6500/0%

Tier 1

Network Tier 2

Network


Tier 1 Network

Tier 2 Network


Tier 1 Network

Tier 2 Network





$6,750 $6,750 $22,000 $5,000 $6,000 $22,000 $6,750 $6,750 $20,700


$13,500 $13,500 $44,000 $10,000 $12,000 $44,000 $13,500 $13,500 $41,400


PCP Office Visit Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%

Specialist Office Visit Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%

Preventive Care 0% 0% Not Covered 0% 0% Not Covered 0% 0% Not Covered



Professional Services (In & Out) Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%

Emergency Room Ded, 20% Ded, 20% Ded, 20% Ded, 0% Ded, 0% Ded, 0% Ded, 0% Ded, 0% Ded, 0%

Urgent Care Facility Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%






DME/Orthotics & Prosthetic Devices Ded, 20% Ded, 30% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%


Outpatient Behavioral Health Ded, 20% Ded, 20% Ded, 50% Ded, 0% Ded, 0% Ded, 50% Ded, 0% Ded, 0% Ded, 50%








Pharmacy:

Generic Drug $10 $10 Ded, 50% $10 $10 Ded, 50% $10 $10 Ded, 50%

Brand Name Formulary $50 $50 Ded, 50% $50 $50 Ded, 50% $50 $50 Ded, 50%

Brand Name Non-Formulary $100 $100 Ded, 50% $100 $100 Ded, 50% $100 $100 Ded, 50%

Specialty Drugs** Ded, 30% Ded, 30% Mail Order

Only Ded, 50%


Only Ded, 50%


Only Ded, 50%

Mail Order 2.5x 2.5x N/A 2.5x 2.5x N/A 2.5x 2.5x N/A


24

PC Choice $500/20%

PC Choice $1000/20%

PC Choice $1500/20%

PC Choice $2000/20%

PC Choice $2500/20%

PC Choice $2500/50%

Annual Single Deductible $500 $1,000 $1,500 $2,000 $2,500 $2,500



(incl Deductible, copay, and coinsurance) $5,000

$6,000

$7,000

$7,900

$7,900 $7,900



$12,000

$14,000

$15,800

$15,800 $15,800

PCP Office Visit $20 $25 $25 $25 $30 $35


(20% for Ancillary Services) $30

$40

$40

$40

$50 $80

Preventive Care 0% 0% 0% 0% 0% 0%


Outpatient Hospital Services Ded, 20%

Ded, 20%

Ded, 20%

Ded, 20%

Ded, 20% Ded, 50%

Professional Services (In & Out) Ded, 20%

Ded, 20%

Ded, 20%

Ded, 20%

Ded, 20% Ded, 50%

Emergency Room $250 $250 $250 $250 $350 $500,50%

Urgent Care Facility $30 $40 $40 $40 $50 $100



(20 visits) Ded, 20%

Ded, 20%

Ded, 20%

Ded, 20%

Ded, 20% $80


(15 visits) $30

$40

$40

$40

$50 $80

DME/Orthotics & Prosthetic Devices Ded, 20%

Ded, 20%

Ded, 20%

Ded, 20%

Ded, 20% Ded, 50%



(4 free visits) $20

$25

$25

$25

$30 $35


(45 days) Ded, 20%

Ded, 20%

Ded, 20%

Ded, 20%

Ded, 20% Ded, 50%


(45 days) Ded, 20%

Ded, 20%

Ded, 20%

Ded, 20%

Ded, 20% Ded, 50%

Home Health

(60 max) Ded, 20%

Ded, 20%

Ded, 20%

Ded, 20%

Ded, 20% Ded, 50%


Out of Network:



Coinsurance for All Services* 50%

50%

50%

50%

50% 50%

Annual OOP Max - Single $9,000 $10,000 $11,000 $12,000 $13,000 $24,450

Annual OOP Max - Family $18,000 $20,000 $22,000 $24,000 $26,000 $48,900

Pharmacy:

Generic Drug $10 $10 $10 $10 $15 $15

Brand Name Formulary $30 $30 $40 $40 $45 $45

Brand Name Non-Formulary $45

$45

$60

$60

$70 $70

Specialty Drugs ** (max $500) Ded, 25%

Ded, 25%

Ded, 25%

Ded, 25%

Ded, 25% Ded, 25%

Mail Order 2.5x 2.5x 2.5x 2.5x 2.5x 2.5x

OON Coinsurance applies to all services, except Emergency Room services, which are legally required to be that of INN **Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by

25

PC Choice $3000/20%

PC Choice $3500/20%

PC Choice $4,000/20%

PC Choice $5000/20%

PC Choice $5000/50%

Annual Single Deductible $3,000 $3,500 $4,000 $5,000 $5,000

Annual Family Deductible $6,000 $7,000 $8,000 $10,000 $10,000



$7,900 $7,900 $7,900 $7,900



$15,800 $15,800 $15,800 $15,800

PCP Office Visit $30 $30 $30 $30 $45


(20% for Ancillary Services) $50

$50 $50 $50 $90

Preventive Care 0% 0% 0% 0% 0%

Inpatient Hospital Services Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 50%

Outpatient Hospital Services Ded, 20%

Ded, 20% Ded, 20% Ded, 20% Ded, 50%

Professional Services (In & Out) Ded, 20%

Ded, 20% Ded, 20% Ded, 20% Ded, 50%

Emergency Room $350 $350 $350 $350 $500,50%

Urgent Care Facility $50 $50 $50 $50 $100

Ambulance Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 50%


(20 visits) Ded, 20%

Ded, 20% Ded, 20% Ded, 20% Ded, 50%


(15 visits) $50

$50 $50 $50 $90

DME/Orthotics & Prosthetic Devices Ded, 20%

Ded, 20% Ded, 20% Ded, 20% Ded, 50%

Inpatient Behavioral Health Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 50%


(4 free visits) $30

$30 $30 $30 $45


(45 days) Ded, 20%

Ded, 20% Ded, 20% Ded, 20% Ded, 50%


(45 days) Ded, 20%

Ded, 20% Ded, 20% Ded, 20% Ded, 50%

Home Health

(60 max) Ded, 20%

Ded, 20% Ded, 20% Ded, 20% Ded, 50%

Hospice Ded, 20% Ded, 20% Ded, 20% Ded, 20% Ded, 50%

Out of Network:

Annual Single Deductible $7,000 $8,000 $9,500 $11,000 $15,800

Annual Family Deductible $14,000 $16,000 $19,000 $22,000 $31,600

Coinsurance for All Services* 50%

50% 50% 50% 50%

Annual OOP Max - Single $14,000 $14,000 $16,000 $19,000 $24,450

Annual OOP Max - Family $28,000 $28,000 $32,000 $38,000 $48,900

Pharmacy:

Generic Drug $15 $15 $15 $15 $15

Brand Name Formulary $45 $45 $45 $45 $45

Brand Name Non-Formulary $70

$70 $70 $70 $70

Specialty Drugs ** (max $500) Ded, 25%

Ded, 25% Ded, 25% Ded, 25% Ded, 25%

Mail Order 2.5x 2.5x 2.5x 2.5x 2.5x


26

Care Plus $500/30%

Care Plus $1000/30%

Care Plus $2500/30%

Care Plus $5000/30%

Annual Single Deductible $500 $1,000 $2,500 $5,000

Annual Family Deductible $1,000 $2,000 $5,000 $10,000

Annual OOP Max - Single (incl Deductible, copay, and coinsurance) $5,000

$6,000 $7,900

$7,900

Annual OOP Max - Family (incl Deductible, copay, and coinsurance) $10,000

$12,000 $15,800

$15,800

PCP Office Visit $20 $25 $30 $30

Specialist Office Visit (20% for Ancillary Services) $40

$50 $50

$50

Preventive Care 0% 0% 0% 0%

Inpatient Hospital Services Ded, 30% Ded, 30% Ded, 30% Ded, 30%

Outpatient Hospital Services Ded, 30% Ded, 30% Ded, 30% Ded, 30%

Professional Services (In & Out) Ded, 30% Ded, 30% Ded, 30% Ded, 30%

Emergency Room $150 $200 $250 $300

Urgent Care Facility $40 $50 $50 $50

Ambulance Ded, 30% Ded, 30% Ded, 30% Ded, 30%

PT/OT/Speech Therapy (20 visits) $40 $50 $50 $50

Chiropractic Services (15 visits) $40 $50 $50 $50

DME/Orthotics & Prosthetic Devices Ded, 30% Ded, 30% Ded, 30% Ded, 30%

Inpatient Behavioral Health Ded, 30% Ded, 30% Ded, 30% Ded, 30%

Outpatient Behavioral Health (4 free visits) $20 $25 $30 $30

Skilled Nursing Facility/LTACH (45 days) Ded, 30% Ded, 30% Ded, 30% Ded, 30%

Acute Inpatient Rehabilitation (45 days) Ded, 30% Ded, 30% Ded, 30% Ded, 30%

Home Health (60 max) Ded, 30% Ded, 30% Ded, 30% Ded, 30%

Hospice Ded, 30%

Ded, 30% Ded, 30%

Ded, 30%

Out of Network:

Annual Single Deductible $2,000 $3,000 $6,000 $11,000


Coinsurance for All Services* 50% 50% 50% 50%

Annual OOP Max - Single $9,000 $10,000 $13,000 $19,000

Annual OOP Max - Family $18,000 $20,000 $26,000 $38,000

Pharmacy:

Generic Drug $10 $10 $10 $10

Brand Name Formulary $40 $40 $40 $40

Brand Name Non-Formulary $60 $60 $60 $60

Specialty Drugs ** (max $500) Ded, 25% Ded, 25% Ded, 25% Ded, 25%

Mail Order 2.5x 2.5x 2.5x 2.5x


27

HSA

$2800/0%

HSA $2800/20%

HSA

$3500/20%

HSA $3500/0%

HSA

$5000/20%

HSA $5000/0%

HSA $6500/0%

Annual Single Deductible $2,800 $2,800 $3,500 $3,500 $5,000 $5,000 $6,500

Annual Family Deductible $5,600 $5,600 $7,000 $7,000 $10,000 $10,000 $13,000

Annual OOP Max - Single Single (incl Deductible and coinsurance)

$6,750 $2,800 $6,750 $3,500 $6,750 $5,000 $6,750

Annual OOP Max - Family (incl Deductible and coinsurance)

$13,500 $5,600 $13,500 $7,000 $13,500 $10,000 $13,500

Family Deductible / OOP Max Embedded Embedded Embedded Embedded Embedded Embedded Embedded

PCP Office Visit Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%

Specialist Office Visit Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%

Preventive Care 0% 0% 0% 0% 0% 0% 0%

Inpatient Hospital Services Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%

Outpatient Hospital Services Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%

Professional Services (In & Out) Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%

Emergency Room Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%

Urgent Care Facility Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%

Ambulance Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%


(20 visits) Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%

Chiropractic Services (15 visits)

Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%

DME/Orthotics & Prosthetic Devices Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%

Inpatient Behavioral Health Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%

Outpatient Behavioral Health Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%


(45 days) Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%


(45 days) Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%

Home Health (60 max) Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%

Hospice Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 0%

Out of Network:

Annual Single Deductible $5,000 $5,000 $8,000 $8,000 $11,000 $11,000 $19,500

Annual Family Deductible $10,000 $10,000 $16,000 $16,000 $22,000 $22,000 $39,000

Coinsurance for All Services* 50% 50% 50% 50% 50% 50% 50%

Annual OOP Max - Single $12,000 $12,000 $14,000 $14,000 $22,000 $22,000 $20,700

Annual OOP Max - Family $264,000 $264,000 $28,000 $28,000 $44,000 $44,000 $41,400

Pharmacy:

Generic Drug Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, $10

Brand Name Formulary Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, $50

Brand Name Non-Formulary Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, $100

Specialty Drugs ** (max $500) Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 20% Ded, 0% Ded, 25%

Mail Order 2.5x 2.5x 2.5x 2.5x 2.5x 2.5x 2.5x


28

* OON Coinsurance applies to all services, except for Emergency Room services, which are legally required to be that of INN. ** Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by injection. Additionally the Specialty Drug Benefit has a coinsurance maximum of $500.

HRA $2800/20%

HRA $2800/0%

HRA $3500/20%

HRA $3500/0%




(incl Deductible, copay, coinsurance) $6,750 $2,800 $6,750 $3,500


(incl Deductible, copay, coinsurance) $13,500 $5,400 $13,500 $7,000

Family Deductible / OOP Max Embedded Embedded Embedded Embedded

PCP Office Visit Ded, 20% Ded, 0% Ded, 20% Ded, 0%

Specialist Office Visit Ded, 20% Ded, 0% Ded, 20% Ded, 0%

Preventive Care 0% 0% 0% 0%

Inpatient Hospital Services Ded, 20% Ded, 0% Ded, 20% Ded, 0%

Outpatient Hospital Services Ded, 20% Ded, 0% Ded, 20% Ded, 0%

Professional Services (In & Out) Ded, 20% Ded, 0% Ded, 20% Ded, 0%

Emergency Room Ded, 20% Ded, 0% Ded, 20% Ded, 0%

Urgent Care Facility Ded, 20% Ded, 0% Ded, 20% Ded, 0%

Ambulance Ded, 20% Ded, 0% Ded, 20% Ded, 0%

PT/OT/Speech Therapy (20 visits) Ded, 20% Ded, 0% Ded, 20% Ded, 0%

Chiropractic Services (15 visits) Ded, 20% Ded, 0% Ded, 20% Ded, 0%

DME/Orthotics & Prosthetic Devices Ded, 20% Ded, 0% Ded, 20% Ded, 0%

Inpatient Behavioral Health Ded, 20% Ded, 0% Ded, 20% Ded, 0%

Outpatient Behavioral Health Ded, 20% Ded, 0% Ded, 20% Ded, 0%


(45 days) Ded, 20% Ded, 0% Ded, 20% Ded, 0%


(45 days) Ded, 20% Ded, 0% Ded, 20% Ded, 0%

Home Health (60 max) Ded, 20% Ded, 0% Ded, 20% Ded, 0%

Hospice Ded, 20% Ded, 0% Ded, 20% Ded, 0%

Out of Network:



Coinsurance for All Services* 50% 50% 50% 50%

Annual OOP Max - Single $12,000 $12,000 $14,000 $14,000

Annual OOP Max - Family $24,000 $24,000 $28,000 $28,000

Pharmacy:

Generic Drug $15 $15 $15 $15

Brand Name Formulary $45 $45 $45 $45

Brand Name Non-Formulary $70 $70 $70 $70

Specialty Drugs ** (max $500) Ded, 25% Ded, 0% Ded, 25% Ded, 0%

Mail Order 2.5x 2.5x 2.5x 2.5x

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HRA $5000/20%

HRA $5000/0%

HRA $6500/0%

Annual Single Deductible $5,000 $5,000 $6,500



(incl Deductible, copay, coinsurance) $6,750 $5,000 $6,500


(incl Deductible, copay, coinsurance) $13,500 $10,000 $13,000


PCP Office Visit Ded, 20% Ded, 0% Ded, 0%

Specialist Office Visit Ded, 20% Ded, 0% Ded, 0%

Preventive Care 0% 0% 0%

Inpatient Hospital Services Ded, 20% Ded, 0% Ded, 0%

Outpatient Hospital Services Ded, 20% Ded, 0% Ded, 0%

Professional Services (In & Out) Ded, 20% Ded, 0% Ded, 0%

Emergency Room Ded, 20% Ded, 0% Ded, 0%

Urgent Care Facility Ded, 20% Ded, 0% Ded, 0%

Ambulance Ded, 20% Ded, 0% Ded, 0%

PT/OT/Speech Therapy (20 visits) Ded, 20% Ded, 0% Ded, 0%

Chiropractic Services (15 visits) Ded, 20% Ded, 0% Ded, 0%

DME/Orthotics & Prosthetic Devices Ded, 20% Ded, 0% Ded, 0%

Inpatient Behavioral Health Ded, 20% Ded, 0% Ded, 0%

Outpatient Behavioral Health Ded, 20% Ded, 0% Ded, 0%


(45 days) Ded, 20% Ded, 0% Ded, 0%


(45 days) Ded, 20% Ded, 0% Ded, 0%

Home Health (60 max) Ded, 20% Ded, 0% Ded, 0%

Hospice Ded, 20% Ded, 0% Ded, 0%

Out of Network:

Annual Single Deductible $11,000 $11,000 $19,500


Coinsurance for All Services* 50% 50% 50%

Annual OOP Max - Single $22,000 $22,000 $20,700

Annual OOP Max - Family $44,000 $44,000 $41,400

Pharmacy:

Generic Drug $10 $10 $10

Brand Name Formulary $50 $50 $50

Brand Name Non-Formulary $100 $100 $100

Specialty Drugs ** (max $500) Ded, 30% Ded, 0% Ded, 0%

Mail Order 2.5x 2.5x 2.5x

* OON Coinsurance applies to all services, except for Emergency Room services, which are legally required to be that of INN. ** Specialty Drug Benefit does not apply to orally administered cancer chemotherapy drugs, which are covered at the same level as chemotherapy administered intravenously or by injection. Additionally the Specialty Drug Benefit has a coinsurance maximum of $500.

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Services

Value Plan

Calendar Year Deductible NONE NONE NONE NONE

Plan Year Benefit $1,500 $1,250 $1,000 $750

Lifetime Orthodontia Maximum $1,000 $1,250 $1,000 N/A

Preventive Services

• Oral Exam (once every 6 months) • Routine Cleanings (once every 6 months)

Fluoride Treatment for Children up to age 14 (once every 6 months)

• Space Maintainers for Children • Topical Sealants for Children up to age 15

100% 100% 100% 100%

Diagnostic Services

• Bitewing X-Rays (once every year) • Full Mouth (one every 4 years)

100% 100% 80% 60%

Basic

• Amalgam, Silicate & Composite Fillings

• Simple Extractions

• Repairs of dentures, bridgework, and crowns

• Endodontic Therapy (Paramount and Preferred Plans only)

80% 80% 60% 50%

Major Services

• Oral Surgery & Complex Extractions • Periodontal Therapy • Endodontic Therapy (Standard and Value Plans only)

• Full & Partial Dentures • Implants as an Alternate Procedure (Covered at 50% on all plans)

• Crowns

• Bridges

50% 80% 50% 50%

(for children under age 19) 50% 50% 50% Not Covered

Employee Only: $33.29 $34.15 $29.04 $26.29

Employee + Spouse: $69.91 $71.73 $60.96 $55.20

Employee + Child(ren): $87.35 $89.58 $76.15 $68.94

Employee + Family: $122.81 $126.04 $107.14 $97.00

Minimum of 2 employees to offer. For more information on the dental plan including OON benefits, please contact [email protected].

Offered through Health Resources Inc. | HRI Network

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Minimum of 2 employees to offer. For more information on the vision plan including OON benefits, please contact [email protected].

Offered through EyeMed Vision I Insight Network

EyeMed Vision

In-Network Benefits 12/12 Plan 12/24 Plan

Eye Exam Frequency Once every 12 Months Once every 12 Months

Eye Exam Copay $10 $10

Eyeglass Lens Frequency Once every 12 Months Once every 12 Months

Eyeglass Lens Copay $25 Additional charge for Progressive $25 Additional charge for Progressive

Eyeglass Frame Frequency Once every 12 Months Once every 24 Months

Eyeglass Frame Allowance $180 – 20% off balance over the $180 $150 – 20% off balance over the $150

Eyeglass Frame Copay $0 $0

Contact Lens Frequency Once every 12 Months Once every 12 Months

Contact Lens Allowance $180 $150

Contact Lens Copay $0 – 15% off balance over the $180 $0 – 15% off balance over the $150

Network EyeMed EyeMed

Employee: $9.62 $6.30

Employee + Spouse: $18.28 $11.97

Employee + Child(ren): $19.24 $12.60

Employee + Family: $28.28 $18.52

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The plans illustrated in this brochure are representative examples.

Because plan details change from time to time, your plan may have

different benefits. Refer to your Certificate of Coverage for the specific

benefits available to you. For more information on these plans, contact

your authorized SIHO agent/broker or SIHO account coordinator.

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