MEDICAL AND DENTAL INSURANCE PLAN -- EMPLOYEE AND DEPENDENTS Sample Clauses

MEDICAL AND DENTAL INSURANCE PLAN -- EMPLOYEE AND DEPENDENTS. (Effective January 1, 2014) Employees will be offered a choice of two health care plans as indicated by the following chart: TALLMADGE CITY SCHOOLS HEALTH INSURANCE PLAN OPTIONS BLUE PLAN GOLD PLAN PHYSICIAN BASED SERVICES NETWORK NETWORK Preventive Care No Cost Ded+30% No Cost $15 Copay Primary Care Physician Office Visit $20 Copay Ded+30% $15 Copay $15 Copay Specialist Office Visit $20 Copay Ded+30% $15 Copay $15 Copay INDEPENDENT X-RAY/LAB SERVICES No Cost Ded+30% No Cost No Cost URGENT CARE $40 Copay $40 Copay Ded+10% Ded+20% EMERGENCY ROOM $100 Copay $100 Copay Ded+10% Ded+10% DEDUCTIBLE Facility Based X-Ray/Lab $1000/$2000 $1250/$2500 $500/$1000 $600/$1200 Outpatient Services Ded+10% Ded+30% Ded+10% Ded+20% Inpatient Services Ded+10% Ded+30% Ded+10% Ded+20% MAXIMUM OUT OF POCKET $1000/$2000 $2000/$4000 $600/$1200 $1000/$2000 PRESCRIPTION BENEFITS Retail Generic $5 Copay $10 Copay RETAIL $10 Copay MAIL ORDER $10 Copay Retail Preferred Brand $25 Copay $50 Copay $25 Copay $25 Copay Retail Non-Preferred Brand $40 Copay $80 Copay $35 Copay $35 Copay MAX WELLNESS CREDITS $1000/Single $2000/Family $500/Single $1000/Family Deductible Dental NETWORK NON- NETWORK NON- Family $100 Single $ 50 Mandatory requirement of ‘generic’ when available and acceptable to physician Dental co-payment will pay eligible expenses (R & C) at the percentage indicated in the Schedule of Benefits. Employee Insurance Premium Share A medical/dental premium share will be assessed as follows: Effective July 1, 2020: Single Coverage 13.5% Family Coverage 13.5% Effective July 1, 2021: Single Coverage 14% Family Coverage 14% This contribution will be automatically deducted via payroll on a pre-tax basis. No Section 125 plan administrative costs will be incurred by the employee to withhold this premium share pre-tax. Open Enrollment will occur every November.