Plan Feature Health Reimbursement Medical Plan Health Savings Medical Plan. Providence Pharmacies (30-day supply) Preventive: No Charge Generic: $10 copay per Rx Formulary brand: 20% of cost (maximum cost is $150 per Rx) after deductible. Non-Formulary brand: 40% of cost (maximum cost is $150 per Rx) after deductible Specialty 20% after deductible Preventive: No Charge Generic: 10% after deductible Formulary brand: 20% (maximum cost is $150 per Rx) after deductible Non-formulary brand: 40% (maximum cost is $150 per Rx) after deductible Specialty 20% after deductible
Plan Feature Health Reimbursement Medical Plan Health Savings Medical Plan. Annual deductible $1,150 per person $2,300 max per family $1,500 employee only $3,000 if covering dependents Annual out-of-pocket maximum (does not include deductible) $2,150 per person $4,300 per family $1,500 employee only $3,000 if covering dependents Preventive Care No Charge No Charge Primary Care Provider visits (non-preventive) PCP: $20 copay Specialist: PH&S employed: 10% after deductible Other in-network: 20% after deductible After deductible: PCP: 10% Specialist: PH&S employed: 10% after deductible Other in-network: 20% after deductible Lab and x-ray 20% after deductible 20% after deductible Alternative care (chiropractic, acupuncture) 20% after deductible Combined 12 visit limit per calendar year 20% after deductible Combined 12 visit limit per calendar year Naturopathy Covered as Specialist Covered as Specialist Behavioral health care providers No Charge 20% after deductible Outpatient hospital/surgery facility PH&S: 10% after deductible Other in-network: 25% after PH&S: 10% after deductible Other in-network: 25% after fees (except hospice, rehab) deductible deductible Inpatient hospital facility fees, including behavioral health PH&S: 10% after deductible Other in-network: 25% after deductible PH&S: 10% after deductible Other in-network: 25% after deductible Hospital physician fees PH&S: 10% after deductible Other in-network: 20% after deductible PH&S: 10% after deductible Other in-network: 20% after deductible Emergency room $250 copay (waived if admitted) 20% after deductible Urgent Care PH&S: 10% after deductible Other in-network: 20% after deductible PH&S: 10% after deductible Other in-network: 20% after deductible Maternity Preventive Care No Charge No charge Pre-natal, Delivery, and Post-natal Provider Care No Charge No Charge (Delivery/Post- Natal: same as hospital stay) Maternity Hospital Stay and Routine Nursery PH&S: 10% after deductible Other in-network: 25% after deductible PH&S: 10% after deductible Other in-network: 25% after deductible The following are the premium contribution for the nurses for each pay period for a total of twenty four (24) pay periods for the year. Level of Benefit Health Reimbursement Medical Plan Health Savings Medical Plan Employee and child(ren) $22.50 8% of premium $11.00 Not to exceed 15% of premium Employee and Spouse/Partner $30.50 8% of premium $19.00 Not to exceed 15% of premium Employee and Family $42.00 8% of premium $30.00 Not to exceed 15% of premium Part Time 0000 0000 0000 0000 Employee Only ...
Plan Feature Health Reimbursement Medical Plan Health Savings Medical Plan. Annual deductible $1,150 per person $2,300 max per family $1,500 employee only $3,000 if covering dependents Preventive Care No Charge No Charge Lab and x-ray 20% after deductible 20% after deductible Hospital physician fees 20% after deductible 20% after deductible Emergency room $250 copay (waived if admitted) 20% after deductible Urgent Care 20% after deductible 20% after deductible
Plan Feature Health Reimbursement Medical Plan Health Savings Medical Plan. Annual deductible $1,150 per person $2,300 max per family $1,500 employee only $3,000 if covering dependents
