2014-2015 Insurance Benefit and Rate Proposals for Alice ISD
ALICE INDEPENDENT SCHOOL DISTRICT - Effective 10/1/2014 Plan One - NPOS -14 HDHP
Humana Insurance Company MEDICAL BENEFITS Lifetime Maximum Annual Deductible/Family Cap Hospital Admission Deductible Medical Out-of-Pocket Maximum Annual Maximum Out of Pocket/Fam Cap HOSPITAL SERVICES In-Patient Services Out-Patient-Surgical Out-Patient-Non Surgical Physician In/Out Patient-Hospital PHYSICIAN OFFICE VISIT Copayment Lab, X-Ray, Injections-In office Lab, X-Ray, Injections-Out of office
MATERNITY DELIVERY PRENATAL COVERAGE Benefits PREVENTIVE CARE Immunizations Pap Smears Routine Mammograms EMERGENCY ROOM VISIT PRESCRIPTION DRUGS Prescription Deductible/Family Prescription Out-of-Pocket Maximum Pharmacy-30 day supply
PAR
District contributes $252.00/Employee/Month Employee Only Employee & Spouse Employee & Children Employee & Family
PAR
$10,000 - 2x/family N/A N/A
$5,000/2x N/A $6,000*/2x $6,250** /2x
Unlimited $5,000/2x N/A N/A $6,000** /2x 70% 70% 70% 70%
after after after after
Plan Three - NPOS - 14 $3,000 NON-PAR
PAR
$10,000 - 2x/family N/A N/A
$3,000/2x N/A $6,000*/2x $6,250** /2x
NON-PAR
Unlimited
$20,000/2x + ded + copays + Rx
deductible deductible deductible deductible
50% 50% 50% 50%
after after after after
deductible deductible deductible deductible
70% after deductible 70% after deductible 70% after deductible at all outpatient facilities
50% after deductible 50% after deductible 50% after deductible at all outpatient facilities
70% after deductible 70% after deductible
50% after deductible 50% after deductible
Covered in full Covered in full Covered in full 70% after deductible
50% 50% 50% 70%
after after after after
deductible deductible deductible deductible
N/A N/A 70% after deductible
Mail Order-90 day supply MENTAL HEALTH In Patient Out Patient OTHER MEDICAL SERVICES Ambulance Durable Medical Equipment Skilled Nursing Facility Home Health/Hospice Care
Plan Two - NPOS -14 $5,000 NON-PAR
Unlimited Plan pays 70% after member pays difference between brand & generic cost
70% 70% 70% 70%
after after after after
deductible deductible deductible deductible
Unlimited
$20,000/2x + ded + copays + Rx
50% 50% 50% 50%
after after after after
deductible deductible deductible deductible
$50 PCP/$70 Specialist/$100 UC Covered in full >Covered in full at free-standing facility >70% after deductible at hospital 70% after deductible 70% after deductible
50% after deductible 50% after deductible 50% after deductible at all outpatient facilities
Covered in full Covered in full Covered in full 100% after $250 copay
50% after deductible 50% after deductible 50% after deductible 100% after $250 copay
50% after deductible 50% after deductible
$250 deductible/2x $2,500*** (all tiers, including ded)
100% 100% 100% 100%
after after after after
$6,000/2x N/A N/A $18,000/2x + ded + copays + Rx
deductible deductible deductible deductible
80% 80% 80% 80%
after after after after
deductible deductible deductible deductible
$30 PCP/$60 Specialist 80% after deductible Covered in full 80% after deductible >Covered in full at free-standing 80% after deductible at all outfacility patient facilities >100% after deductible at hospital 100% after deductible 80% after deductible 100% after deductible 80% after deductible Covered in full Covered in full Covered in full 100% after $250 copay
80% after deductible 80% after deductible 80% after deductible 100% after $250 copay
$100 deductible/3x
Tier 1 - $20 copay (ded waived) Tier 2 - $45 copay after ded Tier 3 - $80 copay after ded
Plan pays 70% after member pays plan deductible, applicable copay and difference between brand & generic cost
Unlimited
$2,500*** (all tiers) Tier 1 - $10 copay (ded waived) Tier 2 - $30 copay after ded Tier 3 - $50 copay after ded Tier 4 - $100 copay after ded
Plan pays 70% after member pays plan deductible, applicable copay and difference between brand & generic cost
Unlimited
N/A
N/A
2.5 times copay
N/A
2.5 times copay
N/A
70% after deductible 70% after deductible
50% after deductible 50% after deductible
70% after deductible $70 specialist copay
50% after deductible 50% after deductible
100% after deductible $60 specialist copay
70% after deductible 70% after deductible
70% 70% 70% 70%
50% 50% 50% 50%
70% 70% 70% 70%
50% 50% 50% 50%
100% 100% 100% 100%
70% 70% 70% 70%
after after after after
deductible deductible deductible deductible
Total Monthly Premium $341.66 $1,021.80 $919.63 $1,338.89
after after after after
deductible deductible deductible deductible
Employee's Monthly Premium $89.66 $769.80 $667.63 $1,086.89
after after after after
deductible deductible deductible deductible
Total Monthly Premium $379.62 $1,135.33 $1,021.80 $1,487.65
after after after after
deductible deductible deductible deductible
Employee's Monthly Premium $127.62 $883.33 $769.80 $1,235.65
after after after after
deductible deductible deductible deductible
Total Monthly Premium $472.03 $1,418.41 $1,276.25 $1,859.60
after after after after
deductible deductible deductible deductible
Employee's Monthly Premium $220.03 $1,166.41 $1,024.25 $1,607.60
*Medical Out-of-Pocket Maximum is a calendar year cap on participating provider medical expenses, including deductibles, coinsurance, and copays. **In compliance with Affordable Care Act, the annual out-of-pocket maximum includes all participating provider deductibles, coinsurance, medical and prescription copays. Medical and prescription expenses have separate calendar year maximums, but the two combined may not exceed an annual out-of-pocket of $6,250 for an individual or $12,500 for a family when using participating providers. ***Prescription Out-of-Pocket Maximum is a calendar year cap on participating provider prescription expenses, including the Rx deductible and copays.
