Beruflich Dokumente
Kultur Dokumente
Renewal Period:
11/01/16 - 10/31/17
PLAN DESIGN
POS 15/0/NY1
POS 20/0/NY11
POS 30/0/NY12
POS 20/750/NY3
EPO 30/0/NY6
EPO 45/0/NY7
EPO 25/1000/NY10
IN-NETWORK
Preventative / Primary Care / Specialist
$0 / $15 / $20
$0 / $20 / $30
$0 / $30 / $50
$0 / $20 / $30
$0 / $30 / $50
$0 / $45 / $65
$0 / $25 / $40
$0
$0
$0
$750 / 2.5x
$0
$0
$1,000 / 2.5x
100%
100%
100%
90%
100%
100%
80%
$2,500 / 2.5x
$3,000 / 2.5x
$4,000 / 2.5x
$5,000 / 2.5x
$3,500 / 2.5x
$4,000 / 2.5x
$4,000/ 2.5x
$150
$150
$150
$150
$200
$200
$200
$75
Covered at 100%
$75
Covered at 100%
$75
Covered at 100%
$0
Covered at 100%
$0
Covered at 100%
80%
80%
80%
140%
Not covered
Not covered
Not covered
Deductible
$2,500 / 2.5x
$2,500 / 2.5x
$3,000 / 2.5x
$2,500 / 2.5x
Not covered
Not covered
Not covered
$5,000 / 2.5x
$5,000 / 2.5x
$5,000 / 2.5x
$8,000 / 2.5x
Not covered
Not covered
Not covered
70%
70%
70%
70%
Not covered
Not covered
Not covered
Deductible
Coinsurance (Carrier Pays)
MOOP*
Hospitalization
2x
2x
2x
2x
2x
MONTHLY RATES
Enrolled
Employee
23
1,006.00
932.00
757.00
675.00
597.00
544.00
517.00
Employee / Spouse
2,164.00
2,002.00
1,626.00
1,452.00
1,284.00
1,168.00
1,113.00
Employee / Child(ren)
1,962.00
1,816.00
1,476.00
1,316.00
1,166.00
1,059.00
1,009.00
Employee / Family
3,119.00
2,886.00
2,346.00
2,094.00
1,852.00
1,683.00
1,605.00
PLAN DESIGN
10
11
12
EPO 30/2000/NY9
HSA 2600/NY5
EPO 30/3000/NY8
EPO HSA/5000/NY13
IN-NETWORK
Preventative / Primary Care / Specialist
$0 / $30 / $50
$0 / $30 / $60
$2,000 / 2.5x
$2,600 / 2x
$3,000 / 2.5x
$5,000 / 2x
80%
90%
80%
100%
$5,000 / 2.5x
$4,500 / 2x
$6,350/ 2x
$5,500 / 2x
$200
$200
Reimbursement Rate
Not covered
140%
Not covered
N/A
Deductible
Not covered
$4,000 / 2x
Not covered
N/A
Not covered
$8,000 / 2x
Not covered
N/A
Not covered
70%
Not covered
N/A
Copay - Generic/Brand/Non-Formulary
2x
2x
Deductible
Coinsurance (Carrier Pays)
MOOP*
Hospitalization
MONTHLY RATES
Employee
Employee / Spouse
Employee / Child(ren)
Employee / Family
* Copay, RX, Ded. and Coinsurance
** Applies to single coverage only. All other levels of coverage must meet full family deductible
465.00
454.00
424.00
399.00
1,000.00
977.00
909.00
859.00
907.00
886.00
825.00
778.00
1,443.00
1,409.00
1,311.00
1,238.00
13