Platinum Plan B

Indemnity PPO Medical Plan, Key Features If You Use In-Network Providers

• Preventive Care: The Plan pays 100% of the allowed amount for designated preventive care services.  There is no deductible for these services.
• Deductible: You pay $1,000 per person or $2,000 per family per calendar year.
• Coinsurance (applies for most services, e.g., office visits, urgent/emergency care, hospital visits, outpatient procedures): You pay 25% of allowed amounts.
• Annual Medical Out-of-Pocket Maximum (includes deductible and coinsurance): You pay $3,000 per person or $6,000 per family per calendar year.

SINGLE COVERAGE

• Automatic Base HRA Contribution from the Fund: $150
• You can EARN $150 for each Healthy Activity completed, up to a maximum of $575 per year (for four activities).
• Total HRA Funding Opportunity (Base + Earned): $725 maximum

EMPLOYEE + CHILDREN COVERAGE

• Automatic Base HRA Contribution from the Fund: $425
• You can EARN $150 for each Healthy Activity completed, up to a maximum of $750 per year (for five activities).
• Total HRA Funding Opportunity (Base + Earned): $1,175 maximum

FAMILY COVERAGE: EMPLOYEE + SPOUSE/DOMESTIC PARTNER, WITH OR WITHOUT CHILDREN

• Automatic Base HRA Contribution from the Fund: $250
• You and your spouse/domestic partner can EARN $150 for each Healthy Activity completed, up to a maximum of $925 per year (for seven activities).
• Total HRA Funding Opportunity (Base + Earned): $1,175 maximum