Plan Benefits Chart
For medical, prescription drug, dental/orthodontics, vision, mental/behavioral health and substance abuse, chiropractic care/acupuncture, and podiatry benefits
View ChartKey Medical Plan Features
Indemnity PPO Medical Plan
See a brief summary of how you and the plan share costs for health care services, as well as your opportunity to earn extra money to pay for eligible health care expenses through a Health Reimbursement Account.
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, including 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 $3,500 per person or $7,000 per family per calendar year.
Health Reimbursement Account (HRA) Funding
Your HRA funding opportunity is based on who’s enrolled in the plan. You receive an automatic “Base HRA Contribution” from the Fund, and you and your enrolled spouse/domestic partner can earn additional contributions to your HRA by completing “Healthy Activities.”
SINGLE COVERAGE
- Automatic Base HRA Contribution from the Fund: $125
- You can EARN $125 for each Healthy Activity completed, up to a maximum of $425 per year (for four activities).
- Total HRA Funding Opportunity (Base + Earned): $550 maximum
EMPLOYEE + CHILDREN COVERAGE
- Automatic Base HRA Contribution from the Fund: $475
- You can EARN $125 for each Healthy Activity completed, up to a maximum of $625 per year (for five activities).
- Total HRA Funding Opportunity (Base + Earned): $1,100 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 $125 for each Healthy Activity completed, up to a maximum of $850 per year (for seven activities).
- Total HRA Funding Opportunity (Base + Earned): $1,100 maximum