| Plan Benefits | Wholeness Plan - 2017 | LLUH Base Plan - 2017 | ||
|---|---|---|---|---|
| Coverage for LLUH Hospital Services | Coverage at Non-preferred Providers | Coverage for LLUH Hospital Services | Coverage at Non-preferred Providers | |
| Out-of-pocket Maximum Co-payments | In Network | Out of Network | In Network | Out of Network |
| Co-payments for out-of-network services, prescriptions, glasses, contacts, chiropractic care, orthotics/prosthetics, bariatric surgery, infertility treatment, wheelchairs, hearing aids and dental services are not included in the out-of-pocket maximum. | $3,500 per individual & $7,000 family | No Limit | $3,500 per individual & $7,000 family | No Limit |
| Out-of-pocket Maximum - Prescription Co-payments | $3,500 per individual & $7,000 family | No Coverage | $3,500 per individual & $7,000 family | No Limit |
Outpatient Services |
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| Preventive Care: | 100% - No Co-pay1 | 25% | 100% - No Co-pay1 | 25% |
| In Network Office Visit Co-payment: | $20 co-payment | $40 co-payment | ||
| In Network "E-Visit" (a physician consulation via internet): | $10 co-payment | NA | $20 co-payment | N/A |
| Out of Network Office Visit: | 25% | 25% | ||
| Lab Services, X-ray & Diagnostic Testing: | 100% | 25% | 100% | 25% |
| Maternity Care - Outpatient Visits | $200 co-payment | 25% | $400 co-payment | 25% |
| 2Infertility treatment - In Vitro Fertilization: | $2,500 co-pay | No Coverage | No Coverage | No Coverage |
| Outpatient ER Visit - emergency treatment only | $200 co-payment | $200 co-payment | $250 co-payment | $250 co-payment |
| Ambulance - emergency transport only | NA | $200 co-payment | NA | $250 co-payment |
| Urgent Care Visit | $20 co-payment | 25% | $40 co-payment | 25% |
| 3Home Care Services - 60 visit limit | 100% | 25% | 100% | 25% |
| 3Hospice Services | 100% | 25% | 100% | 25% |
| Professional Counseling | $20 co-payment | 25% | $40 co-payment | 25% |
| 3Physical/Occupational/Speech Therapy | $20 co-payment | 25% | $40 co-payment | 25% |
| Acupuncture - $500 limit | NA | $20 co-payment | NA | $40 co-payment |
| 3Orthotics/Prosthetics - $10,000 limit | 80% | 25% | 80% | 25% |
| 3Rental or Purchase of Medical Equipment & Supplies | 80% | 25% | 80% | 25% |
| Breast Pumps - $500 limit | NA | 100% | NA | 100% |
| Hearing Aids - $3,000 limit, every three years | NA | 80% | NA | 80% |
| Chiropractic Services - $500 | NA | 50% | NA | 50% |
| Glasses and Contact lenses - $200 benefit | 80% | 80% | NA | 80% |
3 Inpatient Services/Surgery |
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| Hospital Services: | 100% | 25% | 100% | 25% |
| Outpatient Surgery Facility Charges: | 100% | 25% | 100% | 25% |
| Maternity Care - Inpatient Services | 100% | 25% | 100% | 25% |
| Professional Fees - Inpatient and OP Surgery: | 100% | 25% | 100% | 100% |
| Skilled Nursing Facility - 60 day limit | 100% | 100% | 100% | 100% |
| 2 Bariatric Surgery - Facility and Professional Fees: | $1,500 co-pay | No Coverage | No Coverage | No Coverage |
Prescription Drug - Employee Co-payments |
LLUH Pharmacies |
Other Pharmacies |
LLUH Pharmacies |
Other Pharmacies |
| Retail (30-day supply) | ||||
| Generic | $5 | $15 | $10 | $30 |
| Brand | $30 | $40 | $60 | $80 |
| CVS/Caremark Mail Order Service (90-day supply) | ||||
| Generic | NA | $10 | NA | $20 |
| Brand | NA | $60 | NA | $120 |
Dental Services |
||||
| $1,500 Annual Dental Benefit | Preventive Care | 100% | Preventive Care | 100% |
| - Basic and major services are subject to a $50/individual, $150 family deductible | Basic Services | 80% | Basic Services | 80% |
| Major Services | 50% | Major Services | 50% | |
| Orthodontia - $1,000 lifetime benefit | 50% | 50% | ||
Monthly Employee Plan Contributions |
Full-time |
Part-time |
Full-time |
Part-time |
Medical |
||||
| Single | $35 | $500 | $80 | $545 |
| Two-party | $135 | $600 | $225 | $690 |
| Family | $210 | $675 | $345 | $810 |
| Surcharge for employees who opt out of wellness requirements - $150 single, $225 two-party, $300 family | ||||
Dental |
||||
| Single | $5 | $51.50 | $10 | $56.50 |
| Two-party | $25 | $71.50 | $35 | $81.50 |
| Family | $50 | $96.50 | $65 | $111.50 |
1 Limited to specific preventive services
2 Subject to coverage criteria, authorization and a 3 year waiting period
3 Prior authorization required