City Care Benefits Medical Plan Summary

 

 

SHARP HMO HEALTH PLAN AC (HIGH OPTION)

 

·        No Deductibles

·        $15 Physician and Other Professional Services Office Visit Copayment

·        Inpatient and Outpatient Hospital Services Covered in Full

·        $50 Emergency Room Copayment (waived if admitted to hospital)

·        Prescription Drug Coverage

o       Generic Drugs - $10 Copayment/30-day Supply

o       Brand Formulary Drugs - $20 Copayment/30-day Supply

o       Non-Formulary Drugs - $40 Copayment/30-day Supply

o       90-day mail order Generic Drugs - $10 Copayment

o       90-day mail order Brand Formulary Drugs - $20 Copayment

 

Monthly Premiums:    Employee Only                     $245.99

                                      Employee & Spouse              516.60

                                      Employee & Child(ren)         565.78

                                      Employee & Family               836.35

 

 

SHARP HMO HEALTH PLAN AE (LOW OPTION)

 

·        No Deductibles

·        $20 Physician and Other Professional Services Office Visit Copayment

·        Inpatient Hospital Services Covered in Full after a $750 Copayment per Admission

·        Outpatient Surgery Services Covered in Full after a $375 Copayment per procedure

·        $50 Emergency Room Copayment (waived if admitted to hospital)

·        Prescription Drug Coverage

o       Generic Drugs - $10 Copayment/30-day Supply

o       Brand Formulary Drugs - $20 Copayment/30-day Supply

o       Non-Formulary Drugs - $40 Copayment/30-day Supply

o       90-day mail order Generic Drugs - $10 Copayment

o       90-day mail order Brand Formulary Drugs - $20 Copayment

 

Monthly Premiums:    Employee Only                     $224.15

                                      Employee & Spouse              470.73

                                      Employee & Child(ren)         515.56

                                      Employee & Family               762.12

 

NOTE:

1.    HMO Medical Plan Rates are Guaranteed to August 1, 2005.

2.    HMO Plans Will Cover 2+ Eligible Employee Groups.

3.    Dual-choice HMO Plans are NOW Available.

 

 

NOTE:  City Care Benefits plan descriptions provide a brief summary of the benefits only and are not complete regarding all the provisions of the plans, including limitations and exclusions.

 

 

 

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