Colorado Dept of Personnel and Administration (DPA) - Division of Human Resources (DHR)

Division of Human Resources

Medical Insurance for Current FY08 Plan Year

New FY09 Medical Information Return to Benefits Home Enroll/Change Governing Plan Document Rules (Benefits-Chapter 11) Statutes

Important Information about Selecting Your Plan
- Open Enrollment will be April 21 - May 16, 2008. Enrollment will be for the FY09 Plan Year (July 1, 2008 - June 30, 2009).
- New FY09 Medical Information
- The information below pertains only to the current FY08 Plan Year, which will conclude on June 30, 2008.
- OA (Open Access) options comprise the State's Self-Funded plan which is administered by Great-West Healthcare. "Open Access" refers to Great-West's Open Access network of providers.
- PREVENTIVE CARE: For deductible plans, primary preventive services are covered at the appropriate percentage for the plan, even before the plan's deductible has been met.
- The Kaiser and San Luis Valley HMO plans are available only in certain regions of the State.

Your FY08 Medical Insurance Choices

Plan Name	Availability	Employee's Cost (monthly)	Deductible, In-Network (individual / family)	Office Visits (In-Network)	Prescriptions (30-day supply)
OA-1500	Statewide	Employee only $33.12 Employee + Spouse $204.68 Employee + Child(ren) $127.38 Employee + Family $251.74	$1500 / $3000	Plan pays 80% after deductible has been met	Generic - $10 co-pay Preferred Brand Name - $25 co-pay Non-preferred Brand Name - $50 co-pay All subject to $100 per member prescription deductible before co-pay applies
OA-3000	Statewide	Employee only $4.24 Employee + Spouse $141.14 Employee + Child(ren) $75.40 Employee + Family $168.00	$3000 / $6000	Plan pays 70% after deductible has been met	Generic - $10 co-pay Preferred Brand Name - $25 co-pay Non-preferred Brand Name - $50 co-pay All subject to $100 per member prescription deductible before co-pay applies
OA-H	Statewide	Employee only $15.16 Employee + Spouse $165.16 Employee + Child(ren) $95.06 Employee + Family $199.68	$1400 / $2800⁽¹⁾	Plan pays 85% after deductible has been met	Plan pays 85% of costs after deductible is met. Entire plan deductible must be met before prescription coverage begins.
OA-30 Will not be offered for FY09	Statewide	Employee only $253.92 Employee + Spouse $690.46 Employee + Child(ren) $524.84 Employee + Family $892.08	none, co-pay for services	PCP⁽²⁾ - $30 co-pay Specialist - $50 co-pay Preventive - $30 co-pay	Generic - $10 co-pay Preferred Brand Name - $25 co-pay Non-preferred Brand Name - $50 co-pay All subject to $100 per member prescription deductible before co-pay applies
Kaiser HMO	Denver, Boulder, parts of Colo. Springs - see Denver/Boulder zip code list or Colo. Springs zip code list	Employee only $100.90 Employee + Spouse $353.78 Employee + Child(ren) $249.38 Employee + Family $448.30	none, co-pay for services	PCP⁽²⁾ - $30 co-pay Specialist - $50 co-pay Preventive - $15 co-pay	Generic - $10 co-pay Brand Name - $30 co-pay
San Luis Valley HMO	By county - Alamosa, Conejos, Costilla, Mineral, Rio Grande and Saguache	Employee only $59.00 Employee + Spouse $261.62 Employee + Child(ren) $173.96 Employee+ Family $326.80	none, co-pay for services	PCP⁽²⁾ - $30 co-pay Specialist - $50 co-pay Preventive - with PCP, $30 co-pay - with Specialist $50 co-pay	Formulary Generic - $10 co-pay⁽³⁾ Formulary Brand Name - $25 co-pay⁽³⁾ Non-formulary Brand Name or Generic - $50 co-pay ⁽³⁾ All subject to $100 per member prescription deductible before co-pay applies

(1) The $1400 deductible only applies to the Employee Only level of the OA-H option. The $2800 deductible applies to all other levels of this option and there are no individual deductibles for these levels. For the OA-H, the family deductible must be satisfied before benefits are paid for any individual family member.
(2) Primary Care Physician
(3) For the lesser of a 30-day supply or a 100-unit dose.
Note: This is only a summary, not a contract. Consult the "Plan Details & Exclusions" (Summary Plan Description) for each plan to determine the exact terms and conditions of coverage.

For more information about Benefits contact the DPA Benefits Unit.

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