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FY09 Open Access (OA)-1500
Information
Return to FY09 Medical Page
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Medical Page
FY09 OA-1500
Description Self-Funded Plan
Details & Exclusions
Enroll/Change
Summary of
FY09 Benefits for the OA-1500 Option of the Self-Funded Plan
Note:
This is only a
summary, not a contract. For more details, see the
"Description" above and consult the "Plan Details &
Exclusions" above to determine the exact terms and
conditions of coverage.
Plan
Administrator |
Great-West
Healthcare,
now a part of CIGNA |
mygreatwest.com |
1-888-788-6326 |
Provider
Network |
Great-West's
Open
Access Network |
Out-of-Network
providers
may be used, but at
reduced coverage. |
|
Premiums -
FY09 |
Total Premium
(monthly / annually) |
State Pays...
(monthly / annually) |
Employee
Pays...
(monthly / annually) |
| |
Employee
only
$379.18 / $4550.16
Employee + Spouse
$834.20/ $10,010.40
Employee + Child(ren)
$682.52/ $8190.24
Employee + Family
$1137.54/ $13,650.48 |
Employee
only
$340.26 / $4083.12
Employee + Spouse
$565.44/ $6785.28
Employee + Child(ren)
$499.80 / $5997.60
Employee + Family
$782.92 / $9395.04 |
Employee
only
$38.92 / $467.04
Employee + Spouse
$268.76 / $3225.12
Employee + Child(ren)
$182.72 / $2192.64
Employee + Family
$354.62 / $4255.44 |
| Deductibles |
In-Network |
Individual - $1500
Family (1) - $3000 |
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Out-of-Network |
Individual - $3000
Family (1) - $6000 |
|
Out-of-Pocket
Maximums |
In-Network |
Individual - $3000
Family (1) - $6000 |
|
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Out-of-Network |
Individual - $6000
Family (1) - $12,000 |
|
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Prescriptions |
30-day supply |
90-day supply
(mail order) (2) -
New for
FY09, mail order requires
2.5 co-pays for 90-day (3 mo.)
supply |
Find your meds on
approved drug
list |
| |
Generic -
$10 co-pay
Preferred Brand Name
*
-
$25 co-pay
Non-preferred Brand Name *
-
$50 co-pay
Self-administered injectables
-
30% co-insurance, not
to exceed $300 per
34-
day supply* Subject
to $150 per
member prescription
deductible before co-pay
applies |
Generic -
$25 co-pay
Preferred Brand Name
*
-
$62.50 co-pay
Non-preferred Brand Name
*-
$125 co-pay
Self-administered injectables
-
30% co-insurance, not
to exceed $750 per
90-day
supply* Subject to $150 per
member prescription
deductible before co-pay applies |
Prescription Price
Preview/Estimator
(from Express Scripts)
For more information
on prescriptions,
contact customer
service at
1-888-788-6326. |
Preventive
Care -
coverage
increased for
FY09 |
In-Network |
Plan pays
90%,
member
pays 10% - NOT SUBJECT
TO DEDUCTIBLE |
|
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Out-of-Network |
Plan pays
70%,
member
pays 30% - NOT SUBJECT
TO DEDUCTIBLE |
|
Routine Office
Visit |
In-Network |
Plan pays 80%,
member
pays 20%, after deductible
has been met |
|
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Out-of-Network |
Plan pays 60%,
member
pays 40%, after deductible
has been met |
|
In-Patient
Hospital |
In-Network |
Plan pays 80%,
member
pays 20%, after deductible
has been met |
|
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Out-of-Network |
Plan pays 60%,
member
pays 40%, after deductible
has been met |
|
Out-Patient
Surgery |
In-Network |
Plan pays 80%,
member
pays 20%, after deductible
has been met |
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Out-of-Network |
Plan pays 60%,
member
pays 40%, after deductible
has been met |
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(1) Family deductible and out-of-pocket maximum
amounts apply to Employee + Spouse, Employee + Child(ren)
& Employee + Family levels.
(2) More information on the Mail Order
Prescription program, as well as the 90-Day Retail
Participating Provider Program can be found in the
"Self-Funded Plan Details & Exclusions."
Note: This is only a summary of
information, not a contract.
Consult the "Self-Funded
Plan Details & Exclusions" (also called a Summary
Plan Description) to determine the exact terms and
conditions of coverage. Contact the State of Colorado's dedicated customer
service line at 1-888-788-6326, with specific
questions about treatments, prescriptions, doctors and
hospitals.
More Self-Funded / Great-West Information
Prescriptions with Self-Funded Plan
MyGreatWest.com (physician directory, mail order Rx
info, and more)
Diabetes
Initiative
Medicare Part D
Notice for OA-1500 Plan
Evidence of
Disabled Dependent Form
Related Links
Premiums
Who is my
human resources contact?
Insurance
Companies’ Phone Numbers
What do
“Pre-tax” and “After tax” mean?
Instructions for Online Enrollment
HealthLine
Glossary of
Insurance Terms
Forms
Return to Benefits Home
Page
For
more information about Benefits contact the
DPA
Benefits Unit.
Email
comments to: DPA
Benefits
These
documents may be presented in PDF format, which requires the Adobe®
Reader.
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Division of Human Resources