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

Division of Human Resources

FY09 Open Access (OA)-3000 Information

Return to FY09 Medical Page Return to FY08 Medical Page FY09 OA-3000 Description Self-Funded Plan Details & Exclusions Enroll/Change

Summary of FY09 Benefits for the OA-3000 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 $346.76/ $4161.12 Employee + Spouse $762.88 / $9154.56 Employee + Child(ren) $624.18/ $7490.16 Employee + Family $1040.28/ $12,483.36	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 $6.50 / $78.00 Employee + Spouse $197.44/ $2369.28 Employee + Child(ren) $124.38 / $1492.56 Employee + Family $257.36 / $3088.32
Deductibles	In-Network	Individual - $3000 Family⁽¹⁾ - $6000
	Out-of-Network	Individual - $6000 Family⁽¹⁾- $12,000
Out-of-Pocket Maximums	In-Network	Individual - $5000 Family⁽¹⁾- $10,000
	Out-of-Network	Individual - $10,000 Family⁽¹⁾- $20,000
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
	Out-of-Network	Plan pays 70%, member pays 30% - NOT SUBJECT TO DEDUCTIBLE
Routine Office Visit	In-Network - Coverage increased for FY09	Plan pays 75%, member pays 25%, after deductible has been met
	Out-of-Network	Plan pays 50%, member pays 50%, after deductible has been met
In-Patient Hospital -	In-Network - Coverage increased for FY09	Plan pays 75%, member pays 25%, after deductible has been met
	Out-of-Network	Plan pays 50%, member pays 50%, after deductible has been met
Out-Patient Surgery	In-Network - Coverage increased for FY09	Plan pays 75%, member pays 25%, after deductible has been met
	Out-of-Network	Plan pays 50%, member pays 50%, after deductible has been met

(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-3000 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.

tttt