|
|
FY09 Open Access (OA)-H
(an HSA-qualified medical plan) Information
Return to FY09 Medical Page Return
to FY08 Medical Page
FY09 OA-H
Description
Self-Funded Plan
Details & Exclusions
Enroll/Change
Summary of
FY09 Benefits for the OA-H 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
$360.22/ $4322.64
Employee + Spouse
$792.48 / $9509.76
Employee + Child(ren)
$648.40/ $7780.80
Employee + Family
$1080.66/ $12,967.92 |
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
$19.96 / $239.52
Employee + Spouse
$227.04 / $2724.48
Employee + Child(ren)
$148.60 / $1783.20
Employee + Family
$297.74/ $3572.88 |
Deductibles -
Increasing for
FY09 |
In-Network |
Individual -
$1500
Family (1) (2) -
$3000 |
|
| |
Out-of-Network |
Individual -
$3000
Family (1) (2) -
$6000 |
|
Out-of-Pocket
Maximums -
Increasing for
FY09 |
In-Network |
Individual -
$3000
Family (1) (3) -
$6000 |
|
| |
Out-of-Network |
Individual -
$6000
Family (1) (3) -
$12,000 |
|
|
Prescriptions |
In-Network
Pharmacies |
Plan pays 85%
after full
plan deductible is met (4)
except for injectables
administered in an office,
for which Plan pays 70%
after full plan deductible
is met. |
Find your meds on
approved drug
list
For more information
on prescriptions,
contact customer
service at
1-888-788-6326. |
| |
Out-of-Network
Pharmacies |
Plan pays 65%
after full
plan deductible is met
except for injectables
administered in an office,
for which Plan pays 70%
after full plan deductible
is met. |
Prescription Price
Preview/Estimator
(from Express Scripts) |
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 |
Plan pays 85%,
member
pays 15%, after deductible
has been met |
|
| |
Out-of-Network |
Plan pays 65%,
member
pays 35%, after deductible
has been met |
|
In-Patient
Hospital |
In-Network |
Plan pays 85%,
member
pays 15%, after deductible
has been met |
|
| |
Out-of-Network |
Plan pays 65%,
member
pays 35%, after deductible
has been met |
|
Out-Patient
Surgery |
In-Network |
Plan pays 85%,
member
pays 15%, after deductible
has been met |
|
| |
Out-of-Network |
Plan pays 65%,
member
pays 35%, 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) For the OA-H, the family deductible must be
satisfied before
benefits are paid for any individual family member.
(3) For the OA-H, the family out-of-pocket maximum must
be satisfied before
benefits are paid at 100% for any individual family
member.
(4) The Mail Order Prescription Program is available in
the OA-H, but no specific discount is available. 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
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-H 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 |
Division of Human Resources