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Open Access (OA)-1500
Return to FY08 Medical Page
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FY09 Medical Page
OA-1500
Description
Self-Funded Plan
Details & Exclusions
Enroll/Change
Summary of
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 |
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
|
Total Premium
(monthly / annually) |
State Pays...
(monthly / annually) |
Employee
Pays...
(monthly / annually) |
| |
Employee
only
$318.96 / $3827.52
Employee + Spouse
$695.86 / $8350.32
Employee + Child(ren)
$570.22/ $6842.64
Employee + Family
$915.70/ $10,988.40 |
Employee
only
$285.84 / $3430.08
Employee + Spouse
$491.18 / $5894.16
Employee + Child(ren)
$442.84 / $5314.08
Employee + Family
$663.96 / $7967.52 |
Employee
only
$33.12 / $397.44
Employee + Spouse
$204.68 / $2456.16
Employee + Child(ren)
$127.38 / $1528.56
Employee + Family
$251.74 / $3020.88 |
| Deductibles |
In-Network |
Individual - $1500
Family (1) - $3000 |
|
| |
Out-of-Network |
Individual - $3000
Family (1) - $6000 |
|
Out-of-Pocket
Maximums |
In-Network |
Individual - $3000
Family (1) - $6000 |
|
| |
Out-of-Network |
Individual - $6000
Family (1) - $12,000 |
|
|
Prescriptions |
30-day supply |
90-day supply
(mail order) (2) |
Find your meds on
approved drug
list |
| |
Generic -
$10 co-pay
Preferred Brand Name
-
$25 co-pay
Non-preferred Brand Name
-
$50 co-payAll
subject to $100 per
member prescription
deductible before co-pay
applies |
Generic -
$20 co-pay
Preferred Brand Name
-
$50 co-pay
Non-preferred Brand Name
-
$100 co-payAll
subject to $100 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 |
In-Network |
Plan pays 80%,
member
pays 20% - NOT SUBJECT
TO DEDUCTIBLE |
|
| |
Out-of-Network |
Plan pays 60%,
member
pays 40% - NOT SUBJECT
TO DEDUCTIBLE |
|
Routine Office
Visit |
In-Network |
Plan pays 80%,
member
pays 20%, after deductible
has been met |
|
| |
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 |
|
| |
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 |
|
| |
Out-of-Network |
Plan pays 60%,
member
pays 40%, 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" at the top of
this page.
Note: This is only a summary, not a contract.
Consult the "Plan Details & Exclusions" (also called a
Summary Plan Description) to determine the exact terms
and conditions of coverage.
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
(now includes new FY09
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