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Open Access (OA)-30
(an In-Network Only Plan)
Please note that this plan will be eliminated for the
FY09 Plan Year. The information below pertains
only to the remainder of the FY08 Plan Year, which will
conclude on June 30, 2008.
Return to FY08 Medical Page Go
to New FY09 Medical Page
OA-30
Description
Self-Funded Plan
Details & Exclusions
Enroll/Change
Summary of
Benefits for the OA-30 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 |
There are NO
Out-of-
Network benefits. |
|
|
Premiums
|
Total Premium
(monthly / annually) |
State Pays...
(monthly / annually) |
Employee
Pays...
(monthly / annually) |
| |
Employee
only
$539.76/ $6477.12
Employee + Spouse
$1181.64/ $14,179.68
Employee + Child(ren)
$967.68/ $11,612.16
Employee + Family
$1556.04/ $18,672.48 |
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
$253.92 / $3047.04
Employee + Spouse
$690.46 / $8285.52
Employee + Child(ren)
$524.84 / $6298.08
Employee + Family
$892.08 / $10,704.96 |
| Deductibles |
none,
co-pay for
services |
|
|
Out-of-Pocket
Maximums |
In-Network |
Individual - $1000
+ co-pays
Family (1) - $3000 + co-pays |
|
| |
Out-of-Network |
No Out-of-Network
benefits |
|
|
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 |
$30 co-pay |
|
| |
Out-of-Network |
No Out-of-Network
benefits |
|
Routine Office
Visit |
In-Network |
PCP (3)
- $30 co-pay
Specialist - $50 co-pay |
|
| |
Out-of-Network |
No Out-of-Network
benefits |
|
In-Patient
Hospital |
In-Network |
After $250 co-pay
per day,
up to 3 days per admission,
plan pays 100% |
|
| |
Out-of-Network |
No Out-of-Network
benefits |
|
Out-Patient
Surgery |
In-Network |
$150 co-pay per
surgery or
invasive diagnostic test |
|
| |
Out-of-Network |
No Out-of-Network
benefits |
|
(1) Family 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.
(3) Primary Care Physician
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-30 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