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Open Access (OA)-3000
Return to FY08 Medical Page Go
to New FY09 Medical Page
OA-3000
Description
Self-Funded Plan
Details & Exclusions
Enroll/Change
Summary of
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 |
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
$290.08/ $3480.96
Employee + Spouse
$632.32 / $7587.84
Employee + Child(ren)
$518.24/ $6218.88
Employee + Family
$831.96/ $9983.52 |
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
$4.24 / $50.88
Employee + Spouse
$141.14 / $1693.68
Employee + Child(ren)
$75.40 / $904.80
Employee + Family
$168.00 / $2016.00 |
| 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) |
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 70%,
member
pays 30% - NOT SUBJECT
TO DEDUCTIBLE |
|
| |
Out-of-Network |
Plan pays 50%,
member
pays 50% - NOT SUBJECT
TO DEDUCTIBLE |
|
Routine Office
Visit |
In-Network |
Plan pays 70%,
member
pays 30%, after deductible
has been met |
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| |
Out-of-Network |
Plan pays 50%,
member
pays 50%, after deductible
has been met |
|
In-Patient
Hospital |
In-Network |
Plan pays 70%,
member
pays 30%, after deductible
has been met |
|
| |
Out-of-Network |
Plan pays 50%,
member
pays 50%, after deductible
has been met |
|
Out-Patient
Surgery |
In-Network |
Plan pays 70%,
member
pays 30%, after deductible
has been met |
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Out-of-Network |
Plan pays 50%,
member
pays 50%, 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" 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-3000 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