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Open Access (OA)- H
(an HSA-qualified medical plan)
Return to FY08 Medical Page Go
to New FY09 Medical Page
OA-H
Description
Self-Funded Plan
Details & Exclusions
Enroll/Change
Summary of
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 |
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. |
|
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Premiums
|
Total Premium
(monthly / annually) |
State Pays...
(monthly / annually) |
Employee
Pays...
(monthly / annually) |
| |
Employee
only
$301.00/ $3612.00
Employee + Spouse
$656.34 / $7876.08
Employee + Child(ren)
$537.90/ $6454.80
Employee + Family
$863.64/ $10,363.68 |
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
$15.16 / $181.92
Employee + Spouse
$165.16 / $1981.92
Employee + Child(ren)
$95.06 / $1140.72
Employee + Family
$199.68 / $2396.16 |
| Deductibles |
In-Network |
Individual - $1400
Family (1) (2) - $2800 |
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Out-of-Network |
Individual - $2800
Family (1) (2) - $5600 |
|
Out-of-Pocket
Maximums |
In-Network |
Individual - $2500
Family (1) (3) - $5000 |
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Out-of-Network |
Individual - $5000
Family (1) (3) - $10,000 |
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Prescriptions |
In-Network
Pharmacies |
Plan pays 85%
after full
plan deductible is met (4) |
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 |
Prescription Price
Preview/Estimator
(from Express Scripts) |
Preventive
Care |
In-Network |
Plan pays 85%,
member
pays 15% - NOT SUBJECT
TO DEDUCTIBLE |
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Out-of-Network |
Plan pays 65%,
member
pays 35% - NOT SUBJECT
TO DEDUCTIBLE |
|
Routine Office
Visit |
In-Network |
Plan pays 85%,
member
pays 15%, after deductible
has been met |
|
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Out-of-Network |
Plan pays 65%,
member
pays 35%, after deductible
has been met |
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In-Patient
Hospital |
In-Network |
Plan pays 85%,
member
pays 15%, after deductible
has been met |
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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 |
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Out-of-Network |
Plan pays 65%,
member
pays 35%, 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) 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" 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-H 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