POS Co-pays and Deductibles,
The POS Plan shall have the following co-pays and deductibles:
(a) Twenty Dollars ($20.00) per medical_visit:
(b) One Hundred Dollars ($100.00) per emergency room visit:
(c) Two Hundred Fifty Dollars ($250.00) Per Person, Five Hundred Dollars
($500.00) Per 2 Person/Family Inpatient/Outpatient Facility Deductible, and
(d) Three Tier Pharmacy Benefit of $5/$15/$35 ($5/$30/$70 Mail Order).
HMO Co-pays_ and Deductibles:
The HMO Plan shall have the following co-pays and deductibles:
(a) Twenty Dollars ($20.00) per medical_visit:
(b) One Hundred Dollars ($100.00) per emergency room visit:
(c) Two Hundred Fifty Dollars ($250.00) Per Person, Five Hundred Dollars
($500.00) Per 2 Person/Family Inpatient/Outpatient Facility Deductible, and
(d) Three Tier Pharmacy Benefit of $5/$15/$35 ($5/$30/$70 Mail Order).
Effective July_1, 2021, the HMO Plan shall have the following co-pays and deductibles:
(a) Twenty -Five Dollars ($25.00) per medical visit:
(b) One Hundred Dollars ($100.00) per emergency room visit:
(c) One Thousand Five Hundred Dollars ($1.500.00) Per Person, Three Thousand
Dollars ($3,000.00) Per 2 Person/Family Inpatient/Outpatient Facility Deductible:
and
(d) Three Tier Pharmacy Benefit of $10/$30/$50 ($20/$60/$100 Mail Order).
igh Deductible Health Plan with Health S avings Account (HDHP w/ HS A):
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The deductibles in the High Deductible Health Plan with Health Savings Account (HDHP w/
HSA) are $2,000 individual / $4,000 2-person or family. The City’s contribution to Health
Savings Accounts is $1,500 individual / $3,000 2-person or family .
The City HSA contribution will be distributed in 2 installments, one on or about July 1 and on +,_.---{ Formatted:
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one or about October_1, provided however that if an employee is required to pay more towards “~{ Formatted: Space After: 0 pt }
his / her deductible than the initial 50% contribution, upon presentation of suitable
documentation, the City will contribute the remaining 50% before October _1.
Emp loy ees who join the HDHP w/HSA. at any time other than July_1 will receive _a pro-rated | —-"~ (Formatted: Space After: 0 pt )
City contribution of $125 monthly for a single planand $250 monthly for 2-person or family = =39=~"~ { Formatted: Font: (Default) Times New Roman }
plan for each full month remaining in that fiscal y ear.
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