The 2016 Health Care Plan Comparison Chart provides you with high-level coverage details on medical, dental and vision plans.

Transcription

1 2016 HEALTH PLAN COMPARISON CHART The 2016 Health Care Plan Comparison Chart provides you with high-level coverage details on medical, dental and vision plans. Andre Jacobs Field Services North America, Inc. Craft

2 Medical Plans Coinsurance for all medical plans indicates what the employee pays, unless otherwise noted. For plan details, review the appropriate summary available on or by contacting the plan carrier. Plan Feature UHC Choice Plus HDHP A 1 UHC Choice Plus HDHP B 1 UHC Core HDHP C In-Network Out-of-Network 2 In-Network Out-of-Network 2 (Except in true emergencies) In-Network Only Annual Deductible $2,500 per individual 3 $2,500 per individual 3 $1,300 per individual 3 $1,300 per individual 3 $2,500 for individual 3 $5,000 per family 3 $5,000 per family 3 $2,600 per family 3 $2,600 per family 3 $5,000 for family 3 Annual Out-of-Pocket Maximum (includes annual, copays and coinsurance) Office Visits Primary Care Specialist $5,000 per individual 5 $10,000 per family 5 $5,000 per individual 5 $10,000 per family 5 $3,800 per individual 5 $7,600 per family 5 $3,800 per individual 5 $7,600 per family 5 $5,000 for individual 5 $10,000 for family 5 Out-of-pocket maximum includes prescription drugs Out-of-pocket maximum includes prescription drugs Out-of-pocket maximum includes prescription drugs Preventive Care 7 Covered in full Hospital Services Inpatient Outpatient Maternity Covered in full Covered in full Well-Baby Care Covered in full Prescription Drugs at Pharmacy 30% coinsurance up to $150, after (waived for eligible up to a 30-day supply 7 Covered in full 30% coinsurance up to $150, after (waived for eligible up to a 30-day supply 7 Covered in full 30% coinsurance up to $150, after (waived for eligible preventive drugs) per prescription up to a 30-day supply 7 Prescription Drugs by Mail Order 20% coinsurance up to $300, after (waived for eligible up to a 90-day supply 7 20% coinsurance up to $300, after (waived for eligible up to a 90-day supply 7 20% coinsurance up to $300, after (waived for eligible preventive drugs) per prescription up to a 90-day supply 7 Urgent Care Emergency Care (copay waived if admitted) Diagnostic X-ray and Lab Chiropractic Services Physical/Speech/ Occupational Therapy Mental Health and Substance Abuse Inpatient Outpatient ; visits approved ; visits approved ; visits approved ; visits approved ; visits approved 1 In-network and out-of-network annual s and out-of-pocket maximums are satisfied separately. 2 All out-of-network coverages are subject to usual, customary and reasonable charges. 3 If you enroll in a HDHP for Employee Only coverage, the plan pays for eligible medical and/or prescription drug expenses after you satisfy the individual annual. For any coverage level other than Employee Only, the plan pays for eligible medical and/or prescription drug expenses after you and/or any other covered member(s) satisfy the family annual. 4 If you enroll in the UHC Choice Plus, the plan pays for eligible medical and/or prescription drug expenses after you satisfy the per individual, not to exceed the family for all covered family members. 2

3 UHC Choice Plus PPO 1 UHC Out-of-Area UHC Out-of-Area HDHP A UHC Out-of-Area HDHP B In-Network Out-of-Network 2 $1,000 per individual $2,000 per family 4 $1,000 per individual $2,000 per family 4 $1,000 per individual $2,000 per family 4 $2,500 for individual 3 $5,000 for family 3 $1,300 per individual 3 $2,600 per family 3 $3,500 per individual $7,000 per family 6 $3,500 per individual $7,000 per family 6 $3,500 per individual $7,000 per family 6 $5,000 for individual 5 $10,000 for family 5 $3,800 per individual 5 $7,600 per family 5 Out-of-pocket maximum includes prescription drugs Out-of-pocket maximum includes prescription drugs Out-of-pocket maximum includes prescription drugs Out-of-pocket maximum includes prescription drugs Covered in full after $30 copay Covered in full after $60 copay Covered in full Covered in full Covered in full Covered in full and $300 copay per admission and $600 copay per admission and $300 copay per admission Covered in full after $30 copay for first office visit; 20% coinsurance after and $300 copay per admission for delivery for first office visit; 40% coinsurance after and $600 copay per admission for delivery for the first office visit; $300 copay then for delivery Covered in full Covered in full Covered in full Covered in full 30% coinsurance up to $150, after (waived for eligible preventive drugs) per prescription up to a 30-day supply 30% coinsurance up to $150, after (waived for eligible up to a 30-day supply 30% coinsurance up to $150, after (waived for eligible up to a 30-day supply 7 30% coinsurance up to $150, after (waived for eligible up to a 30-day supply 7 20% coinsurance up to $300, after (waived for eligible preventive drugs) per prescription up to a 90-day supply 20% coinsurance up to $300, after (waived for eligible up to a 90-day supply 20% coinsurance up to $300, after (waived for eligible up to a 90-day supply 7 20% coinsurance up to $300, after (waived for eligible up to a 90-day supply 7 and $65 copay and $150 copay True Emergency: 20% after and $150 copay/visit Non-Emergency: 40% after and $150 copay/visit Covered in full after $60 copay; visits approved Covered in full after $30 copay per visit; $60 copay per specialist visit ; visits approved based on medical necessity ; visits approved based on medical necessity ; visits approved based on medical necessity ; visits approved based on medical necessity and $300 copay per admission and $600 copay per admission and $300 inpatient stay copay $30 copay per visit 5 If you enroll in a HDHP for Employee Only coverage, the plan pays 100% of eligible medical and/or prescription drug expenses for the remainder of the year after you satisfy the individual annual out-of-pocket maximum. For any coverage level other than Employee Only, the plan pays 100% of eligible medical/or prescription drug expenses for the remainder of the year after you and/or any other covered member(s) satisfy the family out-of-pocket maximum. However, no individual plan member pays more than $6,850 out-of-pocket in-network costs. 6 If you enroll in the UHC Choice Plus, the plan pays 100% of eligible medical and/or prescription drug expenses for the remainder of the calendar year after you satisfy the annual out-of-pocket maximum per person, not to exceed the family out-of-pocket maximum for all covered family members. 7 To price out medications or find out whether a drug is on the formulary list, visit For questions, contact JESI HR Service Center at or call

4 Medical Plans (continued) Coinsurance for all medical plans indicates what the employee pays, unless otherwise noted. For plan details, review the appropriate summary available on or by contacting the plan carrier. Plan Feature Annual Deductible Annual Out-of-Pocket Maximum (unless otherwise noted, includes annual, copays and coinsurance, as well as prescription drug copays) $1,300 per individual $2,600 per family $3,500 per individual $6,850 per family In-Network Group Health (Seattle) 1 Out-of-Network $1,300 per individual $2,600 per family $3,500 per individual $6,850 per family $2,600 per family 2 $6,850 per family 3 Kaiser California Office Visits Primary Care Specialist Preventive Care 1 Covered in full Covered in full Hospital Services Inpatient Outpatient Maternity Outpatient: Inpatient: Outpatient: Inpatient: Well-Baby Care 1 Covered in full Covered in full through age 23 months Prescription Drugs at Pharmacy 20% coinsurance or 10% coinsurance at Group Health Network per 30-day supply; applies Not covered, not to exceed $20 generic/30% coinsurance, not to exceed $50 brand per 100-day supply Prescription Drugs by Mail Order 2 times prescription cost share per 90-day supply Not covered, not to exceed $20 generic/30% coinsurance, not to exceed $50 brand per 100-day supply Urgent Care Emergency Care (copay waived if admitted) Diagnostic X-ray and Lab Chiropractic Services, 8 visits maximum per year, additional visits when approved by plan Outpatient: : 45 visits per calendar year Inpatient: : 30 days per calendar year, 8 visits maximum per year, additional visits when approved by plan Outpatient: : visit limits shared with in-network Inpatient: : day limits shared with in-network $15 copayment after ; 30 visits maximum per year Physical/Speech/ Occupational Therapy Mental Health and Substance Abuse Inpatient Outpatient Mental/Behavioral Health Substance Abuse 1 In-network and out-of-network annual s and out-of-pocket maximum are combined. 4 2 If you enroll in a HDHP for Employee Only coverage, the plan pays for eligible medical and/or prescription drug expenses after you satisfy the individual annual. For any coverage level other than Employee Only, the plan pays for eligible medical and/or prescription drug expenses after you and/or any other covered member(s) satisfy the family annual. 3 If you enroll in a HDHP for Employee Only coverage, the plan pays 100% of eligible medical and/or prescription drug expenses for the remainder of the year after you satisfy the individual annual out-of-pocket maximum. For any coverage level other than Employee Only, the plan pays 100% of eligible medical/or prescription drug expenses for the remainder of the year after you and/or any other covered member(s) satisfy the family out-of-pocket maximum.

5 Kaiser Colorado Kaiser Georgia Kaiser Mid Atlantic Kaiser Northwest $2,600 per family 2 $2,600 per family 2 $2,600 per family 2 $2,600 per family 2 $6,850 per family 3 $6,850 per family 3 $6,850 per family 3 $6,850 per family 3 and 20% coinsurance for office-administered injectables/ infusions and 20% coinsurance for office-administered injectables/ infusions Covered in full Covered in full Covered in full Covered in full Covered in full for prenatal visits and first week postnatal care; for delivery Covered in full for prenatal visits and first week postnatal care; for delivery Covered in full through age 23 months Covered in full through age 30 months Covered in full for children Covered in full, not to exceed $20 generic/30% coinsurance after, not to exceed $40 brand/50% coinsurance after, not to exceed $70 non-preferred, not to exceed $40 generic/30% coinsurance after, not to exceed $80 brand/50% coinsurance after, not to exceed $140 non-preferred, not to exceed $20 at Kaiser Permanente pharmacies and 30% coinsurance after, not to exceed $40 brand network pharmacies. Network pharmacy limited to a one times fill per medication Generic/30% coinsurance after, not to exceed $40 at Kaiser Permanente pharmacies and, not to exceed $80 brand network pharmacies. Network pharmacy limited to a one times fill per medication brand, not to exceed $40 at Kaiser Permanente Pharmacies only generic/, not to exceed $40 at Kaiser Permanente pharmacies only brand Kaiser pharmacy:, not to exceed $20 generic/30% coinsurance after, not to exceed $40 brand/50% coinsurance after, not to exceed $70 non-preferred Participating community pharmacy: 30% coinsurance after, not to exceed $40 generic/, not to exceed $80 brand/60% coinsurance after, not to exceed $140 non-preferred, not to exceed $40 generic/30% coinsurance after, not to exceed $80 brand/50% coinsurance after, not to exceed $140 non-preferred, not to exceed $20 generic/30% coinsurance after, not to exceed $40 brand/50% coinsurance after, not to exceed $70 non-preferred, not to exceed $40 generic/30% coinsurance after, not to exceed $80 brand/50% coinsurance after, not to exceed $140 non-preferred at designated facilities Covered in full in physician s office; 20% coinsurance after in hospital setting Not covered ; 20 visits maximum per therapy type, per year ; 30 visits maximum per year ; 20 visits maximum for physical and occupational therapy combined; and 20 visits maximum for speech therapy Not covered ; Physical Therapy up to 20 visits per incident. Occupational and Speech up to 2 months. Chiropractic up to 20 visits per contract year. ; 20 visits maximum per therapy type, per year Mental/Behavioral Health 20% coinsurance after ; unlimited visits per year Substance Abuse ; unlimited visits per year For questions, contact JESI HR Service Center at or call

6 Dental Plans Coinsurance indicates what the employee pays. For plan details, review the appropriate summary available on or by contacting the plan carrier. Plan Feature Annual Deductible Delta Dental PPO 1 Aetna DMO In-Network Out-of-Network 2 Services and supplies must be provided by your assigned Aetna DMO dentist $50 per individual None $150 per family Annual Maximum Benefit $1,500 per person None Lifetime Orthodontia Maximum $1,500 per person None Diagnostic and Preventive Services Covered in full Covered in full Covered in full Basic Services 20% coinsurance Major Services (prosthodontic, implants, crowns and casts) 50% coinsurance after 50% coinsurance after 50% coinsurance (implants are not covered) Orthodontia Services 3 50% coinsurance after 50% coinsurance after 50% coinsurance 1 If you go to a provider outside the Delta network, you are responsible for amounts over Delta s maximum benefit allowance. Note that you may pay more for services from a dentist in the Delta Premier network. 2 Delta Dental pays the reasonable and customary service fee, but the employee must pay the difference of the total bill. 3 Orthodontia is covered for children and adults under the Delta Dental Plan. Orthodontia is covered for children and adults under the Aetna Plan and includes 24 months of comprehensive orthodontic treatment plus 24 months of retention. Vision Plan Plan Feature In-Network VSP Out-of-Network Eye Exam every calendar year Covered in full after $10 copay After $10 copay, VSP reimburses up to $50 Lenses every calendar year: Single vision Lined bifocal Lined trifocal lenses Frames every calendar year Contact Lenses every calendar year (in lieu of prescription eyeglass lenses and frames) Covered in full after $15 copay $150 allowance; 20% off the amount over your allowance (Note: This discount does not apply at Costco as their pricing already includes discounts) $150 allowance for contacts; up to $60 copay for contact lens exam (fitting and evaluation) After $15 copay, VSP reimburses as follows: Single vision: up to $50 allowance Lined bifocal: up to $75 allowance Lined trifocal: up to $100 allowance VSP reimburses up to $70 VSP reimburses up to $105 6

7 Plan Contact Information Benefit Plan Carrier Group number Website Phone UHC Choice Plus HDHP A UHC Choice Plus HDHP B UHC Core HDHP C UHC Out-of-Area HDHP A UHC Out-of-Area HDHP B UHC Choice Plus PPO UHC Out-of-Area High Deductible Health Plan Health Maintenance Organizations (HDHP HMOs) UnitedHealthcare (UHC) Express Scripts Prescription Drug Program WA (Seattle) Group Health CA Kaiser Permanente CO Kaiser Permanente GA Kaiser Permanente Mid-Atlantic Kaiser Permanente Northwest Kaiser Permanente HEALTH & WELFARE BENEFITS Express Scripts: Use Member Individual ID Number listed on ID card Employee only Employee and dependents Northern 8444 Southern Denver/Boulder service area: Southern Colorado service area: PPO Dental Plan Delta Dental Dental Maintenance Organization (DMO) Aetna Vision Service Plan (VSP) VSP (Signature) LIFE, ACCIDENT & DISABILITY Supplemental Life Insurance The Standard Accidental Death and Dismemberment The Standard (AD&D) Short Term and Long Term Disability The Standard (STD/LTD) Plans TAX SAVINGS OPTIONS Health Savings Account (HSA) Optum Bank N/A Health Care FSA UnitedHealthcare (UHC) Limited Purpose FSA Dependent Care FSA WELLNESS BENEFITS HealthConnection UnitedHealthcare (UHC) Best Doctors Best Doctors, Inc. N/A MDLive MDLive N/A mdlive.com/jacobs Employee Assistance Program (EAP) United Behavioral Health access code: jacobs FINANCIAL BENEFITS 401(k) Savings Plan Vanguard Employee Stock Purchase Plan (ESPP) Fidelity N/A VOLUNTARY BENEFITS TRICARE Supplement Plan (for active/retired military personnel) TRICARE Military Plan C , ext. 255 Critical Illness Insurance MetLife Critical Illness Simplified Issue; Critical Illness Fully Unwritten jacobsengineeringgroup Legal Plan MetLife/Hyatt Legal Services 150/ Commuter FSA WageWorks N/A commuter/ Home & Renters Insurance Auto Insurance Plan Identity Theft Plan PersonalPlans N/A For questions, contact JESI HR Service Center at or call

8 Important Note This health plan comparison chart is for information purposes only and is neither an offer of coverage nor medical advice. The chart contains only a partial, general description of plan benefits and does not constitute a contract. The benefits are governed by the official plan documents (which may include underlying insurance contracts). This chart is not intended to amend or revise any official plan document or change the terms of any plan in any way. In the event of any inconsistency between the plan documents and the information in this chart, the terms of the plan documents, as interpreted by the Plan Administrator, control. Consult or JESI HR Service Center for further details, including procedures, exclusions and limitations relating to the plans. All terms and conditions of the plans are subject to applicable laws, regulations and policies. The availability of a plan or a plan feature may vary by geographic service area. Copyright 2015, Jacobs Engineering Group Inc. All rights reserved. HB 01 10/15