Benefit Coverage Chart & Rates

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1 Benefit Coverage Chart & Rates Effective July 1, June 30, 2015 PPO Medical Coverage by Category The following coverages are included with the PPO plan: o Prescription o Vision Additional Benefits o Dental o Dental & Orthodontia o Life Insurance o Long Term Disability Deduction Note: The medical health care and dental rates are deducted on a pre-tax basis, while all other rates are post-tax. The contributions taken on a post-tax basis are those for Supplemental and Dependent Life, which are automatically deducted from your paycheck after taxes are taken out. Faculty Members: Benefit contributions for all faculty members will be deducted from September - May. Although the deductions are taken over a 9-month period, your benefit coverages last all year.

2 P P O MEDICAL PLAN July 1, June 30, 2015 Deductible The member must pay all costs up to this amount before the plan begins to pay for covered services. Some specific services, such as preventive care, do not apply to the deductible. See the coverage chart for more details. In-network and Out-of-Network accrue separately. Plan Co-Insurance A cost sharing feature in which the plan (Anthem Blue Cross Blue Shield) pays a fixed percentage of the cost of medical care. Employee Co-Insurance A cost sharing feature in which the Member pays a fixed percentage of the cost of medical care. PLAN YEAR MAXIMUMS Employee Co-Insurance Maximum Equal the total employees will pay for co-insurance during the plan year. Employee Out-of-Pocket Maximum Equals the total employees will pay in deductibles and coinsurance during the plan year. Employee Co-Pay Maximum Equals the total employees will pay for Office Visit co-pays during the plan year. Individual Lifetime Maximum Benefits Pre-Existing Condition Limitations A pre-existing condition is a physical or mental health condition, disability or illness that you have before you enrolled in a health plan. Office Visit (Primary Care, Specialty Care, Physical Therapy, etc.) TIER 1 TIER 2 (In-Network) (Out- of-network) $200/$400 $400/$800 90% for most categories 70% for most categories 10% for most categories 30% for most categories Out-of-pocket maximums accumulate separately; therefore, charges for out-of-network services cannot be applied to the in-network employee out-of-pocket maximum and vice versa $1000/$2000 $1200/$00 $5150/$10,300 None - $20 co-pay Unlimited $1500/$3000 $1900/$3800 Out of Network Co-Pay not applicable None - 70% reimbursement P P O COV ERAGE CH ART July 1, June 30, 2015 CATEGORY (Alphabetical Listing) Ambulance (subject to medical necessity) Child Wellness Visits Anthem Blue Cross and Blue Shield Standards TIER 1 (In-Network) 100% reimbursement for eligible procedures TIER 2 (Out- of-network) Chiropractic Services Durable Medical Equipment Emergencies A medical emergency is defined by insurance company standards. May include a condition that if untreated could be life threatening or seriously impair bodily functions. Gynecological Exams/PAP Smears Preventive and Diagnostic Hearing NOTE: Hearing medical conditions are covered the same as any other condition. Hearing Aid & Supplies 12 visit limit per plan year $20 co-pay $50 co-pay The employee may also be charged the deductible and co-insurance for any care received during the emergency room visit. 100% reimbursement One routine hearing exam covered per plan year (Under Preventive Care) $20 co-pay for office visit -90% reimbursement 70% reimbursement -70% reimbursement 2

3 P P O COV ERAGE CH ART July 1, June 30, 2015 CATEGORY (Alphabetical Listing) Home Health Care Services 100 visit limit per plan year (Combined with Private Duty Nursing) Hospice Services Inpatient & Outpatient Services, Surgery (non-emergency lab, x-ray, diagnostic testing and preadmission testing, allergy injections, serums, medically necessary colonoscopies, etc.) TIER 1 (In-Network) 100% reimbursement TIER 2 (Out- of-network) Mammograms Preventive and Diagnostic 100% reimbursement Maternity Pre and postnatal physician services $20 co-pay for first visit; afterwards 90% reimbursement Delivery: Vaginal & Cesarean Labs & Radiology Mental Health Inpatient and Residential Treatment Outpatient Counseling First 6 visits of plan year with an EAP/Impact or Anthem Network Provider 100% reimbursement After 6 visits - $20 co-pay Occupational Therapy Non Anthem Network Provider 40 visit limit per plan year (combined with Physical Therapy) Inpatient 90% reimbursement Outpatient $20 co-pay Office Visit (Primary Care, Specialty Care, Physical Therapy, etc.) Outpatient & Inpatient Services, Surgery (non-emergency lab, x-ray, diagnostic testing and preadmission testing, allergy injections, serums, medically necessary colonoscopies, etc.) Physical Therapy Inpatient - $20 co-pay 40 visit limit per plan year (combined with Occupational Therapy) 90% reimbursement Outpatient $20 co-pay Prescription Plan Administered by Express Scripts Formulary list maintained and controlled by prescription benefits management company (PBM) and is subject to changes as directed by PBM. Preventive Care Anthem Blue Cross and Blue Shield Standards Retail Co-pays: Generic Drug $10 Brand Name Formulary $20 Brand Name Non-Formulary $30 Mail Order Co-pays: Generic Drug $15 Brand Name Formulary $30 Brand Name Non-Formulary $45 Generics Preferred Program and Exclusive Home Delivery Program Required 100% reimbursement for eligible procedures Second Surgical Opinion 100% reimbursement Skilled Nursing Facility Limited to 60 days. Case management available if applicable. Speech Therapy 30 visit limit per plan year Inpatient Outpatient $20 co-pay 3

4 P P O COV ERAGE CH ART July 1, June 30, 2015 CATEGORY (Alphabetical Listing) Substance Abuse Inpatient and Residential Treatment Outpatient Counseling Surgery (inpatient, outpatient, doctor s office & other) TMJ TIER 1 (In-Network) First 6 visits of plan year with an EAP/Impact or Anthem Network Provider 100% reimbursement After 6 visits - $20 co-pay TIER 2 (Out- of-network) Non Anthem Network Provider Transplants (Transplant program is available) No specific maximums Urgent Care Facility $20 co-pay 70% reimbursement Vision Screening Anthem Blue Cross & Blue Shield Preventive Benefits Vision Administered by Vision Service Plan- VSP Classified Staff Faculty & Administrators L O N G T E R M D I S A B I L I T Y Preventive Vision Screening -100% reimbursement Preventive Vision Screening 70% reimbursement Vision is currently administered by Vision Service Plan (VSP). The administrator is subject to change. VSP pays for 1 exam, lenses or contact lenses, and frames every months for adults and 12 months for a dependent child. The reimbursement level for benefits depends on VSP s agreement with the provider. Call VSP directly at for further details. Exam: plan pays $25 for an exam every 12 months The plan pays for one of the following every months for adults and every 12 months for children: Single Vision Lenses.$45 Frames....$25 Bifocals. $55 Contact Lenses... $45 Trifocals... $75 Medically Necessary Contact Lenses...$150 VSP providers offer a 20% discount, contact directly at: Long-term disability insurance is provided for the employee and is available if an employee becomes totally disabled due to injury or disease. The benefit provides income equal to 60% of the employee s monthly earnings to a maximum of $6,000 per month, minus other income benefits such as Social Security or those provided by the State Teachers Retirement System or Ohio s Public Employees Retirement System. A D D I T I O N A L P R E M I U M S (if applicable, based on dependent eligibility: Spouse/Domestic Partner* Premium Employee's choosing to enroll their spouse or domestic partner in a health insurance plan are charged an additional $50 monthly premium if the spouse/partner is employed and not enrolled in his/her employer's health plan. If your spouse/partner is also employed by Ohio University, the additional premium will not apply. Extended Dependent Premium Additional premium charged for any Unmarried, Full Time Student dependents age to 28. Medical and Prescription Coverage ONLY available. Adult Child Premium Additional premium charged for any Non Full Time Student dependents age to 28. Medical and Prescription Coverage ONLY available. $33.33 $25.00 $23.08 $33.33 $25.00 $23.08 $ $ $ *Medical and dental benefits for a domestic partner are not eligible for the pre-tax deduction from the employee's wages. Additional expenses or taxable wages may be incurred. Refer to Ohio University Policy : Domestic Partner Benefits for more information. 4

5 P P O MEDICAL PLAN RAT ES Effective July 1, 2014 June 30, 2015 Salary Bracket B1 $0 $35,300 Employee Only $43.63 $32.72 $30.20 Employee plus One $87.25 $65.44 $60.41 Employee & Family $ $98.16 $90.61 B2 $35,301 $41,200 Employee Only $47.87 $35.90 $33.14 Employee plus One $95.75 $71.81 $66.28 Employee & Family $ $ $99.42 B3 $41,201 $46,400 Employee Only $52.11 $39.09 $36.08 Employee plus One $ $78.17 $72.15 Employee & Family $ $ $ B4 $46,401 $53,000 Employee Only $56.35 $42.27 $39.01 Employee plus One $ $84.53 $78.03 Employee & Family $ $1.79 $ B5 $53,001 $60,500 Employee Only $60.59 $45.45 $41.95 Employee plus One $ $90.89 $83.90 Employee & Family $1.78 $ $ B6 $60,501 $68,400 Employee Only $64.83 $48.63 $44.88 Employee plus One $ $97.25 $89.77 Employee & Family $ $ $ B7 $68,401 $79,900 Employee Only $69.07 $51.81 $47.82 Employee plus One $ $ $95.64 Employee & Family $ $ $ B8 $79,901 $98,200 Employee Only $73.32 $54.99 $50.76 Employee plus One $ $ $ Employee & Family $ $ $ B9 $98,201 + Employee Only $77.56 $58.17 $53.70 Employee plus One $ $ $ Employee & Family $ $ $ P P O MEDICAL PLAN RAT ES- Part-Time Classified (Hourly) Employees Benefit rates for part-time classified employees are based on the hours worked per pay period. Rates will be deducted each pay period and are based on the B1 salary bracket: 0-$35,300 Hours Worked per pay period Employee Only $ $ $70.38 $30.20 Employee plus One $ $ $ $60.41 Employee & Family $ $ $ $

6 D ENTAL COVERAGE Employee Dental (Free for full-time employees) Dependent Dental (Optional employee paid benefit) $25 deductible -80% Reimbursement up to a $750 plan year maximum Benefit per covered person: $25 deductible -80% Reimbursement up to a $750 plan year maximum D E N T A L R A T E S Effective July 1, 2014 June 30, 2015 Part-Time Classified (Hourly) Employees Part-time employees are eligible to purchase dental coverage for themselves and their dependents. However, employee dental must be purchased in order to cover dependents. ORTHODONTIA COV ERAGE (optional employee paid benefit) O R T H O D O N T I A R A T E S (Includes Dental Coverage) Effective July 1, 2014 June 30, 2015 Part-Time Classified (Hourly) Employees Part-time employees are eligible to purchase dental coverage for themselves and their dependents. However, employee dental must be purchased in order to cover dependents. Employee Only $0.00 $0.00 $0.00 Employee plus One $16.00 $12.00 $11.08 Employee & Family $30.00 $22.50 $20.77 Hours Worked per pay period Employee Only $10.15 $8.12 $6.09 $0.00 Employee plus One $30.92 $.74 $.55 $10.62 Employee & Family $41.08 $32.86 $.65 $20.77 Benefit per covered person: -50% Reimbursement up to a $1,000 lifetime maximum Employee Only $1.33 $1.00 $0.92 Employee plus One $.62 $14.00 $12.92 Employee & Family $34.00 $25.50 $23.54 Hours Worked per pay period Employee Only $11.08 $8.86 $6.65 $.92 Employee plus One $33.69 $.95 $20.22 $12.46 Employee & Family $44.77 $35.82 $.86 $23.54 Rev. 09/2014

7 LIFE INSURANCE COVERAGE Basic Life Insurance* 2.5 times annual pay to a maximum of $50,000 is provided free of charge for full-time employees Supplemental Life Insurance* Dependent Life Insurance** Employees may also purchase up to $500,000 of additional life insurance for themselves Employees may also purchase up to $20,000 of life insurance for their dependents *Accelerated life insurance, which allows employees to access up to one-half of their life insurance if they are deemed to be terminally ill, is included in the life insurance plans. ** Dependent Life coverage limited to age 23 for full-time students. LIFE INSURANCE RATES Effective July 1, 2014 June 30, 2015 B A S I C Part-Time Classified (Hourly) Employees Part-time employees must purchase Basic Life Insurance to be eligible to purchase supplemental and/or dependent life. S U P P L E M E N T A L (Rate quoted is per $10,000 unit) $0.00 $0.00 $0.00 Hours Worked per pay period $ 5.36 $ 4.02 $ 2.68 $ 1.34 AGE Under D E P E N D E N T ** **Dependent Life coverage limited to age 23 for full-time students. COVERAGE Spouse $5,000 Child $2,000** Option B Spouse 10,000 Child $5,000** Option A Spouse $20,000 Child $10,000** Option C Rev. 09/2014

8 Medical Dental Pre-cert Nurseline ( Hours) ( Hours) Rev. 6/ Rev. 09/2014

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