Medical and Prescription Drug coverage
| Standard POS II Medical Option In-Network | Standard POS II Medical Option Out-of-Network | Core Health Savings Account (HSA) Medical Option In-Network | Core Health Savings Account (HSA) Medical Option Out-of-Network | Standard Health Savings Account (HSA) Medical Option In-Network | Standard Health Savings Account (HSA) Medical Option Out-of-Network | |
|---|---|---|---|---|---|---|
| Preventive Care | 100% | 60% after you meet the annual deductible | 100% | 55% after you meet the annual deductible | 100% | 60% after you meet the annual deductible |
| Annual Deductible |
Employee-only: $800 Family (employee + spouse, employee + child(ren) or family): $1,6001 |
Employee-only: $1,600 Family (employee + spouse, employee + child(ren) or family): $3,2001 |
Employee-only: $3,400 Family (employee + spouse, employee + child(ren) or family): $6,8002 |
Employee-only: $6,800 Family (employee + spouse, employee + child(ren) or family): $13,6002 |
Employee-only: $1,700 Family (employee + spouse, employee + child(ren) or family): $3,4002 |
Employee-only: $3,400 Family (employee + spouse, employee + child(ren) or family): $6,8002 |
| Annual S&P Global Inc. HSA Contribution | N/A |
$750 Employee-only; $1,500 Employee + Spouse, or Employee +
Child(ren), or Family (Pro-rated if employee is hired within the year from the date HSA is elected) |
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| Office Visits | 80% after you meet the annual deductible | 60% after you meet the annual deductible | 75% after you meet the annual deductible | 55% after you meet the annual deductible | 80% after you meet the annual deductible | 60% after you meet the annual deductible |
| Most Other Care | 80% after you meet the annual deductible | 60% after you meet the annual deductible | 75% after you meet the annual deductible | 55% after you meet the annual deductible | 80% after you meet the annual deductible | 60% after you meet the annual deductible |
| Emergency Room Visits | 80% after you meet the annual deductible | 80% after you meet the annual deductible | 75% after you meet the annual deductible | 75% after you meet the annual deductible | 80% after you meet the annual deductible | 80% after you meet the annual deductible |
| Mental Health & Substance Abuse Benefits | 80% after you meet the annual deductible | 60% after you meet the annual deductible | 75% after you meet the annual deductible | 55% after you meet the annual deductible | 80% after you meet the annual deductible | 60% after you meet the annual deductible |
| Out-of-Pocket Maximum |
Employee-only: $1,500 Employee + Spouse or Child(ren): $3,000 Family: $4,500 |
Employee-only: $3,000 Employee + Spouse or Child(ren): $6,000 Family: $9,000 |
Employee-only: $4,400 Employee + Spouse or Child(ren): $8,800 Family: $11,0003 |
Employee-only: $8,800 Employee + Spouse or Child(ren): $17,600 Family: $22,000 |
Employee-only: $2,500 Employee + Spouse or Child(ren): $5,000 Family: $7,500 |
Employee-only: $4,400 Employee + Spouse or Child(ren): $8,800 Family: $13,200 |
| Out-of-Pocket Maximum |
Employee-only: $2,100 Employee + Spouse or Child(ren): $4,200 Family: $6,300 |
Employee-only: $4,200 Employee + Spouse or Child(ren): $8,400 Family: $12,600 |
Employee-only: $4,400 Employee + Spouse or Child(ren): $8,800 Family: $11,0003 |
Employee-only: $8,800 Employee + Spouse or Child(ren): $17,600 Family: $22,000 |
Employee-only: $2,500 Employee + Spouse or Child(ren): $5,000 Family: $7,500 |
Employee-only: $4,400 Employee + Spouse or Child(ren): $8,800 Family: $13,200 |
| Out-of-Pocket Maximum |
Employee-only: $2,900 Employee + Spouse or Child(ren): $5,800 Family: $8,700 |
Employee-only: $5,800 Employee + Spouse or Child(ren): $11,600 Family: $17,400 |
Employee-only: $4,400 Employee + Spouse or Child(ren): $8,800 Family: $11,0003 |
Employee-only: $8,800 Employee + Spouse or Child(ren): $17,600 Family: $22,000 |
Employee-only: $2,500 Employee + Spouse or Child(ren): $5,000 Family: $7,500 |
Employee-only: $4,400 Employee + Spouse or Child(ren): $8,800 Family: $13,200 |
| Out-of-Pocket Maximum |
Employee-only: $4,000 Employee + Spouse or Child(ren): $8,000 Family: $12,000 |
Employee-only: $8,000 Employee + Spouse or Child(ren): $16,000 Family: $24,000 |
Employee-only: $4,400 Employee + Spouse or Child(ren): $8,800 Family: $11,0003 |
Employee-only: $8,800 Employee + Spouse or Child(ren): $17,600 Family: $22,000 |
Employee-only: $2,500 Employee + Spouse or Child(ren): $5,000 Family: $7,500 |
Employee-only: $4,400 Employee + Spouse or Child(ren): $8,800 Family: $13,200 |
| Out-of-Pocket Maximum |
Employee-only: $4,700 Employee + Spouse or Child(ren): $9,400 Family: $14,100 |
Employee-only: $9,400 Employee + Spouse or Child(ren): $18,800 Family: $28,200 |
Employee-only: $4,400 Employee + Spouse or Child(ren): $8,800 Family: $11,0003 |
Employee-only: $8,800 Employee + Spouse or Child(ren): $17,600 Family: $22,000 |
Employee-only: $2,500 Employee + Spouse or Child(ren): $5,000 Family: $7,500 |
Employee-only: $4,400 Employee + Spouse or Child(ren): $8,800 Family: $13,200 |
1Dependents in the family may meet the individual deductible until family deductible is met.
2The Plan does not require that you meet the employee only deductible to satisfy the family deductible. If at least one other person in your family is covered under the Plan, the employee only coverage deductible shown in the above table does not apply; the family deductible will apply and no one in the family will be eligible to receive benefits until the family deductible has been satisfied. Any combination of eligible expenses totaling the family deductible will satisfy the combined family deductible.
3For in-network family coverage, an individual who meets $9,100 in eligible expenses will be considered to have met the out-of-pocket maximum.
2The Plan does not require that you meet the employee only deductible to satisfy the family deductible. If at least one other person in your family is covered under the Plan, the employee only coverage deductible shown in the above table does not apply; the family deductible will apply and no one in the family will be eligible to receive benefits until the family deductible has been satisfied. Any combination of eligible expenses totaling the family deductible will satisfy the combined family deductible.
3For in-network family coverage, an individual who meets $9,100 in eligible expenses will be considered to have met the out-of-pocket maximum.
Prescription Drug coverage
| Standard POS II | Core HSA | Standard HSA | |
|---|---|---|---|
| CVS Health | CVS Health | CVS Health | |
| Prescription Drugs - CVS Health | The following benefits are benefits at a participating pharmacy through CVS Health. If you choose an out-of-network pharmacy, you pay 100%. | ||
| Retail Pharmacy4 - Up to 30-day supply; coverage only available through participating pharmacies |
Generic: You pay 10% up to $50 out-of-pocket maximum
Preferred Brand: You pay 30% up to $75 out-of-pocket maximum Non-Preferred Brand5: You pay 50% up to $100 out-of-pocket maximum |
You pay 100% until you have met the Medical Plan annual deductible, then you
begin to pay:
Generic: You pay 10% coinsurance Preferred Brand: You pay 30% coinsurance Non-Preferred Brand: You pay 50% coinsurance Certain preventive medications are covered at 100% without meeting the Medical Plan annual deductible. |
|
| Mail Order or at a CVS Pharmacy - Up to 90-day supply |
Generic: You pay 10% up to $100 out-of-pocket maximum
Preferred Brand: You pay 30% up to $150 out-of-pocket maximum Non-Preferred Brand5: You pay 50% up to $200 out-of-pocket maximum |
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| Annual Deductible6 | Medical Plan annual deductible does not apply to prescription drugs. | Integrated with Medical Plan annual deductible6 | |
| Annual Out-of-Pocket Maximum | Integrated with Medical Plan out-of-pocket maximum | Integrated with Medical Plan out-of-pocket maximum | |
4 After your third purchase of most long-term medications at a participating retail pharmacy, you will be responsible for the full cost of the prescription. For the Plan to pay benefits for your prescription after your third purchase, you must use Mail Order or a CVS Pharmacy.
5 If you choose a brand-name prescription drug when a generic equivalent is available, you will pay your generic coinsurance plus the difference in cost. The cost difference between the generic coinsurance and the brand-name prescription drug does not count toward the out-of-pocket maximum or per-prescription maximum.
6 Certain preventive medications (as classified by CVS Health) are not subject to the deductible under the HSA Medical Plan options. These include certain contraceptives, blood pressure medications, ulcer medications, and cholesterol lowering drugs.
If you elect coverage under any S&P Global medical option, you automatically receive prescription drug benefits. Prescription drug amounts count toward the out-of-pocket maximum.
Contributions
| Standard POS II Medical Option | Core Health Savings Account (HSA) Medical Option | Standard Health Savings Account (HSA) Medical Option | |
|---|---|---|---|
| Employee Only | $65.88 | $27.81 | $49.71 |
| Employee + spouse | $142.29 | $60.08 | $107.37 |
| Employee + Child(ren) | $131.75 | $55.63 | $99.42 |
| Family | $224.63 | $94.84 | $169.51 |
| Employee Only | $111.03 | $71.28 | $98.65 |
| Employee + spouse | $239.80 | $153.97 | $213.09 |
| Employee + Child(ren) | $222.04 | $142.56 | $197.31 |
| Family | $378.59 | $243.07 | $336.40 |
| Employee Only | $149.89 | $100.49 | $133.32 |
| Employee + spouse | $323.76 | $217.03 | $287.99 |
| Employee + Child(ren) | $299.78 | $200.95 | $266.64 |
| Family | $511.12 | $342.64 | $454.64 |
| Employee Only | $188.01 | $129.26 | $167.58 |
| Employee + spouse | $406.07 | $279.20 | $361.97 |
| Employee + Child(ren) | $375.99 | $258.53 | $335.17 |
| Family | $641.07 | $440.79 | $571.46 |
| Employee Only | $223.50 | $155.73 | $199.52 |
| Employee + spouse | $482.76 | $336.36 | $430.95 |
| Employee + Child(ren) | $447.00 | $311.45 | $399.03 |
| Family | $762.13 | $531.01 | $680.35 |
Please note that contribution amounts presented here are on a monthly basis. The amount of
your payroll contributions will vary based on your pay cycle (i.e., weekly or semi-monthly).
Dental coverage
| Dental PPO1 | Dental DMO | |
|---|---|---|
| Annual Deductible |
Individual: $75 Family: $150 |
No deductible |
| Annual Plan Maximum | $2,000 per covered person | None |
| Preventive Care (including routine exams, cleanings and x-rays) | Plan pays 100% (no deductible) | Plan pays 100% |
| Restorative Services (including fillings, most extractions and root canal therapy (except molars)) | Plan pays 80%, after deductible | Plan pays 100% |
| Major Services (including bridges and dentures) | Plan pays 60%, after deductible | Plan pays 60% |
| Orthodontic Services |
Plan pays 50% (no deductible) Lifetime maximum of $2,000 per eligible member applies |
Plan pays 50% No lifetime maximum Limited to one full treatment plan per eligible member |
1 If you use an in-network provider, your share of the cost, or your
coinsurance, is based on the negotiated, network rate for the service. If you use a provider
who does not participate in the network, your coinsurance is based on the reasonable and
customary (R&C) amount for the service. You are also responsible for any amount over the
R&C amount.
Contributions
| Dental PPO | Dental DMO | |
|---|---|---|
| Employee Only | $23.10 | $12.10 |
| Employee + spouse | $46.20 | $24.20 |
| Employee + Child(ren) | $40.43 | $20.90 |
| Family | $72.19 | $36.30 |
| Employee Only | $23.10 | $12.10 |
| Employee + spouse | $46.20 | $24.20 |
| Employee + Child(ren) | $40.43 | $20.90 |
| Family | $72.19 | $36.30 |
| Employee Only | $23.10 | $12.10 |
| Employee + spouse | $46.20 | $24.20 |
| Employee + Child(ren) | $40.43 | $20.90 |
| Family | $72.19 | $36.30 |
| Employee Only | $23.10 | $12.10 |
| Employee + spouse | $46.20 | $24.20 |
| Employee + Child(ren) | $40.43 | $20.90 |
| Family | $72.19 | $36.30 |
| Employee Only | $23.10 | $12.10 |
| Employee + spouse | $46.20 | $24.20 |
| Employee + Child(ren) | $40.43 | $20.90 |
| Family | $72.19 | $36.30 |
Please note that contribution amounts presented here are on a monthly basis. The amount of
your payroll contributions will vary based on your pay cycle (i.e., weekly or semi-monthly).
Vision coverage
| Vision Service Plan (VSP Provider) | Vision Service Plan (Non-VSP Provider) | |
|---|---|---|
| Exam (Includes tests to determine the need for corrective lenses) | Covered in full once every calendar year | Up to $50 |
| Eyeglass Lenses | Covered in full once every calendar year (includes single vision, bifocal, trifocal or lenticular) |
Single vision lenses up to $50
Bifocal lenses up to $75 Trifocal lenses up to $100 Progressive lenses up to $75 |
| Frames |
Covered up to $150 once every other calendar year. If you choose a frame valued at more than $150, the plan provides a 20% discount on the cost in excess of $150. |
Up to $70 |
| Contact Lenses (in lieu of frames and lenses)1 |
Covered up to $150 once every 12 months. Your allowance applies to the cost of your contacts exam and your contact lenses. You’ll receive 15% savings off the cost of your contact lenses from a VSP network doctor. |
Up to $105 |
1 The plan covers either eyeglasses (frames and lenses) or contact lenses in
lieu of eyeglasses in a single plan year. If you use the Plan to cover contact lenses in
lieu of eyeglasses, you will not be eligible for another benefit for frames for two plan
years.
Contributions
| Vision Service Plan | |
|---|---|
| Employee Only | $9.26 |
| Employee + spouse | $17.58 |
| Employee + Child(ren) | $19.44 |
| Family | $31.46 |
| Employee Only | $9.26 |
| Employee + spouse | $17.58 |
| Employee + Child(ren) | $19.44 |
| Family | $31.46 |
| Employee Only | $9.26 |
| Employee + spouse | $17.58 |
| Employee + Child(ren) | $19.44 |
| Family | $31.46 |
| Employee Only | $9.26 |
| Employee + spouse | $17.58 |
| Employee + Child(ren) | $19.44 |
| Family | $31.46 |
| Employee Only | $9.26 |
| Employee + spouse | $17.58 |
| Employee + Child(ren) | $19.44 |
| Family | $31.46 |
Please note that contribution amounts presented here are on a monthly basis. The amount of
your payroll contributions will vary based on your pay cycle (i.e., weekly or semi-monthly).
Base pay does not include bonus amounts, or any other forms of compensation (i.e., overtime, commissions, etc.).