Health Benefits

	$800 DEDUCTIBLE PLAN	$1,500 DEDUCTIBLE PLAN	$2,500 DEDUCTIBLE PLAN	$4,500 DEDUCTIBLE PLAN	$6,550 DEDUCTIBLE PLAN
HSA Eligible	No	Yes	Yes	No	Yes
HSA Company Funding (per pay period)	No	Up to an annual maximum of $150 single; $300 employee plus dependent	Up to an annual maximum of $150 single; $300 employee plus dependent	No	No
Preventive Healthcare Visit	Covered at 100% in-network
In-Network
Individual/Family Deductible1	$800/$1,600	$1,500/$3,000	$2,500/$5,000	$4,500/$9,000	$6,550/$13,100
Individual/Family Out-of-Pocket Max	$3,800/$7,600	$5,200/$6,850	$6,200/$6,850	$6,550/$13,100	$6,550/$13,100
Plan Coinsurance	80% after deductible	80% after deductible	70% after deductible	70% after deductible	100% after deductible
Office Visit (Primary Care/Specialist)	80% after deductible	80% after deductible	70% after deductible	70% after deductible	100% after deductible
Retail Prescriptions - Short-term drugs and maintenance drugs up to first two fills4 (up to 30-day supply)
Generic	70% (min $10, max $20)2	80% after deductible3	70% after deductible3	70%2	100% after deductible3
Preferred Brand5	70% (min $25, max $50)2	80% after deductible3	70% after deductible3	70%2	100% after deductible3
Non-Preferred Brand5	55% (min $40, max $80)2	60% after deductible3	50% after deductible3	50%2	100% after deductible3
Mail Order Prescriptions (up to 90-day supply)
Generic	70% (min $25, max $50)2	80% after deductible3	70% after deductible3	70%2	100% after deductible3
Preferred Brand5	70% (min $62.50, max $125)2	80% after deductible3	70% after deductible3	70%2	100% after deductible3
Non-Preferred5 Brand	55% (min $100, max $200)2	60% after deductible3	50% after deductible3	50%2	100% after deductible3
Specialty Drugs (up to a 30-day supply)	Subject to applicable prescription coinsurance

¹$1,500 and $2,500 Deductible Plans—Family unit must meet family healthcare deductible before coinsurance is available. $800, $4,500, and $6,550 Deductible Plans—Each member must meet individual healthcare deductible, subject to the family maximum, before coinsurance is available

² Healthcare deductible does not apply.

³ Healthcare deductible waived for preventive medications. Under the $6,550 Deductible Plan, coinsurance of 70% generic, 70% preferred brand and 50% non-preferred brand applies to preventive medications.

⁴Maintenance drugs after two fills—plan pays 0%

⁵You will pay the difference between the brand and generic (does not count toward deductible)

The benefits in all healthcare plan options in the state of Massachusetts meet the state's creditable coverage health insurance coverage standards in effect as of September 1, 2015.