PEKIN

 

Click here to print application.  Application need to be submitted to the HR/Safety Office by December 1

 

SHARED DEDUCTIBLE (IN NETWORK)

 

Deductible

                                                                                                                        $5,000,000

$2,500

 

$1,100             Employee ($550 deposited into HSA annually*)                  ALL PEKIN

$280                Employee (20%)

$1,120             City of Brazil (80%)

 

 

Physician/Specialist Copay

NO COPAYS

all expenses apply to deducible

Emergency Room Copay

Urgent Care Copay

MRI, CT, PET Copay

 

Individual Deductible (2X Family)

$2,500

Coinsurance Percent

100% after the $2,500 deductible

Individual Out of Pocket Maximum (2X Family)

$830

 

Prescription Drug

NO COPAYS

all expenses apply to deducible

 

 

*Employees may contribute up to $550 ($21.15 per pay) (or 2X Family) annually pre-tax into their Health Savings Account.

 

**Plan includes $250/year/member for wellness.

 

SCENARIO

 

Medical Expense:  $3,000

 

Responsible Party

Amount

Employee (from HSA)

$550

Employee

550

Employee (20%)

$280

City of Brazil

$1,120

Pekin

$500

 


 

RATES (EMPLOYEE SHARE PER PAY)*

 

 

Employee Share

Employee Only (41):

-0-

Employee & Spouse (12):

$25.36

Employee & Children (3):

$24.20

Employee & Family (15):

$36.11

 

*These rates are estimated and subject to underwriting by Pekin.