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MEDICAL PLAN COMPARISON CHART 2013-2014
MMO Traditional
PPO Network
Tier 2
MMO Traditional
Out-of-Network
Tier 3
MMO Value
PPO Network
Tier 2
MMO Value
Out-of-Network
Tier 3
CSU Health and Wellness
Services
Tier 1
MetroHealth Select
EPO Network
Kaiser
HMO Network
Employee Pre-Tax Payroll
Contributions1
• Full-Time
Faculty/Staff
Single $111.60 / mo.
Family $290.04 / mo.
Single $70.99 / mo.
Family $184.64 / mo.
• Part-Time Staff
30-39 Hours
Single $139.50 / mo.
Family $362.55 / mo.
Single $118.32 / mo.
Family $307.74 / mo.
1
If you are enrolled in MMO
or MetroHealth plans, you
can receive certain health
services at no cost at
CSU Health and Wellness
Services as decribed
below.
Single $21.64 / mo.
Family $56.42 / mo.
Single $70.45 / mo.
Family $188.33 / mo.
Single $108.21 / mo.
Family $282.09 / mo.
Single $117.42 / mo.
Family $313.88 / mo.
Note: IRS rules require that the value of any benefits provided to a same-sex domestic partner is taxable to the employee
Benefit Period
Calendar Year
Annual Deductible
(Calendar Year)
$250 Single /
$500 Family
(Covered preventive care
services NOT subject to
deductible)
$750 Single /
$1,500 Family
$750 Single /
$1,500 Family
(Covered preventive care
services NOT subject to
deductible)
$1,500 Single /
$3,000 Family
None
None
None
Maximum Annual
Co-Insurance Limit
$750 Single /
$1,500 Family
(Does not include copayments or deductibles)
$2,250 Single /
$4,500 Family
(Does not include copayments or deductibles)
$2,250 Single /
$4,500 Family
(Does not include copayments or deductibles)
$4,500 Single/
$9,000 Family
(Does not include copayments or deductibles)
None
N/A
$1,000 Single /
$2,000 Family
Benefit Period Maximum
$2,500,000
$2,500,000
$2,500,000
$2,500,000
Physician Office Visit
Co-Payment
90% after $20
co-payment
70% UCR after deductible
80% after $30
co-payment
60% UCR after deductible
None
100% after $10
co-payment
90% after $25
co-payment
Vike
Inpatient Medical &
100%
70% UCR2
100%
60% UCR2
Limited Services 100%
100%
100%
90% after deductible
70% UCR2 after deductible
80% after deductible
60% UCR2 after deductible
Services not available
100%
90%
Outpatient Hospital Medical 90% after deductible
Get Well.
Stay Well./ Live Well.
& Surgical
Services
Laboratory & Diagnostic Tests
70% UCR2 after deductible
80% after deductible
60% UCR2 after deductible
Covered at 100% Limited
Laboratory & Diagnostic
services
Outpatient Hospital Medical &
Surgical services not available
100%
90%
Urgent Care Services
90% after $35
co-payment
70% UCR2 after deductible
80% after $50
co-payment
60% UCR2 after deductible
Limited Services 100%
100% after $10
co-payment
90% after $35
co-payment
Emergency Room Use
Co-Payment/Co-Insurance
for Emergency Services
90% after $100
co-payment
90% UCR2 after $100
co-payment
80% after $150
co-payment
80% UCR2 after $150
co-payment
Services not available
100% after $75
co-payment
90% after $100
co-payment
Emergency Room Use CoPayment/Co-Insurance for
Non-Emergency Services
90% after $100
co-payment
70% UCR2 after deductible
80% after $150
co-payment
60% UCR2 after deductible
Services not available
100% after $75
co-payment
n/a
Preventive Services
Health
Well-Being
Surgical Hospital Services
&
2
$2,500,000
2
2
MO out-of-network reimbursements are subject to allowable charges. Pre-authorization (by MMO) may be required for some services (e.g. surgical procedures, diagnostic tests, MRI, and scans) for which
M
you are financially responsible. Refer to your plan certificate for details.
Information contained in this chart is in summary format. If discrepancies occur, plan documents and certificates prevail.
PRESCRIPTION DRUG PLAN
COMPARISON CHART 2013 - 2014
MMO Traditional PPO
Medco Network
Pharmacy
Tier 2
Non-Maintenance Retail Pharmacy
Prescription Drugs
30-day Supply
• Mandatory Generic
Rx dispensed
• Mandatory Mail Order co-payment after
three fills for maintenance medications
Pharmacy
Mail Order
(90-day supply)
MMO
Traditional
Out-of-Network
Tier 3
Generic $5
75% UCR3
Brand:
formulary $20
Claim form required
for reimbursement
Brand:
Non-formulary $40
MMO Value
PPO
Medco Network
Pharmacy
Tier 2
Generic Brand:
formulary
$10
MMO Value
Out-of-Network
Tier 3
75% UCR3
Claim form required
for reimbursement
CSU Health
and Wellness
Services
Tier 1
Generic $20
Brand:
formulary $40
Brand:
formulary $60
Brand:
Non-formulary $80
(90-day supply)
N/A
Brand:
Non-formulary $120
(90-day supply)
Metro1 MM02
Generic $10
Limited prescriptions
available
Generic
$0
$10
Brand $25
Brand:
formulary
$15
$30
Brand:
Non-formulary $30
$60
$10
Service not available
Metro1 MM02
Generic Generic
$10
$20
Brand $25
62-day supply
Brand:
formulary
$30
$60
N/A
Brand:
Non-formulary $60
(90-day supply)
1
MetroHealth pharmacy locations only.
2
MMO/Medco network pharmacies (non-Metro Pharmacy)
3
MMO out-of-network reimbursements are subject to allowable charges. Refer to your plan certificate for details.
HMO Network
Pharmacy
Brand:
Non-formulary $60
$10
Kaiser
Generally $5
$30
Generic MetroHealth Select
EPO Network
(Administered
by MMO)2
$120
Information contained in this chart is in summary format. If discrepancies occur, plan documents and certificates prevail.
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