Region 3 – 2017 Active Health Rates

Monthly Premiums

Plan Option*EmployeeFamilyEmployee + SpouseEmployee + Child(ren)
Plan 1$673$2220$1346$1143
Plan 2$606$1998$1211$1029
Plan 3$478$1576$956$812
Plan 3 (with HRA)$507$1671$1013$861
Plan 4$464$1529$926$787
Plan 4 (with HRA)$492$1621$982$834
* To determine the deductible amounts, out-of-pocket maximums, and coinsurance percentages for each plan option, please consult the detailed chart below.

Rates effective for rate region 3.

PlanPlan 1Plan 2* Plan 3Plan 4
Medical Deductible
Individual
$500$1000$2600$3500
Medical Deductible
Family
$1000$2000$5200$7000
Member Cost Share (Co-Insurance) for Covered Medical Expenses After Deductible10% In-Network
30% Non-Network
15% In-Network
30% Non-Network
20% In-Network
30% Non-Network
20% In-Network
50% Non-Network
Medical Out-of-Pocket Maximum
Individual
$1500$3000$5100$6000
Medical Out-of-Pocket Maximum
Family
$3000$6000$10200$12000
Rx Out-of-Pocket Maximum
Individual
$1000$1000Applied to Medical Deductible; then Plan pays 100%$500
Rx Out-of-Pocket Maximum
Family
$2000$2000Applied to Medical Deductible; then Plan pays 100%$1000
Total Plan Out-of-Pocket Maximum
Individual
$2500$4000$5100$6500
Total Plan Out-of-Pocket Maximum
Family
$5000$8000$10200$13000

* Please note: Plan 3 is a Health Savings Account (HSA)-compliant High Deductible Health Plan (HDHP). Benefits and coverage under Plan 3 may be different from other plan options. Please consult the Plan 3 Sumary Plan Description for additional details or contact the Benefit Plans Office.