| HR Benefits - Medical Coverage |  |
Medical Insurance Plan:
Pinal County Community College District Employee Benefit Trust
Medical Plan Document - Effective July 1, 2010
Claims Payer:
Administrative Enterprises, Inc.
Coverage begins:
First of the month following first day of full-time employment.
Employees will receive ID cards within a few weeks of initial date of employment.
Note: The Open Enrollment period is the month of May with an effective date of July 1st. A qualifying event must occur in order for changes to be made at any time other than the open enrollment period.
There is no monthly premium paid for Employee Only medical coverage. Contribution rates for dependent medical coverage are as follows:
| Employee Monthly Contribution Medical Coverage | |
| Employee Only | $0.00 |
| Employee + Spouse | $92.09 |
| Employee + Children | $71.54 |
| Employee + Family | $114.19 |
| Doctor Visit Co-Pays: | [In-Network, Blue Cross/Blue Shield PPO] - $15 per visit [Out-of-Network] - Subject to out-of-network deductible, coinsurance and annual out-of-pocket maximum |
| Major Medical Benefits: | [In-Network, Blue Cross/Blue Shield PPO] - $100 Deductible Per Person, 80% Coinsurance, Annual out-of-pocket maximum of $1,000 [Out-of-Network] - $250 Deductible Per Person (will not cross accumulate), 60% Coinsurance, Annual out-of-pocket maximum of $2,500 (will not cross accumulate) |
Annual Deductible: The annual deductible is $100 per person per calendar year for in-network major medical claims. There is an annual deductible of $250 per person per calendar year for out-of-network claims. Anything paid toward a deductible during the last three months of the year (October, November, December) will be carried over to the next calendar year and applied to the next calendar year deductible.
Lifetime Maximum: $1,000,000.00 per participant.
Blue Cross/Blue Shield PPO: The College contracts with Blue Cross/Blue Shield of Arizona in order to utilize their provider network. To determine whether a physician or facility is a Blue Cross provider, refer to the Blue Cross/Blue Shield of Arizona website at www.azblue.com.
Pre-Existing Conditions: The College’s plan has a pre-existing condition waiting period of 12 months for new employees. Other insurance coverage can be credited toward this waiting period. Twelve (12) or more months of continuous previous coverage will waive the pre-existing condition period. If there has been a break in coverage of sixty-three (63) days or more, a participant will be subject to pre-existing conditions.
Wellness Benefit: Employees and their eligible dependents each have $500 per calendar year for well checkup visits. This amount is not subject to a co-pay or a deductible.
Prescription Medication Co-Pays: Retail (up to 30 day supply):
Generic - $7 Co-Pay
Preferred Brand - $25 Co-Pay
Non-Preferred Brand - $40 Co-Pay
Retail (up to 90 day supply):
Generic - $7 Co-Pay
Preferred Brand - $50 Co-Pay
Non-Preferred Brand - $80 Co-Pay
Prescription Benefit Manager: Innoviant, Inc. www.innoviant.com