Fully-Funded Plans
What do Fully-Funded Plans offer?
Fully-funded major medical plans are a type of employer-sponsored health plan where the company pays a premium to an insurance carrier
These plans offer financial protection to employers by transferring the risk of high medical costs to the insurance carrier
They provide a predictable cost structure for the employer
Monthly Rates (Cigna)
EE (PHCS / Cigna)
EE SP (PHCS / Cigna)
EE CH (PHCS / Cigna)
Family (PHCS / Cigna)
$3500 Copay
$749.90 / $799.90
$1,415.49 / $1,465.49
$1,379.88 / $1,429.88
$2,071.67 / $2,121.67
$4500 Copay
$649.80 / $699.80
$1,339.23 / $1,389.23
$1,213.73 / $1,263.73
$1,796.94 / $1,846.94
3500 HSA
$607.10 / $657.10
$1,252.62 / $1,302.62
$1,125.60 / $1,175.60
$1,759.61 / $1,809.61
8300 HSA
$499.01 / $549.01
$859.47 / $909.47
$969.62 / $1,019.62
$1,214.63 / $1,264.63
Medical Plan Benefit Coverage (Cigna)
(INSURANCE PAYS 100% OF NETWORK ALLOWABLE MINUS MEMBERS COPAY/COINSURANCE/OOP)
Annual Deductible
Individual (In/Out)*
Family (In/Out)
Individual (In/Out)*
Family (In/Out)
Annual Deductible
Individual (In/Out)*
Family (In/Out)
Individual (In/Out)*
Family (In/Out)
$3500 COPAY
BUY-UP #3 PLAN BENEFITS
BUY-UP #3 PLAN BENEFITS
$3,500 / $7,500
$7,000 / $15,000
$4500 COPAY
BUY-UP #2 PLAN BENEFITS
BUY-UP #2 PLAN BENEFITS
$4,500 / $8,500
$9,000 / $17,000
3500 HSA
BUY-UP #1 PLAN BENEFITS
BUY-UP #1 PLAN BENEFITS
$3,500 / $7,500
$7,000 / $15,000
8300 HSA (COMES WITH $25MO ON HSA CARD!)
BASE PLAN BENEFITS
BASE PLAN BENEFITS
$8,300 / $18,900
$16,600 / $37,800
Out-of-Pocket Maximum
Individual (In/Out)
Family (In/Out)
Individual (In/Out)
Family (In/Out)
Out-of-Pocket Maximum
Individual (In/Out)
Family (In/Out)
Individual (In/Out)
Family (In/Out)
$7,350 / $17,500
$14,700 / $35,000
$8,150 / $20,000
$16,300 / $40,000
$7,000 / $17,500
$14,000 / $35,000
$9,450 / $24,000
$18,900 / $48,000
Co-Insurance: Member Pays (In/Out)
Physician Services - Preventative Schedule of Benefits
Telemedicine
Office Services - Value Choice DCP/PCPOffice Services - Value Choice DCP/Specialist
Office Services - Family Physician
Office Services - Specialist
Telemedicine
Office Services - Value Choice DCP/PCPOffice Services - Value Choice DCP/Specialist
Office Services - Family Physician
Office Services - Specialist
Physician Services - Preventative Schedule of Benefits
Telemedicine
Office Services - Value Choice DCP/PCPOffice Services - Value Choice DCP/Specialist
Office Services - Family Physician
Office Services - Specialist
Telemedicine
Office Services - Value Choice DCP/PCPOffice Services - Value Choice DCP/Specialist
Office Services - Family Physician
Office Services - Specialist
Physician Services - Preventative Schedule of Benefits
Telemedicine
Office Services - Value Choice DCP/PCPOffice Services - Value Choice DCP/Specialist
Office Services - Family Physician
Office Services - Specialist
Telemedicine
Office Services - Value Choice DCP/PCPOffice Services - Value Choice DCP/Specialist
Office Services - Family Physician
Office Services - Specialist
Physician Services - Preventative Schedule of Benefits
Telemedicine
Office Services - Value Choice DCP/PCPOffice Services - Value Choice DCP/Specialist
Office Services - Family Physician
Office Services - Specialist
Telemedicine
Office Services - Value Choice DCP/PCPOffice Services - Value Choice DCP/Specialist
Office Services - Family Physician
Office Services - Specialist
Physician Services - Preventative Schedule of Benefits
Telemedicine
Office Services - Value Choice DCP/PCPOffice Services - Value Choice DCP/Specialist
Office Services - Family Physician
Office Services - Specialist
Telemedicine
Office Services - Value Choice DCP/PCPOffice Services - Value Choice DCP/Specialist
Office Services - Family Physician
Office Services - Specialist
20% / 50%
$0 Copay
$0 Copay
$20 Copay
$40 Copay
$75 Copay
30% / 50%
$0 Copay
$0 Copay
$20 Copay
$40 Copay
$75 Copay
30% / 50%
$0 Copay
$0 Copay
$20 Copay
Deductible + 30%
Deductible + 30%
0% / 50%
$0 Copay
$0 Copay
$0 Copay
Deductible + 0%
Deductible + 0%
Inpatient Hospital Services
Outpatient Surgery
Emergency Room
Urgent Care
Labs & X-Rays (Quest Diagnostics/Lab Corp)
Advanced Imaging
Pharmacy Drugs
Deductible
Generic Drugs
Preferred Brand Drugs
Non-preferred Retail / Specialty Drugs
Deductible
Generic Drugs
Preferred Brand Drugs
Non-preferred Retail / Specialty Drugs
Pharmacy Drugs
Deductible
Generic Drugs
Preferred Brand Drugs
Non-preferred Retail / Specialty Drugs
Deductible
Generic Drugs
Preferred Brand Drugs
Non-preferred Retail / Specialty Drugs
Pharmacy Drugs
Deductible
Generic Drugs
Preferred Brand Drugs
Non-preferred Retail / Specialty Drugs
Deductible
Generic Drugs
Preferred Brand Drugs
Non-preferred Retail / Specialty Drugs
Pharmacy Drugs
Deductible
Generic Drugs
Preferred Brand Drugs
Non-preferred Retail / Specialty Drugs
Deductible
Generic Drugs
Preferred Brand Drugs
Non-preferred Retail / Specialty Drugs
Deductible + 20%
Deductible + 20%
Deductible + 20%
$90 Copay
100% of covered charges up to $500
$300 Copay
N/A
$20
$65
$95 / $200
Deductible + 30%
Deductible + 30%
Deductible + 30%
$90 Copay
100% of covered charges up to $500
$300 Copay
N/A
$20
$65
$95 / $200
Deductible + 30%
Deductible + 30%
Deductible + 30%
Deductible + 30%
Deductible + 30%
Deductible + 30%
In-Network Deductible
Deductible + 30%
Deductible + 30%
Deductible + 30%
Deductible + 0%
Deductible + 0%
Deductible + 0%
Deductible + 0%
100% of covered charges up to $500 performed in DPC Office*
$200 Copay from DPC Referral
All prescriptions up to $200 covered, above $200 not covered.
$20
$65
$95 / $200
Monthly Rates (Anthem)
EE (PHCS / Anthem)
EE SP (PHCS / Anthem)
EE CH (PHCS / Anthem)
Family (PHCS / Anthem)
VL $1000/$2000 Deductible Plan
$374.00 / $459.00
$679.00 / $779.00
$669.00 / $769.00
$959.00 / $1,079.00
Medical Plan Benefit Coverage (Anthem)
| In-Network Provider: The provider network is shown on your I.D. card. | ||
|---|---|---|
| Maximum Annual Benefit | See Services Performed | |
| Deductible (The amount the Covered Person pays each benefit year for Covered Services before the Coinsurance is payable.) |
Individual Family |
$1,000 $2,000 |
| Out-of-Pocket Maximum (For member accumulated deductible and copays) |
Individual Family |
$9,200 $18,400 |
| Out of Pocket – Maximum for services beyond the plan visit limits | Unlimited | |
| Copays: Please note that after your deductible has been met, you will still be responsible for paying copayments for your medical services. | ||
|
Other Covered Services (Limitations may apply. This isn't a complete list. Please see your plan document.) |
||
|
- Annual Lab/X-Ray Tests - Annual Pap Smear/Mammogram - Cancer Screenings - Colonoscopies - Diabetic Supply - Immunizations - Other Preventative Screenings - Precision Rx (Prescriptions) - Telemedicine - Urgent Care and Office Visits - Well Baby Care - Wellness Visits |
||
| Services Your Plan Generally Does NOT Cover | ||
|
- Acupuncture - Children’s Dental Check-Up - Children’s Glasses - Children’s Eye Exam - Dialysis - Biofeedback Organ - Transplant Services |
||
| Services may require preauthorization. Failure to obtain preauthorization will result in denial of benefits. | ||
|
Precertification: Required for all in-hospital admissions, imaging (CT/PET/MRI/MRA), home health, skilled nursing, hospice, DME (over $500), chemo/radiation, sleep studies, prosthetics/orthotics, therapies (chiropractic, cardiac, PT/OT/ST), and outpatient surgery. Emergencies are covered but do require authorization/certification within 48 hours. |
||
| This illustration describes the plan in an easily understood manner and is presented as a matter of general information only. | ||
| The contents are not to be accepted or construed as a substitute for the provisions of the plan document or summary plan description, which contains more exact terms and detailed provisions of the plan, and it is not to be considered a policy of insurance. | ||
| Service | Description | Cost |
|---|---|---|
| Physician Office Services |
10 visits/year combined for PCP, Specialist, and Urgent Care; 12/year for Chiropractic. - Primary Care Physician - Specialist Office Visit - Urgent Care Visit - Spinal Manipulation Chiropractic - Surgery Performed in Office |
$50 Copay After Deductible |
| Telemedicine via OurLiveDoc ONLY Call: 940-LIVE-DOC (940-548-3362) |
$0 Copay | |
| Emergency Services |
- ER: 2 visits/year for accidents and sickness - Emergency Transportation (Ground/Air): 2/year *Any provider may be used for true emergencies |
$250 Copay After Deductible |
| Diagnostic Testing/Imaging | 3 per benefit year (Precertification Required) | $200 Copay After Deductible |
| Labs | 3 per Benefit Plan Year | $25 Copay |
| X-rays | 3 per Benefit Plan Year | $50 Copay |
| Outpatient Facility Services |
- Infusions/Injections: 10 visits/year (combined) - Surgical Services: 3 surgeries/year (includes surgeon, anesthesia, etc.) - Chemotherapy/Radiotherapy: 10 visits/year (combined) - Dialysis |
$100 Copay/Visit After Deductible $250 Copay/Service After Deductible $100 Copay/Visit After Deductible Not Covered |
| Inpatient Services |
Limit: 2 ICU and 2 Non-ICU hospitalizations/year 5-day limit per ICU/Non-ICU stay Includes anesthesia, pathology, physician, and incidental services |
$1,000 Copay/Admission After Deductible $250 Copay/Service After Deductible |
| Inpatient Hospital Surgical Services | 2 surgeries per plan year | $1,000 Copay/Surgery After Deductible |
| Inpatient Rehabilitation Facility | 10-day limit per benefit year | $50 Copay/Day After Deductible |
| Preventive Services |
- Annual Physical - Adult Immunizations (Flu, Pneumonia, Tetanus/Diphtheria) - Mammogram - Gynecological Services - Colonoscopy - Well Child/Newborn Care |
$0 Copay |
| Therapy |
16 visits/year (combined): - Physical & Occupational Therapy - Speech Therapy - Cardiac Rehabilitation |
$50 Copay After Deductible |
| Pregnancy/Maternity |
- Routine Vaginal Delivery - Routine C-section Delivery - Other Maternity Services (includes prenatal, postnatal, labs, etc. — excludes genetic testing unless medically necessary) |
$250 Copay After Deductible $500 Copay After Deductible 100% Covered |
| Home Health Care | 10-day limit per benefit year (Precertification Required) | $50 Copay After Deductible |
| Hospice Care | 30-day limit per lifetime | $0 Copay After Deductible |
| Inpatient Skilled Nursing Facility | 10-day limit per benefit year (Precertification Required) | $50 Copay/Day After Deductible |
| Durable Medical Equipment (DME) | 5 items/benefit period (Precertification Required) | $50 Copay/Item After Deductible |
| Prosthetics | 1 item per benefit year (Precertification Required) | $50 Copay/Item After Deductible |
| Organ Transplant | Not Covered | Not Covered |
| Diabetic Nutritional Counseling | 1 visit per benefit year | $0 Copay After Deductible |
| Allergies |
- Shots: 24 visits/year - Visits/Testing: 2 visits/year |
$25 Copay After Deductible $50 Copay After Deductible |
| Prescription Drugs | ||
|
Retail Pharmacy Copayments 30-day supply at retail pharmacies. Mail order required for maintenance meds after 30-day supply. |
Generic Maintenance Rx |
$0 Copay |
| Generic Urgently Needed Care Rx |
$0 Copay | |
| Preferred Brand Name Drugs | Patient Assistance Plans Available | |
| Non-Preferred Brand Name Drugs | Patient Assistance Plans Available | |
| Mail Order or Retail Pharmacy Copayments 90-day supply |
Generic | $0 Copay |
| Preferred Brand Name Drugs | Patient Assistance Plans Available | |
| Non-Preferred Brand Name Drugs | Patient Assistance Plans Available | |
Lets Discover what your options are for a Fully-Funded Plan Today!
Contact Gesla Insurance Agency now to speak with our expert advisors and find the perfect coverage for your needs.