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City of New Brighton Health Insurance Plan Options- <br /> City Councilmembers <br /> Effective 1-1-2012 <br /> This is a general plan comparison only. <br /> For exact terms and conditions of your insurance coverage, please contact Health Partners. <br /> at 952-883-5000 or 1-800-883-2177 <br /> 100%Plan - $40 Co-Pay Plan <br /> Health Partners Health Partners <br /> Benefit Open Access Choice Open Access Choice <br /> Lifetime Maximum In-Network: Unlimited In-Network: Unlimited <br /> Out-of-Network:$1 Million Out-of-Network:$1 Million <br /> In-Network Belefits <br /> Calendar year Plan deductible None-hi Network None-in Network <br /> Annual medical out-of-pocket $2,500 Per Person $2,500 Per Person <br /> Maximum $4,000 Per Family $4,000 Per Family <br /> Annual pharmacy out-of- $500 Per Person $500 Per Person <br /> Pocket maximum _ $1000 Per Family _ $1000 Per Family <br /> Preventive health care 100%Coverage _ _ l00%Coverage <br /> Office visits _ 100%Coverage $40 Co-Pay _ <br /> Hospital—Inpatient care 100%Coverage 80%Coverage —- <br /> Hospital—Outpatient care 100%Coverage __ - 80%Coverage <br /> Urgent care _ 100%Coverage _ $40 Co-Pay <br /> Emergency Care&Ambulance $40 Co-Pay S75 Co-Pay <br /> Prescription drugs 80%Co-Insurance;$10 min/$25 80%Co-Insurance;$10 min/$25 <br /> Maximum Formulary Drugs Maximum Formulary Drugs <br /> Out-of-Network Benefits _ <br /> Calendar year deductible-Out of $300 Per Person $300 Per Person <br /> Network _ $900 Per Family $900 Per Family <br /> Annual medical out-of-pocket $2,500 Per Person $2,500 Per Person <br /> Maximum $4,000 Per Family $4,000 Per Family_ <br /> Annual pharmacy out-of- $500 Per Person $500 Per Person <br /> Pocket maximum $1-000 Per Family $1,000 Per Family <br /> Coinsurance 80%Coverage After Deductible 80%Coverage After Deductible <br /> Utilization of an Out of Network 80%Coverage After deductible 80%Coverage After Deductible <br /> Provider <br /> 2012 Employee Premium Share Single:($0.00) Single:($0.00) <br /> (Monthly Cost) Single+1:$830.00 Single+1:$631.12 <br /> Family:$1.037.68 Family:$790.80 <br /> H:1Assistant to the City ManagerlCity Council12012 Retreat Follow-up Itemsl2012 Council Health Insurance info\Benefits Sheet <br /> 2012-City Councilmembers.doc <br /> Updated 9/18/2007 <br />