Medical
Medical coverage provides healthcare protection for you and your family. You can visit any provider, but in-network doctors offer the highest level of benefits and lower out-of-pocket costs by charging reduced, contracted rates. Out-of-network providers set their own fees, so you may be responsible for charges above the Reasonable and Customary (R&C) limits. Preventive care—such as physical exams, flu shots, and screenings—is covered at 100% when you use in-network providers. The main differences between plan options are how much you pay per paycheck and what you pay when you receive care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums – the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Gold PPO
Benefit Highlights
In-Network
Deductible (Individual/Family)
$1,000 / $3,000
Out-of-Pocket Max (Individual/Family)
$3,000 / $9,000
Preventive Care
$0
Primary Care Visit
20% coinsurance (deductible does not apply)
Specialist Visit
20% coinsurance (deductible does not apply)
Urgent Care
$60/visit (deductible does not apply)
Emergency Room
20% coinsurance
Out-of-Network
Deductible (Individual/Family)
$2,000 / $6,000
Out-of-Pocket Max (Individual/Family)
$6,000 / $18,000
Preventive Care
40% coinsurance
Primary Care Visit
40% coinsurance
Specialist Visit
40% coinsurance
Urgent Care
40% coinsurance
Emergency Room
20% coinsurance
The Coinsurance amount shows what you pay after the deductible has been met. Pharmacy benefits is administered by CVS Caremark. Prescription Drug is not covered out-of-network.
Pharmacy
Retail Rx (Up to 30-Day Supply)
Generic – Tier 1
$10
Preferred Brand – Tier 2
$45
Non-Preferred Brand – Tier 3
$70
Specialty – Tier 4
20% coinsurance
Mail-Order Rx (Up to 90-Day Supply)
Generic – Tier 1
$20
Preferred Brand – Tier 2
$90
Non-Preferred Brand – Tier 3
$140
Specialty – Tier 4
Not covered
You may purchase up to a 90-day supply of maintenance medication at a retail CVS Pharmacy.
Please note that the ability to fill a prescription up to 90 days at a retail pharmacy is subject to federal and state regulations. The copayment and coinsurance amounts above for mail order are also applicable to the Retail 90 program.
Non-Union Plan Cost
Non-Union Weekly
Employee Only: $55.45
Employee and Spouse/DP: $118.85
Employee and Child(ren): $92.43
Employee and Family: $165.26
Non-Union Bi-Weekly
Employee Only: $120.14
Employee and Spouse/DP: $257.51
Employee and Child(ren): $200.26
Employee and Family: $358.06
Union Plan Cost
Union Weekly
Employee Only: $54.32
Employee and Spouse/DP: $116.42
Employee and Child(ren): $90.54
Employee and Family: $161.88
Bi-Weekly
Employee Only: $108.37
Employee and Spouse/DP: $232.27
Employee and Child(ren): $180.63
Employee and Family: $322.96
Gold HSA
Benefit Highlights
Employer HSA Contribution
EE Only:
$500 ($125 quarterly)
Family:
$1,000 ($250 quarterly)
In-Network
Deductible (Individual/Family)
$2,500 / $5,000
Out-of-Pocket Max (Individual/Family)
$3,400 / $6,800
Preventive Care
$0
Primary Care Visit
20% coinsurance
Specialist Visit
20% coinsurance
Urgent Care
20% coinsurance
Emergency Room
20% coinsurance
Out-of-Network
Deductible (Individual/Family)
$5,000 / $10,000
Out-of-Pocket Max (Individual/Family)
$6,800 / $13,600
Preventive Care
50% coinsurance
Primary Care Visit
50% coinsurance
Specialist Visit
50% coinsurance
Urgent Care
50% coinsurance
Emergency Room
20% coinsurance
The Coinsurance amount shows what you pay after the deductible has been met. Pharmacy benefits is administered by CVS Caremark. Prescription Drug is not covered out-of-network.
Pharmacy
Retail Rx (Up to 30-Day Supply)
Generic – Tier 1
20% coinsurance up to $40/prescription
Preferred Brand – Tier 2
25% coinsurance up to $70/prescription
Non-Preferred Brand – Tier 3
35% coinsurance up to $110/prescription
Specialty – Tier 4
20% coinsurance
Mail-Order Rx (Up to 90-Day Supply)
Generic – Tier 1
20% coinsurance up to $80/prescription
Preferred Brand – Tier 2
25% coinsurance up to $140/prescription
Non-Preferred Brand – Tier 3
35% coinsurance up to $220/prescription
Specialty – Tier 4
Not covered
You may purchase up to a 90-day supply of maintenance medication at a retail CVS Pharmacy.
Please note that the ability to fill a prescription up to 90 days at a retail pharmacy is subject to federal and state regulations. The copayment and coinsurance amounts above for mail order are also applicable to the Retail 90 program.
Non-Union Plan Cost
Non-Union Weekly
Employee Only: $33.10
Employee and Spouse/DP: $79.80
Employee and Child(ren): $62.16
Employee and Family: $110.69
Non-Union Bi-weekly
Employee Only: $71.72
Employee and Spouse/DP: $172.91
Employee and Child(ren): $134.69
Employee and Family: $239.83
Union Plan Cost
Union Weekly
Employee Only: $32.42
Employee and Spouse/DP: $78.17
Employee and Child(ren): $60.89
Employee and Family: $108.43
Union Bi-weekly
Employee Only: $64.69
Employee and Spouse/DP: $155.96
Employee and Child(ren): $121.48
Employee and Family: $216.32
Silver PPO
Benefit Highlights
In-Network
Deductible (Individual/Family)
$3,000 / $6,000
Out-of-Pocket Max (Individual/Family)
$5,000 / $10,000
Preventive Care
$0
Primary Care Visit
$30/visit (deductible does not apply)
Specialist Visit
$60/visit (deductible does not apply)
Urgent Care
$75/visit (deductible does not apply)
Emergency Room
$150/visit then 20% coinsurance (deductible does not apply for first visit)
Out-of-Network
Deductible (Individual/Family)
$6,000 / $12,000
Out-of-Pocket Max (Individual/Family)
$10,000 / $20,000
Preventive Care
50% coinsurance
Primary Care Visit
50% coinsurance
Specialist Visit
50% coinsurance
Urgent Care
50% coinsurance
Emergency Room
$150/visit then 20% coinsurance (deductible does not apply for first visit)
Pharmacy benefits is administered by CVS Caremark. Prescription Drug is not covered out-of-network.
Pharmacy
Retail Rx (Up to 30-Day Supply)
Generic
$10
Preferred Brand
$50
Non-Preferred Brand
$100
Specialty
20% coinsurance
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20
Preferred Brand
$100
Non-Preferred Brand
$200
Specialty
Not covered
You may purchase up to a 90-day supply of maintenance medication at a retail CVS Pharmacy.
Please note that the ability to fill a prescription up to 90 days at a retail pharmacy is subject to federal and state regulations. The copayment and coinsurance amounts above for mail order are also applicable to the Retail 90 program.
Non-Union Plan Cost
Non-Union Weekly
Employee Only: $23.49
Employee and Spouse/DP: $57.88
Employee and Child(ren): $44.88
Employee and Family: $80.66
Non-union Bi-weekly
Employee Only: $50.90
Employee and Spouse/DP: $125.41
Employee and Child(ren): $97.23
Employee and Family: $174.76
Union Plan Cost
Union Weekly
Employee Only: $23.01
Employee and Spouse/DP: $56.70
Employee and Child(ren): $43.96
Employee and Family: $79.01
Union Bi-weekly
Employee Only: $45.91
Employee and Spouse/DP: $113.12
Employee and Child(ren): $87.70
Employee and Family: $157.63
Triple-S Óptimo Plus PPO (Puerto Rico Only)
This plan is available for the Puerto Rico residents only.
Benefit Highlights
In-Network
Deductible (Individual/Family)
$0 / $0
Out-of-Pocket Max (Individual/Family)
None
Preventive Care
$0
Primary Care Visit
$5 copay
Specialist Visit
$10 copay
Urgent Care
Not covered
Emergency Room
$50 copay/visit
Pharmacy
Retail Rx (Up to 30-Day Supply)
Generic
$5 copay
Preferred Brand
$10 copay
Non-Preferred Brand
$15 copay
Specialty
20% up to $100 max
Mail-Order Rx (Up to 90-Day Supply)
Generic
$10 copay
Preferred Brand
$20 copay
Non-Preferred Brand
$30 copay
Specialty
Not covered
Non-Union Plan Cost
Non-Union Weekly
Employee Only: $28.17
Employee + 1: $51.29
Employee and Family: $65.96
Bi-weekly
Employee Only: $61.03
Employee + 1: $111.13
Employee and Family: $142.92
HMSA CompMED 730 (Hawaii Only)
This plan is for the Hawaii residents only.
Benefit Highlights
In-Network
Deductible (Individual/Family)
$0
Out-of-Pocket Max (Individual/Family)
$2,500 / $7,500 medical
$3,600 / $4,200 prescription
Preventive Care
$0
Primary Care Visit
$14 copay
Specialist Visit
$14 copay
Urgent Care
$14 copay
Emergency Room
20% coinsurance
Out-of-Network
Deductible (Individual/Family)
$0
Out-of-Pocket Max (Individual/Family)
$2,500 / $7,500 medical
$3,600 / $4,200 prescription
Preventive Care
$0
Primary Care Visit
$14 copay
Specialist Visit
$14 copay
Urgent Care
$14 copay
Emergency Room
20% coinsurance
Pharmacy
Retail Rx (Up to 30-Day Supply)
Tier 1
$7
Tier 2
$30
Tier 3
$30
Tier 4
$100
Tier 5
$200
Mail-Order Rx (Up to 90-Day Supply)
Tier 1
$11
Tier 2
$65
Tier 3
$65
Tier 4
Not covered
Tier 5
Not covered
Retail Rx (Up to 30-Day Supply)
Tier 1
Not covered
Tier 2
Not covered
Tier 3
Not covered
Tier 4
Not covered
Tier 5
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Tier 1
Not covered
Tier 2
Not covered
Tier 3
Not covered
Tier 4
Not covered
Tier 5
Not covered
Non-Union Plan Cost
Non-Union Weekly
Employee Only: $9.55
Employee + 1: $19.26
Employee and Family: $28.59
Bi-weekly
Employee Only: $20.70
Employee + 1: $41.74
Employee and Family: $61.94