Plan Details

 

PPO
Low-deductible copay plan

HDHP
High deductible coinsurance plan with Health Savings Account

  IN NETWORK OUT OF NETWORK IN NETWORK OUT OF NETWORK
Annual Deductible $1,000 Single
$3,000 Family
$2,000 Single
$6,000 Family
$2,000 Single
$4,000 Family
$4,000 Single
$8,000 Family
Out of Pocket Max $4,000 Single
$12,000 Family
$25,000 Single
$75,000 Family
$5,500 Single
$11,000 Family
$25,000 Single
$75,000 Family
Physician Visits Primary / Specialist $20 copay / $40 copay 50% 20% / 20% 50%
Virtual Visits (per member) Visits 1-3: $0
Visits 4+: $20 copay
Not Covered 20% Not Covered
Preventive Care $0 50% $0 50%
Outpatient Lab Services $50 copay
(deductible waived)
50% 20% 50%
Outpatient Radiology Diagnostics $100 copay
(deductible waived)
50% 20% 50%
Outpatient Advanced Radiology Diagnostics (CT Scan, PET Scan or MRI) $250 copay
(deductible waived)
50% 20% 50%
Childbirth / Delivery
Facility & Professional Fees
20% 50% 20% 50%
Emergency Room Services (per member) Visits 1-2: $200 Copay + Deductible + 20%
Visits 3+: $500 Copay + Deductible + 20%
Visits 1-2: $200 Copay + Deductible + 20%
Visits 3+: $500 Copay + Deductible + 20%
Visits 1-2: 20%
Visits 3+: 30%
Visits 1-2: 20%
Visits 3+: 30%
Outpatient Surgery
Facility & Surgeon Fees
20% 50% 20% 50%
Inpatient Hospitalization
Facility & Physician Fees
20% 50% 20% 50%
Prescription Coverage
(Tier 1, 2, 3 & 4)
Retail:
$0 / $10 / $40 / $60
Mail:
$0 / $27.50 / $110 / $165
(deductible waived)
Mandatory generic
Not Covered Retail:
$0 / $10 / $40 / $80
Mail:
$0 / $27.50 / $110 / $220
After Deductible
Mandatory generic
Not Covered
Prescription Coverage
(Tier 5 & 6)
30%
(deductible waived)
Not Covered 20% / 50%
After Deductible
Not Covered
Tobacco User Fee $25 per pay period
Team Member Premiums Refer to the Rate Chart below
*All percentages listed above are representative of a team member’s portion to pay after their deductible has been met.


2024 Team Member Medical Plan Premiums (24-Pays)

For full-time team members, Carle Health covers approximately 80 percent of premium costs, while you pay the remaining 20 percent. 

  PPO HDHP
Full Time Rates | 30 – 40 hours per week
Team Member $76.08 $50.97
Team member & Spouse/Domestic Partner  $171.34 $129.12
Team Member + Child(ren) $144.82 $104.20
Family $227.60 $180.14
Part Time Rates | 20 – 29.99 hours per week
Team Member $152.14 $109.22
Team Member & Spouse/Domestic Partner $342.64 $258.26
Team Member + Child(ren) $289.64 $208.38
Family $455.20 $360.26