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 |
$1,200 Single
$3,600 Family |
$2,000 Single
$6,000 Family |
$2,000 Single
$4,000 Family |
$4,000 Single
$8,000 Family |
| Out of Pocket Max |
$5,000 Single
$13,000 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 Visit (per member per year) |
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.
The tobacco user surcharge applies to team members and their dependents who are enrolled in the health plan and use tobacco products or e-cigarettes that contain nicotine. During Benefits Open Enrollment, team members can indicate their and their covered dependents non-tobacco user status by completing the Tobacco Use Affidavit. Carle makes available a reasonable alternative standard for team members and/or covered dependents to avoid the tobacco-user surcharge. Specifically, during a plan year, team members have the opportunity to participate in a wellness program,
Quit for Life, a smoking cessation program. Additionally, if it is medically inadvisable for a team member and/or covered dependents to participate in the smoking cessation program, team members are afforded the opportunity to comply with the recommendations of the individual’s personal physician. Team members who meet the reasonable alternative standard during a plan year will be provided the lower premium for the entire plan year. After Benefits Open Enrollment, team members must contact the MyHR Help Desk to change their tobacco user status.
2025 Team Member Medical Plan Premiums (24-Pays)
For full-time team members, Carle Health covers over 80 percent of premium costs.
| |
PPO |
HDHP |
| Full Time Rates | 30 – 40 hours per week |
| Team Member |
$79.88 |
$50.97 |
| Team member & Spouse/Domestic Partner |
$185.05 |
$139.45 |
| Team Member + Child(ren) |
$152.06 |
$109.41 |
| Family |
$245.81 |
$194.55 |
| Part Time Rates | 20 – 29.99 hours per week |
| Team Member |
$159.75 |
$114.68 |
| Team Member & Spouse/Domestic Partner |
$370.10 |
$275.90 |
| Team Member + Child(ren) |
$304.12 |
$218.82 |
| Family |
$491.62 |
$389.10 |