Medical insurance plans are through the national Blue Cross Blue Shield program.
| Insurance Carrier | Independence Blue Cross | Independence Blue Cross | Independence Blue Cross |
|---|---|---|---|
| Plan Type | Fully Insured | Fully Insured | Fully Insured |
| Plan Name | PPO HSA $4,000/$40-$70/$250 w/ Int Rx | PPO $3,000/$30-$60/100% | PPO $1,500/$20-$40/100% |
| In-network | |||
| Physician copay |
$40 after deductible | $30, no deductible | $20, no deductible |
| Specialist copay | $70 after deductible | $60, no deductible | $40, no deductible |
| Rehabilitation services | $70 after deductible | $60, no deductible | $40, no deductible |
| Diagnostic (Lab and x-ray) | $70 after deductible freestanding facilities $140 after deductible hospital-based facilities |
$60, no deductible freestanding facilities $120, no deductible hospital-based facilities |
$40, no deductible freestanding facilities $80, no deductible hospital-based facilities |
| Imaging (CT/PET scans, MRI) | $300 after deductible |
$200, no deductible | $80, no deductible |
| Hospital copay | $250/day. Max 5 copay per admission, after deductible | $0 after deductible | $0 after deductible |
| Outpatient surgery copay | $250 after deductible | $300 after deductible | $250 after deductible |
| Emergency room copay | $300 after deductible | $300 after deductible | $250 after deductible |
| Urgent care | $100 after deductible | $100, no deductible | $85, no deductible |
| Deductible | $4,000/$8,000 | $3,000/$6,000 | $1,500/$3,000 |
| Coinsurance | 0% | 0% | 0% |
| Out of pocket maximum (Including deductible) |
$6,750 person/$13,500 | $7,900 person/$15,800 | $7,900 person/$15,800 |
| Lifetime maximum | Unlimited | Unlimited | Unlimited |
| Out-of-network | |||
| Deductible | $6,000/$12,000 | $5,000/$10,000 | $5,000/$10,000 |
| Coinsurance | 50% after deductible | 50% after deductible | 50% after deductible |
| Lifetime maximum | Unlimited | Unlimited | Unlimited |
| Prescription drug | |||
| Tier 1/Tier 2/Tier 3/Tier 4 | T1: $20, T2: $40, T3: $70, T4: 50% to $500 max/fill (all after deductible) | T1: $20, T2: $40, T3: $60, T4: 50% to $500 max/fill (all no deductible) | T1: $20, T2: $40, T3: $60, T4: 50% to $500 max/fill (all no deductible) |
| Tier 1/Tier 2/Tier 3/Tier 4 90 day mail order |
T1: $40, T2: $80, T3: $140, T4: not covered (all after deductible) | T1: $40, T2: $80, T3: $120, T4: not covered (all no deductible) | T1: $40, T2: $80, T3: $120, T4: not covered (all no deductible) |
Medical insurance premiums are based on your status (full -time or part-time) and based on the level of coverage you select (employee only, employee + spouse, employee + children, or family). Below are the per pay premium amounts:
| 2025 Full-Time Employee Contribution | |||
|---|---|---|---|
| Level of coverage | PPO HSA $4,000 | PPO $3,000 | PPO $1,500 |
| Employee only | $0.00/pay | $0.00/pay | $61.85/pay |
| Employee + children | $237.69/pay | $296.77/pay | $404.31/pay |
| Employee + spouse | $306.46/pay | $383.08/pay | $521.54/pay |
| Family | $390.92/pay | $488.31/pay | $665.08/pay |
| 2025 Part-Time Employee Contribution | |||
|---|---|---|---|
| Level of coverage | PPO HSA $4,000 | PPO $3,000 | PPO $1,500 |
| Employee only | $0.00/pay | $0.00/pay | $102.92/pay |
| Employee + children | $445.38/pay | $494.77/pay | $551.08/pay |
| Employee + spouse | $575.08/pay | $638.31/pay | $711.23/pay |
| Family | $732.92/pay | $814.15/pay | $906.92/pay |
