2018 Individual Plan Options

Available at deancare.com

Copay Plus & Classic Plan Overview

Annual Max
Deductible Office Visit Office Visit Preventive Urgent Emergency Outpatient Outpatient
Plan Name Coinsurance Out-of-Pocket Hospitalization
(Single / Family) Primary Specialist Exam* Care Room Lab/X-ray Surgery
(Single / Family)

Gold Copay 20% after 20% after 20% after

$1,500 / $3,000 20% $3,000 / $6,000 $
30 copay $60 copay $60 copay
Plus 1500X deductible deductible deductible
$325 Copay
Silver Copay No before policy 30% after 30% after 30% after
$3,250 / $6,500 30% $7,350 / $14,700 $
30 copay $60 copay $60 copay
Plus 3250X Charge deductible & deductible deductible deductible
coinsurance
Silver Classic 20% after 20% after 20% after 20% after 20% after 20% after
$4,750 / $9,500 20% $7,350 / $14,700
4750X deductible deductible deductible deductible deductible deductible

Copay Plus & Classic Prescription Drugs: Tier 1 Generics: $15 Copay Tier 2 Preferred Brand: $50 Copay Tier 3 Non-preferred Brand: 50% Coinsurance Tier 4 Specialty: 50% Coinsurance
*Preventive exams are covered in accordance with the recommended preventive services as required by the Patient Protection and Affordable Care Act (PPACA).

Value Copay Plan Overview

Annual Max
Deductible Office Visit Office Visit Preventive Urgent Emergency Outpatient Outpatient
Plan Name Coinsurance Out-of-Pocket Hospitalization
(Single / Family) Primary Specialist Exam* Care Room Lab/X-ray Surgery
(Single / Family)
ET
SN W

$25 copay for

FO CU

OR

Gold Value No charge No charge No charge No charge No charge

K AV
*

$3,500 / $7,000 0% $3,500 / $7,000 3 visits then no

AI
LABLE

Copay 3500X after deductible after deductible after deductible after deductible after deductible
charge after ded.
ET
SN W
$325 Copay
$25 copay for 3
FO CU

OR

Silver Value 30% after No 30% after before policy 30% after 30% after 30% after
K AV
*

$5,000 / $10,000 30% $7,350 / $14,700 visits then 30%

AI
LABLE

Copay 5000X deductible Charge deductible deductible & deductible deductible deductible
coins. after ded.
ET
coinsurance
SN W

$25 copay for

FO CU

OR

Bronze Value No charge No charge No charge No charge No charge

K AV
*

$7,350 / $14,700 0% $7,350 / $14,700 3 visits then no

AI
LABLE

Copay 7350X after deductible after deductible after deductible after deductible after deductible
charge after ded.

Value Copay Prescription Drugs Gold and Silver offer: T

 ier 1 Generics: $15 Copay Tier 2 Preferred Brand: 50% Coinsurance Tier 3 Non-Preferred Brand: 50% Coinsurance
Tier 4 Specialty: 50% Coinsurance (Bronze Value Copay 7350X all tiers offer no charge after deductible)
*Preventive exams are covered in accordance with the recommended preventive services as required by the Patient Protection and Affordable Care Act (PPACA).

HSA & Safety Net Plan Overview

Annual Max
Deductible Office Visit Office Visit Preventive Urgent Emergency Outpatient Outpatient
Plan Name Coinsurance Out-of-Pocket Hospitalization
(Single / Family) Primary Specialist Exam* Care Room Lab/X-ray Surgery
(Single / Family)

Silver HSA-E ET 20% after 20% after 20% after 20% after 20% after 20% after 20% after
3500X
SN W
$3,500 / $7,000 20% $6,550 / $13,100
FO CU

OR

deductible deductible deductible deductible deductible deductible deductible

K AV
*

AI
LABLE

Bronze HSA-E No charge No charge No charge No charge No charge No charge No charge

ET
SN W
$6,550 / $13,100 0% $6,550 / $13,100 No
6550X
FO CU

after deductible after deductible after deductible after deductible after deductible after deductible after deductible
OR

Charge
K AV
*

AI
LABLE

Catastrophic $0 copay for

No charge No charge No charge No charge No charge No charge
Safety Net $7,350 / $14,700 0% $7,350 / $14,700 3 visits then no
after deductible after deductible after deductible after deductible after deductible after deductible
charge after ded.

HSA & Safety Net Prescription Drugs: Policy coinsurance after deductible
*Preventive exams are covered in accordance with the recommended preventive services as required by the Patient Protection and Affordable Care Act (PPACA).
Special Note: Our HSA plans are designed to offer maximum consumer value. Embedded deductibles are standard and offer benefits to each individual on a family plan after the single deductible has been met. These plans also offer
a separate HDHP HSA formulary, increasing access to lower cost generic drugs. Contact a Dean Health Plan representative for more information.

NET W
US
FOC

Plans with the Focus Network

OR
K AV

Option are noted with this symbol.

*

Available in Dane, Sauk & Rock counties only.

A
ILA
BLE

You may be eligible for cost savings programs like discounted 2017 Plan Year Federal Poverty Level Guidelines
premiums or reduced costs on medical services.
Percentage of Federal Poverty Level
Visit deancare.com to determine if you are eligible for and
how much you can receive under these programs. Size of Household 100% 250% 400%

Cost sharing reductions are available to individuals who have a 1 $12,060 $30,150 $48,240
household income of at least 100 percent but not more than 250
2 $16,240 $40,600 $64,960
percent of the federal poverty level and are enrolled in a silver tier
plan. Cost sharing reductions reduce the amount you have to pay 3 $20,420 $51,050 $81,680
toward your deductible, coinsurance and copays.
4 $24,600 $61,500 $98,400
Its important to check if you qualify for one or more of these May Qualify for May Qualify for
May Qualify for
programs based on your income level. The following table shows Coverage Cost-Sharing Reductions
and Advanced
Cost-Sharing Reductions
and Advanced
Advanced Premium
Information Tax Credits
the Federal Poverty Level guidelines, but an agent or Dean Health Premium Tax Credits Premium Tax Credits

Plan representative can help you if youre not sure.

Silver Cost Sharing Reduction Eligible Plans
Copay Plus 3250X
Subsidy Level Deductible Coinsurance Annual Max Out-of-Pocket Office Visit Office Visit Urgent Emergency Outpatient Outpatient Hospitalization
(Single / Family) (Single / Family) Primary Specialist Care Room Lab/X-ray Surgery

Standard $3,250 / $6,500 30% $7,350 / $14,700 $30 copay $60 copay $60 copay 30% after ded. 30% after ded. 30% after ded.
$325 Copay
200-250% FPL $3,250 / $6,500 30% $5,550 / $11,100 $30 copay $60 copay $60 copay 30% after ded. 30% after ded. 30% after ded.
before policy
deductible &
150-200% FPL $400 / $800 10% $2,450 / $4,900 $30 copay $60 copay $60 copay 10% after ded. 10% after ded. 10% after ded.
coinsurance
100-150% FPL $100 / $200 5% $750 / $1,500 $30 copay $60 copay $60 copay 5% after ded. 5% after ded. 5% after ded.

Copay Plus 3250X Prescription Drugs: Tier 1 Generics: $15 Copay Tier 2 Preferred Brand: $50 Copay Tier 3 Non-preferred Brand: 50% Coinsurance Tier 4 Specialty: 50% Coinsurance

Classic 4750X
Subsidy Level Deductible Coinsurance Annual Max Out-of-Pocket Office Visit Office Visit Urgent Emergency Outpatient Outpatient Hospitalization
(Single / Family) (Single / Family) Primary Specialist Care Room Lab/X-ray Surgery

Standard $4,750 / $9,500 20% $7,350 / $14,700 20% after ded. 20% after ded. 20% after ded. 20% after ded. 20% after ded. 20% after ded.
$325 Copay
200-250% FPL $3,450 / $6,900 10% $5,000 / $10,000 10% after ded. 10% after ded. 10% after ded. 10% after ded. 10% after ded. 10% after ded.
before policy
deductible &
150-200% FPL $750 / $1,500 5% $2,000 / $4,000 5% after ded. 5% after ded. 5% after ded. 5% after ded. 5% after ded. 5% after ded.
coinsurance
100-150% FPL $200 / $400 5% $800 / $1,600 5% after ded. 5% after ded. 5% after ded. 5% after ded. 5% after ded. 5% after ded.

Classic 4750X Prescription Drugs: Tier 1 Generics: $15 Copay Tier 2 Preferred Brand: $50 Copay Tier 3 Non-preferred Brand: 50% Coinsurance Tier 4 Specialty: 50% Coinsurance

Value Copay 5000X

Subsidy Level Deductible Coinsurance Annual Max Out-of-Pocket Office Visit Office Visit Urgent Emergency Outpatient Outpatient Hospitalization
(Single / Family) (Single / Family) Primary Specialist Care Room Lab/X-ray Surgery
$25 copay for 3 visits then 30% after 30% after 30% after 30% after 30% after
Standard $5,000 / $10,000 30% $7,350 / $14,700
30% coins. after ded. deductible deductible deductible deductible deductible

$25 copay for 3 visits then 20% after 20% after $325 Copay
20% after 20% after 20% after
200-250% FPL $3,000 / $6,000 20% $5,850 / $11,700
20% coins. after ded. deductible deductible before policy deductible deductible deductible

$25 copay for 3 visits then 5% after 5% after deductible & 5% after 5% after 5% after
150-200% FPL $800 / $1,600 5% $2,100 / $4,200 coinsurance
5% coins. after ded. deductible deductible deductible deductible deductible

$25 copay for 3 visits then 5% after 5% after 5% after 5% after 5% after
100-150% FPL $100 / $200 5% $950 / $1,900
5% coins. after ded. deductible deductible deductible deductible deductible

Value Copay 5000X Prescription Drugs: Tier 1 Generics: $15 Copay Tier 2 Preferred Brand: 50% Coinsurance Tier 3 Non-preferred Brand: 50% Coinsurance Tier 4 Specialty: 50% Coinsurance

HSA-E 3500X
Subsidy Level Deductible Coinsurance Annual Max Out-of-Pocket Office Visit Office Visit Urgent Emergency Outpatient Outpatient Hospitalization
(Single / Family) (Single / Family) Primary Specialist Care Room Lab/X-ray Surgery

Standard $3,500 / $7,000 20% $6,550 / $13,100 20% after deductible

200-250% FPL* $2,000 / $4,000 20% $5,000 / $10,000 20% after deductible

150-200% FPL* $950 / $1,900 5% $2,450 / $4,900 5% after deductible

100-150% FPL* $300 / $600 5% $1,500 / $3,000 5% after deductible

HSA-E 3500X Prescription Drugs: Policy coinsurance after deductible (separate HDHP HSA formulary)

*Special Note: Cost sharing reduction plan options (100-250% FPL) do not meet the IRS qualifications for Health Savings Account (HSA) eligibility.

You may be eligible for cost savings

programs like discounted premiums or
reduced costs on medical services.
Visit deancare.com to determine
if you are eligible for and how much
you can receive under these programs.

2017 Dean Health Plan, Inc. 3029_1707