MEDICAL OPTIONS
PPO PLAN
Co-pays are due at time of service.
Out-of-Pocket Maximum Amounts:
| Single | Family | |
| In-Network | $6,100 | $12,200 |
| Non-Network | $12,200 | $24,400 |
| Deductibles | ASSOCIATE | ASSOCIATE & SPOUSE | ASSOCIATE & CHILDREN | ASSOCIATE & FAMILY | ||||
| In-Network | $1,000 | $2,000 | $1,000 | $2,000 | $1,000 | $2,000 | $1,000 | |
| Out-of-Network | $2,000 | $1,000 | $4,000 | $1,000 | $4,000 | $1,000 | $4,000 | $1,000 |
Resources
| IN-NETWORK CO-PAY | |
| Preventative Care Services | 100% Coverage |
| Physician’s Office | Primary: $35 Co-pay per visit |
| Specialist: $70 Co-pay per visit | |
| Urgent Care | $100 Co-pay per visit |
| Emergency Room (Outpatient) | $350 Co-pay per visit |
| Inpatient Hospital Stay | 80% Coverage after deductible |
| Mental Health Visit | $35 Co-Pay |
| PRESCRIPTION CO-PAY | ||
| Retail (up to 30-day supply) | Mail-In (up to 90-day supply) | |
| Tier 1: Generic, Lowest Cost | $10 Co-pay | $25 Co-pay |
| Tier 2: Preferred Brand Name, Midrange Cost | $50 Co-pay | $125 Co-pay |
| Tier 3: Non-Preferred Brand Name, Higher Cost | $75 Co-pay | $187.50 Co-pay |
| Tier 4: Highest Cost | 25% ($250 max) | 25% ($250 max) (30-day supply limit) |
| BI-WEEKLY RATES | ASSOCIATE | ASSOCIATE & SPOUSE | ASSOCIATE & CHILDREN | ASSOCIATE & FAMILY | ||||
| Tobacco | Non-Tobacco | Tobacco | Non-Tobacco | Tobacco | Non-Tobacco | Tobacco | Non-Tobacco | |
| Wellness | $229.72 | $95.01 | $325.68 | $176.11 | $292.51 | $148.91 | $383.46 | $229.84 |
| Wellness Lite | $256.27 | $125.32 | $355.73 | $223.71 | $321.33 | $194.52 | $412.92 | $277.02 |
| No Wellness | $282.83 | $155.64 | $385.78 | $271.31 | $350.14 | $240.13 | $442.38 | $324.19 |
HIGH DEDUCTIBLE PLAN
You will be responsible for 100% of your medical and pharmacy bills out-of-pocket until the deductible amounts have been met.
Out-of-Pocket Maximum Amounts:
| Single | Family | |
| In-Network | $6,100 | $12,200 |
| Non-Network | $12,200 | $24,400 |
| Deductibles | ASSOCIATE | ASSOCIATE & SPOUSE | ASSOCIATE & CHILDREN | ASSOCIATE & FAMILY | ||||
| In-Network | $3,700 | $7,400 | $7,400 | $7,400 | ||||
| Out-of-Network | $6,100 | $12,200 | $12,200 | $12,200 |
Resources
| IN-NETWORK CO-PAY | |
| Preventative Care Services | 100% Coverage |
| Physician’s Office | Primary: 80% Coverage after deductible Specialist: 80% Coverage after deductible |
| Urgent Care | 80% Coverage after deductible |
| Emergency Room (Outpatient) | 80% Coverage after deductible |
| Inpatient Hospital Stay | 80% Coverage after deductible |
| PRESCRIPTION CO-PAY | ||
| Retail (up to 30-day supply) | Mail-In (up to 90-day supply) | |
| Tier 1: Generic, Lowest Cost | 20% Co-insurance | 20% Co-insurance |
| Tier 2: Preferred Brand Name, Midrange Cost | 20% Co-insurance | 20% Co-insurance |
| Tier 3: Non-Preferred Brand Name, Higher Cost | 20% Co-insurance | 20% Co-insurance |
| Tier 4: Highest Cost | N/A | N/A |
| BI-WEEKLY RATES | ASSOCIATE | ASSOCIATE & SPOUSE | ASSOCIATE & CHILDREN | ASSOCIATE & FAMILY | ||||
| Tobacco | Non-Tobacco | Tobacco | Non-Tobacco | Tobacco | Non-Tobacco | Tobacco | Non-Tobacco | |
| Wellness | $151.39 | $72.38 | $215.23 | $134.54 | $199.27 | $114.04 | $255.65 | $173.83 |
| Wellness Lite | $173.93 | $95.27 | $251.86 | $173.91 | $227.66 | $145.04 | $296.38 | $214.85 |
| No Wellness | $196.48 | $118.16 | $288.48 | $213.27 | $256.05 | $176.04 | $337.11 | $255.88 |
Co-Insurance: This is the amount you are responsible for after the deductible has been met. After meeting the deductible, insurance covers 80%. Out-of-network rates may vary.
If a Famous Supply Associate has a Spouse who has alternative employer provided coverage available to him or her, that Spouse is not eligible to be enrolled in the Famous Supply Group Medical Plan.”
Disclaimer: This benefit summary is intended only to highlight your benefits and should not be relied upon to fully determine your coverage. It is recommended that you review the Provider’s Plan documents for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
