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Medical Insurance

For Plan Year 2017 there are three Plan design options for employees to choose from, two PPO plans provided through Blue Cross Blue Shield and an HMO Plan provided by Blue Care Network.  There continues to be the opt-out feature for family members covered by other insurance.   NOTE:  Employees out-of-area have access to the PPO options only.

All three plans have an office visit copay that varies based on plan selected and whether the visit is with the primary care doctor or specialist and prescription drug copays.  Please refer to pages 7 and 8 of the Benefits and Enrollment RoadMap for specific information. 

Medical Plan 2 - 2017

Medical Plan 2, has somewhat higher deductibles and lower employee cost per payroll deduction.  The in-network coverage represents 80% paid after deductible and out-of-network represents 60% paid after deductible.

Deductible                  $1,000/$2,000 in-network, $2,000/$4,000 out-of-network

Office Visit Co-Pay        $30 in-network, Primary Care Physician; $50 in-network, Specialist 

Co-Insurance              20% in-network, 40% out-of-network

Out-Pocket-Max           $3,500/$7,000 in-network, $7,000/$14,000 out-of-network

Employee Premium        $51.04 (biweekly)

Employee + 1 Premium    $106.08 (biweekly)

Family Premium            $148.82 (biweekly) 

Core Plan - 2017

Core Plan has the highest amount in deductibles with limited employee payroll cost.  The in-network coverage represents 80% paid after deductible and out-of-network represents 60% paid after deductible.

Deductible                  $2,500/$5,000 in-network, $5,000/$10,000 out-of-network 

Office Visit Co-Pay         $30 in-network, Primary Care Physician; $50 in-network, Specialist

Co-Insurance               20% in-network, 40% out-of-network

Out-Pocket-Max             $5,000/$10,000 in-network, $10,000/$20,000 out-of-network

Employee Premium         $11.54 (biweekly)

Employee + 1 Premium     $27.69 (biweekly)

Family Premium             $33.23 (biweekly)

BCN HMO - 2017

The HMO Plan provides health care that requires specific use of the doctors, hospitals, etc., within a designated network. The in-network coverage represents 80% paid after deductible; there is no out-of-network coverage.

Deductible                   $1,000/$2,000 in-network, only

Office Visit Co-Pay         $20 in-network, Primary Care Physician; $40 in-network, Specialist

Co-Insurance                20% in-network

Out-Pocket-Max             $6,600/$13,200 in-network, only

Employee Premium         $10.15 (biweekly)

Employee + 1 Premium    $18.46 (biweekly)

Family Premium             $25.38 (biweekly)

Prescription Drug Co-Pays:

For the PPO Plans: Generic Drugs $20.00, Formulary Brand Drugs  $60.00; and $80 Non-Formulary Drugs.  For the HMO: Tier 1A - $6.00; Tier 1B - $25.00; Tier 2 - $50.00.  There are additional options for the HMO so please refer to page 6 of the Benefits and Enrollment Guide for additional information.

Waiver Option allows for an employee to opt out of the medical plan when proof of other medical coverage through a spouse or parent is provided; employee receives a biweekly credit of $15.00.

In accordance with the Patient Protection and Affordable Care Act, attached you will find by Employer Group the required Summary of Benefits and Coverage (SBC) for all three medical plans.  In the event you wish to have a copy and are unable to print the document for yourself, please contact our office and we will provide you a copy free of charge.   

Please keep in mind that these are generic summaries of benefits and coverage provided by Blue Cross and Blue Shield; to know specific coverage under the Ave Maria Employee Health Plan, refer to the Benefits-at-a-Glance for your specific Plan below. 

Note: To refer to the Benefits-at-a-Glance for a summary of benefits, please click on the following:  

For the Medical Claim Form, please click here. For additional Plan information, please refer to the Ave Maria Employee Health Plan Wrap Document, click here.