Trying to compare a couple different plans and looking for thoughts
Hi everyone
My wife and I receive health insurance through her employer. We have until Friday at 5pm to decide if we would like to switch health plans or maintain the current plan we have. Her employer offers two different plans – a PPO and a High deductible plan. I am hoping to provide enough info for someone smarter than us to help us digest it. Currently, we have been enrolled in the High Deductible plan, in this case, we will call it Plan B.
Plan A – The PPO Plan Info
FSA account is offered but employer doesn’t contribute any money towards it
Monthly Cost for the two of us: $466.72
Annual Cost: $5,600.64
Network Deductible: $700/family
Non-Network Deductible: $1400/family
Certain preventive care and all services with copays are covered and paid by the plan before we meet the deductible
There are no other deductibles for specific services
Out of Pocket Limit for Network: $2550/family
Out of pocket limit for non network: $8350/family
Not included in the out of pocket: Cost sharing for prescription drugs, premiums, deductibles balance-billed charges and health care this plan doesn’t cover
No referrer needed to see a specialist
Copay/Coinsurance
Primary care: Network: $20 copay/visit . Non-network: 40% coinsurance
Specialist: Network: $35 copay/visit . Non-network: 40% coinsurance
Preventive care/screening/immunization: Network: No charge . Non-network: 40% coinsurance
X-ray: Network: No charge at physician; 15% coinsurance for all other places . Non-network: 40% coinsurance
Blood word: No charge at physician; 15% coinsurance for all other places . Non-network: 40% coinsurance
Imaging (CT/PET scans, MRIs): No charge at physician; 15% coinsurance for all other places . Non-network: 40% coinsurance
Prescriptions – Copay/Coinsurance
Generic drugs (tier 1): Network – Retail $10 copay/rx, mail $20 copay/rx . Non-network: We pay 100% of retail cost and then file a claim with Caremark. Reimbursement will be based on the allowable network cost
Preferred brand drugs (ie those drugs on the formulary – Tier 2): Network – Retail 20% with $100 max/rx, mail 20% with $300 max/rx . Non-network: We pay 100% of retail cost and then file a claim with Caremark. Reimbursement will be based on the allowable network cost
Non-preferred drugs (Tier 3): Network – Retail 40% w/ $125 max/rx, mail 40% w/ $375 max/rx . Non-network: We pay 100% of retail cost and then file a claim with Caremark. Reimbursement will be based on the allowable network cost
Misc. or Lifestyle drugs (tier 4): Network – Retail 100%, mail – not available. Non-network: We pay 100% of retail cost and then file a claim with Caremark. Reimbursement will be based on the allowable network cost
Specialty: Need to contact Caremark to learn if it is preferred or non-preferred
Surgery/Emergences – Copay/Coinsurance
Outpatient: Facility Fee: Network: 15% coinsurance. Non-Network: 40% coinsurance
Outpatient: Physician/surgeon fees: Network: 15% coinsurance. Non-Network: 40% coinsurance
Emergency room care: Network AND non-network: $100 copay/visit, 15% coinsurance
Emergency medical transportation: Network AND non-network:15% coinsurance
Urgent Care: Network: $20 copay/visit. Non-network: 40% coinsurance
Hospital stay – facility fee: Network: 15% coinsurance. Non-network: 40% coinsurance
Hospital stay – physician/surgeon fee (inpatient): Network: 15% coinsurance. Non-network: 40% coinsurance
Everything else – pregnant related, help recovering or have other special health needs
Plan B – The PPO Plan Info
Her employer contributes $1000 to an HSA
Monthly Cost for the two of us: $188.08
Annual Cost: $2256.96
Network Deductible: $4000/family
Non-Network Deductible: $8000/family
Certain preventive care and all services with copays are covered and paid by the plan before we meet the deductible
There are no other deductibles for specific services
Out of Pocket Limit for Network: $6750/individual, $8000/family
Out of pocket limit for non network: $16,000/family
Not included in the out of pocket: Premiums, balance-billed charges and health care this plan doesn’t cover
No referral needed to see a specialist
Copay/Coinsurance
Primary care: Network: 10% Coinsurance . Non-network: 40% coinsurance
Specialist: Network: 10% Coinsurance . Non-network: 40% coinsurance
Preventive care/screening/immunization: Network: No charge . Non-network: 40% coinsurance
X-ray: Network: Network: 10% Coinsurance . Non-network: 40% coinsurance
Blood word: Network: 10% Coinsurance . Non-network: 40% coinsurance
Imaging (CT/PET scans, MRIs): Network: 10% Coinsurance . Non-network: 40% coinsurance
Prescriptions – Copay/Coinsurance
Generic drugs (tier 1): Network: 10% Coinsurance . Non-network: 40% coinsurance
Preferred brand drugs (ie those drugs on the formulary – Tier 2): Network: 10% Coinsurance . Non-network: 40% coinsurance
Non-preferred drugs (Tier 3): Network: 10% Coinsurance . Non-network: 40% coinsurance
Misc. or Lifestyle drugs (tier 4): Network: 10% Coinsurance . Non-network: 40% coinsurance
Specialty: Need to contact Caremark to learn if it is preferred or non-preferred
Surgery/Emergences – Copay/Coinsurance
Outpatient: Facility Fee: Network: 10% Coinsurance . Non-network: 40% coinsurance
Outpatient: Physician/surgeon fees: Network: 10% Coinsurance . Non-network: 40% coinsurance
Emergency room care: Network AND non-network: 10% coinsurance
Emergency medical transportation: Network AND non-network:10% coinsurance
Urgent Care: Network: 10% Coinsurance . Non-network: 40% coinsurance
Hospital stay – facility fee: Network: 10% Coinsurance . Non-network: 40% coinsurance
Hospital stay – physician/surgeon fee (inpatient): Network: 10% Coinsurance . Non-network: 40% coinsurance
Everything else – pregnant related, help recovering or have other special health needs
Our general info:
My wife and I are both in our mid 30s
Relatively speaking, we are healthy
I have type 1 diabetes that I use insulin for and see an endocrinologist 2-4 times per year and have blood work once a year for
My wife sees her ob and primary care a couple as needed/normal amount
We are not anticipating kids or any life changing event like that
My wife will probably need to have surgery next year to repair a torn labrum in her hip. This is outpatient surgery but has about 3-4 month recovery before she’s back to 100%
43551 zip
$150k+ annual salary
Any thoughts would be appreciated. Any follow up questions are welcome.
We want to try and make the best decision. The surgery will make us meet our deductible on either plan and out of pocket limit.
Thanks!!