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SPU Self-Funded PPO Medical Option 1 and Option 2
Employees may choose between two medical plans, Option 1 or Option 2. Under either plan, employees may choose a preferred provider (PPO) from the Premera Blue Cross network in order to receive the highest level of benefits. If the provider you choose is a network provider, the provider agrees to accept the allowable charge as payment in full. Participants are responsible only for applicable copays, deductibles, coinsurance, amounts in excess of stated benefit maximums, and charges for non-covered services and supplies.
Participants are not required to select a primary care physician to process a referral prior to seeking care from a specialist. However, participants must select a Premera Blue Cross PPO physician in order to receive the highest level of benefits.
If the provider chosen is a non-network provider, benefits are provided at the lowest level and participants will also be responsible for amounts above the allowable charge, in addition to applicable copays, deductibles, coinsurance, amounts in excess of stated benefit maximums, and charges for non-covered services and supplies. Amounts in excess of the allowable charge do not count toward the calendar year deductible, if any, or as coinsurance.
Benefits and provider networks Option 1 and Option 2 are basically the same, except Option 2 has reduced monthly premiums, an annual deductible, higher coinsurance, and increased copayment for brand prescriptions. See comparison chart below.
Coverage Comparison: 7/1/10 - 6/30/12 NEW
Medical Plan Features by calendar year
Option 1
Option 2
Deductible - In network
$100 individual / $300 family
$500 individual / $1,500 family
Deductible - Out-of-network
$300 individual / $900 family
$700 individual / $2,100 family
Copayment - In network
$15
$15
Coinsurance In-network/out-of-network
10% / 30%
20% / 40%
Retail prescription - 30 day supply
($5 Copay for Specific Generic Preventive Drugs)
$10 / $20 / $45
$10 / $25 / $45
Mail order prescription - 90 day supply
($10 Copay for Specific Generic Preventive Drugs)
$20 / $40 / $90
$20 / $50 / $90
Out-of-pocket max (includes deductible)-
in network$1,500 individual / $4,500 family
$2,500 individual / $7,500 family
Out-of-pocket max (includes deductible) -
out-of-network$5,500 individual / $16,500 family
$10,500 individual / $31,500 family
Is the PPO Plan Option 2 the right plan for you and your family?
By selecting option 2, employees with dependent coverage may significantly reduce their premiums. However, the savings could easily be offset by higher out-of-pocket maximums, deductibles and coinsurance as indicated above. If you or your family members experience frequent visits to the doctor, Option 2 could end up being more costly than Option 1.
Services received from health care providers who are only participating/ non-contracting/non-preferred with Premera Blue Cross are also covered, subject to the calendar year deductible, office visit copayment, coinsurance, and other limitations as listed in the Seattle Pacific University Heritage Plus 1 - Option 1 or Seattle Pacific Univeristy Heritage Plus 1 - Option 2 booklets found here.
PPO Identification Cards and Claim Filing
SPU has contracted with Premera Blue Cross to process claims and provide customer service for employees and health care providers. Employees who choose the SPU Self-funded PPO Medical Program will receive a Premera Blue Cross medical ID card for each covered participant to present to the health care provider when receiving services. When utilizing a Premera Blue Cross PPO health care provider, the provider will bill charges directly to Premera Blue Cross on behalf of the patient. When using out-of-network or out of area services, the participant will submit payment directly to the provider and submit a claim to Premera for reimbursement. Additionally, that out-of-network provider will "balance bill" to the participant the difference between the provider's billed rate and the rate that Premera has contracted with their in-network providers. Please refer to the Seattle Pacific University Heritage Plus 1 - Option 1 or Seattle Pacific Univeristy Heritage Plus 1 - Option 2 booklets found here for information regarding filing of claims. The claim form(s) may be found here.
The SPU Self-funded PPO Medical Program ID card is also the prescription drug ID card. The ID card is presented to the pharmacist at the time the prescription drug is purchased. Copayments listed below apply to a 30-day supply of generic, preferred brand, and non-preferred brand prescriptions, when purchased at preferred pharmacies. If, due to extenuating circumstances, an individual finds it necessary to fill a prescription and pay the full price at the pharmacy (without using the prescription ID card), the individual may send in a claim form to Premera for reimbursement. Claim forms are accessible online via the Office of Human Resources website. A list of preferred pharmacies may be found in the Premera Blue Cross directory of preferred providers. Most major chain pharmacies are included as preferred pharmacies as well as numerous neighborhood pharmacies.
Retail Prescription - 30 Day Supply Generic Preferred Brand Non-Preferred Brand For maintenance medications, mail order service is offered through Medcohealth, which allows individuals to order up to a 90-day supply for the price of a 60-day supply - a 33% discount! Copayments listed below are for generic, preferred brand, and non-preferred brand prescriptions. Mail order forms are available in the Office of Human Resources or online at: www.medcohealth.com
Mail Order Prescription - 90 Day Supply Generic Preferred Brand Non-Preferred Brand The University pays the full premium for regular full-time employees' coverage (subject to change each year, based on renewal of program contracts).
For regular part-time employees (.5 FTE through .79 FTE for Staff and .5 FTE through .74 for Faculty), the University pays a prorated portion of the premium for employee coverage, based on the employee's FTE. Employees pay the remainder of the employee premium via payroll deduction. The employee-rate is noted below.
Employees who elect dependent coverage pay for the entire cost of their dependents' premiums by payroll deduction.
All medical insurance premiums deducted from employee earnings are taken on a pretax basis.
MONTHLY PREMIUM COSTS: 7/1/10 - 6/30/11
Coverage Employee-rate
$617
(SPU pays 100% for full-time employees)
$617
(SPU pays 100% for full-time employees)
Spouse Child(ren) Family MONTHLY PREMIUM COSTS: 7/1/11 - 6/30/12 NEW
Coverage Employee-rate
$642
(SPU pays 100% for full-time employees)
$642
(SPU pays 100% for full-time employees)
Spouse Child(ren) Family