YOUR MEDICAL OPTIONS

For your medical coverage, you have three options to choose from – each with different attributes.

View a full summary of each medical plan here: MEDICAL PLAN #1: HIGH DEDUCTIBLE HEALTH PLAN (HDHP), MEDICAL PLAN #2: HIGH DEDUCTIBLE PPO, and MEDICAL PLAN #3: PREMIUM PPO.

  MEDICAL PLAN #1:
HDHP		 MEDICAL PLAN #2:
HD PPO		 MEDICAL PLAN #3:
Premium PPO
  In-Network Coverage
In-Network Coverage
Deductible $3,200 single / $6,000 family $2,500 single / $5,000 family $1,500 single / $3,000 family
Plan Pays 80% 80% 90%
You Pay (coinsurance) 20% 20% 10%
Out-of-pocket (OOP) Maximum $6,000 single / $12,000 family $5,000 single / $10,000 family $3,000 single / $6,000 family
Covered Medications Modernized listing of eligible drugs (managed formulary)
Mandatory Generic Substitution Included
Prescription Drugs 80% (whether retail or mail order)
70% for non-formulary name brand drugs
Retail (30-day supply):
  • $5 - Tier 1
  • $30 - Tier 2
  • $60 - Tier 3
  • 20% to $250 max – Tier 5 Specialty Medications
Mail order (90-day supply):
  • $10 - Tier 1
  • $60 - Tier 2
  • $120 - Tier 3
Primary Care Provider Office Visits 80% $20 copay, then 100% $15 copay, then 100%
Specialist Office Visits 80% $30 copay, then 100% $30 copay, then 100%
Urgent Care 80% $55 copay, then 100% $55 copay, then 100%
Inpatient Services 80% 80% $500 copay, then 90%
Outpatient Services 80% 80% $100 copay, then 90%
Ambulance 80% after in-network deductible (All providers considered in-network) 80% after in-network deductible (All providers considered in-network) 90% after deductible and $100 copay (All providers considered in-network)
Emergency Room Services 80% 80% after deductible and $150 copayment (copayment waived if admitted) 90% after deductible and $150 copayment (copayment waived if admitted)
Telemedicine 80% $20 copay, then 100% $15 copay, then 100%
Therapy and Rehabilitation 80% $30 copay, then 100% $30 copay, then 100%
Preventive Care
(e.g., physical exams, eye exams, vaccinations, etc.)		 100% (no deductible)
Basic Diagnostic Services (standard imaging and lab tests) 80% 100% after $35 copay 100% after $35 copay
Advanced Imaging 80% 80% after deductible and $35 copayment 90% after deductible and $35 copayment
Accidental Dental 80% 80% 90%
Emergency Out of Country Medical Included
Health Savings Account (HSA) $500 / $750 / $1,000 annual employer contribution Not available Not available
Flexible Spending Account (FSA) Dependent Care FSA Health Care FSA and Dependent Care FSA
MetLife Dental
  • Deductible – None
  • Preventative services – 100%
  • Basic services – 80%
  • Major services – 50%
  • Maximums – Combined $2,050 per plan year
  • Orthodontics – 50% for dependent children up to age 19; $1,500 lifetime max
EyeMed Vision
  • Eye exam, eyeglass lenses, frames, contact lenses (in lieu of glasses) – once every 12 months; Safety glasses in addition to dress – once every 12 months (employee only)
  • Eye exam – $10 copay
  • Frames - $130 + 20%
  • Safety frame (employee only) - $100
  • Single, bifocal, and trifocal eyeglass lenses – covered in full
  • Contact lenses – Exclusive Collection – covered in full; or $130 allowance (non-plan contacts) in lieu of glasses
OPT OUT
OPT OUT

If you already have medical coverage under your parent’s, spouse’s or partner’s plan; to receive the $2,000 annual incentive, you must select the option “Medical Plan Opt-out, $2,000 Annual Incentive” during your enrollment window in Connect. (Taxable, paid quarterly through payroll to active employees enrolled in the Opt-Out Incentive for the entire prior quarter.)

If you opt-out of Samuel’s medical coverage, you will be eligible for Health Care FSA and Dependent Care FSA.

Notes
  • The coinsurance percentages shown above apply after the deductible is met, unless otherwise indicated.
  • Certain preventive medications are provided at no cost to you.

Advantages of the HDHP
Of course, you’ll want to choose the plan that best suits your personal needs. However, it’s important to know that the HDHP (Medical Plan #1) offers some key advantages:

  • Samuel pays 100% of the HDHP premiums. That means zero deductions from your paycheck for medical coverage – a significant financial benefit to you!
  • Basic Accident and Critical Illness coverage is included, at no cost to you.
    • Basic Accident Insurance pays up to $1,500 depending on the severity or type of a fracture or dislocation.
    • Basic Critical Illness Insurance pays up to a $5,000 lump sum for specific covered conditions. 
      Examples include:  heart attack, stroke, cancer, or major organ transplant.
Click here for a complete summary of these benefits.

You’ll have access to a Health Savings Account (or HSA), giving you some added flexibility in managing your benefits costs. Your HSA can be used toward a wide range of healthcare expenses (see details here). What’s more, Samuel will contribute up to $1,000 annually to your HSA to help offset your out-of-pocket costs, and you can contribute more to your HSA on a pre-tax basis!


TOBACCO SURCHARGE
Your tobacco status will roll over from 2023. If your status has changed, OE is your only time to update your status.
  • If your tobacco status has changed since last year’s Open Enrollment and you are no longer a tobacco user, but you don’t update your status during Open Enrollment, the only way to remove the $20 per week tobacco surcharge is to complete the tobacco cessation program.
  • Good news! Tobacco users can also earn the non-tobacco user rate by successfully completing the tobacco cessation program. Upon program completion, medical plan contributions will be reduced to the non-tobacco user rates AND tobacco user surcharge paid since the beginning of the year will be refunded. Additional information about the cessation program will be distributed in early 2024.


Medical Plan Rates
Bi-weekly Employee Contributions
Employee
Employee + 1 dependent
Family
In-Network Coverage
MEDICAL PLAN #1:
HDHP
Employee$0.00
Employee + 1 dependent$0.00
Family$0.00
MEDICAL PLAN #2:
HD / PPO
In-Network Coverage
Employee$46.44
Employee + 1 dependent$92.32
Family$140.50
MEDICAL PLAN #3:
Premium PPO
Employee$69.02
Employee + 1 dependent$140.10
Family$210.97

Enrolled employees with an Undisclosed or Tobacco-user status will pay an additional $40 per bi-weekly paycheck.


*Tobacco-User – An Employee who uses a Tobacco Product or Products four or more times per week within the past 6 months by legal users of tobacco products (generally those 18 years and older)

*Tobacco Product – As defined by the US Food and Drug Administration, includes any product made or derived from tobacco intended for human consumption (except products that meet the definition of drugs), including, but not limited to, cigarettes, cigars (including cigarillos and little cigars), dissolvables, hookah tobacco, nicotine gels, pipe tobacco, roll-your-own tobacco, smokeless tobacco products (including dip, snuff, snus, and chewing tobacco), vapes, electronic cigarettes (e-cigarettes), hookah pens, and other electronic nicotine delivery systems.