Medical Plan Options
Moosilauke Visions is committed to helping you and your dependents maintain health and wellness by providing you with access to the highest levels of care. We offer you a choice of three medical plan options for 2024 – 2025 through HPI (Health Plans Inc.):
| Benefit Description | BRONZE QHDHP | SILVER | GOLD |
|---|---|---|---|
| In-Network | |||
| Plan Year Deductible | $5,000 / $10,000 per member / family | $3,000 / $6,000 per member / family | $1,000 / $2,000 per member / family |
| HSA Employer Contribution | $500 - Individual $1,000 - Family | NONE | NONE |
| Plan Year Out-of-pocket Maximum | $6,000 / $12,000 per member / family | $4,000 / $8,000 per member / family | $2,000 / $4,000 per member / family |
| Coinsurance (what you owe) | 30% | 0% | 0% |
| Preventive and Wellness Care | Covered at No Cost | Covered at No Cost | Covered at No Cost |
| Physician Office Visit | Deductible then 30% | $30 copay | $30 copay |
| Specialist Office Visit | Deductible then 30% | $60 copay | $60 copay |
| Mental Health Visits | Deductible then covered at No Cost | Covered at No Cost | Covered at No Cost |
| Complex Radiology | Deductible then 30% | Deductible then No Cost | Deductible then No Cost |
| Inpatient Hospital Care | Deductible then 30% | Deductible then No Cost | Deductible then No Cost |
| Urgent Care | Deductible then 30% | $60 copay | $60 copay |
| Emergency Room Services | Deductible then 30% | $150 copay waived if admitted | $150 copay waived if admitted |
| Retail Prescription Drugs (30 days) | |||
| Generic | Deductible then $10 copay | $10 copay | $10 copay |
| Formulary | Deductible then $30 copay | $30 copay | $30 copay |
| Non-Formulary | Deductible then $50 copay | $50 copay | $50 copay |
| Preferred Specialty | Deductible then $100 copay | $100 copay | $100 copay |
| Mail Order Prescriptions (90 days) | |||
| Generic | Deductible then $20 copay | $20 copay | $20 copay |
| Formulary | Deductible then $60 copay | $60 copay | $60 copay |
| Non-Formulary | Deductible then $100 copay | $100 copay | $100 copay |
| Preferred Specialty (30 Days) | Deductible then $100 copay | $100 copay | $100 copay |
Employees can elect the medical and prescription drug plan without enrolling in the dental or vision plan.
Biweekly Employee Payroll Contributions
| Employee | Employee & Spouse | Employee & Child(ren) | Employee & Spouse & Child(ren) (Family) |
|
|---|---|---|---|---|
| Medical Bronze QHDHP | ||||
| Less than 2 years of service | $28.25 | $116.81 | $107.36 | $220.08 |
| 2+ Years of service | $28.25 | $59.33 | $53.68 | $84.76 |
| Medical POS Silver | ||||
| Less than 2 years of service | $54.99 | $235.55 | $216.46 | $415.16 |
| 2+ Years of service | $54.99 | $115.47 | $104.46 | $164.96 |
| Medical POS Gold | ||||
| Less than 2 years of service | $77.73 | $282.16 | $259.34 | $485.17 |
| 2+ Years of service | $77.73 | $163.24 | $147.69 | $233.20 |
Your medical plan coverage is administered by Health Plans Inc (HPI).
If you live in Massachusetts, Maine, New Hampshire, or Rhode Island, you will utilize the Harvard Pilgrim Health Care (HPHC) network. If you live in any other state, you will utilize the UnitedHealthcare PPO network. To view in-network providers, review Explanation of Benefits (EOBs), and more, log in to your Health Plans Inc (HPI) account at hpitpa.com or call HPI at 800.532.7575.
Group Number: B69
Use the Emergency Room ONLY for emergencies
What are your options? You may want to consider the following the next time you need care:
Summary of Benefits and Coverage
Visit the Plan Documents and Legal Notices page to view the summary of benefits and coverage for each plan.
Mental Health Resources
Download the Mental Health Flyer