New Employee Benefits Enrollment - Dow Corning

Cost and Coverage Comparison Chart
This chart provides a comparison of the most frequently utilized services and their associated cost and coverage under each of the Medical
Plans. NOTE: CDHP out-of-pocket maximum includes all co-pays and co-insurances – including prescription drug co-pays. Once the
CDHP out-of-pocket maximum is met, all expenses are covered at 100% including prescription drugs.
Geographic Eligibility All Locations Mid-Michigan Carrollton/
Elizabethtown
Annual Deductible
HSA Dow Corning
Contribution
HSA Employee
Contribution
Out-of-Pocket Limit
BCBS PPO CDHP Option
In Network Out of Network In-Network
Out-of-
Network
$ 250 EE only
$ 500 EE + 1
$ 750 EE + 2/more
$ 1,250 EE only
$ 2,500 EE + 1
$ 3,750 EE + 2/more
$ 500 EE only
$ 1,000 EE + 1
$ 1,500 EE + 2/more
$ 2,500 EE only
$ 5,000 EE + 1
$ 7,500 EE + 2/more
$1,200 Single
$2,400 Family
$500 Single
$1,100 Family
$0 - $2,300 Single
$0 - $4,600 Family
$900 - age 55 catch up
$1,200 Single
$2,400 Family
(see note below)
HealthPlus Anthem BPP
Greensboro
United Healthcare
$ 0 $ 0 $0
Not Applicable
$ 1,500 EE only
$ 3,000 Family
$ 1,500 EE only
$ 3,000 Family
Lifetime Maximum $ 2,000,000 $ 2,000,000 $2,000,000 $ 2,000,000 $ 5,000,000 Unlimited
Office Visits $ 15 co-pay 70% 90% 70% $ 15 co-pay $ 15 co-pay $ 15 co-pay
Urgent Care Facility $ 35 co-pay 70% 90% 70% $ 25 co-pay $ 25 co-pay $ 50 co-pay
X-Ray & Lab 90% 70% 90% 70% 100% 80% 80%
Outpatient Surgery 90% 70% 90% 70% 100% $ 75 co-pay 80%
Inpatient Hospital
Services (including
surgery)
90% 70% 90% 70%
$ 250 co-pay/
admission
$ 250 co-pay/
admission
Note: CDHP out-of-pocket maximum includes all co-pays and co-insurances - including prescription drug co-pays. Once the CDHP out-of-pocket maximum is met, all expenses are
covered at 100% including prescription drugs.
80%
10