2020 Dow Medical Premiums and Coverage Summary - MAP Plus ...€¦ · Prescription Coverage MAP...

2020 Dow Medical Premiums and Coverage Summary - MAP Plus Plans

Plan Name

Contact Information

Plan Name

Employee Only

Full Time

(Non-tobacco / Tobacco user)

Less Than Full Time: 30 - 39 hours/week




Employee + Spouse/Domestic Partner

Full Time






Employee + Child(ren)

Full Time






Employee + Spouse/DP + Child(ren)

Full Time






Note: If you are paid bi-weekly and would like to calculate your per-pay premium, multiply the monthly premium amount by 12 and divide by 26 (the number of pay periods for 2020).

Plan Name

Network Type In-Network Out-of-Network In-Network Out-of-Network

Deductible: Individual $125 $500 $2,000 $4,000

Deductible: Family EE+1: $250

EE+2 or more: $375

EE+1: $1,000

EE+2 or more: $1,500

Note: Benefits paid based on

Plan Allowable Amount after

annual deductible.

$4,000 with max of $2,800 for

one person

$8,000

Out-of-Pocket Maximum: Individual

(includes deductible)

4% of base salary up to a

maximum of $8,150

8% of base salary $4,000 $8,000

Out-of-Pocket Maximum: Family (includes

deductible)


maximum of $16,300

12% of base salary $8,000 $16,000

Plan Name


Physician Visit $20 primary/$50 specialist

copay

Covered at 70% after

deductible


deductible


deductible

Chiropractic Visit Covered at 85% after

deductible; 30 visit max







Well Baby Care Covered at 100% Covered at 100% Covered at 100% Covered at 100%

Routine Physical Exam Covered at 100% Covered at 100% Covered at 100% Covered at 100%

Routine Gynecological Exam Covered at 100% Covered at 100% Covered at 100% Covered at 100%

Routine Mammography Covered at 100% Covered at 100% Covered at 100% Covered at 100%

Telemedicine $20 copay N/A $40 consult fee until deductible

is met, then subject to

coinsurance

N/A

Plan Name


Pre/Post-Natal Maternity office visit Covered at 100% Covered at 100% Covered at 100% Covered at 100%

Maternity: Inpatient Delivery $250 copay, covered at 85%

after deductible


deductible


deductible


deductible

Plan Costs

Plan Basics

MAP Plus - Option 1 Low Deductible MAP Plus - Option 2 High Deductible

888-488-4488

610-336-1000 outside U.S.

www.aetna.com

888-488-4488

610-336-1000 outside U.S.

www.aetna.com


$129 / $179 $30 / $80

$170 / $220 $75 / $125

$341 / $391 $151 / $201

$296 / $346 $69 / $119

$341 / $391 $151 / $201

$683 / $733 $302 / $352

$254 / $304 $59 / $109

$293 / $343 $129 / $179

$587 / $637 $259 / $309

$436 / $486 $101 / $151

$504 / $554 $222 / $272

$1,008 / $1,058 $445 / $495

Annual Plan Limits


Office Visits


Maternity Care


2020 Dow Medical Premiums and Coverage Summary - MAP Plus Plans

Plan Name


Inpatient Hospital $250 copay, covered at 85%

after deductible


deductible


deductible


deductible

Emergency Room $100 copay, covered at 85%

after deductible

$100 copay, covered at 85%

after deductible


deductible


deductible

Outpatient Surgery: Hospital Covered at 85% after

deductible


deductible


deductible


deductible

Outpatient X-Ray Covered at 85% after

deductible


deductible


deductible


deductible

Outpatient Lab Covered at 100% Covered at 70% after

deductible


deductible


deductible

Urgent Care $20 copay after deductible Covered at 70% after

deductible


deductible


deductible

Plan Name


Mental Health: Inpatient $250 copay; covered at 85%

after deductible


deductible


deductible


deductible

Mental Health: Outpatient $20 copay Covered at 70% after

deductible


deductible


deductible

Substance Abuse: Inpatient $250 copay; covered at 85%

after deductible


deductible


deductible


deductible

Substance Abuse: Outpatient $20 copay Covered at 70% after

deductible


deductible


deductible

Plan Name


Durable Medical Equipment and Maximum Covered at 85% after

deductible


deductible


deductible


deductible

Plan Name


Important Information

Pharmacy Limits

Pharmacy: Generic Drug Covered at 80% after

deductible

Covered at 80% up to the Plan

Allowable Amount after

deductible


deductible


deductible

Pharmacy: Brand Name Covered at 80% preferred

brand/70% non-preferred

brand after deductible

Covered at 80% preferred

brand/70% non-preferred

brand (after deductible) of Plan

Allowable Amount


deductible


deductible, no coverage for

Specialty Rx if non-network

pharmacy is used

Mail Order Limits

Mail Order

Content Steward: Dow North America Benefits | 833-MYDOWHR Lit# 165-02074

Hospital Services

Ancillary Services


Prescription Coverage



Mental Health / Substance Abuse


If a generic drug is available, you are responsible for the

generic coinsurance plus the difference in cost between the

brand-name and generic drug, plus any deductible.

After an initial retail prescription and two refills, coinsurance will

go up to 50% unless you use mail order. This does not apply to

your Out-of-Pocket Maximum.

Certain drugs require pre-certification and/or step therapy.

Specialty drug cost sharing differs.

Certain preventive medications are covered with no deductible

(in-network 80% and out-of-network 60%).

If a generic drug is available, you are responsible for the

generic coinsurance plus the difference in cost between the

brand-name and generic drug, plus any deductible.


Rx deductible: $100/$200/$300

Rx Out-of-Pocket Max combined with medical

The foregoing descriptions provide only general information about Dow’s applicable compensation and benefits programs. You should refer to the plan document and summary plan description of the applicable plan for a more complete

description of the plan’s terms. If there is any conflict between the information provided above and the plan document or summary plan description for the applicable plan, the plan document or summary plan description will govern. This

summary in no way alters any employee’s status as an “at will” employee of Dow and does not create any third-party beneficiary rights, or any right to employment or continued employment with Dow or any of its affiliates. Dow reserves

the right to amend or terminate the terms of the foregoing plans in accordance with their terms.

Deductible and Out-of-Pocket Maximum combined with

medical

Rx deductible: None


Deductible and Out-of-Pocket Maximum combined with

medical

Covered at 80% generic and preferred brand, 70% non-

preferred brand

Covered at 80% after deductible

2020 Dow Medical Premiums and Coverage Summary - Illinois

Plan Name CIGNA HMO National

Contact Information800-CIGNA24 (244-6224)

www.cigna.com


Employee Only

Full Time

(Non-tobacco / Tobacco user)$122 / $172






Full Time







Full Time







Full Time





(Non-tobacco / Tobacco user)$997 / $1,047



Network Type In-Network Out-of-Network In-Network Out-of-Network In-Network

Deductible: Individual $125 $500 $2,000 $4,000 $250


EE+2 or more: $375

EE+1: $1,000


Note: Benefits paid

based on Plan Allowable

Amount after annual

deductible.

$4,000 with max of

$2,800 for one person

$8,000 $500



4% of base salary up to

a maximum of $8,150

8% of base salary $4,000 $8,000 $3,000

Out-of-Pocket Maximum: Family



a maximum of $16,300

12% of base salary $8,000 $16,000 $6,000



Physician Visit $20 primary/$50

specialist copay


deductible


deductible


deductible

$20 copay (PCP), $35 copay

(specialist)









$35 copay; 60 days combined

Well Baby Care Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100%

Routine Physical Exam Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100%

Routine Gynecological Exam Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100%

Routine Mammography Covered at 100% Covered at 100% Covered at 100% Covered at 100% Covered at 100%

Telemedicine $20 copay N/A $40 consult fee until

deductible is met, then

subject to coinsurance

N/A $20 copay



Pre/Post-Natal Maternity office visit Covered at 100% Covered at 100% Covered at 100% Covered at 100% $20 copay for initial visit;

remaining pre/post-natal visits

covered at 90% after deductible

Maternity: Inpatient Delivery $250 copay, covered at

85% after deductible


deductible


deductible


deductible


Office Visits

Maternity Care

888-488-4488

610-336-1000 outside U.S.

www.aetna.com


888-488-4488

610-336-1000 outside U.S.

www.aetna.com

$504 / $554

$1,008 / $1,058

$254 / $304

$293 / $343

MAP Plus - Option 2 High Deductible



$445 / $495

$69 / $119

$59 / $109

$129 / $179

$259 / $309

$101 / $151

$222 / $272

Annual Plan Limits

$341 / $391

$683 / $733

$151 / $201

$302 / $352

$341 / $391

$296 / $346

$151 / $201

$129 / $179

$170 / $220

$30 / $80

$75 / $125

MAP Plus - Option 1 Low Deductible

Plan Basics

Plan Costs



$587 / $637

$436 / $486

2020 Dow Medical Premiums and Coverage Summary - Illinois



Inpatient Hospital $250 copay, covered at



deductible


deductible


deductible


Emergency Room $100 copay, covered at


$100 copay, covered at



deductible


deductible

$100 copay, waived if admitted


deductible


deductible


deductible


deductible



deductible


deductible


deductible


deductible

Covered at 100% in doctor's

office or independent lab;


at outpatient facility


deductible


deductible


deductible





Urgent Care $20 copay after

deductible


deductible


deductible


deductible

$50 copay



Mental Health: Inpatient $250 copay; covered at



deductible


deductible


deductible



deductible


deductible


deductible

$20 copay for office visit, 10%

coinsurance for other services

Substance Abuse: Inpatient $250 copay; covered at



deductible


deductible


deductible



deductible


deductible


deductible





Durable Medical Equipment and

Maximum


deductible


deductible


deductible


deductible

Covered at 100%



Important Information Pharmacy out-of-pocket is

combined with medical

Pharmacy Limits


deductible

Covered at 80% up to

the Plan Allowable

Amount after deductible


deductible


deductible

Greater of 20% or $7; $100

copay maximum per script; 30-

day supply

Pharmacy: Brand Name Covered at 80%

preferred brand/70%

non-preferred brand

after deductible

Covered at 80%

preferred brand/70%

non-preferred brand

(after deductible) of Plan

Allowable Amount


deductible


deductible, no coverage

for Specialty Rx if non-

network pharmacy is

used

Greater of 30% or $30

formulary, greater of 40% or $50

non-formulary; $100 copay

maximum per script; 30-day

supply (open formulary)

Mail Order Limits 90-day supply limit on all mail

order drugs

Mail Order Greater of 20% or $16 generic,

greater of 30% or $85 formulary

brand, greater of 40% or $145

non-formulary brand; $200

copay maximum per script


Hospital Services


Ancillary Services



The foregoing descriptions provide only general information about Dow’s applicable compensation and benefits programs. You should refer to the plan document and summary plan description of the applicable plan for a more complete description of

the plan’s terms. If there is any conflict between the information provided above and the plan document or summary plan description for the applicable plan, the plan document or summary plan description will govern. This summary in no way alters

any employee’s status as an “at will” employee of Dow and does not create any third-party beneficiary rights, or any right to employment or continued employment with Dow or any of its affiliates. Dow reserves the right to amend or terminate the

terms of the foregoing plans in accordance with their terms.

Covered at 80% generic and preferred brand,

70% non-preferred brand


Rx deductible: None


Deductible and Out-of-Pocket Maximum








If a generic drug is available, you are responsible

for the generic coinsurance plus the difference in

cost between the brand-name and generic drug,

plus any deductible.

After an initial retail prescription and two refills,

coinsurance will go up to 50% unless you use mail

order. This does not apply to your Out-of-Pocket

Maximum.

Certain drugs require pre-certification and/or step

therapy. Specialty drug cost sharing differs.

Certain preventive medications are covered with

no deductible (in-network 80% and out-of-network

60%).






therapy.



2020 Dow Medical Premiums and Coverage Summary - Louisiana

Plan Name Humana Health Plan of LA

Contact Information800-448-6262

www.humana.com


Employee Only

Full Time







Full Time







Full Time







Full Time









Deductible: Individual $125 $500 $2,000 $4,000 None


EE+2 or more: $375

EE+1: $1,000


Note: Benefits paid


Amount after annual

deductible.

$4,000 with max of


$8,000 None




a maximum of $8,150

8% of base salary $4,000 $8,000 $6,350 total ($2,500 medical

only)





12% of base salary $8,000 $16,000 $12,700 total ($7,500 medical

only)




specialist copay


deductible


deductible


deductible

$20 copay (PCP): $35 copay

(Specialist)









$20 copay








N/A $20 copay



Pre/Post-Natal Maternity office visit Covered at 100% Covered at 100% Covered at 100% Covered at 100% $50 copay (initial visit only)




deductible


deductible


deductible

$200 copay/day, $600

max/admission (combined mom

& baby); copay for baby if stays

in hospital after mom released

Plan Basics


$170 / $220 $75 / $125

$341 / $391 $151 / $201

$296 / $346 $69 / $119

888-488-4488

610-336-1000 outside U.S.

www.aetna.com

888-488-4488

610-336-1000 outside U.S.

www.aetna.com

$341 / $391 $151 / $201

$683 / $733 $302 / $352

$254 / $304 $59 / $109

Plan Costs


$129 / $179 $30 / $80

$293 / $343 $129 / $179

$587 / $637 $259 / $309

$504 / $554 $222 / $272

$1,008 / $1,058 $445 / $495

Annual Plan Limits

$436 / $486 $101 / $151



Maternity Care

Office Visits


2020 Dow Medical Premiums and Coverage Summary - Michigan

Plan NameBlue Care Network of

Michigan

Contact Information800-662-6667

www.bcbsm.com


Michigan

Employee Only

Full Time







Full Time







Full Time







Full Time








Michigan




EE+2 or more: $375

EE+1: $1,000


Note: Benefits paid

based on Plan


annual deductible.

$4,000 with max of


$8,000 None




a maximum of $8,150

8% of base salary $4,000 $8,000 $6,450





12% of base salary $8,000 $16,000 $12,900


Michigan



specialist copay


deductible


deductible


deductible

$15 copay (PCP); $30 copay

(specialist)

Dow Family Health Center Physician

Visit

$10 copay N/A Subject to deductible

and coinsurance

N/A $10 copay









$30 copay








N/A N/A


Michigan


Pre/Post-Natal Maternity office visit Covered at 100% Covered at 100% Covered at 100% Covered at 100% $0 copay routine pre-natal visit;

$15 copay post-natal visit




deductible


deductible


deductible

$250 copay/admission


Maternity Care



Office Visits

$504 / $554 $222 / $272

$1,008 / $1,058 $445 / $495

Annual Plan Limits

$293 / $343 $129 / $179

$587 / $637 $259 / $309

$436 / $486 $101 / $151

$341 / $391 $151 / $201

$683 / $733 $302 / $352

$254 / $304 $59 / $109

$170 / $220 $75 / $125

$341 / $391 $151 / $201

$296 / $346 $69 / $119

888-488-4488

610-336-1000 outside U.S.

www.aetna.com

888-488-4488

610-336-1000 outside U.S.

www.aetna.com

Plan Costs


$129 / $179 $30 / $80

Plan Basics


2020 Dow Medical Premiums and Coverage Summary - Michigan


Michigan





deductible


deductible


deductible

$250 copay






deductible


deductible

$100 copay, waived if admitted,

however, inpatient copay will

apply


deductible


deductible


deductible


deductible

$100 copay


deductible


deductible


deductible


deductible

Covered at 100%


deductible


deductible


deductible

Covered at 100%


deductible


deductible


deductible


deductible

$15 copay


Michigan





deductible


deductible


deductible

Covered at 100% when

authorized; unlimited days


deductible


deductible


deductible

$15 copay when authorized;

unlimited visits




deductible


deductible


deductible

Covered at 100% when

authorized; unlimited days


deductible


deductible


deductible

$15 copay when authorized;

unlimited visits


Michigan



Maximum


deductible


deductible


deductible


deductible

Covered at 80%


Michigan



Pharmacy Limits


deductible


the Plan Allowable



deductible


deductible

$10 copay, 30-day supply


preferred brand/70%

non-preferred brand

after deductible

Covered at 80%

preferred brand/70%

non-preferred brand

(after deductible) of

Plan Allowable Amount


deductible




network pharmacy is

used

$20 formulary copay, non-

formulary not covered, 30-day

supply (closed formulary)

Dow Family Health Center Pharmacy $2 copay per script.

For maintenance

medication, available for

up to 3 fills. After 3 fills,

must switch to mail

order pharmacy. For

non-maintenance Rx,

$2 copay per script,

subject to certain Rx

N/A Before deductible,

scheduled cost of drug.

After deductible, $2

copay per script

N/A $2 for covered and carried

pharmacy drugs

Mail Order Limits

Mail Order $20 generic, $40 formulary, non-

formulary not covered, 90 day

supply


The foregoing descriptions provide only general information about Dow’s applicable compensation and benefits programs. You should refer to the plan document and summary plan description of the applicable plan for a more complete description of the

plan’s terms. If there is any conflict between the information provided above and the plan document or summary plan description for the applicable plan, the plan document or summary plan description will govern. This summary in no way alters any

employee’s status as an “at will” employee of Dow and does not create any third-party beneficiary rights, or any right to employment or continued employment with Dow or any of its affiliates. Dow reserves the right to amend or terminate the terms of the

foregoing plans in accordance with their terms.





Rx deductible: None













coinsurance will go up to 50% unless you use

mail order. This does not apply to your Out-of-

Pocket Maximum.




no deductible (in-network 80% and out-of-

network 60%).






therapy.




Ancillary Services



Hospital Services

2020 Dow Medical Premiums and Coverage Summary - Louisiana






deductible


deductible


deductible

$200 copay per day, $600 per

admission maximum






deductible


deductible



deductible


deductible


deductible


deductible

$200 copay


deductible


deductible


deductible


deductible

Covered at 100%


deductible


deductible


deductible

Covered at 100%


deductible


deductible


deductible


deductible

$35 copay






deductible


deductible


deductible

$200 copay per day, $600 per

admission maximum; unlimited

days


deductible


deductible


deductible

$20 copay




deductible


deductible


deductible

$200 copay per day; $600 per

admission maximum; unlimited

days


deductible


deductible


deductible

$20 copay




Maximum


deductible


deductible


deductible


deductible

Covered at 80%




Pharmacy Limits Out-of-pocket combined with

medical


deductible


the Plan Allowable



deductible


deductible

$10 copay (level one low-cost

generics), 30-day supply


preferred brand/70%

non-preferred brand

after deductible

Covered at 80%

preferred brand/70%

non-preferred brand


Allowable Amount


deductible




network pharmacy is

used

$30 (level two high-cost generic

and brand name drugs), $50

(level three higher-cost brand

name drugs); 25% (level four

specialty medications), 30-day

supply (closed formulary)

Mail Order Limits

Mail Order $25 level one; $75 level two;

$125 level three, 90-day supply


Hospital Services




Ancillary ServicesMAP Plus - Option 1 Low Deductible MAP Plus - Option 2 High Deductible



the plan’s terms. If there is any conflict between the information provided above and the plan document or summary plan description for the applicable plan, the plan document or summary plan description will govern. This summary in no way alters

any employee’s status as an “at will” employee of Dow and does not create any third-party beneficiary rights, or any right to employment or continued employment with Dow or any of its affiliates. Dow reserves the right to amend or terminate the terms

of the foregoing plans in accordance with their terms.





Rx deductible: None















Maximum.





60%).






therapy.

2020 Dow Medical Premiums and Coverage Summary - New Jersey



www.cigna.com


Employee Only

Full Time







Full Time







Full Time







Full Time











EE+2 or more: $375

EE+1: $1,000


Note: Benefits paid


Amount after annual

deductible.

$4,000 with max of


$8,000 $500




a maximum of $8,150

8% of base salary $4,000 $8,000 $3,000





12% of base salary $8,000 $16,000 $6,000




specialist copay


deductible


deductible


deductible


(specialist)

















N/A $20 copay









deductible


deductible


deductible


Plan Basics


$170 / $220 $75 / $125

$341 / $391 $151 / $201

$296 / $346 $69 / $119

888-488-4488

610-336-1000 outside U.S.

www.aetna.com

888-488-4488

610-336-1000 outside U.S.

www.aetna.com

$341 / $391 $151 / $201

$683 / $733 $302 / $352

$254 / $304 $59 / $109

Plan Costs


$129 / $179 $30 / $80

$293 / $343 $129 / $179

$587 / $637 $259 / $309

$504 / $554 $222 / $272

$1,008 / $1,058 $445 / $495

Annual Plan Limits

$436 / $486 $101 / $151



Maternity Care

Office Visits


2020 Dow Medical Premiums and Coverage Summary - New Jersey






deductible


deductible


deductible







deductible


deductible



deductible


deductible


deductible


deductible



deductible


deductible


deductible


deductible






deductible


deductible


deductible






deductible


deductible


deductible


deductible

$50 copay






deductible


deductible


deductible



deductible


deductible


deductible






deductible


deductible


deductible



deductible


deductible


deductible






Maximum


deductible


deductible


deductible


deductible

Covered at 100%





Pharmacy Limits


deductible


the Plan Allowable



deductible


deductible



day supply


preferred brand/70% non-

preferred brand after

deductible

Covered at 80%


preferred brand (after

deductible) of Plan

Allowable Amount


deductible




network pharmacy is

used

Greater of 30% or $30 formulary,

greater of 40% or $50 non-

formulary; $100 copay maximum

per script; 30-day supply (open

formulary)


order drugs




non-formulary brand; $200 copay

maximum per script


Hospital ServicesMAP Plus - Option 1 Low Deductible MAP Plus - Option 2 High Deductible

Mental Health / Substance AbuseMAP Plus - Option 1 Low Deductible MAP Plus - Option 2 High Deductible



The foregoing descriptions provide only general information about Dow’s applicable compensation and benefits programs. You should refer to the plan document and summary plan description of the applicable plan for a more complete description

of the plan’s terms. If there is any conflict between the information provided above and the plan document or summary plan description for the applicable plan, the plan document or summary plan description will govern. This summary in no way

alters any employee’s status as an “at will” employee of Dow and does not create any third-party beneficiary rights, or any right to employment or continued employment with Dow or any of its affiliates. Dow reserves the right to amend or terminate

the terms of the foregoing plans in accordance with their terms.



Deductible and Out-of-Pocket Maximum combined

with medical

Rx deductible: None



with medical

Covered at 80% generic and preferred brand, 70%

non-preferred brand










Maximum.



Certain preventive medications are covered with no

deductible (in-network 80% and out-of-network

60%).






therapy.

2020 Dow Medical Premiums and Coverage Summary - North Carolina



www.cigna.com


Employee Only

Full Time







Full Time







Full Time







Full Time











EE+2 or more: $375

EE+1: $1,000


Note: Benefits paid


Amount after annual

deductible.

$4,000 with max of


$8,000 $500




a maximum of $8,150

8% of base salary $4,000 $8,000 $3,000





12% of base salary $8,000 $16,000 $6,000




specialist copay


deductible


deductible


deductible


(specialist)

















N/A $20 copay









deductible


deductible


deductible



Maternity Care



Office Visits

$504 / $554 $222 / $272

$1,008 / $1,058 $445 / $495

Annual Plan Limits

$293 / $343 $129 / $179

$587 / $637 $259 / $309

$436 / $486 $101 / $151

$341 / $391 $151 / $201

$683 / $733 $302 / $352

$254 / $304 $59 / $109

$170 / $220 $75 / $125

$341 / $391 $151 / $201

$296 / $346 $69 / $119

888-488-4488

610-336-1000 outside U.S.

www.aetna.com

888-488-4488

610-336-1000 outside U.S.

www.aetna.com

Plan Costs


$129 / $179 $30 / $80

Plan Basics


2020 Dow Medical Premiums and Coverage Summary - North Carolina






deductible


deductible


deductible







deductible


deductible



deductible


deductible


deductible


deductible



deductible


deductible


deductible


deductible






deductible


deductible


deductible






deductible


deductible


deductible


deductible

$50 copay






deductible


deductible


deductible



deductible


deductible


deductible






deductible


deductible


deductible



deductible


deductible


deductible






Maximum


deductible


deductible


deductible


deductible

Covered at 100%





Pharmacy Limits


deductible


the Plan Allowable



deductible


deductible



day supply




deductible

Covered at 80%



deductible) of Plan

Allowable Amount


deductible




network pharmacy is

used





formulary)


order drugs





maximum per script









with medical

Rx deductible: None



with medical


non-preferred brand










Maximum.





60%).






therapy.




Ancillary Services



Hospital Services

2020 Dow Medical Premiums and Coverage Summary - Ohio



www.cigna.com


Employee Only

Full Time







Full Time







Full Time







Full Time











EE+2 or more: $375

EE+1: $1,000


Note: Benefits paid


Amount after annual

deductible.

$4,000 with max of


$8,000 $500




a maximum of $8,150

8% of base salary $4,000 $8,000 $3,000





12% of base salary $8,000 $16,000 $6,000




specialist copay


deductible


deductible


deductible


(specialist)

















N/A $20 copay









deductible


deductible


deductible



Maternity Care



Office Visits

$504 / $554 $222 / $272

$1,008 / $1,058 $445 / $495

Annual Plan Limits

$293 / $343 $129 / $179

$587 / $637 $259 / $309

$436 / $486 $101 / $151

$341 / $391 $151 / $201

$683 / $733 $302 / $352

$254 / $304 $59 / $109

$170 / $220 $75 / $125

$341 / $391 $151 / $201

$296 / $346 $69 / $119

888-488-4488

610-336-1000 outside U.S.

www.aetna.com

888-488-4488

610-336-1000 outside U.S.

www.aetna.com

Plan Costs


$129 / $179 $30 / $80

Plan Basics


2020 Dow Medical Premiums and Coverage Summary - Ohio






deductible


deductible


deductible







deductible


deductible



deductible


deductible


deductible


deductible



deductible


deductible


deductible


deductible






deductible


deductible


deductible






deductible


deductible


deductible


deductible

$50 copay






deductible


deductible


deductible



deductible


deductible


deductible






deductible


deductible


deductible



deductible


deductible


deductible






Maximum


deductible


deductible


deductible


deductible

Covered at 100%





Pharmacy Limits


deductible


the Plan Allowable



deductible


deductible



day supply




deductible

Covered at 80%



deductible) of Plan

Allowable Amount


deductible




network pharmacy is

used





formulary)


order drugs





maximum per script









with medical

Rx deductible: None



with medical


non-preferred brand










Maximum.





60%).






therapy.




Ancillary Services



Hospital Services

2020 Dow Medical Premiums and Coverage Summary - Pennsylvania

Plan Name

Contact Information

Plan Name

Employee Only

Full Time







Full Time







Full Time







Full Time







Plan Name


Deductible: Individual $125 $500 $2,000 $4,000


EE+2 or more: $375

EE+1: $1,000


Note: Benefits paid based on

Plan Allowable Amount after

annual deductible.

$4,000 with max of $2,800 for

one person

$8,000

Out-of-Pocket Maximum: Individual (includes

deductible)


maximum of $8,150

8% of base salary $4,000 $8,000

Out-of-Pocket Maximum: Family (includes

deductible)


maximum of $16,300

12% of base salary $8,000 $16,000

Plan Name


Physician Visit $20 primary/$50 specialist

copay

Covered at 70% after deductible Covered at 80% after deductible Covered at 60% after deductible

Dow Family Health Center Physician Visit $10 copay N/A Subject to deductible and

coinsurance

N/A









Well Baby Care Covered at 100% Covered at 100% Covered at 100% Covered at 100%

Routine Physical Exam Covered at 100% Covered at 100% Covered at 100% Covered at 100%

Routine Gynecological Exam Covered at 100% Covered at 100% Covered at 100% Covered at 100%

Routine Mammography Covered at 100% Covered at 100% Covered at 100% Covered at 100%

Telemedicine $20 copay N/A $40 consult fee until deductible

is met, then subject to

coinsurance

N/A

Plan Name


Pre/Post-Natal Maternity office visit Covered at 100% Covered at 100% Covered at 100% Covered at 100%

Maternity: Inpatient Delivery $250 copay, covered at 85%

after deductible


Maternity Care


$170 / $220 $75 / $125

$341 / $391 $151 / $201

$296 / $346 $69 / $119

888-488-4488

610-336-1000 outside U.S.

www.aetna.com

888-488-4488

610-336-1000 outside U.S.

www.aetna.com


$129 / $179 $30 / $80

Plan Costs

Plan Basics

$293 / $343 $129 / $179

$587 / $637 $259 / $309

$436 / $486 $101 / $151

$341 / $391 $151 / $201

$683 / $733 $302 / $352

$254 / $304 $59 / $109

$504 / $554 $222 / $272

$1,008 / $1,058 $445 / $495

Annual Plan Limits


Office Visits



2020 Dow Medical Premiums and Coverage Summary - Pennsylvania

Plan Name


Inpatient Hospital $250 copay, covered at 85%

after deductible


Emergency Room $100 copay, covered at 85%

after deductible

$100 copay, covered at 85%

after deductible

Covered at 80% after deductible Covered at 80% after deductible

Outpatient Surgery: Hospital Covered at 85% after deductible Covered at 70% after deductible Covered at 80% after deductible Covered at 60% after deductible

Outpatient X-Ray Covered at 85% after deductible Covered at 70% after deductible Covered at 80% after deductible Covered at 60% after deductible

Outpatient Lab Covered at 100% Covered at 70% after deductible Covered at 80% after deductible Covered at 60% after deductible

Urgent Care $20 copay after deductible Covered at 70% after deductible Covered at 80% after deductible Covered at 60% after deductible

Plan Name


Mental Health: Inpatient $250 copay; covered at 85%

after deductible


Mental Health: Outpatient $20 copay Covered at 70% after deductible Covered at 80% after deductible Covered at 60% after deductible

Substance Abuse: Inpatient $250 copay; covered at 85%

after deductible


Substance Abuse: Outpatient $20 copay Covered at 70% after deductible Covered at 80% after deductible Covered at 60% after deductible

Plan Name


Durable Medical Equipment and Maximum Covered at 85% after deductible Covered at 70% after deductible Covered at 80% after deductible Covered at 60% after deductible

Plan Name



Pharmacy Limits

Pharmacy: Generic Drug Covered at 80% after deductible Covered at 80% up to the Plan


deductible

Covered at 80% after deductible Covered at 60% after deductible

Pharmacy: Brand Name Covered at 80% preferred

brand/70% non-preferred brand

after deductible

Covered at 80% preferred

brand/70% non-preferred brand


Allowable Amount

Covered at 80% after deductible Covered at 60% after

deductible, no coverage for

Specialty Rx if non-network

pharmacy is used

Dow Family Health Center Pharmacy $2 copay per script. For

maintenance medication,

available for up to 3 fills. After 3

fills, must switch to mail order

pharmacy. For non-

maintenance Rx, $2 copay per

script, subject to certain Rx

N/A Before deductible, scheduled

cost of drug. After deductible,

$2 copay per script

N/A

Mail Order Limits

Mail Order






Hospital Services


Ancillary Services







Deductible and Out-of-Pocket Maximum combined with medical

Rx deductible: None


Deductible and Out-of-Pocket Maximum combined with medical

Covered at 80% generic and preferred brand, 70% non-preferred

brand



If a generic drug is available, you are responsible for the generic

coinsurance plus the difference in cost between the brand-name

and generic drug, plus any deductible.

After an initial retail prescription and two refills, coinsurance will

go up to 50% unless you use mail order. This does not apply to

your Out-of-Pocket Maximum.


Specialty drug cost sharing differs.

Certain preventive medications are covered with no deductible

(in-network 80% and out-of-network 60%).

If a generic drug is available, you are responsible for the generic

coinsurance plus the difference in cost between the brand-name

and generic drug, plus any deductible.


2020 Dow Medical Premiums and Coverage Summary - Puerto Rico

Plan Name TRIPLE-S, Inc

Contact Information1-787-774-6060

www.ssspr.com


Employee Only

Full Time







Full Time







Full Time







Full Time











EE+2 or more: $375

EE+1: $1,000


Note: Benefits paid


Amount after annual

deductible.

$4,000 with max of


$8,000 None




a maximum of $8,150

8% of base salary $4,000 $8,000 $2,000 for major medical; $6,350

total





12% of base salary $8,000 $16,000 $6,000 for major medical;

$12,700 total




specialist copay


deductible


deductible


deductible

$15 copay (PCP); $20 copay

(specialist)









$15 copay through Triple-S

Natural Program




Routine Mammography Covered at 100% Covered at 100% Covered at 100% Covered at 100% 25% coinsurance; or covered at

100% if preventive




N/A N/A



Pre/Post-Natal Maternity office visit Covered at 100% Covered at 100% Covered at 100% Covered at 100% $20 copay per visit




deductible


deductible


deductible

$200 copay/admission

(combined mom & baby)

Plan Basics


$170 / $220 $75 / $125

$341 / $391 $151 / $201

$296 / $346 $69 / $119

888-488-4488

610-336-1000 outside U.S.

www.aetna.com

888-488-4488

610-336-1000 outside U.S.

www.aetna.com

$341 / $391 $151 / $201

$683 / $733 $302 / $352

$254 / $304 $59 / $109

Plan Costs


$129 / $179 $30 / $80

$293 / $343 $129 / $179

$587 / $637 $259 / $309

$504 / $554 $222 / $272

$1,008 / $1,058 $445 / $495

Annual Plan Limits

$436 / $486 $101 / $151



Maternity Care

Office Visits


2020 Dow Medical Premiums and Coverage Summary - Puerto Rico






deductible


deductible


deductible

$200 copay per admission






deductible


deductible

$50/illness or accident (waived if

admitted); No charge if

recommended by Teleconsulta


deductible


deductible


deductible


deductible

Covered at 100%


deductible


deductible


deductible


deductible

25% coinsurance


deductible


deductible


deductible

25% coinsurance


deductible


deductible


deductible


deductible

N/A






deductible


deductible


deductible

$200 copay per admission, $50

copay per partial admission


deductible


deductible


deductible

$5 group, $20 individual




deductible


deductible


deductible

$200 copay per admission, $50

copay per partial admission


deductible


deductible


deductible

$5 group, $20 individual




Maximum


deductible


deductible


deductible


deductible

25% coinsurance




Pharmacy Limits


deductible


the Plan Allowable



deductible


deductible

$5 copay: Level 1 Preferred

Generics & Level 2 Non-

Preferred Generics; 30 day

supply




deductible

Covered at 80%



deductible) of Plan

Allowable Amount


deductible




network pharmacy is

used

$10 copay: Level 3 Preferred

Brand; $15 copay: Level 4 Non-

Preferred Brand; 20%

coinsurance, $15 min copay:

Level 5 Preferred Specialty &

Level 6 Non-Preferred Specialty;

30 day supply

Mail Order Limits

Mail Order $10 copay: Level 1 Preferred

Generic & Level 2 Non-Preferred

Generic; $20 copay: Level 3

Preferred Brand; $45 copay:

Level 4 Non-Preferred Brand; 90

day supply







the plan’s terms. If there is any conflict between the information provided above and the plan document or summary plan description for the applicable plan, the plan document or summary plan description will govern. This summary in no way alters any

employee’s status as an “at will” employee of Dow and does not create any third-party beneficiary rights, or any right to employment or continued employment with Dow or any of its affiliates. Dow reserves the right to amend or terminate the terms of

the foregoing plans in accordance with their terms.




with medical

Rx deductible: None



with medical


non-preferred brand










Maximum.





60%).






therapy.

2020 Dow Medical Premiums and Coverage Summary - South Carolina



www.cigna.com


Employee Only

Full Time







Full Time







Full Time







Full Time











EE+2 or more: $375

EE+1: $1,000


Note: Benefits paid


Amount after annual

deductible.

$4,000 with max of


$8,000 $500




a maximum of $8,150

8% of base salary $4,000 $8,000 $3,000





12% of base salary $8,000 $16,000 $6,000




specialist copay


deductible


deductible


deductible


(specialist)

















N/A $20 copay









deductible


deductible


deductible



Maternity Care



Office Visits

$504 / $554 $222 / $272

$1,008 / $1,058 $445 / $495

Annual Plan Limits

$293 / $343 $129 / $179

$587 / $637 $259 / $309

$436 / $486 $101 / $151

$341 / $391 $151 / $201

$683 / $733 $302 / $352

$254 / $304 $59 / $109

$170 / $220 $75 / $125

$341 / $391 $151 / $201

$296 / $346 $69 / $119

888-488-4488

610-336-1000 outside U.S.

www.aetna.com

888-488-4488

610-336-1000 outside U.S.

www.aetna.com

Plan Costs


$129 / $179 $30 / $80

Plan Basics


2020 Dow Medical Premiums and Coverage Summary - South Carolina






deductible


deductible


deductible







deductible


deductible



deductible


deductible


deductible


deductible



deductible


deductible


deductible


deductible






deductible


deductible


deductible






deductible


deductible


deductible


deductible

$50 copay






deductible


deductible


deductible



deductible


deductible


deductible






deductible


deductible


deductible



deductible


deductible


deductible






Maximum


deductible


deductible


deductible


deductible

Covered at 100%





Pharmacy Limits


deductible


the Plan Allowable



deductible


deductible



day supply




deductible

Covered at 80%



deductible) of Plan

Allowable Amount


deductible




network pharmacy is

used





formulary)


order drugs





maximum per script









with medical

Rx deductible: None



with medical


non-preferred brand










Maximum.



Certain preventive medications are covered with no

deductible (in-network 80% and out-of-network

60%).






therapy.




Ancillary Services



Hospital Services

2020 Dow Medical Premiums and Coverage Summary - Texas



www.cigna.com


Employee Only

Full Time







Full Time







Full Time







Full Time











EE+2 or more: $375

EE+1: $1,000


Note: Benefits paid


Amount after annual

deductible.

$4,000 with max of


$8,000 $500




a maximum of $8,150

8% of base salary $4,000 $8,000 $3,000





12% of base salary $8,000 $16,000 $6,000




specialist copay


deductible


deductible


deductible


(specialist)

Dow Family Health Center Physician

Visit

$10 copay N/A Subject to deductible

and coinsurance

N/A $10 copay

















N/A $20 copay









deductible


deductible


deductible


Plan Basics


$170 / $220 $75 / $125

$341 / $391 $151 / $201

$296 / $346 $69 / $119

888-488-4488

610-336-1000 outside U.S.

www.aetna.com

888-488-4488

610-336-1000 outside U.S.

www.aetna.com

Plan Costs


$129 / $179 $30 / $80

$293 / $343 $129 / $179

$587 / $637 $259 / $309

$436 / $486 $101 / $151

$341 / $391 $151 / $201

$683 / $733 $302 / $352

$254 / $304 $59 / $109

$504 / $554 $222 / $272

$1,008 / $1,058 $445 / $495

Annual Plan LimitsMAP Plus - Option 1 Low Deductible MAP Plus - Option 2 High Deductible

Office VisitsMAP Plus - Option 1 Low Deductible MAP Plus - Option 2 High Deductible


Maternity Care

2020 Dow Medical Premiums and Coverage Summary - Texas






deductible


deductible


deductible







deductible


deductible



deductible


deductible


deductible


deductible



deductible


deductible


deductible


deductible






deductible


deductible


deductible






deductible


deductible


deductible


deductible

$50 copay






deductible


deductible


deductible



deductible


deductible


deductible






deductible


deductible


deductible



deductible


deductible


deductible






Maximum


deductible


deductible


deductible


deductible

Covered at 100%





Pharmacy Limits


deductible


the Plan Allowable



deductible


deductible



day supply


preferred brand/70%

non-preferred brand

after deductible

Covered at 80%

preferred brand/70%

non-preferred brand


Allowable Amount


deductible




network pharmacy is

used





formulary)

Dow Family Health Center Pharmacy $2 copay per script. For

maintenance medication,

available for up to 3 fills.

After 3 fills, must switch

to mail order pharmacy.

For non-maintenance

Rx, $2 copay per script,

subject to certain Rx

N/A Before deductible,

scheduled cost of drug.

After deductible, $2

copay per script

N/A $2 copay per script, for 30-day

supply limit; subject to certain Rx


order drugs





maximum per script





Prescription CoverageMAP Plus - Option 1 Low Deductible MAP Plus - Option 2 High Deductible








Maximum.





60%).






therapy.








with medical

Rx deductible: None



with medical


non-preferred brand


2020 Dow Medical Premiums and Coverage Summary - MAP Plus ...€¦ · Prescription Coverage MAP...

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Transcript of 2020 Dow Medical Premiums and Coverage Summary - MAP Plus ...€¦ · Prescription Coverage MAP...