Plan	Base Plan - HSA	Buy-Up Plan - Copay	PPO Plan - Copay
Medical Deductible (Single/Family)	$3,000 / $6,000	$2,500 / $5,000	$2,500 / $5,000
Prescription Drug Deductible (Single/Family)	Integrated with Medical	$0 / $0	$0 / $0
Preventive Care**	No Cost	No Cost	​No Cost
Primary Care Visit	0%*	$25	​$25
​Specialty Care Visit	​0%*	$55	$55
Inpatient Services	​0%*	20%*	20%*
​Outpatient Services	0%*	2​0%*	20%*
Emergency Room	​0%*	​$400 / 20%*	​$400 / 20%*
Urgent Care	​0%*	$50	$50
Routine Lab/X-ray	0%*	No Cost	No Cost
​Prescription Drugs: Tier I Tier II Tier III Tier IV ​Tier V	0%* 0%* 0%* 0%* ​0%*	$0 $10 $50 $100 ​20%	$0 $10 $50 $100 ​20%
​Out-of Pocket Maximum (Single/Family)	$3,000 / $6,000	$5,500 / $11,000	$5,500 / $11,000

*After Medical Deductible
**PCP OV Copay waived for dependents, through age 19, for non-HSA plans

Plan	Base Plan - HSA	Buy-Up Plan - Copay	PPO Plan - Copay
Employee Only	$14.18	​$47.60	$115.90
Employee + Spouse	$201.16	​$289.98	​$471.48
Employee + Child(ren)	$122.67	$200.61	​$322.29
Employee + Family	​$201.16	$289.98	​$471.48

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Waiting Period

The health insurance benefit begins on the first day of the month after 60 days from your hire date unless you waive that benefit.

Enrollment

Once an employee is eligible for group health insurance, there is a 31-day period in which you can enroll.  After that, you can sign up only during open enrollment meetings which begin in August and are effective in September of each year.  If you have a change in status (such as marriage, birth or adoption), you have 31 days to adjust your insurance plans without waiting for the open enrollment period.  If you choose not to participate in the health plan, you will still need to sign the paperwork indicating that you decline.

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Disclaimer: Galbraith Group is providing the domain and hosting this Employee Benefits Center (EBC) to the benefit of Carillon, its employees, and its participants.  The content available through this EBC is the property of Carillon and Carillon remains solely responsible for content information, accuracy, and completeness.  This EBC only explains the general purposes of the insurance described, but in no way changes or affects the policy as actually issued. In the event of any discrepancy between any of these documents and the policy, the terms of the policy apply.  Complete coverage information is in the certificate of insurance booklet issued to each insured individual. Please read it carefully and keep it in a safe place with your other important papers.

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