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CALCULATING YOUR PER PAY PERIOD COSTSTe rates shown in this Coverage Comparison chart are monthly and annual amounts.

 You can determine your per pay period costs for your benefits by doing the following calculations.

MEDICAL, DENTAL

AND VISION COST

LONG TERM

DISABILITY COST

SUPPLEMENT

LIFE INSURANCE

1. Multiply your monthlycost by 12.

2. Divide the result by thenumber of pay periods inthe calendar year:

• Staff - 26 pay periods• Faculty - 12 pay periods• Hourly - 52 pay periods• Dining Services - 33 pay

periods

3. Tis equals your per payperiod cost.

 

1. Divide your current actualsalary by 100.

2. Multiply the result by thecost shown for your FE*Salary ier.

3. Divide the result by thenumber of pay periods inthe calendar year:

• Staff - 26 pay periods• Faculty - 12 pay periods• Hourly - 52 pay periods• Dining Services - 33 pay

periods

4. Tis equals your per payperiod cost.

1. Determine the amoSupplemental Life Iyou wish to purchasfive times your actuasalary (if you are fac

 working less-than futhis is your current not your FE).

2. Round to the neare

3. Divide this amount

4. Multiply the result bcost for your age bradetermine your mon

5. Multiply by 12 to dyour annual cost.

6. Divide by the numbperiods in the calend

• Staff - 26 pay period• Faculty - 12 pay per• Hourly - 52 pay per• Dining Services - 33

periods

7. Tis equals your pecost.

*Full-time equivalent salary is your annual salary if you work full-time, or for thosewho work less than full-time, the salary that would be earned working full-time at thesame rate of pay.

J-FULLBENEFITS-COMPCHART-2014 -NON-UNION

COPAYMENT REIMBURSEMENT PROGRAM

Eligible copayments are reimbursed in full once you meet the following thresholds. Copayments used toreach the threshold, and those above the threshold, must be from a Harvard medical coverage option.

Full-Time EquivalentSalary*

Submitting as an Individual(It does not matter if you are enrolledin Individual or Family coverage.)

Submitting as a Family  (You must be enrolled with Familycoverage to submit as a family.)

In-Network

Office Visits

Prescription

Drug

In-Network

Office Visits

Prescription

Drug

Less than $70,000 $135 $500 $330 $1,000

$70,000 to $95,000 $270 $1,000 $660 $2,000

* Tis program is only available to employees with an annual full-time equivalent salary less than or equal to $95,000. Full-timeequivalent salary is your annual salary if you work full-time, or for those who work less than full-time, the salary that would be earnedworking full-time at the s ame rate of pay.

LONG TERM DISABILITY

FTE Salary TierAnnual Cost per$100 of Salary

L ess th an $1 5, 000 $ 0.2 53

$15,000 - $69,999 $0.289

$70,000 - $95,000 $0.623

Mor e t ha n $ 95 ,0 00 $ 0. 78 6

DENTAL

Delta Dental Monthly Cost

Individual $15.94

Family $45.07

DENTAL BENEFITS

Delta Dental Covered Services

P re ve nt iv e Ca re C ov er ed i n f ul l

Basic RestorativeServices

75% coverage, afterdeductible

Periodontics,Endodontics and OralSurgery 

75% coverage, afterdeductible

Major RestorativeServices

75% coverage, afterdeductible

Orthodontics

50% coverage (nodeductible) for childrenunder age 19, up to$1,500 lifetime benefitper person

Maximum AnnualBenefit

$3,000 per person

 Annual Deductible$50 per person, $150 per

family  Your Delta Dental plan provides coverage for services receivedfrom non-participating dentists (in or out-of-state). Althoughthe benefit level is the same as for participating dentists, yourout-of-pocket costs will typically be higher if you use theservices of a non-participating dentist whose fees are higherthan Delta Dental’s negotiated fee for those services. You will beresponsible for the difference between Delta Dental’s paymentand the dentist’s total submitted charges for the services. Yourbenefits dollar goes much further, and you enjoy greater valuefrom your dental plan, when you visit a participating dentist.

SUPPLEMENTAL LIFE INSURANCE

AgeMonthly Costper $1,000 ofInsurance

Under age 25 $ 0.028

25-29 $ 0.034

30-34 $ 0.040

35-39 $ 0.047

40-44 $ 0.058

45-49 $ 0.085

50-54 $ 0.134

55-59 $ 0.211

60-64 $ 0.269

65-69 $ 0.491

70-74 $ 0.783

75-79 $ 1.438

80 and over $ 2.058Please note that the rates on these pages apply only to those employees eligi ble for each of the benets.

VISION CARE

Davis Vision Monthly Cost

Individual $5.43

Family $12.49

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What Type of PlanDo You Want?

HMO (Health Maintenance Organization)Employees must reside within the HMO service area

POS (Point of Service)

In-Network (Authorized) Out-of-Network (Unauthorized

How Benefits are Provided Care must be provided or authorized by your primary care physician (PCP) chosen from withinyour Plan’s network.

Care must be provided or authorized by your primary care physician (PCP)chosen from within your plan’s network.

Care is received from non-participating provider and/or wauthorization from your PCP.

Calendar Year Deductible None None $750 individual coverage/$2,500 family coverage. Once tmet, POS pays 80% of usual,customary and reasonable (charges until annual out-of-pocket maximum (see below)

Out-of-Pocket Annual Maximum $2,000 individual/$6,000 family. (Prescription drug costs do not count toward out-of-pocket maximum.) $2,000 individual/$6,000 family. (Prescription drug costs do not counttoward out-of-pocket maximum.)

$2,500 individual coverage/$7,500 family coverage. Onceof-pocket maximum is met,POS pays 100% of usual,c usreasonable (UCR) 3 covered charges.

General Hospital – InpatientRoom and board and hospital services

100% 100% 80% of usual, customary and reasonable charges (UCR)3

General Hospital – Outpatient 100% 100% 80% of UCR

Lab and X-Ray 100% 100% 80% of UCR

Preventive Services1 100% 100% 80% of UCR

Physician’s ServicesSurgical Fees

Inpatient - 100%Outpatient - $20 copayment

Inpatient – 100%Outpatient – $20 copayment

80% of UCR

In-hospital visits 100% 100% 80% of UCR

Non-preventive office visits $20 copayment $20 copayment 80% of UCR

Vision screening for eyeglasses 100% (one exam per year) 100% (one exam per year) 80% of UCR (one exam per year)

Mental Health  Inpatient - 100%Outpatient - $20 copayment

Inpatient - 100%Outpatient - $20 copayment

Inpatient - 80% of UCROutpatient - 80% of UCR,d eductible does not apply

Substance Abuse Inpatient - 100%Outpatient - $20 copayment

Inpatient - 100%Outpatient - $20 copayment

Inpatient - 80% of UCROutpatient - 80% of UCR,d eductible does not apply

Maternity 100% 100% 80% of UCR

Emergency Care $75 copayment (waived if admitted) $75 copayment (waived if admitted) $75 copayment (waived if admitted)

Prescription Drugs — through ExpressScripts, 30-day supply retail

$7 copayment for generic,$20 for preferred brand, $45 for non-preferred brand at a participating pharmacy $7 copayment for generic,$20 for preferred brand, $45 for non-preferredbrand at a participating pharmacy

Member must submit receipt and will be reimbursed minuapplicable copayment for 30-day prescription at in-netwo

Prescription Drugs — through ExpressScripts, Up to a 90-day supply mail order

$14 copayment for generic, $50 for preferred brand, $110 for non-preferred brand from Express Scriptspharmacy

$14 copayment for generic, $50 for preferred brand, $110 for non-preferredbrand from Express Scripts pharmacy

$14 copayment for generic,$50 for preferred brand, $11preferred brand from Express Scripts pharmacy

Physical Therapy $20 copayment (60 visits per calendar year) $20 copayment (60 visits per calendar year)2 80% of UCR (60 visits per calendar year)2

Chiropractic Care $20 copayment (18 visits per calendar year) $20 copayment (18 visits per calendar year)2 80% of UCR (18 visits per calendar year)2

Dependent Coverage Sp ou se, sa me -se x o r op pos it e s ex do mes ti c p ar tn er, a nd ch il dr en un der ag e 26 S pou se, s ame -s ex or op po si te se x d om est ic par tn er, an d c hi ld ren un der ag e 2 6

Which Company OffersEach Plan Type?

Harvard University Group HealthPlan (HUGHP) HMO

617-495-2008 hughp.harvard.edu

Harvard Pilgrim Health Care HMO888-333-4742

www.harvardpilgrim.org

Harvard University Group Health Plan (HUGHP) POS617-495-2008

hughp.harvard.edu

Harvard Pilgrim Health Care (HPH888-333-4742

www.harvardpilgrim.orgNetwork Primary care network consists of HUHS and Atrius

Health group practices. Access to Blue Cross BlueShield specialty and hospital provider network.

More than 28,000 doctors and 149 hospitals acrossthe region.

Primary care network consists of HUHS and Atrius Health group practices.Access to Blue Cross Blue Shield specialty and hospital provider network.

More than 28,000 doctors and 149 hospitals across the

Access to Harvard University HealthServices (HUHS) Urgent Care

$20 copayment.If HUHS P CP, full access (24 hours,365 days).If no HUHS PCP, access is for employeesonly during work hours.

$20 copayment for urgent care only for employees only,during work hours.

$20 copayment.If HUHS PCP, full access (24 hours, 365 days). If no HUHSPCP, access is for employees only during work hours.

$20 copayment for urgent care only for employees only, d

Other Access to HUHS Pharmacy to fill prescriptions up to90 days in-person (HUHS physician prescription only).

Access to HUHS Pharmacy to fill prescriptions up to 90 days in-person (HUHSphysician prescription only).

HARVARD UNIVERSITY MEDICAL PLAN DECISION & COMPARISO