Disclaimer: This plan is terminating on December 31, 2013. It will not be available during the 2014 plan year.
This plan utilizes the First Health Network network of medical providers and a third party, HealthComp, to administer the plan and pay claims on the Company’s behalf. All part time shift supervisors who enroll in the Espresso Blend Medical Plan will automatically be enrolled in the Prescription Drug Plan administered by Medco.
This plan, while not designed to provide you with comprehensive medical insurance, does provide basic medical benefits to help cover routine medical expenses you may incur during the year. This type of plan is often colloquially referred to as a “Mini-Med” plan. The following is a summary of the benefits provided under this plan:
| Espresso Blend Medical Plan |
| Plan Design & Benefits |
In-Network Providers |
Out Of Network |
| Annual Maximum |
$1,000 |
No Out Of Network Benefits Available |
| Annual Deductible |
None |
| Office Visits |
You pay a $10 Copayment but are limited to 5 visits per calendar year |
| Laboratory, X-Rays & Diagnostic Testing (Whether in or out of office) |
The Plan pays a maximum of $300 per year |
| Prescriptions |
You pay a $10 for generic prescriptions. The plan will pay a maximum benefit of $100 per year. The plan does not pay for non-generic prescriptions under any circumstances |
| Hospital Admission |
The plan pays $400 |
| Emergency Room |
The plan pays $100 |
| Surgery Related Benefits |
The plan pays $250 |
| Ambulance Services |
The plan pays $100 |
| Emergency Air Transportation |
The plan pays $500 |
The cost of the Espresso Blend Medical Plan is as follows:
| Tier Of Coverage |
Your Per Pay Period Deduction |
The Company’s Per Pay Period Contribution |
Total Monthly Cost of Plan |
| Team Member (“TM”) Only |
$10.00 |
$5.14 |
$32.81 |
The Medco Rx network gives you access to nearly 60,000 retail pharmacies nationwide, including most major drugstores. Use one of these pharmacies to fill your prescriptions. To find a local pharmacy, visit www.medco.com and click “Locate a Pharmacy”.
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