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Commonwealth Optimum PPO

​Eligibility

​Current employees, retirees and/or beneficiaries, classified or certified school employees and COBRA participants are eligible to participate. See your insurance coordinator/human resource generalist for specifics.

​Download the Summary of Benefits and Coverage

Effective Date

Coverage for new employees will become effective on the first day of the second calendar month following your date of hire. Example: if you begin any time in August, you are eligible for coverage Oct. 1. New employees may make their elections online in KHRIS or may complete an enrollment application within the first 35 calendar days of employment.

If you fail to make your health insurance election or waive coverage within the designated time frame, you will not have coverage and will not be allowed to enroll until the next open enrollment period, unless an appropriate qualifying event occurs.

​​Medical Benefits ​ ​

Download the Summary Plan Description

​​In Network ​Out of Network

Deductible*

​$370 Single $740 Family​ ​$740 Single ​$1,480 Family

Out-of-pocket Max*

​$1,390 Single ​$2,780 Family ​$2,780 Single ​$5,550 Family

​Co-Insurance

85% Plan / 15% Member​ ​ 70% Plan / 30% Member​ ​

​Doctor's Office Visit

$16 PCP/$21 Specialist​ ​ Deductible then 30%​ ​

​Pharmacy Benefits

​​In Network ​Out of Network

​30-day supply ​ ​

​Generic

$11 30%

​Formulary

​$26 ​30%

​Non-Formulary

​$48 ​30%
     90-day supply** ​ ​

​Generic

$16 ​Not Covered

​Formulary

​$46 ​Not Covered

​Non-Formulary

​$95 ​Not Covered

​ ​ ​View a list of maintenance drugs

View a list of participating local retail pharmacies offering 90-day supplies

​​*Excludes Co-Pays **Retail or mail-order maintenance drugs only​ ​ ​


 

Commonwealth Optimum PPO

How does the deductible accumulate? ​

If you have more than one family member covered under your plan, one family member may satisfy the individual $370 deductible and the remaining $370 family deductible may be met by any combination of the remaining family member's claims up to the $740 family deductible maximum.

Guidelines ​ ​ ​

        • No single family member will pay more than $370 in deductible;
        • No single family member can contribute more than $370 to the family deductible maximum; and
        • Of the $740 family maximum deductible, $370 can be met by a family member and the remaining $370 can be met by a combination of additional family members; or
        • All family members' services can be combined and applied to meet the family $740 deductible.
        • Deductibles and out-of-pocket maximums accumulate separately and do not cross apply.


 

 

Non-Smoker Rates

Commonwealth Optimum PPO

​Total Premium​Employer Contribution​Employee Contribution*
​Single​$675.34​$612.58​$62.76
​Parent Plus​$961.84​$741.84​$220.00
​Couple​$1,476.00​$930.00​$546.00
​Family​$1,642.78​$992.78​$650.00
​Family Cross Reference**​$812.52​$742.72​$69.80

 

Smoker Rates

Commonwealth Optimum PPO​ ​

​Total Premium​Employer Contribution​Employee Contribution*
​Single​$675.34​$586.98​$88.36
​Parent Plus​$961.84​$687.84​$274.00
​Couple​$1,476.00​$875.22​$600.78
​Family​$1,642.78​$938.02​$704.76
​Family Cross Reference**​$812.52​$717.48​$95.04

*All employee contributions are per employee, per month.
**If either employee in a family cross-reference payment option is a smoker, both employees are subject to the monthly smoker rates. See the guidelines ​for choosing the cross-reference payment option.