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Commonwealth Standard 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.

​Effective Date

Current 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 ​ ​

​​In Network ​Out of Network

Deductible*

​$600 Single $1,800 Family​ ​$1,200 Single ​$3,000 Family

Out-of-pocket Max*

​$3,000 Single ​$6,000 Family ​$6,000 Single ​$9,000 Family

​Co-Insurance

75% Plan / 25% Member​ ​ 50% Plan / 50% Member​ ​

​Doctor's Office Visit

Deductible then 25% ​ Deductible then 50%​ ​

Pharmacy Benefits

​​In Network ​Out of Network
      ​30-day supply ​ ​

View the formulary drug listing

​Generic

25%/Min $10 - Max $25 ​Not Covered

​Formulary

​25%/Min $20 - Max $50 ​Not Covered

​Non-Formulary

​25%/Min $35 - Max $100 ​Not Covered
       90-day supply** ​ ​

​Generic

25%/Min $20 - Max $50 ​Not Covered

​Formulary

​25%/Min $40 - Max $100 ​Not Covered

​Non-Formulary

​25%/Min $70 - Max $200 ​Not Covered
​​*Excludes Co-Pays **Retail or mail-order maintenance drugs only​ ​ ​


 

Commonwealth Standard 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 $600 deductible and the remaining $1,200 family deductible may be met by any combination of the remaining family member's claims up to the $1,800 family deductible maximum.

Guidelines​

        • No single family member will pay more than $600 in deductible;
        • No single family member can contribute more than $600 to the family deductible maximum; and
        • Of the $1,800 family maximum deductible, $600 can be met by a family member and the remaining $1,200 can be met by a combination of additional family members; or
        • All family members' services can be combined and applied to meet the family $1,800 deductible.
        • Deductibles and out-of-pocket maximums accumulate separately and do not cross apply.


 

 

Non-Smoker Rates

​Commonwealth Standard PPO

​Total Premium​Employer Contribution​Employee Contribution*
​Single​$506.06​$506.06​$0.00
​Parent Plus​$791.54​$771.54​$20.00
​Couple​$1,177.80​$879.08​$298.00
​Family​$1,314.12​$1,004.12​$310.00
​Family Cross Reference**​$654.18​$649.18​$5.00

 

Smoker Rates

Commonwealth Standard PPO​ ​

​Total Premium​Employer Contribution​Employee Contribution*
​Single​$506.06​$480.56​$25.50
​Parent Plus​$791.54​$719.22​$72.32
​Couple​$1,177.80​$827.48​$350.32
​Family​$1,314.12​$951.80​$362.32
​Family Cross Reference**​$654.18​$624.46​$29.72

*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.