1. Davidson College Plan Comparison
PPO Plan
Single
Family
HSA Plan
Deductible
In - $750
Out - $2,250
In -$2,250
Out - $6,750
In -$2,700
Out - $8,100
In - $5,400
Out - $16,200
Out of Pocket Maximum
In - $3,000
Out – Unlimited
*Includes Deductibles and copays
In - $6,000
In - $5,500
In - $11,000
Copays In-Network Only
PCP - $30
Specialist - $50
Not Applicable
Coinsurance
In – 80%
Out – 60%
HSA Contribution
Employee - $750
EE+SP $1,500
EE + Child(ren) $1,500
Family $1,500

2. Davidson College Pharmacy Plan Comparison – In-Network Only
PPO Plan
Retail (30 day)
Mail Order (90 day)
HSA Plan
Deductible
$100 per individual
Does not apply
Combined Medical/RX ded
Out of Pocket Maximum
Included in Medical OOP Maximum
Combined Medical/RX OOP
Generic
$15 after Rx Ded
$38
20% after combined Ded
Preferred Brand
$30 after Rx Ded
$75
30% after combined Ded
Non-Preferred Brand
$60 after Rx Ded
$150
40% after combined Ded
40% after Combined Ded
Specialty
$150 after Rx Ded
$150 after Rx Ded (30 day supply)
50% after combined Ded
50% after combined Ded (30 day supply)

3. Davidson College Premiums
PPO Plan
Monthly
Bi-Weekly
HSA Plan
Employee Only
$214.43
$98.97
$55.00
$25.38
Employee & Spouse/Domestic Partner
$849.13
$391.91
$307.32
$141.84
Employee & Child(ren)
$675.45
$311.74
$244.46
$112.83
Family
$1,235.10
$570.04
$483.29
$223.06

4. Davidson College Premium Differences
Coverage Tier
PPO Plan
HSA Plan
Difference
Employee Only
$2,573.16
$660
$1,913.16
Employee & Spouse/Domestic Partner
$10,189.56
$3,687.84
$6,501.72
Employee & Child(ren)
$8,105.40
$2,933.52
$5,171.88
Family
$14,821.20
$5,799.48
$9,021.72

5. Employee Only – Normal Utilization
Coverage Tier
Total Annual Charge
PPO
(Member Pays)
HSA
RX – 1 Generic
1 Pref Brand
$924
$640
PCP – 2 Visits
$200
$60
Specialist – 1 Visit
$250
$50
Outpatient Service - 1
$1,500
$900
$1,361
Annual Premiums $,
$660
HSA Contribution
$750
Total Expense
$4,223
$2,645
($1,578 Est. Savings)

6. Employee & Spouse/Domestic Partner – Normal Utilization
Coverage Tier
Total Annual Charge
PPO
(Member Pays)
HSA
RX – 1 Generic
1 Pref Brand
1 Non-Pref Brand
$1,884
$1,360
PCP – 4 Visits
$400
$120
Specialist – 2 Visit
$500
$100
Outpatient Services - 2
$3,000
$2,400
$2,693
Annual Premiums
$10,189.56
$3,687.84
HSA Contribution
Not Applicable
$1,500
Total Expense
$14,270
$7,665
($6,605 Est. Savings)

7. Employee & Child(ren) – Normal Utilization
Coverage Tier
Total Annual Charge
PPO
(Member Pays)
HSA
RX – 1 Generic
$144
PCP – 6 Visits
$600
$180
Specialist – 1 Visit
$250
$50
Outpatient Services - 2
$3,000
$2,400
Annual Premiums
$8,105.40
$2,933.52
HSA Contribution
Not Applicable
$1,500
Total Expense
$10,879
$5,428
($5,452 Est. Savings)

8. Family – Normal Utilization
Coverage Tier
Total Annual Charge
PPO
(Member Pays)
HSA
RX – 1 Generic
1 Pref Brand
1 Non-Pref Brand
$1,884
$1,560
PCP – 6 Visits
$600
$180
Specialist – 2 Visit
$500
$100
Outpatient Services - 3
$4,500
$2,700
$2,833
Annual Premiums
$14,821.70
$5,799.48
HSA Contribution
Not Applicable
$1,500
Total Expense
$19,361
$10,116
($9,245 Est. Savings)

9. Employee Only – High Utilization
Coverage Tier
Total Annual Charge
PPO
(Member Pays)
HSA
In-Patient Hospital - 1
$60,000
$3,000
$5,500
PCP – 10 Visits
$1,000 $0
Specialist – 8 Visit
$2,000
RX – 2 Generic
2 Pref Brand
2 Non-Pref Brand
$3,768
Annual Premiums
$2,573.16
$660
HSA Contribution
$750
Total Expense
$5,573
$5,410
($163 Est. Savings)

10. Employee & Spouse/Domestic Partner – High Utilization
Coverage Tier
Total Annual Charge
PPO
(Member Pays)
HSA
In-Patient Hospital - 2
$120,000
$6,000
$11,000
PCP – 15 Visits
$1,500 $0
Specialist – 12 Visit
$3,000
RX – 2 Generic
4 Pref Brand
2 Non-Pref Brand
$5,328
Annual Premiums
$10,189.56
$3,687.84
HSA Contribution
Total Expense
$16,190
$13,188
($3,002 Est. Savings)

11. Employee & Child(ren) – High Utilization
Coverage Tier
Total Annual Charge
PPO
(Member Pays)
HSA
In-Patient Hospital - 2
$120,000
$6,000
$11,000
PCP – 10 Visits
$1,000 $0
Specialist – 10 Visit
$2,500
RX – 2 Generic
2 Pref Brand
2 Non-Pref Brand
$3,768
Annual Premiums
$8,105.40
$2,933.52
HSA Contribution
$1,500
Total Expense
$14,105
$12,434
($1,672 Est. Savings)

12. Employee & Family – High Utilization
Coverage Tier
Total Annual Charge
PPO
(Member Pays)
HSA
In-Patient Hospital - 2
$120,000
$6,000
$11,000
PCP – 20 Visits
$2,000 $0
Specialist – 15 Visit
$3,750
RX – 3 Generic
2 Pref Brand
3 Non-Pref Brand
$4,872
Annual Premiums
$14,821.20
$5,799.48
HSA Contribution
$1,500
Total Expense
$20,821
$15,299
($5,522 Est. Savings)