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Transcript of egsurveys.netegsurveys.net/.../2014/01/HRPBS-2014-Healthcare.docx · Web viewor Fiscal Year:...
Employer Healthcare Benefits Survey
CONTACT INFORMATION
1) Please provide name of individual and company information regarding this report.First Name: _________________________________________________Last Name: _________________________________________________Phone: _________________________________________________E-mail Address: _________________________________________________Mailing Address: _________________________________________________City: _________________________________________________State: _________________________________________________Zip Code: _________________________________________________Name of Organization: _________________________________________________
2) May we list your company as a participant in the published report? (Check One) Yes No
3) Participation Packages: Based on your membership status, please mark your selection from the options below. Employers Group Member -Please Provide Membership ID: ____________________ Non Employers Group Member
4) Coupon CodeIf Applicable, please provide
Page 1
Employer Healthcare Benefits Survey
THE 2014 EMPLOYER HEALTHCARE BENEFITS SURVEY
Upon completion of the survey (March), a password-protected link will be shared with paid participants to download the full report and access the survey's dashboard. The dashboard allows paid participants to segment critical data points by a full range of demographic variables, including industry, location, size, costs, and employer satisfaction with their current program.
5) Participation Terms: Participate and receive the following:
1. The 2014 Healthcare Benefits Report2. All 2013 Compensation and Benefits Survey Reports
Upon completion of the survey, a password-protected link will be shared to download the files.
Please check box below to confirm participation and report fees:
MEMBERS ONLY
Please check box below to confirm participation package and fees: By participating on this survey I understand that I will receive the following: (1) 2014 Healthcare Benefits
Report and (2) all 2013 Compensation and Benefits Survey Reports. Fee: $295
NON-MEMBERS ONLY
Please check box below to confirm participation package and fees: By participating on this survey I understand that I will receive the following: (1) 2014 Healthcare Benefits
Report and (2) all 2013 Compensation and Benefits Survey Reports. Fee: $395
Page 2
Employer Healthcare Benefits Survey
COMPANY INFORMATION
A. OWNERSHIP TYPE - Check the option that best describes the organization’s ownership. In the case of a division or wholly owned subsidiary, indicate the type of ownership of the parent company.
1. Public Corporation 2. Close Corporation 3. Individual Proprietorship 4. Public Agency 5. Not-for-Profit
B. ORGANIZATION TYPE - Please identify your organization type:
1. Headquarters with division(s) or subsidiaries 2. Subsidiary or division 3. Single organization; no division or subsidiary
C. EMPLOYMENT SIZE - FTE: FTE: Full-time equivalent employees: A full-time equivalent employee is a worker who averages 40 hours per week or a combination of part-time workers who average a combined 40 hours per week (e.g., 2 part-time workers who average 20 hours per week are considered 1 full-time equivalent employee)
a. # of Regular Full-time Employees: _______________b. # of Regular Part-time Employees: _______________Total # of FTE: (a+b): _______________
Page 3
Employer Healthcare Benefits Survey
D. INDUSTRY TYPE - Check that industry which best describes your firm's major activity in terms of income/revenue.
Mfg. - Aircraft & Aircraft Parts Mfg. - Apparel & Other finished Products Mfg. - Chemicals & Allied Products Mfg. - Electrical Machinery, Equip. & Supplies Mfg. - Fabricated Metal Products Mfg. - Food & Kindred Products Mfg. - Furniture & Fixtures Mfg. - Instruments, Photographic & Optical Mfg. - Leather Goods Mfg. - Lumber & Wood Products Mfg. - Machinery Mfg. - Miscellaneous Nondurable Goods Mfg. - Miscellaneous Durable Goods Mfg. - Paper & Allied Products Mfg. - Petroleum Refining & Related
Industries Mfg. - Plastic Products Mfg. - Primary Metal Industries Mfg. - Printing , Publishing & Allied Industries Mfg. - Stone, Glass & Clay Products Mfg. - Textile Mill Products Mfg. - Transportation Equip. (Non-Aircraft) Mfg. of High Tech. Equipment or components Mfg. or R&D of Pharmaceuticals Financial Services - Banking Financial Services - Finance Financial Services - Insurance Financial Services - Real Estate Non-Mfg - Agriculture /other
Non-Mfg - All other Businesses & Services to Businesses
Non-Mfg - Charitable Organizations Non-Mfg - Communication/Other
Utilities/Transportation Non-Mfg - Computer Programs, Data
Processing Non-Mfg - Construction - Family Residential Non-Mfg - Contract Heavy Construction Non-Mfg - E-Based Commerce: Retail Products
and Services Non-Mfg - E-Commerce, Consulting Services Non-Mfg - Education Non-Mfg - Employment Agencies Non-Mfg - Entertainment Industry Non-Mfg - Hospitality Non-Mfg - Hospitals & Health Industry Related
firms Non-Mfg - IS Consulting Services & Software
Development Non-Mfg - Legal Services & Law Firms Non-Mfg - Mining Non-Mfg - Non Profit Non-Mfg - Public Sector Non-Mfg - Retail Trade Non-Mfg - Services to Individuals Non-Mfg - Software Development,
Commercial Products and Services Non-Mfg - Wholesale Trade, Distribution
E. ANNUAL COSTS: MEDICAL AND PAYROLL - Total Medical Costs, Last Calendar or Fiscal Year: Hospital, surgical, medical, and major medical insurance: Report total company payments and employee payroll deductions for premiums and/or expenses (except administration) related to hospital, surgical, medical, and major medical insurance including coverage through HMO, PPO, Point of Service, Indemnity, or self-insured plans. Exclude: Dental, Vision, and retiree health insurance costs.
Total Gross Payroll (required), Last Calander or Fiscal Year: Report last total fiscal calendar year payroll prior to any deductions, e.g., deductions for taxes, 401(k) plans) including bonuses and commission
Total Medical Costs: ______________________Total Gross Payroll: ______________________
Page 4
Employer Healthcare Benefits Survey
Employee Healthcare Insurance - General Features
1. PLAN - Which statement best describes your company’s Group Medical Insurance policy? (Check one)
1. We offer coverage for employee and dependents 2. We only offer coverage for employee 3. We have discontinued coverage (by selecting this option, you will not be able to supply information) 4. We’ve never offered healthcare coverage (by selecting this option, you will not be able to supply
information) 5. Other - Explain ____________________
If healthcare coverage is currently offered, continue with the next set of questions. If no coverage is offered, then you have completed the survey.
2. TYPE OF PLAN - Select the type of plan(s) offered through your coverage: (Check as applicable)
1. Indemnity Plan (Traditional insurance / Fee for service plans) 2. Preferred Provider Organization – PPO 3. Point of Service – POS 4. Health Maintenance Organization - HMO or EPO 5. HDHP/SO: Health Savings Accounts or Health Reimbursement Arrangements 6. Other - Describe: ____________________
3. If you have more than one plan, how are contributions handled? (Check one)
1. Company contributes the same dollar amount regardless of plan chosen 2. Employees contribute the same dollar amount regardless of plan chosen 3. Company contributes same percentage of premium regardless of plan chosen 4. Company contributions vary 5. Other
4. What is the waiting period before a new employee can participate in your healthcare program?(Select best option, 1 or 2, or enter number months) 1. None, immediate enrollment or less than one month of service 2. Employee may enroll 1st day of the month following hire date 3. Employee is eligible after these number of months ____________________ 4. Other, please explain: ____________________
Page 5
Employer Healthcare Benefits Survey
5. # OF COVERAGE TIERS - How many coverage tiers does your plan have? (For the purposes of this question, a dependent can be defined as a spouse or a child) (Check one)
1. One tier, Employee (EE) coverage only 2. Two tiers: Usually EE and family coverage 3. Three tiers: Usually EE; EE + 1 dependent; Family 4. Four tiers: Usually EE; EE + 1 dependent; EE + children; Family 5. More than four tiers 6. Number of tiers vary by plan 7. Other
6. Excluding dependents and retirees, what percent of your company’s active employees are ELIGIBLE for your health benefit plan?
1. Provide Percent (%) ____________________ 2. Do not know
7. Excluding dependents and retirees, what percent of your company’s active employees actually PARTICIPATE in your health benefit plan?
1. Provide Percent (%) ____________________ 2. Do not know
8. As they apply to your healthcare plan, please enter the percent of employees enrolled in the tiers listed below: (The sum total for the percents below should not equal more than 100%)For assistance, please call us at 213.765.3925
______ 1. Employee coverage (%)______ 2. Employee plus spouse (%)______ 3. Employee plus family (%)______ 4. Employee, employee + 1 dependent (spouse or child), family (%)______ 5. Employee, employee + spouse, employee + children, family (%)______ 6. Other, please describe (%):
9. Nontraditional Partners - Does your company offer health coverage to nontraditional partners? (Check one)
1. Yes, for same and opposite-sex unmarried couples 2. Only for opposite-sex unmarried couples 3. Only for same-sex couples 4. No
Page 6
Employer Healthcare Benefits Survey
10. Are part-time and/or temporary employees eligible for health benefits? (Check as applicable)
1. Yes, part-time employees are eligible for health benefits 2. Yes, temporary employees are eligible for health benefits 3. No, part-time employees are not eligible for health benefits 4. No, temporary employees are not eligible for health benefits 5. Other / no information available
11. Can an employee receive cash in lieu of health coverage? (Check one)
1. No 2. Yes, reimbursement is equal to or less than employee’s premium co-share 3. Yes, reimbursement is greater than the employee’s premium co-share 4. Yes, as part of full cafeteria plan
Page 7
Employer Healthcare Benefits Survey
Employee Healthcare Insurance - General Features - Continued
12. HEALTH COST CONTAINMENT - In your latest plan year, what cost controlling measures did you implement? (Please check those that apply)
1. None, same level of service, options, and employee contributions as last plan 2. Added / Switch to a High-Deductive Health Plan with a Saving Options 3. Increased employee contributions for employee coverage 4. Increased plan’s out-of-pocket maximum on family coverage only 5. Increased plan’s out-of-pocket maximum on all coverages 6. Increased employee contributions for dependent coverage 7. Changed carrier 8. Increased deductible for hospitalization 9. Added prescription drug tiers (generic, preferred brand-name, etc.) 10. Added mail-order prescription plan 11. Added drug co-payment to plan(s) 12. Added office visit co-payment to plan(s) 13. Increased drug co-payment to plan(s) 14. Increased office visit co-payment to plan(s) 15. Increased coinsurance levels 16. Decreased retiree benefits 17. Added/increased the number of coverage tiers (i.e., single, coverage for two, and family) 18. Switched to self-insured plan(s) 19. Increased eligibility waiting period 20. Added alternative options(s) (i.e., PPO, POS) 21. Added an annual benefit maximum cap 22. Added a wellness plan 23. Other: ____________________
Page 8
Employer Healthcare Benefits Survey
Preferred Provider Organizations (PPO)
DEFINITION: Preferred Provider Organizations - Group health plans offered by a group of hospitals/physicians that contract on a fee-for-service basis with employers, insurance companies, or other third party administrators to provide comprehensive medical service. Providers exchange discounted services for increased volume. Participants' out-of-pocket costs are typically lower than under a fee-for-service plan.
Note 1: The questions in this topic relate only to medical plans for PPO’s. When answering the following questions, do not provide information for your indemnity plan or other non-traditional medical plans (i.e. HMO’s).
Note 2: If multiple PPO plans are offered, please provide information for the plan that is most popular in terms of employee participation.
1. Do you offer a PPO plan, and if so, is it underwritten by an insurance carrier? (Check one)
1. Do not offer PPO plan 2. Offer a PPO plan underwritten by insurance
carrier
3. Offer a self-insured PPO plan
Check one:
2. What percent of your employees are covered by your PPO plan?
PPO or
1. Please provide percent (%) 2. None 3. No information
available
Enter percent or choose option:
3. Is your plan offered through a union health plan? (Check one) If yes, only provide information for a plan that is not offered exclusively to union employees. If no other plan is offered, skip to next plan.
1. Yes 2. No
Choose one
Page 9
Employer Healthcare Benefits Survey
4. PPO MONTHLY PREMIUM COST - Enter the TOTAL MONTHLY premium cost per employee, including both employer and employee contributions.
Enter MONTHLY premium amounts OR explain policy
1. Premium cost, employee (single) coverage (Monthly Premium $)
2. Premium cost, employee & spouse coverage (Monthly Premium $)
3. Premium cost, employee & children coverage (Monthly Premium $)
4. Premium cost, family coverage (Monthly Premium $)
5. Other, please explain:
5. For the premiums listed above, what was the percent change from the last to the current Policy Year? (Enter the percent change OR detail change)
Enter the percent change OR detail change
1. Coverage for employee (single) (%)
2. Coverage for employee & spouse (%)
3. Coverage for employee & children (%)
4. Coverage for entire family (%)
5. Other, please explain:
6. What is the estimated percent change that is expected from the current to the new Policy Year? (Leave blank if information is not available) (Enter the percent change)
Enter the percent change
1. Coverage for employee (single) (%)
2. Coverage for employee & spouse (%)
3. Coverage for employee & children (%)
4. Coverage for entire family (%)
5. Other, please explain:
Page 10
Employer Healthcare Benefits Survey
7. MONTHLY EMPLOYEE CONTRIBUTIONS (PPO): Provide the employee's monthly dollar contribution toward the monthly premium. ENTER THE WORD "ZERO"IF COMPANY PAYS THE ENTIRE PREMIUM; leave blank if no information is available. (Provide MONTHLY FIGURES, OR select from options 5-8 on the right side of the table)
(Monthly $) or Check as Applicable
1. Employee
(Single) Coverage
2. Employee & Spouse Coverage
3. Employee
& Children Coverage
4. Family Coverage
5. Varies by
earnings
6. Varies by
employee option (e.g.
cafeteria plans)
7. Varies based on
age
8. Other/No
information available
Provide MONTHLY FIGURES, OR select
from options 5-8 on the right side
of the table
8. MONTHLY EMPLOYER CONTRIBUTIONS (PPO): Please indicate the approximate MONTHLY dollar contribution towards the premium that is paid by the employer (company). IF THE COMPANY DOES NOT CONTRIBUTE TOWARDS THE PREMIUM, ENTER THE WORD "ZERO". (Provide amount OR select from options 5-8 on the right side of the table)
(Monthly $) or Check as Applicable
1. Employee
(Single) Coverage
2. Employee & Spouse Coverage
3. Employee
& Children Coverage
4. Family Coverage
5. Varies by
earnings
6. Varies by
employee option (e.g.
cafeteria plans)
7. Varies based on
age
8. Other/No
information available
Provide amount
OR select from
options 5-8 on
the right side of
the table
Page 11
Employer Healthcare Benefits Survey
9. DEDUCTIBLES - Enter the deductible amount for medical expenses that must be met before the employer will pay benefits. (Enter DOLLAR amounts OR select from options 7-13 on the right side of the table)
IN-NETWORK - Annual Deductible $ Amount
OUT-OF-NETWORK - Annual Deductible $
Amount
or Check as Applicable1.
Em
ploy
ee C
over
age
2. F
amily
Cov
erag
e
3. If
eac
h co
vere
d in
divi
dual
requ
ired
to
mee
t a d
educ
tible
, pr
ovid
e pe
r ind
ivid
ual
4. E
mpl
oyee
Cov
erag
e
5. F
amily
Cov
erag
e
6. If
eac
h co
vere
d in
divi
dual
requ
ired
to
mee
t a d
educ
tible
, pr
ovid
e pe
r ind
ivid
ual
7. B
ased
on
earn
ings
8. IN
-NET
WO
RK -
No
dedu
ctibl
e fo
r em
ploy
ee
9. IN
-NET
WO
RK -
No
dedu
ctibl
e fo
r fam
ily
10. O
UT-
OF-
NET
WO
RK -
No
dedu
ctibl
e fo
r
11. O
UT-
OF-
NET
WO
RK -
No
dedu
ctibl
e fo
r fam
ily
12. U
nabl
e to
det
erm
ine
base
d on
pla
n op
tions
13. O
ther
/No
info
rmati
on a
vaila
ble
Enter DOLLAR amounts OR select
from options 7-13 on the right side
of the table
Page 12
Employer Healthcare Benefits Survey
10. Does your PPO plan require a co-payment or coinsurance when employee uses a preferred provider? (Check one)
1. Co-payment only
2. Coinsurance only
3. Both 4. No 5. Do not know /Other
Check one
11. What co-payment amount, if any, is required for office visits made to a preferred provider? (Check one)
1. $2 2. $5 3. $10 4. $15 5. $20 6. Do not know / Other
Check one
12. If coinsurance is required, what is the employee’s percent share for office visits to a preferred provider? (Check one)
1. 5% 2. 10% 3. 15% 4. 20% 5. 25% 6. 30% 7. 40% 8. Do not know / Other
Check one
13. If coinsurance is required, what is the employee’s percent share for office visits to a non-preferred provider? (Check one)
1. 5% 2. 10% 3. 15% 4. 20% 5. 25% 6. 30% 7. 40% 8. Do not know / Other
Check one
Page 13
Employer Healthcare Benefits Survey
14. PPO MAXIMUM ANNUAL OUT-OF-POCKET EXPENSE - Provision in plan(s) where the employer's coinsurance amount increases to 100% after the employee has paid out a set dollar amount for covered expenses. Please enter the maximum expense: (Enter DOLLAR amounts or choose from options 7-13 on the right side of the table)
IN-NETWORK - Maximum $ Amount
OUT-OF-NETWORK - Maximum $ Amount
or Check as Applicable1.
Em
ploy
ee
2. F
amily
3. If
a m
axim
um a
pplie
s to
eac
h co
vere
d in
divi
dual
, pro
vide
the
amou
nt
4. E
mpl
oyee
5. F
amily
Cov
erag
e
6. If
a m
axim
um a
pplie
s to
eac
h co
vere
d in
divi
dual
, pro
vide
the
amou
nt
7. B
ased
on
earn
ings
8. V
arie
s by
coin
sura
nce
rate
s
9. D
oes n
ot li
mit
out-
of-
pock
et e
xpen
se fo
r in
divi
dual
cov
erag
e
10. D
oes n
ot li
mit
out-
of-p
ocke
t exp
ense
for
fam
ily c
over
age
11. D
oes n
ot re
quire
ou
t-of
-poc
ket e
xpen
se
for i
ndiv
idua
l cov
erag
e
12. D
oes n
ot re
quire
ou
t-of
-poc
ket e
xpen
se
for f
amily
cov
erag
e
13. O
ther
/No
info
rmati
on a
vaila
ble
Enter DOLLAR amounts or choose
from options 7-13 on the right side
of the table
15. In regards to your PPO plan, which of the following does your maximum annual out-of-pocket liability include? (Check as applicable)
1. Deductibles 2. Copay for office visits
3. Copay for prescription drugs
Check as applicable
16. MAXIMUM LIFETIME BENEFIT - Per each individual covered, what is your plan’s maximum lifetime payout benefit? (Check as applicable)
1. IN
-NET
WO
RK -
Plan
has
no
max
imum
life
time
payo
ut
2. O
UT-
OF-
NET
WO
RK -
Plan
ha
s no
max
imum
life
time
IN-N
ETW
ORK
3. L
ess t
han
$1,0
00,0
00
4. $
1,00
0,00
0
5. B
etw
een
$1,0
00,0
00 a
nd
$1,4
99,9
99
6. B
etw
een
$1,5
00,0
00 a
nd
$1,9
99,9
99
7. $
2,00
0,00
0
8. B
etw
een
$2,0
00,0
00 a
nd
$2,4
99,9
99
9. $
2,50
0,00
0 or
abo
ve
OU
T-O
F-N
ETW
ORK
10. L
ess
than
$1,
000,
000
11. $
1,00
0,00
0
12. B
etw
een
$1,0
00,0
00 a
nd
$1,4
99,9
99
13. B
etw
een
$1,5
00,0
00 a
nd
$1,9
99,9
99
14. $
2,00
0,00
0
15. B
etw
een
$2,0
00,0
00 a
nd
$2,4
99,9
99
16. B
etw
een
$2,5
00,0
00 o
r ab
ove
17. D
o no
t kno
w /
Oth
er
Check as applicabl
e
Page 14
Employer Healthcare Benefits Survey
17. Which of the following cost-sharing formulas apply to your PPO plan? (Check one)
1. Four or more tiers,
e.g. Generic, Preferred,
Nonpreferred, Biologic
2. Three tiers, e.g. Generic, Preferred, &
Nonpreferred
3. Two tiers, e.g. Generic or brand and Nonpreferred
4. Cost sharing is the
same regardless of type of drug
5. No cost sharing after deductible is
met
6. Do not know / Other
Check one
18. Under your PPO plan, do First-Tier drugs, often called "generic drugs", require a copay or coinsurance? (Check one)
1. Yes, Copay only
2. Yes, Coinsurance
only
3. Yes, either Copay or
Coinsurance
4. Plan Pays Entire Cost After any
Deductibles are Met
5. No 6. Other/No information
available
Check one
19. If yes, provide copay and/or percent of coinsurance:
1. Co-payment ($) 2. Coinsurance (%)
Percent and/or coinsurance
20. Under your PPO plan, do Second-Tier drugs, often called "preferred drugs", require a copay or coinsurance? (Check one)
1. Yes, Copay only
2. Yes, Coinsurance
only
3. Yes, either Copay or
Coinsurance
4. Yes, Copay or
Coinsurance AND the cost difference to
a generic equivalent
5. No 6. Other/No information
available
Check one
21. If yes, provide co-pay and/or percent of coinsurance:
1. Co-payment ($) 2. Coinsurance (%)
Co-pay and/or percent of coinsurance
Page 15
Employer Healthcare Benefits Survey
22. Under your PPO plan, do Third-Tier drugs, often called "non preferred drugs", require a copay or coinsurance? (Check one)
1. Yes, Copay only
2. Yes, Coinsurance
only
3. Yes, either Copay or
Coinsurance
4. Yes, Copay or
Coinsurance AND the cost difference to
a generic equivalent
5. No 6. Other/No information
available
Check one
23. If yes, provide copay and/or percent of coinsurance:
1. Co-payment ($) 2. Coinsurance (%)
Copay and/or percent of coinsurance
Page 16
Employer Healthcare Benefits Survey
Point Of Service Plans (POS)
DEFINITION: Point of Service Plans - Plan where enrollees do not choose services until they are needed. Enrollees may choose a PPO or an outside provider. Typically, benefits are greater if services are obtained within the network.
Note 1: If multiple POS plans are offered, please provide information for the plan that is most popular in terms of employee participation.
1. Do you offer a POS plan, and if so, is it underwritten by an insurance carrier? (Check one)
1. Do not offer POS plan 2. Offer a POS plan underwritten by insurance
carrier
3. Offer a self-insured POS plan
Check one
2. What percent of your employees are covered by your POS plan?
POS or
1. Please provide percent (%) 2. None 3. No information
available
Enter percent or select option
3. POS MONTHLY PREMIUM COST - For the coverage levels listed below, provide the TOTAL MONTHLY premium cost including both employer (company) and employee contributions. (Enter MONTHLY premium amounts OR explain policy)
Enter MONTHLY premium amounts OR explain policy
1. Premium cost, employee (single) coverage (Monthly Premium $)
2. Premium cost, employee & spouse coverage (Monthly Premium $)
3. Premium cost, employee & children coverage (Monthly Premium $)
4. Premium cost, family coverage (Monthly Premium $)
5. Other, please explain:
Page 17
Employer Healthcare Benefits Survey
4. POS PLANS: For the premiums listed above, what was the percent change from the last to the current Policy Year? (Leave blank if information is not available) (Enter the percent change)
Enter percent
1. Coverage for employee (single) (%)
2. Coverage for employee & spouse (%)
3. Coverage for employee & children (%)
4. Coverage for entire family (%)
5. Other, please explain:
5. POS PLANS: What is the estimated percent change that is expected from the current to the new Policy Year? (Leave blank if information is not available) (Enter the percent change)
Enter percent change
1. Coverage for employee (single) (%)
2. Coverage for employee & spouse (%)
3. Coverage for employee & children (%)
4. Coverage for entire family (%)
5. Other, please explain:
6. MONTHLY EMPLOYEE CONTRIBUTIONS (POS): Provide the employee's monthly dollar contribution toward the monthly premium. ENTER the word "ZERO" IF COMPANY PAYS THE ENTIRE PREMIUM; leave blank if no data is available. (Provide MONTHLY FIGURES, OR select from options 5-8 on the right side of the table)
(Monthly $) or Check as Applicable
1. Employee
(Single) Coverage
2. Employee & Spouse Coverage
3. Employee
& Children Coverage
4. Family Coverage
5. Varies by
earnings
6. Varies by
employee option (e.g.
cafeteria plans)
7. Varies based on
age
8. Other/No
information available
Provide MONTHLY FIGURES, OR select
from options 5-8 on the right side
of the table
Page 18
Employer Healthcare Benefits Survey
7. MONTHLY EMPLOYER CONTRIBUTIONS (POS): Please indicate the approximate MONTHLY dollar contribution towards the premium that is paid by the employer (company). IF THE COMPANY DOES NOT CONTRIBUTE TOWARDS THE PREMIUM, ENTER THE WORD "ZERO". (Provide amount OR select from options 5-8 on the right side of the table)
(Monthly $) or Check as Applicable
1. Employee
(Single) Coverage
2. Employee & Spouse Coverage
3. Employee
& Children Coverage
4. Family Coverage
5. Varies by
earnings
6. Varies by
employee option (e.g.
cafeteria plans)
7. Varies based on
age
8. Other/No
information available
Provide amount
OR select from
options 5-8 on
the right side of
the table
8. DEDUCTIBLES - Enter deductible amounts for medical expenses that must be met before benefits are paid: (Enter DOLLAR amounts OR select from options 7-13 on the right side of the table)
IN-NETWORK - Annual Deductible $ Amount
OUT-OF-NETWORK - Annual Deductible $
Amount
or Check as Applicable
1. E
mpl
oyee
Cov
erag
e
2. F
amily
Cov
erag
e
3. If
eac
h co
vere
d in
divi
dual
re
quire
d to
mee
t a
dedu
ctibl
e, p
rovi
de p
er
indi
vidu
al
4. E
mpl
oyee
Cov
erag
e
5. F
amily
Cov
erag
e
6. If
eac
h co
vere
d in
divi
dual
re
quire
d to
mee
t a
dedu
ctibl
e, p
rovi
de p
er
indi
vidu
al
7. B
ased
on
earn
ings
8. IN
-NET
WO
RK -
No
dedu
ctibl
e fo
r em
ploy
ee
cove
rage
9. IN
-NET
WO
RK -
No
dedu
ctibl
e fo
r fam
ily
cove
rage
10. O
UT-
OF-
NET
WO
RK -
No
dedu
ctibl
e fo
r em
ploy
ee
cove
rage
11. O
UT-
OF-
NET
WO
RK -
No
dedu
ctibl
e fo
r fam
ily
cove
rage
12. U
nabl
e to
det
erm
ine
base
d on
pla
n op
tions
13. O
ther
/No
info
rmati
on
avai
labl
e
Provide amount
OR select from
options 4-13 on
the right
side of the
table
Page 19
Employer Healthcare Benefits Survey
9. Does your POS plan require a co-payment or coinsurance when employee uses a preferred provider? (Check one)
1. Yes, co-payment only
2. Yes, coinsurance
only
3. Yes, both 4. No 5. No information
available / Other
Check one
10. What co-payment amount, if any, is required for office visits made to a preferred provider? (Check one)
1. $2 2. $5 3. $10 4. $15 5. $20 6. Do not know / Other
Check one
11. If coinsurance is required, what is the employee’s percent share for office visits to a preferred provider? (Check one)
1. 5% 2. 10% 3. 15% 4. 20% 5. 25% 6. 30% 7. 40% 8. Do not know / Other
Check one
12. If coinsurance is required, what is the employee’s percent share for office visits to a non-preferred provider? (Check one)
1. 5% 2. 10% 3. 15% 4. 20% 5. 25% 6. 30% 7. 40% 8. Do not know / Other
Check one
Page 20
Employer Healthcare Benefits Survey
13. POS MAXIMUM ANNUAL OUT-OF-POCKET EXPENSE - Provision in plan(s) where the employer's coinsurance amount increases to 100% after the employee has paid out a set dollar amount for covered expenses. Please enter the maximum expense:(Enter DOLLAR amounts or choose from options 7-13 on the right side of the table)
IN-NETWORK - Maximum $ Amount
OUT-OF-NETWORK - Maximum $ Amount
or Check as Applicable1.
Em
ploy
ee
2. F
amily
3. If
a m
axim
um a
pplie
s to
eac
h co
vere
d in
divi
dual
, pro
vide
the
amou
nt
4. E
mpl
oyee
5. F
amily
Cov
erag
e
6. If
a m
axim
um a
pplie
s to
eac
h co
vere
d in
divi
dual
, pro
vide
the
amou
nt
7. B
ased
on
earn
ings
8. V
arie
s by
coin
sura
nce
rate
s
9. D
oes n
ot li
mit
out-
of-
pock
et e
xpen
se fo
r in
divi
dual
cov
erag
e
10. D
oes n
ot li
mit
out-
of-
pock
et e
xpen
se fo
r fam
ily
cove
rage
11. D
oes n
ot re
quire
out
-of
-poc
ket e
xpen
se fo
r in
divi
dual
cov
erag
e
12. D
oes n
ot re
quire
out
-of
-poc
ket e
xpen
se fo
r fa
mily
cov
erag
e
13. O
ther
/No
info
rmati
on
avai
labl
e
Enter DOLLAR amounts
or choose
from options 4-13 on the right side of
the table
14. For your POS plan, which of the following co-pays does your maximum annual out-of-pocket liability include? (Check as applicable)
1. Deductibles 2. Copay for office visits
3. Copay for prescription drugs
Check as applicable
Page 21
Employer Healthcare Benefits Survey
15. MAXIMUM LIFETIME BENEFIT - Per each individual covered, what is your plan’s maximum lifetime payout benefit: (Check as applicable)
1. IN
-NET
WO
RK -
Plan
has
no
max
imum
life
time
payo
ut li
mits
2. O
UT-
OF-
NET
WO
RK -
Plan
has
no
max
imum
life
time
payo
ut
IN-N
ETW
ORK
3. L
ess t
han
$1,0
00,0
00
4. $
1,00
0,00
0
5. B
etw
een
$1,0
00,0
00 a
nd
$1,4
99,9
99
6. B
etw
een
$1,5
00,0
00 a
nd
$1,9
99,9
99
7. $
2,00
0,00
0
8. B
etw
een
$2,0
00,0
00 a
nd
$2,4
99,9
99
9. $
2,50
0,00
0 or
abo
ve
OU
T-O
F-N
ETW
ORK
10. L
ess t
han
$1,0
00,0
00
11. $
1,00
0,00
0
12. B
etw
een
$1,0
00,0
00 a
nd
$1,4
99,9
99
13. B
etw
een
$1,5
00,0
00 a
nd
$1,9
99,9
99
14. $
2,00
0,00
0
15. B
etw
een
$2,0
00,0
00 a
nd
$2,4
99,9
99
16. B
etw
een
$2,5
00,0
00 o
r abo
ve
17. D
o no
t kno
w /
Oth
er
Check as applicabl
e
16. Which of the following cost-sharing formulas apply to your POS plan? (Check one)
1. Four or more tiers,
e.g. Generic, Preferred,
Nonpreferred, Biologic
2. Three tiers, e.g. Generic, Preferred, &
Nonpreferred
3. Two tiers, e.g. Generic or brand &
Nonpreferred
4. Cost sharing is the
same regardless of type of drug
5. No cost sharing after deductible is
met
6. Do not know / Other
Check one
17. Under your POS plan, do First-Tier drugs, often called "generic drugs", require a copay or coinsurance? (Check one)
1. Yes, Copay only
2. Yes, Coinsurance
only
3. Yes, either Copay or
Coinsurance
4. Plan Pays Entire Cost After any
Deductibles are Met
5. No 6. Other/No information
available
Check one
18. If yes, provide copay and/or percent of coinsurance:
1. Co-payment ($) 2. Coinsurance (%)
Copay and/or percent of coinsurance
Page 22
Employer Healthcare Benefits Survey
19. Under your POS plan, do Second-Tier drugs, often called "preferred drugs", require a copay or coinsurance? (Check one)
1. Yes, Copay only
2. Yes, Coinsurance
only
3. Yes, either Copay or
Coinsurance
4. Yes, Copay or
Coinsurance AND the cost difference to
a generic equivalent
5. No 6. Other/No information
available
Check one
20. If yes, provide copay and/or percent of coinsurance:
1. Co-payment ($) 2. Coinsurance (%)
Copay and/or percent of coinsurance
21. Under your POS plan, do Third-Tier drugs, often called "non preferred drugs", require a copay or coinsurance? (Check one)
1. Yes, Copay only
2. Yes, Coinsurance
only
3. Yes, either Copay or
Coinsurance
4. Yes, Copay or
Coinsurance AND the cost difference to
a generic equivalent
5. No 6. Other/No information
available
Check one
22. If yes, provide copay and/or percent of coinsurance:
1. Co-payment ($) 2. Coinsurance (%)
Copay and/or percent of coinsurance
Page 23
Employer Healthcare Benefits Survey
Health Maintenance Organizations (HMO)
Note 1: The questions in this topic relate only to medical plans for HMOs.
Note 2: If multiple HMO plans are offered, please provide information for the plan that is most popular in terms of employee participation.
1. Do you offer a HMO plan, and if so, is it underwritten by an insurance carrier? (Check one)
1. Do not offer an HMO plan
2. Offer an HMO plan underwritten by insurance
carrier
3. Offer a self-insured HMO plan
Check one
2. What percent of your employees are covered by your HMO plan?
HMO or
1. Please provide percent (%) 2. None 3. No information
available
Enter percent or select option
3. Does your most popular HMO plan have a point-of-service or out-of-network rider that employees may use for everyday health care expenses? (Check one)
1. Yes 2. No
Check one
4. HMO - TYPE OF PLAN - Please indicate the type of HMO offered to your employees: (Check as applicable)
1. Group or Staff Model
2. Individual Practice
Association
3. Network-model
4. Mixed Model 5. No information
available / Other
Check as applicable
Page 24
Employer Healthcare Benefits Survey
5. HMO - MONTHLY PREMIUM COST - Indicate the total MONTHLY premium cost per employee, including both employer (company) and employee contributions. (Enter MONTHLY premium amounts or explain policy)
Enter MONTHLY premium amounts or explain policy
1. Premium cost, employee (single) coverage (Monthly Premium $)
2. Premium cost, employee & spouse coverage (Monthly Premium $)
3. Premium cost, employee & children coverage (Monthly Premium $)
4. Premium cost, family coverage (Monthly Premium $)
5. Other, please explain:
6. For the premiums listed above, what was the percent change from the last to the current Policy Year? (Enter the percent change)
Enter the percent change
1. Coverage for employee (single) (%)
2. Coverage for employee & spouse (%)
3. Coverage for employee & children (%)
4. Coverage for entire family (%)
5. Other, please explain:
7. What is the estimated percentage change that is expected from the current to the new Policy Year? (Enter the percent change)
Enter the percent change
1. Coverage for employee (single) (%)
2. Coverage for employee & spouse (%)
3. Coverage for employee & children (%)
4. Coverage for entire family (%)
5. Other, please explain:
Page 25
Employer Healthcare Benefits Survey
8. MONTHLY EMPLOYEE CONTRIBUTIONS: Provide the employee's MONTHLY dollar contribution toward the premium. IF COMPANY PAYS THE ENTIRE PREMIUM, enter the word "ZERO"; leave blank if no information is available. (Provide MONTHLY FIGURES, ENTER "ZERO" OR select from options 5 -8 on the right side of the table)
(Monthly $) or Check as Applicable
1. Employee
(Single) Coverage
2. Employee & Spouse Coverage
3. Employee
& Children Coverage
4. Family Coverage
5. Varies by
earnings
6. Varies by
employee option (e.g.
cafeteria plans)
7. Varies based on
age
8. Other/No
information available
Provide MONTHLY FIGURES,
ENTER "ZERO"
OR select from
options 5 -8 on the right side
of the table
9. MONTHLY EMPLOYER CONTRIBUTIONS: Please indicate the approximate AMOUNT of the medical care premium that is paid by the employer (company). ENTER the word "ZERO" IF EMPLOYER DOES NOT CONTRIBUTE TOWARDS THE PREMIUM. (Provide percentage, ENTER "ZERO" OR select from options 5 - 8 on the right side of the table)
(Monthly $) or Check as Applicable
1. Employee
(Single) Coverage
2. Employee & Spouse Coverage
3. Employee
& Children Coverage
4. Family Coverage
5. Varies by
earnings
6. Varies by
employee option (e.g.
cafeteria plans)
7. Varies based on age
8. Other/No
information available
Provide percentage,
ENTER "ZERO" OR select from options 5 -
8 on the right side of
the table
Page 26
Employer Healthcare Benefits Survey
10. What is the office visit co-payment if the employee uses a physician participating in an HMO plan? (Check one)
1. No co-payment
2. $2 per visit
3. $5 per visit
4. $10 per visit
5. $15 per visit
6. $20 per visit
7. Other / Unable to determine
Check one
11. Which of the following cost-sharing formulas apply to your HMO plan? (Check one)
1. Four or more tiers,
e.g. Generic, Preferred,
Nonpreferred, Biologic
2. Three tiers, e.g. Generic, Preferred, &
Nonpreferred
3. Two tiers, e.g. Generic or brand &
Nonpreferred
4. Cost sharing is the
same regardless of type of drug
5. No cost sharing after deductible is
met
6. Do not know / Other
Check one
12. Under your HMO plan, do First-Tier drugs, often called "generic drugs", require a copay or coinsurance? (Check one)
1. Yes, Copay only
2. Yes, Coinsurance
only
3. Yes, either Copay or
Coinsurance
4. Plan Pays Entire Cost After any
Deductibles are Met
5. No 6. Other/No information
available
Check one
13. If yes, provide copay and/or percent of coinsurance:
1. Co-payment ($) 2. Coinsurance (%)
Copay and/or percent of coinsurance
14. Under your HMO plan, do Second-Tier drugs, often called 'preferred drugs", require a copay or coinsurance? (Check one)
1. Yes, Copay only
2. Yes, Coinsurance
only
3. Yes, either Copay or
Coinsurance
4. Yes, Copay or
Coinsurance AND the cost difference to
a generic equivalent
5. No 6. Other/No information
available
Check one
Page 27
Employer Healthcare Benefits Survey
15. If yes, provide copay and/or percent of coinsurance:
1. Co-payment ($) 2. Coinsurance (%)
Copay and/or percent of coinsurance
16. Under your HMO plan, do Third-Tier drugs, often called "non preferred drugs", require a copay or coinsurance? (Check one)
1. Yes, Copay only
2. Yes, Coinsurance
only
3. Yes, either Copay or
Coinsurance
4. Yes, Copay or
Coinsurance AND the cost difference to
a generic equivalent
5. No 6. Other/No information
available
Check one
17. If yes, provide copay and/or percent of coinsurance:
1. Co-payment ($) 2. Coinsurance (%)
Copay and/or percent of coinsurance
INPATIENT HOSPITAL - (Questions 18 to 22) - For your most popular HMO plan, please provide the amounts for the following services: (For the purpose of this section, provide data as it pertains to your most popular plan -do not report data from multiple plans.)
18. If plan fees are based on room and board, please provide amounts:
Provide amounts
1. Room and board, per day ($)
2. Room and board, maximum per admission ($)
3. Other, please explain:
19. If plan fees are based on a co-payment, please provide amount:
Provide amount
1. Hospital Admission Co-payment ($)
2. Other, please explain:
Page 28
Employer Healthcare Benefits Survey
ANNUAL MAXIMUM
20. Single Coverage, inpatient hospital
services, annual maximum ($)
21. Family Coverage, inpatient hospital
services, annual maximum per person ($)
22. Family Coverage, inpatient hospital
services, annual maximum per family ($)
Provide amount
Page 29
Employer Healthcare Benefits Survey
HIGH-DEDUCTIBLE HEALTH PLAN (HDHP) WITH HEALTH REIMBURSEMENT ARRANGEMENTS (HRAs) OR HEALTH SAVINGS ACCOUNTS (HSAs)
HDHP: Health plans with a high deductible amount (generally above $1,000 and $2,000 for single and family coverage, respectively) and usually combined with savings option, HRAs or HSAs. For the purpose of this section, these plans will be referred as High-Deductible Health Plan with a Savings Option or HDHP/SO
HRAs: Medical care reimbursement plans established and funded solely by the employer and available to company employees to pay for health care costs.
HSAs: An employee savings plan tied to a federal-qualified High-Deductible Health Plan (HDHP).
Note 1: The questions in this topic relate only to medical plans covered under a High-Deductible Health Plan with a Savings Option or HDHP/SO (HRAs, HSAs, or similar). If multiple plans are offered, please provide information for the plan that is most popular in terms of employee participation.
1. Do you offer a HDHP/SO plan? (Check one)
1. Yes, we currently offer an HDHP/SO plan
2. No, but plan to set one in the next 12 months
3. No
Check one
2. If yes, what type of savings arrangement does your plan have? (Check as applicable)
Check as applicable
1. HDHP with a Health Reimbursement Arrangement (HRA)
2. HDHP with a Health Savings Account (HSA)
3. HDHP with a Health Savings Account (HSA) and Flexible Spending Account
4. HDHP with a Flexible Spending Account
5. Other, please describe:
3. In addition to your HDHP/SO, do you offer other health care plans e.g. HMO, PPO, etc?
1. Yes 2. Yes, however, plans are to be
replace them with an HDHP/SO plan
3. No 4. Other / No information
available
Check one
Page 30
Employer Healthcare Benefits Survey
4. Which plan will you be reporting? Please select the one that’s the most popular: (Check one)
1. HDHP with a Health
Reimbursement Arrangement
(HRA)
2. HDHP with a Health Savings Account (HSA)
3. HDHP with a Health Savings Account (HSA)
and Flexible Spending Account
4. HDHP with a Flexible
Spending Account
5. Other
Check one
5. What percent of your employees are covered by your HDHP/SO plan?
HDHP/SO or
1. Please provide percent (%) 2. None 3. No information
available
Enter percent or check option
6. HDHP/SO - MONTHLY PREMIUM COST - Indicate the total MONTHLY premium cost per employee, including both employer (company) and employee contributions. (Enter MONTHLY premium amounts or explain policy)
Enter MONTHLY premium amounts or explain policy
1. Premium cost, employee (single) coverage (Monthly Premium $)
2. Premium cost, employee & spouse coverage (Monthly Premium $)
3. Premium cost, employee & children coverage (Monthly Premium $)
4. Premium cost, family coverage (Monthly Premium $)
5. Other, please explain:
7. For the premiums listed above, what was the percent change from the last to the current Policy Year? (Enter the percent change OR detail change)
Enter the percent change OR detail change
1. Coverage for employee (single) (%)
2. Coverage for employee & spouse (%)
3. Coverage for employee & children (%)
4. Coverage for entire family (%)
5. Other, please explain:
Page 31
Employer Healthcare Benefits Survey
8. What is the estimated percent change that is expected from the current to the new Policy Year? (Leave blank if information is not available) (Enter the percent change)
Enter percent change
1. Coverage for employee (single) (%)
2. Coverage for employee & spouse (%)
3. Coverage for employee & children (%)
4. Coverage for entire family (%)
5. Other, please explain:
9. MONTHLY EMPLOYEE CONTRIBUTION TO THE PREMIUM: Provide the employee's monthly dollar contribution toward the monthly premium. IF COMPANY PAYS THE ENTIRE PREMIUM, enter the word "ZERO"; leave blank if no information is available. (Provide MONTHLY FIGURES, ENTER "ZERO" OR select from options 5 -8 on the right side of the table)
(Monthly $) or Check as Applicable
1. Employee
(Single) Coverage
2. Employee & Spouse Coverage
3. Employee
& Children Coverage
4. Family Coverage
5. Varies by
earnings
6. Varies by
employee option (e.g.
cafeteria plans)
7. Varies based on
age
8. Other/No
information available
Provide MONTHLY FIGURES,
ENTER "ZERO"
OR select from
options 5 -8 on the right side
of the table
Page 32
Employer Healthcare Benefits Survey
10. MONTHLY EMPLOYER CONTRIBUTION TO THE PREMIUM: For your HDHP/SO, enter the approximate MONTHLY contribution by the company. ENTER the word "ZERO" IF EMPLOYER DOES NOT CONTRIBUTE TOWARDS THE PREMIUM. (Provide percentage, ENTER "ZERO" OR select from options 5 - 8 on the right side of the table)
(Monthly $) or Check as Applicable
1. Employee
(Single) Coverage
2. Employee & Spouse Coverage
3. Employee
& Children Coverage
4. Family Coverage
5. Varies by
earnings
6. Varies by
employee option (e.g.
cafeteria plans)
7. Varies based on age
8. Other/No
information available
Provide percentage,
ENTER "ZERO" OR select from options 5 -
8 on the right side of
the table
11. As part of your HDHP/SO program and beyond contributions to the premium, does your plan contribute to the employee’s savings account?
1. Yes 2. No
Check one
12. If yes, what is MONTHLY EMPLOYER CONTRIBUTION TOWARDS THE EMPLOYEES’ SAVINGS ACCOUNT? Provide the employer's monthly dollar contribution toward the employees’ savings account. (Provide MONTHLY FIGURES)
1. Employer contribution, Savings Account or Check as Applicable
1. Employee (Single)
Coverage
2. Employee & Spouse Coverage
3. Employee & Children Coverage
4. Family Coverage
5. Varies by employee
option (e.g. cafeteria
plans)
6. Other / No information
available
Enter monthly
figures or check option
Page 33
Employer Healthcare Benefits Survey
13. HDHP/SO DEDUCTIBLES - Based on the type of deductible plan you have (Aggregate or Individual), enter deductible amounts for medical expenses that must be met before benefits are paid: (Enter DOLLAR amounts OR select from options 7-8 on the right side of the table)
1. Annual Deductible $ amount
Dependent Coverage, HDHP/SO Deductibles, Aggregate Amount: Plans where all covered family
members’ out-of-pocket expenses count towards the deductive.
Dependent Coverage, HDHP/SO Deductibles, Separate Amounts per Person: Plans where
each covered individual is required to meet a deductible.
or check as applicable
Employee coverage
2. Employee & spouse coverage
3. Employee
& children coverage
4. Family coverage
5. Provide
the amount
per individual that must
be met
AND 6. Number
of individuals required to meet
the amount
7. Unable to
determine based on
plan options
8. Other/No
information available
Enter DOLLAR amounts
OR select from
options 7-8 on
the right side of
the table
Page 34
Employer Healthcare Benefits Survey
14. HDHP/SO PLANS - Maximum Annual Out-Of-Pocket Expense -Provision in plan(s) where the employer's coinsurance amount increases to 100% after the employee has paid out a set dollar amount for covered expenses. (Enter DOLLAR amounts or select from options 7-14 on the right side of the table)
1. Out-Of-Pocket
Maximum Annual $ amount
Dependent Coverage,
HDHP/SO Out-Of-Pocket Maximum,
Aggregate Amount: Plans
where all covered family members’
out-of-pocket expenses count
towards the deductive.
Dependent Coverage, HDHP/SO Out-Of-Pocket
Maximum, Separate Amounts
per Person: Plans where
each covered
individual is required to
meet a deductible.
or check as applicableEm
ploy
ee c
over
age
2. E
mpl
oyee
& sp
ouse
cov
erag
e
3. E
mpl
oyee
& c
hild
ren
cove
rage
4. F
amily
cov
erag
e
5. P
rovi
de th
e am
ount
per
indi
vidu
al th
at
mus
t be
met
AND
6. N
umbe
r of i
ndiv
idua
ls re
quire
d to
m
eet t
he a
mou
nt
7. U
nabl
e to
det
erm
ine
base
d on
pla
n op
tions
8. A
nnua
l max
imum
out
-of-p
ocke
t ex
pens
e va
ries b
ased
on
earn
ings
9. V
arie
s by
coin
sura
nce
rate
s
10. P
lan
does
not
lim
it ou
t-of
-poc
ket
expe
nse
for i
ndiv
idua
l cov
erag
e
11. P
lan
does
not
lim
it ou
t-of
-poc
ket
expe
nses
for f
amily
cov
erag
e
12. P
lan
does
not
requ
ire o
ut-o
f-poc
ket
expe
nse
for i
ndiv
idua
l cov
erag
e
13. P
lan
does
not
requ
ire o
ut-o
f-poc
ket
expe
nse
for f
amily
cov
erag
e
14. N
o in
form
ation
ava
ilabl
e / O
ther
Enter DOLLAR amount
s or select from
options 7-14 on the right side of
the table
Page 35
Employer Healthcare Benefits Survey
15. Which of the following cost-sharing formulas apply to your HDHP/SO plan? (Check one)
1. Four or more tiers,
e.g. Generic, Preferred,
Nonpreferred, Biologic
2. Three tiers, e.g. Generic, Preferred, &
Nonpreferred
3. Two tiers, e.g. Generic or brand and Nonpreferred
4. Cost sharing is the
same regardless of type of drug
5. No cost sharing after deductible is
met
6. Do not know / Other
Check one
16. Under your HDHP/SO plan, do First-Tier drugs, often called "Generic drugs", require a copay or coinsurance? (Check one)
1. Yes, Copay only
2. Yes, Coinsurance
only
3. Yes, either Copay or
Coinsurance
4. Plan Pays Entire Cost After any
Deductibles are Met
5. No 6. Other / No information
available
Check one
17. If yes, provide copay and/or percent of coinsurance:
1. Co-payment ($) 2. Coinsurance (%)
Provide copay and/or percent of coinsurance
18. Under your HDHP/SO plan, do Second-Tier, drugs, often called "preferred drugs", require a copay or coinsurance? (Check one)
1. Yes, Copay only
2. Yes, Coinsurance
only
3. Yes, either Copay or
Coinsurance
4. Yes, Copay or
Coinsurance AND the cost difference to
a generic equivalent
5. No 6. Other / No information
available
Check one
19. If yes, provide copay and/or percent of coinsurance:
1. Co-payment ($) 2. Coinsurance (%)
Provide copay and/or percent of coinsurance
Page 36
Employer Healthcare Benefits Survey
20. Under your HDHP/SO plan, do Third-Tier drugs, often called "non preferred drugs", require a copay or coinsurance? (Check one)
1. Yes, Copay only
2. Yes, Coinsurance
only
3. Yes, either Copay or
Coinsurance
4. Yes, Copay or
Coinsurance AND the cost difference to
a generic equivalent
5. No 6. Other / No information
available
Check one
21. If yes, provide copay and/or percent of coinsurance:
1. Co-payment ($) 2. Coinsurance (%)
Provide copay and/or percent of coinsurance
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Page 37