Digestive Disease Consultants: Coverage Summaries

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Group Dental Insurance Proposal
Digestive Disease Consultants

Renewal Effective March 1, 2019

HUMANA INSURANCE PPO Plan

Deductible (In):	$25 / $75
(Out):	$50 / $150

Preventive (In):	100%, Deductible Waived
(Out):	80%, Deductible Waived

Basic (In):	Ded., 80%
(Out):	Ded., 50%

Major (In):	Ded., 50%
(Out):	Ded., 50%
Waiting Period: (10 Enrolled)	None

Orthodontics:	Not Covered

Calendar Year Maximum (In):	Unlimited
(Out):	Unlimited

Network Restrictions:	Yes
Non-Par balance-billed
Pre-Existing Limitations:	Yes
Oral Surgery (Simple):	Basic Service
Oral Surgery (Complex)	Major Service
Endodontics / Periodontics:	Basic Service
Endodontics / Periodontics Surgery:	Major Service

PER. PAYCHECK DEDUCTIONS

Employee:	$0.00
Employee w/ Spouse:	$10.50
Employee w/ Child(ren):	$16.27
Employee w/ Family:	$26.77

SPREADSHEET FOR ILLUSTRATIVE PURPOSES ONLY
PLEASE REFER TO INSURANCE CARRIER BENEFIT SUMMARY FOR DETAILS OF BENEFITS PROVIDED
BENEFITS ARE PAYABLE ACCORDING TO THE HUMANA INSURANCE DENTAL CERTIFCATE OF COVERAGE

Vision Group Insurance Benefits
Digestive Disease Consultants

Renewal Effective March 1, 2019

HUMANA Vision Plan 200
Voluntary Enrollment

Deductible:		None

Frequency:
Exam		12 months
Lenses		12 months
Frames		12 months

In-Network Co-Pays:
Exam		$0
Materials - Covered Frames		Up to $200
Materials - Retail Frames		Up to $200
Materials - Standard Lenses		$0
Additional Options		Discounts

Contact Lenses - In lieu of Eyeglasses:
Exam with 2 Fittings		$0
Materials - Retail Lenses		10% Off then up to $55

Out-of-Network Allowance:
Exam		Up to $30
Materials - Frames		Up to $100
Materials - Single Vision Lenses		Up to $25
Materials - Bifocal Lenses		Up to $40
Materials - Trifocal Lenses		Up to $60
Materials - Contact Lenses		Up to $100


Per Paycheck Deductions

Employee:		$7.13
Employee with Spouse:		$14.26
Employee with Child(ren):		$13.55
Employee with Family:		$21.30


SPREADSHEET FOR ILLUSTRATIVE PURPOSES ONLY
PLEASE REFER TO INSURANCE CARRIER SUMMARY FOR DETAILS OF BENEFITS PROVIDED
BENEFITS ARE PAYABLE ACCORDING TO HUMANA INSURANCE VISION CERTIFICATE OF COVERAGE

GROUP LIFE AND DISABILITY BENEFITS
DIGESTIVE DISEASE CONSULTANTS
Renewal Effective March 1, 2019

HUMANA INSURANCE COMPANY
100% EMPLOYER PAID

Basic Life with AD&D:

ALL EMPLOYEES

Guaranteed Issue Benefit Amount $25,000


SPREADSHEET FOR ILLUSTRATIVE PURPOSES ONLY
PLEASE REFER TO INSURANCE CARRIER SUMMARY FOR DETAILS OF BENEFITS PROVIDED
BENEFITS ARE PAYABLE ACCORDING TO THE HUMANA INSURANCE CERTIFICATE OFCOVERAGE

VOLUNTARY GROUP TERM LIFE BENEFITS
DIGESTIVE DISEASE CONSULTANTS
Renewal Effective April 1, 2019

HUMANA INSURANCE COMPANY


Voluntary Life with AD&D

EMPLOYEES	Guaranteed Issue Benefit Amount $75,000

SPOUSE	Guaranteed Issue Benefit Amount $35,000
* Can elect up to 50% of Employee Elected Amount for SP *
CHILD(REN)	Guaranteed Issue Benefit Amount $10,000


SPREADSHEET FOR ILLUSTRATIVE PURPOSES ONLY
PLEASE REFER TO INSURANCE CARRIER SUMMARY FOR DETAILS OF BENEFITS PROVIDED
BENEFITS ARE PAYABLE ACCORDING TO THE HUMANA LIFE INSURANCE CERTIFICATE OF COVERAGE