io/Trak: Coverage Summaries

Group Health Insurance Benefits
BLUE CROSS BLUE SHIELD of FLORIDA
Effective December 1, 2016
OPEN ACCESS	HMO Plan 51	HMO Plan 48	HMO Plan 47
Physician Co-pay (In):	$35	$35	$30
(Out):	N/A	N/A	N/A
PCP Selection Required:	YES	YES	YES

Specialist Co-pay (In):	$50	$65	$55
(Out):	N/A	N/A	N/A
PCP Referral Required:	NO - Open Access	NO - Open Access	NO - Open Access
Deductible (In):	$1,500 per Person	$2,000 / $6,000	$1,500 / $4,500
(Out):	N/A	N/A	N/A
Emergency Room (In):	$300	$300	$250
(Out):	N/A	N/A	N/A
In-Patient Hospital (In):	Ded, 50%	$100 per Occ // Ded, 80%	Ded, 80%
(Out):	N/A	N/A	N/A
Out-Patient Surgery (In):	Ded, 50%	Ded, 80%	Ded, 80%
(Out):	N/A	N/A	N/A
Urgent Care (In):	$70	$70	$60
(Out):	N/A	N/A	N/A
Simple Lab (In):	$0	$0	$0
Simple X-Ray (In):	$50	$50	$50
Complex X-Ray / Lab (In):	$300	$300	$250
X-Ray / Lab (Out):	N/A	N/A	N/A
Out of Pocket Maximum (In):	$10,000 / $10,000	$5,500 / $11,000	$4,500 / $9,000
(Out):	N/A	N/A	N/A
Co-Insurance (In):	50%	80%	80%
(Out):	N/A	N/A	N/A
Pharmacy Deductible:	$100	None	None
Pharmacy:	$10 / $60 / $100	$10 / $30 / $50	$10 / $30 / $50
Home Delivery (90-Day Supply) :	$25 / $150 / $250	$25 / $75 / $125	$25 / $75 / $125
Lifetime Maximum:	Unlimited	Unlimited	Unlimited
Per. Paycheck Deductions
	HMO Plan 51	HMO Plan 48	HMO Plan 47
Employee:	$22.00	$89.00	$97.00
Employee w/ Spouse:	$294.08	$453.80	$471.27
Employee w/ Child(ren):	$195.54	$321.70	$335.50
Employee w/ Family:	$450.78	$663.83	$687.14
SPREADSHEET FOR ILLUSTRATIVE PURPOSES ONLY
PLEASE REFER TO INSURANCE CARRIER SUMMARY FOR DETAILS OF BENEFITS PROVIDED
BENEFITS ARE PAYABLE ACCORDING TO THE BLUE CROSS BLUE SHIELD CERTIFICATE OF COVERAGE

File name : Blue-Care-Plan-47-BC-Benefit-Summary.pdf

File name : Blue-Care-Plan-48-BC-Benefit-Summary.pdf

File name : Blue-Care-Plan-51-BC-Benefit-Summary.pdf

Dental Benefits
AETNA
Effective December 1, 2016
	Freedom of Choice #3 - Monthly Selection
	DHMO Plan	PPO Plan
Deductible:	None	$75 Ind / $225 Fam
Preventive (In):	$10 OV, 100%	Deductible Waived, 100%
(Out):	N/A	Deductible Waived, 100%
Basic (In):	$10 OV, 90%	Deductible, 70%
(Out):	N/A	Deductible, 70%
Major (In):	$10 OV, 60%	Deductible, 40%
(Out):	N/A	Deductible, 40%
Waiting Period:	None	12 mos Major Services
Orthodontics:	$2,400 Copay	Not Covered
Child Orthodontics
Waiting Period:	None	N/A
Calendar Year Maximum (In):	Unlimited	$1,000
(Out):	N/A	$1,000
Network Restrictions:	Yes - Primary w/ Referrals	Yes
		Non-Par balance-billed
Pre-Existing Limitations:	No	Yes
Endo / Perio / Oral Surg	Basic/Major Service	Major Service
Per. Paycheck Deductions
Employee:	$19.65
Employee w/ Spouse:	$37.25
Employee w/ Child(ren):	$39.40
Employee w/ Family:	$56.35
SPREADSHEET FOR ILLUSTRATIVE PURPOSES ONLY
PLEASE REFER TO INSURANCE CARRIER SUMMARY FOR DETAILS OF BENEFITS PROVIDED
BENEFITS ARE PAYABLE ACCORDING TO THE AETNA INSURANCE CERTIFICATE OF COVERAGE

File name : io-Trak-AETNA-Dental-Benefit-Summary.pdf

Vision Group Insurance Benefits
SPECTERA UNITED Healthcare
Effective December 1, 2016
	V0008
Product Type:	Voluntary Enrollment
Employer Contribution:	0% EE / 0% Dep
Minimum Enrollment:	2 Eligible Employees
Deductible:	None
Frequency:
Exam	12 months
Lenses	12 months
Frames	24 months
In-Network Co-Pays:
Exam	$10
Materials - Covered Frames	$25
Materials - Retail Frames	$50 - $130 Allowance
Materials - Standard Lenses	$25
Additional Options	Discounts
Contact Lenses - In lieu of Eyeglasses:	Deductible, 50%
Exam with 2 Fittings	$10
Materials - Covered Lenses	$25
Materials - Retail Lenses	$105 Allowance
Out-of-Network Allowance:
Exam	Up to $40
Materials - Frames	Up to $45
Materials - Single Vision Lenses	Up to $40
Materials - Bifocal Lenses	Up to $60
Materials - Trifocal Lenses	Up to $80
Materials - Contact Lenses	Up to $105
	Per Paycheck Deductions
Employee:	$4.40
Employee with Spouse:	$8.58
Employee with Child(ren):	$9.02
Employee with Family:	$12.55
SPREADSHEET FOR ILLUSTRATIVE PURPOSES ONLY
PLEASE REFER TO INSURANCE CARRIER SUMMARY FOR DETAILS OF BENEFITS PROVIDED
BENEFITS ARE PAYABLE ACCORDING TO THE UNITED SPECTERA VISION CERTIFICATE OF COVERAGE

File name : UHC-Vision-Plan-V0008-Benefit-Summary.pdf

GROUP LIFE w / AD&D AND SHORT-TERM DISABILITY BENEFITS
RELIANCE STANDARD
Effective December 1, 2016
Basic Life w/ AD&D:	$15,000.00
	All Eligible Employees
	Employer Paid
Short-Term Disability:
Benefit Amount	60% to $2,309 weekly
Elimination Period	1 Day Accident
	8 Days Illness
Benefit Period	13 weeks Duration
	All Eligible Employees
	Employer Paid
SPREADSHEET FOR ILLUSTRATIVE PURPOSES ONLY
PLEASE REFER TO INSURANCE CARRIER CERTIFICATE FOR DETAILS OF BENEFITS PROVIDED
BENEFITS ARE PAYABLE ACCORDING TO THE RELIANCE STANDARD CERTIFICATE OF COVERAGE

File name : io-Trak-Reliance-Group-Life-Summary-Sheet.pdf

File name : io-Trak-Reliance-Short-Term-Disability-Summary-Sheet.pdf