io/Trak: Coverage Summaries

- Simple
- Blue Care Plan 47 Benefit Summary
- Blue Care Plan 48 Benefit Summary
- Blue Care Plan 51 Benefit Summary
Group Health Insurance Benefits | |||||||||||||||||||||||||||||||||||||
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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 |
Dental Benefits | ||||
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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 |
Vision Group Insurance Benefits | |
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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 |
GROUP LIFE w / AD&D AND SHORT-TERM DISABILITY BENEFITS | |
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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 |