io/Trak: Coverage Summaries

Group Health Insurance Benefits                               
BLUE CROSS BLUE SHIELD of FLORIDA
Effective December 1, 2016
OPEN ACCESSHMO Plan 51HMO Plan 48HMO Plan 47
Physician Co-pay (In):$35$35$30
(Out):N/AN/AN/A
PCP Selection Required:YESYESYES
Specialist Co-pay (In):$50$65$55
(Out):N/AN/AN/A
PCP Referral Required:NO - Open AccessNO - Open AccessNO - Open Access
Deductible (In):$1,500 per Person$2,000 / $6,000$1,500 / $4,500
(Out):N/AN/AN/A
Emergency Room (In):$300$300$250
(Out):N/AN/AN/A
In-Patient Hospital (In):Ded, 50%$100 per Occ // Ded, 80%Ded, 80%
(Out):N/AN/AN/A
Out-Patient Surgery (In):Ded, 50%Ded, 80%Ded, 80%
(Out):N/AN/AN/A
Urgent Care (In):$70$70$60
(Out):N/AN/AN/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/AN/AN/A
Out of Pocket Maximum (In):$10,000 / $10,000$5,500 / $11,000$4,500 / $9,000
(Out):N/AN/AN/A
Co-Insurance (In):50%80%80%
(Out):N/AN/AN/A
Pharmacy Deductible:$100NoneNone
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:UnlimitedUnlimitedUnlimited
Per. Paycheck Deductions
HMO Plan 51HMO Plan 48HMO 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
AETNA
Effective December 1, 2016
Freedom of Choice #3 - Monthly Selection
DHMO PlanPPO Plan
Deductible:None$75 Ind / $225 Fam
Preventive (In):$10 OV, 100%Deductible Waived, 100%
(Out):N/ADeductible Waived, 100%
Basic (In):$10 OV, 90%Deductible, 70%
(Out):N/ADeductible, 70%
Major (In):$10 OV, 60%Deductible, 40%
(Out):N/ADeductible, 40%
Waiting Period:None12 mos Major Services
Orthodontics:$2,400 CopayNot Covered
Child Orthodontics
Waiting Period:NoneN/A
Calendar Year Maximum (In):Unlimited$1,000
(Out):N/A$1,000
Network Restrictions:Yes - Primary w/ ReferralsYes
Non-Par balance-billed
Pre-Existing Limitations:NoYes
Endo / Perio / Oral SurgBasic/Major ServiceMajor 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
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:
Exam12 months
Lenses12 months
Frames24 months
In-Network Co-Pays:
Exam$10
Materials - Covered Frames$25
Materials - Retail Frames$50 - $130 Allowance
Materials - Standard Lenses$25
Additional OptionsDiscounts
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:
ExamUp to $40
Materials - FramesUp to $45
Materials - Single Vision LensesUp to $40
Materials - Bifocal LensesUp to $60
Materials - Trifocal LensesUp to $80
Materials - Contact LensesUp 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
RELIANCE STANDARD
Effective December 1, 2016
Basic Life w/ AD&D:$15,000.00
All Eligible Employees
Employer Paid
Short-Term Disability:
Benefit Amount60% to $2,309 weekly
Elimination Period1 Day Accident
8 Days Illness
Benefit Period13 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