Medical Insurance - Blue Cross PPO
Deductible
In-Network
$100 deductible per person
Maximum: 3 per family
Out-of-Network
$300 deductible per person
Maximum: 3 per family
Annual Out-of-Pocket Max
In-Network
$2,000 per person/
$6,000 per family
Out-of-Network
$6,000 per person/
$18,000 per family
Emergency Room
Deductible waived if admitted
In-Network
$100 co-pay each visit
Out-of-Network
$100 co-pay each visit
Office Visit . Gen. Practitioner
In-Network
$20 co-pay
Out-of-Network
40%
Specialist
In-Network
$30 co-pay
Out-of-Network
40%
Prescriptions
In-Network
$5/$30/$50 co-pay for generic, preferred, non-preferred (30 day supply)
Out-of-Network
$10/$30/$50 co-pay + 50% of the limited fee schedule + any amounts exceeding the fee schedule
Prescriptions . Mail Order
In-Network
$10/$60/$100 co-pay for generic, preferred, non-preferred (90 day supply)
Out-of-Network
N/A
Chiropractic and Acupuncture - American Specialty Health
Plan
$10 co-pay per visit
40 visits per year for combined chiropractic and acupuncture
Dental Insurance - Delta Dental Preferred Plan
Deductible
In-Network
$50 deductible per person
Maximum of $150 per family
Out-of-Network
$50 deductible per person
Maximum $150 per family
Preventive Care
In-Network
100% (paid by plan, deductible waived)
Out-of-Network
100% (paid by plan, deductible waived)
Basic Restorative Care
In-Network
100% (paid by plan)
Out-of-Network
80% (paid by plan)
Major Restorative Care
In-Network
60% (paid by plan)
Out-of-Network
50% (paid by plan)
Annual Maximum (Excluding Orthodontia)
In-Network
$1500 per person
Out-of-Network
$1500 per person
Adult/Child Orthodontia
In-Network
50% up to max of $1000 per person (lifetime)
Out-of-Network
50% up to max of $1000 per person (lifetime)
Vision - Vision Services Plan
Plan
Eye Exam every 12 months
Frames every 24 months
Lenses/contacts every 12 months
$25 Annual Co-payment
Work Life - MHN
Plan>
Employee Assistance Program Referrals
Mental Health Program
Legal/Financial Referrals
Drug/Alcohol Dependence