Riders
Customers can further enhance coverage with affordable
prescription medications, dental care, vision, life insurance
and more.
|
|
| |
Coinsurance Plan
|
50%
Plan |
$10/20/40 Copay Plan |
$10/35/50 Copay Plan |
| Deductible
|
None |
None |
None |
None |
| Out-of-Pocket Maximum
|
$2,500
|
$2,500 |
None |
None |
| Generic Medications
|
$10
|
50% |
$10 |
$10 |
| Preferred Brand Medications
|
30%
|
50% |
$20 |
$35 |
| Non-Preferred Brand Medications
|
50%
|
50% |
$40 |
$50 |
| BlueEssentialsSM
|
Not available
|
Available |
Not available |
Available |
| BluePreferred®
|
Available
|
Available |
Available |
Available |
| BlueClassicSM
|
Available
|
Available |
Available |
Available |
| |
Plan |
Max Per
Year Benefit |
Deductible |
Preventive
|
Restorative |
Complicated |
Major |
| Value
|
| 65
|
$1,000 |
$50 |
100% w
|
80% |
50% |
50% |
| 66
|
$1,000 |
$50 |
80%
|
80% |
50% |
50% |
| Classic
|
| 84B
|
$1,500 |
$25 |
100% w
|
80% |
80% |
50% |
| 85A
|
$1,000 |
$50 |
100% w
|
80% |
80% |
50% |
| 86B
|
$1,500 |
$50 |
80%
|
80% |
80% |
50% |
| BlueCare*
|
| 51
|
$1,000 |
$0 |
Refer to Schedule
on Benefits Summary
|
W = Deductible waived
* Only fee-for-service dental option available for groups
with 3-10 enrolled employees.
| |
|
Plan |
Visit Copay
|
Crowns |
Root Canal Single |
|
DA
|
$5
|
$0 |
$0 |
|
DB
|
$10
|
$50 |
$40 |
|
DC
|
$10
|
$120 |
$50 |
|
DD
|
$10
|
$180 |
$60 |
|
DE
|
$12
|
$225 |
$60 |
|
DF
|
$15
|
$275 |
$60 |
|
DG
|
$25
|
$400 |
$150 |
Includes orthodontia benefits
| Dental/Dentacare
Plans (Match-ups) - Available to groups of 100 + employees
Percent based on Preventive, Basic, Complicated
and Major Services |
| Dental 65 |
No Dentacare Match-up |
Groups of 11+ |
| Dental 66 |
Dentacare DE and DF *# |
Groups of 11+ |
| Dental 84B |
Dentacare DA and DB *# |
Groups of 11+ |
| Dental 85A |
Dentacare DB, DC and DD *# |
Groups of 11+ |
| Dental 86B |
Dentacare DD and DE *# |
Groups of 11+ |
| Dentacare Standalone Plan |
Dentacare DB, DC, DD, DE, and DF *# |
Groups of 11+ |
| Dentacare Standalone Plan |
Dentacare DG *# |
Groups of 3-10 |
| Dental 51 |
Dentacare DF and DG *# |
Groups of 3+ |
* Not available in all areas
# Orthodontia included
** Deductible waived for Preventive Services
| |
| Life and AD&D
|
| Short-term Disability (STD)
|
| Long-term Disability (LTD)
|
| Voluntary Life, AD&D, STD,
and LTD
|
| |
-
Chiropractic, Acupuncture,
Naturopathic Care / $20 copayment / $500
max per calendar year
-
Chiropractic, Acupuncture,
Naturopathic Care / $20 copayment / $1000
max per calendar year
-
Managed Chiropractic /
$20 copayment
|
| |
|
Full-service Vision / $20 copayment |
| Associated Administrators,
Inc. |
|
Section 125 Plans – Flexible
Spending Accounts (FSA) |
| Section 105 Plans – Health
Reimbursement Arrangements (HRA) |
|
