Health and Wellness

Medical Insurance - Blue Cross PPO

Deductible

In-Network
$100 per person/max (3)
$100 deductible per family
($300 max)

Out-of-Network
$100 per person/max (3)
$100 deductible per family
($300 max)

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
$10 co-pay

Out-of-Network
40%

Specialist

In-Network
$10 co-pay

Out-of-Network
40%

Prescriptions

In-Network
$10/$20/$40 co-pay for generic, preferred, non-preferred (30 day supply)

Out-of-Network
$10/$20/$40 co-pay + 50% of the limited fee schedule + any amounts exceeding the fee schedule

Prescriptions . Mail Order

In-Network
$20/$40/$80 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
Deductible $50 per person/max of (3)
$50 deductible per family ($150 max)

Out-of-Network
$50 per person/max of (3)
$50 deductible per family ($150 max)

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 $20 Annual Co-payment

Work Life - Cigna Behavioral Health

Plan

Employee Assistance Program Referrals

Mental Health Program

Legal/Financial Referrals

Drug/Alcohol Dependence