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Benefit Summary
Your Firm
| Medical Carrier |
800-555-5555 |
|
| Policy #: |
In-Network |
Out-of-Network |
| Deductible (Indiv/Fam) |
None |
$500/Indiv ($1500max) |
| Out-of-Pocket Maximum |
$2,500 |
$10,000 ($30,000 max) |
| Doctor Office Visits |
$20 Co-Pay |
60% of UCR |
| Well Baby Care |
$25/exam |
60% limited to $20/visit |
| Immunizations |
No Charge |
60% to $12 |
| Well Woman Visits |
80% |
60% of UCR |
| Pre & Postnatal Care |
$20 Co-Pay |
60% of UCR |
| Hospitalizations, Outpatient Surgery |
80% |
60% After $500, 60% of UCR |
| Emergency Room |
80% after $100co-pay |
80% After $100 Co-Pay |
| Ambulance |
80% |
80% of UCR |
| Chiropractor (24 visits/year) |
80% |
60% to $25/Visit |
| Acupuncture (12 visits/year) |
80% to $25/Visit |
60% to $25/Visit |
| R/X - Generic |
$10 Co-Pay |
$10 Plus 50% |
| R/X - Brand Name Formulary |
$25 Co-Pay |
$25 Plus 50% |
| R/X-Brand Name/Non-Formulary |
50% |
50% |
| Employee Assistance Program |
Carrier |
(800) 555-5555 |
Counseling: 5 FREE visits, per problem per yr. Family/marital/alcohol/drugs/stress/depression
Referrals: Addiction, parenting & elder care programs, legal & financial svcs (1 free consult)
Your Firm
Dental Carrier 800-555-5555
www.website.com |
HMO |
In-Network |
Out of Network
|
| Individual/Family |
N/A |
$50/$150 |
$50/$150 |
| Annual Maximum |
Unlimited |
$1,500 |
$1,500 |
| Oral Exam, Prophy, X-Rays (ded waived) |
100% |
100% |
100% of UCRRestore |
| Restore, Extract,Endontics,Periodontics |
Scheduled |
80% |
80% of UCR |
| Crowns, Bridges, Dentures |
Scheduled |
50% |
50% of UCR |
| Pre-orthodontic visits & treatment |
300 co-pay |
N/C |
N/C |
| Orthodontics retention |
275 co-pay |
N/C |
N/C |
| Treatment Plan |
$1,450 co-pay |
N/C |
N/C |
Vision Carrier 800-555-5555
www.website.com |
In-Network Provider |
Out-of-Network Provider |
| *Exam: |
$10.00 Co-Pay |
Up to $42.00 |
| Materials: |
$25.00 Co-Pay |
|
| Single Vision Lenses: |
Covered in full |
Up to $40.00 |
| Bifocal/Trifocal/Lenticular Lenses: |
Covered in full |
Up to $60/$80/$125 |
| Frames: |
Covered in full |
Up to $45.00 |
| Contact Lenses:(medically necessary) |
Covered in full |
Up to $210.00 |
| Contact Lenses: (elective) |
Up to $105.00 |
Up to $105.00 |
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| *Exam: 1 every 12 mo., Lenses: 1 pair every 24 mo., Frames: 1 pair every 24 mo.
Questions: See Human Resources or Call Dorothy at Your brocker 800-555-5555 x202
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