benefit summary plan year: december 1, 2013 to november 30, 2014
TRANSCRIPT
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Benefit SummaryPlan Year: December 1, 2013 to November 30, 2014
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2OAP5 1.5K / 90 B In-Network Non-Network
Physician Office Visit Copay: • Primary Care• Specialist (No referral necessary)• Urgent Care• Global Maternity Physician Charge
$25 Copay$50 Copay$60 Copay
Deductible / Coinsurance
Deductible / Coinsurance
Calendar Year Deductible: • Individual• Family
$1,500$4,500
$3,000$9,000
Co-Insurance (after deductible you pay) 10% 40%
Out of Pocket Maximum (includes deductible) • Individual• Family
$4,500$9,000
$9,000$18,000
Prescription Drugs• Tier 1• Calendar Year Deductible• Tier 2 / Tier 3• Tier 4
• Mail Order – Tier 1 / Tier 2 / Tier 3• Tier 4
$15$200 per member
$40 / $7520% to max of $200
$15 / $80 / $22520% to max of $200
60% after deductible
Not Covered
If a member receives a brand name drug that falls on Tier 3 that has a generic equivalent available, the member pays the Tier 1 copay, plus the difference in cost between the brand drug and generic drug. This applies even when physician indicates DAW (dispense as written).
Provider Directory: BlueChoice Open Access ; www.bcbsga.com; Find a Doctor; best to use your 3 digit prefix; Blue Open Access POS
BCBS of Georgia - Medical Plan
Pay period Deduction (24pp) Employee Employee/Spouse Employee/Child(ren) Employee/Family
Medical $0 $227.10 $196.13 $423.22
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Medical Plan In an effort to assist with potential out of pocket expenses, the firm will reimburse each employee up to $1,000.00 of his/her individual out-of-pocket expenses. For in-network services, the firm will pay the out-of-pocket expenses incurred from $3,501 to $4,500 which is the maximum amount of out-of-pocket expense, if applicable. For out of network services, the firm will pay the out-of-pocket expenses incurred also from $3,501 to $4,500, with the employee being responsible for the amounts incurred from $4,501 to $9,000, if applicable.
Employee Assistance
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DENTAL Dental Option 1 – Scheduled Plan(If dentist is in-network)
Dental Option 2 – Unscheduled Plan(If dentist is not in-network)
In-Network Non-Network In-Network Non-Network
Payment Mode Paid at Contracted Rate Max. Allowable Charge Paid at Contracted Rate Paid at 90th percentile
Deductible $50 / waived for Preventive Care $50 / waived for Preventive Care
Co-Insurance 100% Preventive / 100% Basic / 60% Major50% Ortho
100% Preventive / 80% Basic / 50% Major50% Ortho
Plan Maximum $1,000 Annual Maximum / per insured$1,000 Orthodontia Lifetime Maximum
$1,000 Annual Maximum / per insured$1,000 Orthodontia Lifetime Maximum
Preventive Routine exams, cleanings (2 per year), second opinion consults, fluoride treatment, space maintainers, sealants, x-rays
Routine exams, cleanings (2 per year), second opinion consults, fluoride treatment, space maintainers, sealants, x-rays
Basic Periodontic prophylaxis, fillings, stainless steel crowns, general anesthesia, simple oral surgery, complex oral surgery,
periodontics, endodontics
Periodontic prophylaxis, fillings, stainless steel crowns, general anesthesia, simple oral surgery, complex oral surgery, periodontics,
endodontics
Major Repairs to partial denture, bridge crown, crowns, inlays, onlays, cast post and core, bridges, dentures
Repairs to partial denture, bridge crown, crowns, inlays, onlays, cast post and core, bridges, dentures
Rollover Benefit Threshold $500; Rollover amount: $250; Account Limit $1,000 Threshold $500; Rollover amount: $250; Account Limit $1,000
Principal – Dental and Vision
Pay Period Deduction (24pp) Employee Spouse Child(ren) Family
Dental $0 $15.34 $26.83 $48.60
Vision $0 $5.00 $4.41 $9.41
Vision – free to use any provider; benefits are available once per 12 months
Eye Exams Up to $65 for eye exam;
Frames Allowance / Contact Lens Allowance Frames: up to $150; Contact Lenses: up to $200
Lenses $50 for Single lenses; $75 for Bifocal lenses; $100 for Trifocal lenses; $150 for Lenticular lenses
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Benefits Begin
Benefits Payable
Maximum
Duration
Own Occupation
Determine your premium
Rates
Less than age 25
25 – 29
30 – 34
35 – 39
40 – 44
45 – 49
50 – 54
55 – 59
60 – 64
65 and over
Voluntary Short-term Disability
15 Days Accident or Illness
60% of pre-disability earnings
$2,000 Weekly Maximum
Payable up to 11 weeks
N/A
Annual earnings / 52 = weekly earningsWeekly earnings x .60 = weekly benefit
Weekly benefit / 10 x (rate ______) = monthly costMonthly cost x 12 / 24 = payroll deduction $_____(note: if your weekly benefit exceeds $2,000; then
use$2,000 as your weekly benefit.
.40
.44
.39
.36
.38
.39
.46
.58
.71
.79
Voluntary Long-term Disability
90 Days
60% of pre-disability earnings
$10,000 Monthly Maximum
Payable to Social Security Normal Retirement Age
Class I: Attorneys: SSNRA Class II: All Others: 24 Months
Annual earnings / 12 = monthly earningsMonthly earnings / 100 x (rate _____) = monthly cost
Monthly cost x 12 / 24 = payroll deduction $_____(note: if your monthly earnings exceed $16,666; then
use $16,666 as your monthy earnings.
.09
.14
.26
.41
.65
.87
1.12
1.29
1.18
.69
Unum Insurance
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The information contained in this benefits summary is incomplete. Please refer to the certificate of insurance or plan document for coverage terms, conditions, limitations and exclusions. If there is any difference between the contents of this summary and the policy, plan or proposal to which it addresses, the language of the policy, plan or proposal shall rule. Non-network care and treatment is subject to usual, reasonable and customary provisions that may result in reduced reimbursement. Should you have any questions please contact Jennifer Bent, Christine Gottfried, or me, Cindy Nash. Thank you!
Cindy L. NashAngus McRae Insurance Brokerage Services, Inc.4725 Peachtree Corners Circle, Suite 155Norcross, GA [email protected](770) 300-0001 ext. 102 (phone)(770) 366-6896 (mobile)(770) 456-5059 (fax)