| Medical Benefits |
Deluxe Plan |
Standard Plan |
Economy Plan |
| Deductible |
$100 Individual
$300 Family |
$250 Individual
$600 Family |
$500 Individual
$1,500 Family |
| Coinsurance(amount the employee must pay) |
•80% after deductible
• Charges accrue toward maximum out-of-pocket
• No network provisions |
• In network: 80% after deductible
• Charges accrue toward maximum out-of-pocket |
• Out of network: 60% after deductible
• Charges do not accrue toward the maximum out-of-pocket |
Annual
Out-of-Pocket Maximum
|
$400/person
$800/family
|
$750/person
$1,500/family |
$3,000/person
$6,000/family |
(does not include deductible) |
| Lifetime Max. |
$2,000,000 |
Hospital Admissions
(Inpatient) |
• All charges are first subject to the deductible and maximum out-of-pocket. |
• In network: 80%, accrues to maximum out-of-pocket total
• Out of network: 60%
• Charges do not accrue toward maximum out-of-pocket total. |
| Emergency Room Co-Payment |
80% as other expenses, after deductible |
Office Visits, Outpatient Surgery, Pre-op Testing,
Second Surgical Opinions |
80% as other expenses, after deductible |
• In-network 80% as other expenses, after deductible
• 60% out-of-network
• Charges do not accrue toward maximum out-of-pocket |
| Lab
and X-ray |
80% as other expenses, after deductible |
| Mental Health |
25 days inpatient
|
52 visits outpatient |
52 visits outpatient |
| Chemical Dependency |
80% as other expenses, after deductible to a maximum of $10,000 per year |
| Chiropractics |
80% as other expenses, after deductible |
| |
• Maximum of 26 visits per year |
| Bariatric Surgery |
>$25,000 lifetime maximum |
Not covered |
| Orthognathic Surgery |
$25,000 lifetime maximum |
Not covered |
| Well Baby and Well Child Checkups |
• Under age 1: six physical exams including immunizations at 100% with no
deductible
|
| • Over age 1: see general preventive benefits (physical benefit) |
General Preventive Benefit
(Physical Benefit) |
• Up to $750 per person per year toward preventive-related medical services, covered at 100% with no deductible
• Includes annual physical benefits |
| Adult Immunizations |
Covered under preventive benefit with no age limit |
Pharmacy Benefits |
Deluxe Plan |
Standard Plan |
Economy Plan |
• Network Pharmacy: 30-day supply
• Charges do not apply to medical out-of-
pocket maximums |
• $5 copay for generic
• $20 copay for brand
• $40 copay for for non-preferred brand |
| • Home Delivery: 100-day supply (charges do not apply to medical out-of-pocket maximums |
• $10 copay for
• $40 copay for brand
• $70 copay for non-preferred brand |
| Non-Network Pharmacy (charges do not apply to medical out-of-pocket maximums) |
• Pay retail price at time of purchase, submit claim form to be reimbursed at negotiated price less appropriate co-insurance |
| Dental Benefits |
Deluxe Plan |
Standard Plan |
Economy Plan |
| Annual Deductibles |
| Preventive |
$0 |
| Restorative |
$0 |
$25 |
$50 |
| Prosthetic |
$0 |
$25 (combined with restorative) |
$50 (combined with restorative) |
| Coinsurance |
| Preventive |
100% |
80% |
| Restorative |
80% |
| Prosthetic |
50% |
| Annual Maximum |
$2,000 |
| Orthodontia |
$1,500 lifetime max |
not covered |
| Vision Benefits |
Deluxe Plan |
Standard Plan |
Economy Plan |
| Copay |
$10 copay for exam
$25 copay for glasses (lens and frames)
No copay for contacts |
| Exam - every 12 months |
VSP network doctor: covered in full after $10 copay
Non-VSP provider: Up to a $45 reimbursement after the $10 copay |
Lenses and frames - every 24 months
OR
Contacts - every 24 months |
Lenses covered in full after $25 copay, frame of your choice
up to $120, plus 20% off any out-of-pocket costs
Non-VSP provider: Reimbursement after $25 copay as follows:
• Single vision lenses up to $45
• Lined bifocal lenses up to $65
• Lined trifocal lenses up to $85
• Frames up to $47
Contact Lens Care program gives you a $120 allowance with no copay
every 24 months for the cost of your contacts and the contact lens exam.
Soft contact lens wearers may qualify for a special program that includes
evaluation and initial supply of replacement lenses. Learn more from your
doctor, or vsp.com.
Non-VSP provider: Reimbursement up to $105 |
| Discounts and Savings |
When you go to a VSP network doctor, you will receive an average of
30% savings on lens extras (such as scratch resistant and anti-reflective
coatings and progressives), and a 20% discount when you purchase
additional prescription glasses, including prescription sunglasses, from
any VSP network doctor within 12 months of your last eye exam.
You will receive up to 15% off the contact lens fitting and evaluation
exam from a VSP network doctor.
Finally, although the plan does not provide coverage for laser eye
surgery, you can get a discount on laser vision correction through a VSP
network doctor. |
