Health Summary Plan Description

Plan I Benefits Summary

As of January 1, 2016, ValueOptions is now Beacon Health Options. For more information, please see the Winter 2015 Take 2.

Hospital and Medical

Benefit Plan I
Hospital Network Provider Non-Network Provider
Calendar Year Deductible

The Industry Health Network -
$150 / person; $300 / family

BlueCard PPO / ValueOptions -
$250 / person; $500 / family

Not covered
Inpatient (Room and Board and Ancillary Services) 90% Not covered*
Outpatient Surgery 90% Not covered
Emergency Room 90% after $100 copay; copay is waived if immediately confined Not covered*
Out-Of-Pocket Maximum (excludes Deductible and Copays) $1,750 / person; $3,500 / family Not covered
Medical Network Provider Non-Network Provider
Calendar Year Deductible

The Industry Health Network - None

BlueCard PPO / ValueOptions -
$250 / person; $500 / family

$500 / person; $1,000 / family
Office Visit
(including X-ray and Lab)
90% after $15 copay 70%
Surgeon - Inpatient
Outpatient Hospital, Surgical Center, Surgical Suite
Doctor's Office
90% after $100 copay
90% after $100 copay
90% after $15 copay
70%
70%
70%
Maternity Care - Prenatal Visits
Delivery
No deductible; 100%
90% after $100 copay
70%
70%
Routine Physical Exam No deductible; 100% No deductible; 70%
Routine Child Exam No deductible; 100% No deductible; 70%
Mammogram/Pap No deductible; 100% No deductible; 70%
Out-Of-Pocket Maximum (excludes Deductible and Copays) $1,000 / person; $2,000 / family $2,500 / person; $5,000 / family
Hospital / Medical Lifetime Maximum None None

* Emergency treatment within 72 hours after an accident or within 24 hours of a sudden and serious illness will be covered at the Network Level of Benefits.

Plan II Benefits Summary

Hospital and Medical

Benefit Plan II
Hospital Network Provider Non-Network Provider
Calendar Year Deductible

The Industry Health Network -
$150 / person; $300 / family

BlueCard PPO -
$500 / person; $1,000 / family

Not covered
Inpatient (Room and Board and Ancillary Services) 90% Not covered*
Outpatient Surgery 90% Not covered
Emergency Room 90% after $200 copay; copay is waived if immediately confined Not covered*
Out-Of-Pocket Maximum (excludes Deductible and Copays) $1,750 / person; $3,500 / family Not covered
Medical Network Provider Non-Network Provider
Calendar Year Deductible

The Industry Health Network - None

BlueCard PPO -
$500 / person; $1,000 / family

$750 / person;$1,500 / family
Office Visit
(including X-ray and Lab)
90% after $25 copay 70%
Surgeon - Inpatient
Outpatient Hospital, Surgical Center, Surgical Suite
Doctor's Office
90% after $100 copay
90% after $100 copay
90% after $25 copay
70%
70%
70%
Maternity Care - Prenatal Visits
Delivery
No deductible; 100%
90% after $100 copay
70%
70%
Routine Physical Exam No deductible; 100% Not covered
Routine Child Exam No deductible; 100% Not covered
Mammogram/Pap No deductible; 100% 70%
Out-Of-Pocket Maximum (excludes Deductible and Copays) $1,000 / person; $2,000 / family $2,500 / person;$5,000 / family
Hospital / Medical Lifetime Maximum None None

* Emergency treatment within 72 hours after an accident or within 24 hours of a sudden and serious illness will be covered at the Network Level of Benefits.

Plan I Benefits Summary

Prescription Drugs, Mental Health and Substance Abuse, Dental and Vision

Benefit Plan I
Prescription Drugs Express Scripts Participating Retail Pharmacy Express Scripts Home Delivery (includes Specialty)
  Specialty medications must be obtained by mail through the specialty pharmacy, Accredo.
Calendar Year Deductible $150 / person; $300 / family
Supply Up to a 30 day supply / prescription or refill Up to a 90 day supply / prescription or refill

Copay
The greater of:
Generic - $10 or 10%

Preferred Brand - $25 or 25%

Non-Preferred Brand - $40 or 40%

In addition, if you receive a brand name drug when a generic exists, you will pay the difference in cost between the generic and brand name medication.

Generic prescription contraceptives are covered at 100% with no deductible or copay.

The greater of:

Generic - $20 or 10%; max copay is $50 / prescription

Preferred Brand - $50 or 25%; max copay is $125 / prescription

Non-Preferred Brand - $100 or 40%; max copay is $300 / prescription

In addition, if you receive a brand name drug when a generic exists, you will pay the difference in cost between the generic and brand name medication subject to the maximum
copays listed above.

Generic prescription contraceptives are covered at 100% with no deductible or copay.
Mental Health and Substance Abuse ValueOptions Provider Non-Network Provider
Hospital and Alternative Levels of Care Covered under the Hospital Benefit Not covered
Medical Covered under the Medical Benefit Covered under the Medical Benefit
Dental
Delta Dental PPO Provider
Delta Premier and Non-Network Providers
Calendar Year Deductible $75 / person; $200 / family; waived for diagnostic and preventive $75 / person; $200 / family
Diagnostic and Preventive Benefits 100% 75%
Basic Benefits 75% 75%
Major Benefits 50% 50%
Calendar Year Maximum* $2,500 $2,500
Vision - Exam Plus Plan Vision Service Plan Provider Non-Network Provider
Eye Exams 100% after $10 copay; one exam / calendar year 80% up to maximum payment of $50; one exam / calendar year
Glasses 20% discount No benefit
Professional Services for Contact Lenses 15% discount No benefit

* There is no maximum for individuals under age 19.

Plan II Benefits Summary

Prescription Drugs, Mental Health and Substance Abuse, Dental and Vision

Benefit Plan II
Prescription Drugs Express Scripts Participating Retail Pharmacy Express Scripts Home Delivery (includes Specialty)
  Mental health/substance abuse medications are not covered. Specialty medications must be obtained by mail through the specialty pharmacy, Accredo.
Calendar Year Deductible $150 / person; $300 / family
Supply Up to a 30 day supply / prescription or refill Up to a 90 day supply / prescription or refill
Copay The greater of:
Generic - $10 or 10%

Preferred Brand - $25 or 25%

Non-Preferred Brand - $40 or 40%

In addition, if you receive a brand name drug when a generic exists, you will pay the difference in cost between the generic and brand name medication.

Generic prescription contraceptives are covered at 100% with no deductible or copay.
The greater of:
Generic - $20 or 10%; max copay is $50 / prescription

Preferred Brand - $50 or 25%; max copay is $125 / prescription

Non-Preferred Brand - $100 or 40%; max copay is $300 / prescription

In addition, if you receive a brand name drug when a generic exists, you will pay the difference in cost between the generic and brand name medication subject to the maximum copays listed above.

Generic prescription contraceptives are covered at 100% with no deductible or copay.
Mental Health and Substance Abuse ValueOptions Provider Non-Network Provider
Hospital and Alternative Levels of Care Not covered
Medical
Dental Delta Dental PPO Provider Delta Premier and Non-Network Providers
  Must have three or more years of prior Earned Eligibility.
Calendar Year Deductible $100 / person; no family maximum; waived for diagnostic and preventive $100 / person; no family maximum
Diagnostic and Preventive Benefits 100% 60%
Basic Benefits 60% 60%
Major Benefits 50% 50%
Calendar Year Maximum* $1,000 $1,000
Vision - Exam Plus Plan Vision Service Plan Provider Non-Network Provider
Eye Exams Not covered
Glasses
Professional Services for Contact Lenses

* There is no maximum for individuals under age 19.