EMPLOYEE BENEFITS AT-A-GLANCE DECEMBER 1, 2022 - NOVEMBER 30, 2023 UPDATES FOR DECEMBER 1, 2022 Dental and Vision benefits are no longer tied to your Medical Election. Your medical, dental, and vision plans can now be elected independently, and employees will be responsible for 100% of the premium for the dental and vision plans. Please see the updated pricing for these benefits in Employee Navigator.
MEDICAL INSURANCE | ANTHEM BLUE CROSS In Network: Blue Open Access POS Coinsurance Calendar Year Deductible - Employee | Family Out-of-Pocket Max - Employee | Family Wellcare Primary Care Provider Office Visit Specialist Office Visit Urgent Care Emergency Room Outpatient Surgery Inpatient Hospital & Services Prescription Drugs | Rx Deductible - Individual | Family Tier 1 (Deductible waived) Tier 2 Tier 3 Tier 4 Out of Network Coinsurance Calendar Year Deductible - Employee | Family Out-of-Pocket Max - Employee | Family
0% $3,500 | $7,000 $6,600 | $13,200 Covered in Full $25 $75 $60 $300 Deductible Deductible $150 | $300 $15 $35 $60 20% to $300 50% $7,500 | $22,500 $21,450 | $42,900
DENTAL INSURANCE | ANTHEM In Network Annual Maximum Benefits per Member
$1,000
Calendar Year Deductible - Employee | Family
$50 | $150
Preventive (Cleaning, Routine Exams, X-Rays)
Covered in Full - Deductible Waived
Basic Services (Fillings, Extractions)
80%
Major Services (Endo, Perio, Oral Surgery, Crowns, Dentures, Bridges)
50%
Out of Network
90th Percentile of Usual and Customary
VISION INSURANCE | ANTHEM In Network: Blue View Vision Frequency (Exam | Lenses | Frames) Exam (Once per 12 Mos.) Lenses Frames or Contact Lenses
12 | 12 | 24 $10 $25 $130 Allowance