OPTION I BUY UP COMMUNITY. BLUE PLAN 1 All coverages and riders subject to: No Deductibles Prescription Drug Rider $10.00 Generic Prescription Drugs $20.00 Brand Name Prescription Drugs MOPD - Mail Order Prescription Drugs $250 Maximum Annual In Network Preventative Services VCA 80 - Vision Care HCA – Hearing Care $15.00 Office Visit Co-Pay No Out-Of-Pocket Maximum Plus Deductible (Excluding Mental Health Care Services) Annual Employee Cash Cost (Deducted bi-weekly) $ 750.00 – Single Plan $1,250.00 – Two Person Plan $1,500.00 – Family Plan
OPTION I BUY UP COMMUNITY. BLUE PLAN 1 All coverages and riders subject to: No Deductibles Prescription Drug Rider $10.00 Generic Prescription Drugs $20.00 Brand Name Prescription Drugs MOPD - Mail Order Prescription Drugs $250 Maximum Annual In Network Preventative Services VCA 80 - Vision Care HCA – Hearing Care $15.00 Office Visit Co-Pay No Out-Of-Pocket Maximum Plus Deductible (Excluding Mental Health Care Services.) Annual Employee Cash Cost (Deducted bi-weekly) $ 750.00 – Single Plan $1,250.00 – Two Person Plan $1,500.00 – Family Plan B. OPTION II – BUY DOWN COMMUNITY BLUE OPTION 3 Annual Deductible: $250 – Employee $500 – Family Annual Co-Pays: 80%/20% (BC/BS pays 80% all approved charges.) Prescription Drug Rider: 20% co-pay with a $ 5.00 Out-Of-Pocket Minimum $25.00 Out-Of-Pocket Maximum MOPD - Mail Order Prescription Drugs $250 Maximum Annual In Network Preventative Services $20.00 Office Visit Co-Pay Out-Of-Pocket Maximum Including Deductible (Excluding Mental Health Care Services.): $1,250.00 Employee $2,500.00 Family VCA 80 - Vision Care HCA – Hearing Care Annual Cash Rebate (Paid bi-weekly) $200.00 - Single Plan $335.00 - Two Person Plan $410.00 - Family Plan
OPTION I BUY UP COMMUNITY. Blue Plan 1 $ 750.00 – Single $1,250.00 – Two Person Plan $1,500.00 – Family Plan
OPTION I BUY UP COMMUNITY. BLUE PLAN 1 All coverages and riders subject to: No Deductibles Prescription Drug Rider $10.00 Generic Prescription Drugs $20.00 Brand Name Prescription Drugs MOPD - Mail Order Prescription Drugs $500 Maximum Annual In Network Preventative Services VCA 80 - Vision Care HCA – Hearing Care PD-CM - Contraceptive Medications PCD – Contraceptive Devices $15.00 Office Visit Co-Pay No Out-Of-Pocket Maximum Plus Deductible (Excluding Mental Health Care Services) Annual Employee Cash Cost (Deducted bi-weekly) $ 750.00 – Single Plan $1,250.00 – Two Person Plan $1,500.00 – Family Plan
OPTION I BUY UP COMMUNITY. Blue Plan 1 $ 750.00 – Single $1,250.00 – Two Person Plan $1,500.00 – Family Plan B. OPTION III Full time employees eligible to participate in the plan but who elect not to participate shall be entitled annual compensation as follows: * $1350 - Family Plan subscriber * $1100 - Two Person subscriber * $ 650 - One Person subscriber Payment shall be made in equal bi-weekly installments with the employee’s paycheck. The employee may elect the compensation through deferred compensation or individual flexible spending account. The employee shall have sole responsibility to apply for deferred compensation that shall be consistent with all terms and conditions of deferred compensation.
