Table of Content
- Header
-
Page
- What's New for 2022!
- Benefits Overview
- Medical - Aetna
- Prescriptions
- Virtual Visits - Teledoc
- Dental - Delta Dental
- Vision - Delta Dental
- How To Enroll?
- Additional Resources
- Contact Us
- Footer
What's New for 2022!
Medical coverage will be moving from Anthem to Aetna!
Benefits Overview
MEDICAL: Moving from Anthem to Aetna.
DENTAL: Provided through Delta Dental with 100%/80%/50% in network coverage.
VISION: Provided through Delta Dental with one plan option that utilizes a large network of providers.
Medical - Aetna
DEDUCTIBLE:
- Single Deductible - $500
- Family Deductible - $1,000
- COINSURANCE - 80% - (applies after deductible is met) & Out of Pocket Max (includes coinsurance and deductible)
PLAN PAYS:
- Single Out of Pocket Maximum - $3,500
- Family Out of Pocket Maximum - $7,000
- Primary Care (PCP) - Office Visit - $30
- Preventive Services - 100%
- Specialist - Office Visit - $60
- Urgent Care Facility - $75
- Emergency Room Visit - $500
EMPLOYEE CONTRIBUTIONS (BI-MONTHLY)
Single: $135.60
EE+Spouse: $395.43
EE+Children: $338.65
Family: $561.48
Prescriptions
RETAIL - 30 DAY SUPPLY
TIER 1 - $3A/$10
TIER 2 - $45
TIER 3 - $75
TIER 4 - 20% up to $250 (pref.)/40% up to $500 (non-pref.) (30 day only)
Virtual Visits - Teledoc
Access to quality care at your fingertips!
General Medical - Talk to a licensed doctor for non-emergency conditions 24/7
Mental Health - Talk to a therapist 7 days a week
Dermatology - Upload images of a skin issue online and get a custom treatment plan within 2 days
Dental - Delta Dental
You have the freedom to select the dentist of your choice; however, when you visit a participating in-network dentist, you will have lower out-of-pocket costs, no balance billing, and claims will be submitted by your dentist on your behalf.
IN NETWORK:
DEDUCTIBLE:
- Single Deductible - $50
- Family Deductible - $150
*Deductible applies when receiving Basic or Major services (Waived for Preventive services)
CLASS I: - Covered at 100%* (deductible waived)
Diagnostic and Preventive Services - Exams, cleanings, fluoride, space maintainers, sealants, x-rays.
CLASS II: - Covered at 80% (deductible applies)
Basic Services - Fillings, crown repair, root canals, extractions and oral surgery, religns and repairs to prosthetic appliances.
CLASS III: - Covered at 50% (deductible applies)
Major Services - Crowns, bridges, implants, dentures, and crowns over implants
ANNUAL MAXIMUM:
Calendar Year Maximum Allowed per Benefit Period - $1,000 per covered individual
EMPLOYEE CONTRIBUTIONS (WEEKLY)
Employee: $12.99
Employee + 1: $28.29
Employee + 2 or more: $48.76
Vision - Delta Dental
GK's Custom Polishing offers vision benefits provided by Delta Dental. Services rendered by a participating provider will be paid at a higher level.
IN NETWORK:
Vision Exam - $10 copay
COVERED SERVICES – LENSES / FRAMES
Single Lenses - $25 copay
Bifocals - $25 copay
Trifocals - $25 copay
Lenticular - $25 copay
Frames - up to $130 allowance
COVERED SERVICES
Elective Contact Lenses - up to $130 allowance
Necessary Contact Lenses - Covered in full after copay
Contact Lens Evaluation Fitting - Up to $60
BENEFIT FREQUENCY
Exams - Once every 12 Months
Lenses or Contacts - Once every 12 Months
Frames - Once every 24 Months
EMPLOYEE CONTRIBUTIONS (PER PAY PERIOD)
Single: $2.54
EE+Spouse: $5.09
EE+Children: $5.42
Family: $8.65
* NOTES
- The lens frequency limit applies to contact lenses OR lenses for eyeglasses. You cannot purchase both in 12 months—its one or the other.
- If receiving Progressive lenses, contact Vision Benefits of America to verify the plan reimbursement prior to placing your final order. The in-network allowance for these expensive lenses typically covers only a portion of the total cost.
How To Enroll?
Contact Us
Client Contacts
Kristin Zehnder
kristin@gkspolishing.com
440-937-4457