Mtg No 45 Jan 11, 2011 Minutes and Notes

Southern
Indian
This benefits summary of the benefits The Southern Ute Indian Tribe provides if you are regularly scheduled to work a
minimum of 24 hours per week. Coverage will begin on the 91st day of regular employment. Please see benefit
summaries or certificate of coverage for more details and information on additional voluntary benefits.
Benefit Name:
$
Benefit Highlights. This summary
does not include all services or charges.
Medical Insurance:
$
Annual Deductible (In Network)*
No Deductible
PPO Plan- Anthem /BCBS
130.75
Routine Office Visits
You pay $25 co -pay per visit + 10% for all other services (e.g.
$
260.59
Employee & Child(ren)
laboratory and x -ray services)
Employer Cost
$ 9.89
Annual Out -of- Pocket Maximum
$1,000 + copayments
Employee Only $496.81
Employee + Spouse
$784.45
Hospitalization
$ 13.56
Employee + Child(ren)
$745.26
- Inpatient care
You pay 10% after $250 per admission co-pay
Family $1,137.44
- Outpatient care
You pay 10% after$250 per admission co -pay
Urgent, Non - Routine, After Hours
You pay $20 co -pay per visit + 10% for all other services (e.g.
Care
laboratory and x -ray services)
Emergency Care
10% after $100 co -pay per visit; the co -pay is waived if admitted
Tier 1:$15 co -pay /Tier 2:$40 co -pay /Tier 3:$60 co -pay
Prescription Drugs
Tier 4: Self - Injectables 30% up to a $250 co -pay per prescription
*See Benefits Summary for Out of-Network
benefits
Dental Insurance:
Deductible (In and Out of Network)
You pay a $25 Individual \$75 Family deductible each calendar
Delta Dental Premier Plan
year. (Diagnostic, Preventive and Orthodontic Services are not
Employer Cost
subject to the deductib le).
Employee Only $31.95
Employee + Spouse
$47.21
Diagnostic/ Preventative Services
You 0% of the covered amount
Employee + Child(ren)
$59.29
(Example: Cleaning every six months)
Family
$81.29
Basic Services (Example: Fillings)
You pay 20% of the covered amount
Major Services (Example: Crowns)
You pay 50% of the covered amount (Adult Orthodontic Services
are not covered).
Maximum Benefit
$1,500 in each calendar year for Diagnostic, Preventive, Basic
and Major Services. Each eligible dependent child, to age 19,
may receive up to $1,000 per lifetime for Orthodontic Services.
ision Insurance:
Co -pay with a Participating Provider
ision Service Plan (VSP)
Exam
You Pay $10 co -pay
Employer Cost
Prescription Glasses
Contacts
You Pay a $10 material co -pay
No co -pay applies
Employee Only $8.52
Employee + Spouse
$10.88
Employee + Child(ren)
$11.08
Coverage
Family
y
$17,70
xam
Every 12 months
prescription Glasses
Lenses
Every 12 months
- Frames
Every 24 months
OR
Contacts
Every 12 month
Employee Contributions
Employee Only
$
13.07
$ .85
$ .23
$
14.15
Employee & Spouse
$
130.75
$ 7.89
$ 1.81
$
260.59
Employee & Child(ren)
$
124.21
$ 9.89
$ 1.85
$
252.41
Family
$
189.58
$ 13.56
$ 2.96
$
382.58