Mtg No 45 Jan 11, 2011 Minutes and Notes

Southern
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.
does not include all services or charges.
Medical Insurance:
Annual Deductible (In Network)*
No Deductible
PPO Plan- Anthem /BCBS
Routine Office Visits
You pay $25 co -pay per visit + 10% for all other services (e.g.
Customer Service
$ 7.89
laboratory and x -ray services)
1- 800-542 -9402
Annual Out -of- Pocket Maximum
$1,000 + copayments
www.anthem.com
Hospitalization
$ 9.89
$ 1.85
Inpatient care
You pay 10% after $250 per admission co -pay
Family
Outpatient care
You pay 10% after$250 per admission co -pay
$ 13.56
Urgent, Non - Routine, After Hours
You pay $20 co -pay per visit + 10% for all other services (e.g.
382.58
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 der 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
Customer Service
subject to the deductible).
1- 800 - 610 -0201
www.deltadentalco.com
Diagnostic/ Preventative Services
You 0% of the covered amount
(Example: Cleaning every six months)
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.
Vision Insurance:
Co -pay with a Participating Provider
Vision Service Plan (VSP)
Customer Service
Exam
You Pay $10 co -pay
1- 800 - 877 -7195
Prescription Glasses
You Pay a $10 material co -pay
Contacts
No co -pay applies
www.vsp.com
Coverage
Exam
Every 12 months
Prescription Glasses
Lenses
Every 12 months
Frames
Every 24 months
OR
Contacts
Every 12 month
Amount You Pay Per Paycheck Bi- Week /y
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