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HEALTH PLAN

CHISLHB maintains a self-funded Flexible Benefit program. Coverage is available for regular full-time employees beginning the first pay period following 30 days of full-time employment. Part-time employees are eligible for employee-only medical benefits beginning the first pay period following 60 days of employment (EPO only). The hospital and active physician staff function as the network for CHISLHB’s PPO and EPO, along with First Health’s Network.

Medical Plan

 Employer Provided Option

 

Preferred Provider Option
(Grandfathered)

   

BRHS/BHA

 In Network*

 Out of Network*

 

In Network 

Out of Network*

 
 Deductible (Calendar Year)
-Employee Only
-Employee + Family 

$300
$900
$1,000
$2,000
$3,000
$6,000
 
$1,000
$2,000
$3,000
$6,000
Coinsurance - Employee's Coinsurance
10%  20%  40%    20%  40% 
Out of Pocket Maximum
(Deductible & Copays included)

-Employee Only
-Employee + Family 


$2,500
$5,000
 

$6,600
$13,200


$17,500
Unlimited 
 


$6,600
$13,200 
 

$17,500
Unlimited
Physician’s Office
-Primary Care Physician
-Specialist

$30
$50

$30
$50

40%
40%
 

20%
20%

40%
40%
Emergency Care
BUCC
$150 Co-pay
$50 Co-pay
$150 Co-pay
20%
$150 Co-pay
40%
 
$150 Co-pay
$50 Co-pay
$150 Co-pay
$50 Co-pay
Inpatient Hospital $300 Co-pay $500 Co-pay $1,500 Co-pay   $500 Co-pay $1,500 Co-pay
Outpatient Hospital/Surgery $300 Co-pay $500 Co-pay $1,500 Co-pay   20% 40%
Pharmacy
-Generic
-Brand Formulary
-Brand Non-Formulary
-Specialty Medications
Maximum Out-of-Pocket
Per Script for Specialty

-Per Prescription
-Per Calendar Year
 
$15
$50
$75
20%


$250
$2,500
   
$15
$50
$75
20%


$250
$2,500
 


Dental Plan

The dental program encourages preventive treatment, allowing you to achieve oral health while striving to minimize dental costs. Coverage is
provided through CHISLHB’s self-funded dental program and claims are administered by HealthFirst.

 Benefits

You Pay

 Deductible - Waived for Preventive
Individual - $50
Family - $150
 Preventive Care
-Examinations and Cleanings, Routine
-Fluoride
-Oral Hygiene Instruction
-Palliatives
-Prophylaxis
-Sealants (under age 13)
-Space Maintainer (2 per year, under age 19)
-X-rays, Routine
 0%
 Basic Care
-Anesthesia
-Endodontic
-Extractions
-Fillings
-Injection of Antibiotics
-Oral Surgery
-Periodontal
-Relining and Rebasing
-Recementing Crowns, Inlays, Onlays, Denture
 20%*
 Major Care
-Appliances
-Crowns
-Implants
-Inlays, Onlays
-Occlusal Restoration
-Prosthetics
 50%*
 Orthodontia (Children only)

 50%

 Maximum Plan Pays 
 Annual (Preventive/Basic/Major)  $1,250
 Lifetime Orthodontia  $1,250


    Vision Plan

    Eye health is an indicator of overall health. Regular eye exams can detect diseases like glaucoma, diabetes and blindness. To ensure that you
    and your family get the care you need, CHISLHB offers a comprehensive vision benefit provided by UnitedHealthcare.

    Carrier/Plan Provisions 


    In-Network

     


    Out-of-Network

     
     Exam Every  12 Months
     Lenses Every  12 Months
     Frame Every  12 Months
     Copayment
     Exam  $10  
     Materials  $25  
     Service  Plan Pays  Plan Reimburses
     Eye Exam  100%  $40
     Single Vision Lenses  100%  $40
     Lined Bifocal Lenses  100%  $60
     Lined Trifocal Lenses  100%  $80
     Lenticular Lenses  100%  $80
     Frames  Up to $130, then 30% Up to $45
     Contact Lenses
    -Covered in Full Selection Contacts
    -Non-Selection Contacts
     4 Boxes
    Up to $105
    0% up to $120
    Up to $105
    Up to $105
    Up to $120
     Contact Lenses – Medically Necessary  100% Up to $210