Home Benefits Compensation Policies and Handbooks Training Communications Forms and Documents

Health Benefits at a Glance

Benefit COVA Care - You Pay COVA HDHP - You Pay
Deductible

One Person
Two or more persons


$225
$450


$1,750
$3,500
Out-of-Pocket Expense Limit

One Person
Two or more persons


$1,500
$3,000


$5,000
$10,000
Doctor's Visits

Primary Care Physician
Specialist


$25
$40


20% coinsurance after
deductible has been met
Hospital Services

Inpatient
Outpatient


$300 per stay
$125 per visit


20% coinsurance after
deductible has been met
Emergency Room visits $125 per visit
(waived if admitted)
20% coinsurance after
deductible has been met
Outpatient diagnostic laboratory
tests, shots, and x-rays
20% coinsurance after
deductible has been met
20% coinsurance after
deductible has been met
Prescription Drugs
Mandatory Generic


Retail Pharmacy
     Tier One
     Tier Two
     Tier Three
     Tier Four (Specialty Drugs)

Home Deliver Pharmacy
     Tier One
     Tier Two
     Tier Three
     Tier Four (Specialty Drugs)

Diabetic test strips & glucose monitors



Up to 34-day supply
$15
$25
$40
$50

90-day supply
$30
$50
$80
$100

20% (no deductible)



20% coinsurance after
deductible has been met




20% coinsurance after
deductible has been met




20% (after deductible)


Behavioral Health and EAP

Inpatient Treatment

Medical Professional Visit
Non-Medical Professional Visit
EAP (up to 4 visits per incident)


$300 per stay

$25
$25
$0


20% coinsurance after
deductible has been met
20% coinsurance after
deductible has been met

$0
Wellness Services

Well Child - through age 6

Office visits at specified intervals
Immunizations, lab and x-rays

Routine Wellness - age 7 and older

Annual checkup visit
     Primary Care Physician
     Specialist
Immunizations, lab, & x-rays

Preventative Care*

One each per year - specific age limits





$0
$0




$0
$0
$0



$0




$0
$0




$0
$0
$0



$0
Dental Benefit

Plan Year Deductible



Plan maximum payment

Diagnostic and preventative

Primary Services


Complex Restorative


Orthodontics



$50 single
$100 dual
$150 family

$2000 per person/per year

$0 - Two visits/year (no deductible)

20% coinsurance after
deductible has been met

See optional expanded Dental


See optional expanded Dental







$50 single
$100 dual
$150 family

$2000 per person/per year

$0 - (no deductible)

20% coinsurance after
deductible has been met

50% coinsurance after
deductible has been met

50% coinsurance -
no deductible
($2000 lifetime max)




* Includes gynecological exam, Pap test, mammography screening, prostate exam (digital rectal exam), prostate specific antigen test (PSA), and colorectal cancer screening.

COVA Care Additional Coverage Options

Benefit Who Pays Administrator

Out - Of - Network

May be combined with Expanded Dental or Vision, Hearing and Expanded Dental.

Applies to Medical and Behavorial Health Services.



Plan payment is reduced by 25%. You pay applicable deductible, co-payment and/or coinsurance.

Provider may balance bill for amount above allowable charge.



Anthem
Value Options

Expanded Dental

May be combined with Out-of-Network.

Plan pays up to $2,000 per member per plan year for Basic & Complex Services.

Complex Restorative (inlays, onlays, crowns, dentures, and bridgework)

Orthodontics $2,000 lifetime maximum per member









You Pay - 50% coinsurance after deductible


You Pay - 50% coinsurance, no deductible

Delta Dental

Vision, Hearing and Expanded Dental

May be combined with Out-of-Network

Vision
Routine eye exam (every 24 months)
Eyeglass Frames (every 24 months)
Lenses (every 24 months)
     Plastic single vision (pair)
     Plastic bifocal (pair)
     Plastic trifocal (pair)
     Contact Lenses

Hearing
Routine hearing exam (48 mos.)
Purchase of hearing aids and other related hearing services.
($1200 benefit max. every 48 months)

Expanded Dental





In Network
You Pay $40 copay
$100 allowance - then 20% off

$20 copay then covered in full
$20 copay then covered in full
$20 copay then covered in full
See allowance schedule

In Network
You pay $40
You pay $0



See above





Anthem
Blue View







Anthem






Delta Dental