Page 3 - Michigan Fitness Foundation 2021 Booklet

Michigan Fitness Foundation

2021 Renewal Benefits

BCN HMO Platinum $500: $500 Single/$1000 Family Deductible, 0% Coinsurance,
Annual out-of-pocket maximum, $1,500 Single/$3,000 Family

BCN HSA HMO Gold $2000 HDHP: $2,000 Single/$4,000 Family Deductible, 0%
Coinsurance, Annual out-of-pocket maximum $3,500 Single/$7,000 Family

BCBSM SB HSA PPO Gold $2000 HDHP: $2,000 Single/$4,000 Family Deductible,0%
Coinsurance, Annual out-of-pocket maximum $3,000 Single/$6,000 Family

Blue Dental PPO Plus: Preventative Services covered 100%, Basic Services covered
80%, Major Services covered 50% and Orthodontic Services covered 50%. There is a
$25 Single/$75 Family deductible for Basic and Major Services. Each person on the plan
has an Annual benefit of $1,000, running on a calendar year basis. Orthodontics
covered for children up to age 19, with a lifetime maximum of $1,000
Blue Vision VSP Choice: Exam/Lenses/Frames every 12 months, based on the last date
of service. $5 Eye Exam copay/$10 Materials copay, $130 Allowance for Frames and
Lenses.

UNUM Short Term Disability: 14 Day Elimination Period for Injury or Sickness, Benefit
will provide 66.67% of weekly earnings to a maximum of $1,500 per month

UNUM Long-Term Disability: 90 Day Elimination Period, Benefit will provide 66.67% of
monthly earnings to a maximum of $6,000 per month, to age 65

UNUM Life/AD&D Insurance: $50,000 Term Life Insurance and Accidental Death and
Dismemberment benefit

UNUM Voluntary Life Insurance:. Employees can purchase up to 5x annual earnings to
a maximum of $500,000. Employee Guarantee Issue of $75,000. Additional Life
Insurance coverage can be purchased in $10,000 increments. Employees can also
purchase coverage for their spouse and dependents

Flexible Spending Account:. Healthcare; Dependent Care