Page 2 - GMEI Benefits Guide 2020

GMEI

2020 Open Enrollment

 PHP PPO: $500 Single/$1,000 Family Deductible, 10% Coinsurance after
Deductible to a Coinsurance Maximum of $500 Single/$1,000 Family, $20
OV, $40 Specialist, $50 UC, $150 Emergency Room after Deductible, RX
copays: Generic $10/Brand $40/Non-Preferred $80/Specialty 20% maximum
$300; Maximum Out of Pocket $3,000/$6,000

 Base Plan – Delta Dental PPO 80/50/50/50
$0 Deductible, $1000 per member Annual Maximum.
$1,000 per member Lifetime Ortho Maximum

 Buy Up Plan – Delta Dental PPO 100/80/50/50
$0 Deductible, $1,000 per member Annual Maximum
$1,000 per member Lifetime Ortho Maximum

 Essential Health Benefits (EHB)
ACA Mandated Pediatric Dental For Children Under Age 19
$350 Maximum Out-of-Pocket per child
$700 Maximum Out-of-Pocket for 2 or more children in a family

 EyeMed 12/12/12 Frequency, $10 Exam /$25 Materials:
 Examination - once every 12 months
 Lenses or Contact Lenses - once every 12 months
 Frame - once every 12 months
 $150 Allowance

 UNUM Life/AD&D: $75,000 benefit

 UNUM LTD: 90 Elimination Period, 66.667 of monthly earnings to a maximum
monthly benefit of $5,000.

 UNUM Voluntary Life/AD&D: Guarantee Issue - $100,000 Employee, $25,000
Spouse, $10,000 Child

 Allstate Accident and Critical Illness plans are also available on a voluntary
basis on the BerniePortal