Page 2 - Tetra Renewal 2020
P. 2
The Tetra Corporation
2020 Renewal Benefits
BCBSM CB PPO Platinum $500: $500 Single/$1,000 Family
Deductible, 10% coinsurance to an Annual maximum of
$500/$1,000, Annual Out of Pocket Maximum $6,600/$13,200
BCBSM Blue Dental PPO Plus 100/80/50/50 with Pediatric Dental:
Class I covered 100%, Class II covered 80%, Class III covered
50%, Class IV (Ortho) covered 50%. $25 Single/$75 Family
Deductible applies to Class II and Class III services, Annual
Maximum $1000 per member per calendar year. Lifetime Ortho
maximum of $1,000.
BCBSM Blue Vision: 12/12/12, Eye Exam/Lenses/Frames every 12
months. $5 Eye Exam copay/$10 Materials copay, $130
Allowance
Principal Life/AD&D-Executives : Benefit Amount-$200,000
Principal Life/AD&D-All other eligible: Benefit Amount-$100,000
Principal Short-Term Disability: Elimination Period-8/8/12, Weekly
Benefit-60% of pre-disability earnings up to $1,500
Principal Long-Term Disability: Elimination Period-90 Days, Monthly
Benefit-60% of pre-disability earnings up to $10,000
Principal 401K