COUNTY OF YUBA SUMMARY OF BENEFITS Dental Vision Life Insurance PPO HMO Waiver Delta Dental PPO Medical Eye Services ING – ReliaStar PPO Plans administered by Blue HMO: Must be referred to a Choose between the The following information reflects Basic Life Insurance: Proof of other Cross. The following information Specialist by the primary care following Plan Options: services obtained from a coverage MUST be YCEA & DSA/MSA reflects services obtained from a physician. participating provider. provided in order to Basic Plan: employees receive Preferred Provider. waive County $20,000 Choose between 2 of the Examinations, Lens, and Contact provided health www.calpers.ca.gov following Plan Options: Annual Maximum Lens are covered every 12 DDAA & Non- coverage and receive PERS Select: Coverage: months on a rolling calendar Represented premium incentive 80/20% Plan Blue Shield $1,500 per person per year. (i.e. If you receive an eye employees receive savings. Doctor MUST accept Blue calendar year exam in August the next eye $50,000 $20 Co-Pay Shield exam covered will be August of Premium Incentive Deductible: $500/$1,000 Deductible: the following year. Basic Accidental Savings: No Deductibles Out-of-Pocket Maximum: Per calendar year Death & $15 Co-Pays Examinations: YCEA & Non- $3,000/$6,000 $50 per person Dismemberment No charge for preventive care $25 Deductible Represented receive PERS Choice: $150 per family Insurance: visits (i.e. well-baby, periodic $150 per month 80/20% Plan health exams, immunizations, Lens: YCEA & DSA/MSA Premium Plan: DSA/MSA & DDAA $20 Co-Pay allergy testing and treatment). Lens Allowance Depends on employees receive employees receive: Out-of-Pocket Maximum: Prescription $20,000 Deductible: $500/$1,000 Annual Maximum $250 per month $1,500/3,000 Coverage: Standard Lens Covered: Out-of-Pocket Maximum: DDAA & Non- $3,000/$6,000 Retail Prescriptions: $5 $2,000 per person per Single Vision, Bifocal, Trifocal, Waiver premiums are Represented Generic/$15 Brand calendar year Aphakic Monofocal and Aphakic taxable. PERS Care: employees receive Mail-Order Prescriptions: $10 Multifocal 90/10% Plan $50,000 Generic/$25 Brand Deductible: Progressive Lens for dependent Special Open $20 Co-Pay Per calendar year Enrollment Period: A list of Providers is available children through 18 years Basic Dependent Life Deductible: $500/$1,000 at: www.blueshieldca.com $50 per person covered up to $89.50. Insurance: There is a Special 30- $100 per family Day Open Enrollment Out-of-Pocket Maximum: Polycarbonate Lens covered up DDAA & Non- Kaiser Permanente Period when other $2,000/$4,000 to $85.00. Represented Service Area is determined by Orthodontic: coverage is lost (i.e. Prescriptions for PERS employees have the Zip Code. A list of zip codes in spouse changes jobs (Select, Choice & Care): Contact Lens: option of three plans: the service area is attached. Orthodontic coverage is or loses job). Retail: $5 Generic/$15 Brand Contact Lens Allowance covered $1,000 included. Coverage cannot Mail-Order: $10 Generic/$25 Brand No Deductibles up to $105.00 toward the contact $2,000 lapse, it must be lens evaluation, fitting costs and $5,000 PORAC:* $15 Co-Pay Orthodontic coverage continuous. If an materials. 90/10% Plan No charge for preventive care does not count against employee misses the Supplemental Life visits (excludes allergy your annual maximum. Special Enrollment $20 Co-Pay Frames: Insurance: testing). Period they must wait $300 per person deductible Frame Allowance covered up to All County employees A list of PPO Dentists is until the annual open Out-of-Pocket Maximum: $100.00 every 24 month in a may purchase $900 per family deductible available at: enrollment period to $1,500/3,000 rolling calendar year (i.e. If you additional www.deltadentalca.org enroll. Out-of-Pocket Maximum: Retail Prescriptions: receive frames in August 2007 Supplemental Life $3,000/$6,000 $5 Generic/$15 Brand the next time frames will be Insurance for self, Retail Prescriptions: $10 Mail-Order Prescriptions: covered is August 2009). spouse and dependent Generic/$25 Brand $5 Generic/$15 Brand A list of Participating Providers is children. Packets Mail-Order Prescriptions: $20 available at: available in Personnel. www.kaiserpermanente.org Generic/$40 Brand www.mesvision.com Employees may elect to pay their share of premium payments with pre-tax dollars (premium conversation plan options). * Membership in PORAC is required to enroll in this plan.