Page 2 - 2019 Brochure - HiQ
P. 2

DENTAL
                                                                                          MEDICAL HMO
                                                                                                                                                                                              Dental Connect PPO

                                                                                                                                                                                       In Network                   Out of Network

                               Funding                                   First $3500                                                                Deductible Individual                               $25
                               Network                                   In Network                                                                    Deductible Family                                $75
           Annual Deductible Individual                                       $0                                                                              Preventive                               100%
              Annual Deductible Family                                   Last $3,500                                                                Cleanings Frequency                        2x per Calendar Year
                    Max OOP Individual                                      $2,500                                                                     Deductible Waived                                Yes
                       Max OOP Family                                       $8,500                                                                      Basic Endo/Perio                  90%                           80%
                                                                                                                                                                   Major                  60%                           50%
              Office Copay (PC/Specialist)
                                                                                                                                                       Annual Maximum                                 $5,000
                           Lab & X-Ray
                                                                                                                                                     Pays out of network                             90th UCR
                      Hospital Inpatient
                    Outpatient Surgery                                                                                                                             Ortho                               None
                           Urgent Care                              then up to OOP Max                                                                   Ortho Maximum                             Not Covered
                                                                       $0 up to $3500,
                            ER Charge                                                                                                                    Dental Network                  First Dental Health / DenteMax

                            Ambulance
                                                                                                                                                                                                                           VISION
                            Rx Generic
                              Rx Brand                                                                                                                                                          VSP Choice Plan 3

                          Acupuncture                                                                                                                                                 In Network                   Out of Network
                                                                        Not Covered
                           Chiropractic                                                                                                           Comprehensive Exam                             Every 12 Months
                                                                                                                                                              Eye Exams              $10 Copay                      Up to $45
                                                                                        MEDICAL PPO                                                             Lenses                           Every 12 Months
                                                                                                                                                            Single Vision                                           Up to $30

                                                                                                                                                                  Bifocal            $10 Copay                      Up to $50
                               Funding                                   First $3500                                                                              Trifocal                                          Up to $65
                               Network                                   In Network                                                                             Frames                           Every 12 Months
           Annual Deductible Individual                                  Last $2,000                                                                                             $150 Allowance +                   Up to $70
              Annual Deductible Family                                   Last $7,500                                                                                           20% above allowance
                    Max OOP Individual                                      $3,050                                                                             Contacts                          Every 12 Months
                       Max OOP Family                                       $9,600                                                                               Elective         $150 Allowance                    Up to $105
              Office Copay (PC/Specialist)
                           Lab & X-Ray
                      Hospital Inpatient
                     Outpatient Surgery                                                                                                                                                          FSA and COMMUTER
                           Urgent Care

                            ER Charge                                  $0 up to $3500,                                                                             FSA and COMMUTER BENEFITS
                            Ambulance                                then up to OOP Max
                            Rx Generic                                                                                                        Health Care FSA                          $2,700                       Maximum
                                                                                                                                                                                                                     Annual
                              Rx Brand                                                                                                        Dependent Care                           $5,000                      Contribution
                          Acupuncture
                  20 visits per calendar year                                                                                                                                                                       Maximum
                           Chiropractic                                                                                                       Parking & Transit                     $265 / $265                      Monthly
                  20 visits per calendar year                                                                                                                                                                      Contribution
                ** Using your Wex Card to pay for Out of Network services will exhaust your funds more rapidly.
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