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.