$3,500 (I) / $7,000 (F)
Annual Deductible
$5,000 (Individual) / $10,000 (Family)
Out-of-Pocket Maximum
Primary Care/Office Visit
Specialist Visit
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$3,500 (I) / $7,000 (F)
Annual Deductible
$5,000 (Individual) / $10,000 (Family)
Out-of-Pocket Maximum
Primary Care/Office Visit
Specialist Visit
HSA-Powered High Deductible Plan.
Network
Give you flexibility and choice. Unlike an HMO, the PPO plan does not require that you select a Primary Care Physician (PCP) or require any referral from a PCP to see a specialist. At the time of service, you may choose to see a PPO provider or an out-of-network provider.
When you use the services of a PPO provider, your benefits are paid at the highest level (your out of pocket cost will be the lowest). Therefore, it is to your advantage to use PPO providers, but it is not required. If you use an out-of-network provider, you are responsible for paying the difference in cost between the out-of-network provider’s charges and the allowed amount.
You have the option of receiving your 90-day maintenance medications at CVS Pharmacy or through CVS Caremark Mail Service Pharmacy. Benefit from lower copays for 90-day prescriptions.
Generics will be required before brand-name drugs, helping save you up to 75% on your prescriptions.
DHMO plans offer the highest level of coverage. There are no deductibles or annual benefit maximum and there are set copayments for services you receive.
If you choose to enroll in this plan, you must select a primary dentist participating in the DHMO network. Should you require the care of a specialist, your Primary Care Dentist (PCD) will refer you to a specialist within the DHMO network. You will not be covered for any services provided by an out-of-network dentist except in the case of an emergency.
$0 for preventive, $50 for other services
Annual Deductible
$1,000 combined maximum
Calendar Year Maximum
Basic Services
Children covered
Orthodontic Services
EyeMed provides comprehensive vision coverage, offering savings on eye exams, prescription glasses, and contact lenses. With access to a nationwide network of eye doctors, members receive annual eye exams with low copays and discounts on frames, lenses, and elective services.
The plan helps cover routine vision needs while promoting overall eye health.
$10 copay
Eye Exam Copay
Lenses
$150 allowance
Frames
$150 allowance
Contacts
Benefits for you in case of prolonged illness or injury.
Coverage for your family.
Summary Plan Description
Summary Plan Description (amended 1/2023)Summary Plan Description (amended 1/2023)Compliance Notices
Notice of Privacy Practices (February 2026) Notice of Privacy Practices (February 2026)Supplemental Life Insurance
Supplemental Employee & Dependent Life/AD&D Benefits SummarySupplemental Employee & Dependent Life/AD&D Benefits SummaryBasic Life and AD&D
Basic Life and AD&D Benefit SummaryBasic Life and AD&D Benefit Summary
