Coverage Comparison Chart

Coverage
Comparison Chart
Premera Blue Cross $500 Deductible/$1000 Deductible/CDHP Deductible PPO Plans
$500-Deductible
PPO
Provider
Non-PPO
Provider
Alaska
Plan
$1,000-Deductible
PPO
Provider
Non-PPO
Provider
Alaska
Plan
CDHP $1,500-Deductible
HSA-qualifed plan
PPO Provider
Non-PPO Provider
Medical Plan
Annual
Deductible
Annual Out-ofPocket Maximum*
$500 Per Person
$1,000 Per Person
$1,500 Individual
$3,000 Individual
$1,500 Per Family
$3,000 Per Family
$3,000 **
Aggregate Family
$6,000 **
Aggregate Family
$2,500
Per Person
None
$2,500
Per Person
$5,000
Per Person
None
$5,000
Per Person
$4,000 Individual
$7,750 Individual
$7,500
Per Family
None
$7,500
Per Family
$10,000
Per Family
None
$10,000
Per Family
$9,000 **
Aggregate Family
$17,750 **
Aggregate Family
Lifetime Maximum
Unlimited
*Co-pays and benefits with a coinsurance level below 80% do not apply to the out-of-pocket maximum.
** Aggregate Family = Individual plus one or more family members. Services for all family members covered under this CDHP HSA-quaified plan apply to
the family deductible. You must meet the family deductible before the plan will cover services for any enrolled family members. Similar for the Out-ofPocket Maximum.
You will receive better rates and avoid balance billing by using PPO providers.
Note: Residents of Alaska will find their coverage information for the $500 and $1,000 Deductible in the “Alaska Plan” column, regardless of provider
status. You are also eligible for the CDHP $1,500 Deductible plan.
continued on inside
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Premera Blue Cross $500 Deductible/$1000 Deductible/CDHP Deductible PPO Plans
$500-Deductible
$1,000-Deductible
CDHP $1,500-Deductible
HSA-qualifed plan
PPO
Provider
Non-PPO
Provider
Alaska
Plan
PPO
Provider
Non-PPO
Provider
Alaska
Plan
PPO Provider
Non-PPO Provider
Office Visit
100% after
$30 co-pay
60% after
deductible
80% after
deductible
100% after
$30 co-pay
60% after
deductible
80% after
deductible
80% after
deductible
60% after
deductible
Specialist Visit
100% after
$30 co-pay
60% after
deductible
80% after
deductible
100% after
$30 co-pay
60% after
deductible
80% after
deductible
80% after
deductible
60% after
deductible
Outpatient
Hospital Care
> Facility Services
> Physician Services
80% after
deductible
60% after
deductible
80% after
deductible
if PPO;
60% after
deductible
if Non-PPO
80% after
deductible
60% after
deductible
80% after
deductible
if PPO;
60% after
deductible
if Non-PPO
80% after
deductible
60% after
deductible
Preventive Care *
>R
outine GYN
> Routine
Mammograms
>P
SA Tests
> CDL Exam
100%
60%;
deductible
waived
100% if
PPO; 80% if
Non-PPO
deductible
waived
100%
60%;
deductible
waived
100% if
PPO; 80% if
Non-PPO
deductible
waived
100%
60%; deductible
waived
Preventive Care *
Adults and children
>R
outine Physical
> Well Child
> Immunizations
>X
-ray/Lab services
100%
60%;
deductible
waived
100% if
PPO; 80% if
Non-PPO
deductible
waived
100%
60%;
deductible
waived
100% if
PPO; 80% if
Non-PPO
deductible
waived
100%
60%; deductible
waived
100% after
$30 co-pay
60% after
deductible
80% after
deductible
100% after
$30 co-pay
60% after
deductible
80% after
deductible
80% after
deductible
60% after
deductible
Laboratory Services
100%
60% after
deductible
80%;
deductible
waived
100%
60% after
deductible
80%;
deductible
waived
80% after
deductible
60% after
deductible
X-Ray Services
100%
60% after
deductible
80% after
deductible
100%
60% after
deductible
80% after
deductible
80% after
deductible
60% after
deductible
100% after
$30 co-pay
60% after
deductible
80% after
deductible
100% after
$30 co-pay
60% after
deductible
80% after
deductible
80% after
deductible
60% after
deductible
OUTPATIENT SERVICES
Allergy Injections
and Serum
Chiropractic Care
(limited to 16 visits
per calendar year)
Hearing Aids (limited
to 2 devices every 36
months)
Outpatient Physical,
Speech and
Occupational Therapy
Alternative Medicine
(limited to 16 visits per
calendar year)
80% after deductible
80% after
deductible
60% after
deductible
80% after
deductible
80% after deductible
80% after
deductible
80% after deductible
60% after
deductible
80% after
deductible
80% after deductible
80% after deductible
80% after
deductible
60% after
deductible
80% after deductible
You will receive better rates and avoid balance billing by using PPO providers.
Note: Residents of Alaska will find their coverage information for the $500 and $1,000 Deductible in the “Alaska Plan” column, regardless of provider
status. You are also eligible for the CDHP $1,500 Deductible plan.
* Your preventive benefits offer full coverage for many tests, screenings and immunizations. During the exam, your physician may discover an issue or
problem that requires further testing or screening for an accurate diagnosis. These additional diagnostic tests often require you to pay a share of the
costs.
Coverage
Comparison
Chart
$500-Deductible
$1,000-Deductible
PPO
Provider
Non-PPO
Provider
Alaska
Plan
PPO
Provider
Non-PPO
Provider
Alaska
Plan
80% after
$250
co-pay plus
deductible
60% after
$250
co-pay plus
deductible
80% after
$250
co-pay plus
deductible
if PPO; 60%
after $250
co-pay plus
deductible
if Non-PPO
80% after
$250
co-pay plus
deductible
60% after
$250
co-pay plus
deductible
80% after
$250
co-pay plus
deductible
if PPO; 60%
after $250
co-pay plus
deductible
if Non-PPO
CDHP $1,500-Deductible
HSA-qualifed plan
PPO Provider
Non-PPO Provider
80% after
deductible
60% after
deductible
INPATIENT CARE
Inpatient Hospital Care
> Facility Services
> Physician Services
Home Health Care
(limited to 120 visits
per year)
80% after deductible
80% after deductible
80% after deductible
Hospice Care
80% after deductible
80% after deductible
80% after deductible
Skilled Nursing Facility
(limited to 120 days)
80% after deductible
80% after deductible
80% after deductible
EMERGENCY SERVICES
Emergency Room
(Co-pay waived if
admitted)
Ambulance
80% after $100 co-pay plus deductible
80% after $100 co-pay plus deductible
80% after deductible
Non-emergent care may be paid at 60%.
Non-emergent care may be paid at 60%
Non-emergent care may be paid at 60%
80% after deductible
80% after deductible
80% after deductible
BEHAVIORAL HEALTH
Mental Health –
Outpatient
80% after
deductible
60% after
deductible
80% after
deductible
if PPO;
60% after
deductible
if Non-PPO
80% after
deductible
60% after
deductible
80% after
deductible
if PPO;
60% after
deductible
if Non-PPO
80% after
deductible
60% after
deductible
Mental Health –
Inpatient
80% after
$250
co-pay plus
deductible
60% after
$250
co-pay plus
deductible
80% after
$250
co-pay plus
deductible
if PPO; 60%
after $250
co-pay plus
deductible
if Non-PPO
80% after
$250
co-pay plus
deductible
60% after
$250
co-pay plus
deductible
80% after
$250
co-pay plus
deductible
if PPO; 60%
after $250
co-pay plus
deductible
if Non-PPO
80% after
deductible
60% after
deductible
Substance Abuse –
Outpatient
80% after
deductible
60% after
deductible
80% after
deductible
if PPO;
60% after
deductible
if Non-PPO
80% after
deductible
60% after
deductible
80% after
deductible
if PPO;
60% after
deductible
if Non-PPO
80% after
deductible
60% after
deductible
Substance Abuse –
Inpatient
80% after
$250
co-pay plus
deductible
60% after
$250
co-pay plus
deductible
80% after
$250
co-pay plus
deductible
if PPO; 60%
after $250
co-pay plus
deductible
if Non-PP
80% after
$250
co-pay plus
deductible
60% after
$250
co-pay plus
deductible
80% after
$250
co-pay plus
deductible
if PPO; 60%
after $250
co-pay plus
deductible
if Non-PPO
80% deductible
60% after
deductible
continued on back
7.0_CCC
Coverage
Comparison
Chart
Premera Blue Cross $500 Deductible/$1000 Deductible/CDHP Deductible PPO Plans
$500-Deductible
$1,000-Deductible
CDHP $1,500-Deductible
HSA-qualifed plan
Retail (30 day supply)
> Generic
> Preferred Brand
> Non-Preferred Brand
$15 Co-pay
$40 Co-pay
$65 Co-pay
50% Coinsurance
50% Coinsurance
50% Coinsurance
$10 Co-pay after deductible
$25 Co-pay after deductible
$40 Co-pay after deductible
Mail Order (90 day supply)
> Generic
> Preferred Brand
> Non-Preferred Brand
$30 Co-pay
$80 Co-pay
$130 Co-pay
20% Coinsurance
20% Coinsurance
20% Coinsurance
$20 Co-pay after deductible
$50 Co-pay after deductible
$80 Co-pay after deductible
$75 co-pay
$75 co-pay
$75 co-pay after deductible
Plan pays 60% after deductible
Plan pays 60% after deductible
Plan pays 60% after deductible
Covered in full
Covered in full
Covered in full
n/a
n/a
Generic covered in full
PRESCRIPTION DRUGS
Specialty Rx
(Self-Injectable)
Rx from Non-PPO
Preventive Drug Coverage
under Health Care Reform *
Preventive Drug Coverage
for CDHP (to treat heart
disease and diabetes) *
* Visit www.premera.com pharmacy section to learn more.
Note: Maintentance drugs (drugs that are taken on a regular basis or for more than 90 days) are available through the mail order program. You will save
money by using mail order and your prescriptions are conveniently shipped directly to you.
IMPORTANT DISCLOSURE: As an employee, the health benefits available to you represent a significant component of your compensation package. They
also provide important protection for you and your family in the case of illness or injury.
Your plan offers a series of health coverage options. Choosing a health coverage option is an important decision. To help you make an informed choice,
your plan makes available a Summary of Benefits and Coverage (SBC), which summarizes important information about any health coverage option in a
standard format, to help you compare across options.
The SBC is available on the web at: http://office.asrc.com/office/SBC/ A paper copy is also available, free of charge, by calling 1-877-339-6850.
This document is neither a summary plan description nor an employee
handbook. If a discrepancy arises between this document and the
provisions of the plan documents, the plan documents govern. ASRC
reserves the right to modify, amend or terminate its plans and programs
at any time.
7.0_CCC
Medical, Dental, and Vision Benefits (500/1000/CDHP)
COMMITTED TO
OUR SHARED VISION.
COMMITTED TO YOU.
Medical,
Dental,
Vision
ASRC Employee Benefits
Coverage Tiers
Being a part of ASRC means having a shared
When you enroll for medical, dental and/or
mission, and also having talented, dedicated
vision benefits, you have four coverage tiers
people who live that mission every day. To that
to choose from to meet the needs of you and
end, the benefits program offered to our
your family:
employees must live up to the same principles
and standards of excellence. Our goal is to
provide top-quality, people-focused programs
that will support the needs of every employee.
The ASRC benefits program will provide you
> Employee only
> Employee + Spouse
> Employee + Child(ren)
> Employee + Family
the choice and flexibility to select appropriate
The coverage tier you elect can be different
benefits for you and your family.
for medical, dental and vision. For example,
This ASRC benefits program guide is designed
to help you understand the benefit options
available to you and help you make informed
benefit selections. The guide includes helpful
information about:
you can elect medical for your entire family
and dental only for yourself. Remember, for
each plan that you choose, you need to elect
your coverage tier separately. The contribution
rates for each coverage tier are shown on the
Rate Sheet included in the enrollment packet.
> Coverage Tiers
> Eligibility Information
> Medical Plan
> Dental Plan
> Vision Plan
> Contact information for all
plan administrators
Please contact your ASRC Benefits Specialist if
you have any questions about your benefits or
the enrollment process.
Eligibility
ASRC offers health and welfare benefits to all
eligible employees who have met their waiting
period. Eligible employees include all regular,
full-time employees normally scheduled to
work 30 or more hours in a work week.
You may also enroll your eligible dependents;
eligible dependents include your legal
opposite-sex spouse and your natural, step or
legally adopted children under age 26.
Enrolling disabled children requires prior
approval. A copy of your marriage certificate is
required to enroll your spouse, birth
certificates are required to enroll children;
marriage & birth certificates are required to
enroll a stepchild. ASRC and the plan
administrators will conduct periodic audits to
ensure eligibility of enrolled dependents.
Medical, Dental, and
Vision
Medical
24-Hour NurseLine
Premera Blue Cross
Online Resources and
Customer Service
Premera Blue Cross offers all
Premera Blue Cross is the plan administrator
Premera Blue Cross also offers a wide range
24-Hour NurseLine. These
for the ASRC medical plans. Premera
of resources to help you with health-related
nurses have access to high-
will provide ASRC employees access to
issues. Through the Premera website at
quality health resources and
care through comprehensive national and
www.premera.com, you can:
will listen to your health
worldwide provider networks. The Blue Cross
Blue Shield medical ID card is one of the
most widely recognized and accepted ID
cards in the world.
Premera offers national health plan
coverage. In order to facilitate provider
recognition in Washington and Alaska,
the Premera Blue Cross Blue Shield of
Alaska logo will appear on your medical
> Look up claims and benefits
> Search for a network doctor or hospital
> Get medical and prescription drug cost
estimates
> Search the Preferred Drug list
> Download claim and prescription drug
reimbursement forms
> Get information to help you live
healthier
plan members access to a
concerns, answer questions
and offer advice about many
health-related topics. In
addition, NurseLine nurses are
trained to ask the right
questions, enabling them to
make a recommendation about
when and where you should
seek treatment for an injury
or illness. Nurses base their
IDs. For plan members living in other
Customer Service: Get help finding a
recommendations on your
states, you will see the Blue Cross Blue
doctor and your other health care questions
symptoms and other relevant
Shield logo on your medical ID card.
answered via a toll-free telephone number at
health conditions or history.
(877) 370-2772 (ASRC) between 6:00 AM and
6:00 PM (Pacific Time).
All calls to the NurseLine are
You can find out if your doctor is in the
free and confidential – 24 hours
network by visiting www.premera.com
a day, 7 days a week. Just call
and clicking the Find a Doctor link.
(877) 370-2772 (ASRC).
While using this directory, you can
search for providers by name, location,
gender, specialty, and language. When
searching for a provider, please make
sure to select the correct network
based on your geographical region.
> Alaska: AK Heritage Select
> Washington: Heritage and
Heritage Plus 1
> All other states: BlueCard® PPO
If you don’t have access to a computer,
Premera’s customer service team can
help you find a doctor. Just call
(877) 370-2772 (ASRC) between
6:00 AM and 6:00 PM (Pacific Time).
1.0_MDV5001000CDHP
Medical Plan Options
Prescription Drugs
With the ASRC benefits program, eligible
Prescription drug benefits are included in the
employees have the choice of medical plan
ASRC medical plan. When you fill a
options that include both medical and
prescription, you will pay a co-pay or
pharmacy benefits:
coinsurance. The cost varies based on the type
of drug (generic, preferred brand, non-
> $500-Deductible PPO
preferred brand, or specialty) and whether you
> $1,000-Deductible PPO
> CDHP $1,500-Deductible PPO - HSA
qualified plan
Each plan offers employees a broad range of
health care services. Deductibles, out-ofpocket maximums and coverage levels will
vary by plan. To elect the plan that best meets
the needs of you and your family, be sure to
carefully evaluate each medical plan by
looking at the information below and the
purchase medications at a retail pharmacy or
through mail order.
Prescription costs under the Premera Blue
Cross medical plans are shown below. Premera
offers members access to a nationwide network
of retail pharmacies.
Retail versus
Mail-Order Pharmacy
Coverage Comparison Chart, located in your
Retail Pharmacy: For immediate drug needs
enrollment packet.
or short-term (less than 90 days) medications,
If you choose to visit in-network providers,
you will be able to take advantage of deeper
discounts and lower costs offered by Premera’s
contracted providers and facilities. You will
you should use a retail pharmacy. You can fill
your 30-day prescriptions at any of more than
60,000 retail pharmacies in the pharmacy
network.
also avoid balance billing.
Medical: Plan Options
$500-DEDUCTIBLE
PPO Provider
Annual
Deductible
Annual
Out-of-Pocket
Maximum*
Lifetime
Maximum
$2,500
Per Person
$7,500
Per Family
Non-PPO
Provider
Alaska Plan
$1,000-DEDUCTIBLE
PPO Provider
Non-PPO
Provider
Alaska Plan
CDHP $1,500-DEDUCTIBLE
HSA-qualified plan
PPO Provider
Non-PPO Provider
$500 Per Person
$1,000 Per Person
$1,500 Individual
$3,000 Individual
$1,500 Per Family
$3,000 Per Family
$3,000 **
Aggregate Family
$6,000 **
Aggregate Family
$4,000 Individual
$7,750 Individual
$9,000 **
Aggregate Family
$17,750 **
Aggregate Family
None
None
Unlimited
$2,500
Per Person
$7,500
Per Family
$5,000
Per Person
$10,000
Per Family
None
None
$5,000
Per Person
$10,000
Per Family
Unlimited
Unlimited
* Co-pays and benefits with a coinsurance level below 80% do not apply to the out-of-pocket maximum.
** Aggregate Family = Individual plus one or more family members. Services for all family members covered under this CDHP HSA-qualified plan apply to
the family deductible. You must meet the family deductible before the plan will cover services for any enrolled family members. This requirement also
applies to the Out-of-Pocket Maximum.
Note: Residents of Alaska will find their coverage information for the $500 and $1,000 Deductible in the “Alaska Plan” column, regardless of provider
status. You are also eligible for the CDHP $1,500 Deductible plan.
Medical, Dental, and
Vision
Generic versus
Brand-Name Drugs
Mail Order: Maintenance drugs (drugs that
are taken on a regular basis or for more than
90 days) are available through the mail order
ASRC encourages the use of generic drugs versus brand-name drugs
program. You will save money by using the
because generic drugs cost less and are virtually identical to brand-name
mail order pharmacy service and your
drugs in safety and effectiveness. When filling a prescription, here are some
prescriptions are conveniently shipped directly
reasons to select a generic:
to your home.
1. FDA monitored. Generic drugs are regulated by the Food and Drug
It will take approximately two weeks for you to
Administration (FDA) just like brand-name drugs and provide the same
receive your prescriptions by Mail Order. To
level of quality, strength and purity at less cost.
avoid any delay in starting your medicine, ask
2.Dollar savings. Using a generic version of a brand-name drug can help you
your doctor to write two separate prescriptions
control your healthcare costs. Ask your doctor to prescribe a generic drug
– one for a 30-day supply which you can fill at
when available and appropriate.
a local network pharmacy right away, and one
3.Same ingredients. Generic drugs must contain the same active ingredients
for a 90-day supply that you can fill through
and produce the same effect on the body as their brand-name equivalents.
the Mail Order Pharmacy.
You can order refills by phone at (888) 327-9791
or register through the pharmacy section at
www.premera.com.
Medical: Prescription Drugs*
Premera Blue Cross $500 Deductible/ $1000 Deductible/CDHP Deductible PPO Plans
$500-Deductible
$1,000-Deductible
CDHP $1,500-Deductible
HSA-qualified plan
Retail (30 day supply)
> Generic
> Preferred Brand
> Non-Preferred Brand
$15 Co-pay
$40 Co-pay
$65 Co-pay
50% Coinsurance
50% Coinsurance
50% Coinsurance
$10 Co-pay after deductible
$25 Co-pay after deductible
$40 Co-pay after deductible
Mail Order (90 day supply)
> Generic
> Preferred Brand
> Non-Preferred Brand
$30 Co-pay
$80 Co-pay
$130 Co-pay
20% Coinsurance
20% Coinsurance
20% Coinsurance
$20 Co-pay after deductible
$50 Co-pay after deductible
$80 Co-pay after deductible
PRESCRIPTION DRUGS
Specialty Rx (Self-Injectable)
Rx from Non-PPO
Preventive - Health Care Reform *
Preventive for CDHP (to treat
heart disease & diabetes) *
$75 co-pay
$75 co-pay
$75 co-pay
Plan pays 60% after deductible
Plan pays 60% after deductible
Plan pays 60% after deductible
Covered in full
Covered in full
Covered in full
n/a
n/a
Generic covered in full
* Visit www.premera.com pharmacy section to learn more.
1.0_MDV5001000CDHP
Is My Dentist
In the Network?
You can access the provider
directory by calling
(877) 370-2772 (ASRC),
toll-free, or by visiting
United Concordia’s website
at www.ucci.com.
1.Click on the Find a
Dental
Concordia Flex:
Dental benefits are offered separately from the
medical plan through United Concordia. With
over 35 years of experience in dental insurance,
United Concordia offers flexible dental
benefits backed by excellent customer service.
The two dental plan options available to ASRC
employees are:
Dentist link
2.Select the Advantage Plus
The Concordia Flex plan provides the same
level of coverage for preferred and nonpreferred providers. This may be the best plan
for you if there are no preferred providers in
your area or if you want to see a non-preferred
provider. Remember, if you choose to see a
non-preferred provider, you will be responsible
> Concordia Preferred
for any charges above reasonable and
> Concordia Flex
customary limits.
network option
3.You can search for network
dentists by specialty, city,
last name, zip code, distance
to a certain zip code, or
county.
Register for My Dental
Benefits allowing secure
access to benefits, claim
Concordia Preferred:
Predetermination
The Concordia Preferred plan provides the
When the amount of a proposed treatment is
most coverage when you see a preferred
more than $500, we encourage you to request a
provider. Make sure to check for preferred
predetermination from your Dentist. This lets
providers in your area before selecting this
you know if the procedure will be covered; the
plan. Dental benefits are limited and
amount you will owe and notifies you of any
orthodontia is not covered if you see a
alternate treatment options covered by the
non-PPO provider.
dental plan prior to receiving services.
details, procedure history,
deductible accumulations,
printable ID cards and more.
Dental: Concordia Preferred / Concordia Flex
CONCORDIA PREFERRED
CONCORDIA FLEX
PPO Provider
Non-PPO Provider
PPO or Non-PPO
Provider
> Per Person
$50
$50
$50
> Per Family
$150
$150
$150
Annual Limit (per person)*
$2,000
$1,250
$2,000
Orthodontia Limit
$4,000
N/A
$4,000
Preventive and Diagnostic Services (routine cleanings, exams, and most x-rays)
100%
80%
100%
Basic Services (extractions, space maintainers, nonsurgical periodontics,
endodontics, complex oral surgery, general anesthesia, repairs of the
following: Inlays, onlays, bridges, and dentures)
80%
60%
80%
Major Services (inlays, onlays, crowns, prosthetics (bridges & dentures),
surgical periodontics)
80%
60%
80%
Orthodontia Services
80%
Not Covered
80%
Deductible
* Preventive, basic and major services combined
Medical, Dental, and
Vision
Vision
Glasses and Sunglasses
> The name of the organization that offers
> Average 20-25% savings on all non-
Vision benefits for you and your eligible
dependents are offered through Vision Services
covered lens options
Regional Corporation
> 20% off additional glasses and
> The patient’s name, date of birth, address
Plan (VSP), one of the nation’s most complete
sunglasses, including lens options, from
eye-care health plans. Using your VSP benefit
any VSP doctor within 12 months of
is easy. ID cards aren’t required for VSP.
your last WellVision® Exam
To use your VSP benefits:
>F
ind a VSP doctor at www.VSP.com or
call (877) 370-2772 (ASRC)
>M
ake an appointment and tell the doctor
you are a VSP member
>P
rovide your doctor with your Social
Security Number
>Y
our doctor and VSP will handle the rest
You get the best value from your vision benefit
when you visit a VSP network doctor. When
you visit an in-network doctor, you are often
able to take advantage of greater benefits and
your VSP coverage – Arctic Slope
and phone number
> The patient’s relationship to the covered
member (such as “self,” “spouse,” “child”)
Laser Vision Correction Discounts
Out-of-network claims must be submitted to
> Average 15% off the regular price or
VSP within six months. Keep a copy of the
5% off the promotional price
claims information for your files and send a
> Discounts only available from
copy to VSP, P.O. Box 997105, Sacramento,
contracted facilities
CA 95899-7105.
Contact Lenses
> 15% off cost of contact lens exam
(fitting and evaluation)
For additional questions regarding your
eye-care coverage, contact VSP’s Member
Services department at (877) 370-2772 (ASRC)
If you do obtain services from an out-of-
or register at www.VSP.com to view benefits,
network doctor, please send VSP the
access rebates & special offers or printable
following materials:
member vision card.
> An itemized receipt listing the
pay less out-of-pocket.
Extra Discounts and Savings
As a VSP member, you can take advantage of
additional discounts and savings on:
services received
> The name, address and phone number
of the out-of-network provider
> The covered member’s name, date of
birth, address and phone number
YOUR VISION COVERAGE – VSP CHOICE
VSP Provider
Non-VSP Provider
WellVision®
Annual Exam
Covered in full after $20 co-pay; once every calendar year
Covered up to $43; once every calendar year
Lenses
Single, lined bi-focal, tri-focal, and progressive lenses are
covered after co-pay; once every calendar year
Single vision lenses covered up to $26; lined bifocal lenses
covered up to $43; lined trifocal lenses and progressive lenses
covered up to $60; once every calendar year
Frames
Covered up to $175; once every twenty-four months
Covered up to $40; once every twenty-four months
Contact Lens Exam
Fitting & Evaluation
Standard and Premium fit: Covered in full after never to exceed
$60 co-pay.
Combined with Elective Contact allowance noted below.
Elective Contacts
(in lieu of glasses)
Covered up to $130; once every calendar year
Covered up to $100; once every calendar year
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Medical, Dental, and
Vision
Contact
Information
For your convenience, you can call one
number for assistance with most of your
benefit needs. Dial (877) 370-2772 (ASRC) and
select from the following options:
This document is neither a summary plan
description nor an employee handbook. If a
discrepancy arises between this document and
the provisions of the plan documents, the plan
documents govern. ASRC reserves the right to
modify, amend or terminate its plans and
programs at any time.
> Option 1: Premera (Medical and Rx)
>O
ption 2: NurseLine
> Option 3: Flexible Spending and
Transportation Accounts
>O
ption 4: COBRA
> Option 5: United Concordia (Dental)
>O
ption 6: VSP (Vision)
>O
ption 7: Additional Options
> 1. Employee Assistance Program
> 2. Unum (Life and Disability)
> 3. 401K
> 4. ASRC Benefits Team
IMPORTANT DISCLOSURE: As an employee,
the health benefits available to you represent a
significant component of your compensation
package. They also provide important
protection for you and your family in the case
of illness or injury.
Your plan offers a series of health coverage
options. Choosing a health coverage option is
an important decision. To help you make an
informed choice, your plan makes available a
Summary of Benefits and Coverage (SBC),
which summarizes important information
about any health coverage option in a standard
format to help you compare across options.
The SBC is available on the web at
http://office.asrc.com/office/SBC/
A paper copy is also available, free of charge, by
calling (877) 339-6850.
1.0_MDV5001000CDHP