Election Form
Page, Scrantom, Sprouse, Tucker and Ford, P.C. 2022-2023 Benefits Election Form
Employee Name ________________________________________________________________
Group Health Insurance Base Plan Copay Option Humana NPOS-OA GA 80/60 NPOS 16 Copay Plan $2,000 Ind. / $4,000 Fam. Deductible 80% Coinsurance In Network $6,500 Ind. / $13,000 Fam. OOP $40 PCP / $65 SCP Copay $0 Ind. Non-Generic Rx Deductible $10 / $45 / $90 / 25% / 35%
Group Health Insurance Buy-Up Copay Plan Option Humana NPOS-OA GA 80/60 NPOS 16 Copay Plan $2,000 Ind. / $4,000 Fam. Deductible 80% Coinsurance In Network $5,000 Ind. / $10,000 Fam. OOP $40 PCP / $55 SCP Copay $0 Ind. Non-Generic Rx Deductible $10 / $45 / $70 / 25% / 35%
Group Health Insurance High Deductible Health Pan Option Humana NPOS-OA High Deductible Health Plan $5,000 Ind. / $10,000 Fam. Deductible 90% Coinsurance In Network $6,350 Ind. / $12,700 Fam. OOP PCP / SCP Deductible & Coins. Integrated Rx Deductible Rx Deductible & Coinsurance
I elect this benefit (please check)
I elect this benefit (please check)
I elect this benefit (please check)
Employee Only Employee + Spouse Employee + Child(ren) Family
I DECLINE health insurance coverage for this plan year (please check)
Group Dental Insurance Plan Humana Dental Voluntary Traditional Preferred $50 Individual / $150 Family Deductible 100% Preventive / 80% Basic / 50% Major Coinsurance In Network $1,500 Annual Maximum, 30% Benefit Thereafter
Group Vision Insurance Plan HumanaVision Exam Plus $10 copay per Eye Exam
20% retail discount applies to Lenses and Frames 15% discount on Professional contact lens services
I elect this benefit (please check)
I elect this benefit (please check)
Employee Only
Employee Only
Employee + Spouse Employee + Child(ren)
Employee + Spouse Employee + Child(ren)
Family
Family
I DECLINE dental insurance coverage for this plan year (please check)
I DECLINE vision insurance coverage for this plan year (please check)
Printed Name ___________________________________________________________
Signature _______________________________________________________________ Date ___________________________
9 Page, Scrantom 2022 Enrollment Guide
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