Out-of-Network Reimbursement
Dental Plan | MetLife
Premium Plan
Basic Plan
Vision Plan | MetLife
In-Network $10 Copay $20 Copay $20 Copay $20 Copay
Up to $45
Annual Deductible Individual | Family Preventive Services
Eye Exam Lenses Single Bifocals Trifocals
$50 | $150
$50 | $150
Up to $30 Up to $50 Up to $65
100%
100%
Basic Services Major Services
80% 50% 50%
80% N/A N/A
$130 Allowance after $20 Copay*
Up to $70
Frames
Orthodontia (Child up to age 26)
Contacts Elective Medically Necessary
Up to $105 Up to $210
$130 Allowance $20 Copay
Annual Benefit Maximum
$3,000
$1,500
Orthodontia Lifetime Maximum
Frequency Exam/Lenses or Contacts/Frames
$1,500
N/A
12/12/24 Months
Please be advised that should you reach age 65, your coverage will reduce by 35%. Should you reach age 80, your coverage will reduce by 60%. Physician Paid Basic Life and AD&D** | MetLife Employee Coverage 1x your Basic Annual Earnings, rounded to the next higher $1,000 - up to $150,000 Spouse Coverage $5,000 Dependent Coverage 15 days to 6 months: $100 | 6 months to age 26: $2,500 Vision Rates (Monthly) Employee Employee + Spouse Employee + Child(ren) Family $ 7.38 $12.07 $11.82 $19.45 * Costco, Walmart and Sam’s Club: $70 allowance after $20 eyewear copay.
Out-of-Network Reimbursement
90th UCR
90th UCR
Dental Rates (Monthly) Employee Employee + Spouse Employee + Child(ren) Family
$41.93 $81.04 $78.58 $123.98
$22.51 $40.08 $39.00 $59.37
Long Term Disability (LTD) | MetLife Monthly Benefit
60% of your monthly earnings
Maximum Monthly Benefit
$15,000
Benefit Waiting Period
90 Days
Maximum Benefit Period
The later of SSNRA or the period listed in your Certificate of Coverage
Physician Paid
Voluntary Life and AD&D** | MetLife Employee Coverage Guarantee Issue
VOLUNTARY BENEFITS** | AFLAC Accident Insurance provides a cash benefit for out-of-pocket expenses associated with an accidental injury. Refer to the plan summaries from Aflac for more details. Cancer Insurance provides financial peace of mind if a diagnosis of cancer ever occurs. Short Term Disability Insurance provides partial income replacement in the event of a covered illness or accident that occurs outside of work. Hospital Confinement Insurance complements your present major medical coverage by providing cash benefits that can be used to help pay out-of-pocket expenses associated with hospital confinement. Physician Paid
Increments of $10,000 up to a maximum of $500,000, not to exceed 5x your annual earnings $150,000 Increments of $5,000 up to $250,000, not to exceed 50% of the employee amount $50,000
Spouse Coverage Guarantee Issue
Dependent Coverage Guarantee Issue
Flat amount: $2,500, $5,000, $7,500, or $10,000 Up to $10,000
Physician Paid
**If your spouse is also a benefits-eligible employee at Hughston, then you may not be eligible to purchase spousal coverage for Voluntary Life, Accident Insurance, Cancer Insurance and Hospital Confinement benefits. Only one employee can elect life coverage for the child. Please refer to plan documents for details.
Contacts & Information
Dental, Vision, Life & LTD | MetLife Dental: 1.800.275.4638 Vision: 1.855.638.3931
Voluntary Benefits | Aflac Tel.: 1.800.992.3522 www.aflac.com David Crumley 217-355-8900 david_crumley@us.aflac.com
Medical & FSA | Allied Benefit (TPA) Tel.: 1.800.288.2078 www.alliedbenefit.com
Yates LLC Client Advocates Direct: 404.633.4321 Fax: 404.633.1312 yatesins.com
Life: 1.800.638.5000 LTD: 1.800.858.6506 www.metlife.com
Prescription – Liviniti Tel: 1.800.710.9341 www.liviniti.com Telemedicine | Teladoc Tel.: 1.800.835.2362 www.teladoc.com HSA | Pinnacle Tel: 1.800.264.3613 www.pnfp.com
Employee Assistance Program MetLife Tel.: 1.888.319.7819 metlifeeap.lifeworks.com User Name: metlifeeap Password: eap Employee
Please Note: This document is intended as a convenient summary of the major points of benefit plans. This document does not cover all provisions, limitations and exclusions. The official plan documents, policies and certificates of insurance govern in all cases and are available for your inspection at any time.
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