HEALTH PLAN

CHISLHB maintains a self-funded Flexible Benefit program. Coverage is available for regular full-time employees beginning the first pay period following 30 days of full-time employment. Part-time employees are eligible for employee-only medical benefits beginning the first pay period following 60 days of employment (EPO only). The hospital and active physician staff function as the network for CHISLHB’s PPO and EPO, along with First Health’s Network.

Medical Plan

Employer Provided Option					Preferred Provider Option (Grandfathered)
	BRHS/BHA	In Network*	Out of Network*		In Network	Out of Network*
Deductible (Calendar Year) -Employee Only -Employee + Family	$300 $900	$1,000 $2,000	$3,000 $6,000		$1,000 $2,000	$3,000 $6,000
Coinsurance - Employee's Coinsurance	10%	20%	40%		20%	40%
Out of Pocket Maximum (Deductible & Copays included) -Employee Only -Employee + Family	$2,500 $5,000	$6,600 $13,200	$17,500 Unlimited		$6,600 $13,200	$17,500 Unlimited
Physician’s Office -Primary Care Physician -Specialist	$30 $50	$30 $50	40% 40%		20% 20%	40% 40%
Emergency Care BUCC	$150 Co-pay $50 Co-pay	$150 Co-pay 20%	$150 Co-pay 40%		$150 Co-pay $50 Co-pay	$150 Co-pay $50 Co-pay
Inpatient Hospital	$300 Co-pay	$500 Co-pay	$1,500 Co-pay		$500 Co-pay	$1,500 Co-pay
Outpatient Hospital/Surgery	$300 Co-pay	$500 Co-pay	$1,500 Co-pay		20%	40%
Pharmacy -Generic -Brand Formulary -Brand Non-Formulary -Specialty Medications Maximum Out-of-Pocket Per Script for Specialty -Per Prescription -Per Calendar Year		$15 $50 $75 20% $250 $2,500			$15 $50 $75 20% $250 $2,500

Dental Plan

The dental program encourages preventive treatment, allowing you to achieve oral health while striving to minimize dental costs. Coverage is
provided through CHISLHB’s self-funded dental program and claims are administered by HealthFirst.

Benefits	You Pay
Deductible - Waived for Preventive	Individual - $50 Family - $150
Preventive Care -Examinations and Cleanings, Routine -Fluoride -Oral Hygiene Instruction -Palliatives -Prophylaxis -Sealants (under age 13) -Space Maintainer (2 per year, under age 19) -X-rays, Routine	0%
Basic Care -Anesthesia -Endodontic -Extractions -Fillings -Injection of Antibiotics -Oral Surgery -Periodontal -Relining and Rebasing -Recementing Crowns, Inlays, Onlays, Denture	20%*
Major Care -Appliances -Crowns -Implants -Inlays, Onlays -Occlusal Restoration -Prosthetics	50%*
Orthodontia (Children only)	50%
Maximum	Plan Pays
Annual (Preventive/Basic/Major)	$1,250
Lifetime Orthodontia	$1,250

Vision Plan

Eye health is an indicator of overall health. Regular eye exams can detect diseases like glaucoma, diabetes and blindness. To ensure that you
and your family get the care you need, CHISLHB offers a comprehensive vision benefit provided by UnitedHealthcare.

Carrier/Plan Provisions	In-Network	Out-of-Network
Exam Every	12 Months
Lenses Every	12 Months
Frame Every	12 Months
Copayment
Exam	$10
Materials	$25
Service	Plan Pays	Plan Reimburses
Eye Exam	100%	$40
Single Vision Lenses	100%	$40
Lined Bifocal Lenses	100%	$60
Lined Trifocal Lenses	100%	$80
Lenticular Lenses	100%	$80
Frames	Up to $130, then 30%	Up to $45
Contact Lenses -Covered in Full Selection Contacts -Non-Selection Contacts	4 Boxes Up to $105 0% up to $120	Up to $105 Up to $105 Up to $120
Contact Lenses – Medically Necessary	100%	Up to $210