Group Medical Summaries

These are summaries only. Select benefit detail for more specific coverage.

Medical Plans - Effective 10/01/11
  In Plan Benefits Out Of Plan Benefits

*HSA deductible and out of pocket maximums apply to employee only enrollment. Please refer to the benefit summary for amount when coverage is for employee with one or more dependents.

**Five office visits plus One Preventive visit: One preventive office visit and first five office visits for illness or injury, deductible waived, not including TMJ, Mental Health, Chemical Dependency, Occupational Therapy, Speech Therapy, Family Planning or Biofeedback. Subsequent office visits are subject to the deductible and coinsurance.

The AK basic and standard plans are also offered. Contact ODS Alaska for details.

Out of Pocket Maximums (OOP) include deductible amounts for all medical plans except HSA plans.

Plan Abbreviations Key:
HSA Healthcare Savings Account
BEN Beneficial Plan
PPO Preferred Provider Option
Type Plan Ded Office
Visit		 Co-ins. OOP Ded Co-ins. OOP
Beneficial Plans
BEN AK BEN2500_11A1 $2,500 $20 ** 20% $5,000 $2,500 50% No Maximum
BEN AK BEN3500_11A1 $3,500 $30 ** 30% $7,000 $3,500 50% No Maximum
BEN AK BEN5000_11A1 $5,000 $40 ** 30% $10,000 $5,000 50% No Maximum
BEN AK BEN7500_11A1 $7,500 $50 ** 50% $15,000 $7,500 50% No Maximum
HSA PPO Plans
HSA AK HSA1200_11A1 $1,200 20% $3,800 $1,200 40% No Maximum
HSA AK HSA2000_11A1 $2,000 20% $3,000 $2,000 40% No Maximum
HSA AK HSA2800_11B1 $2,800 20% $2,200 $2,800 40% No Maximum
HSA AK HSA2800_11A1 $2,800 50% $2,200 $2,800 50% No Maximum
HSA AK HSA4000_11A1 $4,000 20% $1,000 $4,000 40% No Maximum
HSA AK HSA5000_11A1 $5,000 0% $800 $5,000 50% No Maximum
PPO Plans
PPO AK PPO500_11A1 $500 $20 20% $2,500 $500 40% No Maximum
PPO AK PPO500_11B1 $500 $20 30% $5,000 $500 50% No Maximum
PPO AK PPO1000_11A1 $1,000 $25 20% $3,500 $1,000 40% No Maximum
PPO AK PPO1000_11B1 $1,000 $25 30% $6,000 $1,000 50% No Maximum
PPO AK PPO1500_11A1 $1,500 $25 20% $4,000 $1,500 40% No Maximum
PPO AK PPO1500_11B1 $1,500 $25 30% $7,500 $1,500 50% No Maximum
PPO AK PPO2500_11A1 $2,500 $25 30% $5,000 $2,500 50% No Maximum
PPO AK PPO2500_11B1 $2,500 $25 30% $10,000 $2,500 50% No Maximum
  AK PPO3500_11A1 $3,500 $25 30% $10,000 $3,500 50% No Maximum
PPO AK PPO5000_11A1 $5,000 $25 30% $10,000 $5,000 50% No Maximum

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Prescription Drug Riders
(with oral contraceptives & 90 day mail order) - Effective 10/01/11
Riders are only available to PPO and Beneficial plans.
Plan Copay
Option A 4-Tier $2/$10/$30/$50, 3x Mail Order Copay
Option B 4-Tier $250 Ded. (Waived for Value & Select Generic), $2/$10/$20/$50, 3x Mail Order Copay
Option C 4-Tier $2/$10/$40/$60, 3x Mail Order Copay
Option D 1-Tier 40% Copay, 40% Mail Order Copay
Option E 1-Tier $15/50% (Whichever is greater) Copay, 3x Mail Order Copay

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Vision Riders - Effective 10/01/11
Plan Description
View 100% w/ $200 Max
View 100% w/ $300 Max
View 90% w/ $350 Max

 

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Hearing Rider - Effective 10/01/11
Plan Description
View 80%; $800 every 3 years

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