Review Your Benefit Options

Medical

Medical Benefits

Overview

You have two medical plan options: the Premier Plan and the Value Plan. Both plans are administered by BlueCross BlueShield (BCBS) and provide the maximum benefits when a BCBS provider is used for services.

The ARBA High Plan includes both primary and secondary insurance. The secondary plan does not cover office visit or prescription drug copays or home health services.

NOTE: The out-of-pocket maximum excludes office visits and prescription drug co-pays.

	Premier Plan	Value Plan
	In-Network	In-Network
Office Copay (PCP/SPC) Single/Family	$35 / $50	$35 / $50
Deductible Single/Family	$500 / $1,000	$5,000 / $10,000
Out-of-Pocket Single/Family	$2,500 / $5,000	$7,000 / $14,000
Inpatient Facility Single/Family	20% Coinsurance	20% Coinsurance
Outpatient Facility Single/Family	20% Coinsurance	20% Coinsurance
Angiography/Arteriography Cardiac cath/Arteriography, CAT Scan, Colonoscopy, ERCP, MRI, Muga-gated cardiac scan, PET/SPECT and UGI endoscopy	20% Coinsurance	20% Coinsurance
Chemotherapy, Diagnostic Lab, Dialysis, IV Therapy, Pathology, Radiation Therapy & X-Ray	20% Coinsurance	20% Coinsurance
Maternity Care	20% Coinsurance	20% Coinsurance
Applied Behavioral Analysis	20% Coinsurance	20% Coinsurance
Prescriptions	20% Coinsurance	20% Coinsurance

Total Monthly Premium

Coverage Tier	Premier Plan	Value Plan
Employee Only	$711.98	$635.84
Employee + Spouse	$1,424.22	$1,256.70
Employee + Children	$1,305.93	$1,165.07
Family	$2,018.16	$1,785.92

Dental

Dental Benefits

Overview

ARBA offers dental coverage to you through Blue Cross Blue Shield of Alabama. Your dental plan provides coverage to help with the cost of many dental services including routine cleanings, x-rays, restorative and prosthetic services. The plan includes an extensive network of dental providers. Maximize your benefits by selecting an in-network dentist to save more on all covered services and avoid balance billing.

	Dental Blue 1500A	Dental Blue 1000A
Deductible (Basis)	Deductible Waived on Preventive Services	Deductible Waived on Preventive Services
Individual / Family	$25 / $75	$50 / $150
Plan Maximum	$1,500	$1,500
Orthodontia Lifetime Maximum	$1,500	$1,500
Preventive	100%	100%
Basic	100%	80%
Major	50%	50%
Type IV – Orthodontic Services	50% (Child)	50% (Child)
Basic Services
Fillings	100%	100%
Simple Extractions	100%	100%
General Anesthesia	100%	80%
Oral Surgery	100%	80%
Endodontic	80%	80%
Major Services
Crowns, Inlays, Onlays	50%	50%
Bridges	50%	50%
Dentures	50%	50%
Denture Repairs	100%	100%
Periodontic	80%	50%
Implants	Not Covered	Not Covered
TMJ (temporomandibular joint) Coverage	Not Covered	Not Covered

Dental Rates (Monthly)

Coverage Tier	BCBS Enhanced Plan	BCBS Basic Plan
Single	$31.64	$27.14
Employee + Spouse	$63.27	$54.29
Employee + Child	$79.59	$69.17
Family	$117.08	$101.36

Vision

Vision Benefits

Overview

ARBA offers vision coverage to you through VSP. Receive the maximum benefits and pay less out-of-pocket by visiting an in-network provider. The network includes provider access points nationwide. A comprehensive vision exam is available every 12 months and you may purchase eyewear in the form of an eyeglass frame and lenses, or contact lenses.

Class Description	In-Network	Out-of-Network
Eye Exam	$20 Copay	$45 Allowance
Contact Lens Evaluation and Fitting	Up to $60 Copay	Not Covered
Elective	$130 Allowance	$105 Allowance
Medically Necessary	$20 Copay	$210 Allowance
Single Vision Eyeglass Lenses	$20 Copay	$30 Allowance
Bifocal Vision Eyeglass Lenses	$20 Copay	$50 Allowance
Trifocal Vision Eyeglass Lenses	$20 Copay	$60 Allowance
Lenticular Vision Eyeglass Lenses	$20 Copay	$100 Allowance
Lens Upgrades: Polycarbonate	Single-Vision: $31 Multi-Vision: $35	Not Covered
Lens Upgrades: Anti-reflective	Single-Vision: $41 Multi-Vision: $41	Not Covered
Lens Upgrades: Scratch Resistant	Single-Vision: $17 Multi-Vision: $17	Not Covered
Lens Upgrades: Progressive	Standard Multi-Vision: No Copay Premium Multi-Vision: $95-105 Custom Multi-Vision: 150-175	Not Covered
Lens Upgrades: Transitions/Photochromic	Single-Vision: $75 Multi-Vision: $75	$70 Allowance
Standard Frame	$130 Allowance + 20% off balance	$70 Allowance
Laser Vision Correction	15-20% off Laser Vision Correction	Not Covered
Frequency Exams Lenses Frames Contact Lenses	12 Months	12 Months

Vision Rates (Monthly)

Coverage Tier	Rate
Employee Only	$11.79
Employee + Spouse	$16.47
Employee + Children	$16.73
Family	$24.52

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