Review Your Benefit Options

Medical

Medical Benefits

Overview

HBAA offers four medical plan options administered by Blue Cross and Blue Shield of Alabama (Blue Cross AL). All plans use the same network of providers who have agreed to charge discounted rates to plan members. The amount you pay for health care will vary depending on whether or not you use in- network providers and facilities. You always have the choice to go to any provider, but you’ll pay less if you stay within the Blue Cross AL Blue Options℠ network.

Plan Highlights

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	HIGH PLAN	LOW PLAN
	In-Network	In-Network
Deductible
Individual	$1,000	$5,000
Family	$2,000	$10,000
Coinsurance	80% / 20%	80% / 20%
Out-of-Pocket Max.
Individual	$2,000	$7,000
Family	$4,000	$14,000
Inpatient Services
Inpatient Facility	80% / 20% Coinsurance	80% / 20% Coinsurance
Emergency Room	80% / 20% Coinsurance	80% / 20% Coinsurance
Physician Office Visits
Preventive Care	100% Covered	100% Covered
Primary Care	$35 Copay	$35 Copay
Specialist Office	$50 Copay	$50 Copay
Outpatient Services
Outpatient Surgical	80% / 20% Coinsurance	80% / 20% Coinsurance
Diagnostic X-Ray Lab	80% / 20% Coinsurance	80% / 20% Coinsurance
Mental Health / Substance Abuse	80% / 20% Coinsurance	80% / 20% Coinsurance
Prescription Drug Essential 5 Tier Commercial Formulary
Tier 1	$15 Copay	$15 Copay
Tier 2	$60 Copay	$60 Copay
Tier 3	$100 Copay	$100 Copay
Tier 4	$425 Copay	$425 Copay

Total Monthly Premium

High Plan	Younger Than 40	40-49	50 or Older
Single	$629.34	$645.76	$681.44
Employee + Spouse	$1,237.98	$1,269.96	$1,342.70
Employee + Child	$1,155.44	$1,179.95	$1,214.34
Family	$1,762.44	$1,796.52	$1,870.96

Low Plan
Single	$591.63
Employee + Spouse	$1,167.80
Employee + Child	$1,082.85
Family	$1,659.25

Dental

Dental Benefits

Overview

HBAA offers dental coverage to you through Blue Cross AL. 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.

Plan Highlights

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	Dental High Plan	Dental Low Plan
Benefits	In-Network	In-Network
Annual Maximum per Individual	$1,500	$750
Type I – Diagnostic & Preventive
Exams, Cleanings, Flouride Treatment, Space Maintainers, X-Rays, Sealants	100%	100%
Type II – Basic Services
Fillings, Simple Extractions, General Anesthesia, Oral Surgery, Endodontics	80%	80%
Type III – Major Services
Crowns, Inlays, Onlays, Bridges, Dentures, Periodontic, Implants, TMJ	50%	50%
Type IV – Orthodontic Services	50% (Child)	Not Covered
Calendar Year Deductible Applies to:
Individual	$50 single	$50 single
Family	$150 family	$150 family
Lifetime Orthodontia Maximum	$1,000	Not Covered

Total Monthly Premium

Coverage Tier	High Plan	Low Plan
Single	$30.57	$26.14
Employee + Spouse	$60.17	$51.29
Employee + Child	$79.28	$67.17
Family	$118.52	$100.94

Vision

Vision Benefits

Overview

HBAA offers vision coverage to you through Blue Cross AL. You will 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.

Plan Highlights

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VSP SBC ›
VSP SPD ›

Class Description	In-Network	Out-of-Network
Eye Examination
Comprehensive exam of visual fuctions and prescription of corrective eye wear.	$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
Materials/ Eye wear
Single Vision Eyeglass Lenses	$20 Copay	$30 Allowance
Lined Bifocal Eyeglass Lenses	$20 Copay	$50 Allowance
Lined Trifocal Eyeglass Lenses	$20 Copay	$60 Allowance
Lenticular Eyeglass Lenses	$20 Copay	$100 Allowance
Frame Allowance
Standard Frame	$130 Allowance + 20% off balance	$70 Allowance
Lens Upgrades
PolyCarbonate (single vision/multi-vision)	$31 / $35	Not Covered
Anti-Reflective (single vision/multi-vision)	$41 / $41	Not Covered
Scratch Resistant (single vision/multi-vision)	$17 / $17	Not Covered
Transitions / Photochromic (single vision/ multi-vision)	$75 / $75	$70 Allowance
Progressive Lenses
Standard Multi-Vision	No-Copay
Premium Multi-Vision	$95 – $105	Not Covered
Custom Multi-Vision	$150 – $175
Laser Vision Correction	15% – 20% off Laser Correction	15% – 20% off Laser Correction

Total Monthly Premium

Coverage Tier	Rate
Employee Only	$9.37
Employee + Spouse	$13.20
Employee + Child(ren)	$13.41
Employee + Family	$19.78

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