Group Medical Summaries

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

Medical Plans - Effective 10/01/10
  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.

**First five office visits cover all kinds of office visits except for services for physical therapy, occupational therapy or speech therapy. For subsequent visits, enrollee pays coinsurance and deductible applies.

***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_10A1 $2,500 $20** 20% $5,000 $2,500 50% No Maximum
BEN AK BEN3500_10A1 $3,500 $25** 30% $7,000 $3,500 50% No Maximum
BEN AK BEN5000_10A1 $5,000 $25** 30% $7,500 $5,500 50% No Maximum
HSA PPO Plans
HSA AK HSA1200_10A1 $1,200* 20% 20% $3,800* $2,400* 40% No Maximum
HSA AK HSA2000_10A1 $2,000* 20% 20% $3,000* $4,000* 40% No Maximum
HSA AK HSA2800_10A1 $2,800* 50% 50% $2,200* $5,600* 50% No Maximum
HSA AK HSA2800_10B1 $2,800* 20% 20% $2,200* $5,600* 40% No Maximum
HSA AK HSA4000_10A1 $4,000 20% 20% $1,000 $8,000 40% No Maximum
HSA AK HSA5000_10A1 $5,000 0% 0% $800 $10,000 50% No Maximum
PPO Plans
PPO AK PPO500_10A1 $500 $20 20% $2,500 $500 40% No Maximum
PPO AK PPO500_10B1 $500 $20 30% $5,000 $500 50% No Maximum
PPO AK PPO1000_10A1 $1,000 $25 20% $3,500 $1,000 40% No Maximum
PPO AK PPO1000_10B1 $1,000 $25 30% $6,000 $1,000 50% No Maximum
PPO AK PPO1500_10A1 $1,500 $25 20% $4,000 $1,500 40% No Maximum
PPO AK PPO1500_10B1 $1,500 $25 30% $7,500 $1,500 50% No Maximum
PPO AK PPO2500_10A1 $2,500 $25 30% $5,000 $2,500 50% No Maximum
PPO AK PPO2500_10B1 $2,500 $25 30% $10,000 $2,500 50% No Maximum
PPO AK PPO5000_10A1 $5,000 $25 30% $7,500 $5,000 50% No Maximum

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

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

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

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