2022 Benefits Workbook - WE ARE WORKING TOWARD A HEALTHIER TOMORROW - Oakland County, Michigan
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2022 Benefits Workbook
WE ARE WORKING TOWARD A HEALTHIER TOMORROWIMPORTANT PHONE NUMBERS & WEBSITES
(PPO) (PPO) (HMO)
MEDICAL ASR Health Benefits Blue Cross/Blue Shield of Michigan Health Alliance Plan
(800) 968-2449 (877) 790-2583 (313) 872-8100
asrhealthbenefits.com bcbsm.com hap.org
Navitus Health Solutions Birdi Mail Order
PRESCRIPTION (866) 333-2757 (888) 240-2211
navitus.com birdirx.com
Dental Vision Flexible Spending Accounts
DENTAL • VISION • FLEX SPENDING Delta Dental National Vision Administrators (NVA) WageWorks
(800) 524-0149 (800) 672-7723 (877) 924-3967
deltadentalmi.com e-nva.com wageworks.com
The Hartford – Disability The Hartford – Life
DISABILITY & LIFE INSURANCE (800) 898-2458 (877) 320-0484
TheHartfordatWork.com
Connect Your Care (Optum Financial) – COBRA
COBRA (855) 687-2021
optum.com
Stephanie Bedricky Samantha Cremer Kate Saranas
Supervisor Disability, COBRA Medical, RX, Unemployment
(248) 420-7155 (248) 520-7041 (248) 202-0476
bedrickys@oakgov.com cremers@oakgov.com saranask@oakgov.com
Carmen Cargill Paige Ritchie L. Brooks Patterson Building
New Hires, Dental, Vision, Benefits Support, Life Ins. 2100 Pontiac Lake Road 41W
Flexible Spending Accounts (248) 520-2779 Waterford, MI 48328-0440
(248) 892-3278 ritchiep@oakgov.com oakgov.com/benefits
cargillc@oakgov.com
IF YOU HAVE MEDICARE OR WILL BECOME ELIGIBLE FOR MEDICARE IN THE NEXT 12 MONTHS, FEDERAL LAW GIVES YOU MORE CHOICES ABOUT YOUR
PRESCRIPTION DRUG COVERAGE. PLEASE REFER TO THE CREDITABLE COVERAGE NOTICE FOR DETAILS ON PRESCRIPTION DRUG COVERAGE AND
MEDICARE NOTICE IN THE REQUIRED NOTICE SECTION ON THE WEBSITE AT OAKGOV.COM/BENEFITSTABLE OF CONTENTS 2022 Open Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 How To Enroll . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Important Reminders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Life Insurance and Accidental Death & Dismemberment Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Life Insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Accidental Death & Dismemberment Insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Flexible Spending Accounts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Health Care Flexible Spending Account (FSA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Dependent Care Flexible Spending Account (FSA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Dependent Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Criteria for Spouses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Criteria for Children.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Medical Plan Options Comparison. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Dental Plan Options Comparison. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Vision Plan Options Comparison. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 This workbook is intended to be a high-level overview of our flexible benefits cafeteria plan program. It is not intended to be a complete and thorough restatement of the individual plan options and the provisions, conditions, limitations, and exceptions that may apply specifically to a particular benefit. If there is any conflict between this workbook and the actual terms of our plan(s), the provisions of the Plan(s) will prevail.
2022 OPEN ENROLLMENT
Monday, November 1, 2021 through November 19, 2021
HOW TO ENROLL:
1. Log into Workday
• How to access Workday: Go to https://myapps.oakgov.com from an Internet connected computer. For difficulty signing into OKTA/MFA, please contact
IT at servicecenter@oakgov.com or 248-858-8812.
2. Navigate to your Workday inbox
3. Complete steps outlined in the 2022 Open Enrollment Job Aid
4. Print a summary of your benefits for your records
IMPORTANT REMINDERS
• Important for all employees! Open Enrollment will close on Friday, November 19, 2021 at 11:59 p.m. If Open Enrollment is not completed, your coverage
will remain the same, excluding flexible spending accounts. Your dependents will be removed if they were not verified by you. You will not have the
opportunity to add these dependents to your coverage again until 2023 Open Enrollment.
• Opting out of coverage? Per IRS requirements, you are required to complete a Form A - Other Coverage Verification Form every year if you’re opting-out
of County Medical and/or Dental coverage. Forms can be found at oakgov.com/benefits. If you elect to not fill out the form, then you will be enrolled in the
PPO3 plan, single coverage.
• Adding a dependent? Proper documentation (marriage license/birth certificate) is required for all dependents added during Open Enrollment.
• If forms are not uploaded in the Open Enrollment event, employees can upload these documents to their profile in Workday. From the Workday homepage:
click on the cloud or picture in the top right corner/view profile/personal/documents/add/select files/upload.
Employees may also email them to benefits@oakgov.com. Due no later than Friday, November 19, 2021.
Page 4LIFE INSURANCE AND ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE
More Information can be found at TheHartford.com
Life and Accidental Death & Dismemberment (AD&D) Insurance through Oakland County are term insurance plans administered by The Hartford. Loans are not
available from the plan. Coverage for your spouse or dependent children is not available. There is no cash value.
At age 70, your coverage amount is reduced to 60% of your pre-age 70 amount; at age 75, it is reduced to 40%; and at age 80, it is reduced to 30%.
The amount of insurance shown in Workday is determined by your Annual Benefit Salary.
LIFE INSURANCE
During Open Enrollment, you can select one of the four levels (1x, 1.5x, 2x, or 3x Annual Benefit Salary) of group term life insurance, to a maximum of $400,000.
Each year you may increase your current life insurance coverage by one level without providing Evidence of Insurability (EOI).
Any increase of more than one level will require you to complete an EOI, which you will receive notification by mail or e-mail from The Hartford after the Open
Enrollment period has ended. Increases of more than one level will be subject to approval by The Hartford.
You must complete the EOI and be approved by The Hartford; otherwise your coverage will be returned to one level above your previous election. For example; if
you are currently covered at one and one-half times (1.5x) your Annual Benefit Salary and elect three times (3x) your Annual Benefit Salary, coverage will increase
to two times (2x) your Annual Benefit Salary if you do not submit an EOI to The Hartford or if you are not approved by The Hartford.
TAX CONSIDERATIONS
Federal tax laws state that the first $50,000 of group life insurance coverage is not subject to taxes. Amounts in excess of $50,000 are taxable. The government
assigns a value to these amounts, and this value is added to your W-2 earnings based on your age as of the end of the calendar year. These amounts are called
Imputed Income. Refer to the 2022 Benefits Guide on www.oakgov.com/benefits for additional information including tax rate tables to help you calculate taxes on
insurance amounts in excess of $50,000.
ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE (AD&D)
During Open Enrollment, you can choose a different level of AD&D Insurance coverage than you selected for your life insurance coverage. You can select any of
the three levels available, 1x, 2x or 3x your annual salary, up to a maximum of $400,000.
AD&D BENEFITS
If you suffer bodily injury caused by an accident that results in loss of life or bodily impairment, you may be eligible for this benefit. If your accident causes you
to lose your life, your beneficiary will receive the AD&D amount you selected. This AD&D amount will be in addition to your Employee Life Insurance amount.
Payment for all other losses are payable to the participant. The amount payable is determined by the type of loss incurred. The amount payable due to injury, as
well as exclusions that apply can be found in the Plan Description at OakGov.com/benefits.
Page 5FLEXIBLE SPENDING ACCOUNTS (FSA) are pre-tax benefit accounts used to pay for certain health, dental, vision, Rx and dependent care ex-
penses. Using an FSA can reduce your taxes.
TYPES OF FSAS
Health Care FSA (pre-funded for use)
• Elect up to $2,750
• Use for eligible expenses such as co-pays, deductibles, dental, orthodontia, eyeglasses, contact lenses, prescriptions and some over-the-counter drugs.
• FSAs may also be used to cover costs of medical equipment such as crutches, supplies such as bandages, and diagnostic devices such as blood sugar
test kits. Visit wageworks.com for a complete list of eligible expenses.
• Access the full amount of your account on the first day of the plan year (January 1st).
• Receive a Health Care FSA card that works like a pre-loaded debit card to pay for eligible expenses.
Dependent Care FSA (reimbursement of funds)
• Elect up to $5,000
• Use on eligible expenses such as daycare centers, before and after school programs, babysitter inside or outside of a household, and day camps. Visit
wageworks.com for a complete list of eligible expenses and dependents, and when you can use these expenses.
• Allows reimbursement up to the actual amount in your account at the time the claim is filed.
• Funds are reimbursed using the “Pay Me Back Option” in your WageWorks account.
WHY YOU NEED IT
• Save an average of 30% on eligible expenses
• Save on everyday items you wouldn’t think of as a tax savings!
HOW IT WORKS
Based on your spending, simply decide how much to contribute.
Enroll in an FSA during 2022 Open Enrollment!
Funds are withdrawn from your paycheck into your account before taxes are deducted.
QUESTIONS?
Visit wageworks.com or contact your HR Benefits team at benefits@oakgov.com or 248-892-3278.
Rev. 9-24-2021
Page 6DEPENDENT ELIGIBILITY
CRITERIA FOR SPOUSES
Oakland County allows for the legal spouse of an employee to be covered under your benefits. Spouses are NOT eligible if you are legally separated (separate
maintenance agreement in Michigan) or divorced. If you are legally separated or divorced and have a legal judgment that requires you to maintain health
insurance for your ex-spouse, this individual still CANNOT remain on your healthcare coverage. They must be removed from your Oakland County coverage, and
you must obtain separate coverage for them.
CRITERIA FOR CHILDREN
Children of the employee by birth or legal adoption may be covered through the end of the year in which they have their 26th birthday.
If a child does not meet the above criteria, they may only be covered if the employee is directed to do so by a National Medical Support Order and Human
Resources - Employee Benefits has been provided with the appropriate updated and current legal documentation.
Children by birth or legal adoption of the employee’s spouse (step-children of the employee) may be covered through the end of the year in which they have their
26th birthday or until such time that the marriage to your spouse has ended due to divorce, annulment, legal separation, or death.
Permanently Disabled children of the employee may be covered to any age if:
• The child became totally and permanently disabled prior to age 19; AND
• They are incapable of self-sustaining employment; AND
• The employee provides over half their total support as defined by the Internal Revenue Code; AND
• Their disability has been certified by a physician and the health carrier is notified in writing by the end of the year in which the child turns age 26.
Legal Guardianship children of the employee may be covered through the end of the year in which they have their 26th birthday if:
• They are unmarried
• Their legal residence is with you
• You supply over half their total support as defined by the Internal Revenue Code
• You provide up-to-date legal guardianship papers
Children, of whom you are the legal guardian, may only remain on your healthcare coverage while the Legal Guardianship Order is in effect. If at any point the
Legal Guardianship Order ends, the children can no longer be covered and must be removed from county coverage.
Page 7AFFORDABLE CARE ACT OUT-OF-POCKET MAXIMUM LIMITS ON COST-SHARING REQUIREMENT
As a result of the Affordable Care Act (ACA), all health plans (including prescription coverage) will be subject to maximum out-of-pocket limits. The ACA defines
cost-sharing as deductibles, coinsurance, copayments or similar charges, and any other expenditures required of an individual which is a qualified medical ex-
pense with respect to an essential health benefit covered by the plan. Cost sharing does not include biweekly payroll contributions, premiums, balance-billing for
non-participating providers, or spending for non-covered services.
In order to comply with this requirement, the County has assigned a portion of the 2022 out-of-pocket maximum to the prescription drug plan and the remaining
portion to the medical plan(s). The 2022 out-of-pocket is $7,900 for self-only coverage and $15,800 for coverage other than self-only (family).
The 2022 Maximum Out-of-Pocket Limits will be:
Plan Self-Only (1 person) Family (2 or more persons)
Prescription $3,775 $5,550
Medical $4,125 $10,250
Total $7,900 $15,800
Should the maximum be reached in a calendar year in the prescription or medical plan, the out-of-pocket costs
would be zero for the remainder of the calendar year.
Page 8IMPORTANT NOTE: This document is not a contract. It is intended to provide a comparison of available benefit options and to summarize the provisions and features of each plan. Please refer to
the Summary Plan Document (SPD) to confirm coverage details. Every effort has been made to ensure the accuracy of this document. In the event that the information contained in this document
differs from the SPD, the information contained within the SPD will prevail. This document does not establish or determine eligibility for benefits or procedures, nor does it constitute an amend-
ment, modification or change to the SPD or to any existing contract. All coverage is subject to medical necessity guidelines as outlined in the SPD.
* In order to be eligible for benefits as specified in the SPD, services received by a Covered Person must be administered or ordered by a Physician, be Medically Necessary for the diagnosis and
treatment of an illness or injury and allowable/covered charges, unless otherwise specifically noted in the SPD.
Medical Plan Options Comparison
ONLY AVAILABLE TO
Benefits AVAILABLE TO ALL EMPLOYEES EMPLOYEES CURRENTLY
ENROLLED
PPO1 PPO2 PPO3 HMO TRADITIONAL
ASR Health Benefits Blue Cross/Blue Shield PPO ASR Health Benefits Health Alliance Plan (HAP) Blue Cross/Blue Shield
Community Blue Plan Traditional Plan (BC/BS)
asrhealthbenefits.com BCBSM.com asrhealthbenefits.com HAP.org BCBSM.com
Employee Bi-Weekly $32 / $65 / $75 $42 / $70 / $85 $16 / $35 / $45 $32 / $65 / $75 $52 / $89 / $94
Contributions
No Coverage Option Refer to Open Enrollment benefit elections in Workday
Network(s) HAP Alliance Health & Life Blue Cross/Blue Shield HAP Alliance Health & Life Health Alliance Plan HMO Blue Cross/Blue Shield
PPO / Physicians Care / Aetna PPO / Physicians Care / Aetna
/ Multiplan / Multiplan
Deductible(s) $200 per person/$400 per $100 per person/$200 per $250 per person/$500 per No Deductible $200 per person/$400 per
family per calendar year family per calendar year family per calendar year family per calendar year
Coinsurance 0% for most services; l0% l0% after deductible as noted. 20% after deductible as No Coinsurance 10% after deductible as
after deductible as noted. 50% for private duty nursing. noted. 50% after deductible noted. 25% for private duty
for private duty nursing. nursing.
Coinsurance Maximum $1,000 per person/family per $500 per person/$1,000 per $1,000 per person/$2,000 Not Applicable $1,000 per person/family per
calendar year. family per calendar year. per family per calendar year. calendar year.
INPATIENT HOSPITAL CARE
General Conditions Semi- 100%* 90% after deductible* 80% after deductible* 100%* 100%*
Private Drugs Bariatric Copay: $1,000
Intensive Care Unit Meals
Hospital Equipment Special
Diets Nursing Care
OUTPATIENT HOSPITAL CARE
Emergency Room Care $100 copay $100 copay $100 copay, deductible and $100 copay $100 copay
Accidental Injuries coinsurance may also apply
for
Page 9Medical Plan Options Comparison
ONLY AVAILABLE TO
Benefits AVAILABLE TO ALL EMPLOYEES EMPLOYEES CURRENTLY
ENROLLED
PPO1 PPO2 PPO3 HMO TRADITIONAL
ASR Health Benefits Blue Cross/Blue Shield PPO ASR Health Benefits Health Alliance Plan (HAP) Blue Cross/Blue Shield
Community Blue Plan Traditional Plan (BC/BS)
asrhealthbenefits.com BCBSM.com asrhealthbenefits.com HAP.org BCBSM.com
Medical Emergencies Copay waived for accidental Copay waived for accidental some services. Copay waived Copay waived if admitted Copay waived for accidental
injury or if admitted injury or if admitted for accidental injury or if injury or if admitted
admitted
Physical Therapy 100%* 90% after deductible* 80% after deductible* 100%* 90% after deductible*
Includes Speech Therapy
60 combined visits per and Occupational Therapy 60 combined or consecutive
calendar year Up to 60 consecutive visits visits per calendar year.
per benefit period. May be
rendered at home.
URGENT CARE
Urgent Care Visits $20 copay 90% after deductible*
PREVENTATIVE CARE SERVICES
Routine Health Maintenance
Exam – includes chest
x-ray, EKG, cholesterol 100%*
screening andother select lab
procedures
Routine Physical 100%*
Routine Gynecological Exam 100%*
Routine Pap Smear
Screening – laboratory and 100%*
pathology services
Well-Baby Child Care Visits 100%* 100%* 100%* 100%* 100%*
• 6 visits, birth through 12 Plan covers 8 visits (birth No limits on number of visits Plan covers 8 visits (birth
months through 12 months) through 12 months)
• 6 visits, 13 months through
23 months
• 6 visits, 24 months through
35 months
• 2 visits, 36 months through
47 months
Visits beyond 47 months are
limited to one per member
per calendar year under the
health maintenance exam
benefit
Page 10Medical Plan Options Comparison
ONLY AVAILABLE TO
Benefits AVAILABLE TO ALL EMPLOYEES EMPLOYEES CURRENTLY
ENROLLED
PPO1 PPO2 PPO3 HMO TRADITIONAL
ASR Health Benefits Blue Cross/Blue Shield PPO ASR Health Benefits Health Alliance Plan (HAP) Blue Cross/Blue Shield
Community Blue Plan Traditional Plan (BC/BS)
asrhealthbenefits.com BCBSM.com asrhealthbenefits.com HAP.org BCBSM.com
Adult and Childhood
Preventive Services
and Immunizations as
recommended by the
USPSTF, ACIP, HRSA or other
sources as recognized by 100%*
BCBSM, ASR and HAP that
are in compliance with the
provisions of the Patient
Protection and Affordable
Care Act
Routine Fecal Occult Blood 100%*
Screening
Routine Flexible 100%*
Sigmoidoscopy Exam
Routine Prostate Specific 100%*
Antigen (PSA) Screening
Routine Mammogram and 100%* 100%* 100%* 100%* 100%*
Related Reading NOTE: Subsequent medically NOTE: Medically necessary NOTE: Subsequent medically
necessary mammograms performed mammograms are subject to your necessary mammograms performed
during the same calendar year deductible and percent coinsurance during the same calendar year
are subject to your deductible and are subject to your deductible and
percent coinsurance. percent coinsurance
Colonoscopy – Routine or 100%* 100%* 100%* 100%* 100%*
Medically Necessary NOTE: Subsequent colonoscopies NOTE: Subsequent colonoscopies NOTE: Subsequent colonoscopies
performed during the same calendar performed during the same calendar performed during the same calendar
year are subject to your deductible year are subject to your deductible year are subject to your deductible
and percent coinsurance. and percent coinsurance and percent coinsurance.
MENTAL HEALTH CARE
Inpatient Mental Health 100%* 90% after deductible* 80% after deductible* 100%* 100%*
Outpatient Mental Health $20 copay 90% after deductible* $20 copay $20 copay 100%*
Visits Office visits $20 copay
Inpatient Substance Abuse 100%* 90% after deductible* $20 copay 100%* 100%*
Care Chemical Dependency
Outpatient Substance Abuse $20 copay 90% after deductible* $20 copay $20 copay 100%*
Care Chemical Dependency Office visits $20 copay In approved facilities only
Page 11Medical Plan Options Comparison
ONLY AVAILABLE TO
Benefits AVAILABLE TO ALL EMPLOYEES EMPLOYEES CURRENTLY
ENROLLED
PPO1 PPO2 PPO3 HMO TRADITIONAL
ASR Health Benefits Blue Cross/Blue Shield PPO ASR Health Benefits Health Alliance Plan (HAP) Blue Cross/Blue Shield
Community Blue Plan Traditional Plan (BC/BS)
asrhealthbenefits.com BCBSM.com asrhealthbenefits.com HAP.org BCBSM.com
SPECIAL HOSPITAL PROGRAMS
Hospice Card 100%* 100%* 80% after deductible* Covered up to 210 days per 100% of approved amount
lifetime
Specified Human Organ 100%* 90% to 100%* 80% after deductible* $20 copay 100% in approved facilities
Transplants Covered according to plan
guidelines.
MEDICAL AND SURGICAL CARE
Surgery 100%* 90% after deductible* 80% after deductible* 100%* 100%*
Voluntary second surgical Voluntary second surgical
opinion; $20 copay. opinion on certain surgeries.
Technical Surgical Assist. 100%* 90% after deductible* 80% after deductible* 100%* 100%*
Anesthesia 100%* 90% after deductible* 80% after deductible* 100%* 100%*
Maternity Care Delivery 100%* 90% after deductible* 80% after deductible* 100%* 100%*
Pre- and Post-Natal Care 100%* 100%* 100% for some pre-natal 100% pre-natal visits* 100% pre-natal visits
visits; otherwise 80% after $20 copay post-natal visits 90% after deductible post-
deductible* natal visits*
Inpatient Medical Care 100%* 90% after deductible* 80% after deductible* 100%* 100%*
Inpatient Consultations 100%* 90% after deductible* 80% after deductible* 100%* 100%*
Laboratory & Pathology 100%* 90% after deductible* 80% after deductible* 100%* 90% after deductible*
Diagnostic Services 100%* 90% after deductible* 80% after deductible* 100%* 90% after deductible*
Diagnostic and Therapeutic 100%* 90% after deductible* 80% after deductible* Covered* 90% after deductible*
Radiology
ADDITIONAL BENEFITS
Office Visits $20 copay $20 copay $20 copay $20 copay 90% after deductible*
Chiropractic Care $20 copay $20 copay $20 copay Not Covered 90% after deductible*
Limited to 38 visits per Limited to 24 visits per Limited to 38 visits per Limited to 38 visits per
calendar year. calendar year calendar year calendar year
Allergy Testing 100%* 100%* 80% after deductible* $20 copay 90% after deductible*
Allergy Therapy 100%* 100%* 80% after deductible* 100%* 90% after deductible*
Ambulance Services 90% after deductible* 90% after deductible* 80% after deductible* 100%* 90% after deductible*
Durable Medical Equipment 90% after deductible* 90% after deductible* 80% after deductible* 100%* 90% after deductible*
Page 12Medical Plan Options Comparison
ONLY AVAILABLE TO
Benefits AVAILABLE TO ALL EMPLOYEES EMPLOYEES CURRENTLY
ENROLLED
PPO1 PPO2 PPO3 HMO TRADITIONAL
ASR Health Benefits Blue Cross/Blue Shield PPO ASR Health Benefits Health Alliance Plan (HAP) Blue Cross/Blue Shield
Community Blue Plan Traditional Plan (BC/BS)
asrhealthbenefits.com BCBSM.com asrhealthbenefits.com HAP.org BCBSM.com
Diabetic Supplies 90% No Annual deductible* 90% after deductible* 80% after deductibe* 100%* 90% after deductible*
Private Duty Nursing 90% after deductible* 50% after deductible* 50% after deductibe* Not Covered 75% after deductible*
Skilled Nursing 100%* 90% after deductibe* 80% after deductibe* 100%* 100%*
Voluntary second surgical Voluntary second surgical
opinion; $20 copay. opinion on certain surgeries.
Assisted Reproductive Not Covered Not Covered* Not Covered 100%* Not Covered
Treatment One attempt of artificial
insemination per lifetime.
Voluntary Sterilization and 100%* 100%* 100%* 100%* 100%*
FDA Approved Contraceptive
Methods
PROGRAM PROVISIONS
Out of Network Services In general, Plan pays 85% Plan pays 70% of approved In general, Plan pays 65% Not covered except for
of approved amount less amount, after out-of-network of approved amount after emergencies
applicable copays. For deductible, less applicable deductible less applicable
diabetic supplies, durable copays. copays. For private duty
medical equipment, and nursing, Plan pays 50% of
private duty nursing, Plan approved amount after
pays 75% of approved deductible.
amount after deductible (if
applicable).
Payment of Covered Services Preferred (Network) Hospitals: Preferred (Network) Hospitals: Preferred (Network) Hospitals: Copays as noted. Participating Hospitals:
100% of covered benefits. 90% of covered benefits, after 80% of covered benefits, less 100% of covered benefits
Non-Network Hospitals: deductible. applicable deductible. Non-participating Hospitals:
85% of approved payment Non-Network Hospitals: Non-Network Hospitals: 65% Inpatient care in acute-care
amount Preferred (Network) 70% of approved payment of approved payment amount, hospital - $70 a day.
Physicians - Outpatient: amount after out-of-network after deductible. Inpatient care in other
100% after $20 copay. deductible. Preferred (Network) hospitals -$15 a day.
Non-network Physicians - Preferred (Network) Physicians - Outpatient: Medicare Surgical:
Outpatient: Physicians: 100% after $20 100% after $20 copay. 100% of BCBSM’s approved
85% of approved payment copay. Non-network Physicians - amount.
amount after $20 copay. Non-network Physicians: Outpatient:
70% of approved payment 85% of approved payment
amount after out-of-network amount after $20 copay.
deductible and $20 copay.
Page 13Medical Plan Options Comparison
ONLY AVAILABLE TO
Benefits AVAILABLE TO ALL EMPLOYEES EMPLOYEES CURRENTLY
ENROLLED
PPO1 PPO2 PPO3 HMO TRADITIONAL
ASR Health Benefits Blue Cross/Blue Shield PPO ASR Health Benefits Health Alliance Plan (HAP) Blue Cross/Blue Shield
Community Blue Plan Traditional Plan (BC/BS)
asrhealthbenefits.com BCBSM.com asrhealthbenefits.com HAP.org BCBSM.com
NOTE: Hearing aids and services are not covered under any Oakland County medical plans; however, there is a discount program available through Nations Hearing for a limited time.
PRESCRIPTION DRUG PROGRAM
Retail Prescription Carrier Navitus Navitus Navitus Health Alliance Plan Navitus
www.navitus.com www.navitus.com www.navitus.com www.HAP.org www.navitus.com
Mail Order Prescription Birdi Birdi Birdi Pharmacy Advantage Birdi
Carrier www.birdirx.com www.birdirx.com www.birdirx.com PharmacyAdvantageRx.com www.birdirx.com
Participating/Network Covered / Copays: Covered / Copays: Covered / Copays: Covered / Copays: Covered / Copays:
Pharmacies Tier 1: $5 Most Generics/ Tier 1: $5 Most Generics/ Tier 1: $5 Most Generics/ Tier 1: $5 Most Generic; Tier Tier 1: $5 Most Generics/
Some Brands; Some Brands; Some Brands; 2: $20 Select Brand name; Some Brands; Tier 2: $20
Tier 2: $20 Preferred Brands/ Tier 2: $20 Preferred Brands/ Tier 2: $20 Preferred Brands/ Tier 3: $40 Non-Preferred. Preferred Brands/Some
Some Generics; Some Generics; Some Generics; Select Birth Control pills Generics;
Tier 3: $40 Non-Preferred Tier 3: $40 Non-Preferred Tier 3: $40 Non-Preferred covered $0 copay. Tier 3: $40 Non-Preferred
products (could include both products (could include both products (could include both products (could include brand
brand and generic) brand and generic) brand and generic products) and generic)
Select Birth Control pills Select Birth Control pills Select Birth Control pills Select Birth Control pills
covered $0 copay. covered $0 copay. covered $0 copay. covered $0 copay.
Non-Participating/Non- Paid at the in-network cost, Paid at the in-network cost, Paid at the in-network cost, Not Covered Paid at the in-network cost,
Network Pharmacies less $5, $20 or $40 copay. less $5, $20 or $40 copay. less $5, $20 or $40 copay. less $5, $20 or $40 copay.
Maintenance Drugs Maintenance drugs taken Maintenance drugs taken Maintenance drugs taken Maintenance drugs taken on Maintenance drugs taken
on a long-term basis can on a long-term basis can on a long-term basis can a long-term basis – a 30 or on a long-term basis can
be filled as a three-month be filled as a three-month be filled as a three-month 90-day supply, whichever is be filled as a three-month
supply for a one-month copay supply for a one-month copay supply for aone-month copay greater, can be obtained for supply for a one-month copay
through either the Mail Order through either the Mail Order through either the Mail Order a one-month copay at your through either the Mail Order
Drug carrier or at a retail Drug carrier or at a retail Drug carrier or at a retail local pharmacy. Drug carrier or at a retail
pharmacy. pharmacy. pharmacy. pharmacy.
A 90-day supply of
maintenance drugs may be
obtained through mail order.
Note: While in the hospital, If you request a prescription be If you request a prescription be If you request a prescription be If you request a prescription be If you request a prescription be
drugs are covered under your filled with a brand name drug filled with a brand name drug filled with a brand name drug filled with a brand name drug filled with a brand name drug
medical plan and there is a generic equivalent and there is a generic equivalent and there is a generic equivalent and there is a generic available, and there is a generic equivalent
available, you will be responsible available, you will be responsible available, you will be responsible you will be responsible for the available, you will be responsible
for the Tier 3 copay plus the for the Tier 3 copay plus the for the Tier 3 copay plus the full cost differential between for the Tier 3 copay plus the
differential between the cost of differential between the cost of differential between the cost of the cost of the brand and the differential between the cost of
the brand and the generic drug. the brand and the generic drug. the brand and the generic drug. copay of the generic drug. If your the brand and the generic drug.
If your doctor makes the request, If your doctor makes the request, If your doctor makes the request, doctor makes the request, you If your doctor makes the request,
you will be responsible for the you will be responsible for the you will be responsible for the will be responsible for the Tier 3 you will be responsible for the
Tier 3 copay. Tier 3 copay. Tier 3 copay. copayment. Tier 3 copay.
Page 14Dental Plan Options Comparison
Benefits AVAILABLE TO BU 9, 10, & 15 AVAILABLE TO ALL EMPLOYEES AVAILABLE TO ALL EMPLOYEES AVAILABLE TO ALL EMPLOYEES
High Plus High Standard Modified
Delta Dental Delta Dental Delta Dental Delta Dental
www.deltadentalmi.com www.deltadentalmi.com www.deltadentalmi.com www.deltadentalmi.com
Employee Bi-Weekly Contributions / (Earning) $1.15 / $1.73 / $5 $1.15 / $1.73 / $5 $0 / $0 / $0 ($1.15) / ($1.73) / ($3.27)
NO COVERAGE Option Refer to the Open Enrollment benefit elections in Workday.
Network(s) Delta Dental PPO / Delta Dental Premier
DIAGNOSTICS AND PREVENTIVE
Diagnostics and Preventive Services – routine oral 100% 100% 100% 100%
exams, cleanings, fluoride, and space maintainers
Emergency Palliative 100% 100% 100% 100%
Treatment – to temporarily relieve pain
Periodontal Maintenance – 100% 100% 100% 100%
cleanings following periodontal therapy
Dental Sealants – children 14 years and under 100% 100% 100% 100%
Oral Cancer Brush Biopsy 100% 100% 100% 100%
BASIC SERVICES
Radiographs – X-rays 85% 85% 85% 50%
Minor Restorative Services– composite (white) fillings 85% 85% 85% 50%
and crown repair
Endodontic Services – root canals 85% 85% 85% 50%
Periodontic Services – to treat gum disease 85% 85% 85% 50%
Oral Surgery Services – 85% 85% 85% 50%
extractions and dental surgery
Major Restorative Services – crowns 85% 85% 85% 50%
Page 15Dental Plan Options Comparison
BENEFITS AVAILABLE TO BU 9, 10, & 15 AVAILABLE TO ALL EMPLOYEES AVAILABLE TO ALL EMPLOYEES AVAILABLE TO ALL EMPLOYEES
High Plus High Standard Modified
Delta Dental Delta Dental Delta Dental Delta Dental
www.deltadentalmi.com www.deltadentalmi.com www.deltadentalmi.com www.deltadentalmi.com
Other Basic Services – miscellaneous services 85% 85% 85% 50%
Relines and Repairs – to 85% 85% 85% 50%
bridges, dentures, and implants
MAJOR SERVICES
Prosthodontic Services – 50% 50% 50% 50%
bridges, implants, and dentures
ORTHODONTIC SERVICES
Orthodontic Services – minor treatment for tooth 50% 50% 50% 50%
guidance, full banding treatment, and monthly active
treatment visits
Orthodontia Maximum Limit $1,000 per eligible member per lifetime. $750 per eligible member per
lifetime.
Orthodontic Age Limit Up to age 19
PROGRAM/PROVISIONS
Deductibles $25 per person / $50 per family/per calendar year
Maximum Benefit $1,500 per individual per calendar year. $1,000 per individual per $750 per individual per calendar
calendar year. year.
All benefits based on maximum
All benefits based on maximum All benefits based on maximum
approved fees.
NOTE: For additional information, refer to the Delta Dental Certificates and Benefit Summaries found OakGov.com/benefits under Medical/Dental/Vision.
Page 16Vision Plan Options Comparison
BENEFITS AVAILABLE TO ALL EMPLOYEES AVAILABLE TO ALL EMPLOYEES
High Standard
National Vision Administrators (NVA) National Vision Administrators (NVA)
www.e-nva.com www.e-nva.com
Employee Bi-Weekly Contributions $1.35 / $2.88 / $3.85 $0 / $0 / $0
NO COVERAGE Option No Earning is provided for No Coverage option.
Network(s) National Vision Administrators
EYE EXAM
Vision Examinations $5 copayment
LENSES AND FRAMES
Lenses and Frames Lenses: Standard Glass or Plastic / Covered 100% after $7.50 copayment
Frames: $100 retail allowance / 20% discount off remaining balance for frames that are not proprietary frame brands.
CONTACT LENSES
Contact Lenses $50 allowance
PROGRAM/PROVISIONS
Benefits Payable Benefit payable every 12 months. Benefit availability will start over Benefit payable every 24 months. Benefit availability
on January 1 (following a 12-month period). will start over on January 1 (following a 24-month
period).
Additional Discounts See the Benefit Summary for additional discounts available.
NOTE: For additional information refer to the NVA Benefit Summaries found on OakGov.com/benefits under Medical/Dental/Vision.
Page 17NOTES
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