Large Group Medical and Prescription Plans

2019 Large Group Medical and Prescription Plan Options (>51 Employees)
PLAN HIGHLIGHTS $500 PPO
Plan B
$750 PPO
Plan C
$1,000 PPO
Plan D
$1,500 PPO
Plan E
$2,700 HDHP
Plan F
$2,700 HDHP
Plan H
$3,500 HDHP
Plan I
$5,000 HRA
Plan J
UnitedHealthcare Choice Plus In-Network In-Network In-Network In-Network In-Network In-Network In-Network In-Network
Deductible
Individual
Family
$500
$1,000
$750
$1,500
$1,000
$2,000
$1,500
$3,000
$2,700
$5,200
$4,100
$8,200
$4,500
$9,000
$6,000
$12,000
Coinsurance (applied after deductible is met)
Paid by Insurance
Paid by Individual
80%
20%
80%
20%
80%
20%
80%
20%
100%
0%
80%
20%
80%
20%
100%
0%
Out-of-Pocket Maximum (includes deductible and medical/prescription copays)
Individual
Family
$3,000
$6,000
$3,250
$6,500
$3,500
$7,000
$4,000
$8,000
$2,700
$5,200
$4,100
$8,200
$4,500
$9,000
$6,000
$12,000
Co-Payments (paid by individual)
PCP Office Visit (PP/Non-PP)
SCP Office Visit (PP/Non-PP)
Virtual Visit
Urgent Care
Emergency Room
Inpatient Hospital
$15/$25
$15/$25
$10
$75
$250
20%*
$15/$25
$15/$25
$10
$75
$250
20%*
$15/$25
$15/$25
$10
$75
$250
20%*
$15/$30
$15/$30
$10
$75
$250
20%*
0%*
0%*
0%*
0%*
0%*
0%*
10%*/20%*
10%*/20%*
20%*
20%*
20%*
20%*
10%*/20%*
10%*/20%*
20%*
20%*
20%*
20%*
0%*
0%*
0%*
0%
0%*
0%*
Wellness Benefit
No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Prescriptions (paid by individual)
Tier 1
Tier 2
Tier 3
Specialty
$10
$30
$40
$100
$10
$30
$50
$100
$15
$30
$50
$100
$20
$40
$60
$100
0%*
0%*
0%*
0%*
20%*
20%*
20%*
20%*
20%*
20%*
20%*
20%*
$10
$30
$60
$100
Lifetime maximum is unlimited for all plan options

Notes:
*After deductible
Medical and prescription copayments accumulate towards the out-of-pocket maximum.
Premium rates are calculated for new municipal members based upon underwriting requirements
set forth by the Indiana Department of Insurance.
PP – Premium Provider Designation
Non-PP – Non-Premium Provider Designation

Small Group Medical and Prescription Plans

2019 Small Group Medical and Prescription Plan Options (<50 Employees)
PLAN HIGHLIGHTS $500 PPO
Plan 1
$750 PPO
Plan 2
$750 PPO
Plan 3
$750 PPO
Plan 4
$1,500 PPO
Plan 5
$1,500 PPO
Plan 6
$1,500 HDHP
Plan 7
$2,700 HDHP
Plan 8
$3,000 HDHP
Plan 9
UnitedHealthcare Choice Plus In-Network In-Network In-Network In-Network In-Network In-Network In-Network In-Network
Deductible
Individual
Family
$500
$1,000
$750
$1,500
$750
$1,500
$750
$1,500
$1,500
$3,000
$1,500
$3,000
$1,500
$3,000
$2,700
$5,200
$3,000
$6,000
Coinsurance (applied after deductible is met)
Paid by Insurance
Paid by Individual
80%
20%
80%
20%
80%
20%
80%
20%
80%
20%
80%
20%
80%
20%
100%
0%
80%
20%
Out-of-Pocket Maximum (includes deductible and medical/prescription copays)
Individual
Family
$3,000
$6,000
$3,500
$7,000
$3,500
$7,000
$3,500
$7,000
$5,000
$10,000
$5,000
$10,000
$5,000
$10,000
$2,700
$5,200
$6,000
$12,000
Co-Payments (paid by individual)
PCP Office Visit
SCP Office Visit
Virtual Visit
Urgent Care
Emergency Room
Inpatient Hospital
$15/$25
$15/$25
$10
$75
$250
20%*
$15/$30
$30/$60
$10
$75
$250
20%*
$15/$30
$30/$60
$10
$75
$250
20%*
$15/$30
$30/$60
$10
$75
$250
20%*
$15/$30
$30/$60
$10
$75
$250
20%*
$15/$30
$30/$60
$10
$75
$250
20%*
$15/$30
$30/$60
$10
$75
$250
20%*
0%*
0%*
0%*
0%*
0%*
0%*
10%*/20%*
10%*/20%*
10%*
20%*
20%*
20%*
Wellness Benefit
No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Prescriptions Tier 3 & 4 Ded $250 Indiv $500 Fam (paid by individual)



Tier 1
Tier 2
Tier 3
Tier 3



$10
$30
$40
$100



$10
$40
$60
$100



$15
$30
$60
$100


$5
$50
$100
$250



0%*
0%*
0%*
0%*



20%*
20%*
20%*
20%*



20%*
20%*
20%*
20%*



0%*
0%*
0%*
0%*
Lifetime maximum is unlimited for all plan options

Notes:
*After deductible
Medical and prescription copayments accumulate towards the out-of-pocket maximum.
$200 deductible on prescription programs is applicable to Tier 2 and Tier 3 for Plan 4 and Plan 7 only.
Premium rates are calculated for new municipal members based upon underwriting requirements set
forth by the Indiana Department of Insurance.
PP – Premium Provider Designation
Non-PP – Non-Premium Provider Designation

Dental Plans

Delta Dental
Option 1 Option 2
Deductible (Single/Family)
Coinsurance (Preventive/Basic/Major/Ortho Services)
Annual Dental Maximum (per insured)
Lifetime Child Ortho Maximum (to age 19)
Out-of-network
Endodontics & Periodontics
$50/$150
100/80/50/50
$1,500
$1,500
Fee Schedule
Basic
$50/$150
100/80/50/50
$1,000
$1,000
Fee Schedule
Basic
Monthly Premium Rates (Guaranteed through December 31 2021)
Employee Only
Employee/Spouse
Employee/Child(ren)
Family
$26.92
$53.86
$72.75
$109.33
$24.97
$49.93
$66.16
$99.86

 

Vision Plan Options

VSP Vision Care
Option 1 Option 2 Option 3
Exam Copay
Materials Copay
Frequency (Exam/Lenses/Frames)
$10
$20
12/12/24
$15
$25
12/24/24
$10
$20
12/12/24*
*Includes KidsCare Plan–2 exams and 1 pair of glasses every year.
Monthly Premium Rates (Guaranteed through December 31 2023)
Employee Only
Employee/Spouse
Employee/Child(ren)
Family
$5.94
$11.90
$12.71
$20.33
$4.43
$8.88
$9.49
$15.16
$6.84
$13.67
$14.63
$23.37

Dental and vision coverage is available to municipalities participating in the medical plan. Dental and
vision coverage can be provided as a contributory, non-contributory or voluntary insurance benefit.
The Aim Medical Trust is a multiple employer welfare arrangement. The multiple employer welfare
arrangement may not be subject to all of the insurance laws and regulations of Indiana. State insurance
guaranty funds are not available for the Aim Medical Trust.

 

Basic Life and AD&D Plans

Choose from four basic Life/AD&D plans with MetLife.
PLAN HIGHLIGHTS Option 1 Option 2 Option 3 Option 4
Class Description All FTA Employees All FTA Employees All FTA Employees All FTA Employees
Life Benefit $25,000 $50,000 1 x Basic Annual Earnings to $50,000 Max 2 x Basic Annual Earnings to $100,000 Max
AD&D Benefit $25,000 $50,000 1 x Basic Annual Earnings to $50,000 Max 2 x Basic Annual Earnings to $100,000 Max
Age Reduction Schedule 35% @ 65
50% @ 70
65% @ 75
Terminate @ retirement
35% @ 65
50% @ 70
65% @ 75
Terminate @ retirement
35% @ 65
50% @ 70
65% @ 75
Terminate @ retirement
35% @ 65
50% @ 70
65% @ 75
Terminate @ retirement
Guaranteed Issue $25,000 $50,000 $50,000 $100,000
Dependent Life: Spouse / Child(ren)
Option 1
$2,500 / $2,500
(14 days to 6 mos $250)
$2,500 / $2,500
(14 days to 6 mos $250)
$2,500 / $2,500
(14 days to 6 mos $250)
$2,500 / $2,500
(14 days to 6 mos $250)
Dependent Life: Spouse / Child(ren)
Option 2
$10,000 / $10,000
(14 days to 6 mos $1,000)
$10,000 / $10,000
(14 days to 6 mos $1,000)
$10,000 / $10,000
(14 days to 6 mos $1,000)
$10,000 / $10,000
(14 days to 6 mos $1,000)
Employee Contributions Non-contributory Non-contributory Non-contributory Non-contributory
Minimum Participation 100% 100% 100% 100%
Premium Rates
Life Rate per $1,000 of Benefit $0.199 $0.199 $0.199 $0.199
AD&D Rate per $1,000 of Benefit $0.020 $0.020 $0.020 $0.020
Monthly Premium Per Person $5.48 per month $10.95 per month
Dependent Life Rate per Family Unit
Option 1
$1.50 $1.50 $1.50 $1.50
Dependent Life Rate per Family Unit
Option 2
$6.00 $6.00 $6.00 $6.00

Notes:
**Life plan offers Value Added Features such as: Accelerated Life Benefits, Life Conversion, Beneficiary Assistance – Delivering The Promise,
Grief Counseling
MetLife: A+ Superior Best Rating
MetLife reserves the right to review, and if necessary, adjust the pricing for any group who:
– Requests a non-standard Plan design, -Has 25% or more retirees,
– Has 75 lives or more, and who’s population is composed of 75% or more police/fire
The Aim Medical Trust is a multiple employer welfare arrangement. The multiple employer welfare arrangement may not be subject
to all of the insurance laws and regulations of Indiana. State insurance guaranty funds are not available for the Aim Medical Trust.

Your browser is out-of-date!

Update your browser to view this website correctly. Update my browser now

×

Top