Benefits plans

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.