13
Add’l Health Benefits
*The amount indicated is the co-pay for brand name drugs. If a generic of the drug is
available, you also will pay the difference between the generic and brand name prices.
Supplemental Benefits
If you are a full-time employee and enroll in medical benefits, you automatically will receive
even more benefits after 90 days on the job — prescription drug and the supplemental
benefits package consisting of dental, vision and hearing aid plans — at no additional cost to
you. A letter will be sent to your mailing address to explain more about your prescription drug
and supplemental benefit options at that time. Unless you call the HR Service Center to decline
coverage, you will be enrolled automatically in the prescription drug and supplemental benefits
at no additional cost. Part-time employees have additional costs for prescription drug and
supplemental benefits, and as a result, will not be automatically enrolled. Part-time employees
should contact the HR Service Center for information on the costs and enrollment.
If you do not enroll in medical benefits, you can still elect to participate in these additional
benefits — but it is not automatic. After you have been on the job for 90 days, you can enroll
by calling the HR Service Center to request prescription drug and/or supplemental benefits.
Upon enrollment in any of the health plans (medical, prescription drug, supplemental
benefits), employees contribute 2.5% or 5% of their biweekly gross base salary, depending on
if they participate in the Get Healthy program. If you also want to enroll eligible dependents,
you will need to complete an enrollment packet.
• Dental — Dental benefits are provided through United Concordia (UCCI). The plan pays for
up to $1,500 of dental work per person per calendar year with participating providers. It
covers 100% of diagnostic services and preventive care with no co-pay. You will have less
out-of-pocket costs when you use a participating dentist.
Basic work (i.e., fillings and root canals) is typically covered at 90% after a $50 deductible.
Major work (i.e., crowns and dentures) typically is covered at 60% after a $50 deductible.
Orthodontic lifetime maximum is $1,750 per person.
• Vision — Vision benefits are provided through National Vision Administrators (NVA).
Benefits cover routine eye exams and glaucoma tests with participating providers. The plan
provides you and your enrolled dependents with an allowance for contact lenses, frames
and lenses during specified time periods. Contact NVA at 800.672.7723 for more
information.
• Hearing Aid — Hearing aid benefits are provided by the PEBTF, which covers one hearing
aid per ear every 36 months (1,095 days). Monaural hearing aids are covered up to $900.
Binaural hearing aids are covered up to $1,800. CROS hearing aids are covered up to
$2,400.
Prescription drug, dental and vision providers will send membership cards to you directly. No
card is needed for hearing aid coverage. If you do not receive cards within 30 days of your
enrollment date, call the PEBTF at 800.522.7279.
Remember, if you are a full-time employee and you enrolled in medical benefits during your
first 90 days of employment, your prescription drug and supplemental benefits will be added
automatically after this period has expired. If you did not enroll in medical benefits, you can
enroll in prescription drug and/or supplemental benefits — or all three (medical, prescription
drug and supplemental benefits) — at any time after this period has expired. If you are a part-
Up to 30-day
supply
Up to 90-day supply
2021
Copayments
Retail Network
Pharmacy
CVS
Pharmacy
Rite Aid
Pharmacy
CVS Caremark
Mail Service
Generic $15 $22.50 $30 $22.50
Preferred
Brand Name
$40* $60* $80* $60*
Non-Preferred
Brand Name
$80* $120* $160* $120*