benefit plan comparison guide 2017 plan year options · benefit plan comparison guide 2017 plan...

January 1 – December 31

Benefit Plan Comparison Guide

2017 Plan Year Options

PhYsical financial PersOnal

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Choosing the Right Medical/Prescription PlanThe following medical/prescription plans will be available through Meijer for 2017 coverage. When comparing your options, remember all Meijer medical/prescription plan options cover most in-network preventive care services at 100% with no deductible required.

Newly hired full-time hourly and salaried team members, and part-time team members with an annual average of 30 or more hours per week* will be offered:

• Core Health Plan (CHP): You pay the plan year deductible before the plan begins to pay. Beginning January 1, 2017, the plan will include a Personal Health Bank (PHB), which is funded by Meijer ($100 for team member only coverage or $200 for team member plus dependents).

• Core Health Plan Plus (CHP+): You pay the plan year deductible before the plan begins to pay. The plan includes a Personal Health Bank (PHB), which is funded by Meijer ($250 for team member only coverage or $500 for team member plus dependents in 2017).

• Advantages Health Plan (AHP): You pay the plan year deductible, including the cost of non-preventive prescription drugs, before the plan begins to pay. The plan includes a Health Savings Account (HSA), to which Meijer makes a contribution ($500 for team member only coverage or $1,000 for team member plus dependents). And you can contribute too, up to the allowed IRS maximum.

If you enroll in the AHP, the AH Companion Plan is also available to you. It provides additional funds that you may use toward hospital expenses that are subject to the deductible.

• Premier Health Network (PHN)/ Steps2Health (S2H): Available in select Michigan, Ohio and Kentucky areas only. You must select a participating primary care physician, and you pay lower copays for most services and lower out-of-pocket expenses than the plans above. These plans include a Personal Health Bank (PHB), which is funded by Meijer ($250 for team member only coverage or $500 for team member plus dependents).

Newly hired part-time and team members averaging less than 30 hours per week will be offered:

• Core Health Plan Plus (CHP): As described above.

Important Contacts

For specific questions about your benefits, you may reach the vendors directly using the contact information listed later in this booklet.

*Grandfathered team members hired before 2006 must have an annual average of 28 or more hours per week.

PHYSICAL FINANCIAL PERSONAL

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If you are eligible to enroll in a Meijer medical/prescription plan, and if you do not enroll in the AHP, you can make pre-tax contributions between $200 – $2,000 to the Health Flexible Spending Account.

Use the money to pay for eligible medical/prescription, dental, and vision services including deductibles and copays.

So What Should I Compare?CONTRIBUTIONS

Contributions vary based on the plan and coverage level you choose. Review 2017 contribution amounts on the Meijer Rewards site.

DEDUCTIBLES, COPAYS, COINSURANCE, AND ANNUAL OUT-OF-POCKET MAXIMUMS

These are key factors to compare:

DEDUCTIBLE – The amount you must pay before the plan begins to pay.

COPAY – A flat dollar amount you pay for certain services.

COINSURANCE – The percentage amount you pay for services once your deductible has been met.

ANNUAL OUT-OF-POCKET MAXIMUM – The maximum amount you pay in a calendar year before the plan pays 100% of covered services. Don’t overlook this key feature; it limits your financial risk should you face major expenses.

PRESCRIPTION DRUG COVERAGE

Prescription coverage is included with all medical/prescription plan options, but there are some important differences to consider.

If you enroll in the CHP and CHP+:

• You pay coinsurance for covered prescription drugs on the brand formulary which, compared to other plan options, is a more restrictive “High Performance” brand formulary.

• Important! Brand non-formulary prescription drugs are not covered. This means if your physician prescribes a medication that is a non-formulary brand, you will pay the full retail cost under these plans.

If you enroll in the AHP:

• You pay up to the medical/ prescription plan deductible (except for those prescription drugs considered preventive by the plan) before the plan provides prescription benefits.

Brand prescription drug formularies vary with the medical/prescription plan you select. AHP and PHN/S2H use the National Preferred Formulary and CHP/CHP+ use the High Performance Formulary. Be sure to check out the brand name formulary list for your selected medical/prescription plan on mBenefitsConnect (MBC).

See the prescription summary for more information about how prescription drugs are covered under each medical/prescription plan option.

Accounts to Help Meet Your Deductible and Pay Out-of-Pocket CostsIf you enroll in the CHP, CHP+ or PHN/S2H, a Personal Health Bank is automatically opened and funded by Meijer to help you pay eligible medical expenses.

Any account balance rolls over year-to-year, provided you remain enrolled in a plan with the PHB. You cannot contribute to the PHB, and if you leave Meijer prior to retirement, you forfeit any remaining balance in the account.

If you enroll in the AHP, a Health Savings Account is automatically opened, and Meijer makes a contribution to help you meet the deductible and pay out-of-pocket costs.

You can make pre-tax contributions too. According to IRS limits, the maximum combined contribution (yours and Meijer’s) for 2017 is $3,400 for individual or $6,750 for family coverage. The money rolls over each year and is always yours – even if you change jobs or retire.

EMPLOYEE ASSISTANCE PROGRAM (EAP)

HELP IS JUST A CLICK OR A PHONE CALL AWAY

All Meijer team members and their immediate family members can access HelpNet, a free, confidential counseling and referral service. For 2017, you are eligible to receive up to six phone counseling sessions at no charge. It’s available 24/7:

• ONLINE: helpnet.powerflexweb.com USERNAME: Meijer PASSWORD: Teammember

• PHONE: 1-866-413-4165

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Medical Options Summary

Plan Name Core Health Plan (CHP) Core Health Plan Plus (CHP+) Advantages Health Plan (AHP) Advantages Health Companion PlanService Area Nationwide Nationwide Nationwide Eligible with Advantages Health Plan

Plan Payment Information BCBS Network Providers Out‑of‑Network Providers BCBS Network Providers Out‑of‑Network Providers BCBS Network Providers Out‑of‑Network Providers

Effective Date – If you enroll during Open Enrollment, the effective date will be January 1 (provided you are actively at work). For mid-year enrollments, coverage under the Companion Plan will be the same effective date as your AHP coverage effective date.

The In-patient Hospital Benefits described below are payable for illness, injury, or pregnancy. This applies to all in-patient claims that include the Initial Hospitalization Confinement Benefit, the Daily Hospital Confinement Benefit, and the Hospital Intensive Care Benefit.

Daily Hospitalization Confinement Benefit:• Benefit Amount Day 1 – $1000• Benefit Amount for Days 2-10 – $100 benefit• Maximum Days per Confinement – 10 • Maximum Confinements per Benefit Period – Unlimited

Hospital Intensive Care Unit Confinement:• Benefit Amount per Day – $100 • Maximum Days per Benefit period – 30

Hospital Emergency Room Benefit for Injuries: • Benefit Amount per Day – $300 • Maximum Days per Benefit period – 3Treatment must be within 72 hours of the Accident.

[Federal law only allows ER visits to be payable for accidental injury for personswho have HSA contributions during the same Plan Year.]

Health Accounts: Meijer contributes to Spending Account

Personal Health Bank$100 Team Member only

$200 Team Member Plus Dependents



Health Savings Account Meijer contribution applied to active non-COBRA accounts only

$500 Team Member only$1,000 Team Member Plus Dependents

Plan Year Deductible: The amount you must pay before the Plan begins payment (In- and Out-of-Network expenses combined).

$1,500 Per Person$3,000 per Family


$950 Per Person$1,900 per Family


$1,300 Team Member Only;$2,600 Team Member and Dependent(s)


Coinsurance Percentage: The portion of the allowable expense paid by the Plan and by the Member once deductible has been met.

Plan Pays 70%You Pay 30%






Maximum Medical Out-of-Pocket: Once you reach this amount during the Plan Year, the Plan Pays 100% (In- and Out-of-Network expenses combined).





$5,000 Team Member Only; $6,750 per individual with a combined

family OOP of $10,000


Plan Year/Lifetime Maximum: Per Person Unlimited Unlimited Unlimited Unlimited

Wellness/Preventive Services

Pap Smear, Mammogram, Prostate Exam, Wellness Exams, Well Baby Care, Immunizations, Colonoscopy

Plan Pays 100% You Pay 50% After Meeting Plan Year Deductible Plan Pays 100% You Pay 50% After Meeting

Plan Year Deductible Plan Pays 100% You Pay 50% After Meeting Plan Year Deductible

Physician Office Services

Office Visits (for Illness or Injury) You Pay $30 You Pay 50% After Meeting

Plan Year Deductible You Pay $20 You Pay 50% After Meeting Plan Year Deductible You Pay 20% After Meeting

Plan Year DeductibleYou Pay 50% After Meeting

Plan Year DeductibleSpecialist Office Visits You Pay $60 You Pay 50% After Meeting

Plan Year Deductible You Pay $40 You Pay 50% After Meeting Plan Year Deductible

Other Physician Services

Pre- and Post-Natal Care

Pre and Post Natal Visits: Plan Pays 100%; $100 Prenatal

Bonus Available Through Meijer1,2

You Pay 50% After Meeting Plan Year Deductible,

$100 Prenatal Bonus Available Through Meijer1,2




$100 Prenatal Bonus Available Through Meijer1, 2

Prenatal visits 100%Postnatal visits, You Pay 20%

After Meeting Plan Year Deductible,$100 Prenatal Bonus Available

Through Meijer1,2



Physician Delivery Charges You Pay 30% After Meeting Plan Year Deductible

You Pay 50% After Meeting Plan Year Deductible





Allergy Testing and Injections You Pay $60 per Visit You Pay 50% After Meeting Plan Year Deductible You Pay $40 per Visit You Pay 50% After Meeting



Plan Year Deductible

ChiropracticYou Pay 30% After Meeting

Plan Year Deductible, up to 24 visits per Plan Year


up to 24 visits per Plan Year






up to 24 Visits per Plan Year



Online visits You Pay $10 Not covered You Pay $10 Not covered You pay 20% after meeting your deductible Not covered

Autism Spectrum Disorders, Diagnoses and Treatment — Up to and including age 18

Applied Behavorial Analysis limited to 25 hours per week







Physical, Occupational and Speech Therapy – unlimited visits per benefit period







Nutritional counseling You Pay 30% After Meeting Plan Year Deductible






Other covered services, including behavioral health services for Autism Spectrum Disorder

See your Outpatient Behavioral Health and Medical

Office Visit Benefit.









1 Maternity delivery services are not covered for dependent children, see Member Handbook for more details.2 Your doctor may bundle charges for pre- and post-natal care with delivery charges. Deductible and coinsurance would apply.

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Plan Name Core Health Plan (CHP) Core Health Plan Plus (CHP+) Advantages Health Plan (AHP) Advantages Health Companion PlanService Area Nationwide Nationwide Nationwide Eligible with Advantages Health Plan


Effective Date – If you enroll during Open Enrollment, the effective date will be January 1 (provided you are actively at work). For mid-year enrollments, coverage under the Companion Plan will be the same effective date as your AHP coverage effective date.

The In-patient Hospital Benefits described below are payable for illness, injury, or pregnancy. This applies to all in-patient claims that include the Initial Hospitalization Confinement Benefit, the Daily Hospital Confinement Benefit, and the Hospital Intensive Care Benefit.

Daily Hospitalization Confinement Benefit:• Benefit Amount Day 1 – $1000• Benefit Amount for Days 2-10 – $100 benefit• Maximum Days per Confinement – 10 • Maximum Confinements per Benefit Period – Unlimited

Hospital Intensive Care Unit Confinement:• Benefit Amount per Day – $100 • Maximum Days per Benefit period – 30

Hospital Emergency Room Benefit for Injuries: • Benefit Amount per Day – $300 • Maximum Days per Benefit period – 3Treatment must be within 72 hours of the Accident.

[Federal law only allows ER visits to be payable for accidental injury for personswho have HSA contributions during the same Plan Year.]






Health Savings Account Meijer contribution applied to active non-COBRA accounts only

$500 Team Member only$1,000 Team Member Plus Dependents




$950 Per Person$1,900 per Family











Maximum Medical Out-of-Pocket: Once you reach this amount during the Plan Year, the Plan Pays 100% (In- and Out-of-Network expenses combined).





$5,000 Team Member Only; $6,750 per individual with a combined

family OOP of $10,000


Plan Year/Lifetime Maximum: Per Person Unlimited Unlimited Unlimited Unlimited


Pap Smear, Mammogram, Prostate Exam, Wellness Exams, Well Baby Care, Immunizations, Colonoscopy

Plan Pays 100% You Pay 50% After Meeting Plan Year Deductible Plan Pays 100% You Pay 50% After Meeting

Plan Year Deductible Plan Pays 100% You Pay 50% After Meeting Plan Year Deductible


Office Visits (for Illness or Injury) You Pay $30 You Pay 50% After Meeting

Plan Year Deductible You Pay $20 You Pay 50% After Meeting Plan Year Deductible You Pay 20% After Meeting


Plan Year DeductibleSpecialist Office Visits You Pay $60 You Pay 50% After Meeting

Plan Year Deductible You Pay $40 You Pay 50% After Meeting Plan Year Deductible


Pre- and Post-Natal Care








$100 Prenatal Bonus Available Through Meijer1, 2

Prenatal visits 100%Postnatal visits, You Pay 20%

After Meeting Plan Year Deductible,$100 Prenatal Bonus Available

Through Meijer1,2



Physician Delivery Charges You Pay 30% After Meeting Plan Year Deductible






Allergy Testing and Injections You Pay $60 per Visit You Pay 50% After Meeting Plan Year Deductible You Pay $40 per Visit You Pay 50% After Meeting




ChiropracticYou Pay 30% After Meeting

Plan Year Deductible, up to 24 visits per Plan Year











Online visits You Pay $10 Not covered You Pay $10 Not covered You pay 20% after meeting your deductible Not covered

Autism Spectrum Disorders, Diagnoses and Treatment — Up to and including age 18

Applied Behavorial Analysis limited to 25 hours per week














Nutritional counseling You Pay 30% After Meeting Plan Year Deductible

















This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. For a complete description of benefits, please see the applicable plan documents your group uses. If there is a discrepancy between this summary and any applicable plan document, the plan document will control.

Medical Options Summary Plan information continued on next page

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Plan information continued

Plan Name Core Health Plan (CHP)

Core Health Plan Plus (CHP+)

Advantages Health Plan (AHP)


Hospital Inpatient Services

Room and Board(Ward, Semi-Private, ICU); Miscellaneous Inpatient Services (Medical Supplies, Lab, X-Ray)







In-Hospital Care(Physician Visits, Surgeon, Anesthesiologist)







Outpatient Services

Diagnostic Services Including Lab Tests,X-Rays, EKGs, MRIs, CAT Scans, etc.

You Pay $30; (You Pay 30% for MRIs, CAT Scans

and PET Scans After Meeting Plan Year Deductible)







Physical, Speech or Occupational Therapy







Outpatient Surgery — Physician’s Office, Hospital

You Pay $30 PCP Office/ $60 Specialist Office

In Hospital: You Pay 30% After Plan Year Deductible

You Pay 50% After Meeting Plan Year Deductible(Office and Hospital)






Emergency Care

Hospital Emergency Room (Qualified Emergency)

You Pay $200Copay waived if admitted






Urgent Care Centers You Pay $60 You Pay $100 You Pay $60 You Pay $100You Pay 20% After Meeting



Ambulance Services (Medically Necessary)







Mental Health and Substance Abuse Treatment

Outpatient Mental Health and Substance Abuse Treatment

You Pay $30You Pay 50% After Meeting

Plan Year DeductibleYou Pay $20




Inpatient Mental Health and Substance Abuse Treatment — Hospital orTreatment Center







Special Features

Durable Medical Equipment (DME) (Limitations Apply)







Temporomandibular Joint Dysfunction (TMJ)


Up to $1,000 per Plan Year











Other Plan Requirements

Coordination of BenefitsNon-Duplication: The Plan will only pay up to the amount it would have paid as Primary, minus whatever the

primary plan paid for the same covered expense. Non-Duplication: The Plan will only pay up to the amount it would have paid as Primary,

minus whatever the primary plan paid for the same covered expense.

Michigan Residents OnlyBy Michigan Law, you are required to have an automobile insurance policy which covers injuries arising out of an accident involving a motor vehicle.

If you elect coverage under a Blue Cross Blue Shield PPO (Traditional / non-HMO), Paramount Steps2Health, or Premier Health Network Medical plan, it does not contain such coverage. Please review the complete Michigan Residents Only section online at the mBenefitsConnect site.

By Michigan Law, you are required to have an automobile insurance policy which covers injuries arising out of an accident involving a motor vehicle. If you elect coverage under a

Blue Cross Blue Shield PPO (Traditional / non-HMO), Paramount Steps2Health or Premier Health Network Medical plan, it does not contain such coverage. Please review

the complete Michigan Residents Only section online at the mBenefitsConnect site.


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Plan Name Core Health Plan (CHP)

Core Health Plan Plus (CHP+)




Room and Board(Ward, Semi-Private, ICU); Miscellaneous Inpatient Services (Medical Supplies, Lab, X-Ray)














Outpatient Services

Diagnostic Services Including Lab Tests,X-Rays, EKGs, MRIs, CAT Scans, etc.









Physical, Speech or Occupational Therapy







Outpatient Surgery — Physician’s Office, Hospital









Emergency Care

Hospital Emergency Room (Qualified Emergency)







Urgent Care Centers You Pay $60 You Pay $100 You Pay $60 You Pay $100You Pay 20% After Meeting



Ambulance Services (Medically Necessary)









You Pay $30You Pay 50% After Meeting

Plan Year DeductibleYou Pay $20




Inpatient Mental Health and Substance Abuse Treatment — Hospital orTreatment Center







Special Features








Temporomandibular Joint Dysfunction (TMJ)














Coordination of BenefitsNon-Duplication: The Plan will only pay up to the amount it would have paid as Primary, minus whatever the

primary plan paid for the same covered expense. Non-Duplication: The Plan will only pay up to the amount it would have paid as Primary,

minus whatever the primary plan paid for the same covered expense.

Michigan Residents OnlyBy Michigan Law, you are required to have an automobile insurance policy which covers injuries arising out of an accident involving a motor vehicle.

If you elect coverage under a Blue Cross Blue Shield PPO (Traditional / non-HMO), Paramount Steps2Health, or Premier Health Network Medical plan, it does not contain such coverage. Please review the complete Michigan Residents Only section online at the mBenefitsConnect site.

By Michigan Law, you are required to have an automobile insurance policy which covers injuries arising out of an accident involving a motor vehicle. If you elect coverage under a

Blue Cross Blue Shield PPO (Traditional / non-HMO), Paramount Steps2Health or Premier Health Network Medical plan, it does not contain such coverage. Please review


Plan information continued on next pageMedical Options Summary

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Plan Name Paramount Steps2Health Premier Health Network (PHN)Service Area Ohio, Kentucky, SE Michigan, SE Indiana Michigan

Plan Payment Information







$250 individual$500 family

$250 individual$500 family


You pay 20% or 50% for select services. You pay 20% or 50% for select services

Maximum Medical Out-of-Pocket: Onceyou reach this amount during the Plan Year, the Plan Pays 100% (In- and Out-of-Network expenses combined).

$5,000 per person / $10,000 per family per calendar year applied to all cost sharing amounts

$5,000 per person / $10,000 per family per calendar yearapplied to all cost sharing amounts

Plan Year/Lifetime Maximum: Per Person Unlimited Unlimited


Pap Smear, Mammogram, Prostate Exam, Prostate Exam, wellness Exams, Well Baby Care, Immunizations, Colonoscopy

Plan Pays 100% Plan Pays 100%


Office Visits (for Illness or Injury) You Pay $15 per Visit You pay $15 per Visit

Specialist Consultations You Pay $35 per Visit You pay $35 per Visit, when referred by your PCP


Pre- and Post-Natal CarePlan Pays 100%,

$100 Prenatal Bonus Available Through MeijerPlan Pays 100%,

$100 Prenatal Bonus Available Through Meijer

Physician Delivery ChargesYou Pay 20%

Deductible appliesYou Pay 20%

Deductible applies.

Allergy Testing and InjectionsYou Pay $0 for allergy injections/serum. Office visit copay may apply for testing.

See “Specialist Consultations.”

You Pay $0 for allergy injections/serum. Office visit copay may apply for testing.

See “Specialist Consultations.”

ChiropracticYou Pay $35 per Visit

for Chiropractic Spinal Manipulation. Limited to 12 Visits per Plan Year.

You Pay $35 per Visit, when Referred by PCP for Chiropractic Spinal Manipulation.

Limited to 12 Visits per Plan Year.

Online visit You Pay $10 You Pay $10

Autism Spectrum Disorders, Diagnoses and Treatment – Up to and including age 18

Applied Behavioral Analysis (ABA) limited to 25 hours per week

You Pay $35 You Pay $35


You Pay $35 You Pay $35

Nutritional counseling You Pay $35 You Pay $35


See your Outpatient Behavioral Health and Medical Office Visit Benefit.

See your Outpatient Behavioral Health and Medical Office Visit Benefit.


Room and Board (Ward, Semi-Private, ICU);Miscellaneous Inpatient Services (Medical Supplies, Lab, X-Ray)

You Pay $500 per Admission up to a copay maximum of $1,000 per member, $1,500 per family per Plan Year. Unlimited Days.

You Pay $500 per Admission up to a copay maximum of $1,000 per member, $1,500 per family per Plan Year. Unlimited Days.


You Pay 20%Deductible applies

You Pay 20%Deductible applies.


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Plan Name Paramount Steps2Health Premier Health Network (PHN)Outpatient Services

Diagnostic Services Including Lab Tests, X-Rays, EKGs, MRIs, CAT Scans, etc.

Lab tests and X-rays – Plan Pays 100%. CT, MRI, PET, other high tech imaging and

radiation therapy – You Pay 20%. Deductible applies.

Lab tests and X-rays – Plan Pays 100%. CT, MRI, PET, other high tech imaging and

radiation therapy – You Pay 20%. Deductible applies.

Physical, Speech or Occupational Therapy You Pay $35; Limited to 60 visits combined per yearYou Pay $35 per visit;

Limited to 60 Consecutive Days per Episode per Plan Year for a Combination of Therapies

Outpatient Surgery — Physician’s Office, HospitalYou Pay 20% after Plan Year Deductible.

See member benefit document for specifics.You Pay 20% after Plan Year Deductible.

See member benefit document for specifics.

Emergency Care

Hospital Emergency Room (Qualified Emergency)You Pay $200.

Copay waived if admittedYou Pay $200.

Copay waived if admitted

Urgent Care Centers You Pay $35 You Pay $35

Ambulance Services (Medically Necessary)You Pay 20%


Deductible applies.



You Pay $15 per Visit You Pay $15 per Visit

Inpatient Mental Health and Substance Abuse Treatment — Hospital or Treatment Center

You Pay $500 copay per inpatient admission, up to $1,000 per person, $1,500 per contract per calendar year, combined with inpatient medical admission. You Pay 20%

copay for professional charges after deductible.

You Pay $500 copay per inpatient admission, up to $1,000 per person, $1,500 per contract per calendar year, combined with inpatient medical admission. You Pay 20%

copay for professional charges after deductible

Special Features


You Pay 20%Deductible applies

You Pay 20%Deductible applies.

Temporomandibular Joint Dysfunction (TMJ)You Pay 20%


Deductible applies.


Coordination of Benefits Does apply Does Apply

Michigan Residents Only

By Michigan Law, you are required to have an automobile insurance policy which covers injuries arising out of an accident involving a motor vehicle. If you elect coverage under a Blue Cross Blue Shield PPO (Traditional / non-HMO), Paramount Steps2Health, or Premier Health Network Medical plan, it does not contain such coverage. Please review


* Requires pre-authorization from Blue Care Network Behavioral Health Management


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Dental and Vision Summary

Team members are eligible for either the Meijer Dental / Vision Plan or the Basic Dental / Vision Plan; they are not eligible for both plans.

Delta Dental will administer the dental coverage for the Meijer Dental PlanFor claim status, verification of benefit levels or to find a participating Delta Dental provider call 1-800-524-0149,

or online at www.deltadentalmi.com. Group 5695

Limitations – All time limitations are measured from last date of service in any Delta Dental record, or at the request of Meijer.

Preventive CareExams and Cleanings (including Periodontal Cleanings) Plan Pays 100%, up to Two Visits per person/per Plan Year.

Radiographs (X-rays)Plan Pays 100%Adult Bitewing X-Rays – Payable once in any 2-year period (over past history) Children up to age 15 Bitewing X-Rays – Payable once in a Plan Year

Sealants (Ages 5-15 Only) Plan Pays 100%, Molars and Bicuspids Only

Restorative ServicesBridges, Crowns, Dentures, Inlays, Veneers, Implants You Pay 50% After Meeting Plan Year Deductible

Minor fillings You Pay 50% After Meeting Plan Year Deductible

Replacement Bridges, Crowns, Dentures, Inlays, Veneers, Implants You Pay 50% Every 7 Years (over past history)

Other ServicesPeriodontal (gum) treatment You Pay 50% After Meeting Plan Year Deductible

Root canal treatment You Pay 50% After Meeting Plan Year Deductible

DeductibleApplies to Restorative Care and Other Services You Pay $50 per Person; $150 per Family

Plan Year MaximumThe most the Plan will pay during the Plan Year $1,500 per person / per Plan Year

OrthodonticsDependent Children Only (through age 19) 50% Up to $1,000 Lifetime Maximum

EyeMed will administer the vision coverage for the Meijer Vision PlanFor verification of benefit levels, claim status or ID cards call 1-866 -723-0514 or go online to register as a member at www.eyemed.com.

To locate a provider prior to enrollment call 1-866-299-1358 or go online at www.eyemed.com and enter your zip code; Choose the “Select” Network.

In-Network Out-of-NetworkExam Plan Pays 100%

Frames Plan Pays 100%; $125 Allowance, 20% off balance over $125

50%

Exam Options/Contact Lens Fit and Follow-up Standard up to $40; Premium 10% off Retail Does Not Apply

Lenses (standard plastic) You Pay $20 Copay – Single Vision You Pay $20 Copay – BifocalYou Pay $20 Copay – Trifocal

You Pay $65 Copay – Standard Progressive

50%

Lens Options (UV Coating, Tint, Anti-Reflective Coating, etc.)

You Pay $15 – $45 CopayOther Add-ons and Services – 20% off Retail Price

50%

Contact Lens Conventional –Disposable –

$125 Allowance; 15% off balance over $125$125 Allowance; no discount off balance

50%

Examination Once Every Plan Year

Frame Once Every Plan Year

Lenses or Contact Lenses (but not both) Once Every Plan Year

Plan Year MaximumDoes Not Apply

$150 Per Person per Plan Year, Combined for Exam, Frames, Lenses or Contact Lenses

Coordination of benefits – When this plan is secondary, Non Duplication: The Dental and Vision Plans will only pay up to the amount they would have paid as primary, minus whatever the primary plan paid for the same covered expense.

Meijer Dental/Vision Plan

Accounts to Help Meet Your Deductible and Pay Out-of-Pocket Costs

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Team members are eligible for either the Meijer Dental / Vision Plan or the Basic Dental / Vision Plan; they are not eligible for both plans.

Delta Dental will administer dental coverage for the Basic Dental Plan. The dental plan is Delta Dental PPO (standard).

Preventive CareExams and Cleanings 85%, up to Two Visits per person/per Plan Year.

Sealants (Ages 5-15 Only) 85%, once per lifetime

Radiographs 60%, Bitewing x-rays limited to twice per plan year and full-mouth x-rays limited to once per three years.

Basic ServicesFillings, including anterior and posterior composite resin, Periodontal Treatments, Root Canals, Oral Surgery, etc.

50%

Major Restorative ServicesBridges, Crowns, Dentures, Implants, Inlays, Veneers Not covered

OrthodonticsNot Covered Not Covered

DeductibleNone None

Plan Year MaximumThe most the Plan will pay during the Plan Year $750, per person / per Plan Year

EyeMed will administer the vision coverage for the Basic Vision PlanIn-Network Out-of-Network

Exam You Pay $10 Copay Plan Pays up to $40

Frames Plan Pays 100%; $100 allowance; 20% off balance over $100

Plan Pays up to $40

Lenses (per lens*) Limited to one set of lenses per plan yearYou Pay $25 Copay – Single Vision

You Pay $25 Copay – BifocalYou Pay $25 Copay – Trifocal

Plan Pays up to $18.50Plan Pays up to $29.00Plan Pays up to $32.50

Lens Options (UV Coating, Tint, Anti-scratch Coating, etc.). Contact plan for other lens option costs.

You Pay $15 Copay No Coverage

Contact Lens – limited to once per Plan Year in place of regular lenses.

ConventionalDisposable

Medically Necessary

You Pay $0; $100 allowance, 15% discount over $100You Pay $0; $100 allowance, plus balance over $100

You Pay $0

Plan Pays $100Plan Pays $100Plan Pays $100

Examination Once Every Plan Year

Frame Once Every Plan Year

Lenses or Contact Lenses (but not both) Once Every Plan Year

Plan Year Maximum Does not apply Does not apply

Dental and Vision SummaryBasic Dental/Vision Plan

Note: Part-time team members may cover themselves only (no dependents) in the Basic Dental/Vision Plan.

Accounts to Help Meet Your Deductible and Pay Out-of-Pocket Costs

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Express ScriptsPrescription drug coverage is included with all Medical Plans, at no additional weekly contribution. If you are already enrolled, continue to use your current ID card. Express Scripts will send ID cards if you are enrolling for the first time.

Advantages Health Plan

Paramount Steps2Health and Premier Health

Network

Core Health Plan

Core Health Plan Plus

Triple Tier Rx Plan* Triple Tier Rx Plan* Limited Triple Tier Rx Plan*

Limited Triple Tier Rx Plan*

Subject to Medical Deductible, THEN:

Separate from MedicalSeparate from

MedicalSeparate from

Medical

Copay Min/Max Copay Copay Min/Max

Copay Copay Copay

Generic 30-Day $4 NA $4 NA $4 $4

Generic 90-Day Maintenance $4 NA $7 NA $7 $7

Brand Formulary 25% $30/$60 25% $30/$6050% coinsurance after $150 brand deductible $30 minimum copay

25% coinsurance $30 minimum/$60 maximum copay

Brand Non-Formulary 50% $50/$100 50% $50/$100 Not covered Not covered

Max Out-of-Pocket Combined with Medical Plan $1,600/$3,200 $1,600/$3,200 $1,600/$3,200

Max Plan Year Benefit Unlimited Unlimited Unlimited Unlimited

Affordable Care Act required preventive and contraceptive medications and devices covered in full if on approved list. Contact Express Scripts or visit mBenefitsConnect for a complete list.


If you enroll in the AHP it’s important to understand that the prescription drug coverage is first subject to the Plan Year deductible amount, before the Plan will pay. This is a Federal Requirement for a high deductible plan. However, preventive drugs are not subject to this rule and can be covered according to the coinsurance amounts listed in the chart above.

All Prescription Drug Plans These Plans will usually cover up to a 30-day supply per prescription or refill.

• A 90-day supply can be obtained for drugs on the Express Scripts Maintenance Drug List.

• Certain drugs will be subject to other quantity limits (see Drug Quantity Management information in the mBenefitsConnect site on the Meijer portal).

• If you receive a brand-name drug when a generic is available, you will pay the appropriate coinsurance amount plus the cost difference between the two medications. The cost difference will not apply to the out-of-pocket maximum (for the AHP).

• The coinsurance amount for certain medications used for weight loss, infertility or sexual dysfunction will be 50% with no maximum copay per prescription or refill (quantity limits may apply).

• Some medications may require prior authorization or that you try another medication first to obtain coverage (see Prior Authorization and Step Therapy information in the mBenefitsConnect site).

*Triple Tier Rx Plan means there are three different copay levels: one for generic drugs, one for brand name drugs on Formulary, and one for brand name drugs not on Formulary

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EFFECTIVE JANUARY 1, 2017, FOR MEMBERS AND DEPENDENTS ENROLLED IN A MEIJER MEDICAL PLAN.

With 24/7 online health care, you can see a U.S. board-certified doctor anytime, anywhere.

No appointment needed.

Simply use your mobile device or computer to meet online with an Amwell™ doctor when:

• Your doctor isn’t available.

• You can’t leave home or your workplace.

• You’re on vacation or traveling for work.

• You need care for your children or family members.

• You’re looking for affordable after-hours care.

• It’s convenient for you.

POWERED BY AMERICAN WELL®

FAST, EASY, CONVENIENT.Be ready to see a doctor before you need one.

Sign up now:

Mobile – Download the Amwell™ app

If you are enrolled in the Advantages Health Plan, Core Health Plan, Core Health Plan Plus, or Premier Health Network

Phone – Call 1-844-733-3627.

Web – Go to bcbsm.amwell.com

If you are enrolled in Paramount Steps2Health

Phone – Call 1-877-491-5511.

American Well® is an independent company that provides online health care for Blue Cross Blue Shield of Michigan and Blue Care Network members. Blue Cross and BCN don’t control the content of the Amwell website.

EXPERIENCE WEBSIDE MANNER.

24/7 online health care

14

Notes

15

Additional Contact Information Plan Year is January 1 through December 31

Medical PlansCore Health Plan (CHP)Core Health Plan Plus (CHP+)Advantages Health Plan (AHP)1-800-452-6933www.bcbsm.comBlueCard® provider information: 1-800-810-BLUE (2583) or www.bcbs.com

Advantages Health Companion Plan1-866-387-3402FAX 1-866-408-6643

Paramount Steps2Health1-877-491-5511www.paramounthealthcare.com/meijer

Premier Health Network (PHN)1-800-662-6667www.bcbsm.com

Pharmacy AdministratorExpress Scripts1-866-804-7647www.express-scripts.com

Vision AdministratorEyeMed1-866-723-0514 www.eyemed.com

Dental AdministratorDelta Dental1-800-524-0149www.deltadentalmi.com

R059742

A

QYou Have Questions. We Have Answers.

Meijer Rewards Service Center

1-866-681-6116 www.resources.hewitt.com/meijer/

benefit plan comparison guide 2017 plan year options · benefit plan comparison guide 2017 plan...

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