2017 Faculty Benefits
Blue Advantage Pont of Service
HMO (In-Network)

NEW 2017
Out of Pocket Maximum
All co-payments and co-
insurance will apply to the
OPM. No co-payments or co-
insurance required after
OPM is reached
Inpatient Co-payment
$600
Specialist Office Visit
$40
Out Patient Surgery
$125
• Hospital Based
Advanced Imaging
$120
• Hospital Based
Advanced Imaging
$60
• Free-Standing Facility
Emergency Room
$150
Chiropractic
20 Visits
Acupuncture & Massage Thp
20 Visits Combined
Pharmacy
Essential Rx Formulary
Pharmacy Co-payments
$10/$40/$60
• Retail 30 Day Supply
Pharmacy Co-payments
$10/$80/$120
• Mail Order (90 day)

Blue Priority PPO (In-Network)

NEW 2017
Out of Pocket Maximum
All co-payments and co-
insurance will apply to the
OPM. No co-payments or co-
insurance required after
OPM is reached
Out of Pocket Maximum
$2,000/$4,000 including
deductible
Chiropractic
20 Visits
Acupuncture & Massage Thp
20 Visits Combined
Pharmacy Co-payments
$10/$40/$60
• Retail 30 Day Supply
Pharmacy Co-payments
$10/$80/$120
• Mail Order (90 day)



Blue Priority PPO (Out-of-Network)

New 2017
Deductible
$1,000/$2,000
Out of Pocket Maximum
$4,000/$8,000

Blue Priory HMO

NEW 2017
Chiropractic
20 Visits
Acupuncture & Massage Thp
20 Visits Combines
Pharmacy
Essential Rx Formulary

Lumenos High Deductible Health Plan

NEW 2017
Chiropractic
20 Visits
Acupuncture & Massage Thp
20 Visits Combined
Pharmacy
Essential Rx Formulary

Custom Plus (Closed to New Enrollment)

NEW 2017
Deductible
$800/$1,600
Out of Pocket Maximum
$3,000/$6,000

Dental
Dental PPO Plus and Dental PPO

NEW 2017
Maximum Benefits
$2,000
Cleanings (age 19 and over)
3 adult cleanings per year
Orthodontia
Adult Benefit added
50% up to $1,500

Blue View Vision Plan – No Changes
Medical Rates
Blue Advantage HMO/POS, Blue Priority PPO, Custom Plus

Monthly Cost
Your Cost
Employee
$637.52
$0.00
Employee + Spouse
$1,528.84
$0.00
Employee + Child(ren)
$1,401.84
$0.00
Family
$1,759.13
$0.00


Blue Priority HMO

Monthly Cost
Your Cost
Employee
$586.52
$0.00
Employee + Spouse
$1,406.84
$0.00
Employee + Child(ren)
$1,289.84
$0.00
Family
$1,619.13
$0.00

Lumenos High Deductible Health Plan

Monthly Cost
Your Cost
Employee
$573.52
$0.00
Employee + Spouse
$1,376.84
$0.00
Employee + Child(ren)
$1,261.84
$0.00
Family
$1,584.13
$0.00

Dental Rates

2016 Monthly Cost
NEW 2017
Your Cost
Employee
$39.00
$41.00
$0.00
Employee + Spouse
$90.00
$94.00
$0.00
Employee + Child(ren)
$86.00
$90.00
$0.00
Family
$102.00
$107.00
$0.00

Blue View Vision Voluntary – Materials Only (Individuals enrolled in a Mines Medical Plan)

Monthly Cost
Your Cost
Employee
$6.36
$6.36
Employee + Spouse
$11.92
$11.92
Employee + Child(ren)
$11.92
$11.92
Family
$17.31
$17.31

Blue View Vision Voluntary – Exam and Materials (No Mines Medical Plan)

Monthly Cost
Your Cost
Employee
$8.80
$8.80
Employee + Spouse
$16.49
$16.49
Employee + Child(ren)
$16.49
$16.49
Family
$23.95
$23.95