ALVMA Benefits

Medical Benefits

Overview

You have four medical plan options: the Platinum Plan, Gold Plan, Silver Plan and the Bronze Plan. All plans are administered by BlueCross BlueShield (BCBS) and provide the maximum benefits when a BCBS provider is used for services.

The ALVMA Platinum Plan and Silver Plan includes both primary and secondary insurance. The secondary plan does not cover office visits or prescription drug copays or home health services.

NOTE: The out-of-pocket maximum excludes office visits and prescription drug co-pays.

For rate inquiries, please contact Patrick Pittman at 205-215-8152 or via email at patrick@southviewbenefits.com

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	Platinum (Includes Secondary)	Gold	Silver (Includes Secondary)	Bronze
Medical Benefits	In-Network Individual / Family	In-Network Individual / Family	In-Network Individual / Family	In-Network Individual / Family
Deductible Individual / Family Coinsurance	$500 / $1,000 80%	$1,000 / $2,000 100%	$2,000 / $4,000 80%	$4,000 / $8,000 80%
Out-of-Pocket Maximum Individual / Family	$3,300 / $6,600	$6,000 / $12,000	$4,800 / $9,600	$6,800 / $13,600
Inpatient Services Inpatient Facility	$500 CYD, then GAP pays up to $3,500	$250 Copay (Days 1-5)	$2,000 CYD, then GAP pays up to $2,000	20% Coinsurance Subject to CYD
Emergency Room	$500 CYD, then GAP pays up to $3,500	$250 Copay	$2,000 CYD, then GAP pays up to $2,000	20% Coinsurance Subject to CYD
Physician Office Visits Preventative Care Primary Care Specialist Office	100% Covered $45 Copay $65 Copay	100% Covered $40 Copay $60 Copay	100% Covered $45 Copay $65 Copay	100% Covered $45 Copay $65 Copay
Outpatient Services Outpatient Facility	$500 CYD, then GAP pays up to $3,500	$250 Copay	$2,000 CYD, then GAP pays up to $2,000	20% Coinsurance Subject to CYD
Diagnostics (X-ray / Lab)	$500 CYD, then GAP pays up to $3,500	$250 Copay	$2,000 CYD, then GAP pays up to $2,000	20% Coinsurance Subject to CYD
Mental Health / Substance Abuse	$500 CYD, then GAP pays up to $3,500	$250 Copay	$2,000 CYD, then GAP pays up to $2,000	20% Coinsurance Subject to CYD
Prescription Drugs Tier 1 Tier 2 Tier 3 Tier 4	$15 Copay $60 Copay $100 Copay $425 Copay	$15 Copay $50 Copay $100 Copay $395 Copay	$15 Copay $60 Copay $100 Copay $425 Copay	$15 Copay $60 Copay $100 Copay $425 Copay

Dental Benefits

Overview

ALVMA offers dental coverage to you through Canopy Dental. Your dental plan provides coverage to help with the cost of many dental services including routine cleanings, x-rays, restorative and prosthetic services. The plan includes an extensive network of dental providers. Maximize your benefits by selecting an in-network dentist to save more on all covered services and avoid balance billing.

For rate inquiries, please contact Patrick Pittman at 205-215-8152 or via email at patrick@southviewbenefits.com

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	Enhanced	Basic
Benefits	In-Network	In-Network
Annual Maximum per Individual	$1,500	$1,000
Type I - Diagnostics & Preventatives Exams, Cleanings, Fluoride, Treatment, Space Maintainers, X-Rays, Sealants	100%	100%
Type II - Basic Services Fillings, Simple Extractions, General Anesthesia, Oral Surgery, Endodontics	80%	80%
Type III - Major Services Crowns, Inlays, On-lays, Bridges, Dentures, Periodontics, TMJ	50%	50%
Type IV - Orthodontic Services	50%	N/A
Calendar Year Deductible Applies to: Individual Family	$25 Single $75 Family	$50 Single $150 Family
Lifetime Orthodontia Maximum	$1,000	Not Covered

Vision Benefits

Overview

ALVMA offers vision coverage to you through Canopy (VSP). Receive the maximum benefits and pay less out-of-pocket by visiting an in-network provider. The network includes provider access points nationwide. A comprehensive vision exam is available every 12 months and you may purchase eyewear in the form of an eyeglass frame and lenses, or contact lenses.

For rate inquiries, please contact Patrick Pittman at 205-215-8152 or via email at patrick@southviewbenefits.com

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Class Description	In-Network
Eye Examination Comprehensive exam of visual functions and prescriptions of corrective eye wear	$10 Copay
Contact Lens Evaluation and Fitting Elective Medically Necessary	Up to $60 Copay Covered in full
Material / Eye Wear Single Vision Eyeglass Lenses Lined Bifocal Eyeglass Lenses Lined Trifocal Eyeglass Lenses Lenticular Eyeglass Lenses	$15 Copay $15 Copay $15 Copay $15 Copay
Frame Allowance Standard Frame	$130 Allowance Covered + 20% Off Balance
Standard Progressive Lenses	Covered in full
Lens Enhancements	All lens enhancements are covered with a copay, saving an average of 30%