top of page
Open Enrollment
February 1 - 15, 2021
Premium Choice Express is offering three (3) medical benefit options, vision and dental (optional) benefits for our 2021 plan year. Below are the options to select. All employees are REQUIRED to enroll OR deny medical coverage in the enrollment form below.
2021 Medical Benefit Overview - Effective March 1, 2021
HMO Essential $1500
Ded: $1,500 Ind/$3,000 Family
PCP: $20 co-pay / Specialist: $40 copay
In-Patient Hospital: 100% after Deductible
Emergency Room Copay: $250 copay
Out-of-Network: Emergency Only
Prescriptions:
Retail: $20/50/100
Mail Order: $40/100/300
​
Payroll Deductions: Weekly
$53.07 Single:
$106.14 EE/SP:
$98.18 EE/CH:
$151.24 Family:
HMO Essential $3000
​
Ded: $3,000 Ind/$6,000 Family
PCP: $25 co-pay / Specialist: $40 copay
In-Patient Hospital: 100% after Deductible
Emergency Room Copay: $250 copay
Out-of-Network: Emergency Only
Prescriptions:
Retail: $20/50/100
Mail Order: $40/100/300
​
Payroll Deductions: Weekly
$43.09 Single:
$86.18 EE/SP:
$79.72 EE/CH:
$122.81 Family:
PPO National Essential $1000
​
Ded: $1,000 Ind/$2,000 Family
PCP: $20 co-pay / Specialist: $40 copay
In-Patient Hospital: 100% after Deductible
Emergency Room Copay: $250 copay
Out-of-Network: 20% after Deductible
Prescriptions:
Retail: $20/50/100
Mail Order: $40/100/300
​
Payroll Deductions: Weekly
$62.88 Single:
$125.77 EE/SP:
$116.34 EE/CH:
$179.22 Family:
2021 Vision & Dental - Optional Add-on
Dental: Standard Plan
$1500 calendar year maximum
$50 member deductible ($150 family max)
Preventative Visits
Cleaning (2)
Fluoride
Bite wing x-rays
Basic Service
80% paid by carrier
Oral surgery
General anesthesia
Periodontics
​
Major Service
50% paid by carrier
Crowns
Bridges
Root canals
​
Payroll Deductions: Weekly
$4.51 Single:
$9.00 EE/SP:
$10.64 EE/CH:
$15.14 Family:
Vision: Standard Plan
VSP Network Providers
​
Well Visit Eye Exam
No member cost
Non-routine Eye Exam
$10 copay
​
Frame Allowance
$130 every 12 months
Lease Allowance
$130 every 12 months
​
Contact Lense Fitting
$60 copay
​
Lense & Frame Deductible
$25
​
Payroll Deductions: Weekly
$1.12 Single:
$2.16 EE/SP:
$1.92 EE/CH:
$2.97 Family:
2021 Benefit Overview Video
Summary of Benefit Details
(click button to get details about plan option)
bottom of page