ACA SUMMARIES OF BENEFITS & COVERAGE (SBC) / BENEFITS AT A GLANCE (BAAG)

Blue Cross Community Blue PPO Plans
Active Employees of Legislative Branch Exempt (including Elected Officials & Judges), 3rd Circuit GAA, JAA	SBC	BAAG
Pre-Medicare Retirees of Legislative Branch Exempt (including Elected Officials & Judges), 3rd Circuit GAA, JAA	SBC	BAAG
Medicare-Eligible Retirees of POAM, Legislative Branch Exempt (including Elected Officials & Judges), 3rd Circuit GAA, JAA	Not Required	BAAG

Blue Cross Simply Blue High Deductible Health Plans (HDHP) PPO
Active Employee of Legislative Branch Exempt (INCLUDING Elected Officials & Judges), 3rd Circuit GAA, JAA	SBC	BAAG
All Other Benefit-Eligible Active Employees	SBC	BAAG
Pre-Medicare Retirees of Legislative Branch Exempt (INCLUDING Elected Officials & Judges), 3rd Circuit GAA, JAA	SBC	BAAG
Medicare-Eligible Retirees of Legislative Branch Exempt (INCLUDING Elected Officials & Judges), 3rd Circuit GAA, JAA	Not Required	BAAG
All Other Pre-Medicare-Eligible Retirees (EXCLUDES retirees eligible under Retiree Stipend Program)	SBC	BAAG
All Other Medicare-Eligible Retirees (EXCLUDES retirees eligible under Retiree Stipend Program)	Not Required	BAAG

Blue Care Network (BCN) Full Provider Network HMO Plans
Active Employees of Legislative Branch Exempt (INCLUDING Elected Officials & Judges), 3rd Circuit GAA, JAA	SBC	BAAG
All Other Benefit-Eligible Active Employees	SBC	BAAG
Pre-Medicare Retirees of Legislative Branch Exempt (INCLUDING Elected Officials & Judges), 3rd Circuit GAA, JAA	SBC	BAAG
Medicare-Eligible Retirees of Legislative Branch Exempt (INCLUDING Elected Officials & Judges), 3rd Circuit GAA, JAA	Not Required	BAAG
All Other Pre-Medicare Benefit-Eligible Retirees (EXCLUDES retirees eligible under Retiree Stipend Program)	SBC	BAAG
All Other Medicare-Eligible Retirees (EXCLUDES retirees eligible under Retiree Stipend Program)	Not Required	BAAG

Blue Care Network (BCN) PCP Focus HMO Plans+
All Active Employees EXCLUDING Legislative Branch Exempt (INCLUDING Elected Officials & Judges), 3rd Circuit GAA, JAA Employees	SBC	BAAG
Pre-Medicare Benefit-Eligible Retirees EXCLUDING Retirees of Legislative Branch Exempt (INCLUDING Elected Officials & Judges), 3rd Circuit GAA, JAA, and retirees eligible under Retiree Stipend Program)	SBC	BAAG
Medicare-Eligible Retirees EXCLUDING Retirees of Legislative Branch Exempt (INCLUDING Elected Officials & Judges), 3rd Circuit GAA, JAA, and retirees eligible under Retiree Stipend Program	Not Required	BAAG

Blue Care Network (BCN) PCP Focus Copay HMO Plans
Active Employees EXCLUDING Legislative Branch Exempt (INCLUDING Elected Officials & Judges), 3rd Circuit GAA, JAA	SBC	BAAG
All Other Benefit-Eligible Active Employees	SBC	BAAG
Pre-Medicare Benefit-Eligible Retirees EXCLUDING Retirees of Legislative Branch Exempt (INCLUDING Elected Officials & Judges), 3rd Circuit GAA, JAA and retirees eligible under Retiree Stipend Program)	SBC	BAAG
Medicare-Eligible Retirees EXCLUDING Retirees of Legislative Branch Exempt (INCLUDING Elected Officials & Judges), 3rd Circuit GAA, JAA	Not Required	BAAG

ACA Minimum Value Plan-Blue Cross Simply Blue HDHP
Plan for Employees Working 30 or More Hours Per Week on Average	SBC	BAAG

DENCAP Dental Plan
DENCAP Dental Retiree Advantage Plan (Retirees Only)	BAAG / Fee Schedule

Delta Dental Plans
Delta Dental PPO Standard Plan (Active Employees Only)	BAAG / Fee Schedule
Delta Dental EPO Plan (Active Employees Only)	BAAG / Fee Schedule
Delta Dental PPO Standard Plan (Executive)	BAAG / Fee Schedule
Delta Dental PPO Standard (Retirees)	BAAG / Fee Schedule

Golden Dental Plans
Golden Dental Radiant DHMO Plan (Active Employees Only)	BAAG / Fee Schedule
Golden Dental Smile Guard DHMO Plan (Active Employees Only)	BAAG / Fee Schedule
Golden Dental DHMO Voluntary Retiree Dental Plan	BAAG / Fee Schedule

Heritage Vision Plans
Heritage Vision Plan (Active Employees Only)	BAAG / Fee Schedule
Heritage Vision Enhanced Plan	BAAG / Fee Schedule
Heritage Vision Plan Supplemental Retiree Vision Plan This plan does NOT replace retiree Optical Reimbursement benefits.	BAAG / Fee Schedule

Wayne County Optical Plan
Wayne County Optical Reimbursement Program	Program Summary