Your Program

At-A-Glance

Benefit Year – 12 months from your effective date of coverage

Ingredient Costs – cover usual and customary costs. They do not include "dispensing" fees.

Prescription Drug Care

Reimbursement Percentage

70% of the ingredient cost for each Insured Person

Annual Maximum for Each Insured Person

Year One	Year Two	Year Three
$1,000	$2,000	$3,000	Maximum increases each year

AFBS Drug Formulary

The AFBS prescription drug formulary will be used to settle all drug claims.

Extended Health Care

Reimbursement Percentage

70% for each Insured Person

Annual Maximum for Each Insured Person*

Year One	Year Two	Year Three
$7,500*	$7,500*	$7,500*
*Maximum includes benefits paid for Vision/Paramedical Care

Vision/Paramedical Care

Reimbursement Percentage

50% for each Insured Person

Annual Maximum for Each Insured Person

Year One	Year Two	Year Three
$500	$500	$750	Maximum increases in year three

Annual Deductible

$100 each Insured Person

III

Dental Care

Reimbursement Percentage For Each Insured Person

Year One	Year Two	Year Three
50%	50%	50%

Annual Maximum for Each Insured Person

Basic Services
(cleaning, recall exams)

Year One	Year Two	Year Three
$300	$300	$500	Maximum increases in year three

Periodontal
(gum disease)
Endodontic
(root canal)
Major Restorative Services
(crowns, bridges, dentures)

Year One	Year Two	Year Three
$500	$500	$750	Maximum increases in year three

Annual Deductible

$50 each Insured Person

AFBS Dental Formulary

AFBS dental formulary will be used to settle all claims.