Annual Benefits Enrollment - Pinnaclesportclips.pinnaclepeo.com/wp-content/uploads/2018/06/... · 2018-06-22 · The Annual Enrollment period will begin July 2st to July 24th, 2018

Annual Benefits Enrollment Supplemental Benefit Guide

2018‐2019

The Annual Enrollment period will begin July 2st to July 24th, 2018. During this time you will have the opportunity to review your benefit choices and enroll, cancel or make changes.

If you choose to make any changes to your plan(s), please complete a new enrollment application and return it to the Benefits Department. Any changes to a plan must be made during the enrollment period, will be effective as of August 1st, and will remain in effect until the next Annual Enrollment period next year.

The premium amount for all benefits will be deducted from your paycheck(s) each month, according to your specified pay period (usually split between two deductions per month for a bi‐weekly pay schedule).

Employees classified as full‐time (30+ hours per week) are eligible for benefits. Newly hired employees will be eligible for benefits after meeting a 60‐day waiting period.

Under Federal Government regulations, once a plan year begins (August 1st through July 31st), employees may not make any changes to their benefit elections except when a qualifying event occurs (see box below). Make sure to contact the Benefits Department within 31 days of that event, in order to make changes to your benefit.

The enrollment forms can be found at this website: http://www.pinnaclepeo.com/services/annual‐benefits‐enrollment‐

2018‐2019/.

If you have any questions, please contact your Benefits Department:

Office (210) 344‐2088 Fax (210) 344‐2777

Email: [email protected]

The Benefits Department

QUALIFYING EVENTS: Marriage, Divorce, or Death

Birth or Adoption Change in client employment (part‐time to full‐time or full‐time to part‐time)

EMPLOYEE BENEFITS

Supplemental Plans

Table of Contents: Page

1. Ternian Limited Medical 1

2. Gap Plan Reimbursement Benefit 6

3. Cigna Dental 8

4. MetLife Dental High Plan 9

5. MetLife Dental Low Plan 11

6. VSP Vision Benefit 13

7. UNUM Basic and Optional Life Summary 14

8. UNUM Optional Life Rates 15

9. UNUM Short Term Disability 16

10. Aflac – Call for details

11. Retirement Plan Options – Call for details (the plan is customized for each client)

TRN-AXIS-EC10152013 1

HealthSelect Benefit Highlights ꞏ $10 Doctor Visit Pre-Pay * ꞏ Inpatient Hospital Coverage ꞏ Outpatient Accident Coverage ꞏ Emergency Room Coverage ꞏ Accidental Death & Dismemberment Coverage ꞏ Prescription Drug Coverage

Also Available ꞏ Critical Med Plans

Value-Added Services*

ꞏ Teladoc - Telephonic Doctor Office Visits ꞏ SupportLinc - EAP ꞏ First Health PPO Network Discounts

The insurance described in this guide provides limited benefits. Limited benefits plans are insurance products with reduced benefits intended to supplement comprehensive health insurance plans. This insurance is not an alternative to comprehensive coverage. It does not provide major medical or comprehensive medical coverage and is not designed to replace major medical insurance. Further, this insurance is not minimum essential benefits as set forth under the Patient Protection and Affordable Care Act.

* This service is not insurance and is not provided by AXIS Insurance Company.

An Affordable Limited Medical Plan is Now Available for You!

Enroll Now! Time is limited.

PAPER Enrollment: Turn your form in to your HR Department

Search First Health network providers at: www.myternian.com or call 1-800-226-5116 (You DO NOT need to use these providers – they provide discounts should you choose to visit them. You can visit ANY licensed physician and present your insurance card – you may qualify for a discount. But regardless, you still have insurance coverage as outlined in this brochure.)

Who can enroll? All full-time employees working 30 or more hours per week.

When can I enroll? During the annual open enrollment or with 60 days of your hire date.

When will coverage begin? First of the month following 60 days of enrollment.

When will coverage end? The earlier of: 1. The date the Policy terminates; 2. The date the employee’s Active Service ends; or 3. The period ends for which premium has been paid.

NOTICE: The Limited Medical Plans are a combination of limited scope, fixed indemnity, and accident insurance plans which do not provide Major Medical or Comprehensive Medical coverage.

NOTICE: These plans DO NOT fulfill the Individual Mandate for Health Insurance Coverage required under the Affordable Care Act (ACA) starting 01/01/2014.

The Limited Medical Plans are a combination of limited scope, fixed indemnity, and accident insurance plans which do not provide Major Medical or Comprehensive Medical coverage.


Benefits at a Glance This information is a brief description of the important features of the insurance plan. It is not a contract of insurance. The terms and conditions of coverage are set forth in the policies issued in the state in which policy is delivered. Complete details may be found in the policies on file at your employer’s office. The policy is subject to the laws of the state in which it is issued. Coverage may not be available in all states or certain terms may be different if required by state law. Please keep this information as a reference.

Ternian HealthSelect Indemnity Plans MONTHLY RATES Plan 1 - Basic Plan 2 - Choice Plan 3 - Max

Employee Only $83.18 $177.25 $271.89 Employee +1 $182.76 $381.91 $581.36 Family $265.84 $556.43 $850.52

INPATIENT (1)

Hospital Confinement Day 1 benefit amount Days 2+ benefit amount per day

Maximum benefit Surgery benefit amount (incl. maternity) - per day

Anesthesia benefit amount - per day

$2,000 per day x 1 day $750 thereafter 5 days per year

$1,000 per day x 1 day $250 per day x 1 day

$2,500 per day x 1 day $1,500 thereafter 5 days per year

$2,000 per day x 2 days $500 per day x 2 days

$3,000 per day x 1 day $2,000 thereafter 10daysperyear

$2,500 per day x 2 days $625 per day x 2 days

OUTPATIENT (1) $10

$65 per day x 5 days $100 per day x 1 day

N/A

$5,000 per year 80% U&C

$0

$300 per day x 1 day

N/A N/A

$30 per day x 2 days


N/A

Discount Only (2)

$10


N/A

$7,500 per year 80% U&C

$0


$1,000 per day x 1 day $250 per day x 1 day

$30 per day x 2 days $75 per day x 2 days $125 per day x 1 day

N/A

$10 $30 $30 $90

$200/400

$10

$85perdayx5days $100 per day x 1 day

N/A

$10,000 per year 80% U&C

$0


$1,750 per day x 1 day $437.50 per day x 1 day

$30 per day x 2 days $175 per day x 2 days $200 per day x 1 day $750 per day x 1 day

$10 $30 $20 $60

$300/600

Physician Office Visit Pre-pay (2)

Benefit amount per day Wellness benefit amount per day Well child care (up to age 4) benefit amount

Accident maximum benefit amount per year up to Benefit % payable Deductible per accident

Emergency Room (sickness) benefit amount per day

Surgery benefit amount per day Anesthesia benefit amount - per day

Diagnostic, X-ray, Lab - benefit amount per test Class I: Blood work, CMP, Lipid Panel, ECG, Pap/PSA, urinalysis and all other laboratory tests Class II: Radiology , Ultrasound, Mammogram, Sonogram, Angiogram Class III: Imaging CT, PET Class IV: Other Diagnostic tests- Endoscopy, Bronchoscopy, Colonoscopy without Biopsy, MRI

PRESCRIPTION (3)

Retail - Generic RX co-pay Retail - Preferred Brand RX co-pay Mail Order - Generic RX co-pay Mail Order - Preferred Brand RX co-pay Monthly benefit maximum - INDIVIDUAL/FAMILY

AD&D Accidental Death & Dismemberment benefit amount* *Benefit amounts listed are for: Employee/Spouse/Child(ren)

$10,000/5,000/1,000

$15,000/5,000/1,000

$25,000/5,000/1,000

OTHER SERVICES (4)

Teladoc: Telephonic Doctor Office Visits SupportLinc-EAP First Health PPO Discounts

Yes Yes Yes

Yes Yes Yes

Yes Yes Yes

(1) The Fixed Indemnity, Outpatient Accidental-Only, Critical Illness and AD&D Benefit Plans (are underwritten by AXIS Insurance Company. HealthSelect is a limited medical plan. It is not considered creditable coverage under HIPAA, is not major medical insurance, and is NOT designed to replace, provide, or modify major medical insurance. This information is a brief description of the important features of the insurance plan. It is not a contract of insurance. The terms and conditions of coverage are set forth in the policy issued in the state in which the policy is delivered. The policy is subject to the laws of the state in which it is issued. Coverage may not be available in all states or certain terms may be different if required by state law. This insurance does not apply to the extent that trade or economic sanctions or regulations prohibit us from providing insurance, including, but not limited to, the payment of claims. (2) The office visit pre-pay is a service through the First Health PPO Network. (3)The prescription benefits are underwritten by an A.M. Best Rated Carrier. (4)These services are not insurance and are not provided by AXIS Insurance Company.

HealthSelect A fixed indemnity medical plan which provides limited coverage for accidents, illness, and specified disease to help cover basic, minor-medical expenses. The HealthSelect benefits outlined below do not have a pre-existing condition limitation.


Ternian CriticalMed Indemnity Plans MONTHLY RATES

Employee Only Employee +1 Family

$45,000 Plan $47.81 $104.73 $152.34

$75,000 Plan $73.81 $162.38 $236.18

INPATIENT Hospital Confinement benefit amount per day Additional ICU benefit amount per day

$1,000 per day x 10 days $1,000 per day x 5 days

$1,500 per day x 10 days $1,000 per day x 10 days

OUTPATIENT Accident Only Coverage Benefit Maximum, per year up to

Benefit % Payable Deductible per year

$15,000 80% U&C $1,500

$25,000 80% U&C $2,500

Accidental Death & Dismemberment

$15,000 Emp $10,000 Sp $1,000 Ch

$25,000 Emp $10,000 Sp $1,000 Ch

CRITICAL ILLNESS* Benefit Maximum

Payable for 10 conditions: Cancer, Heart Attack, Renal Failure, Stroke, Major Organ Transplant, Multiple Sclerosis, Coronary Artery Bypass Surgery, Alzheimer’s, ALS, Terminal Illness

$15,000

$25,000

OTHER SERVICES (4)

SupportLinc-EAP First Health PPO Discounts

Yes Yes

Yes Yes

* Pre-existing condition exclusions apply to this component. Please see Exclusion & Limitations as outlined on the following pages. (4) These services are not insurance and are not provided by AXIS Insurance Company

CriticalMed Plan A buy-up fixed indemnity and accident medical option if you enroll in HealthSelect and are looking for enhanced coverage for catastrophic events, OR, a stand-alone option (instead of HealthSelect) if you are willing to self-pay your day-to-day medical expenses because you are more concerned about major events.


What’s Not Covered Under the Group Hospital Indemnity We will not pay for any loss, injury or sickness that is caused by, or results from: • Intentionally self-inflicted injury, suicide or attempted suicide. • War or any act of war, whether declared or not. • Service in the military, naval or air service of any country or international organization. • Piloting or serving as a crew member or riding in any aircraft except as a fare-paying passenger on a regularly scheduled or charter airline.

• Commission of, or attempt to commit, a felony. • Commission of or active participation in a riot, or insurrection. • Bungee cord jumping, parachuting,skydiving, parasailing, hang-gliding. • Flight in, boarding or alighting from any aircraft except as a fare-paying passenger on a regularly scheduled commercial airline.

• An accident if the Insured Person is the operator of a motor vehicle and does not possess a valid motor vehicle operator’s license, except while participating in Driver’s Education Program.

• Medical or surgical treatment, diagnostic procedure, administration anesthesia, or medical mishap or negligence, including malpractice. (This exclusion applies to the Accidental Death and Dismemberment benefit only.)

• Travel or activity outside the United States, Canada or Mexico, except for a Medical Emergency.

• Travel in any aircraft owned, leased or controlled by the Policyholder, or any of its subsidiaries or affiliates. An aircraft will be deemed to be “controlled” by the Policyholder if the aircraft may be used as the Policyholder wishes for more than 10 straight days, or more than 15 days in any year.

• Alcoholism, drug addiction or the use of any drug or narcotic except as prescribed by a Physician unless specifically provided herein.

• Repair or replacement of existing dentures, partial dentures, braces, fixed or removable bridges, or other artificial dental restoration.

• Repair, replacement, examinations for, prescriptions, or the fitting of eyeglasses or contact lenses.

• While the Insured Person is legally intoxicated (as determined by that state’s laws) or while ministered under the influence of any drug unless administered under the advice and consent of a Physician.

• Elective Abortion. Elective Abortion means an abortion for any reason other than to preserve the life of the female upon whom the abortion is performed.

• Mental and Nervous Disorders. • Cosmetic surgery, except for reconstruction surgery needed as the result of an injury or sickness.

• Experimental or Investigational drugs, services, supplies or any procedure held to be experimental or investigatory by Us at the time the procedure is done.

• Treatment for being overweight, gastric bypass or stapling, intestinal bypass, and any related procedures, including complications.

• Sexual reassignment surgery, sexual transformation surgery, sexual trans- gendering surgery.

• Services related to sterilization, reversal of vasectomy or tubal ligation; in vitro fertilization and diagnostic treatment of infertility or other problems related to the inability to conceive a child, unless such infertility is a result of a covered Injury or Sickness.

• Treatment or services provided by a private duty nurse, unless provided for in the Policy.

• Organ or tissue transplants and related services. • Personal comfort or convenience items. • Rest or custodial cures. • Hearing aids. • Radial keratotomy. • Treatment by a family member or member of the Insured Person’s household. • Routine dental care and treatment, except for treatment of Injury as specified in the Policy.

Under the Accident Medical Expense Policy We will not pay for loss, injury or sickness that is caused by, or results from: • Suicide or attempted suicide, intentionally self-inflicted injury. • War or any act of war, whether declared or not. • A Covered Accident that occurs while on active duty service in the military, naval or air force of any country or international organization. Upon Our receipt of proof of service, We will refund any premium paid for this time. Reserve or National Guard active duty training is not excluded unless it extends beyond 31 days.

• Sickness, disease, or any bacterial infection, except one that results from an accidental cut or wound or pyogenic infections that result from accidental ingestion of contaminated substances.

• Piloting or serving as a crew member or riding in any aircraft except as a fare-paying passenger on a regularly scheduled or charter airline.

• Injury that occurs while the Insured Person is legally intoxicated (as determined by that state’s law) or while under the influence of any drug unless administered under the advice and consent of a Physician.

• Medical or surgical treatment, diagnostic procedure, administration of anesthesia, or medical mishap or negligence, including malpractice.

• Commission of, or attempt to commit, a felony. • Aggravation or re-injury of a prior Injury the Insured Person suffered prior to his or her coverage effective date, unless We receive a written medical release from the Insured Person’s Physician. In addition to the above Exclusions, under the Accident Medical Expense Policy, We will not pay for any loss, treatment or services resulting from or contributed to by:

• Treatment by persons employed or retained by the Policyholder, or by any Immediate Family or member of the Insured Person’s household.

• Treatment of sickness, disease or infections except pyogenic infections or bacterial infections that result from the accidental ingestion of contaminated substances.

• Treatment of hernia, Osgood-Schlatter’s Disease, osteochondritis, appen- dicitis, osteomyelitis, cardiac disease or conditions, pathological fractures, congenital weakness, detached retina unless caused by an Injury, or mental disorder or psychological or psychiatric care or treatment (except as provided in the Policy), whether or not caused by a Covered Accident.

• Pregnancy, childbirth, miscarriage, abortion or any complications of any of these conditions.

• Mental and nervous disorders (except as provided in the Policy). • Injury covered by Workers’ Compensation, Employer’s Liability Laws or

similar occupational benefits, including any insurance policy that provides benefits to the Insured Person for injuries resulting from an occupational accident, or while engaging in activity for monetary gain from sources other than the Policyholder.

• Cosmetic surgery, except for reconstructive surgery needed as the result of an Injury.

• Any elective treatment, surgery, health treatment, or examination, including any service, treatment or supplies that: (a) are deemed by Us to be experimental; and (b) are not recognized and generally accepted medical practices in the United States.

• Eyeglasses, contact lenses, hearing aids, examinations or prescriptions for them, or repair or replacement of existing artificial limbs, orthopedic braces, or orthotic devices.

• Expenses payable by any automobile insurance Policy without regard to fault. (This exclusion does not apply in any state where prohibited.)

• Damage to or loss of dentures or bridges, or damage to existing orthodontic equipment (except as specifically covered by the Policy).

• Expenses incurred for treatment of temporomandibular or craniomandibular joint dysfunction and associated myofacial pain (except as provided by the Policy).

• Conditions that are not caused by a Covered Accident. • Participation in any activity or hazard not specifically covered by the Policy. • Any treatment, service or supply not specifically covered by the Policy.


In addition, Critical Illness Benefits will not be paid for: • Injury or Sickness, other than one of the Covered Illnesses, even though such

Injury or Sickness may have been complicated by one of the Covered Illnesses; • Any complication of Human Immuno deficiency Virus (HIV) infection or any

variance thereof including AIDS and AIDS Related complex; except for residents of TX, FL, MO, NC.

• The use, existence or escape of nuclear weapons, material or ionizing radiation from or contamination by radioactivity from any nuclear fuel or waste from the combustion of nuclear fuel;

• Misuse of medication or the abuse of drugs or intoxicants; • Any Pre-existing Condition, except where coverage has been in effect for a

period of twenty-four (24)* consecutive months following the Insured Person’s effective date of coverage. “Pre-existing Condition” means a Sickness suffered by a Insured Person for which he or she sought or received medical advice, consultation, investigation, or diagnosis, or for which treatment was required or recommended by a Physician during the 24* months immedi- ately prior to the Insured Person’s effective date of coverage, that directly or indirectly causes the condition to occur within the first 24* months from the Insured Person’s most recent effective date of coverage.

No Prescription Drug Benefits will be paid for: • All over-the-counterproductsandmedicationsunlessshowninthedefinition of Prescription Drug. This includes, but is not limited to, electrolyte replacement, infant formulas, miscellaneous nutritional supplements, and all other over-the-counter products and medications.

• Blood glucose meters and insulin injecting devices. • Depo-Provera; condoms, contraceptive sponges, and spermicides; sexual dysfunction drugs.

• Biologicals (including allergy tests); blood products; growth hormones; hemophiliac factors; MS injectables; immunizations; and all other injectables unless shown in the definition of Prescription Drug.

• Medical supplies and durable medical equipment. • Liquid nutritional supplements; pediatric Legend Drug vitamins; prescribed versions of Vitamins A, D, K, B12, Folic Acid, and Niacin – used in treatment verses as a dietary supplement; and all other Legend Drug vitamins and nutritional supplements.

• Anorexiants; any cosmetic drugs including, but not limited to, Renova and skin pigmentation preps; any drugs or products used for the treatment of baldness; and topical dental fluorides.

• Refills in excess of that specified by the prescribing Physician , or refills dispensed after one year from the original date of the prescription.

• Any drug labeled “Caution – limited by Federal Law for Investigational Use” or experimental drugs.

• Any drug which the Food and Drug Administration has determined to be contraindicated for the specific treatment.

• Drugs needed due to conditions caused, directly or indirectly, by a Insured Person taking part in a riot or other civil disorder; or the Insured Person taking part in the commission of a felony.

• Drugs needed due to conditions caused, directly or indirectly, by declared or undeclared war or any act of war; or drugs dispensed to a Insured Per- son while on active duty service in any armed forces.

• Any expenses related to the administration of any drug. • Drugs or medicines taken while in or administered by a Hospital or any other health care facility or office.

• Drugs covered under Worker’s Compensation, Medicare, Medicaid or other governmental program.

• Drugs, medicines or products which are not medically necessary. • Diaphragms; erectile dysfunction Legend Drugs; and infertility Legend Drugs. • Epi-Pen, Epi-Pen Jr., Ana-Kit, Ana-Guard; Glucagon-auto injection; and

Imitrex-auto injection. Smoking deterrents, Legend or over-the-counter drugs. • Replacement of stolen medication (except under circumstances approved by us), or lost, spilled, broken or dropped Prescription Drugs.

• Vacation supplies of Prescription Drugs (except under circumstances approved by us).

• All newly marketed pharmaceuticals or currently marketed pharmaceuticals with a new FDA approved indication for a period of one year from such FDA approval for its intended indication.

The following applies to the Group Term Life Insurance benefit: SUICIDE EXCLUSION: We will not pay a death benefit if an insured person dies by suicide, while sane or insane, within two years of the date his/her insurance starts. If You or Your spouse dies by suicide, We will refund the premiums paid for Your insurance (if a dependent child dies by suicide, We will refund the premiums paid for the dependent children’s insurance only if You have no surviving insured dependent children). If any death benefit is increased, this suicide exclusion starts anew, but will apply only to the amount of the increase.

*Please note that certain exclusions and limitations listed in the “What’s Not Covered” sections may vary by state law.

IMPORTANT NOTICE: Insurance policies providing certain health insurance coverage issued or renewed on or after September 23, 2010 are required to comply with all applicable requirements of the Patient Protection and Affordable Care Act (PPACA). However, there are a number of insurance coverages that are specifically exempt from the requirements of PPACA (See § 2791 of the Public Health Services Act). AXIS maintains that the Limited Accident and Sickness Plan presented In this brochure Is “fixed Indemnity insurance”, and is therefore, exempt from the requirements of PPACA.

Frequently Asked Questions Q: When will I get my ID card? A: You will get your ID card within 10 business days of your employer approved enrollment. You will receive a separate ID card for each product you enroll in.

Q: How do I find a First Health network provider? A: Please visit www.myternian.com or call 1-800-226-5116

Q: Is this major medical or comprehensive medical coverage? A: No. This Limited Medical Plan is a combination of limited scope, fixed indemnity, and accident-only coverages which provide limited benefits for accidents, illness, and specified diseases to help cover basic, minor- medical expenses.

Claims Administered by: Administrative Concepts, Inc. (ACI)

994 Old Eagle School Road, Ste. 1005 Wayne, PA 19087 1-800-964-7096

Fixed indemnity medical, accident-only accidental death and dismemberment, critical illness, short-term disability and prescription drug coverages are underwritten by AXIS Global Accident and Health Insurance Company. Term life insurance is underwritten by Minnesota Life Insurance Company. These plans are not major medical insurance and are NOT designed to replace, provide or modify major medical insurance. This insurance does not apply to the extent that trade or economic sanctions or regulations prohibit Us from providing insurance, including, but not limited to, the payment of claims. Marketed and administered by Ternian Insurance Group LLC. www.ternian.com

6

THE GAP PLAN REIMBURSEMENT PROCEDURES

What is the Gap Plan? The Gap Plan is a first dollar benefit program that reimburses the insured for charges accruing towards their annual deductible and coinsurance.

Base Plan

In-Patient Benefit Up to $1,000 (per calendar year)

Out-Patient Benefit Up to $1,000 (per condition: 4 / family per calendar year)

Buy Up Plan

In-Patient Benefit Up to $2,000 (per calendar year)

Out-Patient Benefit Up to $2,000 (per condition: 4 / family per calendar year)

What does an insured need to submit a claim for reimbursement?

1. Claim Form- A completed claim form is required one time per year. If your address or phone number has changed since your last claim you will need to send in a new claim form with the updated information. Sign and date the authorization section (the insured must sign and date the claim form for dependent children). 2. Explanation of Benefits ( EOB ) from your primary insurance company. This is the statement from the primary carrier that lists what charges they are paying, denying or applying to deductibles, etc. This is sent to your home address following activity on your health insurance account. 3. Itemized Provider Bill- Attach copies of the original bills showing the diagnosis and procedure codes, date of service, name and address of the provider and the provider tax identification number. (REGULAR BILLING STATEMENTS NOT ACCEPTED)

What should I know about claim payment?

1. If you submit all of the information necessary to process your claim it will take 5-10 days to issue payment.

2. Payment will be made directly to the provider if there is a balance due on the claim form. Special Insurance Services will reimburse you directly if the documentation you submitted shows that you have already paid the account in full and the account balance is $0.

What is not reimbursed by the Gap Plan?

1. Copays for doctor visits or Prescriptions 2. Durable Medical equipment 3. Outpatient mental health 4. Wellness / Annual Exams (usually covered by office visit copay)

Where do I submit my paperwork? Special Insurance Services, PO Box 250349, Plano, TX 75025-0349 For claim status please contact customer service at 1-800-767-6811. You may fax your paperwork directly to Special Insurance Services at 1-972-960-0377. Please make sure your name, social security number, group name and policy number is on all correspondence.

7

First Dollar Reimbursement Plan - NEXSTEP-

Special Insurance Services & Fidelity

Plan:

Base Plan

I

Bwy-Up Plalil . , II

In-Patient Benefit:

Out-Patient Benefit:

Maximum # of Occurrences

Pre-Ex isting Conditions Clause:

$1,000

$1,000

4 per family per year

No

$2,000

$2,000

4 per family per year

No

Type of Coverage

Monthly

Monthly

Under 40 - Employee Only

$22.62

$32.51

Under 40 - Employee + Child

$54.71

$76.67

Under 40 - Employee + Spouse

$40.72

$58.53

Under 40 - Employee + Family

$72.28

$102.63

40 to 49 - Employee Only

$28.69

$41.15

40 to 49 - Employee + Child

$56.98

$92.21

40 to 49 - Employee + Spouse

$51.57

$74.09

40 to 49 - Employee+ Family

$79.92

$121.72

- 50 and Older - Employee Only

$60.75

$84.32

50 and Older - Employee + Child

$103.90

$143.66

50 and Older - Employee + Spouse

$109.33

$151.73

50 and Older - Employee + Family

$152.42

$211.02

8

CIGNA DENTAL DHMO

Diagnostic/Preventive

All covered by plan 100%

Consultation

Office Visit for Observation

Periodic and Limited Oral Evaluation

All X‐Rays

Cleanings covered every 6 months

Call Cigna for a Charge Schedule on the following:

Restorative (Fillings)

Crown and Bridge (All charges for crown and bridge are per unit) (Each replacement or supporting tooth equals one unit – replacement limit 1 every 5 years)

Endodontics (Root canal treatment, excluding final restorations)

Periodontics (Treatment of supporting tissues [gum and bone] of the teeth)

Prosthetics (Removable tooth replacement – dentures) (Includes up to 4 adjustments within first 6 months after insertion – replacement limit 1 every 5 years)

Repair to Prosthetics

Denture Relining (Limit 1 every 36 months)

Interim Dentures (Limit 1 every 5 years)

Oral Surgery (Includes routine post‐operative treatment)

Orthodontics (Tooth movement)

General Anesthesia/I.V. Sedation

Emergency Services

In‐ network benefits only No deductibles No annual dollar maximum

Selectadentistfromalistofnetworkprovidersonwww.cigna.com.CustomerServicetollfree#: 1‐800‐244‐6224NOTE: A dentist must be selected on application. Please log on or call customer service for a list of providers.

CIGNA DENTAL MONTHLY RATES

Employee Only $19.73

Employee & Spouse $52.65

Employee & Child(ren) $52.65

Family $52.65

9

MetLife®

Dental Plan Benefits- High Plan (Contrib)

For the savings you need, the flexibility you want and service you can trust.

Benefit Summary Coverage Type PDP In-Network Out-of-Network

Type A – Preventative 100% of PDP Fee* 100% of PDP Fee*

Type B – Basic 90% of PDP Fee* 90% of PDP Fee*

Type C – Major 60% of PDP Fee* 60% of PDP Fee*

Type D- Orthodontia 50% of PDP Fee* 50% of PDP Fee*

Deductible† In-Network Out-of-Network

Individual $50.00 $50.00

Family $150.00 $150.00

Annual Maximum Benefit In-Network Out-of-Network

Per Person $2,000 $2,000

Orthodontia Lifetime Maximum In-Network Out-of-Network

Per Person $2,000 $2,000

Late Enrollment Waiting Period: Preventive Services No waiting period Basic Restorative Services (Fillings) 6 month waiting period Basic – All Other Services 12 month waiting period Major Services 24 month waiting period Orthodontic Services 24 month waiting period

* PDP Fee refers to the fees that participating PDP dentists have agreed to accept as payment in full, subject to any co-payments, deductibles, cost sharing and benefits maximums. †Applies only to Type B & C Services.

Monthly Rates

Eligibility Options


Employee + Spouse $80.49

Employee + Child(ren) $98.52

Employee + Family $150.37

10

List of Primary Covered Services & Limitations

Type A • Preventive Prophylaxis (cleanings) Oral Examinations

• Once per 6 month period.


How Many/How Often

Topical Fluoride AppHcalions

X-rays

Type B - Basic Restorative Amalgam Fillings Full Mouth X Rays

Periodontal Maintenance

Space Maintainers

Sealants

Type C - Major Restorative Simple Extractions Crown, Denture, and Bridge Repalr/Recementalions Implants

Bridges and Dentures

Crowns/lnlays/Onlays

Endodontlcs

General Anesthesia

Oral Surgery

Periodontics

• One fluoride treatment per 12 months for dependent children up lo 141n birthday.

• Bilewing X-rays: one set per 12 months.

How Many/How Often • One replacement per surface in 24 months • Once in 60 months

• Total number of periodontal maintenance treatments and prophylaxis cannot exceed 2r

treatments in a calendar year. • Once per lifetime for dependent chlldren up to 14th birthday. • One appllcation of sealant material every 60 months for each non-restored, non-decayed 1st

and 2ndmolar of a dependent child up to 14th birthday.

How Many/How Often

• Once per tooth position in 10 years. • Initial placement toreplace one or more natural teeth, which are lost while covered by the Plan. • Dentures and bridgework replacement: one every 10 years. • Replacement of an existing temporary full denture ff the temporary denture cannot be repaired

and the permanent denture is installed within 12 months after the temporary denture was Installed.

• Replacement: once every 10 years.

• Root canal treatment limited to once par tooth per lifetime. • When dentally necessary in connection with oral surgery, extractions or other covered dental

services.

• Periodontal scaling and root planing once per quadrant, every 24 months. • Periodontal surgery once per quadrant, every 36 months.

Type D • Orthodontia How Many/How Often • You, Your Spouse, and Your Children, up to age 26, are covered while Dental Insurance is in

effect. • All dental procedures performed in connection with orthodontic treatment are payable as

Orthodontia. • Payments are on a repetitive basis. • 20% of the Orthodontia Lifetime Maximum will be considered at initial placement of the

appliance and paid based on the plan benefit's coinsurance level for Orthodontia as defined in the Plan Summary.

• Orthodontic benefits end at cancellation of coverage.

The service categories and plan limitations shown above represent an overview of your Plan Benefits. This document presents the majority of services within each category, but is not a complete description of the Plan.

11

MetLife®

Dental Plan Benefits- Low Plan (Voluntary)

For the savings you need, the flexibility you want and service you can trust.

Benefit Summary Coverage Type PDP In-Network Out-of-Network

Type A – Preventative 100% of PDP Fee* 100% of PDP Fee*

Type B – Basic 80% of PDP Fee* 80% of PDP Fee*

Type C – Major 50% of PDP Fee* 50% of PDP Fee*

Type D- Orthodontia 50% of PDP Fee* 50% of PDP Fee*

Deductible† In-Network Out-of-Network

Individual $50.00 $50.00

Family $150.00 $150.00

Annual Maximum Benefit In-Network Out-of-Network

Per Person $1,250 $1.250

Orthodontia Lifetime Maximum In-Network Out-of-Network

Per Person $1,250 $1,250

Late Enrollment Waiting Period: Preventive Services No waiting period Basic Restorative Services (Fillings) 6 month waiting period Basic – All Other Services 12 month waiting period Major Services 24 month waiting period Orthodontic Services 24 month waiting period

* PDP Fee refers to the fees that participating PDP dentists have agreed to accept as payment in full, subject to any co-payments, deductibles, cost sharing and benefits maximums. †Applies only to Type B & C Services.

Monthly Rates

Eligibility Options


Employee + Spouse $61.08

Employee + Child(ren) $77.45

Employee + Family $117.35

12

List of Primary Covered Services & Limitations

Type A • Preventive Prophylaxis (cleanings) Oral Examinations



How Many/How Often

Topical Fluoride AppHcalions

X-rays

Type B - Basic Restorative Amalgam Fillings Full Mouth X Rays

Periodontal Maintenance

Space Maintainers

Sealants

Type C - Major Restorative Simple Extractions Crown, Denture, and Bridge Repalr/Recementalions Implants

Bridges and Dentures

Crowns/lnlays/Onlays

Endodontlcs

General Anesthesia

Oral Surgery

Periodontics

• One fluoride treatment per 12 months for dependent children up lo 141n birthday.

• Bilewing X-rays: one set per 12 months.

How Many/How Often • One replacement per surface in 24 months • Once in 60 months

• Total number of periodontal maintenance treatments and prophylaxis cannot exceed 2r

treatments in a calendar year. • Once per lifetime for dependent chlldren up to 14th birthday. • One appllcation of sealant material every 60 months for each non-restored, non-decayed 1st

and 2ndmolar of a dependent child up to 14th birthday.

How Many/How Often

• Once per tooth position in 10 years. • Initial placement toreplace one or more natural teeth, which are lost while covered by the Plan. • Dentures and bridgework replacement: one every 10 years. • Replacement of an existing temporary full denture ff the temporary denture cannot be repaired

and the permanent denture is installed within 12 months after the temporary denture was Installed.

• Replacement: once every 10 years.

• Root canal treatment limited to once par tooth per lifetime. • When dentally necessary in connection with oral surgery, extractions or other covered dental

services.

• Periodontal scaling and root planing once per quadrant, every 24 months. • Periodontal surgery once per quadrant, every 36 months.

Type D • Orthodontia How Many/How Often • You, Your Spouse, and Your Children, up to age 26, are covered while Dental Insurance is in

effect. • All dental procedures performed in connection with orthodontic treatment are payable as

Orthodontia. • Payments are on a repetitive basis. • 20% of the Orthodontia Lifetime Maximum will be considered at initial placement of the

appliance and paid based on the plan benefit's coinsurance level for Orthodontia as defined in the Plan Summary.

• Orthodontic benefits end at cancellation of coverage.

The service categories and plan limitations shown above represent an overview of your Plan Benefits. This document presents the majority of services within each category, but is not a complete description of the Plan.

0699562 - 11/18/11

VSP provides an affordable eyecare plan. Sign up today. Doctor Network..................................... VSP Signature

Your Coverage with a VSP Doctor

WellVision Exam® focuses on your eye health and overall wellness

• $10.00 copay......................................every 12 months

Prescription Glasses

• $25.00 copay

Lenses..................................................every 12 months

• Single vision, lined bifocal and lined trifocal lenses • Polycarbonate lenses for dependent children

Frame................................................... every 24 months

• $120 allowance for a wide selection of frames • 20% off amount over your allowance

~OR~

Contact Lens Care

No copay applies.................................. every 12 months

$120.00 allowance for contacts and the contact lens exam (fitting and evaluation) Current soft contact lens wearers may qualify for a special program that includes a contact lens exam and initial supply of lenses.

Extra Discounts and Savings

Glasses and Sunglasses • Average 35 - 40% savings on all non-covered lens options • 30% off additional glasses and sunglasses, including lens options, from the same VSP doctor on the same day as your WellVision Exam. Or get 20% off from any VSP doctor within 12 months of your last WellVision Exam

Contacts • 15% off cost of contact lens exam (fitting and evaluation)

Laser Vision Correction • Average 15% off the regular price or 5% off the promotional price. Discounts only available from contracted facilities. • After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor.

VSP guarantees service from VSP doctors only. In the event of a conflict between this information and your organization's contract with VSP, the terms of the contract will prevail.

VSP VISION MONTHLY RATES

Employee Only $11.19 Employee & Spouse $17.90 Employee & Child(ren) $18.27 Family $29.46

13

UUNNUUMM PPRROOVVIIDDEENNTT LLIIFFEE IINNSSUURRAANNCCEE

Plan Description: Basic Life & AD&D Insurance

Client Employee Life Benefit Amount Overall Maximum

1 X annual earnings rounded to the next higher $1,000 $100,000

Client Employee Life Benefit Reduction Formula

Life Benefit Reduces to: ‐ 65% at age 65; and ‐ 50% at age 70

One Time Basic Annual Earnings (BAE)

Calculate: 1x BAE is .53 per 1,000 Example: $30,000 x .53 = $15.90 per month

Important: Premiums are adjusted throughout the year according to current base salary changes. Maximum of 100,000.

Plan Description: Optional Term Life Insurance

Client Employee Life Benefit Amount Overall Maximum

Amounts in $10,000 benefit units as applied for The lesser of 5 X annual earnings by the employee and approved by UnumProvident or $500,000

ClientEmployeeLifeBenefitReductionFormulaLife Benefit Reduces to: ‐ 65% at age 65; and ‐ 50% at age 70

Dependent Life Benefit Amount Overall Maximum Spouse: Amounts in $5,000 benefit units The lesser of 100% of the employee life amount

not to exceed 50% of the employee’s or $250,000 coverage amount

Child: ‐ Live birth to 14 days: $1,000 The lesser of 100% of the employee life amount ‐ 14 days to 6 months: $1,000 or $10,000 ‐ 6 months to 19 years (26 years if full‐time student): $10,000 Amounts in $2,000 benefit units

Child(ren): Available in increments of $2,000 up to 10,000, cost is $0.76 up to $3.80 per month whether it’s one child or five children.

SEE NEXT PAGE FOR RATE CHART

14

UNUM PROVIDENT OPTIONAL LIFE

CLIENT EMPLOYEE RATES-MONTHLY COST PER COVERAGE AMOUNT

AGE 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000 100,000 200,000 300,000 400,000 500,000 15-29 $1.47 $2.94 $4.41 $5.88 $7.35 $8.82 $10.29 $11.76 $8.82 $14.70 $29.40 $44.10 $58.80 $73.50 30-34 $1.49 $2.98 $4.47 $5.96 $7.45 $8.94 $10.43 $11.92 $13.41 $14.90 $29.80 $44.70 $59.60 $74.50 35-39 $1.83 $3.66 $5.49 $7.32 $9.15 $10.98 $12.81 $14.64 $16.47 $18.30 $36.60 $54.90 $73.20 $91.50 40-44 $2.37 $4.74 $7.11 $9.48 $11.85 $14.22 $16.59 $18.96 $21.33 $23.70 $47.40 $71.10 $94.80 $118.50 45-49 $3.54 $7.08 $10.62 $14.16 $17.70 $21.24 $24.78 $28.32 $31.86 $35.40 $70.80 $106.20 $141.60 $177.00 50-54 $5.21 $10.42 $15.63 $20.84 $26.05 $31.26 $36.47 $41.68 $46.89 $52.10 $104.20 $156.30 $208.40 $260.50 55-59 $8.24 $16.48 $24.72 $32.96 $41.20 $49.44 $57.68 $65.92 $74.16 $82.40 $164.80 $247.20 $329.60 $412.00 60-64 $12.91 $25.82 $38.73 $51.64 $64.55 $77.46 $90.37 $103.28 $116.19 $129.10 $258.20 $387.30 $516.40 $645.50 65-69 $22.36 $44.72 $67.08 $89.44 $111.80 $134.16 $156.52 $178.88 $201.24 $223.60 $447.20 $670.80 $894.40 $1,118.00 70-74 $40.02 $80.04 $120.06 $160.08 $200.10 $240.12 $280.14 $320.16 $360.18 $400.20 $800.40 $1,200.60 $1,600.80 $2,001.00 75+ $80.62 $161.24 $241.86 $322.48 $403.10 $483.72 $564.34 $644.96 $725.58 $806.20 $1,612.40 $2,418.60 $3,224.80 $4,031.00

SPOUSE RATES-MONTHLY COST PER COVERAGE AMOUNT

AGE 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 50,000 100,000 150,000 200,000 250,000

15-29 $0.73 $1.46 $2.19 $2.92 $3.65 $4.38 $5.11 $5.84 $6.57 $7.30 $14.60 $21.90 $29.20 $36.50 30-34 $0.75 $1.50 $2.25 $3.00 $3.75 $4.50 $5.25 $6.00 $6.75 $7.50 $15.00 $22.50 $30.00 $37.50 35-39 $0.95 $1.90 $2.85 $3.80 $4.75 $5.70 $6.65 $7.60 $8.55 $9.50 $19.00 $28.50 $38.00 $47.50 40-44 $1.27 $2.54 $3.81 $5.08 $6.35 $7.62 $8.89 $10.16 $11.43 $12.70 $25.40 $38.10 $50.80 $63.50 45-49 $1.86 $3.72 $5.58 $7.44 $9.30 $11.16 $13.02 $14.88 $16.74 $18.60 $37.20 $55.80 $74.40 $93.00 50-54 $2.78 $5.56 $8.34 $11.12 $13.90 $16.68 $19.46 $22.24 $25.02 $27.80 $55.60 $83.40 $111.20 $139.00 55-59 $4.15 $8.30 $12.45 $16.60 $20.75 $24.90 $29.05 $33.20 $37.35 $41.50 $83.00 $124.50 $166.00 $207.50 60-64 $6.93 $13.86 $20.79 $27.72 $34.65 $41.58 $48.51 $55.44 $62.37 $69.30 $138.60 $207.90 $277.20 $346.50 65-69 $11.68 $23.36 $35.04 $46.72 $58.40 $70.08 $81.76 $93.44 $105.12 $116.80 $233.60 $350.40 $467.20 $584.00 70-74 $20.64 $41.28 $61.92 $82.56 $103.20 $123.84 $144.48 $165.12 $185.76 $206.40 $412.80 $619.20 $825.60 $1,032.00 75+ $41.12 $82.24 $123.36 $164.48 $205.60 $246.72 $287.84 $328.96 $370.08 $411.20 $822.40 $1,233.60 $1,644.80 $2,056.00

CHILD RATES-MONTHLY COST PER COVERAGE AMOUNT

2,000 4,000 6,000 8,000 10,000 $0.76 $1.52 $2.28 $3.04 $3.80

15

Plan Highlights

Eligibility All Active Full Time Client Employees working a minimum of 30 hours per week

Benefit Amount 60% of your weekly earnings to maximum of

$1,500 per week of benefit.

Elimination Period 14 days injury/14 days sickness

Benefit Period 11 weeks

Premium Voluntary-Employee Paid

Federal Income Taxation Benefits are tax-free.

Rehabilitation Benefits Included

Maternity Benefits Included

Current Client Employees: If you enroll on or before the enrollment deadline of 08/01/2018, coverage is available to you without answering any medical questions or providing evidence of insurability. (After the enrollment period, your coverage will be medically underwritten, and you will be required to qualify based on information you provide on your overall medical health including routine, planned, unplanned or ongoing medical care or consultation. This review may result in a declination of coverage.)

Client Employees hired on or after 08/01/2018: You may apply for coverage without answering any medical questions or providing evidence of insurability if you apply for coverage within 31 days after your eligibility date. If you apply more than 31 days after your eligibility date, your coverage will be medically underwritten, and you will be required to qualify based on information you provide on your overall medical health including routine, planned, unplanned or ongoing medical care or consultation. This review may result in a declination of coverage.

This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Details may differ from state to state. Please refer to your certificate booklet for your complete plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern.

16

VOLUNTARY SHORT TERM DISABILITY Unum Policy # 405164

Pinnacle Corporation P.O Box 33698 San Antonio, TX 78265

Phone (210) 344-2088 Fax (210) 344-2777

www.pinnaclepeo.com

Documents

Annual Benefits Enrollment - Pinnaclesportclips.pinnaclepeo.com/wp-content/uploads/2018/06/... · 2018-06-22 · The Annual Enrollment period will begin July 2st to July 24th, 2018