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Enrollment Guide [Template]
Know your benefits.
Protingent Employee Benefits Guide
2020 Benefits – Effective 9/1/2020 through 8/31/2021
2020 Open Enrollment Learn more information at protingentbenefits.com
[Protingent|protingentbenefits.com | 2020
Learn more on the Protingent benefits website:protingentbenefits.com
Your 2020-2021 Benefits
Medical Benefits Medical Network
Payer Matrix Pharmacy Benefits
Long-term, Short-term Disability, Life and Voluntary Life, Dental Vision Benefits
New Carrier
What you need to know:
Learn more:
• Healthcare Definitions
• Who’s Eligible to Enroll
• Changing Your Benefits
• Your Medical Plan
• Your Prescription Plan
• Your HSA Plan
• Your Dental Plan
• Your Voluntary Vision Plan
• Your Voluntary Life & Disability Plan
• Your EAP Plan
• Resources and Contact Information
• Required Notices
Protingent provides employees and their eligible dependents a vital program of benefits designed to keep you healthy, protect your financial security, and help you balance your life at work and home.
This guide highlights your benefits. Official plan and insurance documents govern your rights and benefits under each plan. For more details about your benefits, including covered expenses, exclusions, and limitations, please refer to the individual Summary Plan Description (SPD), plan document, or certificate of coverage for each plan, which can be found in our company’s designated office. If any discrepancy exists between this guide and the official documents, the official documents will prevail.
What’s inside?
What’s inside?
What you need to know:
Learn more:
In-Network vs. Out-of-Network – Our plans are designed to give you the freedom to use the healthcare
provider of your choice. However, when you use an in-network provider, the percentage you pay out of
pocket will be based on a set fee, which is usually lower than the actual charge. If you use a provider
who is out-of-network, you may be responsible for paying the difference between the reasonable and
customary (R&C) charges and what the provider charges. R&C is the amount that is generally
considered reasonable based on the average that most providers charge for a particular service in a
geographic region.
Preventive Care Services – These are services that are generally linked to routine wellness exams and
screenings. Non-preventive services are those that are considered treatment or diagnosis for an illness,
injury, or other medical condition. Preventive care is covered at 100% in-network.
Copayments and Coinsurance – A copayment (or copay) is the fixed dollar amount you pay for certain
in-network services. In some cases, you may be responsible for coinsurance after the copay is made.
Coinsurance is the percentage of covered expenses shared by you and the plan. In some cases,
coinsurance is paid after you meet a deductible. For example, if the plan pays 80% of an in-network
covered charge, you pay the remaining 20%.
Definitions
What you need to know:
Learn more:
Annual Deductible – The amount of money you must first pay out of pocket before your plan
begins paying for services covered by coinsurance is your annual deductible. After you meet your
deductible, the plan pays for a percentage of eligible expenses (coinsurance) until you meet your
out-of-pocket maximum. If you receive services from an out-of-network provider, the plan has a
higher deductible and pays a lower percentage of coinsurance.
Out-of-Pocket Maximum – The amount of coinsurance you will be required to pay for eligible
health care expenses is limited. Once you reach the maximum amount, the plan begins to pay
100% of eligible expenses. Please note that there may be separate in-network and out-of-network
annual out-of-pocket maximums.
Summary Plan Description (SPD) – The SPD is an important document that tells participants
what the plan provides and how it operates, including when an employee can begin to participate
in the plan, how service and benefits are calculated, when benefits become vested, and how to file
a claim for benefits. Employers are legally obligated by The Employee Retirement Income Security
Act (ERISA) to provide employees SPDs for each benefit plan offered by the employer.
Health Savings Account (HSA) – An HSA is a savings account used in conjunction with a high
deductible health plan (HDHP) that allows users to save money tax-free for IRS-qualified medical
expenses. An HSA allows the employer to make contributions to the account, and the account
balance rolls over from year to year. For a complete list of IRS-qualified medical expenses, consult
IRS Pub 502 (https://www.irs.gov/pub/irspdf/p502.pdf).
Definitions (Continued)
What you need to know:
Learn more:
Who is eligible?
A full-time Employee of the Employer who regularly
works 30 Hours of Service per week will be eligible
to enroll for coverage under this plan.
Participation in the plan will begin as of the first day
of the month following the date he or she completes
at least one (1) hour of service with the Employer
provided all required election and enrollment forms
are properly submitted to the Plan Administrator. You
must enroll for benefits within 31 days of your hire
date.
You are not eligible to participate in the Plan if you
are a part-time, temporary, leased or Seasonal
Employee, an independent contractor or a person
performing services pursuant to a contract under
which you are designated an independent contractor
(regardless of whether you might later be deemed a
common law employee by a court or governmental
agency).
Eligible dependents include your:
Legally married spouse
Same- or opposite sex spouse
Children up to age 26 (health plan) with
integral dental and/or vision*
Children under the age of 20; or to age 26
if a fulltime student (stand-alone dental or
standalone vision)
What you need to know:
Learn more:
Certain Qualified Life Events (QLEs) may enable you to change your benefit elections at a time other
than during open enrollment. You can change your benefit elections during the year if you experience a
qualified life event.
Generally, your benefits election change must be consistent with the QLE. If you experience a QLE, you
must generally notify Protingent within 31 days of the change. You may need to provide proof of the
change. If you do not make contact within 31 days, you will have to wait until the next annual open
enrollment period to make changes, unless you have another QLE.
QLEs include: Marriage
Divorce, annulment, or legal separation
Birth of your child
Death of your spouse or dependent child
Adoption of/placement for adoption of your child
Termination or commencement of your spouse’s
employment
Change of employment status by you or your
spouse, or another dependent
A significant change in your or your spouse’s
health coverage due to your spouse’s employment
Qualification by the Plan Administrator of a
Medical Child Support Order
Entitlement to Medicare or Medicaid
Commencement of or return from an unpaid leave
of absence
A change in the place of residence of you, your
spouse, or your dependent
Your dependent satisfies or ceases to satisfy
eligibility requirements
Changing your benefits
Enrollment Guide [Template]
Medical BenefitsKnowing your health plan
[Protingent|protingentbenefits.com | 2020
Learn more on the Protingent benefits website:
protingentbenefits.com
Medical Benefits
Medical BenefitsFinding the right doctor for you is
very important for your overall health.
Our Group Medical plans make it
easier to prioritize your health. You
can minimize out-of-pocket costs by
taking advantage of our large
network of providers.
Learn more about your benefits on
the Protingent Benefits website:
protingentbenefits.com
Plan Network Plan Administrator
YOUR HEALTH PLAN 1. POS Choice Plus Plan
IN-NETWORK / OUT-OF-NETWORK
2. HDHP / HSA Plan
IN-NETWORK / OUT-OF-NETWORK
PLAN-YEAR DEDUCTIBLE
Individual / Family
$2,000 individual (in network)
$4,000 family (in network)
$4,000 individual (out of network)
$8,000 family (out of network)
$1,500 individual (in network)
$3,000 family (in network)
$3,000 individual (out of network)
$6,000 family (out of network)
PLAN-YEAR OUT-OF-
POCKET MAX
Individual / Family
$4,000 individual (in network)
$8,000 family (in network)
$10,000 individual (out of network)
$20,000 family (out of network)
$3,425 individual (in network)
$6,850 family (in network)
$15,000 individual (out network)
$30,000 family (out of network)
Coinsurance 80% (in network)
40% (out of network)
80% (in network)
80% (out of network)
Outpatient care IN-NETWORK / OUT-OF-NETWORK IN-NETWORK / OUT-OF-NETWORK
Preventive care 100% deductible waived (in network)
60% after deductible (out of network)
100% Deductible Waived (in network)
60% after deductible (out of network)
Physicians Office visits $30 (in network)
60% after deductible (out of network)80% after deductible (in network)
60% after deductible (out of network)
Urgent Care $50 (in network)
60% after deductible (out of network)80% after deductible (in network)
60% after deductible (out of network)
Emergency Room $200, then 100% (in network, out of network) 80% after deductible (in network, out of network)
Prescription Drug Card Retail (30 days supply)
Generic - $15
Preferred - $45
Non-preferred $75
Mail Order (up to 90 days supply)
Generic - $30
Preferred - $90
Non-preferred - $150
Retail (30 days supply)
Generic – 20%
Brand Name – 20%
Mail Order (up to 90 days supply)
Generic – 20%
Brand Name – 20%
This is a brief outline of your benefits. It is not a Summary Plan Description or intended to replace the Schedule of Benefits contained within the Plan Document. If any provision is inconsistent with the language of the Plan Document, the Plan Document will govern.
Your Medical Plan Options
2020-2021 Medical Rates
Monthly Rates HDHP POS
Employee- $175
Employee + Spouse$750 $1,100
Employee + Children$300 $550
Employee + Family$1,050 $1,480
1. Please allow two-three days before your medication runs out to fill a prescription around the dates of 9/1. This allows time in case there are challenges in transferring information or filling your prescription.
2. Tell your pharmacist your pharmacy benefit manager has changed, even if they have your information saved on file. You can provide the pharmacist with your new group number.
3. The Pharmacy Benefit Manager will change September 1, 2020. If you have questions regarding filling your prescription, please contact 800-424-0472 or visit the benefits website for additional contact information.
PBM Change
Pharmacy Benefits Manager
Maximize Your BenefitYour decisions play a key role in the effectiveness of your prescription benefit. Here are a few tips to help you maximize your benefit.
Request Generics• Generic medications provide quality, cost-effective alternatives to brand medications and may help reduce costs to you and your plan. • Ask your local pharmacy if they offer any low-cost generic programs. Use your prescription benefit card to process your order and receive the lower priced alternative, whether it is the pharmacy’s generic program price or your copay
Take Your Medications As Directed • Taking medications exactly as prescribed is one of the most important things you can do to enhance your health and prevent medical complications. • Missing doses, stopping medication early or swapping medications with other people can lead to serious problems that may negatively impact health outcomes.
Helping you achieve the best possible health outcomes Promoting the use of safe, cost-effective and clinically appropriate medications Helping you save money and providing convenient access to your prescription medications
Take Advantage of Over-The-Counter (OTC) Products • Some medications that used to only be available by prescription (e.g., Claritin®, Prilosec®, and Zyrtec®) are now available over-the-counter without a prescription. • Ask your doctor if any OTC alternatives are available to effectively treat your condition. Switching to an OTC product could save both you and your plan money.
Home delivery by Magellan Rx Pharmacy Save time and money with a 90-day supply of your medications by mail
If you take maintenance medications for long-term conditions like arthritis, asthma, diabetes, high blood pressure or high cholesterol, you could save with home delivery through Magellan Rx Pharmacy.
How to get started First, ask your doctor to write two prescriptions: 1. 30-day supply to fill at your local pharmacy 2. 90-day supply plus refills to fill by mail
Next, you may either: Ask your doctor to e-prescribe to Magellan Rx Pharmacy, LLC (Mail-ORL) or fax your prescription to 888-282-1349.
Faxed prescriptions may only be sent by a doctor’s office and must include patient information and diagnosis. • For prompt delivery, please provide your payment information by mailing in your completed home
delivery order form or by calling 800-424-8274.• Mail us your 90-day prescription and completed order form with payment to Magellan Rx
Pharmacy, P.O. Box 620968, Orlando, FL 32862. • Home delivery order forms are available at www.magellanrx.com/member/forms
Healthcare Savings Account (HSA)
Health Savings Account (HSA)
What is an HSA?
If you enroll in Protingent Staffing's High
Deductible Health Plan (HDHP), then you
may be eligible to open and HSA. An HSA
is a bank account where you can set aside
money to pay for expenses that your
health plan does not cover. The money in
your HSA is not considered income, so it is
not subject to taxes.
Healthcare Savings Account (HSA)
Health Savings Account (HSA)
An HSA is designed to work with a qualifying high-deductible health plan (HDHP). The money goes in tax-free, grows income tax-free and comes out income tax-free when you use it for qualified medical expenses.You can carry over unused funds from year to year and the account is yours to keep even if you change jobs, change health plans or retire.
Group: 911736Customer Service: 866-234-8913www.optumbank.com
Enrollment Guide [Template]
Dental BenefitsYour Dental Plan
Learn more on the Protingent benefits website:
protingentbenefits.com
Dental Benefits
METLIFE DENTAL
Good dental care is key to your overall
health and wellness. Find an in-network
dentist on the MetLife mobile app or online
at www.metlife.com/mybenefits
Learn more about your benefits on
the Protingent Benefits website:
protingentbenefits.com
BENEFIT IN-NETWORK OUT OF NETWORK
Annual Calendar-Year $3000 $3000
Calendar-Year Deductible/Combined for Basic and Major
$50 (Type B & C) $50 (Type B & C)
A. Preventive Services 100% 100%
B. Basic Services 80% 80%
C. Major Services 50% 50%
Orthodontia Coinsurance $1000 $1000
Orthodontia Lifetime Maximum Ortho applies to Adult and Child (Up to dependent age limit)
Your Dental Plan
Type A · Oral Examinations 1 in 6 months. · Cleanings 1 in 6 months
Type B · Periodontal Maintenance 4 in 1 year less the number of teeth cleanings. · Space Maintainers For dep
Type C · Crowns 1 in 84 months. · Dentures 1 in 84 months. · Bridges 1 in 84 months. · Periodontal Surgery 1 in 36 months
Orthodontia· Dependent children are covered up to their 26th birthday.
2020-2021 Dental Rates
Monthly Dental Rates
Employee $36.06
Employee + Spouse $71.69
Employee + Children $75.58
Employee + Family $118.50
Enrollment Guide [Template]
Vision Benefits
Learn more on the Protingent benefits website:
protingentbenefits.com
Vision Benefits
To find a vision provider, you can use the search tool on the VSP provider search tool:
vsp.com/eye-doctor
Vision care - Voluntary
Learn more about your benefits on
the Protingent Benefits website:
protingentbenefits.com
Covered Charges VSP Network Copay
Eye Exam Focuses on your eyes and overall wellness $10 copay
Frames $130 allowance for a wide selection of frames
$150 allowance for featured frame brands 20%
savings on the amount over your allowance
$70 Walmart®/Costco® frame allowance
$25 copay
Lenses Single vision, lined bifocal, and lined trifocal
lenses
$25 copay
Contact Lenses $130 allowance for contacts; copay does not
apply
Up to $60
Your Vision Plan
Extra $20 to spend on featured frame brands. Go to vsp.com/offers for details. 30% savings on additional glasses and sunglasses, including lens enhancements, from the same VSP provider on the same day as your WellVision Exam. Or get 20% from any VSP provider within 12 months of your last WellVision Exam.
2020-2021 VSP Vision Rates
Monthly Vision Rates
Employee $7.46
Employee + Spouse $11.93
Employee + Children $12.18
Employee + Family $19.64
Enrollment Guide [Template]
Additional Benefits
Learn more on the Protingent benefits website:
protingentbenefits.com
Short-term Disability
The elimination period is as follows:For Injury: 14 daysFor Sickness (includes pregnancy): 14 days
Benefits continue for as long as you are disabled up to a maximum duration of 11 weeks of Disability.
The Benefit amount is 60% of your predisability weekly earnings subject to the plan's maximum weekly benefit of $2,500.
Benefits begin after the end of the elimination period. The elimination period begins on the day you become disabled and is the length of time you must wait, while disabled, before you are eligible to receive a benefit.
Learn more about benefit offerings and rates on the Protingent Employee Benefits website:
protingentbenefits.com
Voluntary Long-term Disability
Long Term Disability: The Long-Term Disability benefit replaces a portion of your predisability monthly earnings, less other income you may receive from other sources during the same Disability (e.g., Social Security, Workers’ Compensation, vacation pay etc.).
The Benefit amount is 60% of your predisability monthly earnings.
Learn more about benefit offerings and rates on the Protingent Employee Benefits website:
protingentbenefits.com
Voluntary Life
Build Your Benefit With MetLife's Supplemental Term Life insurance, your employer gives you the
opportunity to buy valuable life insurance coverage for yourself, your spouse and your dependent children --
all at affordable group rates.
Learn more about benefit offerings and rates on the Protingent Employee Benefits website:
protingentbenefits.com
Employee Contributions Per Month
Monthly Cost MedicalHDHP
Medical PPO
Dental Vision
Employee- $175 $36.06 $7.46
Employee / Partner $750 $1,100 $71.69 $11.93
Employee / Children $300 $550 $75.58 $12.18
Employee + Family $1,050 $1,480 $118.50 $19.64
Contact Information and Resources
BENEFIT PROVIDER WEBSITE / EMAIL PHONE
Medical Admin Meritain meritain.com 800-925-2272
Medical Network Aetna aetna.com 877-204-9186
Pharmacy Magellan Rx magellanrx.com 1.800.424.0472
Dental Life and AD&D MetLife metlife.com 800-275-4638
Vision VSP vsp.com 800-877-7195
HR Human Resources Department at Protingent
[email protected] 425-284-7777
Claims Advocate Kris Kirkpatrick [email protected] 425-778-2800
The U.S. government requires companies offering
certain employee benefit plans to inform covered
employees and their dependents about
laws/provisions that affect the governance and/or
coverage within those plans. The company has full
details available for you concerning the following
laws/provisions:
Summaries of each can be found in the Your
Required Notices brochure. For complete
information and more detailed explanations about
any of these notices, contact Protingent’s Human
Resources department. Also, from time to time,
you may receive detailed explanations directly
from the company via letter or email.
• Wellness Program Disclosure Notice of
Alternative Standard
• Medicare Part D Notice
• Children’s Health Insurance Program
(CHIP) Notice
• Grandfather Status
• Notice of Patient Protection Provisions
• COBRA Notice
• Medical Child Support Order Notice
• Women’s Health and Cancer Rights Act
• Summary of Benefits and Coverage
• Mental Health Parity and Addiction Equity Act
(MHPAEA) Notice
Required Notices