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Employee Benefits Enrollment Guide Plan Year: October 1, 2016 – September 30, 2017 Design © 2008-2014 Zywave, Inc. All rights reserved. Who is Eligible? If you are a full-time employee (working 35 or more hours per week) you are eligible to enroll in the benefits described in this guide. The following family members are eligible for medical, dental and vision coverage: spouse and dependent children 26 years or younger. How to Enroll Complete an application form and return at least 15 days before your effective date. You may elect medical, dental, and vision or any of these separately. Once you have made your elections, you will not be able to change them until the next open enrollment period (October 1st each year) unless you have a qualified change in status. When to Enroll You must enroll at least 15 days before the end of your 60-day introductory period. The benefits you elect at this time will be effective through September 30, 2017. How to Make Changes Unless you have a qualified change in status, you cannot make changes to the benefits you elect until the next open enrollment period. Qualified changes in status include, for example: marriage, divorce, legal separation, birth or adoption of a child, change in child’s dependent status, death of spouse, child or other qualified dependent, change in residence, commencement or termination of adoption proceedings, change in employment status or change in coverage under another employer-sponsored plan. What’s New for 2016 Bright Start offers plans through Innovation Health for the following lines of coverage: Medical Dental Vision Medical and Prescription Drugs Several changes have been implemented to our medical and prescription drug benefits for the upcoming plan year October 1, 2016 to September 30, 2017. Our HMO plan is an open access plan that allows you to select a primary care physician or secure a referral from one provider to another. As a reminder, the plan does not provide coverage when you use out-of-network providers. Innovation Health Silver Open HMO 2000 100% Renewal As of October 1, 2016 Services Physician Visit PCP - $45 Copay/Specialist - $75 Copay Deductible - Individual - Family $2,000 $4,000 Hospitalization Deductible, then $500 Copay/admission Preventive Care No Charge based on age/frequency schedules Emergency Room $350 Copay Out-of-Pocket Max - Individual - Family $6,850 $13,700 Prescription Drugs - Retail/Mail Order - Generic - Preferred - Non-Preferred Tier 1A preferred generic - $3/$7.50 Tier 1 – preferred generic - $15/$37.50 Preferred brand - $50/$125 Non preferred generic/brand - $100/$250 Specialty - $300 Copay Your Cost in 2016-2017 EMPLOYEE BI-WEEKLY DEDUCTIONS Employee Only HMO $68.41 Employee & Spouse $136.82 Employee & Children $133.40 Employee & Family $201.81 Dental The dental plan offered will be the Aetna PPO Max 1500 B which has both in/out of network benefits and allows you to seek treatment from the dentist of your choice. Balance bill may apply to out of network dentists. Services Amount You Pay Preventive Services Exams, cleanings, x-rays – 100% in/out network Deductible Applies to basic and major services only – $50/$150 Basic Services Fillings, simple extractions, root canal – Deductible applies. Coinsurance is 80/20 in/out network Major Services Oral surgery, dentures, crowns – Deductible applies. Coinsurance is 50/50 in/out of network Annual Maximum $1,500 Bi-Weekly Deduction Employee only – $7.48 Employee & Spouse – $14.44 Employee & Child – $17.74 Family – $24.70 Vision When you are enrolled in our medical plan you also eligible to participate in vision benefits. If you utilize the services of a provider listed in the Preferred Provider Directory, your benefits include routine vision exams for a $10 copay every 12 months, and preferred pricing on a large selection of brand-name, designer frames, lenses, and lens options every 12 months. The frame allowance is $130 and new frames are allowed every 12 months. Bi-Weekly Deduction Employee only – $1.66 Employee & Spouse – $3.15 Employee & Child – $3.32 Family – $4.88 The information in this Enrollment Guide is presented for illustrative purposes and is based on information provided by the employer. The text contained in this Guide was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of discrepancy between the Guide and the actual plan documents the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any questions about your Guide, contact Human Resources. Questions & Answers Forms to be completed if you w ould like to enroll : Medical & Dental Enrollment Form to add medical plans for you and any of your dependents that you would like to enroll. Vision Enrollment Form to enroll in the vision plan Where do I find these forms? All enrollment forms are on Bright Start’s website under the “For Employees” tab. You may also see Kerri for a copy or for assistance with completing the enrollment form. When are the forms due and w here do I return them? All forms are due by 15 days before the end of your introductory period and must be returned to Kerri Chase’s inbox in the office. Who do I contact with questions? Contact Kerri Chase with any questions you may have.