Pavement Restoration 2019 (Arizona)

Pavement Restoration 2019 (Arizona)

Arizona

CONTENTS & CONTACT INFORMATION

Refer to this list when you need to contact one of your benefit vendors. For general information contact Human Resources.

BROKER Provider Name Broker Contact

M.E. Wilson Company

Amanda Sands

Provider Phone Number Provider Email Address

813-229-8021 Ext. 139 [email protected]

MEDICAL

page 3

Provider Name

United Healthcare

Provider Phone Number Provider Web Address

866-633-2446

www.myuhc.com.com

DENTAL

page 5

Provider Name

Mutual of Omaha

Provider Phone Number Provider Web Address

877-999-2330

www.mutualofomaha.com

VISION

page 6

Provider Name

Mutual of Omaha

Provider Phone Number Provider Web Address

877-999-2330

www.mutualofomaha.com

BASIC AND VOLUNTARY LIFE

_____________ Mutual of Omaha

page 7

Provider Name

Provider Phone Number Provider Web Address

877-999-2330

www.mutualofomaha.com

SUPPLEMENTAL BENEFITS

___________________

page 8

Provider Name

Aflac – Jay Diaz 800-992-3522 www.aflac.com

Provider Phone Number Provider Web Address

DISCLOSURE NOTICES

page 9

BENEFIT INFORMATION

Benefit

Who pays the cost?

Pavement Restoration pays the majority of the employee portion of the medical plan. You may enroll your eligible dependents for an additional cost.

Medical Insurance

YOUR BENEFITS PLAN

You may elect dental coverage for yourself and your eligible dependents on a voluntary basis and you will be responsible for the cost.

Pavement Restoration offers a variety of benefits allowing you the opportunity to customize a benefits package that meets your personal needs. In the following pages, you’ll learn more about the benefits offered. You’ll also see how choosing the right combination of benefits can help protect you and your family’s health and finances – and your family’s future .

Dental Insurance

You may elect vision coverage for yourself and your eligible dependents on a voluntary basis and you will be responsible for the cost.

Vision Insurance

You may elect voluntary life coverage for yourself and your eligible dependents on a voluntary basis and you will be responsible for the cost.

Voluntary Life Insurance

Pavement Restoration pays the entire cost for employee coverage.

Basic Life

Voluntary Supplemental Benefits

The employee pays the entire cost.

ELIGIBILITY

All Regular full-time employees are eligible to join the Pavement Restoration Benefits Plan on the 1st of the month following 60- Days. “Regular Full-Time Employees” must be regularly scheduled and working at least 30 hours per week.

You may also enroll your dependents in the Benefits Plan when you enroll.

Eligible dependents include:

Your legal spouse

•

• Your married or unmarried natural children, step-children living with you, legally adopted children and any other children for whom you have legal guardianship, who are:

WHEN CAN YOU ENROLL?

► Under 26 years of age;

► A dependent who is older than 26 years of age, but less than 30 years of age may be eligible for medical benefits. To be eligible, a Dependent must: • Be unmarried and not have dependents of his or her own; AND

You can sign up for Benefits at any of the following times:

• After completing your initial eligibility period; • During the annual open enrollment period; • Within 30 days of a qualified family-status change.

Be a resident of Florida or a student; AND

•

• Not have coverage of their own, or covered under any other plan, including Medicare

If you do not enroll at one of the above times, you may enroll during the next annual open enrollment period.

1

BENEFIT INFORMATION

?

CHOOSING YOUR BENEFITS

You must actively choose any benefit that you pay for, or share in the cost with Pavement Restoration . Your part of the cost is automatically taken out of your paycheck. There are two ways that the money can be taken out:

WHY DO I PAY FOR BENEFITS WITH BEFORE-TAX MONEY?

There is a definite advantage to paying for some benefits with before-tax money: Taking the money out before your taxes are calculated lowers the amount of your pay that is taxable. Therefore, you pay less in taxes.

• BEFORE YOUR TAXES ARE CALCULATED – medical, dental, and vision

• AFTER YOUR TAXES ARE CALCULATED – voluntary life and accidental death & dismemberment, supplemental benefits

MAKING CHANGES

Generally, you can only change your benefit choices during the annual benefits enrollment period. However, you may be able to change your benefit choices during the plan year if you have a change in status including:

If you fail to notify Human Resources within 30 days of a family status change, you will be required to wait until the next annual enrollment period to make benefit changes unless you have another family status change.

Your marriage

•

Your divorce or legal separation

•

Birth or adoption of an eligible child

•

Death of your spouse or covered child

•

• Change in your spouse’s work status that affects his or her benefits

• Change in your work status that affects your benefits

WHEN COVERAGE ENDS

• Change in residence or work site that affects your eligibility for coverage

Coverage will stop on the last day of the month in which employment with the company ends.

• Change in your child’s eligibility for benefits

• Receiving Qualified Medical Child Support Order (QMCSO)

KEY BENEFIT TERMS

Copayment – A flat fee that you pay for medical services, regardless of the actual amount charged by your doctor or another provider. This generally applies to physicians’ office visits and prescription drugs. Deductible – The amount you pay toward medical and dental expenses each year before the plan begins paying benefits. Out of Pocket Maximum – The maximum amount you will pay in deductibles, coinsurance and copayments during the year.

2

MEDICAL INSURANCE

Pavement Restoration offers two medical plans through United Healthcare. To find participating providers go to www.myuhc.com and click on “Find a Doctor”, then follow the prompts to complete the search. The chart below provides a brief overview of the medical plans. This chart is intended only to highlight the benefits available and should not be relied upon to fully determine your coverage.

If the below illustration of benefits conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your exact description of services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage .

ChoicePlus AQOQ

IN-NETWORK:

Plan Year April 1, 2019 – March 30, 2020

Plan Year or Calendar Year Basis

Deductible (Individual / Family)

$1,500 / $4,500

Coinsurance

80% / 20%

Maximum Out-of-Pocket (Individual/Family)

$4,500 / $9,000

Maximum Out-of-Pocket Includes

Deductible, Coinsurance & Copayments

Lifetime Maximum PREVENTIVE CARE:

Unlimited

Wellness Immunizations Mammography/Colonoscopy COPAYMENTS: Referral Required

Covered 100%

No

Office Visits Consultations for Illness/Injury

$25 Copayment

Specialist Visits

$50 Copayment

Inpatient Hospital

Deductible & Coinsurance Deductible & Coinsurance

Outpatient Surgery Emergency Room Urgent Care

$250 Copayment $75 Copay

OUTPATIENT DIAGNOSTIC SERVICES: Independent/Freestanding Lab Complex Diagnostic (MRI, CT, PET, Etc.) – Freestanding Facility

Covered 100%

Deductible & Coinsurance

PRESCRIPTIONS:

Tier 1: $10 Copay Tier 2: $60 Copay Tier 3: $100 Copay

Retail (30 day supply)

OUT-OF-NETWORK Deductible

$3,000 / $9,000

(Individual / Family)

Maximum Out-of-Pocket (Individual/Family)

$6,250 / $12,500

Coinsurance

60% / 40%

3

MEDICAL CONTRIBUTION SCHEDULE

Employee Pays (Weekly)

ChoicePlus AQOQ

Employee Only

$ 55.93 $217.82 $157.41 $300.59

Employee + Spouse Employee + Child(ren)

Family

4

DENTAL INSURANCE

Pavement Restoration offers two dental plans through Mutual of Omaha. The Dental PPO Plan allows you to use in-network or out-of- network benefits. If out-of-network dentists are used, you will be responsible for pay the difference between Mutual of Omaha’s allowed amount and what the dentist may charge, also known as “balance billing”. The chart below provides a brief overview of the plan.

Low Dental PPO Plan (Option 1)

High Dental PPO Plan (Option 2)

Out-of Network 1

In-Network

In-Network

Out-of Network 1

Calendar Year Deductible Individual

$50

$100 $300

$50

$50

Family

$150

$150

$150

Annual Maximum

$1,000

$1,500 $1,000

Diagnostic & Preventive Exams Cleanings Fluoride X-Rays Sealants Regular Restorative Services Fillings Extractions - Single Tooth Periodontics (Gum Disease) Endodontics (Root Canal) Major Services Crowns

Covered in full

Covered in full

Covered in full

Covered in full

Covered 80% after deductible

Covered 50% after deductible

Covered 80% after deductible

Covered 50% after deductible

Covered 50% after deductible

Covered 25% after deductible

Covered 50% after deductible

Covered 25% after deductible

Bridges Dentures Orthodontia Child Only

Not Available

Not Available

Not Available

Not Available

1 Subject to balance billing. Please refer to your plan document for specific details.

Low PPO Dental Plan (Option 1)

High PPO Dental Plan (Option 2)

Employee Contributions (Weekly)

Employee Only

$ 3.92 $ 9.00 $ 9.92 $14.54

$ 6.23 $14.31 $15.69 $23.08

Employee + Spouse Employee + Child(ren)

Family

5

VISION INSURANCE

Pavement Restoration offers vision coverage through Mutual of Omaha. The Vision Plan allows you to use in-network (EyeMed Providers) or out-of-network benefits. If out-of-network vision providers are used, you will be responsible for pay the difference between Mutual of Omaha’s allowed amount and what the provider may charge, also known as “balance billing”.

Vision

Routine Eye Exams

$10 Copay

Lenses* Single

$25 Copay $25 Copay $25 Copay $25 Copay

Bifocal Trifocal Lenticular

Frames

$100 allowance, less applicable copay

Contact Lenses

$100 allowance, less applicable copay

Frequency Exam

Once every 12 months

Lenses or contact lenses

Once every 12 months

Frame

Once every 24 months

• Lenses, Frames & Contacts are limited to either one pair of contacts or frames/lenses per calendar year.

Employee Contributions (Weekly)

Vision

Employee Only

$1.51 $2.54 $2.59 $4.10

Employee + Spouse Employee + Child(ren)

Family

6

BASIC LIFE AND AD&D & VOLUNTARY LIFE INSURANCE

BASIC LIFE INSURANCE Pavement Restoration provides life insurance to all active full time employees at no cost to the employee. The chart below provides an overview of the plan.

Basic Life Insurance

Employee Benefit Amount

$15,000

35% at age 65 60% at age 70 75% at age 75

Age Reduction Schedule

Included Equal to basic life

Accidental Death & Dismemberment (AD&D)

VOLUNTARY LIFE INSURANCE

Pavement Restoration provides all active employees working 30 or more hours per week the option to purchase life insurance coverage through a group plan, at the employee’s cost. The chart below provides an overview of the plan. Please note that anyone enrolling outside of their initial open enrollment period is considered a late entrant and will be subject to medical underwriting.

Voluntary Life Insurance

Employee Life

Increments of $25,000 up to $200,000

Employee Guarantee Issue

$100,000 for timely entrants

Spouse Life

Increments of $5,000 up to 100% of employee's amount or $100,000

Spouse Guarantee Issue

$25,000 for timely entrants

10% of employee’s amount not to exceed $10,000 (Coverage limits based on child age.)

Dependent Life

VOLUNTARY LIFE - Weekly

$50,000 Policy (Employee) Election Amount

$75,000 Policy (Employee) Election Amount

$100,000 Policy (Employee) Election Amount

$25,000 Policy (Employee) Election Amount

Age

Employee

Spouse

Child

Employee

Spouse

Child

Employee

Spouse

Child

Employee

Spouse

Child