2022 Partner Benefit Guide - Visit your benefits website, thriveatweaver.com
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Visit your benefits website,
thriveatweaver.com
2022 Partner
Benefit Guide
Table of Contents Benefits Overview 3 Medical/Rx Benefits 4 Teladoc 5 Health Savings Account (HSA) 5 Dental Benefits 6 Vision Benefits 6 Basic Life and AD&D Insurance 7 Voluntary Life and AD&D Insurance 7 Long-Term Disability Insurance 7 Voluntary Critical Illness, Accident, Hospital Indemnity 8 (Only available during annual open enrollment) Additional Voluntary Benefits 9 Legal Updates 10 Premium Assistance Under Medicaid and 11 the Children’s Health Insurance Program (CHIP) Important Notice for Weaver about your Prescription Drug Coverage 12 Contact Information 14 Partner Premiums for Benefits 14 If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, a Federal Law gives you choices about your prescription drug coverage. Please see page 13 for more details. This document is an outline of the coverage proposed by the carrier(s), based on information provided by your company. It does not include all of the terms, coverage, exclusions, limitations, and conditions of the actual contract language. The policies and contracts themselves must be read for those details. Policy forms for your reference will be made available upon request. The intent of this document is to provide you with general information regarding the status of, and/or potential concerns related to, your current employee benefits environment. It does not necessarily fully address all of your specific issues. It should not be construed as, nor is it intended to provide, legal advice. Questions regarding specific issues should be addressed by your general counsel or an attorney who specializes in this practice area. 2022 2 Weaver
Benefits Overview Weaver is proud to offer a comprehensive benefits package to eligible, full-time partners who work 30 hours per week on a regular basis, or a variable-hour partner who is credited with 1,560 hours during measurement period under ACA. Medical/Rx Basic Life/AD&D Insurance Voluntary Hospital Indemnity TelaDoc Long-Term Disability Progyny Dental Voluntary Life/AD&D Insurance Adoption Assistance Vision Voluntary Critical Illness Milk Stork Health Savings Account (HSA) Voluntary Accident Pet Insurance Eligible dependents are your spouse, children under age 26, and disabled dependents of any age. A $100 monthly surcharge will be applied for any spouse who is employed and who is eligible for medical coverage through his/her own employer, but chooses to join the Weaver medical plan. Elections made now will remain throughout calendar year 2022 unless you or your family members experience a qualifying event. If you experience a qualifying event, you must contact HR within 31 days. Phone: 844.373.3960 Email: bac.weaverbenefits@ajg.com Monday through Friday Visit thriveatweaver.com for more benefit information. 2022 3 Weaver
Medical/Rx Benefits
Administered by Blue Cross Blue Shield of Texas
Comprehensive and preventive healthcare coverage is important in protecting you and your family from the financial risks of unexpected
illness and injury. A little prevention usually goes a long way—especially in healthcare. Routine exams and regular preventive care provide an
inexpensive review of your health. Small problems can potentially develop into large expenses. By identifying the problems early, often they
can be treated at little cost.
Comprehensive healthcare also provides peace of mind. In case of an illness or injury, you and your family are covered with an ex-
cellent medical plan through Weaver.
Weaver offers you a choice of two Medical Plans—a Low and High plan to suit your own needs.
With a High Deductible Health Plan, you may select where you receive your medical services. If you use in-network providers, your costs will
be less.
In-Network Out-of-Network In-Network Out-of-Network
Annual Deductible
(individual/family) $2,800/$5,200 $5,000/$10,000 $4,000/$8,000 $8,000/$16,000
Annual Out-of-Pocket
Maximum
(includes calendar year $5,000/$10,000 $10,000/$20,000 $5,000/$10,000 $10,000/$20,000
deductible)
Coinsurance
DOCTOR’S OFFICE
Wellness Care
immunizations, well
baby care and mammograms)
Retail—Generic Drug $10 copay after $10 copay after $10 copay after $10 copay after
(30-day supply) deductible deductible deductible deductible
Drug $30 copay after $30 copay after $30 copay after $30 copay after
(30-day supply) deductible deductible deductible deductible
Brand Drug $50 copay after $50 copay after $50 copay after $50 copay after
(30-day supply) deductible deductible deductible deductible
$25 copay after $25 copay after $25 copay after $25 copay after
(90-day supply) deductible deductible deductible deductible
Mail Order—Preferred
Brand Drug $62.50 copay after $62.50 copay after $62.50 copay after $62.50 copay after
(90-day supply) deductible deductible deductible deductible
Mail Order—Non-Preferred
Brand Drug $125 copay after $125 copay after $125 copay after $125 copay after
(90-day supply) deductible deductible deductible deductible
Emergency Room 80% of allowable amount 80% of allowable amount 80% of allowable amount 80% of allowable amount
after deductible after deductible after deductible after deductible
Hospital Deductible 80% of allowable amount 50% of allowable amount 80% of allowable amount 50% of allowable amount
after deductible after deductible after deductible after deductible
Urgent Care 80% of allowable amount 50% of allowable amount 80% of allowable amount 50% of allowable amount
after deductible after deductible after deductible after deductible
Inpatient 80% of allowable amount 50% of allowable amount 80% of allowable amount 50% of allowable amount
after deductible after deductible after deductible after deductible
80% of allowable amount 50% of allowable amount 80% of allowable amount 50% of allowable amount
after deductible after deductible after deductible after deductible
2022 4 Weaver
Teladoc
Teladoc gives you access 24 hours, 7 days a week to a U.S. board-certified doctor through the convenience of phone, video
or mobile app visits. It's an affordable option for quality medical care. Talk to a doctor anytime for $55.
Get the care you need
Teladoc doctors can treat many medical conditions, including:
- Cold & Flu Symptoms - Respiratory Infection
- Allergies - Sinus Problems
- Pink Eye - Skin Problems
- Ear Infection
Visit Teladoc.com or call 1.800.Teladoc
Health Savings Account (HSA)
Weaver offers a HSA option for partners who elect medical coverage, the following amounts may be contributed.
If you (the partner) are 55 or older but less than age 65, you may contribute an additional $1,000 each year.
2022 HSA IRS Maximum:
2022 5 Weaver
Dental Benefits
Insured by Guardian
Good oral care enhances overall physical health, appearance and mental well-being. Problems with the teeth and gums are
common and easily treated health problems. Keep your teeth healthy and your smile bright with one of the three Weaver
dental benefit plans offered.
NETWORK
Annual Deductible $50 individual $50 individual
$150 family $150 family
Annual Benefit Maximum
(per calendar year) See Schedule of Benefits
Ortho Benefit Maximum
See Schedule of Benefits
(cleanings, exams, x-rays)
Basic Dental Services
See Schedule of Benefits
Major Dental Services
See Schedule of Benefits
See Schedule of Benefits
Vision Benefits
Insured by Guardian
Regular eye examinations can not only determine your need for corrective eyewear but also may detect general health
problems in their earliest stages. Protection for the eyes should be a major concern to everyone. Eye care is a vital component
of a healthy lifestyle. With vision insurance, having regular exams and purchasing contacts or glasses is simple and
affordable. The coverage is inexpensive, yet the benefits can be significant! Guardian provides rich, flexible plans that allow
you to safeguard your health while saving you money. Review your plan options and see why vision insurance may be a great
benefit for you. Visit any doctor with your Full Feature plan, but save by visiting any of the 50,000+ locations in the nation’s
largest vision network.
IN-NETWORK OUT-OF-NETWORK
You pay (after copay if applicable)
(waived for elective contact lenses)
Single Vision Lenses Amount over $47
Lined Bifocal Lenses Amount over $66
Amount over $85
Amount over $125
Frames Amount over $47
Elective Amount over $150 Amount over $120
Amount over $210
No Need for an ID card. To take advantage of you VSP vision benefit, simply contact a VSP provider and let them know you
have VSP coverage—they handle the paperwork for you.
2022 6 WeaverBasic Life and Accidental Death & Dismemberment Insurance Insured by Sun Life Basic Life/AD&D insurance provides financial security for the people who depend on you. Your beneficiaries will receive a lump -sum payment if you die or become dismembered while employed by Weaver. Basic Life insurance is provided to all eligible partners, at 2 times of your annual benefit salary, up to $1,000,000. Voluntary Life and AD&D Insurance Insured by Sun Life You may purchase life and AD&D insurance in addition to the company-provided coverage. You may also purchase life and AD&D insurance for your dependents if you purchase additional coverage for yourself. Partner—$1,000,000 or 5 times annual benefit salary, whichever is less. Coverage is guaranteed up to $200,000 without an- swering medical questions if you enroll when you are first eligible. Spouse—Up to 100% of partner amount in increments of $10,000; not to exceed $500,000. Coverage is guaranteed up to $30,000 without answering medical questions if you enroll when you are first eligible. Children—$10,000 (14 days to 6 months $500, no benefit prior to 14 days) Long-Term Disability Insurance Insured by Sun Life Meeting your basic living expenses can be a real challenge if you become disabled. Your options may be limited to personal savings, spousal income and possibly Social Security. Disability insurance provides protection for your most valuable asset— your ability to earn an income. Benefits begin 180 days after disability due to an injury, hospitalization or illness and can continue up to your Normal Social Security Retirement Age. Benefit Amounts— 60% of monthly benefit salary Benefit Maximum— $20,000 per month for Partners 2022 7 Weaver
Voluntary Critical Illness (Only available during annual open enrollment)
Insured by Guardian
Being diagnosed with a critical illness can be devastating personally as well as financially. While comprehensive Medical/
Rx Insurance is designed to cover the cost of treatment, the Critical Illness and Cancer policy offered through Guardian
provides a lump sum payment that can be used at your discretion so you can focus on your health.
Pre-existing condition exclusions are waived
Maximum Benefit Amounts
If you have certain wellness visits or screenings,
you can receive a benefit of $50 per insured Employee $10,000 or $20,000
adult or child
$5,000 or $10,000
Pays full amount twice on same illness with a Spouse & Child(ren)
(50% of employee amount)
12-month separation between the diagnosis/
occurrence dates Covered Conditions Include
Coverage available for entire family Heart attack Loss of Sight or Hearing
Child coverage is automatically included at no Organ failure End-stage renal (kidney) failure
additional cost when you elect coverage
Parkinson’s Disease Stroke
Severe Burns 8 Childhood Conditions
Cancer ALS
Please refer to the policy for complete details about these covered conditions.
Voluntary Accident (Only available during annual open enrollment)
Insured by Guardian
Benefits Summary
Accidents can happen to anyone, at any time. While
comprehensive Medical/Rx Insurance is designed to cov- $1,000 initial hospitalization
Hospitalization
er the cost of treatment, the supplemental off-the-job $225 per day up to 365 days
Accident policy offered through Guardian can help pay Emergency Room/Urgent Care $175
for those out-of-pocket costs, or be used on whatever
you need—groceries, utilities, etc. Wellness Benefit $50 per person per year
Physical Therapy $25 (Up to 10 visits)
Voluntary Hospital Indemnity (Only available during annual open enrollment)
Insured by Guardian
Being confined to a hospital can be financially devastating. While comprehensive Medical/Rx insurance is designed to
assist with this cost, Guardian’s supplemental Hospital Indemnity policy pays a policyholder (you) a lump sum benefit
that can be used at your discretion.
Key Features to Consider
No Pre-Existing Condition Waiting Period
Benefits Summary Pays in addition to Medical/Rx insurance benefits
Initial Hospitalization $1,000 Pays a benefit for initial hospital confinement
Daily Hospitalization $200 per day up to 30 days Pays a benefit for daily hospital confinement
Covered with no waiting Portable upon leaving employment
Pregnancy
period
Coverage available for the entire family
2022 8 WeaverProgyny (Family Benefit Solution)
Weaver has partnered with Progyny to cover all of the family planning basics in one convenient place. Progyny helps
you maximize fertility by connecting you with leading infertility specialists to help increase your family's chances of
parenthood with a healthy, timely, and supported
fertility journey.
You’ll get a dedicated patient care advocate who
will help you:
find a clinic that’s right for you
coordinate appointments
answer questions you have along the way
Support you and your family emotionally.
With Progyny, you also get access to a
community of families who are walking the same
road — allowing you to give and receive support.
For more information, support or guidance:
Email: membersupport@progyny.com
Call: Your Personal Care Advocate at 844-930-3343
Adoption Assistance
Progyny will be there to guide you through the adoption process, offering adoption and
surrogacy education and counseling. If you decide to grow your family through adoption, you are
eligible to receive $1,500 in adoption assistance from Weaver. We want to support Weaver
employees no matter how they hope to welcome a new member to their family.
For more information, support or guidance, visit progyny.com
Milk Stork (Breast Milk Shipping Services and Virtual, On-Demand Lactation Consulting)
Milk Stork’s breast milk delivery service makes life easier for Weaver’s busy moms by giving them the ability to
conveniently travel with or ship breastmilk home while they are away. At beastpumps.com,
Weaver moms can learn about and shop for breast pumps and order their free pump through
their insurance. Breastpumps.com make it easy to determine which pumps will work best for
every mum and have them delivered straight to their doorsteps.
Visit www.milkstork.com/weaver for more information
Pet Insurance (Direct Bill option through Pet Benefit Solutions)
We are offering you Pet Insurance through Pet Benefit Solutions. Wishbone Pet
Insurance is a comprehensive pet health insurance plan that offers maximum coverage
in the event of any accidents and illnesses. Enjoy high-value, easy-to-use insurance so
your best friend can live their best life.
Coverages Includes:
- Accidents & illnesses - Hospitalization
- Diagnostics & testing - Emergency care
- Hereditary & congenital conditions - And more!
- Surgery
Visit www.petbenefits.com/land/weaver for more information
202 9 WeaverLegal Updates
The Women’s Health And Cancer Rights Act
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998
(WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending
physician and the patient, for:
All states of reconstruction of the breast on which the mastectomy was performed;
Surgery and reconstruction of the other breast to produce a symmetrical appearance;
Prostheses; and
Treatment of physician complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under the
plan.
HIPAA Special Enrollment Rights
Loss of Other Coverage
Our records show that you are eligible to participate in Weaver & Tidwell, LLP’s group health plan (to actually participate, you must complete an
enrollment form and pay part of the premium through payroll deduction).
A federal law called HIPAA requires that we notify you about an important provision in the plan - your right to enroll in the plan under its “special
enrollment provision” if you acquire a new dependent, or if you decline coverage under this plan for yourself or an eligible dependent while other
coverage is in effect and later lose that other coverage for certain qualifying reasons.
Loss of Other Coverage (Excluding Medicaid or a State Children’s Health Insurance Program). If you decline enrollment for yourself or for an eligible
dependent (including your spouse) while other health insurance or group health plan coverage is in effect, you may be able to enroll yourself and
your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or
your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or
after the employer stops contributing toward the other coverage).
Loss of Coverage for Medicaid or a State Children’s Health Insurance Program. If you decline enrollment for yourself or for an eligible dependent
(including your spouse) while Medicaid coverage or coverage under a state children’s health insurance program is in effect, you may be able to
enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request
enrollment within 60 days after your or your dependents’ coverage ends under Medicaid or a state children’s health insurance program.
New Dependent by Marriage, Birth, Adoption, or Placement for Adoption. If you have a new dependent as a result of marriage, birth, adoption, or
placement for adoption, you may be able to enroll yourself and your new dependents. However, you must request enrollment within 30 days after
the marriage, birth, adoption, or placement for adoption.
Eligibility for Medicaid or a State Children’s Health Insurance Program. If you or your dependents (including your spouse) become eligible for a state
premium assistance subsidy from Medicaid or through a state children’s health insurance program with respect to coverage under this plan, you
may be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days after your or your
dependents’ determination of eligibility for such assistance.
To request special enrollment or to obtain more information about the plan’s special enrollment provisions, contact Weaver & Tidwell, LLP Human
Resources Office at 817.332.7905
HIPAA Privacy Notice
Weaver & Tidwell, LLP is committed to the privacy of your health information. The administrators of Weaver & Tidwell LLP’s health plan (the “Plan”)
use strict privacy standards to protect your health information from unauthorized use or disclosure. The plan’s policies protecting your privacy rights
and your rights under the law are described in the plan’s Notice of Privacy Practices. You may receive a copy of the Notice of Privacy Practices by
contacting Weaver & Tidwell, LLP Human Resources Office at 817.332.7905.
Newborn’s and Mother’s Health Protection Act
Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection
with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section.
However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the
mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a
provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
2022 10 WeaverPremium Assistance Under Medicaid and the Children's Health
Insurance Program (CHIP)
PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assis-
tance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or
CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance
Marketplace. For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find
out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your depend-
ents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find
out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must
allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage
within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of
Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is
current as of July 31, 2021. Contact your State for more information on eligibility.
STATE ASSISTANCE WEBSITE PHONE
Alabama Medicaid http://myalhipp.com 855-692-5447
Alaska Medicaid The AK Health Insurance Premium Payment Program: http://myakhipp.com/ 866-251-4861
Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.asp CustomerService@MyAKHIPP.com
Arkansas Medicaid http://myarhipp.com 1-855-MyARHIPP (855-692-7447)
California Medicaid https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx 916-440-5676
Colorado Health First Colo- Health First Colorado: https://www.healthfirstcolorado.com/ Health First Colorado: 800-221-3943
rado/Child Health CHP+: Colorado.gov/HCPF/child-health-plan-plus CHP+: 800-359-1991
Plan Plus/Health Health Insurance Buy-In Program (HIBI): https://www.colorado.gov/pacific/hcpf/health- HBIB: 1-855-692-6442
Insurance Buy-In insurance-buy-program (State relay 711)
Program
Florida Medicaid https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/index.html 877-357-3268
Georgia Medicaid https://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp 678-564-1162 ext 2131
Indiana Medicaid Healthy Indiana Plan for low-income adults 19-64: http://www..in.gov/fssa/hip/ 877-438-4479
All other Medicaid: http://www.indianamedicaid.com 800-403-0864
Iowa Medicaid http://dhs.iowa.gov/hawk-I / https://dhs.iowa.gov/ime/members 800-257-8563
Kansas Medicaid http://www.kdheks.gov/hcf/default.htm 1-800-792-4884
Kentucky Medicaid https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx 1-855-459-6328
KIHIPP.PROGRAM@ky.gov 1-877-524-4718
https://kidshealth.ky.gov/Pages/index.aspx
https://chfs.ky.gov
Louisiana Medicaid httpwww.medicaid.la.gov 888-695-2447
Maine Medicaid http://www.maine.gov/dhhs/ofi/public-assistance/index.html 800-442-6003
TTY: Maine relay 711
Massachusetts Medicaid /CHIP http://www.mass.gov/eohhs/gov/departments/masshealth/ 800-462-1120
Minnesota Medicaid http://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and- 800-657-3739
services/other-insurance.jsp
Missouri Medicaid http://www.dss.mo.gov/mhd/participants/pages/hipp.htm 573-751-2005
Montana Medicaid http://dphhs.mt.gov//MontanaHealthcarePrograms/HIPP 800-694-3084
2022 11 WeaverSTATE ASSISTANCE WEBSITE PHONE
Phone: 855-632-7633, Lincoln: 402-473-7633,
Nebraska Medicaid http://www.ACCESSNebraska.ne.gov
Amaha: 402-595-1178
Nevada Medicaid https://dhcfp.nv.gov 800-992-0900
New Hampshire Medicaid http://www.dhhs.nh.gov/ombp/nhhpp/ 603-271-5218 or 888-901-4999
Medicaid: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/ Medicaid: 609-631-2392
New Jersey Medicaid/CHIP
CHIP: http://www.njfamilycare.org/index.html CHIP: 800-701-0710
New York Medicaid http://www.nyhealth.gov/health_care/medicaid/ 800-541-2831
North Carolina Medicaid http://dma.ncdhhs.gov/ 919-855-4100
North Dakota Medicaid http://www.nd.gov/dhs/services/medicalserv/medicaid/ 844-854-4825
Oklahoma Medicaid/CHIP http://www.insureoklahoma.org 888-365-3742
http://healthcare.oregon.gov/Pages/index.aspx
Oregon Medicaid 800-699-9075
http://www.oregonhealthcare.gov/index-es.htm
http://www.dhs.pa.gov/provider/medicalassistance/
Pennsylvania Medicaid 800-692-7462
healthinsurancepremiumpaymenthippprogram/index.htm
Rhode Island Medicaid http://www.eohhs.ri.gov/ 855-697-4347
South Carolina Medicaid http://www.scdhhs.gov 888-549-0820
South Dakota Medicaid http://dss.sd.gov 888-828-0059
Texas Medicaid http://gethipptexas.com/ 800-440-0493
Medicaid: https://medicaid.utah.gov/
Utah Medicaid/CHIP 877-543-7669
CHIP: http://health.utah.gov/chip
Vermont Medicaid http://www.greenmountaincare.org/ 800-250-8427
Medicaid: http://www.coverva.org/programs_premium_assistance.cfm Medicaid: 800-432-5924
Virginia Medicaid/CHIP
CHIP: http://www.coverva.org/programs_premium_assistance.cfm CHIP: 855-242-8282
http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-
Washington Medicaid 800-562-3022 ext. 15473
payment-program
West Virginia Medicaid http://mywvhipp.com/ 855-699-8447
Wisconsin Medicaid/CHIP https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf 800-362-3002
Wyoming Medicaid https://wyequalitycare.acs-inc.com/ 307-777-7531
To see if any other states have added a premium assistance program since July 31, 2021, or for more information on special enrollment rights,
contact either:
U.S. Department of Labor U.S. Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare & Medicaid Services
www.dol.gov/agencies/ebsa www.cms.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection
displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a
collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no
person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB
control number. See 44 U.S.C. 3512.
The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are
encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to
the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue,
N.W., Room N-5718, Washington, DC 20220 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.
2022 12 WeaverImportant Notice from Weaver about your Prescription
Drug Coverage
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with
Weaver & Tidwell, LLP and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not
you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are cov-
ered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where
you can get help to make decisions about your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare
Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans
provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
2. Weaver has determined that the prescription drug coverage offered by the Weaver plan is, on average for all plan participants, expected to pay
out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing cover-
age is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join a Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from Oct. 15 – Dec. 7. However, if you lose your
current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two-month Special Enrollment Period
(SEP) to join a Medicare drug plan.
What Happens to Your Current Coverage if You Decide to Join a Medicare Drug Plan?
If you decide to join a Medicare drug plan, your current coverage from Weaver will not be affected. If you do decide to join a Medicare drug plan
and drop your current Weaver coverage, be aware that you and your dependents will still be able to get this coverage back during the Annual
Enrollment period under Weaver Health Benefits Plan.
When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with Weaver & Tidwell, LLP and don’t join a Medicare drug plan within 63
continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the
Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months
without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have
to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the fol-
lowing October to join.
For More Information About This Notice or Your Current Prescription Drug Coverage
Contact the person listed below for further information. You’ll get this notice each year. You will also get it before the next period you can join a
Medicare drug plan, and if this coverage through Weaver & Tidwell, LLP changes. You also may request a copy of this notice at any time.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information
collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather
the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Bal-
timore, Maryland 21244-1850.
For More Information About Your Options Under Medicare Prescription Drug Coverage
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of
the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.
For more information about Medicare prescription drug coverage:
Visit www.medicare.gov
Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their
telephone number) for personalized help
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra
help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this creditable coverage notice. If you decide to join one of the
Medicare drug plans, you may be required to provide a copy of this notice when you join
to show whether or not you have maintained creditable coverage and, therefore,
whether or not you are required to pay a higher premium (a penalty).
Date: January 2022
Name of Entity/Sender: Weaver & Tidwell, LLP
Contact: Demetrice Branch
Phone Number: 817.332.7905
Email: demetrice.branch@weaver.com
2022 13 WeaverContact Information
If you have specific questions about any of the benefit plans, please contact the administrator listed below, or your local human re-
sources department.
PHONE OTHER
Medical/Rx Customer Service BCBS of TX 1.800.521.2227 www.bcbstx.com
Helpline
Medical Preauthorization BCBS of TX 1.800.441.9188 www.bcbstx.com
Helpline
Mental Health/Chemical
Dependency Pre-authorization BCBS of TX 1.800.528.7264 www.bcbstx.com
Helpline
Dental 1.866.633.2446 www.guardianlife.com
Vision 1.877.814.8970 www.guardianlife.com
Basic and Voluntary Life/AD&D Sun Life 1.800.247.6875 www.sunlife.com
Long Term Disability Sun Life 1.800.247.6875 www.sunlife.com
Voluntary Critical Illness Guardian 1.800.268.2525 www.guardiananytime.com
Voluntary Accident Guardian 1.800.541.7846 www.guardiananytime.com
Voluntary Hospital Indemnity Guardian 1.800.268.2525 www.guardiananytime.com
Progyny Progyny 1.844.930.3343 membersupport@progyny.com
Adoption Assistance Progyny 1.844.930.3343 www.progyny.com
Pet Benefit Solutions petbenefits.com/land/weaver
Pet Insurance Group #5130 1.800.891.2565 customercare@petbenefits.com
www.milkstork.com/weaver Monday – Friday
Milk Stork Milk Stork 1.510.356.0221 8:00 a.m. – 5:00 p.m.
Partner Premiums for Benefits
LOW HIGH
MEDICAL/Rx (Semi-Monthly) (Semi-Monthly)
Partner
Partner + Children
Family
DENTAL (Semi-Monthly) (Semi-Monthly) (Semi-Monthly)
Partner $6.19
Partner + Children
Family
VISION (Semi-Monthly)
Partner $5.91
$9.95
Partner + Children
Family
2022 14 WeaverVisit your benefits website,
thriveatweaver.com
2022 Partner
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