Benefits Summary ANNUAL OPEN ENROLLMENT - August 1, 2020
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ANNUAL OPEN ENROLLMENT
August 1, 2020
Benefits Summary
Review
About Your Open Enrollment
Annual Benefits Open Enrollment Period: [7/24/2020] to (8/7/2020)]
Welcome to Open Enrollment 2020. Open Enrollment is your annual opportunity to make changes to
your benefits for the new plan year, effective [8/1/2020]. During Open Enrollment you may opt to do the
following:
• Change to existing benefits or waiving coverage
• If you’re waiving coverage, you must show proof of new coverage
• Enroll eligible family members in your health plan
Deadlines
You do not have to re-enroll if you’re not making any changes. All changes must be completed between
7/24/2020 and 8/7/2020.
Questions on Benefit Plans and Changes?
Loomis TPA: 1-800-346-1223
Plan Changes & Information
Health Plan – The Loomis Company
• There are no changes to the current benefits.
• No changes to copays, deductibles and coinsurance
• Teledoc: Free Telemedicine virtual visits for non-emergent care
• Benefit Guide: Please refer to the Summary of Benefits and Coverage (SBC)
Pharmacy Benefit – Express Scripts
• There are no changes to the current pharmacy copays
• Save Money, Ask For Generic Medications
Drug Channel Retail Pharmacy Mail – Home Delivery
Generic Drugs 15% Coinsurance 10% Coinsurance
Preferred Brand (Formulary) 30% Coinsurance 20% Coinsurance
Non-Preferred Brand 70% Coinsurance 60% Coinsurance
Specialty Drugs 15% Coinsurance 15% Coinsurance
Vision Benefit – Reimbursement Plan up to $250 per year
• No change to $10.00 copay
• 1 Eye Exam every 24 months
Dental Benefit: The Loomis Company
• No change to current copays. Annual Plan Maximum $2,500 per member
• Class A Benefits: No charge for routine preventative dental cleanings
• Class B Benefits: 20% Coinsurance
• Class C Benefits: 20% Coinsurance
• Orthodontia: 50% Coinsurance limited to $1,000 per year
Life Insurance: Unum
• Benefit Amount: $25,000
Pre-Tax Contributions & Premium Increases Non Tobacco User Pre-Tax Contributions The following are the bi-weekly contribution rates for benefits that may be paid for on a pre-tax basis: Coverage Tier Medical/Rx Dental Vision Employee $48.45 $4.76 $1.00 Employee + Child(ren) $120.00 $10.51 $2.00 Employee + Spouse $165.00 $10.51 $2.00 Family $175.00 $15.22 $3.00 Tobacco User Pre-Tax Contributions Smoking Cessation is covered at 100% through Express Scripts All FDA approved cessation therapies (Rx and OTC) for a 90 day regimen when prescribed by a health care provider without a prior authorization. Common therapies include: • Nicotrol – spray or inhaler • Nicotine patches and gum • Zyban: bupropion has a generic available • Chantix – varenicline has a generic available The following are the bi-weekly contribution rates for benefits that may be paid for on a pre-tax basis: Coverage Tier Medical/Rx Dental Vision Employee $140.70 $4.76 $1.00 Employee + Child(ren) $253.26 $10.51 $2.00 Employee + Spouse $298.28 $10.51 $2.00 Family $450.23 $15.22 $3.00 Center for Disease Control Resources Guides to Quit Smoking https://www.cdc.gov/tobacco/campaign/tips/partners/health/ https://www.verywellmind.com/your-quit-smoking-toolbox-2825129
Health and Rx Benefits
BENEFIT PLAN DESIGN AmeriHealth - NJ, PA, DE
Effective 8-1-2018 CIGNA - Ohio
IN-NETWORK ONLY PHCS - Medical Emergency Travel Network Inside US
Amounts are "What Employee Pays"
Single Family
Deductible (Single/Family) $300 $500
Coinsurance 10‐20% (After Deductible) ‐ See below Schedules
Out of Pocket Maximum (Medical) $2,500 $5,000
Primary Visit Copay $15
Specialist Visit Copay $25
Preventative Care 0% (No Charge)
Direct Emergency ER Visit: $200.00
Emergency Room Copay (The ER Copay will be Waived if Admitted)
Non‐Emergent: Not Covered
Teledoc ‐ Telemedicine Vendor No Copay
Urgent Care Copay $35
Outpatient Facility
Ambulatory surgery centers 10% Coinsurance (After Deductible)
Hospital Setting 20% Coinsurance (After Deductible)
Outpatient Profesional
Ambulatory surgery centers 10% Coinsurance (After Deductible)
Hospital Setting 20% Coinsurance (After Deductible)
Members are encouraged to receive surgical services at a freestanding facility
Optimize Your Benefits ($)
(Not the Hospital)
Inpatient Facility / Profesional 10% Coinsurance (After Deductible)
Diagnostic Labs & Imaging
Preventative Lab Work No Charge (Covered 100%)
10% coinsurance (After Deductible)
All other outpatient blood work
(Member Limit $100.00 per claim)
Genetic Lab Panels 20% coinsurnace (After Deductible)
Outpatient Imaging
Diagnostic Imaging (X‐Ray) 10% coinsurance (After Deductible)
Free Standing Non‐hospital based Facility Outpatient at Hosptital
Diagnostic Imaging (CT, PET, MRI)
10% After Deductible 20% After Deductible
Members are encouraged to receive imaging services at a freestanding imaging center
Optimize Your Benefits ($)
(Not the Hospital)
Mental Health / Behavior Health or
10% Coinsurance (After Deductible)
Substance Abuse needs
Transplant Covered Services Benefit Now Covered under Swiss RE (CIGNA Life Source)
See Separate Benefit Design
Express Scripts Pharmacy Benefit Effective 8‐1‐2018
Member Responsibility
Generic Drugs Retail: 15% / Mail: 10%
Preferred Brand Retail: 30% / Mail: 20%
Non‐Preferred Brand Retail: 70% / Mail: 60%
Specialty Drugs Member Responsibility 15%
Days Supply (Retail and Mail) Retail: 34 Day Supply Mail Order: 90 Day Supply
Out of Pocket Maximum(Pharmacy) Retail: $2,000 / Mail: $1,500
Optimize Your Benefits ($) Save Money and ask your doctor for Generic Drugs whenever possible
Vision Reimbursement Plan Limit Per Plan Year
Eye Exam $10.00 Copay (1 Eye Exam Every 24 Months)
Glasses/Contacts $250.00 limit per person (glasses, hardware, contacts) ‐ Combined
Dental Insuruance ‐ CIGNA See separate Dental Schedule of Benefits
Loomis TPA (CIGNA)
Summary of Benefits
Dental Insurance
Employer Sponsored Dental
Class Description All Active Full Time Employees (30 Hours)
In-Network Out-of-Network*
R&C
Reimbursement Negotiated Fee Schedule
90th Percentile
Type A – Preventive 100% 100%
Type B – Basic 80% 80%
Type C – Major 50% 50%
Calendar Year B&C B&C
Deductible applies to:
Individual $50 $50
$150 $150
Family Aggregate Aggregate
Calendar Year
Maximum $2,500 $2,500
(applies to A,B,C
services)
Orthodontia 50% 50%
Orthodontia Lifetime
$1,000 $1,000
Maximum
* Out of Network benefits are payable for services rendered by a dentist who is not a participating provider. The Reasonable and
Customary charge is based on the lowest of (1) the dentist’s actual charge (the ‘Actual Charge’), (2) the dentist’s usual charge for the
same or similar services (the ‘Usual Charge’) or (3) the charge of most dentists in the same geographic area for the same or similar
services as determined by MetLife (the ‘Customary Charge’). Services must be necessary in terms of generally accepted dental
standards.
Frequency & Allocations / Exclusions
TYPE A
Benefits are payable immediately from the start date of an individual’s benefits
Examinations 2 times in 1 calendar year
Examinations – Problem Focused Combined with Examinations Limit
Prophylaxis: Cleanings 1 time in 6 months
Sealants 1 per molar in 60 months for a child under
age 14
Fluoride 1 time in 12 months for a dependent child
under age 14
Bitewing X-Rays For a child under 14: 1 time in 12 months
Adult: 1 time in 12 months
Labs & Other Tests
TYPE B
Benefits are payable immediately from the start date of an individual’s benefits
Space Maintainers 1 per lifetime for a child under age 14
Full Mouth X-Rays Once in 60 months
Amalgam Fillings 1 replacement per surface in 24 Months
Periodontal Maintenance 2 perio. Treatments in 1 calendar yr, includes
2 cleanings (total comb: 2)
Periodontal Surgery 1 per quadrant in any 36 month period
Scaling & Root Planing 1 per quadrant in any 24 month period
Repairs 1 in 12 months
Recementations 1 in 12 months
Emergency Palliative Treatment Pulpotomy
Periapical X-Rays Pulp Capping
Other X-Rays Pulp Therapy
Resin Composite Fillings(includes coverage Apexification & Recalcification
for composite fillings on molars)
Pulpotomy Periodontal Surgery – Soft & Connective
Tissue Grafts
Pulp Capping Periodontics – Non-Surgical
Pulp Therapy Oral Surgery: Simple Extractions
Apexification & Recalcification Oral Surgery: Surgical Extractions
TYPE C
Benefits are payable immediately from the start date of an individual’s benefits
Consultations 1 in 12 months
Root Canal 1 per tooth per lifetime
Prefabricated Crowns 1 per tooth in 10 calendar years
Crown Buildups / Post Core 1 per tooth in 10 calendar years
Dentures 1 in 10 calendar years
Immediate Temporary Dentures – Complete 1 replacement in 12 months
/ Partial
Dentures – Rebases / Relines 1 in 36 months
Denture Adjustments 1 in 12 months
Fixed Bridges 1 in 10 calendar years
Inlays / Onlays /Crowns 1 replacement per tooth in 10 calendar years
Implant Services 1 per tooth position in 10 calendar years
Implant Repairs 1 per tooth in 10 calendar years
Implant Supported Prosthetic 1 per tooth in 10 calendar years
Tissue Conditioning 1 in 36 months
Occlusal Adjustments 1 in 12 months
General Anesthesia
See Next Page for Enrollment Form
Be Smart With Your Money Use Express Scripts Mail Order
Cigna Payer Solutions
STICK WITH LABS THAT
DELIVER QUALITY CARE
AT LOWER COSTS.
Cigna network laboratories
and need a pathology test, they may send you to the lab that’s right onsite. But did you know that if you go to
a national lab such as Quest Diagnostics® or Laboratory Corporation of America® (LabCorp), you can save up
to 75%** and still get the same quality service? Even though other labs may be part of the Cigna network, you’ll
get even bigger savings when you go to Quest and LabCorp for your lab work. And with hundreds of locations
nationwide, they make it easy to get lab services at a lower cost.
Keep the cost of lab work low with these savings**:
National labs Other outpatient lab Outpatient hospital lab
Description
average cost average cost average cost
General health panel* $21.85 $43.59 $191.32
Complete blood count (CBC) $5.34 $11.67 $42.26
Prostate screen (PSA) $12.62 $27.58 $71.26
Strep throat $8.34 $15.01 $44.92
Cholesterol $2.96 $6.45 $22.26
Hemoglobin A1C $6.65 $15.17 $47.48
Table shows the average costs for the stated lab services based on 2013 - 2014 claim data. The average allowable
charges were used for these calculations. Costs will vary based on the services provided, location and benefit plan.
* A general health panel consists of a comprehensive metabolic panel (CMP), a complete blood count (CBC) and a thyroid stimulating hormone (TSH).
To find a Quest or LabCorp lab near you, go to myCigna.com or call your TPA at the number on your ID card.
Or, contact the labs directly:
Quest: 800.377.7220 • questdiagnostics.com
LabCorp: 888.522.2677 • labcorp.com
**Claim Data: DOS July 2013 - June 2014. Actual costs will vary.
Health care professionals and facilities that participate in the Cigna network are independent contractors solely responsible for the care and services delivered to their patients. They are not
agents of Cigna.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. The Cigna name, logo,
and other Cigna marks are owned by Cigna Intellectual Property, Inc.
894421 01/16 © 2016 Cigna. Some content provided under license.
IS THERE A GENERIC FOR THAT?
Six simple, money-saving words
When it comes to shopping, most consumers want to know the price of a product and will often look for the best
deal before making a purchase. That’s not always the case when buying prescription drugs, which means many
people are paying more than they should for their medications.
One way to save money on prescriptions is to ask for a generic, which typically costs less because the manufacturer
did not have to conduct the initial research or repeat the studies that the first-to-market branded drug did. Generics
fall into two categories:
Direct chemical equivalent: a drug that has the same active ingredient as its brand-name counterpart
Therapeutic alternative: a drug that may not be chemically equivalent to the brand, but has the same
therapeutic or treatment effect
Think of it this way: direct chemical equivalents are practically identical to the branded product, while therapeutic
alternatives are part of the same family.
SAFETY FIRST
The Food & Drug Administration (FDA) requires generic-drug
“A generic medicine works in the same way
manufacturers to adhere to strict guidelines, ensuring the
safety and effectiveness of all approved generics. In 2017, and provides the same clinical benefit as its
the FDA approved more generic drugs than ever before, brand-name version. This standard applies
including the first generic versions of commonly used to all FDA-approved generic medicines. A
brands like Strattera®, Truvada®, Coreg CR® and generic medicine is the same as a brand-
Vytorin®.* name medicine in dosage, safety,
effectiveness, strength, stability, and
Furthermore, our pharmacy benefit manager, Express
quality, as well as in the way it is taken and
Scripts, protects their supply of drugs from substandard
should be used.”
manufacturing practices and counterfeit products. Their
pharmacies only dispense medications that are
— U.S. Food & Drug Administration
manufactured according to the FDA’s strict standards,
which provide guidance for manufacturing, testing and
quality assurance to ensure product safety.
Here are some other six-word phrases to help keep money-saving generics top-of-mind:
Check it out during your checkup: Before leaving a doctor’s office with prescription in hand, be sure to ask the
doctor or nurse, “Is there a generic for that?”
Give your prescriptions a quick checkup: Review all of your medications regularly with a doctor or pharmacist,
because there may be new, lower-cost treatments available.
Ask about generics before you fill: When you hand over a new prescription to your pharmacist, or during refill or
renewal time, ask, “Is there a generic for that?” The pharmacist can tell you and then call your doctor to discuss
changing the prescription accordingly.
Get the most from your dollars: You can learn more about your specific generics savings opportunities by going to
express-scripts.com and reviewing your prescriptions.
Get the facts from the FDA: Learn more about the benefits of generic drugs and the policies guiding their
development from fda.gov.
* Office of Generic Drugs (OGD) Annual Report for 2017
© 2018 Express Scripts and the “E” Logo are trademarks of Express Scripts Strategic Development Inc. All other trademarks are the property of their respective owners.
FS48077I CRP1807_0336Getting Started with Home Delivery from
the Express Scripts PharmacySM
Online access to savings and convenience
Whether you are viewing the member website or using the Express ScriptsTM mobile app1,
you can easily manage your home delivery prescriptions:
• Check order status
• Refill and renew prescriptions
• Check prices and coverage
• Find convenient pharmacies
• View your Rx claims and balances
• Pay your balance using a variety of payment options
• View our therapeutic resource centers for information
• And much more
To access the member website …
Log in to express-scripts.com (Register if it is your
first visit. Just have your member ID or SSN handy.)
If you have a NEW prescription …
Get started by contacting your doctor to request a
90-day prescription that he or she can ePrescribe
directly to Express Scripts
Or print a form by selecting “Forms” or “Forms & Cards” from the menu under “Benefits,” print a mail
order form and follow the mailing instructions.
Or call us and we’ll contact your doctor for you.
Please allow 10 to 14 days for your first prescription order to be shipped.
If you already have a prescription …
Check Order Status online or using our app to view details and track shipping.
Transfer retail prescriptions to home delivery. Just click Add to Cart for eligible prescriptions and check out.
We’ll contact your provider on your behalf and take care of the rest. Check Order Status to track your order.
Refill and Renew Prescriptions for yourself
and your family while online or while using
our app. Just click Add to Cart for eligible
prescriptions and check out. We’ll contact
your provider on your behalf, if renewals are
included, and take care of the rest.
1 You can search for “Express Scripts” in your app store and download it for free. Then register, if first visit, or log in. FS47536E
2018 Express Scripts. All Rights Reserved. Express Scripts and E Logo are trademarks of Express Scripts Strategic Development, Inc.
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physicians reserve the right to deny care for potential misuse of services. 10E-101_413370312_11062019FIND A DOCTOR AT MYAHABENEFITS.COM
Better information can help you make better choices
The new Find a Provider tool on myahabenefits.com is a better way to help you to make
confident decisions about your health care.
Easy-to-use search
A single search bar helps you find network doctors and facilities, as well as treatments and
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Doctor and hospital profiles
Informative doctor and hospital profiles and nationally recognized quality measurements
help you find the doctor that is right for you. The profiles offer more than just location and
phone number. They also show credentials, network and hospital affiliations, and office
hours, as well as gender, specialty, language, and if a doctor is accepting new patients.
Rate and review your experience
Feedback and ratings provide insights into other plan members’ experiences with doctors
and hospitals. Anyone can read ratings and reviews, but you must be registered at
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Compare doctors and facilities
The Compare feature lets you easily compare up to five doctors or hospitals at once. You
can compare specialties, education, board certifications, quality reviews, and more.
Questions?
Call the service number on your ID card (TTY: 711) for more information.
myahabenefits.comNondiscrimination Notice and Language Access Services This plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call the number on your ID card (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al número que aparece en su tarjeta de identificación (TTY: 711). © 2017 AmeriHealth Administrators, Inc. FIND_A_PROVIDER_LEAP_2017_02
Cigna Payer Solutions
FIND A HEALTH CARE PROVIDER
Better value. Better together.
With a growing nationwide PPO network* of more than
1 million health care professionals and more than 6,300 Option 1
facilities, Cigna offers you a range of quality choices to Log in to myCigna.com
help you stay healthy.
Three ways to find what you need
There are three ways to find a network provider:
› If you’re already enrolled, visit myCigna.com and
log in using your User ID and Password.
› Visit Cigna.com and click “Find a Doctor, Dentist,
or Facility.” Be sure to select PPO. Note: the
network name may appear differently in different
geographical areas.
› Call your Third Party Administrator during Option 2
business hours. 1. Visit Cigna.com - click on “Find a Doctor,
Dentist, or Facility” (upper right)
Features on myCigna.com allow you to:
2. Choose “Employer or School”
› Narrow your results by distance, specialty and more. 3. Enter the geographic location you want to
› Email a copy of your search results. search and select the search type
› Find doctors in 22 different medical specialties, 4. Either Login/Register for myCigna.com, OR
who meet certain quality and cost-efficiency “Continue as guest”
measures and have been awarded the Cigna 5. Fill in the “I Live in” field
Care Designation. 6. Select PPO (Note: the network name may
› Estimate procedure costs based on Cigna’s appear differently in different geographical areas)
historical data.
If you’re looking for a mental health or substance
abuse professional, please refer to the “Find a
Behavioral Provider/Facility” flyer for detailed
instructions. You may request this flyer from your
Third-Party Administrator.
Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates.
864732 o 11/19A good way to avoid unexpected medical bills is to Why out-of-network care often costs more
know how your plan works. Certain choices you make
You’re probably being charged full price. We don’t have
can affect what you'll pay out of pocket.
a contracted relationship with out-of-network doctors
In-Network vs. Out: What’s the difference? and facilities. So we can’t control what they charge for
their services. And their rates may be higher than the
To help you save money, your health plan provides
discounted “in-network” rate.
access to a network of providers. These include:
You may be billed for the difference between the
› Doctors doctor’s bill and what your plan will pay. Many health
› Hospitals plans list an amount that is the most they’ll pay for a
› Labs certain service received out-of-network. If the doctor
› Radiology centers or facility charges more than your plan is willing to pay,
› Surgical centers. you pay the difference. In-network doctors and facilities
To be a part of the plan’s network, these doctors and have agreed not to do that.
facilities must meet certain credential requirements and
Your share of costs is different – and usually higher:
agree to accept a discounted rate for covered services
When you use a doctor or facility that is out-of-network,
under the health plan. These health care professionals
your deductible and other out-of-pocket costs may be
are considered “in-network.”
much higher than the in-network cost. Review your plan
If a doctor or facility has no contract with Cigna, they materials for details on your specific medical plan.
are considered “out-of-network” and can charge you
full price. It’s usually much higher than the in-network
discounted rate.
Cigna’s extensive PPO Network gives you access to qualified health care
professionals. Your good health is important, and we’re here to help.
* ” Cigna PPO Network” refers to the health care providers (doctors, hospitals, specialists) contracted as part of the Cigna PPO Network for Shared Administration.
Quality designations, cost-efficiency and other ratings reflect a partial assessment of quality and cost-efficiency and should not be the sole basis for decision-making. They are not a guarantee of the quality of
care that will be provided to individual patients. You are encouraged to consider all relevant factors and consult with your physician when selecting a health care professional or facility. Health care professionals
and facilities that participate in the Cigna network are independent contractors solely responsible for the care and services provided to their patients. They are not agents of Cigna.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company and Cigna Behavioral Health, Inc.
The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
864732 o 11/19 © 2019 Cigna. Some content provided under license.CDC’S TIPS FROM FORMER SMOKERS® CAMPAIGN
Reasons to Quit Smoking
Everyone has their own reasons for quitting smoking. Maybe they
want to be healthier, save some money, or keep their family safe
from secondhand smoke. As you prepare to quit, think about your
own reasons for quitting. Remind yourself of those reasons every
day. They can inspire you to stop smoking for good. Whatever your
reasons, you will be amazed at all the ways your life will improve
when you become smokefree.
It’s best to quit as soon as possible. This allows your body a
chance to heal and reduces your risk for serious health problems,
like heart attacks.
Here are a few reasons to quit you may want to consider:
Your Health and Appearance
• Your chances of having cancer, heart attacks, heart
disease, stroke, and other diseases will go down.
• You will be less likely to get sick.
•
• Your skin will look healthier, and you will look more youthful.
•
Quitting will make you feel better and improve your
health. But there are other reasons to quit that you
may not have considered:
Your Lifestyle:
• You will have more money to spend.
• You can spend more time with family, catch up on
work, or dive into your favorite hobby.
• You won’t have to worry about when you can smoke
next or where you can or can’t smoke.
• Your food will taste better.
• Your clothes will smell better.
• Your car and home won’t smell like smoke.
•
August 2019 2019 Reasons to Quit SmokingCDC’S TIPS FROM FORMER SMOKERS® CAMPAIGN
Reasons to Quit Smoking
More reasons to quit that you may not have considered:
Your Loved Ones:
• You will set a great example for your kids; it takes a lot of strength to quit.
• Your friends, family, co-workers, and other loved ones will be proud of you.
• You will protect your friends and family from the dangers of secondhand smoke.
• Your children will be healthier.
• You will have more energy to do the things you love with friends and family.
• You will get healthy to make sure you are around to share in your family’s
special moments.
Make a list of all of the reasons you want to become smokefree. Keep the
list in a place where you will see it often, like your car or where you used to
keep your cigarettes. When you feel the urge to smoke, take a look at the
list to remind yourself why you want to quit.
RESOURCES TO HELP YOU QUIT
CDC.gov/tips
smokefree.gov
Smokefree SmartPhone Apps:
QuitGuide
quitSTART
Smokefree Texting Programs
Free Quit Help: 1-800-QUIT-NOW (1-800-784-8669)
August 2019 2019 Reasons to Quit SmokingEMPLOYER SECTION
Group # ___________ Effective Date__________
2020 Benefits Enrollment Form
August 1, 2020 to July 31, 2021 Division ____________ Date of Hire __________
HR Rep./Date _____________________
IMPORTANT: This form only needs to be completed if you are adding or making a change to coverage.
Open enrollment is the only time when you can make enrollment changes, drop coverage, or add/delete dependent(s) from your coverage,
unless a qualified change in family status occurs. All elections remain in effect for the duration of the plan year.
Employee Name: _______________________________________ Hire Date: _____________ Effective Date: _____________________
Address: _________________________________________ City: _____________________ State: __________ Zip: ______________
Phone Number: _____________________________
Medical, Dental and Vision Information
COVERAGE TIER BI‐WEEKLY CONTRIBUTIONS SMOKER CONTRIBUTIONS
Medical Dental Vision Medical Dental Vision
Employee $48.45 $4.76 $1.00 $140.70 $4.76 $1.00
Employee + Child(ren) $120.00 $10.51 $2.00 $253.26 $10.51 $2.00
Employee + Spouse/DP $165.00 $10.51 $2.00 $298.28 $10.51 $2.00
Family $175.00 $15.22 $3.00 $450.23 $15.22 $3.00
Please complete information below for ALL covered members
Spouses are not eligible for medical benefits if they are self-employed or have coverage available through their employer
First Name/Last Name Gender Date of Birth Social Security Number
Employee
Spouse
Child 1
Child 2
Child 3
Child 4
I have been informed and acknowledge that I am eligible and have been offered the opportunity to purchase health coverage under my employer’s Benefit Plan.
I decline enrollment at this time because:
I have coverage through my spouse’s employer
I have other coverage (if so, please specify) ______________________________________________
I have Medicare coverage
I do not wish to enroll myself in any type of medical coverage at this time
I do not wish to enroll my ____ spouse _____ Child(ren) in any type of medical coverage at this time.
If you are declining enrollment for yourself or dependents (including your spouse) because of other health care coverage, you may: under certain circumstances in
the future, enroll yourself or your dependents in the company’s plan prior to the next open enrollment period. To do this, you must have involuntarily lost your other
coverage and we must receive your enrollment application within 30 days after your other coverage ended. 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 dependents, provided we receive your completed application within 30 days after
the marriage, birth, adoption or placement for adoption.
Printed Name ____________________________________ Signature ______________________________Date_____/____/_____
Please return your form to either Daniela or Louise once completedYou can also read
