Phoenix #1 Employee Bene ts Guide - School Year 2021-2022
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Phoenix #1
Employee Benefits Guide
School Year 2021-2022
We Care Health + Wellness Thrive Together
BENEFITS CONTACT INFORMATION
Lauren Pagnotta
Office: 602-257-6072
Fax: 602-257-2838
Email: lauren.pagnotta@phxschools.org
TABLE OF CONTENTS
Introduction ................................................................ 1
Enrollment Information ........................................... 2
Qualifying Life Event ................................................ 3
COBRA ........................................................................ 3
Frequently Asked Questions .................................... 4
Medical Plan Information ......................................... 5
Where to Turn for Health Care ................................ 6
On Call Doctor ........................................................... 7
Simple Steps to Connect to Care .............................. 8
Blue Cross Alliance Network ................................... 9
Hospitals/Medical Centers ...................................... 10
Dental Plan ................................................................. 11
Vision Plan .................................................................. 12
What is an FSA? ......................................................... 13
FSA Sample Eligible Expenses ................................. 14
Dependent Care Assistance FSA .............................. 15
403(b) Tax-Sheltered Account ................................... 17
Employee Assistance Program Services ................. 18
Summary of Group Life Insurance .......................... 19
Employee/Dependent Insurance Rates ................. 22
Important Phone Numbers ...................................... 23
FIRST CLASS BENEFITS AT PHOENIX #1
We work hard to make sure you have the best care and resources to thrive!
Introduction
Whether you are a new employee enrolling for the first time or considering your benefits
during open enrollment, this guide is designed to help you through the process.
Phoenix #1 is proud to offer a benefits package that includes medical, dental, and vision
insurance coverage for you and your dependents.
Please take the time to read this information and ask questions so you can make the best
benefit decisions for you and your family.
If you should have any questions:
Contact Laura Lopez-Gomez, Benefits and Wellness Specialist, directly.
602-257-6075 or laura.lopez-gomez@phxschools.org.
This booklet highlights important features of Phoenix #1 benefits for benefit eligible
employees.
1
ENROLLMENT INFORMATION
Annual Open Enrollment
Open Enrollment is limited to May 1st
through May 31st each year.
All benefit eligible employees are
required to elect coverage via iVisions.
Any coverage not actively selected will
be considered a waiver of coverage.
New Employees
New Employees have 31 days from hire date to complete enrollment in the group
insurance program. If you have moved from a non-benefits eligible status to a benefits
eligible status, you will have 31 days to complete your enrollment. All insurance
coverage starts the first of the month.
Remember, if elections are not made within the 31-day initial period of eligibility, you
will be required to wait until Annual Open Enrollment or until a Qualifying Life Event
takes place.
Pre-Tax Deductions
Our medical plans are IRS Section 125 which allow your deductions to be deducted
pre-tax. Participation in a Section 125 Plan is on an annual basis. Your insurance
premiums are paid with money removed from your gross wages prior to any tax
calculations. This reduces your tax liability and is a more efficient way to pay for
premiums.
2
Qualifying Life Event
The elections that you make during Open Enrollment or at initial benefits eligibility will
remain in effect for the plan year (July 1 - June 30). During that time, if your life or family
status changes according to the recognized events listed below, you are permitted to
revise your benefits coverage to accomodate your new status. You may make benefits
changes by contacting the Benefits Department and providing the proper documentation.
QUALIFYING LIFE EVENTS LIST
Marital Status Changes Covered Dependent Changes
• Marriage • Birth or adoption of a child
• Death of spouse • Dependent beomces ineligible
• Divorce for coverage
• Spouse employer’s • Death of dependent child
Open Enrollment
• Spouse gains or loses
coverage from another source
IRS regulations govern under what circumstances you may make changes to your
benefits, which benefits you can change and what kind of changes are permitted.
• All changes must be consistent with the qualifying event.
• In most cases, you cannot change your benefit plan, but may modify the level of your
coverage (in other words, you can add or delete dependents, enroll or disenroll yourself
or dependents, but not switch insurance carriers or plans).
Any changes in benefit levels must be completed within 31 days of the qualifying life
event.
COBRA
In most cases, if your employment ends, benefits will terminate on the last day of the
month in which you worked.
COBRA is for continuation of benefits when an employee leaves the District’s active
medical and dental plans. Coverage will continue to be provided, but the employee will
assume the entire monthly premium plus an addition 2% P&A administration fee. The
District currently pays the premium amount for the employee’s standard coverage.
COBRA is provided through P&A, our third party administrator. Your monthly
premiums are due to P&A by their due date and coverage will be cancelled by P&A if not
received on time. ASRS Retirees need to stop by the Benefits Office to complete a form to
participate in the supplemental benefits plan.
3
FREQUENTLY ASKED QUESTIONS
How do I enroll in Phoenix #1 benefits?
As a new hire, you have 31 days from your hire date to fill out your Benefits Election
Forms and turn them in to the Benefits Department.
Am I required to enroll in all of the elections, or can I decline them?
You can elect to enroll or decline in any plan you would like. For example, you are able to
enroll in the dental plan without enrolling in the medical plan, if desired.
When will my benefits begin?
The waiting period for benefits to start is the first of the month following your date of
hire. For example, if you start with Phoenix #1 on July 20, your benefits will begin on
August 1st. If your date of hire is August 1st, your benefits will begin on August 1st.
How long will I have coverage?
You will be covered until the end of the school year, June 30, 2022. You will have to
re-elect your benefits in May 2022 for the next school year.
What if I want to make changes to my benefi t elections during the year?
Phoenix #1’s benefit plan year runs from July 1st through June 30th. The benefits you
select during your initial eligibility period will be in effect until the end of the plan year
and can only be changed during Phoenix #1 Open Enrollment period which takes place
in May, or if you experience a Qualifying Life Event.
4
2021 MEDICAL SUMMARY PLAN
PPO Buy Up PPO Alliance HDHP $3000
Plan Summary • Buy-up plan that costs • No cost plan • No cost plan
employees $50.90 per • Narrow network • Broad network
month • $1,000/$2,000 • $3000/$6000
• Broad Network deductible deductible
• $1500/$3000 • Free preventative • No co-pays, but an
deductible. care HSA option with
• Free preventive care $670.44* district
contribution
• Free preventative care
Emp. Cost/Per Month $50.90 $0 $0
Emp. Cost +1/Per Month $672.62 $570.82 $514.96
Emp. Cost + Fam /Per
$902.66 $782.03 $705.49
Month
In Network Deductible $1,500 single $1,000 single $3,000 single
$3,000 family $2,000 family $6,000 family
In Network $3,500 single $3,500 single $6,000 single
OOP Max $7,000 family $7,000 family $12,000 family
Doctor Office Copay No Co-Pay;
$25 $25 20% Co-Insurance after
Deductible
Specialist Copay No Co-Pay;
$50 $50 20% Co-Insurance after
Deductible
Urgent Care Copay No Co-Pay;
$75 $75 20% Co-Insurance after
Deductible
Rx Copay After Deductible
$10/$35/$60 $10/$35/$60
$10/$35/$60
In-Network Coinsurance 20% 20% Co-Insurance after
20%
Deductible
Out of Net. Deductible $3,000 single $3,000 single $6,000 single
$6,000 family $6,000 family $12,000 family
Out of Net. OOP Max $8,000 single $8,000 single $10,000 single
$16,000 family $16,000 family $20,000 family
Out of Net. Coinsurance 50% 50% 50%
5
WHERE TO TURN FOR HEALTHCARE WITH
PPO ALLIANCE OR BUY UP
Save Money by Choosing the Best Service for Your Needs
Where you receive medical services makes a huge impact on your costs. Choosing the
right health care service can provide more appropriate care, more convenience, and more
reasonable costs to you.
$25 Blue Care Anywhere
One of the key benefits of Blue Care Anywhere is convenience. Virtual doctor visits are
available 24/7 to a mobile device, tablet or computer with internet access.
$25 Office Visit
Schedule a visit with a participating provider for non-life-threatening conditions.
$25 Minute Clinic or Health Care Clinic
Schedule or walk in to any of the Walgreens or CVS clinics for only $25. Open 7 days and
weeknights for non-life-threatening but urgent care needs.
$75 Urgent Care
Visit an Urgent Care facility for non-life-threatening but urgent care needs. Urgent Care
facilities give you the convenience of extended hours. Stitches, x-rays, broken bones, and
labs can be handled at most Urgent Care facilities.
$300 Emergency Room (ER) Visit
Visit the ER for serious and/or life-threatening conditions. ERs are not set up to care for
routine illness and work on the most serious cases first. This means you may have to wait
longer for your care and costs are very high.
6
Simple Steps to Connect to Care
One of the key benefits of BlueCare Anywhere is
convenience. Virtual visits* are available 24/7 and
can be conducted anywhere you have access to
a mobile device, tablet or computer with internet
access, using these simple steps:
SIGN UP
It’s simple and only requires name, email
and password.
SELECT A PROVIDER TYPE
Medical, Counseling or Psychiatry
ENTER YOUR HEALTH DATA
and insurance information (first visit only)
PAY THE COST SHARE
with a credit card, FSA or HSA card
CHOOSE A PHARMACY
in case medication is required
SEE THE DOCTOR
or schedule an appointment
AFTER THE VISIT, GET A SUMMARY
that you can share with your primary care provider
CARE IS AVAILABLE NOW
BlueCareAnywhereAZ.comOR DOWNLOAD THE
VISIT
BlueCare Anywhere MOBILE APP FROM GOOGLE PLAY ™OR THE APP STORE®
*Virtual visits do not provide emergency care. In an identified or probable emergency,
the virtual visit provider will direct the patient to seek emergency care.
364992-17
App Store is a service mark of Apple Inc., registered in the United States and other
countries. Google Play and the Google Play logo are trademarks of Google Inc.
D15141 10/17 TEL-0197-120817
8ALLIANCE
NETWORK
The Alliance network from Blue Cross ® Blue Shield ® of Arizona
delivers on our commitment to improve care quality and create
a better healthcare experience—while lowering costs.
A network of doctors and hospitals that are close
and convenient
• The Alliance network is for residents of Maricopa County.
• The network features doctors and hospitals from Banner Health
and HonorHealth.
• To keep your healthcare costs lower, it is important to use a
participating lab or imaging service such as Sonora Quest
Laboratories, Banner Imaging, Southwest Diagnostic Imaging,
and Sun Radiology.
• Only providers contracted with the Alliance network are considered
“in-network.” Please check with your doctors, facilities, and other
health professionals to make sure they are in the Alliance network
before receiving care.
• Finding in-network care is easy with the Find a Doctor tool, available
at azblue.com/findadoctor or on the MyBlue AZ SM app. Be sure to
search for providers in the Alliance network, indicated at the top-right
of the search page.
Alliance Network
Wickenburg Community Hospital
WICKENBURG
NEW RIVER
17 CAVE
CREEK
PEORIA
60
PHOENIX
SCOTTSDALE
HonorHealth Deer Valley
Banner Del E Webb Medical Center Medical Center
101 HonorHealth Scottsdale Thompson Peak
Medical Center
SURPRISE
SUN CITY
HonorHealth John C Lincoln
Medical Center
HonorHealth Scottsdale Shea Medical
Banner Boswell Medical Center Center/Piper Surgery Center
Banner Thunderbird
Medical Center 51
BUCKEYE Banner Estrella Medical Center Core Institute HonorHealth Scottsdale Greenbaum/Osborn
Medical Center
Specialty Hospital
202 Banner Heart Hospital
10
Banner University Medical Center Banner Baywood Medical Center
Phoenix Campus Banner MESA
Desert Banner Goldfield
Medical Medical Center
60
Center
Banner Gateway APACHE JUNCTION
GOODYEAR TEMPE GILBERT Medical Center
AVONDALE
CHANDLER QUEEN CREEK
10
Banner Ironwood
Medical Center
9 See reverse sideHospitals/Medical Centers in the Alliance Network Location
Banner Baywood Medical Center 6644 E. Baywood Ave., Mesa, AZ 85206
Banner Boswell Medical Center 10401 W. Thunderbird Blvd., Sun City, AZ 85351
Banner Del E Webb Medical Center 14502 W. Meeker Blvd., Sun City West, AZ 85375
Banner Desert Medical Center 1400 S. Dobson Rd., Mesa, AZ 85202
Banner Estrella Medical Center 9201 W. Thomas Rd., Phoenix, AZ 85037
Banner Gateway Medical Center 1900 N. Higley Rd., Gilbert, AZ 85234
Banner Goldfield Medical Center 2050 W. Southern Ave., Apache Junction, AZ 85120
Banner Heart Hospital 6750 E. Baywood Ave., Mesa, AZ 85206
Banner Ironwood Medical Center 37000 N. Gantzel Rd., San Tan Valley, AZ 85140
Banner Thunderbird Medical Center 5555 W. Thunderbird Rd., Glendale, AZ 85306
Banner University Medical Center Phoenix Campus 1111 E. McDowell Rd., Phoenix, AZ 85006
HonorHealth Deer Valley Medical Center 250 E. Dunlap Ave., Phoenix, AZ 85020
HonorHealth Greenbaum Surgical Specialty Hospital 3535 N. Scottsdale Rd., Scottsdale, AZ 85251
HonorHealth John C Lincoln Medical Center 250 E. Dunlap Ave., Phoenix, AZ 85020
HonorHealth Piper Surgery Center 9007 E. Shea Blvd., Scottsdale, AZ 85260
HonorHealth Scottsdale Greenbaum/Osborn Medical Center 7400 E. Osborn Rd., Scottsdale, AZ 85251
HonorHealth Scottsdale Shea Medical Center/Piper 9003 E. Shea Blvd., Scottsdale, AZ 85260
Surgery Center
HonorHealth Scottsdale Thompson Peak 7400 E. Thompson Peak Pkwy., Scottsdale, AZ 85255
The Core Institute Specialty Hospital 6501 N. 19th Ave., Phoenix, AZ 85015
Wickenburg Community Hospital 520 Rose Ln., Wickenburg, AZ 85390
Urgent-Care/Retail Health Clinics
Did you know that urgent-care centers and retail health clinics can treat many injuries and illnesses,
and often cost less than an emergency room? However, visits to retail health clinics, urgent-care centers,
and emergency rooms are not a substitute for an ongoing relationship with a primary care physician.
In a true emergency, always dial 911 first.
For more information, please call the number on
the back of your member ID card.
Blue Cross, Blue Shield, and the Cross and Shield Symbols are registered service marks, and MyBlue AZ is a service mark,
of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
587720-19
©2019 Blue Cross Blue Shield of Arizona, Inc. All rights reserved.
10
D24066 11/19 NT-MB-0362-12201911
12
13
FLEXIBLE SPENDING ACCOUNT
SAMPLE ELIGIBLE EXPENSES FOR FSA REIMBURSEMENTS
14Dependent Care Assistance
Flexible Spending Account
What Is a Dependent Care Assistance Flexible Determining Your Election Amount
Spending Account?
A Dependent Care Assistance Flexible Spending estimate how much you usually spend on eligible
Account (FSA) allows you to set aside a portion of your daycare expenses in a year and set aside that dollar
pay pre-tax to use for child day care or elder care amount into your FSA (this is also called your annual
expenses. Because it is deducted from your pay before election). Per IRS regulations, if you have unspent money
taxes, you can save up to 30% on each dollar you spend left over in your account at the end of the plan year the
on eligible expenses (depending on your tax bracket). money will be forfeited- it does not apply to the next plan
If you are a New Jersey or Pennsylvania taxpayer, the year. Your annual election is divided by the number
New Jersey or Pennsylvania state income tax will apply to of paychecks you have in a year and deducted pre-tax
from your paycheck each pay period. The maximum
annual election amount is $5,000. This is a “pay-as-
Under tax laws, dependent day care expenses are you-go account” which means that you can only have
eligible only if the expenses are necessary so that you access to the amount of money that has been payroll
and your spouse can work or attend school full-time. deducted to date.
Your spouse also may be unemployed but actively
looking for work. If your spouse works part-time, your
election may not exceed the lesser of your annual Example
income or your spouse’s annual income.
PLEASE NOTE: Non-custodial parents check with your If you set aside $2,500 into this account and get paid
legal or tax advisor to see if special rules apply to you weekly, the amount of money that will be deducted
that would enable you to utilize this account. pre-tax from your paycheck each week is $48.07.
$2,500 annual election amount ÷ by 52 paychecks=
Eligible Day Care Expenses May Be $48.07 deducted pre-tax from each paycheck
Reimbursed For...
• Your “qualifying child” (including a stepchild, foster
Changing Your Election Amount
child, child placed for adoption or younger brother/
sister) under age 13 who has the same principal
Generally, you can change your election amount if
residence as you for more than one half the year and
you experience the following: 1) change in status (i.e.,
does not provide more than one-half of his or her own
marriage or divorce), 2) a reduction or increase in the
support during the calendar year
hours that you and/or your spouse work, and 3) a
• Your spouse or other dependent who receives over change in the place where you, your spouse or your
one-half of his/her support from you (i.e., your disabled dependent work or reside.
elderly parent) and has the same principal place of
residence as you for more than one-half of the year
15Dependent Care
Flexible Spending Account
Eligible Dependent Care Assistance FSA
Expenses
• Payments to nursery schools, day care centers or
individuals who satisfy all state and local laws and
regulations
• Payments for before-school care and after-school
care beginning with kindergarten and higher grades
• Payments to relatives for care of a qualifying
dependent(s); however, the relative cannot be your
tax dependent or your child if under age 19 as of the
end of the calendar year
• Payments (in lieu of regular day care) to day camp
(e.g., soccer camp, computer camp, etc.) but not
overnight camps
• Payments to adult daycare centers Claim Submission Options*
• Payments to senior daycare QuikClaim
• Payment for eldercare so that you can work or look Instantly submit claims and receipts directly through
for work your smartphone. Capture a picture of your receipt
or other supporting documentation of your eligible
expense. Log into your P&A Account from your
Ineligible Dependent Care Assistance FSA mobile device and select Submit a Claim.
Expenses Electronic Claim Upload
• Enter claims directly online from your computer
dependent beginning with kindergarten and higher or laptop. Log into your account at www.padmin.
grades com, select Upload Claim/Documentation under the
• Expenses incurred while you and/or your spouse Member Tools tab and follow the instructions.
are not working (except for short temporary absences Fax/Mail a Claim Form
like vacation and minor illnesses)
Claim forms are available by logging into your account
• Expenses for overnight camps at www.padmin.com. Complete a form and submit it
• Nursing home care via fax or mail to P&A Group.
• Custodial elder care that is NOT in place so that you Fax: (877) 855-7105
can work Mailing Address: P&A Group 17 Court Street, Suite 500
• Transportation fees
• Prepayment for services not received while covered
• Late payment fees *When submitting a claim, make sure to include a proof of
service documentation (register receipts, etc).
Filing a Claim
To receive reimbursement from your account simply Customer Service
save a copy of the proof of the expense (i.e., a receipt
from the daycare provider) and submit it to P&A HOURS: Monday - Friday 8:30AM - 10:00PM ET.
Group. Claim reimbursement is based on the date PHONE: (800) 688-2611 | WEB: www.padmin.com
you receive the dependent day care service, not the
date you pay the invoice or the date you are billed. • Online chat available during customer service hours
Remember, you will only be reimbursed up to your • Toll-free account information available in English
available balance in your Dependent Care Assistance and Spanish
FSA on the processing date. • Visit P&A Group’s mobile site @ www.padmin.com
on your smartphone
16403b TAX-SHELTERED
ACCOUNT
Retirement Plan
Phoenix #1 is proud to offer a 403b plan
through VOYA, MetLife, and Security
Benefit. The 403b plans allow you to
shelter income on a pre-tax basis, which
lowers your current year taxable
liability and increases savings for
retirement.
Contact: Gerardo Garza
Phone: 602-419-3247
Email: ggarza@sji.us.com
Contact: Jonathan Mabb
Phone: 480-638-2175
Email: jmabb@financialguide.com
Contact: Erica Gargol
Phone: 480-719-7469
Email: egargol@stratoswp.com
17EMPLOYEE ASSISTANCE PROGRAM SERVICES
The Phoenix Elementary School District Employee Assistance Program (EAP) is available to all
employees and eligible dependents
The EAP provides confidential assessment and short-term, professional counseling services for personal problems that
interfere with everyday living. Services available to you include:
Counseling Services
Up to three (3) free face-to-face sessions provided for issues such as:
Grief and loss Interpersonal relationship difficulties
Coping with change Stress-related problems
Marital/family issues Referrals to other professionals when necessary
Work/Life Services Personal Advantage
Unlimited Telephonic Coaching: scheduled telephonic sessions for non- Personal Advantage is work-life
clinical work/life issues such as grief, change, relationship issues, and
website that contains more than
stress.
20,000 articles and interactive
Eldercare Support Services: referrals for eldercare; resources and
materials on retirement, housing concerns, grief and loss, disaster resources for topics such as
support, Medicare/Medicaid, and respite. emotional well-being, family life,
Legal Counseling Services: a free, comprehensive legal consultation with health, financial, legal, personal
access to a 25% discounted rate for future services. (These services do growth, and stress. Some popular
not apply to employment issues.) items on the website include
Financial Counseling Services: a free session with a certified financial personal development trainings,
professional with access to a 15% discount for future services and/or
downloadable will kits, financial
local community referrals to other financial advisement resources.
Community Support Resources: access to referrals to thousands of calculators, and parenting articles.
community resources including 12-step groups, community mental
Visit www.americanbehavioral.com
health agencies, support groups, and more.
Online Services: the American Behavioral website allows you to navigate and click on Member Login. To
services offered, locate a provider in your area, take surveys, and much register, use company name
more. Please visit www.americanbehavioral.com.
PHOENIXELEMENTARY to create
your username and password.
For more information or to schedule an appointment, please call
American Behavioral at 800-925-5327.
18CONTACT US
Symetra Life Insurance Company
th
777 108 Avenue NE, Suite 1200
Bellevue, WA 98004-5135
1-800-796-3872
TTY/TDD 1-800-833-6388
SUMMARY OF GROUP LIFE INSURANCE
For the Employees of
Phoenix Elementary School District #1
For coverage effective July 1, 2016.The information in this summary may be replaced by any subsequently issued
summary or policy amendment.
GROUP BASIC LIFE INSURANCE & ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCE
Description of Life Insurance Basic Life Insurance is term life coverage made available through your employer. Term
life insurance is the most common type of life insurance and, initially, usually is the
least expensive. To put it simply, it pays a death benefit if you die while you have coverage.
Description of AD&D Insurance This benefit pays an additional benefit in the event of loss of life or contractually
defined injury. Coverage can be extended for other reasons not qualified as — but
relating to — accidental death or dismemberment. Refer to your employee certificate for details.
Eligibility All Other Active Employees working a minimum of 30 hours each week.
Benefits All Other Active Employees- 1 x your Basic Annual Earnings rounded to the next higher $1,000 not to exceed
$100,000 of Basic Life and AD&D coverage at no cost to you paid for by your employer.
Additional AD&D Benefits Loss of Life, Loss of Speech and/or Hearing, Loss of Hand, Foot or Eye, Loss of Thumb
and Index Finger on one Hand, Paralysis Benefit, Seat Belt/Airbag Benefit and
Repatriation Benefit are included under AD&D for actively insured employees. Child Education, Day Care,
Rehabilitation, Spouse Education and Adaptive Home and Vehicle benefits are included under AD&D at or the actual
cost. Certain restrictions apply. Refer to your employee certificate.
Waiver of Premium With proof of disability, Symetra Life Insurance Company will waive Life Insurance premiums for
an employee that becomes disabled. Certain restrictions apply. Refer to your employee certificate.
Accelerated Death Benefit If an employee has been diagnosed as terminally ill, Symetra Life Insurance Company
may pay a portion of the death benefit in advance to the employee. Refer to your
employee certificate.
Conversion A conversion benefit is available that allows you to convert your group coverage to an individual policy if
certain conditions are met. Refer to your employee certificate.
Benefit Reduction
Benefit amounts will be reduced by the following percentages according to age category:
35% at Employee’s age 70
55% at Employee’s age 75
70% at Employee’s age 80
Benefit reduction will apply to the original benefit amount in force and will be rounded to the nearest $1000.
19GROUP SUPPLEMENTAL LIFE INSURANCE & SUPPLEMENTAL ACCIDENTAL DEATH &
DISMEMBERMENT (AD&D) INSURANCE
Eligibility All Other Active Employees working a minimum of 30 hours each week.
Benefits
All Active Administrative Employees – Increments of $10,000 to a maximum of $500,000, not to exceed 5 x
Basic Annual Earnings of Supplemental Life coverage and Supplemental AD&D coverage.
Spouse – Increments of $5,000 to a maximum of $150,000 not to exceed 50% of Employee’s Supplemental Life
coverage amount
Child (ren) – for child (ren) ages 15 days to 26 years old, Increments of $1,000 to a maximum of $10,000 of
Supplemental Life coverage.
Evidence of Insurability Evidence of Insurability is required for all amounts of insurance selected after the initial 31
day eligibility period. Evidence of Insurability is required for Employee Supplemental Life
Insurance amounts in excess of $250,000
Evidence of Insurability is required for Spouse Supplemental Life Insurance amounts in excess of $50,000.
Conversion A conversion benefit is available that allows you to convert your group coverage to an individual policy if
certain conditions are met. Refer to your employee certificate.
Portability This coverage may be continued at group rates upon termination of employment. Certain restrictions
apply. Refer to your employee certificate.
Waiver of Premium With proof of disability, Symetra Life Insurance Company will waive Life Insurance premiums for
an employee that becomes disabled. Certain restrictions apply. Refer to your employee certificate.
Accelerated Death Benefit If an employee has been diagnosed as Terminally Ill, Symetra Life Insurance Company
may pay a portion of the death benefit in advance to the employee. Refer to your
employee certificate.
Benefit Reduction
Employee:
Benefit amounts will be reduced by the following percentages according to age category:
35% at Employee’s age 70
55% at Employee’s age 75
70% at Employee’s age 80
80% at Employee’s age 85
85% at Employee’s age 90
Benefit reduction will apply to the original benefit amount in force and will be rounded to the nearest $1000.
Spouse:
Benefit amounts will be reduced by the following percentages according to age category:
35% at Employee’s age 70
55% at Employee’s age 75
70% at Employee’s age 80
80% at Employee’s age 85
85% at Employee’s age 90
Benefit reduction will apply to the original benefit amount in force and will be rounded to the nearest $1000.
20Rates for Supplemental Life and AD&D coverage:
Employee Supplemental Life Rates per $1,000 of coverage.
Employee’s Age Rates Employee’s Age Rates
Under 25 $0.040 50-54 $0.237
25-29 $0.040 55-59 $0.371
30-34 $0.045 60-64 $0.579
35-39 $0.054 65-69 $1.039
40-44 $0.084 70-74 $1.859
45-49 $0.143 75 and over $3.066
Spouse Supplemental Life Rates per $1,000 of coverage.
Spouse’s Age Rates Spouse’s Age Rates
Under 25 $0.053 50-54 $0.315
25-29 $0.053 55-59 $0.493
30-34 $0.059 60-64 $0.769
35-39 $0.072 65-69 $1.380
40-44 $0.112
45-49 $0.191
Child Supplemental Life rate per $1,000 of coverage: $0.100
Employee AD&D rate per $1,000 of coverage: $0.015
How to Calculate Your Cost:
Employee Life: /1,000= $
(volume) x (rate) Monthly cost
Employee AD&D: $0.015 /1,000= $
(volume) x (rate) Monthly cost
Spouse Life: /1,000= $
(volume) x (rate) Monthly cost
Child Life: $0.100 /1,000= $
(volume) x (rate) Monthly cost
Total Monthly
Cost
This summary provides only a brief description of the Life Insurance coverage insured by Symetra Life Insurance
Company under the LGC-13000 8/06 series Group Life Insurance policy. For a complete description, including all
definitions, exclusions, limitations, and reductions in coverage, as well as information on termination of benefits, please
call 1-800-426-7784 or refer to the Group Insurance Certificate you will receive when you become insured. Coverage will
be offered under Group Policy number 01-017015-00. All benefits are subject to the terms and conditions of the Group
Policy. If there is a difference between the information in this summary and the information contained in the Group
Insurance Certificate, the terms of the Group Insurance Certificate will prevail. The terms of coverage may change over
time; always refer to your current Group Insurance Certificate for information regarding your insurance benefits. For
Class 3 Employees Only.
21EMPLOYEE/DEPENDENT INSURANCE RATES
FOR FISCAL YEAR 2021/2022
EFFECTIVE 7/1/2021 – 6/30/2022
Employee Monthly Seasonal Employees 12 Month Employees
Blue Cross Blue Shield COBRA
Premium Per Pay Deduction Per Pay Deduction
HDHP $3,000 Monthly Premium
21 pays 26 pays
Employee Only $0.00 $0.00 $0.00 $514.95
Employee + 1 $514.95 $294.26 $237.67 $1,029.91
Employee + 2/More $705.49 $403.14 $325.62 $1,220.44
Employee Monthly Seasonal Employees 12 Month Employees
Blue Cross Blue Shield COBRA
Premium Per Pay Deduction Per Pay Deduction
PPO Alliance Monthly Premium
21 pays 26 pays
Employee Only $0.00 $0.00 $0.00 $570.82
Employee + 1 $570.82 $326.19 $263.46 $1,141.64
Employee + 2/More $782.03 $446.88 $360.94 $1,352.85
Employee Monthly Seasonal Employees 12 Month Employees
Blue Cross Blue Shield COBRA
Premium Per Pay Deduction Per Pay Deduction
PPO Buy-Up Monthly Premium
21 pays 26 pays
Employee Only $50.90 $29.09 $23.50 $621.72
Employee + 1 $672.62 $384.36 $310.44 $1,243.44
Employee + 2/More $902.66 $515.81 $416.62 $1,473.48
Employee Monthly Seasonal Employees 12 Month Employees COBRA
Delta
Premium Per Pay Deduction Per Pay Deduction Monthly Premium
Dental
21 pays 26 pays
Employee Only $0.00 $0.00 $0.00 $35.36
Employee + 1 $38.48 $21.99 $17.76 $73.84
Employee + 2/More $83.62 $47.78 $38.60 $118.98
Employee Monthly Seasonal Employees 12 Month Employees
Delta Vision COBRA
Premium Per Pay Deduction Per Pay Deduction
Voluntary Vision Plan Monthly Premium
21 pays 26 pays
Employee Only $5.96 $3.41 $2.76 $5.96
Employee + 1 $12.05 $6.89 $5.57 $12.05
Employee + 2/More $21.13 $12.08 $9.76 $21.13
These are the amounts per payday. You will have deductions for 26 paydays (12-month employees) or 21
paydays (all seasonal employees) for fiscal year 2021/2022. Payday amount = Monthly amount x 12
months/26 or 21 paydays. The payday amounts will be different for mid-year hires/changes; payday
amount will equal the monthly amount multiplied by the number of months from the effective date
through 6/30/22 divided by the number of paydays left to deduct for fiscal year 2021/2022.
COBRA is for continuation of benefits when an employee leaves the District’s active medical and dental
plans. Coverage will continue to be provided, but the employee will assume the entire monthly premium
plus an additional 2% P&A administration fee; The District currently pays the premium amount for the
employee’s standard coverage. COBRA is provided through P&A, our third-party administrator. Your
monthly premiums are due to P&A by their due date and coverage will be cancelled by P&A if not
received on time. ASRS Retirees need to stop by the Benefits Office to complete a form to participate in
the supplemental benefits plan.
Our medical plans are IRS Section 125 plans, which allow your deductions to be deducted pre-tax.
Participation in Section 125 plans is on an annual basis. An employee is not allowed to change his/her
election during the plan year. You will not be able to make changes to this plan year’s election until the
next annual open enrollment or during certain qualifying events. All enrollments/cancellations must be
processed within 31 days of the qualifying event.
22IMPORTANT PHONE NUMBERS
Blue Cross Blue Shield of Arizona
Medical
1-855-801-4633
www.azblue.com
Delta Dental of Arizona
Dental
1-800-352-6132
www.deltadentalaz.com
EyeMed/Delta Vision of AZ
Vision
1-866-559-5252
www.eyemedvisioncare.com
Arizona State Retirement System
Long Term Disability
1-800-621-3778
www.azasrs.gov
P&A
Flexible Spending Account
1-800-688-2611
www.padmin.com
23PhxSchools.org
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