STAFF - 2021 BENEFITS GUIDE - My Gardner White Benefits

 
STAFF - 2021 BENEFITS GUIDE - My Gardner White Benefits
2 0 21   B E N E F I T S G U I D E
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STAFF - 2021 BENEFITS GUIDE - My Gardner White Benefits
TABLE OF CONTENTS
Welcome........................................................................................................................... 3
Elections........................................................................................................................... 4
Benefits At-A-Glance........................................................................................................ 5
Medical Plan Options....................................................................................................... 6
Wellness Program............................................................................................................ 7
Non-Smoking Incentive.................................................................................................... 7
Medical..........................................................................................................................8-9
Health Equity HSA Account............................................................................................ 10
Blue Member Secured Services..................................................................................... 11
Online Telemedicine Visits............................................................................................. 12
Dental.........................................................................................................................13-15
Vision............................................................................................................................... 16
Basic Life and AD&D....................................................................................................... 17
Voluntary Life and AD&D................................................................................................ 18
Short Term Disability....................................................................................................... 19
Voluntary Long Term Disability....................................................................................... 20
FSA.............................................................................................................................21-22
Employee Assistance Program...................................................................................... 23
Will Preparation Services............................................................................................... 24
Identity Theft................................................................................................................... 24
Travel Assist.................................................................................................................... 25
Pet Insurance.................................................................................................................. 26
Accident.....................................................................................................................27-28
Whole Life....................................................................................................................... 29
Hospital Indemnity.......................................................................................................... 30
Mandatory Notices......................................................................................................... 31
Medicare Part D Notice.............................................................................................32-33
CHIP Notice................................................................................................................34-37
Resources....................................................................................................................... 37

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STAFF - 2021 BENEFITS GUIDE - My Gardner White Benefits
WELCOME
Gardner-White Furniture is pleased to offer an
excellent benefit program. These health and welfare                   Medicare Part D Prescription
benefits are designed to protect you and your                               Drug Information
family while you are an active employee. We                       If you are enrolled in or will be eligible
encourage you to carefully review this information
                                                                    for Medicare in the next 12 months,
and share it with your covered dependents.
                                                                 Federal law gives you more choices for
Eligibility                                                      prescription drug coverage. See pages
Health and welfare benefits are available to all                        32-33 for more information.
full-time regular employees who work more than 30
hours per week.
                                                              New Hire Waiting Period
Dependent Eligibility                                         As a condition of eligibility for benefits, employees must
Your dependents may also be covered under the                 complete a one-month bona fide employment-based
medical, dental, vision and optional life benefits.           orientation period.
Eligible dependents include:
                                                              Eligible employees may enroll for benefits on the first
    • Your legal spouse.                                      of the month following 60 days after they complete
    • Medical, Dental and Vision:                            the orientation period. If elected, coverage will be
       Your children to the end of the calendar year          effective on that date if you completed the necessary
       they attain the age 26 regardless of their             online enrollment. As a new employee you have up to
       marital, student, or financial status.                 30 days after your eligibility date to make your benefit
    • Optional Life:                                         selections. If you do not enroll within the first 30 days
       Your children to the end of the calendar year          of your eligibility date, you will not be eligible for
       they attain the age 26 regardless of their             coverage until the next open enrollment period.
       marital, student, or financial status.
                                                              Terminating Coverage
                                                              If you leave Gardner White for any reason all benefit
                                                              coverages will end on your last date of employment.

This guide highlights the main benefits available. For a more complete description, please see the Plan Documents. If any
conflict should arise between this guide and the Plan Documents, the Plan Documents will govern.

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STAFF - 2021 BENEFITS GUIDE - My Gardner White Benefits
ELECTIONS
Knowing that every employee has different needs, Gardner-White Furniture’s Employee Benefit Program is
specifically designed to provide basic benefits and allow you the flexibility to elect those levels of coverage you
choose for you and your family.

Elections
It is important that you make your choices carefully. Changes to those elections can generally only be made
during the annual open enrollment period. Exceptions will be made for certain changes in status during the year,
allowing you to make a mid-year benefit change consistent with the change in status. If you have a change in
status, you must change your benefit elections within 30 days of the qualifying event, or you will need to wait
until the next annual open enrollment period. A change in status includes:

   • Change in legal marital status (marriage, death of spouse, divorce or legal separation)
   • Change in the number of dependents (birth, death, adoption or placement for adoption)
   • Change in the employment status of the employee or the employee’s spouse including begin or terminate
      employment, change in eligibility (full time to part time), a strike or lockout, commencement or return from
      an unpaid leave of absence and a change in worksite
   • Dependent satisfies or ceases to satisfy eligibility requirements (attains a particular age)
   • Alternate open enrollment time frame for spouse or loss of other coverage

What happens if I do not enroll?
If you do not enroll within the required time period, you will not be eligible for benefits until the next annual open
enrollment period or you experience a change in status. You may
be subject to waiting periods or reduced benefits if you decide to
enroll at a later date.

Will my election choices continue if I do not make changes
during Open Enrollment?
No, you must actively call the enrollment center to make your 2021
elections.

COBRA Continuation Coverage
When you or any of your dependents no longer meet the
eligibility requirements for your employer’s health and welfare
plans, you may be eligible for continued coverage as required by
the Consolidated Omnibus Budget Reconciliation Act of 1986
(COBRA). In the event of divorce, legal separation or change in
dependent status, it is your responsibility to notify human
resources within 60 days for complete COBRA detail requirements.

Your Tax Advantage
Your contributions for medical, dental, vision and FSA benefits are
made on a pre-tax basis. Your taxable income will be reduced
by the amount you contribute for each benefit. You will not pay
income tax on the amount you contribute, thus saving you tax
dollars. The fact that your taxable income will be lowered does
not affect your salary-related benefits, which will continue to be
calculated upon your base earnings before contributions. You may,
however, realize slightly lower Social Security benefits in the future
because of this pre-tax feature.

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STAFF - 2021 BENEFITS GUIDE - My Gardner White Benefits
BENEFITS AT-A-GLANCE
We take pride in offering a benefits program which provides flexibility for the diverse and changing needs of our
employees. The following is an overview of the benefits provided to eligible employees and their dependents.
Benefit Plan                                      Options
                                                  4 Plans Options (New HSA Plan)
Medical/Rx Insurance                              • BCN HMO HRA 1,500
Blue Cross Blue Shield of Michigan                • BCN HMO 4,000
(BCBSM)                                           • BCBS Simply Blue PPO 500
Blue Care Network (BCN)                           • BCBS Simply Blue QHDP PPO 2,000
                                                    • Health Savings Account (HSA) via Health Equity
                                                  2 Plans Options
Dental Insurance
                                                  • Delta DHMO
Delta Dental (New Carrier)
                                                  • Delta Dental PPO
Voluntary Vision Insurance                        Enhanced Benefits
NVA (New Carrier)                                 • $150 frame and contact allowance
Basic Life / AD&D Insurance                       Employer Paid
Mutual of Omaha (New Carrier)                     • $10,000 Benefit
                                                  Voluntary Benefit - 100% Employee Paid
Voluntary Term Life Insurance                     • Coverage up to $500,000
Mutual of Omaha (New Carrier)                     • Guaranteed Issue (GI) increased to $250,000
                                                    • TRUE Open Enrollment for all employees with GI
                                                  Voluntary Benefit - 100% Employee Paid
                                                  • Spouse: Coverage up to $250,000 or 100% of employee amount
Voluntary Dependent Term Life Insurance
                                                  • Guaranteed Issue (GI) increased to $50,000
Mutual of Omaha (New Carrier)
                                                     • TRUE Open Enrollment for all employees with GI
                                                  • Child(ren): Coverage $5,000 or $10,000
                                                  Voluntary Benefit - 100% Employee Paid
Voluntary Short Term Disability                   • 60% of weekly earnings
Mutual of Omaha (New Carrier)                     • Maximum weekly benefit of $1,000
                                                    • TRUE Open Enrollment for all employees
                                                  Voluntary Benefit - 100% Employee Paid
Voluntary Long Term Disability                    • 60% of monthly earnings
Mutual of Omaha (New Carrier)                     • Maximum monthly benefit of $5,000
                                                    • TRUE Open Enrollment for all employees
                                                  Health Care:
Flexible Spending Account                         • Annual Max of $2,000 tax-free for eligible health care expenses
iSolved (New Vendor)                              Dependent Care:
                                                  • Annual Max of $5,000 tax-free for eligible day care expenses
                                                  100% CONFIDENTIAL SUPPORT
Employee Assistance Program (EAP)
                                                  • 24/7 services to support you and your family
Mutual of Omaha (New Carrier)
                                                  • Legal/Financial, Substance abuse, grief and loss, stress manage
                                                  Voluntary Benefit - 100% Employee Paid
Voluntary Accident Insurance
                                                  • Pays a set benefit amount based on the type of injury
UNUM
                                                  • Wellness Benefit
Voluntary Whole Life Insurance                    Voluntary Benefit - 100% Employee Paid
UNUM                                              • Earns cash value
                                                  Voluntary Benefit - 100% Employee Paid
Voluntary Hospital Indemnity Insurance
                                                  • Pays a set benefit amount
UNUM
                                                  • Wellness Benefit
                                                  Voluntary Benefit - 100% Employee Paid
Pet Insurance New Offering                        • 2 levels of benefit offerings
Nationwide                                        • My Pet Protection
                                                  • My Pet Protection with Wellness

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STAFF - 2021 BENEFITS GUIDE - My Gardner White Benefits
MEDICAL PLAN OPTIONS
Gardner-White Furniture offers four medical options with different benefit levels so that you may select the
option that best meets the needs of you and your family.

  • BCN HMO HRA 1,500
  • BCN HMO 4,000
  • BCBS Simply Blue PPO 500
  • BCBS Simply Blue QHDP PPO 2,000
		    • Health Savings Account (HSA) via Health Equity

HMO Specifics (Only available to Michigan residents)
  • An HMO utilizes a network of participating doctors and hospitals.
  • Coverage is limited to use of in-network providers except in the case of an emergency.
  • You must pick a primary care physician (PCP) and this doctor coordinates all of your health care services.
  • Females using this option may select a PCP as well as an OB/GYN and are not required to obtain referrals for
     routine OB/GYN services.
  • If you need to see a specialist, your PCP must give you a referral to a specialist within the network. If you
     see a specialist without obtaining a referral, you will either have no benefits for that service or have a
     reduced benefit.
  • To find an HMO provider, go to www.bcbsm.com or call the phone number on the back of your ID card.

PPO Specifics
  • Benefits are provided through a Preferred Provider Organization (PPO), where a network of hospitals and
     doctors are available for your use.
  • If you use the network, you will receive the highest level of benefits offered by the PPO.
  • Although the network is available, you are not required to use it. You always have the complete freedom to
     select any provider whenever you need care. However, the out-of-network benefits are lower and your
     out-of-pocket costs will be higher.
  • This option does not require any referrals to see a specialist.
  • To find a PPO provider, go to www.bcbsm.com or call the phone number on the back of your ID card.

Elections
You may elect medical coverage for yourself; you and your
spouse; you and child(ren); or for your entire family.

Contributions
You and Gardner-White Furniture share in the cost of
coverage. Please see the ADP benefit portal for
information on your contributions.

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STAFF - 2021 BENEFITS GUIDE - My Gardner White Benefits
WELLNESS PROGRAM
Gardner-White Furniture is continuing their wellness program incentive for the 2021 plan year.

The below will explain the requirements for both the member and any applicable spouse. In order to qualify for
the incentive, both items must be completed. You and your spouse are eligible for two separate rewards.

Wellness Requirements
  • Schedule and obtain your annual physical with your Primary Care Physician. Ask him or her to complete the
     2021 Annual Wellness Incentive Form. The 2021 Annual Wellness Incentive Form can be found on the ADP
     benefits portal.
  • Go to www.bcbsm.com and log in as a member and complete your Health Risk Assessment. You and your
     spouse will each need separate logins due to HIPAA. Your results are completely confidential.

In order to qualify for the incentive, both the 2021 Annual Wellness Incentive Form and the BCBSM/BCN Health
Risk Assessment must be completed within 90 days of your new hire benefits eligibility (or by July 1, 2021 for
open enrollment).

Incentive
Each employee and their applicable spouse has the opportunity to earn a $100 gift card. The potential combined
gift card for both employee and spouse is $200. Please keep in mind in order to qualify for the gift card, you must
complete both the Health Assessment as well as have your Primary Care Physician complete the 2021 Annual
Wellness Incentive Form within the specified time frame.

Please note: The gift card is a taxable benefit and must be reported as income at the end of the year under your
W2 earnings.

NON-SMOKING INCENTIVE
Gardner-White Furniture will continue to provide the non-tobacco incentive contribution rates for 2021.

Gardner-White offers a wellness incentive in the form of reduced weekly employee contributions if you and your
spouse are both non-tobacco users.

Blue Cross Blue Shield and Blue Care Network offer resources to assist you on your tobacco free journey.

To qualify as a non-tobacco user, you must be tobacco free for the last 12 months.

All non-tobacco members will receive the reduced contributions as of 4/1/2021 (or your initial effective date for
new hires), however, you must confirm and verify that you are a non-tobacco user at the time of your enrollment.

If the required documentation is not received within 30 days of your effective date, your payroll deductions will
change to the standard contribution. In addition, if a member ceases to actively participate in a tobacco
cessation program throughout the year they will move back to the standard contribution rate.

Please be advised that any reporting and information obtained in regards to a member’s participation status will
be used only for the purposes of certifying willingness to comply and will be kept completely confidential.

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STAFF - 2021 BENEFITS GUIDE - My Gardner White Benefits
MEDICAL HMO OPTIONS – BLUE CARE NETWORK (BCN)
Both Blue Care Network HMO Plans will renew and accumulate the deductible and annual out-of-pocket
maximum on a plan year basis. This means that all deductibles and out-of-pocket maximums will restart as of
April 1 each year.

BLUE CARE NETWORK                            BCN HMO HRA $1,500                      BCN HMO $4,000
Deductible                                      $4,000 per member                   $4,000 per member
(Plan Year 4.1.2021 - 3.31.2022)                 $8,000 per family                   $8,000 per family
                                                $1,500 per member                   $4,000 per member
Member Deductible Responsibility
                                                 $3,000 per family                   $8,000 per family
                                                $6,350 per member                   $6,350 per member
Annual Out-of-Pocket Maximum
                                                 $12,700 per family                  $12,700 per family
Lifetime Dollar Maximum                                None                                 None
Primary Care Visit                                   $20 copay                           $20 copay
Specialist Visit                             $40 copy after deductible            $40 copy after deductible
Preventive Care/Screening/                       100% covered;                       100% covered;
Immunization                                 deductible does not apply           deductible does not apply
Diagnostic Test (x-ray, blood work)             80% after deductible                80% after deductible
Imaging (CT/PET Scans, MRIs)                $150 copay after deductible         $150 copay after deductible
Emergency Room Care                         $150 copay after deductible         $150 copay after deductible
Urgent Care                                          $50 copay                           $50 copay
Online Visit                                        $20 copay                            $20 copay
Prescription Drugs
Tier 1A - Value Generics                             $6 copay                             $6 copay
Tier 1B - Generics                                   $40 copay                           $40 copay
Tier 2 - Preferred Brand                             $60 copay                           $60 copay
Tier 3 - Non-Preferred Brand                         $80 copay                           $80 copay
Tier 4 - Preferred Specialty                20% coinsurance (max $200)          20% coinsurance (max $200)
Tier 5 - Non-Preferred Specialty            20% coinsurance (max $300)          20% coinsurance (max $300)

What is an HRA?
HRA’s are health care accounts funded by your employer to help cover employees’ out-of-pocket costs when they
receive health care services.

  • Member carry a single medical ID card with a BCN HMO - HRA Designation
  • A continuous care process that is seamless for HRA and medical services
  • Hassle-free coverage with no reimbursement paperwork
  • You receive a single Explanation of Benefits statement that tracks your deductible and coinsurance
     obligations and your HRA balances
  • You can view your balances online at www.bcbsm.com through Member Secured Services
  • The plan utilizes the same extensive BCN provider network.

    BCN HMO Plan Deductible                    Your Deductible                       Deductible
         Requirement                            Responsibility                   BCN HRA Reimburses
                                                                              (Employer Funded Account)
     $4,000 Single/$8,000 Family          $1,500 Single/$3,000 Family        Up to $2,500 Single/$5,000 Family

As a reminder, the BCN Buy-Down HMO does not include the HRA aspect and truly does have a $4,000 Single/
$8,000 Family Deductible.

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STAFF - 2021 BENEFITS GUIDE - My Gardner White Benefits
MEDICAL PPO OPTIONS
BLUE CROSS BLUE SHIELD OF MICHIGAN (BCBSM)
Blue Cross Blue Shield Simply Blue PPO plan elections are effective April 1, 2021, however the deductibles and
annual out-of-pocket maximums will accumulate on a calendar year basis (January 1 - December 31).
                                                                                             Simply Blue QHDHP
BCBSM                                                Simply Blue PPO $500
                                                                                            PPO $2,000 with HSA
Deductible                                              $500 per member                       $2,000 per member
(1.1.2021 - 12.31.2021)                                 $1,000 per family                      $4,000 per family
                                                       $1,500 per member
Annual Coinsurance Maximum                                                                           None
                                                        $3,000 per family
Annual Out-of-Pocket Maximum                           $8,150 per member                      $4,000 per member
(includes deductibles, coinsurance and copays)          $16,300 per family                     $8,000 per family
Lifetime Dollar Maximum                                                           None
Primary Care Visit                                          $20 copay                    80% after in-network deductible
Specialist Visit                                            $20 copay                    80% after in-network deductible
                                                                                               100% covered;
Online Visit                                                $20 copay
                                                                                           deductible does not apply
Preventive Care/Screening/                              100% covered;
                                                                                         80% after in-network deductible
Immunization                                        deductible does not apply
Diagnostic Test (x-ray,                          80% coinsurance after in-network
                                                                                         80% after in-network deductible
blood work)                                                deductible
                                                 80% coinsurance after in-network
Imaging (CT/PET scans, MRIs)                                                             80% after in-network deductible
                                                           deductible
Emergency Room Care                                        $150 copay                    80% after in-network deductible
Urgent Care                                                 $20 copay                    80% after in-network deductible
Prescription Drugs
                                                                                          $15 copay after deductible
                                                   $15 copay for 30-day supply;                for 30-day supply;
Generic
                                                   $30 copay for 90-day supply            $30 copay after deductible
                                                                                               for 90-day supply
                                                                                          $30 copay after deductible
                                                   $30 copay for 30-day supply;                for 30-day supply;
Preferred Brand-Name Drugs
                                                   $60 copay for 90-day supply;           $60 copay after deductible
                                                                                               for 90-day supply;
                                                                                          $60 copay after deductible
Non Preferred Brand-Name                           $60 copay for 30-day supply;                for 30-day supply;
Drugs                                              $120 copay for 90-day supply          $120 copay after deductible
                                                                                               for 90-day supply
*Out-of-Network deductibles and coinsurance are higher when utilizing out-of-network services. Refer to the
Summary Benefits of Coverage for details.

  Embedded Deductible: Under family coverage, the deductible is the individual deductible for each covered
  person. The Simply Blue PPO 500 plan has an embedded deductible.

  Aggregate Deductible: The total family deductible must be paid out-of-pocket before the insurance begins
  paying for services. The Simply Blue QHDHP PPO $2000 with HSA plan has an aggregate deductible.

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STAFF - 2021 BENEFITS GUIDE - My Gardner White Benefits
HEALTH SAVINGS ACCOUNT (HSA)
A Health Savings Account (HSA) is a tax advantaged medical savings account designed to help individuals pay for
their health care. Gardner White partners with Health Equity.

Who is Eligible for an HSA?
To qualify for an HSA, eligible individuals must meet the following requirements:
    • You must be covered under a Qualified High Deductible Health Plan on the first day of the month
    • You have no other health coverage (that is not an QHDHP)
    • You are not enrolled in Medicare
    • You cannot be claimed as a dependent on another person’s income tax return

The Benefits of an HSA
   • You can claim a tax deduction for contributions that you make to
      your HSA
   • HSA distributions may be tax-free if you use them to pay for
      qualified medical expenses
   • The interest in your account are tax-free
   • An HSA is “Portable” so it stays with you even if you change jobs,
      become unemployed or retire

How Much Can You Contribute to Your HSA for 2021?

                                     2021 Contributions
           Individual                       $3,600
            Family                          $7,200
       55 Years or Older               Additional $1,000

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BLUE MEMBER SECURED SERVICES
You and your family members can manage your health and health plan online at bcbsm.com.

Register for Member Secured Services to access all of our online services.

Registering is easy. Here’s how:
   • Visit bcbsm.com
   • Click on the I am a Member tab
   • Click on Register
   • Follow the registration steps that appear on the screen

If you are registering for the first time, you will be asked a few brief questions to verify your identity. This security
step is required because Member Secured Services offers you personalized online services that contain
protected health information. We are committed to protecting your privacy.

If you are the Blues subscriber on the account, you will also be given the opportunity to “go green” and receive
your Explanation of Benefit Payments statements electronically.

Once you register you will be able to:
   • Review you Explanation of Benefit Payments
      statements online. We’ll send you an email when
      each statement becomes available. In addition to
      viewing the statements online, you can also save
      them as a PDF.
   • View detailed claim and benefit information.
   • Access your pharmacy information.
   • Take an interactive health assessment and receive a
      lifestyle score and tailored action plan.
   • Participate in online health coaching programs so
      you can achieve health goals identified by your
      health assessment.
   • Access extensive, up-to-date health content,
      including multimedia components like podcasts and
      videos.
   • Find and compare doctors and hospitals based on
      factors most important to you, like cost and quality.
   • Save money on the healthy products and services
      you use everyday through our member savings
      programs, Health Blue XtrasSM and Blue365®.

All features may not be available, depending on your plan.

Questions?
For Web registration or access help, call 888-417-3479.

For benefit, eligibility or claims information, call the
Customer Service number on the back of your BluesID
card.

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ONLINE TELEMEDICINE VISITS
When you use Blue Cross Online VisitsSM (previously called 24/7 online health care), you will have access to
online medical and behavioral health services anywhere in the US.

You can rest assured knowing you and your covered family members can see and talk to:
   • A doctor for minor illnesses such as a cold, flu or sore throat when your primary care doctor is not
      available.
   • A behavioral health clinician or psychiatrist to help work through different challenges such as anxiety,
      depression and grief. (Behavioral health visits are available by appointment only.)

While online health care should not replace your relationship with your primary care physician, it can be
invaluable when:
    • Your doctor is not available
    • You can not leave home or your workplace.
    • You are on vacation or traveling for work.
    • You are looking for affordable after-hours care.

How do I get started?
Start by doing one of the following:
    • Mobile - Download the BCBSM Online Visits app
    • Web - Visit bcbsmonlinevisits.com
    • Phone - Call 844-606-1608

If you are new to online visits, you will need to register with your Blue Cross or Blue Care Network health
plan information.

Share information with your primary care physician
To ensure that your primary care physician knows about all of your
medical care, let them know when you use online health care. At the
end of your visit, check the box to share your visit summary report with
your family doctor or other health care providers.

How much does it cost?
For medical services, an online visit is based on your office visit
cost share. Costs for behavioral health services vary depending
on the type of provider and service received. You will be charged
using your existing outpatient behavioral health benefits.

Questions?
For questions regarding online health care, contact:
844-606-1608
bcbsmonlinevisits.com

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DENTAL
Gardner-White Furniture provides you with a choice of two different dental options through Delta Dental.
  • Delta Dental PPO
  • Delta Dental DHMO

To find providers near you, refer to the network directory online at www.deltadentalmi.com or call 800-524-0149.

DHMO
With a Delta Dental DHMO plan, you enjoy negotiated discounts from network dentists. You pay a fixed copay
for each covered service. Out of network dentists are not covered. This plan also features no annual
maximum.

PPO
Through the PPO, you are not required to use a network provider – you have freedom to select any dentist.
However, benefits are highest if you receive care from a PPO network provider in the Delta Dental PPO network.

Using a PPO dentist is the best way to maximize your dental benefits as these dentists agree to accept the PPO
network pre-negotiated fee and are prohibited from billing you for amounts in excess of this fee. You are still
responsible for any applicable employee copayment based on the type of service performed.

Delta Premier
Delta Premier dentists are not part of the PPO network, however Premier dentists agree to adhere to Delta Dental
processing policies and are prohibited from billing a patient above the pre-negotiated fee for the Premier
network. The pre-negotiated fee under the Premier network may be higher than the PPO network, potentially
increasing your out-of-pocket expense.

Out-of-Network (Nonparticipating dentists)
If you use a non-participating provider you may be balance billed for up to the actual billed amount, even when
it exceeds the amount Delta Dental approves. Using an out-of-network dentist can significantly increase your
out-of-pocket expense.
                                 DELTA DENTAL DHMO                          DELTA DENTAL PPO
                                You are only covered if you
What’s the most                                                You may go to any dentist, however those who
                                go to a dentist who belongs
cost-effective way to use                                     belong to the Delta Dental - Michigan network will
                                 to the Delta Dental - HMO
dental insurance?                                                           be most cost effective.
                                        (MI) network.
                                                                PPO™          Premier®      Non-Participating
                                                                Dentist       Dentist*          Dentist*
                                                                              $25 single        $25 single
Calendar year deductible                   None                   None
                                                                              $75 family        $75 family
Calendar Year Maximum
                                         Unlimited                                 $1,500
Benefit
Lifetime Orthodontia
                                      Not Applicable                               $1,500
Maximum
Office Visit Co-pay (one
office visit may cover                      $0                     N/A           N/A               N/A
multiple services)
Preventive Care                  Refer to the fee schedule        100%          100%               100%
Basic Care                       Refer to the fee schedule        80%            80%               80%
Major Care                       Refer to the fee schedule        50%            50%               50%
Orthodontia up to age 19         Refer to the fee schedule        50%            50%               50%

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DENTAL                                                                                         Delta Dental Plan EPO 32
                             MEMBER COPAYMENT SCHEDULE
Delta Dental DHMO Fee Schedule                                                                                                                                                                   CDT-202 1

DIAGNOSTIC SERVICES                                                                                                                                   D2980      Crown repair, by report                     $70
C L I N I C A L O RA L EV A L U A TI O N S                                            R E S I N RE S TO R A T IO N S                                  D2981      Inlay repair                                $70
D0120         Oral examination, periodic                                        $0    D2330 1 surface, anterior                                $39    D2982      Onlay repair                                $70
D0140         Oral examination, limited, problem                                $0    D2331       2 surfaces, anterior                         $48
              focused (emergency)                                                     D2332       3 surfaces, anterior                         $57    ENDODONTICS
D0145         Oral evaluation for patients under                                $0    D2335       Involving incisal angle or 4 or more         $72    P U LPO T OM Y
              age 3 and counseling with primary                                                   surfaces, anterior                                  D3220 Therapeutic pulpotomy                            $48
              caregiver                                                               D2390 Crown, anterior                                    $60    D3221     Pulpal debridement, primary and              $46
D0150         Oral examination, comprehensive                                   $0    D2391       1 surface, posterior                         $45              permanent teeth
              evaluation                                                              D2392       2 surfaces, posterior                        $59
D0160         Oral examination, detailed and                                    $0    D2393       3 surfaces, posterior                        $72    R O O T CA N A L TH ER A P Y
              extensive evaluation, problem                                           D2394 4 or more surfaces, posterior                      $88    D3310     Anterior (excludes final restoration)       $201
              focused, by report                                                                                                                      D3320 Premolar (excludes final restoration)           $239
D0180         Oral examination, comprehensive                                   $0                      R E ST O R A T IO N S 1
                                                                                      I N L A Y / O N LA Y                                            D3330 Molar tooth (excludes final                     $295
              periodontal evaluation                                                                                                                            restoration)
                                                                                      D2510         Inlay, metallic, 1 surface                $252
D0190         Screening of a patient                                            $0                                                                    D3346 Retreatment, anterior                           $220
                                                                                      D2520 Inlay, metallic, 2 surfaces                       $265
                                                                                      D2530 Inlay, metallic, 3 or more surfaces               $279
W h e n a n y e x a m is p e r f o r m e d b y a s pe c i a l i s t , t h e r e is                                                                    D3347      Retreatment, premolar                      $268
                                                                                      D2542         Onlay, metallic, 2 surfaces               $292
a $1 2 c op a ym e nt .
                                                                                      D2543         Onlay, metallic, 3 surfaces               $302    D3348      Retreatment, molar                         $326
                                                                                      D2544 Onlay, metallic, 4 or more surfaces                $313
R A D I O G R AP H S
                                                                                      D2610         Inlay, porcelain/ceramic, 1 surface       $256    P E R I AP I C A L S E R VIC E S
D0210        Intraoral, complete series (includes                                $0
                                                                                      D2620 Inlay, porcelain/ceramic, 2 surfaces              $268    D3410         Apicoectomy/periradicular surgery -     $173
             bitewings)
                                                                                      D2630 Inlay, porcelain/ceramic, 3 or more                $281                 anterior
D0220 Intraoral, periapical first film                                           $0
                                                                                                    surfaces                                          D3421         Apicoectomy/periradicular surgery -     $186
D0230 Intraoral, periapical each addt'l film                                     $0                                                                                 premolar, first root
                                                                                      D2642         Onlay, porcelain/ceramic, 2 surfaces       $311
D0240 Intraoral, occlusal                                                        $0                                                                   D3425         Apicoectomy/periradicular surgery -     $207
                                                                                      D2643 Onlay, porcelain/ceramic, 3 surfaces              $321
D0270 Bitewing, 1 film                                                           $0                                                                                 molar, first root
                                                                                      D2644 Onlay, porcelain/ceramic, 4 or more               $332
D0272        Bitewing, 2 films                                                   $0                                                                   D3426 Apicoectomy/periradicular surgery -              $74
                                                                                                    surfaces
D0273 Bitewing, 3 films                                                          $0                                                                                 each additional root
                                                                                      D2650 Inlay, resin-based, 1 surface                     $220
D0274 Bitewing, 4 films                                                          $0                                                                   D3430 Retrograde filling - per root                    $49
                                                                                      D2651         Inlay, resin-based, 2 surfaces            $232
D0277        Bitewing, vertical, 7 to 8 films                                    $0
                                                                                      D2652         Inlay, resin-based, 3 or more surfaces    $245
D0330 Panoramic film                                                             $0                                                                   PERIODONTIC SERVICES
                                                                                      D2662         Onlay, resin-based, 2 surfaces            $257
                                                                                                                                                      S U R G I C A L S E R V ICE S
                                                                                      D2663         Onlay, resin-based, 3 surfaces            $267    D4210        Gingivectomy or gingivoplasty – 4 or      $117
T E S T S & L A B O R ATO R Y
                                                                                      D2664 Onlay, resin-based, 4 or more                     $277                 more teeth per quadrant
D0460 Pulp vitality                                                              $0
                                                                                                    surfaces                                          D4211        Gingivectomy or gingivoplasty – 1 to      $82
D0486 Accession of brush biopsy sample,                                          $0
            microscopic exam, prep and written                                                                                                                     3 teeth per quadrant
                                                                                      C R O W N S - S IN G L E R E S T O RA T I ON ON L Y 1
            report                                                                                                                                    D4240 Gingival flap procedure, includes root          $159
                                                                                      D2710      Resin (indirect)                             $229                 planing – 4 or more teeth per quadrant
D0999 Diagnostic procedure - unspecified,                                        $0
            by report                                                                 D2720      Resin with high noble metal                   $317   D4241        Gingival flap procedure, includes root    $111
                                                                                      D2721      Resin with predominantly base metal          $279                 planing, 1 to 3 teeth per quadrant
PREVENTIVE                                                                            D2722      Resin with noble metal                       $298    D4245 Apically positioned flap                        $185
D E N T A L P R OP H Y L A X I S ( c l ea n i n g )                                   D2740 Porcelain/ceramic                                 $345    D4249 Clinical crown lengthening                       $141
D1110       Prophylaxis – adult                                                  $0   D2750 Porcelain fused to high noble metal               $327    D4260 Osseous surgery – 4 or more teeth               $233
D1120       Prophylaxis – child                                                  $0   D2751      Porcelain fused to predominantly             $289                 per quadrant
                                                                                                 base metal                                           D4261        Osseous surgery – 1 to 3 teeth per       $148
F L U O R I D E T RE A TM E N T                                                       D2752      Porcelain fused to noble metal               $308                 quadrant
D1206        Topical fluoride varnish - child                                   $0    D2753      Porcelain fused to titanium and              $327
D1208        Topical application of fluoride                                    $0               titanium alloys                                      N O N -S U R G I CA L S ER V I C E S
                                                                                      D2780 3/4 cast high noble metal                         $303    D4341       Periodontal scaling and root planing –     $72
O T H E R P R EV E N TIV E SE R V I C ES                                              D2781      3/4 cast predominantly base metal            $268                4 or more teeth per quadrant
D1351       Sealant (per tooth)                                                  $0   D2782      3/4 cast noble metal                         $284    D4342 Periodontal scaling and root planing –           $45
D1353       Sealant repair (per tooth)                                           $0   D2783      3/4 porcelain/ceramic                        $337                1 to 3 teeth per quadrant
                                                                                      D2790 Full cast high noble metal                        $322    D4346 Scaling in the presence of                        $0
S P A CE MA I N TA I N ER S                                                           D2791      Full cast predominantly base metal           $284                inflammation
D1510     Fixed, unilateral – per quadrant                                      $0    D2792      Full cast noble metal                        $303    D4355       Full mouth debridement to enable           $51
D1516     Fixed, bilateral, maxillary                                           $0    D2794      Titanium                                     $322                comprehensive evaluation and
D1517     Fixed, bilateral, mandibular                                          $0                                                                                diagnosis
D1520     Removable, unilateral – per quadrant                                  $0    O T H E R RE S TO R A TI V E SE R V I CE S                      D4910       Periodontal maintenance                    $46
D1526     Removable, bilateral, maxillary                                       $0    D2910      Recement onlay or partial coverage            $30
D1527     Removable, bilateral, mandibular                                      $0               restoration                                          PROSTHODONTICS (Removable)2
D1551     Recement or rebond bilateral –                                        $0                                                                    C O M P LE T E DE N TU R E S
                                                                                      D2915      Recement cast or prefabricated post           $30
          maxillary                                                                              and core                                             D5110      Denture -   complete, maxillary            $120
D1552     Recement or rebond bilateral –                                        $0    D2920 Recement crown                                     $30    D5120      Denture -   complete, mandibular           $120
          mandibular                                                                  D2930 Crown - prefabricated stainless steel,             $83    D5130      Denture -   immediate, maxillary           $432
D1553     Recement or rebond – unilateral – per                                 $0               primary                                              D5140      Denture -   immediate, mandibular          $432
          quadrant                                                                    D2931      Crown - prefabricated stainless steel,        $83
D1556     Removal, fixed unilateral – per                                       $0               permanent                                            P A R T IA L D E NT U RE S
          quadrant                                                                    D2932      Crown - prefabricated resin                   $95    D5211       Maxillary, resin base                     $332
D1557     Removal, fixed bilateral – maxillary                                  $0    D2933      Crown - prefabricated stainless               $111   D5212       Mandibular, resin base                    $332
D1558     Removal, fixed bilateral - mandibular                                 $0               steel with resin window                              D5213       Maxillary, cast metal framework with      $445
D1575     Distal shoe – fixed, unilateral – per                                 $0    D2940 Sedative filling                                   $33                resin denture base
          quadrant                                                                    D2950 Crown buildup (substructure)                       $83    D5214       Mandibular, cast metal framework          $445
                                                                                                 including any pins                                               with resin denture base
RESTORATIVE PROCEDURES                                                                D2951      Pin retention - per tooth, in addition        $15    D5221       Maxillary, immediate, resin base          $365
A M A LG AM R ES T OR A T I O NS                                                                 to restoration                                       D5222       Mandibular, immediate, resin base         $365
D2140         1 surface                                                         $31   D2952      Post and core in addition to crown,           $111   D5223       Maxillary, immediate, cast metal          $490
D2150         2 surfaces                                                       $38               indirectly fabricated                                            framework with resin denture base
D2160         3 surfaces                                                       $46    D2954 Prefabricated post and core in                     $99    D5224       Mandibular, immediate, cast metal         $490
D2161         4 or more surfaces                                               $56               addition to crown                                                framework with resin denture base
                                                                                      D2971      Addt’l procedures to construct new            $65    D5225       Maxillary partial denture – flexible      $452
                                                                                                 crown under existing partial denture                             base (including retentive/clasping

                                                                                                                       14
DENTAL
Delta
 DeltaDental
       DentaDHMO
             l EPO Fee
                   PlanSchedule
                        32 continued
            materials, rests, and teeth)                           D5863       Overdenture,       complete maxillary                 $159    D7140         Extraction, erupted tooth or exposed                            $38
 D5226      Mandibular partial denture – flexible           $452   D5864       Overdenture,       partial maxillary                  $159                  root
            base (including retentive/clasping                     D5865       Overdenture,       complete mandibular                $159
            materials, rests, and teeth)                           D5866       Overdenture,       partial mandibular                 $159    S U R GI C A L E XT R AC T I O N S
 D5282      Removable unilateral partial denture –          $223                                                                             D7210       Surgical removal of erupted tooth                                 $76
            one piece cast metal (including                        PROSTHODONTICS (Fixed)1                                                   D7220       Removal of impacted tooth – soft                                  $92
            retentive/clasping materials, rests,                   BRIDGE      P O N T IC S (P e r U n i t )                                             tissue
            and teeth), maxillary                                  D6210       Cast high noble metal                                 $300    D7230 Removal of impacted tooth – partially                                  $125
 D5283      Removable unilateral partial denture –          $223   D6211       Cast base metal                                       $286                bony
            one piece cast metal (including                        D6212       Cast noble metal                                      $292    D7240 Removal of impacted tooth –                                            $146
            retentive/clasping materials, rests,                                                                                                         completely bony
                                                                   D6240       Porcelain fused to high noble metal                    $313
            and teeth), mandibular                                                                                                           D7241       Removal of impacted tooth –                                      $184
                                                                   D6241       Porcelain fused to base metal                         $292
 D5284      Removable unilateral partial denture –          $223                                                                                         completely bony with complications
                                                                   D6242       Porcelain fused to noble metal                        $302
            one piece flexible base (including                                                                                               D7250         Surgical removal of residual roots                              $80
                                                                   D6243       Porcelain fused to titanium and                        $313
            retentive/clasping materials, rests,
                                                                               titanium alloys
            and teeth) – per quadrant
                                                                   D6250       Resin with high noble metal                           $288    O T H E R S U R G I CA L P R O C E DU R E S
 D5286      Removable unilateral, one piece resin           $223
                                                                   D6251       Resin with base metal                                 $274    D7286       Biopsy of oral tissue – soft                                      $46
            (including retentive/clasping
                                                                   D6252       Resin with noble metal                                $280    D7288       Brush biopsy                                                      $35
            materials, rests, and teeth) – per
            quadrant
                                                                   F I X E D B R I D G E RE TA I N E R S – I N L A Y S/O N L A Y S           A L V E O L OP L A S T Y ( S u r g i c a l P r e p a r a t io n o f R i d g e f o r
 A D J U S TM E NT T O D E N T U RE S                              D6545 Retainer - cast metal for resin bonded                       $87    Dentures )
 D5410       Complete, maxillary                             $25                fixed prosthesis                                             D7310       In conjunction with extractions, 4 or                                $73
                                                                   D6548 Retainer - porcelain/ceramic for resin                       $87                more teeth or spaces per quadrant
 D5411       Complete, mandibular                            $25
                                                                                bonded fixed prosthesis                                      D7311       In conjunction with extractions, 1 to 3                             $45
 D5421       Partial, maxillary                              $25
                                                                   D6549 Retainer – resin for resin bonded fixed                      $87                teeth or spaces per quadrant
 D5422       Partial, mandibular                             $25
                                                                                prosthesis                                                   D7320 Not in conjunction with extractions, 4                                    $80
                                                                   D6600 Inlay, porcelain/ceramic, 2 surfaces                        $287                or more teeth or spaces per quadrant
 R E P A I RS T O C OM PL E T E D EN T U RE S
                                                                   D6601        Inlay, porcelain/ceramic, 3 or more                  $296    D7321       Not in conjunction with extractions, 1                              $48
 D5511       Repair broken complete denture base,            $58                surfaces                                                                 to 3 teeth or spaces per quadrant
             mandibular                                            D6602 Inlay, cast high noble metal, 2                             $279
 D5512       Repair broken complete denture base,            $58                surfaces
                                                                                                                                             E X C I S I ON O F BO NE T I SS U E
             maxillary                                             D6603 Inlay, cast high noble metal, 3 or more                     $292
                                                                                                                                             D7471         Removal of lateral exostosis                                   $143
 D5520 Replace missing or broken teeth                       $48                surfaces
                                                                                                                                             D7472         Removal of torus palatinus                                     $143
             (each tooth)                                          D6604 Inlay, cast predominantly base metal,                       $252
                                                                                2 surfaces                                                   D7473         Removal of torus mandibularis                                  $143
 R E P A I RS T O PA R T IA L D E N TU R E S                       D6605 Inlay, cast predominantly base metal,                       $265
                                                                                3 or more surfaces                                           S U R G I C A L I N C I SI ON
 D5611       Repair resin partial denture base,              $58
                                                                   D6606 Inlay, cast noble metal, 2 surfaces                         $265    D7510        Incision and drainage of abscess –                               $49
             mandibular
                                                                   D6607 Inlay, cast noble metal, 3 or more                          $279                 intraoral soft tissue
 D5612       Repair resin partial denture base,              $58                surfaces
             maxillary                                                                                                                       D7922        Placement of intra-socket biological                               $0
                                                                   D6608 Onlay, porcelain/ceramic, 2 surfaces                        $231                 dressing to aid in homeostasis or clot
 D5621       Repair cast partial framework,                  $83   D6609 Onlay, porcelain/ceramic, 3 or more                         $301                 stabilization – per site
             mandibular                                                         surfaces
 D5622       Repair cast partial framework,                  $83   D6610        Onlay, cast high noble metal, 2                      $224
                                                                                                                                             O T H E R RE PA I R P RO C E D U RE S
             maxillary                                                          surfaces
                                                                                                                                             D7961      Buccal/labial frenectomy                                           $89
 D5630 Repair or replace broken clasp (per                   $83   D6611       Onlay, cast high noble metal, 3 or                    $292
                                                                                                                                                        (frenulectomy)
             tooth)                                                            more surfaces
                                                                                                                                             D7962      Lingual frenectomy (frenulectomy)                                  $89
 D5640 Replace broken tooth (each)                           $48   D6612       Onlay, cast predominantly base metal,                 $252
                                                                                                                                             D7963      Frenuloplasty                                                      $89
 D5650 Add tooth to existing partial denture                 $61               2 surfaces
 D5660 Add clasp to existing partial denture                 $83   D6613       Onlay, cast predominantly base metal,                 $265
                                                                                                                                             ADJUNCTIVE GENERAL SERVICES
             (per tooth)                                                       3 or more surfaces
                                                                                                                                             U N C L A SS I F I E D T RE A T ME N T
 D5670 Replace all teeth and acrylic on cast                $249   D6614       Onlay, cast noble metal, 2 surfaces                   $292
             metal framework (maxillary)                                                                                                     D9110         Palliative (emergency) treatment of                             $30
                                                                   D6615       Onlay, cast noble metal, 3 or more                    $302
                                                                                                                                                           dental pain – minor procedure
 D5671       Replace all teeth and acrylic on cast          $249               surfaces
             metal framework (mandibular)
                                                                                                                                             P R O F E S SI O NA L CO N S U L TA T I ON
                                                                   BRIDGE      R E TA I NE RS – C R O W N S
 D E N T U RE R E BA S E P R O CE D U R ES                                                                                                   D9310        Consultation by dentist other than                               $20
                                                                   D6720       Resin with high noble metal                            $317
 D5710      Complete maxillary denture                      $159                                                                                          requesting dentist
                                                                   D6721       Resin with base metal                                 $279
 D5711      Complete mandibular denture                     $159
                                                                   D6722       Resin with noble metal                                $298    P R O FE S SI O NA L V IS I T S
 D5720 Maxillary partial denture                            $162
                                                                   D6750       Porcelain fused to high noble metal                   $327    D9440 Office visit after regularly scheduled                                    $0
 D5721      Mandibular partial denture                      $162
                                                                   D6751       Porcelain fused to base metal                         $289                hours
 D E N T U RE R E L IN E P R O C E DU R E S                        D6752       Porcelain fused to noble metal                        $308
 D5730 Complete maxillary, direct                            $99   D6753       Porcelain fused to titanium and                       $327    M I S C E L L AN E OU S S E R V I CE S
                                                                               titanium alloys                                               D9997 Dental case management – patients                                         $0
 D5731      Complete mandibular, direct                      $99
                                                                   D6780       3/4 cast high noble metal                              $317                 with special health care needs
 D5740 Maxillary partial, direct                             $93
                                                                   D6781       3/4 cast base metal                                   $279    D9999 Unspecified, by report                                                  $50
 D5741      Mandibular partial, direct                       $93
                                                                   D6782       3/4 cast noble metal                                  $298
 D5750 Complete maxillary, indirect                         $130
 D5751      Complete mandibular, indirect                   $130
                                                                   D6784       3/4 titanium and titanium alloys                       $317   ORTHODONTICS3
                                                                   D6790       Full cast high noble metal                            $322    R E C O R D S (s o l e l y fo r o r t h o d o n t i c p u r p o s e s )
 D5760 Maxillary partial, indirect                          $130
                                                                   D6791       Full cast base metal                                  $284    D0340         Cephalometric film                                                $0
 D5761      Mandibular partial, indirect                    $130
                                                                   D6792       Full cast noble metal                                 $303    D0350         Oral/facial photographic images                                   $0
 O T H E R RE MO V A BL E P R OS T H ET I C SE R V I C ES                                                                                    D0470         Diagnostic casts                                                  $0
                                                                   O T H E R F I X ED P ROS T H E TI C SE R V I C ES
 D5820 Interim partial denture (including                   $148
            retentive/clasping materials, rests,                   D6930 Recement fixed partial denture                               $42    C O M P RE H EN S I VE O R T H O DO N T I C T RE A T ME N T
            and teeth), maxillary                                  D6940 Stress breaker                                               $68    D8070 Transitional dentition                                $2,100
 D5821      Interim partial denture (including              $148                                                                             D8080 Adolescent dentition                                  $2,100
            retentive/clasping materials, rests,                   ORAL SURGERY                                                              D8090 Adult dentition (to age 19)                           $2,100
            and teeth), mandibular                                 E X T R A C T I ON S (S im p l e )
 D5850 Tissue conditioning, maxillary                        $64   D7111       Extraction, coronal remnants –                         $29
 D5851      Tissue conditioning, mandibular                  $64               primary tooth

11/2020                                                                                                 15
VISION
Gardner-White Furniture offers you vision benefits administered by NVA. You may choose to visit a provider
within the NVA network and take advantage of higher benefits coverage, or visit an out-of-network provider of
your choice for a reduced benefit if desired. Keep in mind, when you stay within the network, you will pay less.
To find a provider go to www.e-nva.com.
                                                                     In- Network                       Out-of-Network
                                                                                   Exams: Every 12 months
    How often can I obtain service?                                                Lenses: Every 12 months
                                                                                   Frames: Every 12 months
    Eye exams                                                                $0                              Up to: $46
    Lenses                                                            $10 Copay
    Single vision lenses                                             Covered 100%                            Up to: $47
    Lined bifocal lenses                                             Covered 100%                            Up to: $66
    Lined trifocal lenses                                            Covered 100%                            Up to: $85
    Lenticular lenses                                                Covered 100%                            Up to: $125
    Lens Options
    Polycarbonate - Under age 19                                     Covered 100%                               N/A
    Solid Tints                                                      Covered 100%                               N/A
    Fashion Gradient Tint                                            Covered 100%                               N/A
    Oversized                                                        Covered 100%                               N/A
    Frames
    Retail Frame Allowance2                                      Covered up to $150                          Up to $47
    20% Discount of Frame Balance3                                      Yes                                    N/A
    Contact Lenses Fit/Follow-up1
    Standard Daily Wear                                            Covered 100%                              Up to: $20
    Standard Extended Wear                                         Covered 100%                              Up to: $30
    Specialty Wear                                                 Covered 100%                              Up to: $50
    Elective4                                                    Covered up to $150                          Up to: $105
      15% discount on Conventional/                                    Yes                                     N/A
       10% discount on Disposable on
       remaining balance5
    Medically Necessary6                                             Covered 100%                            Up to: $210
1
  Only covered if member chooses contact lenses.
2
  Includes frames up to $61 every day low price-price point at Walmart/
   Sam’s Club locations (if included in the network).
3
   Discount does not apply at Walmart/Sam’s Club locations, LensCrafters
    or for certain proprietary frame brands or where prohibited by law.
4
    $105 every day low price-price point for contact lenses at Walmart/
     Sam’s Club locations (if included in the network).
5
     Discount does not apply at Walmart/Sam’s Club locations, Cole
      corporate locations (if applicable), LensCrafters or Contact Fill or where
      prohibited by law. Prohibited by some manufacturers.
6
      Prior authorization required from NVA included fitting & follow-up.

Note: if covered participants choose extra options, they are responsible
for the additional cost of the options paid directly to the provider.

                                                                          16
BASIC LIFE AND AD&D
Gardner-White Furniture provides Basic Life and Accidental Death & Dismemberment (AD&D) insurance benefits
to all eligible employees through Mutual of Omaha Life Insurance.

Basic Life
As an active employee of Gardner-White Furniture, you have access to a life insurance policy from Mutual of
Omaha Life Insurance Company.

How much insurance is enough?
When determining how much life insurance you need, think about the expenses you may encounter now and
through every stage of your life. Coverage guidelines and benefits are outlined in the chart below.
BASIC LIFE AND AD&D INSURANCE
                                       You must be actively working a minimum of 30 hours per week to be
Eligibility Requirement
                                       eligible for coverage.
                                       The premiums for this insurance are paid in full by Gardner-White
Premium Payment
                                       Furniture. There is no cost to you for this insurance.
Life Insurance Benefit Amount          For You: $10,000
                                       In the event of death, the benefit paid will be equal to the benefit
                                       amount after any age reductions less any living care/accelerated death
                                       benefits previously paid under this plan.
Accidental Death &                     For You: The Principal Sum amount is equal to the amount of your life
Dismemberment (AD&D) Benefit           insurance benefit.
Amount
Living Care/Accelerated                50% of the amount of the life insurance benefit is available to you if ter-
Death Benefit                          minally ill, not to exceed $5,000.
                                       In addition to basic AD&D benefits, you are protected by the following
                                       benefits:
Additional AD&D Benefits
                                         - Childcare - Child Education      - Seat Belt
                                         - Airbag      - Spouse Education - Common Carrier
                                       Insurance benefits and guarantee issue amounts are subject to age
                                       reductions:
Age Reductions and Exclusions            - At age 70, amounts reduce to 50%
                                       Information about the AD&D exclusions for this plan will be included in
                                       the summary of coverage, which you will receive after enrolling.

                                                       17
VOLUNTARY LIFE AND AD&D
As an active employee of Gardner-White Furniture, you have access to a life insurance policy from Mutual of
Omaha Life Insurance Company.

How much insurance is enough?
When determining how much life insurance you need, think about the expenses you may encounter now and
through every stage of your life.

Coverage guidelines and benefits are outlined in the chart below.

VOLUNTARY LIFE AND AD&D INSURANCE
                                       You must be actively working a minimum of 30 hours per week to be
Eligibility Requirement
                                       eligible for coverage.
                                       To be eligible for coverage, your dependents must be able to perform
                                       normal activities, and not be confined (at home, in a hospital, or in any
Dependent Eligibility
                                       other care facility), and any child(ren) must be under age 26. In order for
Requirement
                                       your spouse and/or children to be eligible for coverage, you must elect
                                       coverage for yourself.
Premium Payment                        The premiums for this insurance are paid in full by you.

COVERAGE GUIDELINES
                            Minimum                  Guaranteed Issue                       Maximum
                                                                            $500,000, in increments of
                                               5 times annual salary, up to
For You           $10,000                                                   $10,000, but no more than 5
                                               $250,000
                                                                            times annual salary
Spouse                                         100% of employee’s                100% of employee’s
                  $10,000
                                               benefit, up to $50,000            benefit, up to $250,000
Children                                                                         100% of employee’s benefit, up
                  $5,000                       100% of employee’s benefit
                                                                                 to $10,000

BENEFITS
                                       Within the coverage guidelines defined above, you select the amount of
                                       life insurance coverage you want.
                                       This plan includes the option to select coverage for your spouse and
                                       dependent children.
Life Insurance Benefit Amount
                                       Children include those, up to age 26.
                                       In the event of death, the benefit paid will be equal to the benefit
                                       amount after any age reductions less any living care/accelerated death
                                       benefits previously paid under this plan.
                                       For you, your spouse and your dependent child(ren): The Principal Sum
                                       amount is equal to the amount of the life insurance benefit.
Accidental Death &
                                       AD&D coverage is available if you or your dependents are injured or die
Dismemberment (AD&D)
                                       as a result of an accident, and the injury or death is independent of
Benefit Amount
                                       sickness and all other causes. The benefit amount depends on the type
                                       of loss incurred, and is either all or a portion of the Principal Sum.
Age Reductions and Exclusions          Insurance benefits and guarantee issue amounts are subject to age
                                       reductions:
                                       - At age 70, amounts reduce to 50%
                                       Spouse coverage terminates when you reach age 70.

                                                       18
VOLUNTARY SHORT-TERM DISABILITY INSURANCE
As an active employee of Gardner-White Furniture, you have access to a disability income insurance policy from
Mutual of Omaha Life Insurance Company. A disability income insurance policy can help provide security when
you need it, plus give you peace of mind so you can recover faster and get back on the job sooner.
Coverage guidelines and benefits are outlined below.

VOLUNTARY SHORT-TERM DISABILITY
                                       You must be actively working a minimum of 30 hours per week to be
Eligibility Requirement
                                       eligible for coverage.
Premium Payment                        The premiums for this insurance are paid in full by you.
Elimination Period                     If you become disabled, there is an elimination period before benefits
                                       are payable. Your benefits begin:
                                          • On the 15th day of your disabling injury.
                                          • On the 15th day of your disabling illness.
Weekly Benefit                         Your benefit is equivalent to 60% of your before-tax weekly earnings,
                                       not to exceed the plan’s maximum weekly benefit amount less other
                                       income sources.
                                       The premium for your short-term disability coverage is waived while you
                                       are receiving benefits.
Maximum Benefit Period                 Up to 24 weeks
Maximum Weekly Benefit                 $1,000
Minimum Weekly Benefit                 $25

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VOLUNTARY LONG-TERM DISABILITY INSURANCE
As an active employee of Gardner-White Furniture, you have access to a disability income insurance policy from
Mutual of Omaha Life Insurance Company. A lengthy disability can be devastating, and is more common than you
might think. It may lead to a loss of income, independence and financial security. A disability income insurance
policy can help provide security when you need it most. It pays you cash benefits when you’re sick or hurt and
can’t work.

Coverage guidelines and benefits are outlined in the chart below.

VOLUNTARY LONG-TERM DISABILITY
                                       You must be actively working a minimum of 30 hours per week to be
Eligibility Requirement
                                       eligible for coverage.
Premium Payment                        The premiums for this insurance are paid in full by you.
Elimination Period                     Your benefits begin on the later of 180 calendar days after the onset of
                                       your disabling injury or illness or the date your short term disability ends.
Monthly Benefit                        Your benefit is equivalent to 60% of your before-tax monthly earnings,
                                       not to exceed the plan’s maximum monthly benefit amount less other
                                       income sources.
                                       The premium for your long-term disability coverage is waived while you
                                       are receiving benefits.
Maximum Monthly Benefit                $5,000
Minimum Monthly Benefit                $100
                                       If you become disabled prior to age 62, benefits are payable to age 65,
                                       your Social Security Normal Retirement Age or 3.5 years, whichever
Maximum Benefit Period
                                       is longest. At age 62 (and older), the benefit period will be based on a
                                       reduced duration schedule.

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FLEXIBLE SPENDING ACCOUNT
With an FSA, participants elect an annual contribution amount, up to the IRS maximum, to be deducted from their
paychecks each pay period in equal installments throughout the year. The amount of pay that goes into an FSA
will not count as taxable income, so participants will have immediate tax savings. FSA dollars can be used during
the plan year to pay for qualified expenses and services. Isolved Benefit Services is the plan administrator for the
FSA plan.

   • A Health FSA allows reimbursement of qualifying out-of-pocket medical expenses NOT enrolled in the
      Simply Blue QHDHP PPO $2,000
   • A Dependent Care FSA allows reimbursement of dependent care expenses, such as day care, incurred by
      eligible dependents.

With all FSA account types, participants receive access to a secure, easy-to-use web portal and smartphone app
where they can track their account balances and submit requests for reimbursements.

In addition, you will receive a convenient debit card to make it easy to pay for eligible services and products.
When participants use the card, payments are automatically withdrawn from the FSA account, so there are no
out-of-pocket costs and many times they won’t have to submit receipts to verify the purchase.

Health Care FSA
Allows you to pay for medical, dental, vision and other health care expenses that are not covered under any other
plan with pre-tax dollars. The maximum amount you may contribute to your health care FSA is $2,000. Funds are
available on first day of plan year. Plan carefully—Claims must be incurred in the plan year in order to be eligible
for reimbursement.

Dependent Care FSA
A Dependent Care FSA provides pre-tax reimbursement of out-of-pocket expenses related to dependent care. It’s
a great option for employees who have dependent children under the age of 13 who attend day care, afterschool
care or summer day camp, and/or provide care for a person of any age who is claimed as a dependent on the
federal income tax return and who is mentally or physically incapable of caring for himself or herself.

Who is a qualified dependent under the Dependent Care FSA?
  • Dependent under the age of 13
  • Dependent or spouse of employee who is mentally or physically disabled and whom the employee claims
     as a dependent on their federal income tax return

Rollover of Unused Funds
This plan does contains a provision which allows you to rollover unused funds to the next plan year as long as
the balance does not exceed the maximum rollover amount of $550. If you rollover funds it will not decrease
your ability to elect the full plan maximum of $2,000.

Use it or Lose It
IRS regulations specify that the money you contribute to your spending accounts for any plan year may only be
used to reimburse eligible expenses incurred during that year. Any money over the $550 rollover limit remaining
in your account, at the end of the plan year, will be forfeited. iSolved Benefit Services gives a 90-day run out
period which allows you to submit claims from the prior plan year, participants have until June 29, 2022.

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FLEXIBLE SPENDING ACCOUNT
Prepaid Benefits Card
The Prepaid Benefits Card is a special-purpose MasterCard® card that gives participants an easy, automatic
way to pay for eligible health care/benefit expenses. The card lets participants electronically access the pre-tax
amounts set aside in their Flexible Spending Accounts (FSAs).

How does the Benefits Card work?
It works like a MasterCard® card, with the value of your account(s) contribution stored on it. When you have
eligible expenses at a business that accepts MasterCard® debit cards, you simply use the card. The amount of
the eligible purchase will be automatically deducted from your account and the pre-tax dollars will be
electronically transferred to the provider/merchant for immediate payment.

Where can you use the Benefits Card?
You to use the Benefits Cards in participating pharmacies, mail-order pharmacies, discount stores, department
stores and supermarkets that can identify FSA/HRA eligible items at checkout and accept MasterCard® prepaid
cards. You can find out which merchants are participating by visiting the website on the back of the card.

You may also use the card to pay a hospital, doctor, dentist or vision provider that accepts MasterCard®. In this
case, auto-substantiation technology is used to electronically verify the transaction’s eligibility according to IRS
rules. If the transaction cannot be auto substantiated, follow-up will be required.

The iFlex App

You have your phone with you all the time. Why not use the iFlex App to review your account information, take a
photo of the receipt and submit the claim right away?

The iFlex App connects you with the details
   • Quickly check available balances 24/7
   • Access account details
   • View charts summarizing account(s)
   • Click to call or email Customer Service

Provides additional time-saving options
   • View claims requiring receipts
   • Submit medical FSA and HRA claims
   • Take a picture of a receipt to submit for a claim
   • View HSA transaction details
   • Using Expense Tracker, enter medical expense information and support documentation to store for later use
      in paying claims via your health benefits website
   • Report a lost or stolen debit card

The iFlex App is easy, convenient and secure. Simply login to the app using your same health benefits website
username and password (or follow alternative instructions if provided to you).

Follow these steps to download the iFlex App
    1. Visit the iTunes App Store or the Android Market to download the isolved app on your iPhone, iPad or
        Android.
    2. Once installed, enter the Username and Password to log into your account at
        www.isolvedbenefitservices.com

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