Supacolor Benefit Guide - CA

2022 - 2023

BENEFITS GUIDE April 1, 2022 - March 31, 2023

TA B L E O F

CONTENTS Eligibility & Enrollment

2

Employee Navigator Enrollment Guide

4-5

Medical

6-7

Dental

8

Vision

9

Voluntary Life + AD&D

10

Voluntary Short + Long-Term Disability

11

Worksite Coverage

12

Notices & Rights

13

Important Contacts

14

Benefit Guide | 2

E L I G I B I L I T Y & E N RO L L M E N T Who is Eligible to Join the Benefit Plan?

Qualifying Event Changes

You and your dependents are eligible to join the health and our company welfare benefit plans if you are a full-time employee regularly scheduled to work 30 hours per week.

You must be enrolled in the plan to add dependent coverage.

You are allowed to make changes to your current benefit elections during the plan year if you experience an IRSapproved qualifying change in life status. The change to your benefit elections must be consistent with and on account of the change in life status.

Who is an Eligible Dependent?

IRS-approved qualifying life status changes include:

•

Your spouse to whom you are legally married

•

Marriage, divorce or legal separation

•

Your domestic partner with whom you have shared a residence and financial obligations for 6 months or more

•

Birth or adoption of a child or placement of a child for adoption

•

Your dependent child under the maximum age specified in the Carriers’ plan documents including: • Natural child • Adopted child • Stepchild • Child for whom you have been appointed as the legal guardian

•

Death of a dependent

•

Change in employment status, including loss or gain of employment, for your spouse or a dependent

•

Change in work schedule, including switching between fulltime and part-time status, by you, your spouse or a dependent

•

Change in residence or work site for you, your spouse, or a dependent that results in a change of eligibility

•

If you or your dependents lose eligibility for Medicaid or the Children’s Health Insurance Program (CHIP) coverage

•

If you or your dependents become eligible for a state’s premium assistance subsidy under Medicaid or CHIP

*Your child’s spouse and a child for whom you are not the legal guardian are not eligible.

The Dependent Maximum Age Limits is up to age 26. The dependent does not need to be a full-time student; does not need to be an eligible dependent on parent’s tax return; is not required to live with you; and may be unmarried or married.

Once the dependent reaches age 26, coverage will terminate on the last day of the birth month.

A totally disabled child who is physically or mentally disabled prior to age 26 may remain on the if the child is primarily dependent on the enrolled member for support and maintenance.

If you have a life status change, you must notify the company within 60 days for changes in life status due to a Medicare or CHIP event and within 31 days of the other events.

If you do not notify the company during that time, you and/or your dependents must wait until the next annual open enrollment period to make a change in your benefit elections.

When Do Benefits Become Effective?

Your benefits become effective on the first day of the month following your 60 days as a full-time employee with Supacolor.

Annual Open Enrollment?

Each year during the annual Open Enrollment Period, you are given the opportunity to make changes to your current benefit elections. To find out when the annual Open Enrollment Period occurs, contact Human Resources.

!

Please note, loss of coverage due to nonpayment or voluntary termination of other coverage outside a spouse’s or parent’s open enrollment is not an IRS-approved qualifying life event and you do not qualify for a special enrollment period.

Benefit Guide | 3

E M P L O Y E E N AV I G AT O R E N R O L L M E N T G U I D E Step 1: Log In Go to www.employeenavigator.com and click Login •

Returning users: Log in with the username and password you selected. Click Reset a forgotten password.

•

First time users: Click on your Registration Link in the email sent to you by your admin or Register as a new user. Create an account, and create your own username and password.

•

COMPANY IDENTIFIER: SUPACOLOR

Step 2: Welcome!

After you login, click Let’s Begin to complete your enrollment and additional required tasks if applicable.

Step 3: Start Enrollments After clicking Start Enrollment, you’ll need to complete some personal & dependent information before moving to your benefit elections.

TIP Have dependent details handy. To enroll a dependent in coverage you will need their date of birth and Social Security number.

Step 4: Benefit Elections To enroll dependents in a benefit, click the checkbox next to the dependent’s name under Who am I enrolling?

Below your dependents you can view your available plans and the cost per pay. To elect a benefit, click Select Plan underneath the plan cost.

Click Save & Continue at the bottom of each screen to save your elections.

If you do not want a benefit, click Don’t want this benefit? at the bottom of the screen and select a reason from the drop-down menu.

Benefit Guide | 4

E M P L O Y E E N AV I G AT O R E N R O L L M E N T G U I D E

Step 5: Forms If you have elected benefits that require a beneficiary designation, Primary Care Physician, or completion of an Evidence of Insurability form, you will be prompted to add in those details.

Step 6: Review & Confirm Elections Review the benefits you selected on the enrollment summary page to make sure they are correct then click Sign & Agree to complete your enrollment.

You can either print a summary of your elections for your records or login at any point during the year to view your summary online.

TIP If you miss a step you’ll see Enrollment Not Complete in the progress bar with the incomplete steps highlighted. Click on any incomplete steps to complete them.

Step 7: You’re Finished You are finished. You can go back to your homepage to view your elections and you can make changes until the enrollment window closes.

You can login to review your benefits 24/7!

Benefit Guide | 5

KAISER MEDICAL PLAN OPTION 1 + 2 HMO Plan 8811 1000/30/3K

HMO Plan 9980 0/100/3.5K

In Network Only – You Pay

In Network Only – You Pay

Deductible (Individual)

$1,000

$0

Deductible (Family)

$2,000

$0

30% after deductible

30% after deductible

Out-of-Pocket Maximum (Individual)

$3,000

$3,500

Out-of-Pocket Maximum (Family)

$6,000

$7,000

Primary Care Physician Office Visit

$30 copay

$30 copay

Specialist Office Visit

$30 copay

$50 copay

Preventive Care Services

Plan pays 100%

Plan pays 100%

Laboratory Diagnostics & X-Ray

Plan pays 100%

$10 copay

Complex Imaging Services (CT Scans, PET Scans & MRI’s)

Deductible, then 30%

$100 copay

Hospital Inpatient Care

Deductible, then 30%

$500 per day

Outpatient Surgery

Deductible, then 30%

$250 copay

Emergency Room

Deductible, then 30%

$150 copay

$30 copay

$30 copay

Plan Highlights

Coinsurance

Urgent Care Prescription Drugs (Kaiser Only)

This plan meets the CMS standard for creditable prescription drug coverage.

Tier 1 — Generic Drugs

$10

$15

Tier 2 — Preferred Brand-Name

$30

$35

20% up to $250

30% up to $250

Tier 4 - Specialty Drugs

!

Please refer to the Summary of Benefit Coverage for full plan designs. Plan 1 + 2 has no Out-Of-Network Benefit.

Benefit Guide | 6

KAISER MEDICAL PLAN OPTION 3 POS Plan 13887 Tiered 500/20/3K

Plan Highlights

In Network Kaiser – You Pay

In Network POS Network– You Pay

Deductible (Individual)

$0

$500

Deductible (Family)

$0

$1,000

0% after deductible

20% after deductible

Out-of-Pocket Maximum (Individual)

$1,500

$3,000

Out-of-Pocket Maximum (Family)

$3,000

$6,000

Primary Care Physician Office Visit

$20 copay

$35 copay

Specialist Office Visit

$20 copay

$35 copay

Coinsurance

Preventive Care Services Laboratory Diagnostics & X-Ray Hospital Inpatient Care Outpatient Surgery

Plan pays 100% Plan pays 100%

$35 copay

$250 per day

Deductible, then $250 copay + 20%

$100 copay

Deductible, then 20%

Emergency Room Urgent Care Prescription Drugs (Kaiser | Community)

$150 copay $20 copay

Deductible, then 20%

This plan meets the CMS standard for creditable prescription drug coverage.

Tier 1 — Generic Drugs

$10 copay

$20 copay

Tier 2 — Preferred Brand-Name

$30 copay

$40 copay

Tier 3 — Non-Preferred Brand-Name

$30 copay

$50 copay

20% up to $250

30% up to $250

Tier 4 - Specialty Drugs

!

Please refer to the Summary of Benefit Coverage for full plan designs. Plan 3 allows Out-Of-Network benefits, but you may be balance billed.

H OW T O F I N D A P H Y S I C I A N / P H A R M AC Y To locate participating providers or pharmacies follow these easy steps: 1. Log onto https://www.multiplan.com/webcenter/portal/ProviderSearch?ProviderSearchConfig=ClientSite&SiteUrlSuffix=kaiser 2. Search Providers and Pharmacies in your zip code!

Plan A only allows Kaiser Facilities and no Out-Of-Network Facilities

Benefit Guide | 7

D E N TA L Dental By Design Service Waiting Period for Late Enrollees?

Employees are eligible for dental benefits after they have worked for Supacolor for 60 days. Employees and their enrolled dependents who submit the application within 30 days following the initial eligibility period will not be subject to waiting periods for dental services.

Employees who enroll themselves and/or their dependents 31 or more days after the initial eligibility period will be subject to a 12-month waiting period before the plan elected will pay for Basic or Major services. The waiting periods may be decreased or eliminated based on the number of months the member had dental insurance immediately before their effective date.

Select A Dental Plan That Meets Your Needs Both dental plans provide In- Network and Out-of-Network benefits. At the time of service, you will pay either a copayment or deductible and co-insurance. The In-Network providers participate in the DenteMax Plus / AlwaysCare Network. DenteMax dentists have agreed to accept as payment in full a discounted fixed fee schedule for the services they perform and will never collect more than the DenteMax fee for the procedure performed—no ‘balance billing.’

To find a dentist, log on to https://unum.go2dental.com/member/dental_search/searchprov.cgi

In-Network

Out-Of-Network*

Your Deductible

$50 individual / $150 Family

$50 individual / $150 Family

Calendar Year Maximum Applies to preventive, basic, and major services

$1,000 combined In-network and Out-of-Network

$1,000 combined In-network and Out-of-Network

Preventive & Diagnostic Services Exams, Cleanings & Bitewing X-Rays, Fluoride, Sealants

100% (Deductible waived)

100% (Deductible waived)

Basic Services Filings, Extractions, Endodontics (root canal), Periodontics (gum surgery), Oral Surgery, Repair of Dentures

80% After deductible

80% After deductible

Major Services Crowns, Bridgework, Full & Partial Dentures, Implants

50% Coinsurance

50% Coinsurance

Orthodontics (Adult & Children)

Not Covered

Not Covered

Lifetime Orthodontia Maximum

N/A

N/A

In-Network

Out-Of-Network*

Base Unum Dental Plan Highlights

Buy-Up Unum Dental Plan Highlights

(Plan Pays)

(Plan Pays)

(Plan Pays)

(Plan Pays)

Your Deductible

$50 individual / $150 Family

$50 individual / $150 Family

Calendar Year Maximum Applies to preventive, basic, and major services

$2,000 combined In-network and Out-of-Network

$1,000 combined In-network and Out-of-Network

Preventive & Diagnostic Services Exams, Cleanings & Bitewing X-Rays, Fluoride, Sealants

100% (Deductible waived)

100% (Deductible waived)

Basic Services Filings, Extractions, Endodontics (root canal), Periodontics (gum surgery), Oral Surgery, Repair of Dentures

80% Coinsurance

80% Coinsurance

Major Services Crowns, Bridgework, Full & Partial Dentures, Implants

50% Coinsurance

50% Coinsurance

Orthodontics (Adult & Children)

50%

50%

Lifetime Orthodontia Maximum

$2,000

$2,000

*Going Out-Of-Network may subject you to Balance Billing. Unum reimburses providers on the 90th percentile level, and you may be billed by your provider if the total amount exceeds Unum’s reimbursement. We encourage you to go In-Network whenever possible.

Benefit Guide | 8

VISION Unum, in association with EyeMed Vision Care, offers easy access to thousands of conveniently located vision care providers.

Unlike other programs that may restrict provider options, EyeMed offers a nationwide network of convenient, accessible options for eye care including optometrists, ophthalmologists, opticians and many leading optical retailers, such as Private Practitioners, LensCrafters, Target Optical, most Sears Optical, Pearl Vision and JC Penny Optical locations.

• • • •

Access to more than 71,200 vision care providers at 27,000 convenient locations nationwide Evening and weekend hours at many locations Choice of thousands of fashionable, designer frames No appointment necessary, and service in “about an hour” in most locations

Unum Vision Plan Services

In Network

Out Of Network

Routine Exam with Dilation

$10 Copay

$40 allowance

Standard Contact Lens fit and follow-up

$40 Copay

$0 allowance

$130 frame allowance 20% off balance over allowance

$91 allowance

Single

$25 Copay

$30 allowance

Bifocal

$25 Copay

$50 allowance

Trifocal

$25 Copay

$70 allowance

UV Coating

$15

Discount available

Tint (Solid and Gradient)

$15

Only at Network

Standard Scratch Resistant Coating

$15

Providers and Retailers

Standard Polycarbonate

$40

Standard Anti-Reflective Coating

$45

Eye Exam:

Frames: Any available frame at provider location

Standard Plastic Lenses:

Lens Options:

Standard Progressive (Add-on to Bifocal) Other Add-Ons and Services

$90-$135 copay 20% off retail

Contact Lenses: (Material Only) Conventional Medically Necessary

$130 allowance 15% off balance over allowance

$130 allowance

Paid in full

$210 allowance

Frequency: Examination

12 months

Frames

24 months

Eyeglass Lenses

12 months

Contact Lenses

12 months

S U P P L E M E N TA L L I F E A N D A D & D Employees may elect a basic program of $10,000 or increments of $5,000 up to a maximum of $500,000, subject to guaranteed issue schedule. An employee's Voluntary Life benefit may not exceed five (5) times annual salary. Spouses may elect increments of $5,000 up to a maximum of $500,000, subject to guaranteed issue schedule. The spouse's Voluntary Life benefit cannot exceed 100% of the employee's Voluntary Life amount. Dependent Child(ren) coverage is available in increments of $2,000, up to a maximum benefit of $10,000.

Guaranteed Issue Schedule • • •

Employee: $150.000 Spouse: $15,000 Child: All coverage is guarantee issue

Voluntary Life benefit amounts will reduce to 65% of the original amount at age 65, to 50% at age 70. Benefits terminate at retirement.

The spouse's Voluntary Life benefit amount will reduce in accordance with the spouse’s age.

Life and AD&D are sold together for Employee and Spouse Coverage. The amount of AD&D coverage must be equal to the amount of Voluntary Life benefits the employees select for themselves and their covered spouses. AD&D coverage is not available for a child.

• Employee coverage must be elected in $10,000 increments, minimum amount $10,000, the maximum amount per employee is $500,000 subject to Guarantee Issue schedule.

• Spouse coverage must be elected in $5,000 increments, not to exceed 100% of the employee amount.

The maximum spouse benefit is $500,000, subject to Guarantee Issue schedule.

• Dependent Child(ren) coverage is available in increments of $2,000, up to a maximum benefit of $10,000.

Monthly Life Rates Per $1,000 Of Benefit

Employee

Spouse

Age < 25

$0.090

$0.090

25-29

$0.090

$0.090

30-34

$0.110

$0.110

35-39

$0.170

$0.170

40-44

$0.240

$0.240

45-49

$0.390

$0.390

50-54

$0.600

$0.600

55-59

$0.870

$0.870

60-64

$1.150

$1.150

65-69

$1.480

$1.480

70-74

$2.71

$2.71

$0.030

$0.030

$0.300

$0.030 AD&D

Monthly AD&D Rates Per $1,000 Of Benefit Employee & Spouse Only Monthly Child Cost Per $1,000 Of Benefit All Children, one unit

Benefit Guide | 10

VO L U N TA RY D I S A B I L I T Y I N S U R A N C E Disability coverage provides the financial security of knowing that you will continue to receive income if you are unable to work due to illness or injury.

Short-Term Disability Even a few weeks away from work can make it difficult to manage household expenses. Voluntary Short-Term Disability is available to you through Unum. This coverage will pay up to 60% of your weekly salary up to a maximum of $2,500 for non work-related accidents or sickness, so you can focus on getting better, and worry less about keeping up with your bills. Benefits begin on the 14th day of disability for accident and sickness. Benefits are payable up to a maximum of 11 weeks.

Long-Term Disability Serious illnesses or accidents can come out of nowhere. They can interrupt your life and your ability to work for months ─ even years. Voluntary Long-Term Disability coverage is available to you through Unum. This benefit pays 60% of your monthly earnings in the event of a disability after 90 days for accident and illness up to a maximum monthly benefit of $10,000. The Long-Term Disability benefit pays up to the Social Security Normal Retirement Age (SSNRA).

The policy does not provide benefits for a disability caused by a pre-existing condition. A pre-existing condition is any condition for which you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines prior to your effective date of coverage. Please refer to the plan certificate for the pre-existing guidelines.

Short-Term Disability

Long-Term Disability

Age

Rate per $10 of Weekly Benefit

Age

Rate per $100 of Monthly Covered Payroll

Age < 25

$0.072

Age < 25

$0.10

25-29

$0.134

25-29

$0.15

30-34

$0.198

30-34

$0.28

35-39

$0.150

35-39

$0.45

40-44

$0.117

40-44

$0.77

45-49

$0.127

45-49

$1.05

50-54

$0.165

50-54

$1.41

55-59

$0.228

55-59

$1.68

60+

$0.287+

60+

$1.55+

O T H E R S TA N DA R D F E AT U R E S Full Maternity Benefits

Social Security Assistance

Vocational Rehabilitation

Continuity of Coverage

Workplace Modification Benefit

Cost of Living Freeze Benefit Guide | 11

WORKSITE INSURANCE ACCIDENT + HOSPITALIZATION

No one plans on getting injured…but just in case, we’ve got you covered.

You do everything you can to stay active and healthy, but accidents happen every day, especially sports-related accidents. An injury that hurts an arm or a leg can hurt your finances too. That’s where Unum’s Group Accident can help.

Group Accident pays cash benefits directly to you or anyone you choose regardless of any other coverages you have. Accident also pays extra benefits for injuries resulting from participating in organized sports. Let Accident help take care of yourself and your family.

Unum Accident Plan Tier

Monthly Premiums

Employee

$11.96

Employee + Spouse

$20.63

Employee + Child(ren)

$27.48

Employee + Family

$36.15

Unum Hospital Offering: Hospital insurance is designed to help provide financial protection for covered individuals by paying a benefit due to a hospitalization and in some cases, for treatment received for an accident or sickness, even if that treatment occurs outside the hospital. Employees can use the benefit to meet the out-of-pocket expenses and extra bills that can occur.

Lump sum, direct cash benefits are paid directly to the employee based on the amount of coverage listed in the schedule of benefits.

Unum Hospital Offering Tier

Monthly Premiums

Employee

$9.39

Employee + Spouse

$24.67

Employee + Child(ren)

$16.37

Employee + Family

The Sports Package increases the total benefit payment by 25%

$31.65

Benefit Guide | 12

I M P O R TA N T I N F O R M AT I O N This guide provides a summary of you employee benefits rights and regulations as determined by Federal and State Laws.

Information included in this guide includes the following: Special Open Enrollment Rights Children’s Health Insurance Program (CHIP) Premium Assistance

General Notice of the Cobra Continuations Rights Affordable Care Act (ACA) – Insurance Mandate

Health Insurance Marketplace Coverage Options and Your Group Health Coverage Affordable Care Act (ACA) – Preventive Services for Non-grandfathered Plans Newborns’ and Mothers’ Health Protection Act of 1996 Break Time for Nursing Mothers Under the Fair Labor Standards Acts (FLSA) Women’s Health & Cancer Rights Act The Generic Information Nondiscrimination Act of 2008 (GINA) HIPAA Privacy Rules

S P E C I A L O P E N E N RO L L M E N T R I G H T S This notice is being provided to ensure that you understand your right to apply for group health insurance coverage. A special enrollment period is a time outside of the annual open enrollment period during which you and your family have a right to sign up for health coverage. In the Marketplace, you qualify for a special enrollment period 60 days following certain life events that involve a change in family status (for example, marriage or birth of a child) or loss of other health coverage. Job-based plans must provide a special enrollment period of 30 days. Some events will require additional documentation to be submitted with the application at the time of enrollment. You should read this notice even if you plan to waive coverage at this time.

Marriage, Birth, or Adoption

Loss of Other Coverage

Medicaid or CHIP

If you have a new dependent as a result of a marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, or placement for adoption.

If you are declining coverage for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

If you or your dependents lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or become eligible for a premium assistance subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents. You must request enrollment within 60 days of the loss of Medicaid or CHIP coverage or the determination of eligibility for a premium assistance subsidy.

To request special enrollment or obtain more information, please contact HR. Benefit Guide | 13

KEY CONTACTS & RESOURCES Questions on your benefits or need assistance with Claims, contact Sterling Seacrest Pritchard:

Your Employee Support Contact

Claims Questions?

Benefit Questions?

Darlene Moorman 770.635.0439 dmoorman@sspins.com

Marie Volk 770.635.0451 mvolk@sspins.com

BE SURE TO HAVE THE FOLLOWING INFORMATION WHEN CALLING:

Jeb Blazevich 770-635-4019 jblazevich@sspins.com

Subscriber ID # Date of Service Name of Patient Name of Doctor, Facility or Hospital Copy of Bill or Explanation of Benefits (EOB)

Trevor Holder 770-635-0451 tholder@sspins.com

Benefit

Company

Phone

Website

Medical Coverage

Kaiser Permanente

833-574-2273

www.healthy.kaiserpermanente.org

Dental

Unum

866-679-3054

www.unum.com

Vision

Unum

866-679-3054

www.unum.com

Life/AD&D

Unum

866-679-3054

www.unum.com

Long-Term Disability

Unum

866-679-3054

www.unum.com

Short-Term Disability

Unum

866-679-3054

www.unum.com

Worksite

Unum

866-679-3054

www.unum.com

Benefit Guide | 14