Issuu

2022-2023

BENEFITS GUIDE May 1st, 2022 – April 30th, 2023

Welcome! Our employees are our greatest resource. That's why FormFree is continuing to provide you with health plans, wellness enhancements, and benefits that make sense for you and your family, your busy lifestyle, and your wallet. Please take the time to carefully review the information, carrier changes and all the benefits offered to you, to ensure you get the best value based on your needs. We hope the benefits offered will inspire you and your dependents to take charge of your health and continue making wellness a priority.

OPEN ENROLLMENT Open Enrollment is your opportunity to add, cancel, or make changes to your benefits. This year, open enrollment will be Thursday, March 31st – Thursday April 7th. Once you elect your benefits, the elections remain in effect for the plan year, May 1st, 2022 – April 30st , 2023. You may only change coverage due to an IRS qualified “life event” and must do so within 30 days of the event. A qualifying event is a significant change in a person’s life that creates the need to add, cancel, increase, or change coverage. We encourage you to review all your benefits and make selections wisely. This year we will be using Employee Navigator to make our benefits elections. You must elect or decline coverage through Employee Navigator no later than Thursday, April 7th.

ELIGIBILITY

QUALIFYING EVENTS

New hires are eligible for benefit first of the month following 60 days. You may enroll yourself and or eligible dependents for coverage. You must enroll yourself in benefits in order to enroll your dependents. Eligible dependents include your spouse, dependent children, legally adopted children and stepchildren. Spouses and dependent children are eligible for: Medical, Dental, Vision, Voluntary Life, Accident, Hospital Indemnity and Critical Illness Insurance.

Once you have made your elections, you are NOT eligible to change or drop coverage until the next Open Enrollment period unless you have a qualifying event. If you experience a qualifying life event, contact the Human Resources Department within 30 days of your qualifying event. If you fail to do so, you will have to wait until the next open enrollment period to make any changes to your coverage. Qualifying life events include, but are not limited to:

Dependent children are eligible for the group health plan until their 26th birthday regardless of whether they are a full-time student.

•

Marriage

•

Divorce

• •

Birth or adoption Employment changes from Part-time to Full-time Change in dependent status (i.e. Dependent child reaches age 26 limit)

•

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HOW TO ENROLL All employees are required to login to Employee Navigator to make elections or waive coverage. To begin, visit www.employeenavigator.com and use the steps below to login or you can click here to watch an instructional video. 1. Click "Login" at the top right-hand corner of the page.

2. Click on Register as a new user. For the 2022 Open Enrollment, all employees will need to register as a NEW USER. Prior Employee Navigator logins will not be active.

Create your account by entering: • Your first and last name as they appear in payroll. • The FormFree company identifier – FORMFREE1 • The last 4 digits of your SSN. • Your date of birth. If you encounter a login error, please reach out to Marie Volk at Sterling Seacrest Pritchard – mvolk@sspins.com. FormFree Benefit Guide | 3

All Savers– $3,000 DEDUCTIBLE HSA PPO HP30002575 Plan Highlights

In Network – You Pay

Out-of-Network – You Pay

Deductible

$3,000 Individual | $6,000 Family

$6,000 Individual | $12,000 Family

Coinsurance

80% after deductible

50% after deductible

$7,000 Individual | $14,000 Family

$14,000 Individual | $28,000 Family

Primary Care Physician Office Visit

$25 copay after Deductible

Deductible, then 50%

Specialist Office Visit

$75 copay after Deductible

Deductible, then 50%

$45 copay

Not covered

Plan pays 100%

Deductible, then 50%

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

Deductible, then 20%

Deductible, then 50%

Hospital Inpatient Care

Deductible, then 20%

Deductible, then 50%

Outpatient Surgery

Deductible, then 20%

Deductible, then 50%

Emergency Room

$300 copay after Deductible

Paid as In-network

Urgent Care

$50 copay after Deductible

Deductible, then 50%

Annual Out-of-Pocket Maximum

Telemedicine Preventive Care Services

Prescription Drugs*

Retail = 30-day supply Mail-Order = 90-day supply

Tier 1 — Generic Drugs Tier 2 — Preferred Brand-Name Tier 3 — Non-Preferred Brand-Name Tier 4 - Specialty Drugs

Deductible applies Tier 1: $10 copay Mail Order: 2.5 times retail copay Tier 2: $35 copay Mail Order: 2.5 times retail copay Tier 3: $70 copay Mail Order: 2.5 times retail copay Tier 4: $150 Mail Order: 2.5 times retail copay

Tier 1: $10 copay Mail Order: 2.5 times retail copay Tier 2: $35 copay Mail Order: 2.5 times retail copay Tier 3: $75 copay Mail Order: 2.5 times retail copay Tier 4: $150 Mail Order: 2.5 times retail copay

PER CHECK DEDUCTIONS BASED ON 24 PAYROLL DEDUCTIONS Employee Only

Employee + Spouse

$236.12

Employee + Children

$192.20

Family

$433.73

*Prescription drug coverage excludes CVS pharmacy on the HP3002575 plan.

When you visit an ER for non-emergency medical care, services are subject to the deductible. This documents is intended as a summary of the major points of the benefits plans. Please refer to all plan summaries for limitations and exclusions.

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H E A LT H S AV I N G S AC C O U N T Employees electing the HSA plan have the option to enroll in an iSolved Health Savings Account

WHAT IS AN HSA? A Health Savings Account (HSA) is like a 401(k) for healthcare. It is a tax advantaged personal savings or investment account that you can use to save and pay for qualified health expenses, now or in the future.  Funds contributed to the HSA are not subject to federal income tax at the time of deposit.  Withdrawals for qualified medical expenses are also taxfree.  HSA funds may be used to pay for qualified medical expenses at any time without federal tax liability or penalty.  HSAs are portable, which means you keep your HSA, even if you leave FormFree or are unemployed.  Funds roll over and accumulate year to year if not spent.

CONTRIBUTIONS Maximum contributions for the 2022 plan year are listed below. • $3,650 for Individual coverage • $7,300 for Family coverage • Additional $1,000 for “Catch-Up” age 55 and older

WHAT ARE QUALIFIED MEDICAL EXPENSES? Examples of HSA eligible expenses are copays, deductibles, qualifying prescriptions, and qualifying medical equipment. A full description of qualified HSA expenditures can be found in IRS Publication 502 and is located on the web at www.irs.gov/pub/irs-pdf/p502.pdf.

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All Savers– $1,000 DEDUCTIBLE PPO P10003060 Plan Highlights

In Network – You Pay

Out-of-Network – You Pay

Deductible

$1,000 Individual | $2,000 Family

$2,000 Individual | $4,000 Family

Coinsurance

80% after deductible

50% after deductible

$3,500 Individual | $7,000 Family

$7,000 Individual | $14,000 Family

Primary Care Physician Office Visit

$30 copay

Deductible, then 50%

Specialist Office Visit

$60 copay

Deductible, then 50%

Telemedicine

$0 copay

Not covered

Plan pays 100%

Deductible, then 50%

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

Deductible, then 20%

Deductible, then 50%

Hospital Inpatient Care

Deductible, then 20%

Deductible, then 50%

Outpatient Surgery

Deductible, then 20%

Deductible, then 50%

Emergency Room

$300 copay

Paid as In-network

Urgent Care

$100 copay

Deductible, then 50%

Annual Out-of-Pocket Maximum

Preventive Care Services

Prescription Drugs Retail = 30-day supply Mail-Order = 90-day supply

Tier 1 — Generic Drugs Tier 2 — Preferred Brand-Name Tier 3 — Non-Preferred Brand-Name Tier 4 - Specialty Drugs

Tier 1: $10 copay Mail Order: 2.5 times retail copay Tier 2: $35 copay Mail Order: 2.5 times retail copay Tier 3: $75 copay Mail Order: 2.5 times retail copay Tier 4: $250 Mail Order: 2.5 times retail copay

PER CHECK DEDUCTIONS BASED ON 24 PAYROLL DEDUCTIONS Employee Only

$49.35

Employee + Spouse

$351.13

Employee + Children

$296.25

Family

$598.25

*When you visit an ER for non-emergency medical care, services are subject to the deductible. This documents is intended as a summary of the major points of the benefits plans. Please refer to all plan summaries for limitations and exclusions.

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D E N TA L Dental benefits are available through Unum using the AlwaysAssist network. To find dental providers visit www.alwaysassist.com or download the AlwaysAssist App.

$1,500 Max - Dental Plan Highlights

Participating Dentist

Nonparticipating Dentist

Your Deductible

$50 individual / $150 Family

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

$1,500 combined In-network and Out-of-Network

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

100% (Deductible waived)

Basic Services Filings, Extractions, Restorations; Emergency Treatment, Endodontics (root canal), Periodontics

80% After deductible

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

50% Coinsurance

90th Percentile

$1,500 Max - Dental Plan Based on 24 Payroll Deductions Employee Only

$5.59

Employee + Spouse

$23.17

Employee + Children

$33.62

Family

$51.70

VISION Vision benefits are available through Unum using the EyeMed network To find dental providers visit www.eyemedvisioncare.com/unum

In-Network Exam Copay

$10

Materials Copay

$10

Frames Allowance

$150

Benefit Frequency

12/12/12

Contact Lens Allowance Elective Medical Necessary

$150 Covered in full after copay

Based on 12 Payroll Deductions Employee Only

$2.96

Employee + Spouse

$5.90

Employee + Children

$6.72

Family

$10.64

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Fo r m F r e e p r ov i d e s : Basic Life Insurance and AD&D – All full-time benefit eligible employees are eligible for up to one times their earnings to a maximum of $175,000 of Life and Accidental Death and Dismemberment Insurance at no cost to the employee. FormFree covers 100% of the cost of this benefit.

Short-Term Disability – Through Unum, all full-time employees are provided short-term disability at NO COST. Benefit Amount: 60% of weekly salary up to a maximum of $2,500 for non-work related accidents or sicknesses. Waiting Period: Benefits begin on day 8 Benefit Period: up to 12 weeks

Long-Term Disability – Through Unum, all full-time employees are provided long-term disability at NO COST. Benefit Amount: 60% of monthly earnings up to a maximum of $9,000 for a covered accidents or sicknesses. Waiting Period: 90 days Benefit Period: up to Social Security Normal Retirement Age (SSNRA)

Fo r m F r e e o f f e r s : Voluntary Life Insurance and AD&D – Employees are offered the option to purchase additional life insurance through Guardian. Rates will vary based on age and the benefit you select. All rates can be found in your Employee Navigator portal. Plan Highlights Employee: Spouse: Child(ren):

Increments of $10,000 up to a maximum of $500,000 subject to medical eligibility. At your initial enrollment, you are eligible for up to a $130,000 with no medical questions asked. Increments of $5,000 up to a maximum of $500,000 (not to exceed 100% of employee’s amount). Subject to medical eligibility. At your initial enrollment, your spouse is eligible for up to a $25,000 with no medical questions ask. Increments of $1,000 up to a maximum of $10,000. Coverage begins at 15 days.

Accident Insurance – Provides benefits to help with out-of pocket expenses due to an accident. Coverage is provided through Unum and rates can be found in your enrollment portal.

Critical Illness Insurance – Provides a lump sum benefit if you or a covered family member are diagnosed with a critical illness such as a heart attack or stroke. Coverage is provided through Unum and rates can be found in your enrollment portal. Hospital Confinement Insurance – Provides a $1,000 lump sum benefit if you are confined in the hospital and a $100 daily stay benefit. Coverage is provided through Unum and rates can be found in your enrollment portal. FormFree Benefit Guide | 9

Additional Benefits: Employee Assistance Program: EAP is designed to help you lead a happier and more productive life at home and at work. Call for confidential access to a Licensed Professional Counselor* who can help you.  Who is covered? Unum’s EAP services are available to all eligible partners and employees, their spouses or domestic partners, dependent children, parents and parents-in-law.  Always by your side • Expert support 24/7 • Convenient website • Mobile App • Short-term help • Referrals for additional care • Monthly webinars • Medical Bill SaverTM — helps you save on medical bills  Help is easy to access: Phone support: 1-800-854-1446 Online support: unum.com/lifebalance In-person: You can get up to three visits, available at no additional cost to you with a Licensed Professional Counselor. Travel Assistance Program: Whenever you travel 100 miles or more from home — to another country or just another city — be sure to pack your worldwide emergency travel assistance phone number. Travel assistance speaks your language, helping you locate hospitals, embassies and other “unexpected” travel destinations. Add the number to your cell phone contacts, so it’s always close at hand. Just one phone call connects you and your family to medical and other important services 24 hours a day. Within the U.S. 1-800-872-1414 Outside the U.S. (U.S. access code) +609-986-1234 Via e-mail: medservices@assistamerica.com

F o r m F r e e Pe r k s  Cell phone reimbursement program  Professional development  401K matching  Unlimited paid time off

With the Assist America Mobile App, you can:  CallAssist America’s Operation Center from anywhere in the world with the touch of a button.  Access pre-trip information and country guides.  Search for local pharmacies (U.S. only).  Download a membership card.  View a list of services.  Search for the nearest U.S. embassy.  Read Assist Alerts.

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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 704.996.6517 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)

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LEGAL NOTICES THIS GUIDE - This brochure summarizes the health care and income protection benefits that are available to FormFree and their eligible dependents. Official plan documents, policies, and certificates of insurance contain the details, conditions, maximum benefit levels and restrictions on benefits. These documents govern your benefits program. If there is any conflict, the official documents prevail. These documents are available upon request through your Human Resources department. Information provided in this brochure is not a guarantee of benefits. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) FormFree, in accordance with HIPAA, protects your Protected Health Information (PHI). We will only discuss your PHI with medical providers and third-party administrators when necessary to administer the plan that provides you your medical, dental and vision benefits or as mandated by law. A copy of the Notice of Privacy is available upon request through your Human Resources department. WOMEN'S HEALTH ACT If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women's Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient for: • All stages of reconstruction of the breast on which the mastectomy was performed; • Surgery and reconstruction of the other breast to produce a symmetrical appearance; • Prostheses; and • Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. If you have any questions about your coverage, please contact your Human Resources department.

CONTINUATION REQUIRED BY FEDERAL LAW FOR YOU & YOUR DEPENDENTS (COBRA) The continuation required by Federal Law does not apply to any benefits for loss of life, dismemberment or loss of income. Federal law enables you or your dependent to continue health insurance if coverage would cease due to a reduction of your work hours or your termination of employment (other than gross misconduct). Federal law also enables your dependents to continue health insurance if their coverage ceases due to your health, divorce, or legal separation, or with respect to a dependent child, failure to continue to qualify as a dependent. Continuation must be elected in accordance with the rules of your Employer's group health plan(s) and is subject to federal law, regulations and interpretations. MEDICAID AND THE CHILDREN'S HEALTH INSURANCE PROGRAM (CHIP) The continuation required by Federal Law does not apply to any benefits for loss of life, dismemberment or loss of income. Federal law enables you or your dependent to continue health insurance if coverage would cease due to a reduction of your work hours or your termination of employment (other than gross misconduct). Federal law also enables your dependents to continue health insurance if their coverage ceases due to your health, divorce, or legal separation, or with respect to a dependent child, failure to continue to qualify as a dependent. Continuation must be elected in accordance with the rules of your Employer's group health plan(s) and is subject to federal law, regulations and interpretations.

SPECIAL ENROLLMENT NOTICES

NEWBORNS' & MOTHERS' HEALTH PROTECTION ACT

If you decline enrollment in your employer's health plan for you or your dependents (including your spouse) because of other health insurance or group health plan coverage, you or your dependents may be able to enroll in your employer's plan without waiting for the next open enrollment period if you: • Lose other health insurance or group health plan coverage. You must request enrollment within 30 days after the loss of other coverage. • Gain a new dependent as a result of marriage, birth, adoption or placement for adoption. You must request (medical plan OR health plan) enrollment within 30 days after the marriage, birth, adoption or placement for adoption. • Lose Medicaid, or Children's Health Insurance Program (CHIP) coverage because you are no longer eligible. You must request medical plan enrollment within 60 days after the loss of such coverage.

Federal law prohibits the plan from limiting a mother's or newborn's length of hospital stay to less than 48 hours for a normal delivery or 96 hours for a Cesarean delivery or from requiring the provider to obtain pre-authorization for a stay of 48 or 96 hours, as appropriate. However, federal law generally does not prohibit the attending provider, after consultation with the mother, from discharging the mother or her newborn earlier than 48 hours for normal delivery or 96 hours for Cesarean delivery.

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