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2019-2020 Benefits Guide


Benefits are as easy as 1-2-3! 1. Get to Know Your Benefits! Review this guide to see what benefits are available to you.

2. Ask Questions! Send an email to our benefit consultants at SL Goodell Insurance Services (connect@slgoodell.com)

3. Take Action! Make your elections in Employee Navigator. This is intended only as a general description of the plan's benefits and quoted rates. It is not a contract. For additional information about benefits or exclusions and limitations please refer to the plan's disclosure or summary plan description. In the event of any discrepancy, wording in the policy will prevail.


Benefits

Health Medical Blue Shield of California - Two PPO options: one base plan and one buy-up option. Kaiser Permanente (CA employees only) - One HMO plan

Income Protection Basic Life/AD&D

Principal Financial Group - 1x Earnings

Long-Term Disability

Dental

Principal Financial Group - 60% of monthly earnings

Vision

Voluntary Life/AD&D

Delta Dental Premier Value PPO

VSP 12/12/24 Signature Plan

Retirement 401K Options

Principal Financial Group - Additional employee-paid coverage for employees, spouses, and dependent children.


Medical, Dental, and Vision Effective Dates Effective: Oct 1, 2019 to Sept 30, 2020

New Hire Effective Date

First of the month following date of hire.

Qualifying Life Event Effective Date

Subject to the nature of the qualifying event, either first of the month following or coinciding with date of life event. - Employees may elect to participate in the Company's medical, dental and/or vision plan(s) or decline coverage by consenting to an electronic waiver of insurance coverage and providing proof of health coverage, if applicable.

Elections or changes made during Open Enrollment

All benefits-eligible employees are entitled to an annual open enrollment period to make election changes, effective October 1st each year.


Rates: Your Monthly Contribution Effective Oct 1, 2019

Medical

Blue Shield of CA - Base Plan Gold Full PPO 1200/35

Kaiser Permanente Gold HMO 500/30 + Child Dental

Blue Shield of CA - Buy Up Plan Platinum Full PPO 250/15

$0

$0

Employee pays the difference

Employees Only

in cost between this plan and Dependents

25% of additional premium

Dental

Vision

Delta Dental PPO Plus Premier Value 1500 w/DPM

VSP Signature 12/12/24

Employee Only

$0

the base plan.

25% of additional premium

Employee Only

$0

Employee + 1

$14.62

Employee + Spouse/Domestic Partner

$2.37

Employee + 2 or more

$30.23

Employee + Child(ren)

$2.49

Employee + Family

$6.04


Plan Details Medical Plan Basics

Blue Shield - Gold Full PPO 1200/35

Kaiser - Gold HMO 500/30

Blue Shield - Platinum Full PPO 250/15

Deductible: Individual

$1,200

$500

$250

Deductible: Family

$2,400

$1,000

$500

Maximum out-of-pocket: Individual

$7,550

$7,000

$3,900

Maximum out-of-pocket: Family

$15,100

$14,000

$7,800

Infertility

Not covered

Not covered

Not covered

Primary Care Physician

$35 copay (deductible waived)

$30 copay (deductible waived)

$15 copay (deductible waived)

Specialist Physician

$50 copay (deductible waived)

$35 copay (deductible waived)

$30 copay (deductible waived)

Laboratory Services

$35 copay (deductible waived)

X-ray/Lab: $40/$20 copay (ded waived)

$15 copay (deductible waived)

Referal Required for Specialist

No

Yes

No

Chiropractic Care

50% (deductible waived) 12

Limited coverage

50% (deductible waived) 12

Copays & Coinsurance

visits/yr

visits/yr

Urgent Care Facility

$35 copay (deductible waived)

$30 copay (deductible waived)

Hospitalization: Inpatient

20% after deductible

$600 copay (after deductible)

Pharmacy

$10/$30/$50

$15/$50/$50

$15 copay (deductible waived) 10% after deductible $5/$30/$50


Plan Details Dental With your Delta Dental PPO Plus Premier Value Plan, employees select from any dentist in the PPO network to experience the most savings. Employees who cannot find a PPO dentist may also visit Delta Dental Premier dentists which provide services at s slightly higher rate but at greater cost savings than an out-of-network provider. Out-of-Network benefits are limited to our PPO fee schedule.

PPO Delta Dental Providers

In Network

Non-PPO & Out-of-Network

Individual Deductible (per calendar year)

$50

$50

Family Deductible (per calendar year)

$50 per person

$50 per person

Wavied for

Preventive

Preventive

$1500 per person, per calendar year

Annual Maximum Benefit Preventive Care

100%

80%

Basic Care

90%

60%

Major Care

60%

50%

Orthodontia

Notes Diagnostic and preventive services are not applied to your annual maximum benefit.

Not covered


Plan Details Vision The Plan Basics

VSP Signature 12/12/24

Exams Copay

$10 (every 12 months)

Materials Copay

$25 combined for lenses & frames

Services Frequencies Exams

Once every 12 months

Lenses (for glasses or contact lenses)Â

Once every 12 months

Frames

Once every 24 months

Network discounts (cosmetic extras, glasses and

Limitless within 12 months of exam

contact lens professional services)


Plan Details Life and AD&D

Principal Financial Group

Employee Benefit

Your employer provides 1x salary amount of Basic Term Life coverage for all full time employees. ($100,000 maximum)

Accidental Death and Dismemberment

Your Basic Life coverage includes Enhanced Accidental Death and Dismemberment coverage equal to one times the employee's life benefits to a maximum of $100,000.

Premiums

Paid by the company in full

Voluntary Life and AD&D

Principal Financial Group

Employee Benefit

PlanetScale offers additional Voluntary Life/AD&D benefits for employees, their spouses, and dependent children. Benefit selections are limited to carrier designed minimums and maximums, and may require proof of good health/evidence of insurability.

Accidental Death and Dismemberment

Your Voluntary Life coverage includes Enhanced Accidental Death and Dismemberment coverage equal to the selected Life benefit amount.

Premiums

Paid 100% by the employee


Plan Details Disability Long-Term Disability Coverage amount

60% of salary to maximum $6,000/month

Maximum payment period: Maximum length of time you can receive disability benefits.

Social Security Normal Retirement Age

Accident benefits begin: The length of time you must be disabled before benefits begin.

Day 91

Illness benefits begin: The length of time you must be disabled before benefits to begin.

Day 91

Understanding your Disability Benefits Disability (Long-Term): For the first two years of disability, you will receive benefit payments while you are unable to work in your own occupation. After two years, you will continue to receive benefits if you cannot work in any occupation based on training, experience and education. Earnings definition: Your covered salary includes average bonuses and commissions.


Additional Resources and Contact Information Name

Services

Contact

Web

Blue Shield of CA

Medical

1-800-393-6130

https://www.blueshieldca.com/home

Kaiser Permanente

Medical

1-800-464-4000

https://healthy.kaiserpermanente.org/

Delta Dental of CA

Dental

1-800-765-6003

https://www.deltadental.com/

VSP

Vision

1-800-877-7195

https://www.vsp.com/

1-800-986-3343

https://www.principal.com/

Principal Financial Group

Life & Accidental Death and Dismemberment, Voluntary Life & Accidental Death and Dismemberment, Long Term Disability,


https://www.employeenavigator.com/benefits/Account/Login

For questions, contact SL Goodell Insurance Services: connect@slgoodell.com 1-877-490-3535

Profile for SL Goodell - Employee Benefits

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