EMPLOYEE BENEFIT GUIDE 2020
At Ward Kraft, we value the contribution you make to our company and recognize the important role your family plays in supporting your efforts. It is a top priority that we offer a high-quality benefit program that promotes and supports the health and welfare of our employees and their families. Each year, our goal is to offer high-quality, convenient and flexible benefit options, working diligently to keep employee costs as low and affordable as possible without sacrificing quality. We are very pleased to be able to offer zero increase to all premiums for the 2020 plan year, and no plan design changes! This was made possible due to the large majority of employees that took advantage of programs connecting them with the BEST quality doctors and hospitals. To continue this momentum and get our members to the best quality providers, we’ll continue using TopCare through Continental Benefits in 2020. This guide serves as a reference to help you decide what benefits work best for you. Carefully review the benefits available so you can understand your options and take full advantage of the resources available. We appreciate your hard work and dedication to Ward Kraft and are looking forward to a healthy and prosperous 2020! Warm Regards, Roger Kraft
2020 Benefits What’s in your Guide? NEW IN 2020 & ELIGIBILITY…………………………………………………………………………………………. 2 OVERVIEW………………………………………………………………………………………………………………….. 3 GLOSSARY OF TERMS………………………………………………………………………………………………….. 4 MEDICAL & RX COVERAGE …..…………………………………………………………………………………... 5, 6
TOPCARE…………………………………………………………………………………………………………………….. 7 TELEMEDICINE…………………………………………………………………………………………………………….. 8 FLEXIBLE SPENDING ACCOUNTS………………………………………………………………………………….. 9 DENTAL COVERAGE…………………………………………………………………………………………………….. 10 VISION COVERAGE……………………………………………………………………………………………………... 11 DISABILITY……………………………………………………………………………………………………..………….. 12 LIFE INSURANCE…………………………………………………………………………………………………………. 1 3
ANCILLARY BENEFITS………………………………………………………………………………………………….. 14, 15
DISCLAIMER: the actual Plan Document (SPD) on file with the Human Resources Department. You may request copy of 1
WHAT YOU NEED TO KNOW WHAT‘S NEW FOR 2020? Electronic Passive Enrollment—all changes must be made online through PayCor. If you do not log into PayCor and make changes to your benefit elections, then all coverages and tiers you’re enrolled in for 2019 will auto-roll over into 2020. The deadline to make online changes is November 29, 2019. After this date, enrollment changes will be locked and you will NOT be allowed to make any changes or updates unless you have a qualifying event. No Benefit Changes! No Premium Increases!
WHO IS E L I G I B L E FOR B E N E F I T S ? • •
All full-time employees on the 1st of the month following 60 days of employment The following family members are eligible as well: • A spouse: a person to whom you are legally married; with complete and valid waiver returned • Eligible child dependent (under age 26), defined as one of the following: your natural born children a child placed in your home pending a final adoption decree adopted children for whom the final court order has been issued stepchildren for whom you are responsible for more than half of their support children for whom you have legal guardianship or legal custody unmarried, beyond age 26, incapable of self -support because of a developmental disability or physical handicap that occurred before age 26, and dependent on you for more than half their support. Contact the Benefits Department prior to the child’s 26th birthday to apply for this provision. Foster children, exchange students and children who are wards of the court are not considered dependents. For questions about specific dependent eligibility, contact the Benefits Department.
•
WHEN CAN I MAKE BENEFIT CHANGES? • •
Open Enrollment Changes outside of Open Enrollment can only be made due to a Qualifying Event; examples include marriage, birth/adoption, death, divorce, and change of dependent status, just to name a few.
Please ask HR immediately if you think you’ve had a qualifying event and need to make benefit changes.
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W/K Holding Company, Inc.
OVERVIEW OF 2020 BENEFITS BENEFITS
PREMIUM PAYMENTS
COVERAGE SUMMARY
HEALTH INSURANCE CONTINENTAL BENEFITS
Employer/ Employee Paid
Provides medical insurance plan benefits; claims administered through Continental using the TopCare program & Aetna Signature PPO network.
LIFE INSURANCE SUNLIFE
Employer/ Employee Paid
Provides benefit in the event of death or accidental death and dismemberment.
FLEXIBLE SPENDING ACCOUNT (FSA) NUESYNERGY
Employee Paid
An FSA allows you to save on your eligible health care expenses and dependent care expenses each year by using pre-tax dollars.
DENTAL INSURANCE SUNLIFE
Employee Paid
Provides benefits for preventative, basic and major dental services.
VISION INSURANCE VSP, SUNLIFE
Employee Paid
Provides benefits for materials, frames, lenses and contacts; claims administered through SunLife using the VSP network.
DISABILITY INSURANCE W/K HOLDING, INC. for Short-Term,
Employee Paid
Provides income protection in the event that you miss work due to an accident or illness, under a doctor’s care.
ACCIDENT, CRITICAL ILLNESS PLANS SUNLIFE
Employee Paid
Ancillary benefits offered through SunLife this year include an Accident plan, and a Critical Illness plan with a Cancer rider
CANCER INSURANCE
Employee Paid
SUNLIFE for Long-Term
KEMPER HEALTH
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GLOSSARY OF INSURANCE TERMS TERM
DEFINITION An arrangement where an individual pays a specified amount for various health care services and the health plan or insurance company pays the remainder (such
COPAYMENT
as $35 per primary care office visit or $50 for specialist office visit), rather than a
percentage of the charges. The individual must usually pay his or her copay when services are rendered.
DEDUCTIBLE
COINSURANCE
OUT-OF-POCKET MAXIMUM
IN-NETWORK
A set dollar amount that a person must pay before insurance coverage for medical expenses can begin; typically charged on an annual basis.
employee pays 20 percent of the charges while the health plan pays 80 percent.
-of-pocket maximum, the plan pays 100 percent of the allowable charges for covered services the rest of that calendar year. Typically refers to physicians, hospitals or other health care providers who contract with the insurance plan to provide services to its members. Coverage for services received from in-network providers will typically be greater than for services received from out-of-network providers. It is always best to begin with in -
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W/K Holding Company, Inc.
MEDICAL PARTIALLY EMPLOYER PAID
IN-NETWORK
OUT-OFNETWORK
$500 $1,000
$4,500 $9,000
$6,000 $12,000
100%
$6,500 $13,000 50%
$15,000 $30,000 50%
$35 / $50 No Cost Share Covered 100%
Ded. & Coinsurance n/a Ded. & Coinsurance
$50 Copay $1,500 Copay then 20% Ded. & Coinsurance Ded. & Coinsurance Ded. & Coinsurance No Cost Share $1,500 Copay then 20% Ded. & Coinsurance No Cost Share
Ded. & Coinsurance Ded. & Coinsurance Ded. & Coinsurance Ded. & Coinsurance Ded. & Coinsurance Ded. & Coinsurance Ded. & Coinsurance Ded. & Coinsurance Ded. & Coinsurance
25% Coins./ $100 cap 25% Coins./ $150 cap 25% Coins./ $200 cap 25% Coins./ $250 cap 25% Coins./triple cap
n/a
Top Care DEDUCTIBLES, COINSURANCE, AND MAXIMUMS DEDUCTIBLE Individual Family OUT-OF-POCKET MAXIMUM Individual Family Coinsurance
COVERED SERVICES & BENEFITS PROFESSIONAL SERVICES No Cost Share
Office Visit (Primary/ Specialist) Telemedicine (MDLive)
HOSPITAL AND OTHER MEDICAL FACILITY SERVICES Urgent Care Benefit Emergency Room Advanced Imaging at Free-standing Imaging Ctr. Maternity and Newborn
PHARMACY OPTION Tier 1 Tier 2 Tier 3 Tier 4 Mail-Order Pharmacy / 90 Day Retail Employee Weekly
Yearly Employee Premium
Employee Only
$43.83
$2,279.16
$4,922.04
Employee + Spouse
$117.27
$6,097.92
$9,147.00
Employee + 1 Child
$74.78
$3,888.60
$5,832.96
Employee + 2 Children
$99.71
$5,184.84
$7,777.32
Employee + 3 or more Children
$119.10
$6,192.96
$9,289.56
Family
$177.26
$9,217.56
$13,826.28
Tier
7
for Employee
PHARMACY Getting the Most out of Your Pharmacy Benefits Southern Scripts is your pharmacy benefit manager offering you multiple ways to save on your prescription drugs. Check your plan for pharmacy cost-share information.
First Choice and Retail: Present your member ID card when filling a prescription at any major retail chain or independent pharmacy across the country. If your pharmacy is not yet in Southern Scripts’ network, have your pharmacist call the number on your ID card to enroll. Visit our pharmacy locator tool to find a pharmacy: www.southernscripts.net/members.php. Our preferred network, FirstChoice, will help you reduce your prescription costs by providing the best discounts.
Mail Order: To find a mail order pharmacy, call 800.710.9341 or visit our website:
southernscripts.net/members.php. Specialty Pharmacy: Certain medications used to treat serious or complex health conditions are provided by top quality specialty pharmacies. Use the pharmacy locator tool at www.southernscripts.net/members.php to find specialty pharmacies in your area, or call Southern Scripts to find the right option for you.
Variable Copay Program: The Variable Copay™ Program is designed to combat the rising cost on higher cost medications. The Variable Copay™ Program uses coupons provided by the manufacturer to greatly reduce costs for eligible medications. Certain medications including Humira, Enbrel, and Prolia are eligible for savings. Your copay may be drastically reduced at CRx preferred pharmacy & our Variable Copay network for variable copay medications. Your medication(s) may be eligible for variable copay savings. Please contact a CRx Customer Care Associate at 1.800.710.9341 or visit www.southerscripts.net/members.php.
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W/K Holding Company, Inc.
TOPCARE PROFESSIONAL HEALTH ADVOCACY First of its Kind Unfortunately, not all medical providers and facilities are created equal when it comes to quality and outcomes. This is where TopCare can help. This program is designed to help you connect with the highest quality surgeons, hospitals, and facilities. By using only the highest quality doctors and facilities, your overall healthcare costs will decrease due to better outcomes. In addition, your employer supports you through financial relief for seeing the highest quality doctors to ensure the best possible outcome. The TopCare program is administered by Continental Benefits and is included and offered to you through W/K Holding’s medical plan. TopCare includes T/C Guides. T/C Guides are highly trained healthcare advocates available to support and assist you in finding the best quality care. Consider them your personal healthcare concierge. Your T/C Guide can help ensure you maximize savings, as well as answer any questions you may have about your plan benefits or healthcare needs. With your T/C Guides, even Second Procedural Opinions (SPOs) and Pre-Certification services, while a requirement of the plan, are made easier.
Using the TopCare program, you will now know: •
The highest quality ranked specialists in a metro area by specialty & procedure from the most credible 3rd party objective databases
•
The most efficient hospitals, or Ambulatory Surgery Centers (ASCs), in an area by procedure
Through TopCare, you’ll be connected with a Health Professional Advocate, called a TopCare Guides, who will provide you: •
Locations of in-network specialists, rated with a 90% or higher quality score for 39 different clinical specialty categories
•
Quality-based 2nd opinion referrals to high-quality specialists
•
Member/patient assistance; by speaking directly to doctors/care coordinators, T/C Guides support and coordinate your care
•
Assistance with any required precertification processes to authorize the procedure and care
•
Coordination of coverage levels & benefits with Continental Benefits
•
Provide consistent support through any procedural or surgical process & answer any additional questions or concerns
How Does It Work? If you are having a medical issue that may lead to surgery—call TopCare so they can help guide you to the BEST doctors for your medical condition/issue. For your convenience, TopCare Guides are available Monday through Friday from 8 a.m. to 7:00 p.m. CST.
Please contact Marnie Zimmerman or Sara Griffith so they can make sure you get the best service and care from your TopCare program.
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TELEMEDICINE—MDLive
MDLive, our offering in Telemedicine, makes it easy to visit a doctor in minutes through their mobile app, online, and by phone. Get access to quality healthcare without ever leaving your home, your job, or wherever you may be. Find out how easy it is to receive quality care without traveling to a doctor’s office, and…..at NO COST share to you!
Avoid the inconvenience and High costs of an urgent care center or ER for true non-emergent, but pressing, medical needs. Prescriptions can be sent directly to your local pharmacy if medically necessary.
MDLive Treats Over 50 Routine Medical Conditions, including: • Common cold
• Pink eye
• Headache
• Allergies
• Respiratory problems
• Nausea
• Constipation
• Sore throat
• Vomiting
• Cough
• UTI (*for females age 18 and older)
• Diarrhea
• Fever
• Ear problems
• Flu
• And more!
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W/K Holding Company, Inc.
FLEXIBLE SPENDING ACCOUNTS FSAs through NueSynergy.
MAXIMUM CONTRIBUTION AMOUNTS FOR EMPLOYEES
WHY AN FSA?
An FSA allows you to save up to 30% on your eligible healthcare and/or dependent care expenses every year by using pre-tax dollars. Offering an FSA as part of our employee benefits program provides valuable benefits to our employees:
EMPLOYEE BENEFITS • •
• •
Reduces income tax (Federal, State, and FICA): pre-tax payroll contributions result in a lower taxable salary. Saves on the cost of eligible healthcare and/ or dependent care expenses: using pre-tax dollars spells out a savings of nearly 30%. Offers immediate access to elected healthcare FSA funds. Covers common types of expenses: medical, dental, ortho, vision, prescription drugs, day care and more.
HOW IT WORKS
An employee who participates in a flexible spending account must place a certain dollar amount into the FSA each year. This “election” amount is automatically deducted from the employee’s check (for that amount divided by the number of payroll periods). For every dollar you put into these accounts, the more money you save by paying less in taxes. As you incur eligible expenses, you simply use your provided NueSynergy debit card, or submit a request for reimbursement to NueSynergy, up to the amount of your annual contribution.
FOR EMPLOYEES/ PARTICIPANTS: • • • • • •
Convenient Multiple account management tools (web, phone, and fax) Fast reimbursements Toll-free Customer Care Center Easy online enrollment or reenrollment Tax Savings Calculator
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• •
$2,700 At time of print (may increase to $2,750 for 2020) - Medical Reimbursement $5,000 - Dependent Care
HOW FSA PLANS WORK
In the example shown, Jane estimates she will spend $2,400 on medical expenses for herself and her child next year. Here’s how she can save with a health care FSA: WITH FSA Jane‘s Annual Income Flex Plan Contribution (Pre-Tax) Taxable Income Estimated Taxes Jane‘s Take-Home Pay Out-of-Pocket Health Care Expenses Jane‘s Spendable Income Jane‘s Savings Each Year
WITHOUT FSA
$30,000
$30,000
$2,400
0
$27,600 $6,900 $20,700
$30,000 $7,500 $22,500
$0
$2,400
$20,700
$20,100
$600
0
DENTAL Dental health contributes to your over all well-being. Through SunLife’s dental network, our dental insurance provides coverage for preventative, basic, and major services.
DENTAL SERVICES
BASE PLAN Covers
BUY-UP PLAN Covers
In-Network Only Shown
In-Network Only Shown
Preventive Services
100% in-network
100% in-network
Basic Services
80% in-network
80% in-network
Major Services
Not Covered
50% in-network
Orthodontia Services
Not Covered
50% in-network $1,000 Lifetime Max
Annual Maximum
$1,000 per person
$1,000 per person
Deductible
$50 per person $150 per family
$50 per person $150 per family
WEEKLY RATES
BASE PLAN
BUY-UP PLAN
Employee
$3.18
$6.06
Employee + Spouse
$6.39
$12.20
Employee + Child(ren)
$7.35
$14.04
Family
$12.12
$23.14
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W/K Holding Company, Inc.
VISION Through SunLife’s administration and using the VSP network, our vision insurance is offered to help people see their best. By providing affordable access to high-quality eye care and eyewear, an individual or family vision insurance plan helps to provide you coverage on frames, lenses, contacts, eye exams and more.
VISION CARE SERVICES (In-Network Shown) Eye Exam
$10 copay
CONTACTS Elective
Up to $130
LENSES Standard Frames Single Vision Bifocal Trifocal
SERVICES
$130 Allowance plus 20% Discounts Covered 100% after $25 copay Covered 100% after $25 copay Covered 100% after $25 copay
FREQUENCY
Exam
12 months
Frames
12 months
Lenses
12 months
Contact lenses
12 months
WEEKLY RATES
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Employee
$1.60
Employee + Spouse
$2.55
Employee + Child(ren)
$2.60
Family
$4.20
DISABILITY Disability insurance, both short and long term, provide you relief and assistance in instances of sickness, injury and other circumstances altering your ability to perform at your full working capacity. W/K’s Benefits Administrator will inform you of your cost and the details for your disability coverage. Below are the highlights for your reference.
Short-Term Benefit Details BENEFIT AMOUNT
2/3 of base wage
WAITING PERIOD
3 days for illness, 1 day for accident
MAXIMUM BENEFIT PERIOD
13 weeks
Long - Term Benefit Details BENEFIT AMOUNT
60% of salary up to a maximum of $7,000 / month
MAXIMUM MONTHLY BENEFIT
$7,000
BENEFITS BEGIN ON MAXIMUM BENEFIT PERIOD
OWN OCCUPATION PERIOD
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W/K Holding Company, Inc.
LIFE and AD&D BASIC TERM LIFE
W- K Holding Company, Inc. offers you a basic term life policy. W/K will pay 66.67% of the premium on your behalf. BENEFIT DETAILS
PREMIUM
Employee
$20,000; Doubles for Accidental Death (AD&D)
$0.26 / per week
Spouse & Children
$10,000 Spouse; $5,000 per Child (above 6 months); $500 per Child (0-6 months)
$0.16 / per week
VOLUNTARY TERM LIFE
You’re eligible for benefits on the first of the month following 60 days of employment. BENEFIT DETAILS
Primary Benefits
EMPLOYEE SPOUSE
$5k increments to a MAX of $150k
CHILD(REN)
$10,000
$250k Employee-only; $50k Spouse; Guaranteed Issue (ee/sp/ch) 65% at age 65 40% at age 70 Benefits Reduce to:
25% at age 75
Disability Waiver of Premium
If total disability starts before age 60 and lasts up to 6 mos., premium waiver applies.
Conversion & Portability
Yes 13
ACCIDENT INSURANCE ACCIDENT INSURANCE
As we all know, life can throw us curves. Accident Insurance is a quick and affordable way to receive financial help in the form of a direct payout to you in instances of many covered accidents that can happen off-thejob. Please refer to your full Employee benefit packet for the detailed list of covered benefits (examples include -related services, just to name a few). This benefit is administered by SunLife.
Accident Plan Monthly Rates Employee
Off Job $11.26
Employee and Spouse
$19.61
Employee and Children
$21.91
Employee and Family
$30.26
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W/K Holding Company, Inc.
CRITICAL ILLNESS CRITICAL ILLNESS INSURANCE
Critical Illness insurance helps protect employees and their families from financial loss by providing a lump-sum benefit upon diagnosis of a covered condition. SunLife administers this benefit.
Class 1 EMPLOYEE BENEFIT Age band
Tobacco Monthly rate*
Non-Tobacco Monthly rate*
Under age 30
$0.41
$0.37
30-39
$0.88
$0.68
40-49
$2.56
$1.60
50-59
$6.07
$3.27
60-69
$11.14
$5.57
70 and over
$20.17
$10.63
Rate basis: Per $1,000 of coverage *Issue age rating applies—premiums will not increase due to age increase.
Class 1 SPOUSE BENEFIT Age band**
Tobacco*** Monthly rate*
Non-Tobacco*** Monthly rate*
Under age 30
$0.41
$0.37
30-39
$0.88
$0.68
40-49
$2.56
$1.60
50-59
$6.07
$3.27
60-69
$11.14
$5.57
70 and over
$20.17
$10.63
Rate basis: Per $1,000 of coverage *Issue age rating applies—premiums will not increase due to age increase. **The employee’s age is used to determine rates. ***Rates are based on t he spouse’s tobacco use.
Class 1 CHILD BENEFIT Coverage
Monthly rate
All age bands
$0.74
Rate basis: Per $1,000 of coverage
Monthly Wellness Premium (if included in your choice) Wellness screening benefit Monthly add-on rate
Employee
Spouse
Child
$50
$50
$50
$1.25
$1.25
No Charge
The wellness premium will be added to the elected Critical Illness premium amounts.
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Coverage Period: Beginning on or after 1/1/19 Coverage for: Individual + Family | Plan Type: PPO
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
No. $6,500 Individual / $13,000 Family for In-Network $15,000 Individual / $30,000 Family for Out-of-Network The Out-Of-Pocket Limit will be reduced to $3,000 Individual / $6,000 Family if TopCare provider is utilized Out-Of-Pocket Limit is embedded.
Are there other deductibles for specific services?
You can see the specialist you choose without a referral.
Yes. See www.aetna.com/ASA for a list of network providers. No.
Will you pay less if you use a network provider?
Do you need a referral to see a specialist?
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Even though you pay these expenses, they don’t count toward the out–of– pocket limit. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Premiums, balance-billing charges, Pre-Certification penalties, and health care this plan doesn’t cover.
What is not included in the out-of-pocket limit?
What is the out-of-pocket limit for this plan?
You don’t have to meet deductibles for specific services.
Yes. In-Network preventive care and services covered at “No charge”.
Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
Why This Matters:
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Answers $4,500 Individual / $9,000 Family for In-Network $6,000 Individual / $12,000 Family for Out-of-Network The deductible will be reduced to $500 Individual / $1,000 Family if TopCare provider is utilized Deductible is embedded.
Are there services covered before you meet your deductible?
What is the overall deductible?
Important Questions
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, contact your employer. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 844-657-0891 to request a copy.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services W/K Holding Company, Inc.: WK Health Plan
In-Network Provider (You will pay the least)
Imaging (CT/PET scans, MRIs)
Diagnostic test (x-ray, blood work)
Preventive care/screening/ immunization
No charge (If Basic or Complex Imaging Services provided at a Free Standing Imaging Center.
Basic Imaging Outpatient Hospital: InNetwork deductible, then 50% coinsurance until Out-of-Pocket Maximum is met. Complex Imaging Outpatient Hospital; In-Network deductible (Up to $4,500), then 50% coinsurance until Out-of-Pocket Maximum is met.
Basic X-rays: In-Office Visit - PCP Copay $35, Specialist Copay $50;
50% coinsurance after deductible in outpatient.
Labs: No charge in office (Independent Labs);
No charge
Primary care visit to $35 copay/visit, deductible does not apply treat an injury or illness $50 copay/visit, deductible does not apply Specialist visit Copay is waived if TopCare provider is utilized
Services You May Need
* For more information about limitations and exceptions, see the plan document.
If you have a test
If you visit a health care provider’s office or clinic
Common Medical Event
What You Will Pay
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
Out-of-Network Provider (You will pay the most)
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No Pre-Certification is required for Free Standing Imaging Services (Basic and Complex)
Services may be denied if not PreCertified for Outpatient Hospital.
Services may be denied if genetic testing and sleep studies not PreCertified.
You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.
None
Telemedicine visits are covered at no charge.
Limitations, Exceptions, & Other Important Information
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies, unless otherwise stated.
Benefits and cost sharing accumulate on a Calendar Year basis from 1/1 through 12/31 each year.
Retail Only: 25% coinsurance
Retail Only: 25% coinsurance
Retail Only: 25% coinsurance
Retail Only: 25% coinsurance
Retail: 25% coinsurance up to $150 maximum copay, deductible does not apply 90-Day Retail: 25% coinsurance up to $450 maximum copay, deductible does not apply $40 maximum copay or 25% coinsurance for Diabetic Rx. Retail: 25% coinsurance up to $200 maximum copay, deductible does not apply 90-Day Retail: 25% coinsurance up to $600 maximum copay, deductible does not apply $60 maximum copay or 25% coinsurance for Diabetic Rx. Retail: 25% coinsurance up to $250 maximum copay, deductible does not apply 90-Day Retail: 25% coinsurance up to $750 maximum copay, deductible does not apply $60 maximum copay or 25% coinsurance for Diabetic Rx.
Preferred brand drugs
Non-preferred brand drugs
Specialty drugs
Out-of-Network Provider (You will pay the most)
Generic drugs
In-Network Provider (You will pay the least)
Retail: 25% coinsurance up to $100 maximum copay, deductible does not apply. 90-Day Retail: 25% coinsurance up to $300 maximum copay, deductible does not apply. $10 maximum copay or 25% coinsurance for Diabetic Rx.
Services You May Need
* For more information about limitations and exceptions, see the plan document.
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.southernscripts.net.
Common Medical Event
What You Will Pay
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The Overall deductible does not apply to in-network prescription drug coverage. Retail drugs are covered up to a 30-day supply; Mail order drugs are covered up to a 90-day supply. Prior authorization may be required on some prescriptions.
Limitations, Exceptions, & Other Important Information
50% coinsurance after deductible; No charge after $500 TopCare deductible if TopCare provider is utilized
None
50% coinsurance
50% coinsurance after deductible
Inpatient services
50% coinsurance
$35 copay/visit, deductible does not apply 50% coinsurance
Outpatient services
50% coinsurance
50% coinsurance
Emergency use only
Same as in-network
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Services may be denied if not PreCertified.
None
None
Second opinion required to receive TopCare benefits. Services may be denied if not PreCertified.
None
Same as in-network
50% coinsurance after deductible; No charge after $500 TopCare deductible if TopCare provider is utilized
50% coinsurance after deductible; No charge after $500 TopCare deductible if TopCare provider is utilized
None
Second opinion required to receive TopCare benefits. Services may be denied if outpatient surgical procedures not Pre-Certified (does not include surgeries performed in the physician’s office).
Limitations, Exceptions, & Other Important Information
50% coinsurance
Physician/surgeon fees
Facility fee (e.g., hospital room)
Physician/surgeon fees
50% coinsurance
What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most)
50% coinsurance after deductible; No charge after $500 TopCare deductible if TopCare provider is utilized $1,500 copay/visit, then 20% Emergency room care coinsurance, deductible does not apply Emergency medical 50% coinsurance after deductible transportation Urgent care $50 copay/visit, deductible does not apply
Facility fee (e.g., ambulatory surgery center)
Services You May Need
* For more information about limitations and exceptions, see the plan document.
If you need mental health, behavioral health, or substance abuse services
If you have a hospital stay
If you need immediate medical attention
If you have outpatient surgery
Common Medical Event
Not Covered
50% coinsurance
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None
50% coinsurance after deductible
Durable medical equipment
50% coinsurance
Not Covered
Occupational and Physical Therapy: Combined limit 30 visits/calendar year Speech Therapy: Limit 30 visits/calendar year
Services may be denied if admissions exceeding 48/96 hours not PreCertified. Services may be denied if not PreCertified. Occupational and Physical Therapy: Combined limit 30 visits/calendar year Speech Therapy: Limit 30 visits/calendar year
50% coinsurance after deductible 50% coinsurance $50 copay/visit, deductible does not apply 50% coinsurance Not Covered Not Covered
50% coinsurance after deductible
Hospice services Children’s eye exam Children’s glasses Children’s dental check-up
50% coinsurance
50% coinsurance
50% coinsurance
50% coinsurance
None
None
Limitations, Exceptions, & Other Important Information
Services may be denied if not PreCertified. 60 days/calendar year Services may be denied if electric/motorized scooters, wheelchairs or pneumatic compression devices not Pre-Certified. None 1 exam/24-month period None
Skilled nursing care
Habilitation services
Physical Therapy in office: $35 copay/visit, deductible does not apply All other services: 50% coinsurance after deductible Office: $35 copay/visit, deductible does not apply. Cardiac Rehabilitation: $35 copay; 50% coinsurance, deductible does not apply. All other services: 50% coinsurance after deductible
$50 copay/visit after deductible
Home health care
Rehabilitation services
$1,500 copay/visit, then 20% coinsurance, deductible does not apply
$35 copay/visit, deductible does not apply 50% coinsurance 20% coinsurance, deductible does not apply; Preventive prenatal services are 50% coinsurance covered at no charge.
What You Will Pay In-Network Provider Out-of-Network Provider (You will pay the least) (You will pay the most)
Childbirth/delivery facility services
Childbirth/delivery professional services
Office visits
Services You May Need
* For more information about limitations and exceptions, see the plan document.
If your child needs dental or eye care
If you need help recovering or have other special health needs
If you are pregnant
Common Medical Event
* For more information about limitations and exceptions, see the plan document.
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Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 844-657-0891. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 844-657-0891. Chinese (中文): 如果需要中文的帮助，请请打请个号请 844-657-0891. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 844-657-0891. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––
Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Does this plan provide Minimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact your employer or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Chiropractic care (30 visits/calendar year) • Private duty nursing (60 • Routine eye care (Adult), (1 exam/24-month period) shifts/calendar year) • Infertility treatment- diagnosis and surgical correction of physiological abnormalities
Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Dental care (Adult) • Non-emergency care when traveling outside the U.S. • Bariatric surgery • Hearing aids • Routine foot care • Cosmetic surgery • Long-term care • Weight loss programs
$4,500 $50 20% 20%
In this example, Peg would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Peg would pay is
Total Example Cost
$4,500 $50 50% 50%
In this example, Joe would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Joe would pay is
Total Example Cost
$55 $3,109
$1,695 $1,358 $0
$7,400
This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)
The plan’s overall deductible Specialist copayment Hospital (facility) coinsurance Other coinsurance
(a year of routine in-network care of a wellcontrolled condition)
Managing Joe’s type 2 Diabetes
$4,500 $50 50% 50%
In this example, Mia would pay: Cost Sharing Deductibles Copayments Coinsurance What isn’t covered Limits or exclusions The total Mia would pay is
Total Example Cost
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$0 $1,555
$800 $755 $0
$1,900
This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)
The plan’s overall deductible Specialist copayment Hospital (facility) coinsurance Other coinsurance
Mia’s Simple Fracture
(in-network emergency room visit and follow up care)
The plan would be responsible for the other costs of these EXAMPLE covered services.
$60 $3,203
$200 $1,500 $1,443
$12,800
This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)
The plan’s overall deductible Specialist copayment Hospital (facility) coinsurance Other coinsurance
(9 months of in-network pre-natal care and a hospital delivery)
Peg is Having a Baby
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
About these Coverage Examples:
Annual Notices & Rights Packet Available Please Note: Annual Rights and Notices regarding the health benefits offered through WardKraft are posted outside of Marnie Zimmerman’s office, and on Paycor. These can also be requested as hard copy (copy for yourself) free of charge at any time upon your request from HR. Please let us know any questions or concerns on this, or anything else.
Thank you, Ward-Kraft Benefits Team
W/K Holding Company, Inc.
Sara Griffith ext. 4287 sgriffith@wardkraft.com
Marnie Zimmerman ext. 4600 mzimmerman@wardkraft.com