2013 Benefit & Premium Summary

Transcription

1 2013 Benefit & Premium Summary The following is a list of all benefits provided to or for American Diagnostic Technologies full-time employees: 1. Health Insurance (Blue Cross Blue Shield - PremierBlue) Portion of employee premium paid by ADT. 2. Dental Insurance (AlwaysCare Dental) Portion of employee premium paid by ADT. 3. Vision Insurance (AlwaysCare Vision) Portion of employee premium paid by ADT. Premiums are listed as per month TYPE OF COVERAGE HEALTH PREMIERBLUE-PPO ALWAYSCARE DENTAL ALWAYSCARE VISION TOTAL ONLY $136 $12 $ 4 $ 152 & CHILD $320 $24 $8 $ 352 & SPOUSE $336 $24 $8 $ 368 & FAMILY $380 $40 $10 $ Life Insurance (Assurant, $10,000) premium paid 100% by ADT. 5. Long Term Disability (Assurant) premium paid 100% by ADT. 6. Retirement Plan (Guardian 401K) can contribute up to IRS limits. 7. Additional Insurance (Colonial Life) Colonial Life offers our employees additional coverage for Short- Term Disability, Long-Term Disability, Accident, Cancer, Critical Illness, and Life Insurance. Any of these plans may be purchased in addition to the employee s other benefits. ADT will pay up to $20.00 per month toward the employee s premium; any amount over the allowable bank ($20.00) is paid by the employee via bi-weekly payroll deduction. 8. Vacation, sick days, etc. are explained in the policy manual. Notes: Upon termination of employment, health insurance benefits will be offered to former employee under Cobra plan and Colonial premiums will become the sole responsibility of the former employee.

2 BLUE CROSS BLUE SHIELD PremierBlue PPO Health Insurance BENEFIT Calendar Year Deductible Individual Family Coinsurance Limit Individual Family In-Network PREFERRED PROVIDER ORGANIZATION Three per Family Out of Network $3,500 $6,000 Coinsurance 80% 60% Physician In - Office Visits $35 Co-pay per visit Wellness Option No deductible then 100% Physician Inpatient Services Surgery Hospital Inpatient Coverage Hospital Outpatient Coverage Accidental Injury Benefit 100% up to $300, then subject to a deductible & 80% coinsurance 100% up to $300, then subject to the deductible & 60% coinsurance Diagnostic X-Ray & Laboratory Mental & Nervous Disorders Inpatient Max days per Cal Yr Outpatient Max visits per Cal Yr *Alcohol & Drug Addiction Inpatient Max days per Cal Yr Outpatient Max visits per Cal Yr *Note: Coinsurance for Alcohol & Drug Addiction does not accrue towards the Out of Pocket Maximum Prescription Drug Co-payments Refer to the contract for applicable supply limitations Retail up to 30 day supply Mail Order up to 90 day supply [Prescription Drug Deductible] Generic / Preferred Brand / Non-Preferred Brand / Multi-Source / Injectables Contraceptives Included $7 / $30 / $55 / $70/ $50 $21/ $90 / $165 / $210 / $150 [$100 per family member/per Calendar Year] Providers for this PPO plan are listed in the BlueCross & Blue Shield of Louisiana PremierBlue 65 Provider Network Directory or any Blue Cross & Blue Shield Blue Card PPO directory nationwide. This outline is presented for general information only. It is not a contract, nor intended to be a contract. If there is any discrepancy between this document and the Benefit Plan, the provisions of the Benefit Plan will govern. *Out of Network Deductible and Out of Pocket amounts will be credited toward the In Network Deductible and Out of Pocket. In Network Deductibles and Out of Pocket amount will not be credited towards the Out of Network Deductible and Out of Pocket. BCBSLA Customer Service: Express Script Customer Service:

3 BENEFIT SUMMARY AlwaysCare Dental Insurance COVERAGE AMOUNTS Annual Deductible $50 per calendar year Family (up to 3 persons individually) $50 per person per calendar year The individual deductible does not apply to Class I Dental Services Benefit Maximums Benefit Year Maximum per Person Overall Benefit Maximums for TMJ Co-Insurance Percentages Class A, Preventative Services 100% Limited to one visit every 6 months and 1 set of bitewing x-rays per calendar year. Class B, Basic Services 80% Class C, Major Services 50% Class D, Orthodontics 50% Carryover Benefits $250 Threshold Limit $500 Carryover Account Maximum Vision Care Services Exam (Once per 12 month period) Materials (see below) Materials Eye Glass Lenses (once per 12 month period) Single Vision Bifocal Trifocal Lenticular Progressive Lens Options: Scratch Resistant Coating Polycarbonate Lenses for Children Materials Frames (Once per 24 month period) Members choose from any frame available at Providers locations. AlwaysCare Vision Insurance WAL-MART COPAYS $10 $0 $80 allowance $70 allowance Up to $74 retail allowance covers 2/3 of frames available at Wal-Mart. $10 $15 OTHER PARTICIPATING PROVIDER COPAYS $80 allowance $70 allowance $100 retail frame allowance. Covers a wide selection of frames. OUT OF NETWORK ALLOWANCES Up to $30 Up to $25 Up to $40 Up to $50 Up to $50 Up to $40 Up to $50 retail

4 Materials Contact Lenses (once per 12 month period) Elective Medically Necessary Up to $130 retail Up to $130 retail Up to $120 retail Up to $210 retail Up to $100 retail Up to $210 retail Assurant Insurance Long-Term Disability Benefit 60% of employee income Assurant Insurance Life Insurance $10,000 Guardian 401(K) Retirement Plan Can contribute up to IRS limit (Deferral Limit is $16,500 per year) (Age 50 or older Deferral Limit is $22,000 per year) Colonial Life Optional Insurance May choose to elect additional Optional Insurances. Insurances available may include, but are not limited to: Short Term Disability Life Cancer Critical Illness Benefit amounts vary based upon the choices made for coverage by the employee. ADT provides $20 per month allowance toward premium of one optional insurance, if elected.

5 Accrued Time See policy manual for more details regarding eligibility and rules TERMS OF BENEFIT PTO Benefit Amount Eligible after completing 90 days probationary period 0 1 year of service 1 5 years of service 5 years and above Paid Holidays 4 hrs/pay period (13 days per yr) 5.23 hrs/pay period (17 days per yr) 6.15 hrs/pay period (20 days per yr) New Year s Day Good Friday Independence Day Labor Day Thanksgiving Day Christmas Day