Communications Unlimited, Inc.

Transcription

1 Communications Unlimited, Inc Employee Benefits Booklet

2 Contents Welcome to Your Benefits Program...2 Medical Plan...3 Dental Plan...10 Vision Plan...12 Short Term Disability Insurance...15 Long Term Disability Insurance...16 Term Life Insurance...17 Colonial Life Voluntary Products...18 Rate Summary

3 Welcome to The CUI Comprehensive Employee Benefits Program! On behalf everyone at CU Employment, Inc. (herein called CUI ) we welcome you to CUI and wish you much success! We firmly believe our employees are our greatest asset and that each employee contributes directly to CUI s growth and success. It is our intention that you will take great pride in being a member of our team, and we hope to reaffirm your commitment by offering the following employee benefits program to protect you and your family. CUI is committed to our employees and their families and will continue to strive to offer you the most quality work experience possible. Our general policy is simple, we treat all of our employees, our clients, and our vendors with courtesy, dignity, and respect at all times. This Employee Benefits Guide was developed to describe and outline the policies, programs, and benefits available to eligible employees while employed at CUI. Our new hire waiting period is the first of the month after 60 days for all benefits. One of our objectives is to provide a work environment that is conducive to both personal and professional growth. Therefore, we strongly encourage you to take this manual home to review and share with your family. As a new employee you will receive a welcome call from your dedicated benefits specialist shortly after receiving this guide to introduce you to the programs and answer any questions you may have. This dedicated benefit specialist will stay with you through your entire employment with CUI and is available for you to contact at any time for all aspects of your employee benefit needs. Also during that call you will be scheduled to set up your one-on-one enrollment with your benefit specialist when it is convenient for you. This enrollment will be mandatory for all employees and will occur shortly before your new hire waiting period for benefits is exhausted. This will be your dedicated time to enroll in all the programs found in this guide. We ask you to prepare accordingly prior to this call so you can make the proper decisions for you and your family. We are a proud company that believes in dedication and service to our customers as well as our employees. We hope you will find this employee benefits program a valuable asset to being an employee at CUI. We look forward to a long, prosperous relationship with you and all of our team members! Sincerely, Martin Rocha President 3

4 BlueCross/BlueShield Medical - Buy-Up Plan Effective June 1, 2015 BENEFIT IN-NETWORK OUT-OF-NETWORK Benefit payments are based on the amount of the provider s charge that Blue Cross and Blue Shield recognizes for payment of benefits. The allowed amount may vary depending upon the type provider and where services are received. Some services require a copay, coinsurance, calendar year or for each admission, visit or service. INPATIENT HOSPITAL AND PHYSICIAN BENEFITS Precertification is required for inpatient admissions (except medical emergency and maternity); notification within 48 hours for medical emergencies. Generally, if precertification is not obtained, no benefits are available. Call (toll free) for precertification. Inpatient Hospital Covered at 100% after $175 per day hospital copay days 1-5 for each admission Inpatient Physician Visits and Consultations Covered at 100% subject to calendar year Mental Health Disorders and Substance Abuse Services covered at 100%; no copay or Covered at 80% after $750 per admission Note: In Alabama, available only for accidental injury Covered at 50% subject to calendar year Mental Health Disorders and Substance Abuse Services covered at 80%; no copay or OUTPATIENT HOSPITAL BENEFITS Precertification is required for some outpatient hospital benefits; please see benefit booklet. Precertification is also required for physician-administered specialty drugs; visit AlabamaBlue.com/DrugList. If precertification is not obtained, no benefits are available. Outpatient Surgery (Including Covered at 100% after $350 hospital copay Covered at 80% subject to calendar year Ambulatory Surgical Centers) Emergency Room (Medical Emergency) CU Employment, Inc. BlueCard PPO Effective June 1, 2015 Covered at 100% after $250 hospital copay ; in Alabama, not covered Covered at 100% after $250 hospital copay and subject to calendar year Emergency Room (Accident) Note: If you have a medical emergency as defined by the plan after 72 hours of an accident, refer to Emergency Room (Medical Emergency) above. Emergency Room Physician Covered at 100% after $250 hospital copay Covered at 100% after $50 physician copay Mental Health Disorders and Substance Abuse Services covered at 100% after $250 hospital copay; copay applies to the innetwork out-of-pocket maximum Covered at 100% after $250 hospital copay for services within 72 hours, thereafter and when not a medical emergency as defined by the plan, 80% subject to calendar year Covered at 100% after $50 physician copay and subject to calendar year Outpatient Diagnostic Lab, X-ray & Pathology Note: The first covered mammogram each calendar year is not subject to the hospital copay Dialysis, IV Therapy, Chemotherapy & Radiation Therapy Intensive Outpatient Program (IOP) and Partial Hospitalization Program (PHP) Covered at 100% after $100 hospital copay Covered at 100% after $100 hospital copay Covered at 100% after $50 daily hospital copay 4 Mental Health Disorders and Substance Abuse Services covered at 100% after $50 physician copay; copay applies to the innetwork out-of-pocket maximum Covered at 80% subject to calendar year ; in Alabama, not covered Covered at 80% subject to calendar year ; in Alabama, not covered Covered at 50% subject to calendar year ; in Alabama, not covered PHYSICIAN BENEFITS Precertification is required for some physician benefits; please see benefit booklet. Precertification is also required for physician-administered specialty drugs; visit AlabamaBlue.com/DrugList. If precertification is not obtained, no benefits are available. IN-NETWORK SERVICES NOT SUBJECT TO $500 CALENDAR YEAR DEDUCTIBLE Office Visits & Consultations Second Surgical Opinions Covered at 100% after $35 primary physician copay or $50 specialist physician copay Covered at 100% after $50 specialist physician copay Covered at 50% subject to calendar year Covered at 50% subject to calendar year

5 BENEFIT IN-NETWORK OUT-OF-NETWORK Diagnostic Lab, X-ray, Pathology, Dialysis, IV Therapy, Chemotherapy & Radiation Therapy Covered at 100%; no copay or Covered at 50% subject to calendar year IN-NETWORK SERVICES SUBJECT TO $500 CALENDAR YEAR DEDUCTIBLE Surgery & Anesthesia Covered at 100% subject to calendar year Covered at 50% subject to calendar year Maternity Care Covered at 100% subject to calendar year Covered at 50% subject to calendar year Routine Immunizations and Preventive Services PREVENTIVE CARE BENEFITS Covered at 100%; no copay or See AlabamaBlue.com/preventiveservices for a listing of the specific immunizations and preventive services Note: In some cases, office visit copays or facility copays may apply PRESCRIPTION DRUG BENEFITS Prescription Drug Card The pharmacy network for the plan is the Prime Participating Pharmacy Network Some drugs require prior authorization Some copays combined for diabetic supplies Prescription drugs (other than specialty drugs) can be dispensed for up to a 90-day supply but the copayment is applicable for each 30-day supply Specialty drugs can be dispensed for up to a 30-day supply. The only in-network pharmacy for some specialty drugs is the Prime Therapeutics Specialty Pharmacy network. Go to AlabamaBlue.com/web/pharmacy/druggui de.html for a list of these specialty drugs. View the Standard Prescription Drug list that applies to the plan at AlabamaBlue.com/web/pharmacy/druggui de.html 100% after the following copays: Tier 1 Drugs: $15 copay per prescription Tier 2 Drugs: $40 copay per prescription Tier 3 Drugs: $100 copay per prescription Tier 4 Drugs: $150 copay per prescription Generic drugs mandatory when available and may be classified at any Tier SUMMARY OF COST SHARING PROVISIONS Calendar Year Deductible $500 individual; $1,500 aggregate amount per family Calendar Year Out-of-Pocket Maximum $6,600 individual; $13,200 aggregate amount per family All s, copays and coinsurance for in-network services and all s, copays and coinsurance for out-of-network mental health disorders/substance abuse emergency services apply to the out-of-pocket maximum. Coinsurance for out-of-network Home Health, Hospice, and Other Covered Services (excluding occupational therapy, physical therapy, and DME in Alabama) applies to the out-of-pocket maximum. After you reach Calendar Year Out-of-Pocket Maximum, applicable expenses covered at 100% for remainder of calendar year. BENEFITS FOR OTHER COVERED SERVICES Precertification is required for some other covered services; please see benefit booklet. If no precertification is obtained, no benefits are available. Allergy Testing & Treatment Limited to 12 visits per calendar year Covered at 80% subject to calendar year Covered at 80% subject to calendar year Ambulance Service Covered at 80% subject to calendar year Covered at 80% subject to calendar year Participating Chiropractic Services Limited to 12 visits per calendar year Durable Medical Equipment (DME) Occupational and Physical Therapy Occupational, physical and speech therapy limited to combined maximum of 30 visits per year Covered at 80% subject to calendar year Covered at 80% subject to calendar year Covered at 80% subject to calendar year Covered at 80% subject to calendar year ; in Alabama, not covered Covered at 80% subject to calendar year ; in Alabama, covered at 50% subject to calendar year Covered at 80% subject to calendar year ; in Alabama, covered at 50% subject to calendar year 5

6 BENEFIT IN-NETWORK OUT-OF-NETWORK Covered at 80% subject to calendar year Covered at 80% subject to calendar year Speech Therapy Occupational, physical and speech therapy limited to combined maximum of 30 visits per year Home Health and Hospice Individual Case Management Disease Management Baby Yourself Contraceptive Management Air Medical Services Covered at 100% subject to calendar year Covered at 80% subject to calendar year ; in Alabama, not covered HEALTH MANAGEMENT BENEFITS Coordinates care in event of catastrophic or lengthy illness or injury. Coordinates care for chronic conditions such as asthma, diabetes, coronary artery disease, congestive heart failure and chronic obstructive pulmonary disease. A prenatal wellness program; For more information, please call You can also enroll online at Behealthy.com. Covers prescription contraceptives, which include: birth control pills, injectables, diaphragms, IUDs and other non-experimental FDA approved contraceptives; subject to applicable s, copays and coinsurance. Air ambulance service to a hospital near home if hospitalized while traveling more than 150 miles from home; to arrange transportation, call AirMed at Useful Information to Maximize Benefits To maximize your benefits, always use in-network providers for services covered by your health benefit plan. To find in-network providers, check a provider directory, provider finder website (AlabamaBlue.com) or call BLUE (2583). In-network hospitals, physicians and other healthcare providers have a contract with a Blue Cross and/or Blue Shield Plan for furnishing healthcare services at a reduced price (examples: BlueCard PPO, PMD, Preferred Care). In-network pharmacies are pharmacies that participate with Blue Cross and Blue Shield of Alabama or its Pharmacy Benefit Manager(s). In Alabama, in-network services provided by mental health disorders and substance abuse professionals are available through the Blue Choice Behavioral Health Network. Out-of-network providers generally do not contract with Blue Cross and/or Blue Shield Plans. If you use out-of-network providers, you may be responsible for filing your own claims and paying the difference between the provider s charge and the allowed amount. The allowed amount may be based on the negotiated rate payable to in-network providers in the same area or the average charge for care in the area. Please be aware that providers/specialists may be listed in a PPO directory or provider finder website, but not covered under this benefit plan. Please check your benefit booklet for more detailed coverage information. Bariatric Surgery, Gastric Restrictive procedures and complications arising from these procedures are not covered under this plan. Please see your benefit booklet for more detail and for a complete listing of all plan exclusions. This is not a contract, benefit booklet or Summary Plan Description. Benefits are subject to the terms, limitations and conditions of the group contract. Check your benefit booklet for more detailed coverage information. Please visit our website, AlabamaBlue.com 6

7 BlueCross/BlueShield Medical - Base Plan CU Employment, Inc. BlueCard PPO Effective June 1, 2015 Effective June 1, 2015 BENEFIT IN-NETWORK OUT-OF-NETWORK Benefit payments are based on the amount of the provider s charge that Blue Cross and/or Blue Shield plans recognize for payment of benefits. The allowed amount may vary depending upon the type provider and where services are received. Some services require a copay, coinsurance, calendar year or for each admission, visit or service. SUMMARY OF COST SHARING PROVISIONS Calendar Year Deductible Calendar Year Out-of-Pocket Maximum All s, copays and coinsurance for innetwork services and out-of-network mental health disorders/substance abuse emergency services apply to the out-of-pocket maximum. $3,000 per individual; $6,000 aggregate amount per family Calendar year amounts met innetwork will not apply to the out-of-network calendar year $6,000 individual (including calendar year ); $12,000 aggregate amount per family (including calendar year ) After you reach the Calendar Year Out-of-Pocket Maximum, applicable expenses covered at 100% of the allowed amount for remainder of calendar year $3,000 per individual; $6,000 aggregate amount per family Calendar year amounts met outof-network will not apply to the in-network calendar year There is no out-of-pocket maximum for outof-network services INPATIENT HOSPITAL AND PHYSICIAN BENEFITS Precertification is required for inpatient admissions (except medical emergency and maternity); notification within 48 hours for medical emergencies. Generally, if precertification is not obtained, no benefits are available. Call (toll free) for precertification. Inpatient Hospital subject to calendar year Inpatient Physician Visits and Consultations subject to calendar year OUTPATIENT HOSPITAL BENEFITS Precertification is required for some outpatient hospital benefits; please see benefit booklet. Precertification is also required for physician-administered specialty drugs; visit AlabamaBlue.com/DrugList. If precertification is not obtained, no benefits are available. Outpatient Surgery (Including Ambulatory Surgical Centers) Emergency Room (Medical Emergency) Emergency Room (Accident) Note: If you have a medical emergency as defined by the plan after 72 hours of an accident, refer to Emergency Room (Medical Emergency) above. Emergency Room Physician Outpatient Diagnostic Lab, X-ray, Pathology, Dialysis, IV Therapy, Chemotherapy & Radiation Therapy Intensive Outpatient Program (IOP) and Partial Hospitalization Program (PHP) subject to calendar year subject to calendar year subject to calendar year subject to calendar year subject to calendar year subject to calendar year subject to calendar year subject to calendar year for services within 72 hours; thereafter and when not a medical emergency as defined by the plan, not covered subject to calendar year PHYSICIAN BENEFITS Precertification is required for some physician benefits; please see benefit booklet. Precertification is also required for physician-administered specialty drugs; visit AlabamaBlue.com/DrugList. If precertification is not obtained, no benefits are available. Office Visits, Consultations & Second Surgical Opinions Surgery & Anesthesia Covered at 100% of the allowed amount after $30 physician copay for first three illness related office visits; thereafter, covered at 80% of the allowed amount subject to calendar year subject to calendar year 7

8 BENEFIT IN-NETWORK OUT-OF-NETWORK Maternity Care subject to calendar year Diagnostic Lab, X-ray, Pathology, Dialysis, IV Therapy, Chemotherapy & Radiation Therapy subject to calendar year Routine Immunizations and Preventive Services See AlabamaBlue.com/preventiveservices for a listing of the specific immunizations and preventive services Certain immunizations may also be obtained through the Pharmacy Vaccine Network. See AlabamaBlue.com/pharmacy for more information. PREVENTIVE CARE BENEFITS Covered at 100% of the allowed amount; no copay or Note: In some cases, office visit copays or facility copays may apply PRESCRIPTION DRUG BENEFITS Prescription Drug Card The pharmacy network for the plan is the Prime Participating Pharmacy Network Prescription drugs (other than Tier 4 (specialty) drugs) can be dispensed for up to a 90-day supply but the copayment is applicable for each 30-day supply Some drugs require prior authorization Some copays combined for diabetic supplies Tier 4 (specialty) drugs can be dispensed for up to a 30-day supply. The only innetwork pharmacy for some Tier 4 (specialty) drugs is the Prime Therapeutics Specialty Pharmacy network. Go to AlabamaBlue.com/web/pharmacy/drugg uide.html for a list of these Tier 4 (specialty) drugs. View the Standard Prescription Drug list that applies to the plan at AlabamaBlue.com/web/pharmacy/drugg uide.html Allergy Testing & Treatment Limited to 6 visits per calendar year for allergy treatment Ambulance Service Chiropractic Services Limited to 15 visits per calendar year Durable Medical Equipment (DME) Occupational, Physical and Speech Therapy Occupational, physical and speech therapy limited to a combined maximum of 30 visits per year Children ages 0-9 with an autistic diagnosis are allowed unlimited visits for occupational and speech therapy Home Health and Hospice Covered at 100% of the allowed amount after the following copays for a 30-day supply for each prescription: Tier 1 Drugs: $15 copay per prescription Tier 2 Drugs: $50 copay per prescription Tier 3 Drugs: $70 copay per prescription Tier 4 (specialty) Drugs: $395 copay per prescription Generic drugs are mandatory when available and may be classified at any Tier. BENEFITS FOR OTHER COVERED SERVICES Precertification is required for some other covered services; please see benefit booklet. If no precertification is obtained, no benefits are available. subject to calendar year subject to calendar year subject to calendar year subject to calendar year subject to calendar year subject to calendar year Covered at 50% of the allowed amount subject to calendar year 8

9 BENEFIT IN-NETWORK OUT-OF-NETWORK HEALTH MANAGEMENT AND ADDITIONAL BENEFITS Individual Case Management Coordinates care in event of catastrophic or lengthy illness or injury. For more information, please call Disease Management Coordinates care for chronic conditions such as asthma, diabetes, coronary artery disease, congestive heart failure and chronic obstructive pulmonary disease. Baby Yourself A prenatal wellness program; For more information, please call You can also enroll online at Behealthy.com. Contraceptive Management Covers prescription contraceptives, which include: birth control pills, injectables, diaphragms, IUDs and other non-experimental FDA approved contraceptives; subject to applicable s, copays and coinsurance. Air Medical Services Air ambulance service to a hospital near home if hospitalized while traveling more than 150 miles from home; to arrange transportation, call AirMed at Useful Information to Maximize Benefits To maximize your benefits, always use in-network providers for services covered by your health benefit plan. To find in-network providers, check a provider directory, provider finder website (AlabamaBlue.com) or call BLUE (2583). In-network hospitals, physicians and other healthcare providers have a contract with a Blue Cross and/or Blue Shield Plan for furnishing healthcare services at a reduced price (examples: BlueCard PPO, PMD). In-network pharmacies are pharmacies that participate with Blue Cross and Blue Shield of Alabama or its Pharmacy Benefit Manager(s). In Alabama, in-network services provided by mental health disorders and substance abuse professionals are available through the Blue Choice Behavioral Health Network. Sometimes an in-network provider may furnish a service to you that is not covered under the contract between the provider and a Blue Cross and/or Blue Shield Plan. When this happens, benefits may be denied or reduced. Please refer to your benefit booklet for the type of provider network that we determine to be an in-network provider for a particular service or supply. Out-of-network providers generally do not contract with Blue Cross and/or Blue Shield Plans. If you use out-of-network providers, you may be responsible for filing your own claims and paying the difference between the provider s charge and the allowed amount. The allowed amount may be based on the negotiated rate payable to in-network providers in the same area or the average charge for care in the area. Please be aware that providers/specialists may be listed in a PPO directory or provider finder website, but not covered under this benefit plan. Please check your benefit booklet for more detailed coverage information. Bariatric Surgery, Gastric Restrictive procedures and complications arising from these procedures are not covered under this plan. Please see your benefit booklet for more detail and for a complete listing of all plan exclusions. This is not a contract or benefit booklet. Benefits are subject to the terms, limitations and conditions of your contract with us (including your benefit booklet). Check your benefit booklet for more detailed coverage information. Please visit our website, AlabamaBlue.com. 9

10 BlueCross/BlueShield (Dentemax) - National Dental Blue Cross and Blue Shield of Alabama's National Dental program offers access to dental providers in many areas throughout the United States. This program is designed to promote quality and cost effective dental care. There are now more than 163,000 access points for participating dentists nationwide in the National Dental program through Blue Cross partnership with DenteMax. Dental Network Provisions: Network dentists should file claims for you. Network dentists accept the Blue Cross fee schedule as payment in full (after any and coinsurance you owe). Blue Cross payments offer an average savings of approximately 25% off billed charges. Covered dental services, level of coverage, and benefit maximum amounts will be the same for in-network and out-of-network dentists. However, if you do not use an in-network dentist, Blue Cross will pay you the allowed amount for covered services. You may be responsible for the difference between the Blue Cross payment and the dentist s charge (plus any and coinsurance). You may also have to file the claim if your dentist s office will not. To find a network dentist, go to and click on Find a doctor, dentist or hospital/alabama or National. Then, click on Find a Dentist and enter the requested information. Filing Dental Claims: File all claims for dental services to Blue Cross and Blue Shield of Alabama. If your dentist files your claim, ask him or her to send the claim to Blue Cross and Blue Shield of Alabama s address. You should fill out the top portion of the form and ask the dentist to complete the bottom portion of the form. To file your own dental claim, you should complete the top portion of the claim form and attach an itemized statement from your dentist. Send Dental Claims to this address: Blue Cross and Blue Shield of Alabama P.O. Box Birmingham, Alabama If you have questions about your dental coverage or claim, please call the following number: Blue Cross and Blue Shield of Alabama

11 BlueCross/BlueShield (Dentemax) - National Dental CU Employment, Inc. National Dental Benefits Effective June 1, 2015 GENERAL PROVISIONS Deductible $25 per member per calendar year; maximum of 3 s per family each calendar year. Maximum $1,000 per member each calendar year. DIAGNOSTIC AND PREVENTIVE (Exams and Cleanings) Covered at 100%, subject to the. Includes: Dental exams up to twice per benefit period. Full mouth x-rays, one set during any 36 consecutive months. Bitewing x-rays, up to twice per benefit period. Other dental x-rays, used to diagnose a specific condition. Routine cleanings, twice per benefit period. Tooth sealants on teeth numbers 3, 14, 19, and 30, limited to one application per tooth each 48 months. Benefits are limited to a maximum payment of $20 per tooth. Limited to the first permanent molars of children through age 13. Fluoride treatment for children through age 18 twice per benefit period. Space maintainers (not made of precious metals) that replace prematurely lost teeth for children through age 18. RESTORATIVE (Fillings and Root Canals) Covered at 100%, subject to the. Includes: Fillings made of silver amalgam and synthetic tooth color materials. Simple tooth extractions. Direct pulp capping, removal of pulp and root canal treatment. Repairs to removable dentures. Emergency treatment for pain. SUPPLEMENTAL (Oral Surgery and Anesthesia) Covered at 100%, subject to the. Includes: Oral surgery for tooth extractions and impacted teeth. General anesthesia given for oral or dental surgery. This means drugs injected or inhaled for relaxation or to lessen pain, or to make unconscious, but not analgesics, drugs given by local infiltration, or nitrous oxide. Treatment of the root tip of the tooth including its removal. PROSTHETIC (Crowns and Dentures) Covered at 50%, subject to the. Includes: Full or partial dentures. Fixed or removable bridges. Inlays, onlays, or crowns to restore diseased or accidentally broken teeth, if less expensive fillings are not adequate. PERIODONTIC (Gum Disease) Covered at 80%, subject to the. Includes: Periodontic exams twice each 12 months. Removal of diseased gum tissue and reconstructing gums. Removal of diseased bone. Reconstruction of gums and mucous membranes by surgery. Removing plaque and calculus below the gum line for periodontal disease. This is not a contract. Benefits are subject to the terms, limitations and conditions of the group contract. 11

12 Vision CU Employment, Inc. Group Number: Vision Benefit Summary About Your Benefits: Eye care is a vital component of a healthy lifestyle. With vision insurance, having regular exams and purchasing contacts or glasses is simple and affordable. The coverage is inexpensive, yet the benefits can be significant! Guardian provides rich, flexible plans that allow you to safeguard your health while saving you money. Review your plan options and see why vision insurance may be a great benefit for you. Significant out-of-pocket savings available with your Full Feature plan by visiting one of Davis Vision's network locations including retail centers such as Wal-Mart, JCPenney, Sears, Target, Sam s Club, and Pearle. Your Vision Plan Your Network is Full Feature - Designer Davis Vision Your Bi-weekly premium $ 3.77 You, spouse and child(ren) $ 8.10 Copay Exams Copay $ 20 Materials Copay (waived for non-formulary elective contact lenses) $ 20 Sample of Covered Services In-network You pay (after copay if applicable): Out-of-network Eye Exams $0 Amount over $50 Single Vision Lenses $0 Amount over $48 Lined Bifocal Lenses $0 Amount over $67 Lined Trifocal Lenses $0 Amount over $86 Lenticular Lenses $0 Amount over $126 Frames 80% of amount over $130* Amount over $48 Contact Lenses (Elective and conventional) 85% of amount over $130* Amount over $105 Contact Lenses (Planned replacement and disposable) 85% of amount over $130* Amount over $105 Contact Lenses (Medically Necessary) $0 Amount over $210 Cosmetic Extras Avg % off retail price No discounts Glasses (Additional pair of frames and lenses) Courtesy discount from most No discounts providers Laser Correction Surgery Discount Up to 25% off the usual charge or 5% No discounts off promotional price Service Frequencies Exams Every calendar year Lenses (for glasses or contact lenses) Every calendar year Frames Every two calendar years Network discounts (cosmetic extras, glasses and contact lenses.) Applies to first purchase & courtesy discount from most providers on subsequent purchases. Dependent Age Limits 26 Benefit includes coverage for glasses or contact lenses, not both. This is only a partial list of vision services. Your certificate of benefits will show exactly what is covered and excluded. 12

13 With the Davis Vision Designer plans, frames from the Fashion or Designer collections are covered in full in excess of the plan s materials copay, if applicable. Frames from the Premier collection are covered in full in excess of a $25 copay applied in addition to the plan s materials copay, if applicable. Frames from a network provider that are not in the collections are covered up to the plan s retail allowance in excess of the plan s materials copay, if applicable. Contact lenses from Davis Vision's Collection are available at most private practice locations with Full Feature and Materials Only plans. Contacts from the collection are covered in full including fitting and evaluation, in excess of the plan's materials copay. Elective contacts that are not part of the Collection are covered up to the plan's elective contact lens allowance and the materials copay is waived. For Davis Vision, complete eyeglasses must be purchased at one time from one provider. For example, if a member purchases only lenses, he or she cannot purchase frames later in the same benefit period. The member is not eligible for new vision materials until the next benefit period. Only charges for an initial purchase can be used toward the material allowance. Any unused balance remaining after the initial purchase cannot be banked for future use. *Due to lower prices available at Wal-mart and Sam's Club locations, discounts do not apply. Members will pay 100% of the amount over their allowance. Manage Your Benefits: Go to to access secure information about your Guardian benefits including access to an image of your ID Card. Your on-line account will be set up within 30 days after your plan effective date. Find A Vision Provider Visit Click on Find A Provider ; You will need to know your plan and vision network, which can be found on the first page of your vision benefit summary. EXCLUSIONS AND LIMITATIONS Important Information: This policy provides vision care limited benefits health insurance only. It does not provide basic hospital, basic medical or major medical insurance as defined by the New York State Insurance Department. Coverage is limited to those charges that are necessary for a routine vision examination. Co-pays apply. The plan does not pay for: orthoptics or vision training and any associated supplemental testing; medical or surgical treatment of the eye; and eye examination or corrective eyewear required by an employer as a condition of employment; replacement of lenses and frames that are furnished under this plan, which are lost or broken (except at normal intervals when services are otherwise available or a warranty exists). The plan limits benefits for blended lenses, oversized lenses, photochromic lenses, tinted lenses, progressive multifocal lenses, coated or laminated lenses, a frame that exceeds plan allowance, cosmetic lenses; U-V protected lenses and optional cosmetic processes. The services, exclusions and limitations listed above do not constitute a contract and are a summary only. The Guardian plan documents are the final arbiter of coverage. Contract #GP-1-DAVIS-05-VIS et al. Laser Correction Surgery: Up to 25% off for vision laser surgery. Laser surgery is not an insured benefit. The surgery is available at a discounted fee. The covered person must pay the entire discounted fee. In addition, the laser surgery discount may not be available in all states. 13

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15 For Employees of CUI CU Employment, Inc ELIGIBILITY ALL ELIGIBLE FULL-TIME EMPLOYEES You must be actively at work and able to perform all normal duties of your job on the Eligibility Requirement effective date of coverage to be eligible. Minimum Work Hours You must be working a minimum of 30 hours per week to be eligible for coverage Coverage Payment You pay 100% of the premium for this coverage through easy payroll deduction. BENEFITS - FOR OFF THE JOB DISABILITES ONLY If you become disabled, there is an elimination period before benefits are payable. Your benefits begin: Benefits Begin On the 15th day of your disabling injury. On the 15th day of your disabling illness. Your benefit is equivalent to 60% of your before-tax weekly earnings, not to exceed the Weekly Benefit plan's maximum weekly benefit amount. Maximum Benefit Period Short-term disability benefits are available for up to 24 weeks. Maximum Weekly Benefit $1,500 DEFINITIONS Disability and disabled mean that because of an injury or illness, a significant change in your mental or functional abilities has occurred, for which you are prevented from Definition of Disability performing at least one of the material duties of your regular job and are unable to generate current earnings which exceed 99% of your weekly earnings from your regular job. You can be totally or partially disabled during the elimination period. Weekly earnings is the gross weekly income you receive from your employer which is Definition of Weekly Earnings used to determine your benefit in the event of a claim. Earnings may include commissions, bonuses, overtime, shift differential pay or other extra compensation. FEATURES You have the opportunity to enroll in this coverage on each anniversary date without Annual Open Enrollment providing Evidence of Insurability. Pre-existing Conditions Exclusion applies. If you become disabled and participate in the vocational rehabilitation program, which Vocational Rehabilitation offers services that help you return to work and ability, you will be eligible for a Benefit weekly benefit increase of 5%. The premium for your short-term disability coverage is waived while you are Waiver of Premium receiving benefits. Note: Additional information about the benefits and features of this plan will be included in the summary of coverage, which you will receive after enrolling, and in the certificate booklet, available from your employer. Please contact your employer if you have questions prior to enrolling. EXCLUSIONS Pre-existing Conditions Exclusion Other Exclusions Disabilities that occur during the first 6 months of coverage due to a pre-existing condition during the 3 months prior to coverage are excluded. If you currently participate in the disability plan, you have either satisfied the pre-existing limitation period or gained credit towards the pre-existing limitation period, depending on how long you have been in the plan. Information about other exclusions for this plan will be included in the certificate booklet, which is available from your employer. Please contact your employer if you have questions prior to enrolling. This information describes some of the features of the benefits plan. Benefits may not be available in all states. Please refer to the certificate booklet for a full explanation of the plan s benefits, exclusions, limitations and reductions. Should there be any discrepancy between the certificate booklet and this outline, the certificate booklet will prevail. Benefits availability is subject to final acceptance and approval of the group application by Mutual of Omaha. Short-term disability insurance is underwritten by Mutual of Omaha Insurance Company or United of Omaha Life Insurance Company. Mutual of Omaha Insurance Company is licensed in all 50 states. United of Omaha Life Insurance Company is licensed in all states but New York. In New York, Mutual of Omaha Insurance Company underwrites the plan. Policy Form Number7000GM-MU-EZ

16 For Employees of CUI CU Employment, Inc. ELIGIBILITY ALL ELIGIBLE Full-Time Employees You must be actively at work (able to perform all normal duties of your job) on the effective date of Eligibility Requirement coverage to be eligible. Minimum Work Hours You must be working a minimum of 30 hours per week to be eligible for coverage. Coverage Payment You pay 100% of the premium for this coverage through easy payroll deduction. BENEFITS FOR OFF THE JOB DISABILITIES ONLY If you become disabled, there is an elimination period before benefits are payable. Your benefits Benefits Begin (Elimination begin the later of 180 days after the onset of your disabling injury or illness or the date your sick pay Period) is exhausted. Your benefit is equivalent to 60% of your before-tax monthly earnings, not to exceed Monthly Benefit the plan's maximum monthly benefit amount less other income sources. If you become disabled prior to age 65, benefits are payable for five years. At age 65 Maximum Benefit Period through 68, benefits are payable to age 70 for at least one year. At age 69 (and older), benefits are payable for one year. Maximum Monthly Benefit $6,000 DEFINITIONS Definition of Disability Definition of Monthly Earnings FEATURES Partial Disability Benefits Vocational Rehabilitation Incentive Survivor Benefit Waiver of Premium Evidence of Insurability EXCLUSIONS Pre-existing Conditions Exclusion Other Exclusions Disability and disabled mean that because of an injury or illness, a significant change in your mental or functional abilities has occurred, for which you are: Prevented from performing at least one of the material duties of your regular occupation during the first 2 years of disability and after 2 years are unable to perform all of the material duties of any gainful occupation; and During the first 2 years of disability are unable to generate current earnings which exceed 99% of your monthly earnings from your regular occupation, and after 2 years are unable to generate current earnings which exceed 85% of your monthly earnings from any gainful occupation. You can be totally or partially disabled during the elimination period. Monthly earnings is the gross monthly income you receive from your employer which is used to determine your benefit in the event of a claim. Earnings may include commissions, bonuses, overtime, shift differential pay or other extra compensation. If you become disabled and can work part-time (but not full-time), you may be eligible for partial disability benefits, which will help supplement your income until you are able to return to work fulltime. If you become disabled and participate in the vocational rehabilitation program, which offers services that help you return to work and ability, you will be eligible for a monthly benefit increase of 5%. If you pass away while receiving long-term disability benefits, your benefits will be provided to your beneficiaries for a period of time after your death. The premium for your long-term disability coverage is waived while you are receiving benefits. There will be no Evidence of Insurability required for timely enrollees during the initial open enrollment period. At future enrollments, Evidence of Insurability will be required. Disabilities that occur during the first 12 months of coverage due to a pre-existing condition are excluded. A pre-existing condition means any injury or sickness for which you have received medical treatment, advice or consultation, care or services, or had drugs or medicines prescribed or taken in the 12 months prior to the day you become insured under the policy. Information about other exclusions for this plan will be included in the certificate booklet, available from your employer. Please contact your employer if you have questions prior to enrolling. Note: Additional information about the benefits and features of this plan will be included in the summary of coverage, which you will receive after enrolling, and in the certificate booklet, available from your employer. Please contact your employer if you have questions prior to enrolling. 16

17 For Employees of CUI CU Employment, Inc ELIGIBILITY : ALL ELIGIBLE FULL-TIME EMPLOYEES Employee Eligibility Requirement Dependent Eligibility Requirement Minimum Work Hours Coverage Payment You must be actively at work (able to perform all normal duties of your job) to be eligible for coverage. To be eligible for coverage, your dependents must be able to perform normal activities and not be confined (at home, in a hospital, or in any other care facility). You must be working a minimum of 30 hours per week to be eligible for coverage. You pay 100% of the premium for this coverage through easy payroll deduction. COVERAGE GUIDELINES Employee Spouse Child(ren) Minimum $10,000 $5,000 $10,000 Maximum 10 times annual salary, 100% of employee s benefit, 100% of employee s benefit, up to $150,000 up to $50,000 up to $10,000 Guarantee Issue Amount 10 times annual salary, up to $150, % of employee s benefit, up to $50, % of employee s benefit, up to $10,000 Note: Securing coverage up to the Guarantee Issue Amount assumes a participation requirement is met by your group (you and your fellow employees). Coverage amounts over the Guarantee Issue Amount will require a health application/evidence of insurability. BENEFITS Life Insurance Benefit Amount FEATURES Living Care/Accelerated Death Benefit Waiver of Premium Annual Benefit Amount Increase Portability Conversion Within the coverage guidelines defined above, you select the amount of life insurance coverage you want. This plan includes the option to select coverage for your spouse and dependent child(ren). Children include those 14 days old, up to age 26. Note: In the event of death, the benefit paid will equal the benefit amount after any age reductions less any living care/accelerated death benefits previously paid under this plan. 75% of the amount of the life insurance benefit is available to you if terminally ill, not to exceed $500,000. If it is determined that you are totally disabled, your life insurance benefit will continue without payment of premium, subject to certain conditions. If you enroll for even the minimum amount of coverage during your initial enrollment, you have the ability to increase coverage up to the Guarantee Issue Amount during future annual enrollments. This feature allows you to secure additional life insurance protection in the event your needs change (ex. you get married or have a child). The portability feature allows you to continue this insurance program for yourself and your dependents should you leave your employer for any reason, without having to provide evidence of insurability (information about your health). If your employment ends, you may apply for an individual life insurance policy from Mutual of Omaha without having to provide evidence of insurability (information about your health). You will be responsible for the premium for the coverage. Note: Additional information about the benefits and features of this plan will be included in the summary of coverage, which is available on the Employee Benefits Center and in the certificate booklet. AGE REDUCTIONS AND LIFE INSURANCE EXCLUSIONS Your life insurance benefits are not subject to any age reductions. Coverage terminates at the end of the month in which you are no longer eligible for coverage. Life insurance benefits will not be paid if the insured s death is the result of suicide within two years from the date of issue (the date coverage begins) of this coverage. If this occurs, the sum of the premiums paid will be returned to the beneficiary. The same applies for any future increases in coverage under this plan. This information describes some of the features of the benefits plan. Benefits may not be available in all states. Please refer to the certificate booklet for a full explanation of the plan s benefits, exclusions, limitations and reductions. Should there be any discrepancy between the certificate booklet and this outline, the certificate booklet will prevail. Benefits availability is subject to final acceptance and approval of the group application by Mutual of Omaha. Term life insurance is underwritten by United of Omaha Life Insurance Company, Mutual of Omaha Plaza, Omaha, Nebraska United of Omaha Life Insurance Company is licensed in every state except New York. Term Life Policy Form Number 7000GM-C-EZ

18 Colonial Life Voluntary Benefits Group Accident Insurance Accidents can happen anytime, anywhere. Accidents are usually followed by a series of bills. Even if you have good insurance, you may still have to cover out-of-pocket costs, such as: Doctor bills Ambulance fees Hospital expenses Accident insurance from Colonial Life & Accident Insurance Company can help protect you, your spouse and your dependent children from the unexpected expenses of an accident. Features of Colonial Life s Accident Insurance: You are paid benefits to help you with the care and treatment of a covered accidental injury. Your benefits are paid directly to you (unless you specify otherwise). You are paid benefits regardless of any other insurance you may have with other insurance companies. You can take your coverage with you if you change jobs or retire. Coverage is subject to policy exclusions and limitations that may affect benefits payable. Products may vary by state and may not be available in all states. For cost and complete details, see a Colonial Life benefits counselor. 18

19 Colonial Life Voluntary Benefits Group Cancer Insurance How will you pay for what your health insurance won t? If diagnosed with cancer, would you have the money to cover: Out-of-network treatments Experimental treatments Rehabilitation Travel and lodging Child care expenses Cancer insurance from Colonial Life & Accident Insurance Company helps guard against financial hardship if you or a loved one is diagnosed with cancer. Features of Colonial Life s Cancer Insurance: Helps pay some of the direct and indirect costs related to cancer diagnosis and treatment. Helps pay for expenses health insurance may not cover, such as s and coinsurance. Pays an annual benefit for specified cancer screening tests. Coverage is subject to policy exclusions and limitations that may affect benefits payable. Products may vary by state and may not be available in all states. For cost and complete details, see a Colonial Life benefits counselor. 19

20 Group Hospital Confinement Indemnity Insurance You may have health insurance, but are you really covered? Health insurance may cover: Hospital fees Outpatient surgery Doctor/ER visits Prescriptions It may not cover: Deductibles Co-payments Coinsurance Group hospital confinement indemnity insurance from Colonial Life & Accident Insurance Company helps provide a lump-sum benefit for a covered hospital confinement and a covered outpatient surgery to assist with costs that your medical plan may not cover. It pays one hospital confinement benefit per covered person per year. Features of Colonial Life s Group Hospital Confinement Indemnity Insurance: Benefits are paid directly to you, unless you specify otherwise. Benefits are paid regardless of any other insurance you may have with other insurance companies. Coverage is available for you, your spouse and your dependent children. Coverage is subject to policy exclusions and limitations that may affect benefits payable. Products may vary by state and may not be available in all states. For cost and complete details, see a Colonial Life benefits counselor. 20

21 CUI Employee Benefit Package JUNE 1, 2015 MAY 31, 2016 BI-WEEKLY PAYROLL DEDUCTED RATES BLUE CROSS/BLUE SHIELD MAJOR MEDICAL (Buy-up Plan) Single - $72.42 Family - $ BLUE CROSS/BLUE SHIELD MAJOR MEDICAL (Base Plan) Single - $42.46 Family - $ BLUE CROSS/BLUE SHIELD (DENTEMAX) DENTAL PLAN Single - $7.70 Family - $19.80 GUARDIAN VISION (DAVIS VISION NETWORK) VISION PLAN Single - $3.77 Family - $8.10 MUTUAL OF OMAHA SHORT TERM & LONG TERM DISABILIY PLANS Benefit and rate is based on your income. Speak with Carla Burwell for details MUTUAL OF OMAHA VOLUNTARY TERM LIFE (EMPLOYEE/SPOUSE/CHILD) Rates are based on employee age. Speak with Carla Burwell for details COLONIAL GROUP MEDICAL BRIDGE (HOSPITAL INDEMNITY) Rates are based on employee age. Speak with Carla Burwell for details COLONIAL GROUP ACCIDENT INSURANCE Single $6.55 Employee/Spouse $10.60 One Parent Family - $11.86 Family - $15.91 COLONIAL GROUP CANCER INSURANCE LEVEL 2 LEVEL 3 Single - $7.36 Single - $10.41 Family - $12.28 Family - $17.31 *Rates are illustrative and subject to change at any time. All final rates must be confirmed and approved by making a telephone appointment and speaking with your dedicated employee benefit specialist Carla Burwell ( ). 21

22 Contact your dedicated benefits specialist if you have questions regarding all your benefit needs: Carla Burwell ColonialLife.com 2015 Colonial Life & Accident Insurance Company, Columbia, SC Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand NS