Basic Life and Accidental Death & Dismemberment (AD&D) Insurance
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1 Basic Life and Accidental Death & Dismemberment (AD&D) Insurance USC recognizes the importance of life insurance for employees at all ages and stages in life, by automatically providing Basic Life and AD&D Insurance of 2X your basic annual earnings rounded to the next highest multiple of $1,000 up to $500,000 at no cost to you. Life Insurance pays benefits upon your death. AD&D Insurance provides you with additional financial protection if your death is accidental. AD&D Insurance also pays benefits if you are severely injured and suffer a loss such as the loss of a limb or eyesight. USC pays the premiums for Basic Life and AD&D Insurance. The Hartford Life and Accident Insurance Company AGE REDUCTIONS Basic Life and AD&D Insurance will decrease to a 65% benefit at age 65 and a 50% benefit at age 70. EVIDENCE OF INSURABILITY (EOI) RULES There is no Evidence of Insurability for employer-provided Basic Life and AD&D Insurance. USC pays 100% of the premium for Basic Life and AD&D insurance. OTHER THINGS TO KNOW Imputed Income - The IRS requires that USC tax you on the value of Company-paid Employee Basic Life Insurance coverage over $50,000. If you leave USC, you may be eligible to convert your basic coverage, by submitting an application and paying premiums directly to the insurance company, provided you contact the insurance company within 31 days of termination. Always remember to keep your beneficiary designation(s) up-to-date.
2 Supplemental Life and Accidental Death & Dismemberment (AD&D) Insurance AGE REDUCTIONS Supplemental Life and AD&D Insurance will decrease to a 65% benefit at age 65 and a 50% benefit at age 70. In addition to your Basic Life and AD&D Insurance, you can purchase Supplemental Life and AD&D Insurance to increase your own coverage and buy coverage for your spouse/ registered domestic partner (RDP) and/or child(ren). You must purchase Employee Supplemental Life insurance in order to purchase coverage for your eligible dependents (spouse or registered domestic partner and/or child(ren)). The spouse or Registered Domestic Partner of a covered employee Child(ren) of a covered employee, who are at least 15 days old but less than 26 years old The Hartford Life and Accident Insurance Company EMPLOYEE SUPPLEMENTAL LIFE AND AD&D INSURANCE You may purchase Employee Supplemental Life and AD&D Insurance from $10,000 to $300,000 in $10,000 increments, up to a maximum of $300,000 (or 5X basic annual earnings, whichever is less). SPOUSE OR REGISTERED DOMESTIC PARTNER SUPPLEMENTAL LIFE AND AD&D INSURANCE You may purchase Spouse or RDP Supplemental Life and AD&D Insurance from $5,000 to $150,000 in $5,000 increments, up to a maximum of $150,000 (the amount of Spouse or RDP Supplemental coverage may never exceed 50% of the Supplemental Amount of Life Insurance in force for the employee). CHILD SUPPLEMENTAL LIFE AND AD&D INSURANCE You may purchase Child Supplemental Life and AD&D Insurance, as follows: EVIDENCE OF INSURABILITY (EOI) RULES If you enroll within 31 days of first being eligible, EOI is only required for amounts above: Employee $100,000 Spouse/RDP $30,000 Child(ren) Not required If you enroll for Supplemental Life and AD&D Insurance greater than 31 after you are first eligible, or increase coverage at a later date, EOI will be required for all amounts of coverage. You pay 100% of the premium for Supplemental Life and AD&D insurance. Rate per $1,000 of Coverage Employee Age Employee/Spouse or RDP Child < and > Child(ren) Age Less than 15 days 15 days but less than 6 6 but less than 26 years Coverage No Coverage $1,000 increments of $1,000, subject to a minimum of $1,000 and a maximum of $20,000 To calculate your monthly cost, take the coverage amount divided by 1,000 and multiply by the rate per $1,000 of coverage based on the employee' age. Example: Assume you are 33 years old and want to purchase $100,000 of life insurance coverage for yourself. Your monthly cost is: ($100,000 1,000) X $.059 = $5.90
3 Long Term Disability (LTD) and Short Term Disability (STD) Insurance Short-term disability insurance (STD) provides a source of income should you experience a short-term illness or injury that prevents you from working. Long-term disability insurance (LTD) provides a source of income should you experience a long-term illness or injury that prevents you from working. The Hartford Life and Accident Insurance Company DEFINITION OF DISABILITY You are disabled when the insurance company determines that you are limited from performing or unable to perform the material and substantial duties of your regular occupation due to your sickness or injury. For LTD, after 24 of payments, you are considered to be continuously disabled when the insurance carrier determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience. HOW IT WORKS Short Term Disability Insurance (STD) If you become disabled and your claim for disability is approved, the plan pays a weekly benefit equal to 60% of your pre-disability base pay up to a maximum weekly benefit of $2,500 (combined with income from all other sources, including Social Security, workers compensation, any State Disability, sick leave, pension benefits). Benefits begin on the 15 th consecutive day of Total Disability, up to a maximum duration of 11 weeks. Long Term Disability Insurance (LTD) EVIDENCE OF INSURABILITY (EOI) RULES FOR LTD and STD There is no Evidence of Insurability for employer-provided Short Term or Long Term Disability Insurance. USC pays 100% of the premium for both Short and Long Term Disability insurance. LTD provides a monthly benefit after you have been totally disabled for 90 days. Benefits continue while you are totally disabled or until you reach the maximum benefit period based on your age at the time of disability. The monthly benefit amount, when combined with income from all other sources (including Social Security, workers compensation, any State Disability, sick leave, pension benefits) will equal 60% of your pre-disability base pay up to a maximum monthly benefit of $13,000. For both STD and LTD, you must provide proof of continued disability on a regular basis to continue to receive benefits. All disability payments you receive are considered taxable income in the year payments are received.
4 Medical / Rx Insurance Anthem Blue Cross Blue Shield NV BlueSecure The Medical Plan provides comprehensive medical and prescription drug coverage. The plan is considered a preferred provider organization plan (a PPO ), which takes advantage of network providers that have negotiated lower rates with the plan s PPO network. The plan offers different benefits depending on if you choose an in-network provider or out-of-network provider when you seek care. For non-participating providers, you must pay the difference between the maximum allowed amount and the non-participating provider s billed charges, unless noted otherwise. Charges in excess of the maximum allowed amount do not count toward the satisfaction of the deductible. Please see the section of your certificate entitled About Your Health Coverage for details about cost sharing requirements. USC pays 100% of the cost of Employee-Only coverage. If you elect to cover your eligible dependent(s), you will pay $100 per month. Eligible dependents include your Spouse or Registered Domestic Partner (RDP) and children under age 26 Anthem Blue Cross Blue Shield (NV) SPECIAL NOTE When you enroll for medical insurance, you (and any covered dependents) will automatically be enrolled in the Anthem Blue Cross Blue Shield Prime Dental and BlueView Vision coverage. Benefits Anthem Blue Cross Blue Shield of Nevada BlueSecure PPO Providers Non-Network Providers Calendar Year Deductibles Each Individual / Family Maximum $250 / $750 $500 / $1,500 One member may not contribute any more than the individual deductible toward the family deductible. Out-of-Pocket Annual Maximum Each Individual / Family Maximum $2,250 / $4,750 $4,500 / $9,500 One member may not contribute any more than the individual out-of-pocket annual maximum toward the family out-of-pocket annual maximum. Lifetime Maximum Benefit No Lifetime Maximum Physician Office Visits PCP $15 copay ($200 for the 1st prenatal care visit) 60% coinsurance after deductible Specialist $30 copay 60% coinsurance after deductible - Preventive Care 100% 60% coinsurance after deductible - Well Baby Visits 100% 60% coinsurance after deductible Urgent Care Centers $30 copay 60% coinsurance after deductible Emergency Care (waived if admitted) 90% coinsurance after $200 copay per visit 90% coinsurance after $200 copay per visit Ambulance 90% after deductible Diagnostic X-Ray / Laboratory 90% coinsurance after deductible 60% coinsurance after deductible Inpatient Hospital Services All hospital admissions are subject to the Prior Authorization Program - Facility 90% coinsurance after deductible 60% coinsurance after deductible - Surgery/doctor visits 90% coinsurance after deductible 60% coinsurance after deductible Skilled nursing facility All SNF admissions are subject to the Prior Authorization Program / 100 Day/Yr. Limit 90% coinsurance after deductible 60% coinsurance after deductible Ambulatory Surgery (facility/physician) 90% coinsurance after deductible 60% coinsurance after deductible Durable Medical Equipment 90% coinsurance after deductible 60% coinsurance after deductible Behavioral Health / Substance Use - Inpatient - Facility 90% coinsurance after deductible 60% of UCR, after deductible - Inpatient - Physician 90% coinsurance after deductible 60% of UCR, after deductible - Outpatient - Facility 90% coinsurance after deductible 60% of UCR, after deductible - Outpatient - Professional $15 60% of UCR, after deductible Prescription Drugs - generic $5 copay 50% - brand / no generic $45 copay 50% - brand / generic available $75 copay 50% - specialty drug 30% up to $500 copay 30% up to $1,000 copay
5 Dental Insurance Anthem Blue Cross Blue Shield NV Prime For the many things in life worth smiling about, network dentists have agreed to provide services at discounted or negotiated fees. This means savings for you by getting the most out of your annual benefit at the lowest out-ofpocket costs. You are not responsible for any charges that exceed the negotiated fee. You have the flexibility to visit any dentist. However, for most covered services you will pay less out-of-pocket if you use an Anthem Prime network dentist. Eligible dependents include your Spouse or Registered Domestic Partner (RDP) and children under age 26 Anthem Blue Cross Blue Shield (NV) SPECIAL NOTE When you enroll for medical insurance, you (and any covered dependents) will automatically be enrolled in the Anthem Blue Cross Blue Shield Prime Dental and BlueView Vision coverage. USC pays 100% of the cost of Dental coverage. Benefits In-Network Out-of-Network CALENDAR YEAR DEDUCTIBLES Per Individual Per Family Waived For Preventive $50 Yes $150 CALENDAR YEAR MAXIMUM $1,500/person $1,000/person PREVENTIVE & DIAGNOSTIC 100%, no deductible 80%, no deductible BASIC SERVICES Routine Extractions Fillings Root Canal Therapy Osseous Surgery Oral Surgery MAJOR SERVICES Crowns Bridges Dentures ORTHODONTIA Lifetime Maximum 80%, after deductible 60%, after deductible 50%, after deductible 50%, after deductible 50%, no deductible $1,500
6 Vision Insurance Anthem Blue Cross Blue Shield NV BlueView To help keep your life in focus, USC provides vision benefits are through Anthem s BlueView Vision program. USC pays 100% of the cost of vision coverage. Eligible dependents include your Spouse or Registered Domestic Partner (RDP) and children under age 26 Anthem Blue Cross Blue Shield (NV) SPECIAL NOTE When you enroll for medical insurance, you (and any covered dependents) will automatically be enrolled in the Anthem Blue Cross Blue Shield Prime Dental and BlueView Vision coverage. Benefits Frequency In-Network Out-of-Network Well Vision Exam $10 copay Up to $35 Frames Up to $130 Up to $45 Lenses - Single Vision - Lined Bifocal - Lined Trifocal - Lenticular $10 copay $10 copay $10 copay Refer to Benefit Schedule Up to $25 Up to $40 Up to $55 Refer to Benefit Schedule Contacts (in lieu of glasses) Medically Necessary: $10 copay Elective: Up to $130 Medically Necessary: Up to $210 Elective: Up to $80
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