PACIFIC WESTERN TECHNOLOGIES, LTD. your employee benefits at a glance 2011
Eligibility If you are an employee working 32 hours a week or more, you are eligible for all benefits outlined in this summary. For Medical, Dental, and Vision eligible employees may elect to cover a spouse and/ or children who are under 26 years of age. Medical, dental and vision benefits are effective on your date of hire. Calendar Year Deductible: Employee Coinsurance: Calendar Year Out-of-Pocket Max: (Deductible included) HUMANA Humana National POS 10 Copay 80/50 Medical Plan Effective: 1/1/2011-12/31/2011 In Network Out-of-Network $1,000 Single $3,000 Family 80% After deductible $4,000 Single $12,000 Family $3,000 Single $9,000 Family 50% After deductible of UCR $12,000 Single $36,000 Family Physician Office Visit: $25 Copay Medical Pacific Western Technologies' medical plan utilizes the Humana National POS- Open Access network of doctors and hos- Specialist Office Visit: Inpatient Hospital: Outpatient Hospital: $55 Copay 80% after Deductible 50% After deductible of UCR pitals who have agreed to provide services at discounted rates. If you use the network, you will receive the highest level of benefits offered by the plan at the lowest cost to you. However, you are not required to use the network. You always have the complete freedom to select any provider whenever you need care. The non-network benefits are lower and your out-of-pocket costs are higher. Once enrolled, you may you may use the directory at the back of this brochure to look up Humana s website to access claims payment information, physician directories, ID cards, and to inquire about eligibility. The charts are designed to help you understand and compare your medical benefit options. Emergency Room: $250 Copay $250 Copay Urgent Care: PRESCRIPTIONS $75 Copay Level 1: $10 Copay $10 Copay Level 2 : $40 Copay $40 Copay Level 3 : $70 Copay $70 Copay Level 4: Lifetime Maximum Benefit: 25% Copay to an Annual Max of $2,500 Unlimited Per Month 50% After deductible of UCR 30% after copayment of: 25% Copay to an Annual Max of $2,500 CONTRIBUTIONS w/ Wellness With Dental Low Plan With Dental High Plan Employee Only: $109.00 $118.73 Employee + Spouse: $422.00 $450.65 Employee + Child(ren): $310.00 $332.18 Family: $536.00 $567.51 CONTRIBUTIONS w/out Wellness With Dental Low Plan With Dental High Plan Employee Only: $130.00 $139.73 Employee + Spouse: $443.00 $461.68 Employee + Child(ren): $331.00 $353.18 Family: $557.00 $588.51
Calendar Year Deductible: Calendar Year Max Benefit: Preventive Care: Basic Services: Major Services: HUMANA High Dental Plan HUMANA Low Dental Plan Effective: 1/1/2011-12/31/2011 1/1/2010-12/31/2011 In Network Out-of-Network In Network Out-of-Network $50 Single $150 Family $50 Single $150 Family $50 Single $150 Family $100 Single $300 Family $2,000 per member $2,000 per member $2,000 per member $2,000 per member 100% deductible waived 100% after deductible 60% after deductible 100% of allowed amount, deductible waived 80% of allowed amount after deductible 50% of allowed amount after deductible 100% deductible waived 90% after deductible 60% after deductible 80% of allowed amount, deductible waived 50% of allowed amount after deductible 30% of allowed amount after deductible Orthodontic Treatment: Not covered Not covered Not covered Not covered CONTRIBUTIONS Per Month (Stand Alone) Per Month (Stand Alone) Employee Only: $ 15.24 $ 5.51 Employee + Spouse: $ 52.13 $ 29.95 Employee + Child(ren): $ 46.53 $ 27.85 Family: $ 89.29 $ 57.78 Humana Vision Care Plan Effective: 1/1/2011-12/31/2011 In Network Out-of-Network Exam: $15 Copay Up to $35 Lenses (Materials): Frames: Single - $20 Copay Bifocal - $20 Copay Trifocal - $20 Copay Single - Up to $25 Bifocal - Up to $40 Trifocal - Up to $60 Contacts (Elective): $150 Allowance Up to $150 Frequency: CONTRIBUTIONS Employee Only: Employee + Spouse: Employee + Child(ren): Family: Up to $50 Wholesale Frame allowance (Equal to $100-$150 Retail) Up to $40 Exam - Once every 12 Months Frames - Once every 24 Months Contacts - Once every 12 months Included with Medical Included with Medical Included with Medical Included with Medical Dental Staying healthy includes obtaining quality dental care for you and your family. Pacific Western Technologies dental plans allow you to use an extensive network of providers and offers flexibility based upon where you choose to access care. You are covered at the highest level if you select dental care through this network, but have the option to obtain care outside the network at a higher cost to you. Once enrolled, you may use the directory at the back of this brochure to look up Humana s website to inquire about additional information. Vision Pacific Western Technologies offers vision coverage in order to help you pay for your routine vision services and supplies. You can elect vision coverage for yourself and your eligible dependents. You can see any vision provider you choose, but you will enjoy significant savings when you use Humana contracted providers. You may use the directory at the back of this brochure to find more information.
Voluntary Life Insurance Life insurance is an important part of your financial well-being, especially if others depend on you for support. Through Pacific Western Technologies voluntary life benefit, you can purchase Life and AD&D coverage for yourself and your dependents. The table provides a summary of the coverage available. If you choose to apply for Voluntary Life insurance coverage (or increase your original amount) during a subsequent enrollment period, you and your dependents will be subject to medical underwriting. See SunLife packet for cost and benefit details. Employee Spouse Insurance Schedules: $10,000 Increments $5,000 Increments Dependent Child $10,000 per child up to age 19 or 25 if a fulltime student Non Medical Maximum: $50,000 up to age 60 $10,000 up to age 60 $10,000 Overall Benefit Maximum: $300,000 (not to exceed 5x annual earnings, minimum of $20,000) Sun Life Voluntary Life and AD&D $100,000 (not to exceed 50% of employee benefit amount, minimum of $10,000) $10,000 Short Term Disability Pacific Western Technologies offers a Voluntary Short Term Disability benefit in case you are unable to perform your job due to an illness or injury unrelated to your work. You will begin receiving this benefit after the waiting period and you will only receive the benefit while you are unable to perform your job or until the benefit duration has expired. As long as you remain disabled and meet the plan s disability requirements, you will continue to receive a percentage of your earnings. See SunLife packet for cost and benefit details. STD Benefit Amount: STD Benefit Begin: STD Benefit Duration: STD Maximum Weekly Benefit: Sun Life Short Term Disability 60% of your weekly earnings 1st day for accidents 8th day for sickness 13 weeks $1,500 per week
Long Term Disability If you are unable to perform your job for a continuous 90 day period due to illness or injury, your LTD benefit will take effect. LTD benefits are subject to pre-existing condition limits, and benefits are reduced if the disability begins after age 60. See SunLife packet for cost and benefit details. Sun Life Long Term Disability LTD Benefit Amount: 60% of monthly salary LTD Maximum Monthly Benefit: $5,000 LTD Benefit Waiting Period: 90 days LTD Benefit Duration: Social Security Normal Retirement Age
Change in Family Status All benefit selections are binding except in the event you have a change in family status. If one of these situations occurs, you have 30 days to notify the group administrator and complete the appropriate paperwork. If you do not make the change within the 30 days following the event, your next opportunity to make a change will occur during the plan s open enrollment period. Examples of status changes include: Flexible Spending Account (FSA) Flexible Spending Accounts (FSAs) allow you to set aside pre-tax dollars from each paycheck to pay for out-of-pocket healthcare and dependent care expenses. Each year, you can contribute up to $5,000.00. Then, you draw on your contributions throughout the year to pay for eligible expenses. You don t pay federal taxes on your FSA contributions or reimbursements. In many cases, that means a savings of 10% to 35%! Dependent Care expenses can also be paid through a Flexible Benefits Dependent Care Account. Each year you can elect to redirect up to $2,500 if you are married filing a separate return or up to $5,000 if you are single or married filing a joint return. This benefit is administered through Rocky Mountain Reserve. Marriage or divorce Birth or death of dependent Adoption Loss of eligibility for insurance Spouse s employment or termination of employment Unpaid leave of absence of employee or spouse Reduction or Increase in hours worked from part time to full time Change in residence that affects eligibility
Women s Health and Cancer Rights Act of 1998 In October 1998, Congress enacted the Women s Health and Cancer Rights Act of 1998. This notice explains some important provisions of the Act. Please review this information carefully. As specified in the Women s Health and cancer Rights Act, a plan participant or beneficiary who elects breast reconstruction in connection with a mastectomy is also entitled to the following benefits: Reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; and Prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas. Health plans must determine the manner of coverage in consultation with the attending physician and the patient. Coverage for breast reconstruction and related services may be subject to deductibles and coinsurance amounts that are consistent with those that apply to other benefits under this plan. HIPAA (Health Insurance Portability and Accountability Act of 1996) HIPAA legislation provides rules that govern group health plans. One of the primary goals in passing HIPAA was to ensure that employees who have a medical condition could leave or change employment without losing their much needed health insurance. HIPAA includes provisions that set limitations on the use of preexisting condition provisions. HIPAA requires that all group health plans reduce the period of the preexisting condition exclusion by an individual s creditable coverage under a previous group health plan or individual health insurance. Employers and health insurance carriers are responsible for providing each covered individual with a certificate of Creditable Coverage upon termination of coverage. This HIPAA certificate is the document of creditable coverage for future group health insurance. Enrollment rights are also governed by HIPAA. An individual that originally waives coverage at the initial offering and later wants to join the plan will fall into one of the categories below: Special Enrollment rights Special Enrollee must enroll within 30 days of an event listed below (normal preexisting condition limits apply) Marriage Divorce Birth Adoption Loss of coverage elsewhere Late Enrollee (an additional 6 month late entrant penalty could apply in addition to preexisting condition limits) These notices are a summary only and not to be interpreted as legal advice.
Directory For Questions About Contact Phone # Web Medical Benefits HUMANA 866-427-7478 www.humana.com Dental HUMANA 800-233-4013 www.humana.com Vision HUMANA 866-537-0229 www.humana.com Voluntary Life Sun Life 800-451-2513 www.sunlife.com Short Term Disability Sun Life 800-451-2513 www.sunlife.com Long Term Disability Sun Life 800-451-2513 www.sunlife.com Flexible Spending Accounts Rocky Mountain Reserve 888-722-1223 www.rockymountainreserve.com Human Resources Ginnie Nelson, HR Administrator 303-274-5400 x 10 gnelson@pwt.com Human Resources Susan Deffert, Director of Administration 303-274-5400 x 17 sdeffert@pwt.com All of the Above Kimber Jones, Account Manager 720-207-2335 Kimber.Jones@hubinternational.com All of the Above Lee Littlejohn, Client Manager 720-207-2336 Lee.Littlejohn@hubinternational.com HUB International 1125 17th Street, Suite 900 Denver, CO 80202 Telephone (303) 893-0300 Fax (866) 243-0727 http://www.hubinternational.com Your Employee Benefits...at a Glance was created by: About This Brochure This is a custom brochure that provides only a highlight of the plans offered to you by your employer and in no way serves as the actual plan description or plan document for the plans. The plan documents will always govern the offered benefits that your employer provides for you. We reserve the right to modify any or all of these plans at anytime.