YOUR BENEFITS GUIDE Benefit plans effective January 1, 2017, through December 31, 2017.
The Oakley Transport Benefits Package Benefits are an integral part of the overall compensation package provided by Oakley Transport. Within this Benefits Guide you will find important information on the benefits available to you for the 2017 plan year (January 1, 2017, through December 31, 2017). Please take a moment to review the benefits Oakley Transport offers to determine which plans are best for you. This guide contains only general and summary information; it should not be considered a replacement for the more detailed information set forth in certificates of coverage or master plan documents produced by each insurance company. Every care is taken to assure the accuracy of this guide; however, in the event of any conflict between this guide and information produced by each insurance company, the insurance company s documents will be the final authority. Table of Contents How Benefits Work Benefits Eligibility...3 Enrollment...3 How to Enroll...3 Changing Your Benefits During the Year...3 Health Plans Medical Insurance... 4 Dental Insurance...7 Vision Insurance...8 Other Benefit Plans Health Savings Account...6 Life and AD&D Insurance...9 Voluntary Short- and Long-Term Disability Insurance...10 Accident Insurance...11 Critical Illness Insurance...11 Legal Plan...11 Additional Information Important Contact Information...12 2
Your Benefits Overview Benefits Eligibility If you are scheduled to work at least 30 hours per week you are eligible for benefits on the first day of the month following 60 days of employment. All coverages end on your last day of employment. Many of the plans offer coverage for eligible dependents, including: Your legal spouse. Your dependent children of any age who are physically or mentally unable to care for themselves. Your children to age 26, regardless of student, marital, or tax-dependent status (including a stepchild, legally-adopted child, a child placed with you for adoption, or a child for whom you are the legal guardian). Enrollment You can sign up for benefits or change your benefit elections at the following times: Within 30 days of your initial eligibility date (as a newly-hired employee). During the annual benefits open enrollment period. Within 30 days of experiencing a qualifying life event. The choices you make at this time will remain the same through December 31, 2017. If you do not sign up for benefits during your initial eligibility period or during the open enrollment period, you will not be able to elect coverage until the following plan year. How to Enroll Access the Explain My Benefits (EMB) Portal: 1. Go to www.explainmybenefits.biz/oakley. 2. Click the red box: Enroll in Your 2017 Open Enrollment. 3. Enter Explain My Benefits to review current elections, learn about your benefit options, and make any elections or changes. 4. You may also update your life insurance beneficiary designation(s). 5. You have the option to print out your enrollment summary statement containing all your benefit elections for you and your family including your life insurance beneficiary designations. 6. If you have questions or need assistance with your enrollment, call the EMB Enrollment Call Center at 407-574-7889, available Monday through Friday from 9:00 a.m. to 5:00 p.m. EST. During your enrollment session you must verify your tobacco/nicotine usage status for the previous six months. Verification with the EMB benefit counselors will be recorded, and you may be subject to disciplinary action if you knowingly and willfully make a false or fraudulent statement or representation to Oakley regarding the information reported. Proof of non-tobacco/nicotine use must be provided upon request. Oakley provides the American Cancer Society Quit For Life Program at no cost to our employees. If you have other insurance coverage, please be prepared to provide information including social security numbers for yourself and your dependents, spouse employer, carrier, effective date, policy number, and telephone number of other insurance carrier. Changing Your Benefits During the Year Oakley Transport allows you to pay your portion of the medical, dental, and vision plan costs on a pre-tax basis. Thus, due to IRS regulations, once you have made your elections for the plan year, you cannot change your benefits until the next annual open enrollment period. The only exception is if you experience a qualifying life event. Election changes must be consistent with your life event. To request a benefits change, notify Human Resources within 30 days of the qualifying life event. Change requests submitted after 30 days cannot be accepted. Qualifying life events include, but are not limited to: Marriage, divorce, or legal separation. Birth or adoption of an eligible child. Death of your spouse or covered child. Change in your spouse s work status that affects his or her benefits. Change in your child s eligibility for benefits. Qualified Medical Child Support Order. 3
Medical Insurance Plans Oakley Transport offers three medical plan options through Aetna. The plans offer in- and out-of-network benefits, providing you the freedom to choose any provider. However, you will pay less out of your pocket when you choose a network provider. Locate an Aetna network provider at www.aetna.com. The table below summarizes the key features of the medical plans. The coinsurance amounts listed reflect the amount you pay. Please refer to the official plan documents for additional information on coverage and exclusions. Base Plan Preferred Plan High Plan In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Plan Year Deductible Individual/Family $4,500/$9,000 $13,500/$27,000 $2,600/$5,200 $6,850/$13,700 $1,750/$3,500 $4,500/$9,000 Out-of-Pocket Max (includes deductible, copays, and coinsurance) Individual/Family $6,550/$13,100 $19,500/$39,000 $5,000/$10,000 $15,000/$30,000 $3,250/$6,500 $9,000/$18,000 Preventive Care Plan pays 100% Plan pays 100% Plan pays 100% Physician Services Primary Care Physician Specialist Urgent Care Lab/X-Ray Diagnostic Lab/X-Ray High-Tech Services (MRI, CT, PET) Hospital Services Inpatient Outpatient $20 copay $40 copay $50 copay Plan pays 100% Emergency Room $200 copay $200 copay Prescription Drugs Generic Preferred Brand Non-Preferred Brand Specialty Mail Order (up to 90-day supply) After ded.: $20 copay $40 copay $70 copay 30% up to $250 2x retail copay 30% of submitted cost after applicable copay Not covered After ded.: $20 copay $40 copay $70 copay 30% up to $250 2x retail copay 30% of submitted cost after applicable copay Not covered $10 copay $30 copay $50 copay 30% up to $250 2x retail copay 30% of submitted cost after applicable copay Not covered Medical Plan Costs Listed below are the weekly costs for medical insurance. The amount you pay for coverage is deducted from your paycheck on a pre-tax basis. 4 Medical Insurance Base Plan Preferred Plan High Plan Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Employee Only $14.54 $26.08 $34.85 $46.38 $59.55 $71.09 Employee + Spouse $67.62 $79.15 $104.31 $115.85 $152.84 $164.38 Employee + Child(ren) $78.69 $90.23 $121.62 $133.15 $178.12 $189.66 Employee + Family $85.85 $97.38 $149.31 $160.85 $229.69 $241.23
Medical Insurance Plans Preventive Care The Aetna medical plans cover in-network preventive care at 100%. This includes routine screenings and checkups, as well as counseling to prevent illness, disease, or other health problems. Talk to your primary care physician to find out which screenings, tests, and vaccines are right for you, when you should get them, and how often. Please be aware that you will be responsible for the cost of any non-preventive care services you receive at your preventive care exam. You won t have to pay anything no deductible, copay, or coinsurance for preventive services when: You get them from a doctor or other health care provider in the Aetna network. The main purpose of your visit is to get preventive care. Women s preventive care services Due to health reform, the medical plans offer additional no-cost preventive care/services for women. Learn more about preventive care at www.aetna.com. Health Reform Law Individual Mandate You and your family members are required to have health insurance in 2017 or pay a penalty to the government. The 2017 penalties have not yet been released. In 2016, the penalties are $695 per adult and $347.50 per child or 2.5% of your income, whichever is greater. Beginning in 2017, the penalties may increase by the cost-of-living adjustment. Some people may qualify for an exemption to this fee. The Oakley Transport medical plans meet all of the health reform law requirements to satisfy your individual mandate. Oakley Transport pays a substantial amount of your coverage. The amount you pay for Oakley Transport coverage is deducted from your paycheck on a pre-tax basis. If you are covered by any of the following in 2017, you will meet the individual mandate requirements: your parent s or spouse s employer plan, an individual policy, a government plan such as Medicare, Medicaid, CHIP, TRICARE, or veterans coverage, student health coverage, state high-risk pool coverage, or coverage for non-u.s. citizens provided by another country. Learn more about the health reform law requirements at www.healthcare.gov. 5
Health Savings Accounts If you enroll in the Aetna Base plan or Preferred plan, you may be eligible to open and fund a health savings account (HSA) through HealthEquity. An HSA is a personal health care savings account that you can use to pay out-of-pocket health care expenses with pre-tax dollars. Your contributions are tax free, and the money remains in the account for you to spend on eligible expenses no matter where you work or how long it stays in the account. Contributions to a health savings account cannot exceed the annual IRS contribution maximums. Employees age 55+ by 12/31/2017 may contribute additional funds to their HSA (up to $1,000 in 2017). 2017 IRS HSA Contribution Maximums Employee Only $3,400 All other tiers $6,750 HSA Eligibility You are eligible to open and fund an HSA if: You are enrolled in the Aetna Base plan or Preferred plan. You are not covered by a non-hsa plan, health care FSA, or health reimbursement arrangement. You are not eligible to be claimed as a dependent on someone else s tax return. You are not enrolled in Medicare or TRICARE for Life. You have not received Veterans Administration Benefits in the last three months. Use Your HSA to Pay for Qualified Medical Expenses You can use your HSA money to pay for eligible expenses now or in the future. Funds in your HSA can be used for your expenses and those of your spouse and eligible dependents, even if they are not covered by the Aetna Base plan or Preferred plan. Eligible expenses include deductibles, doctor s office visits, dental expenses, eye exams, prescription expenses, and LASIK eye surgery. A complete list of eligible expenses can be found at www.irs.gov/pub/irs-pdf/p502.pdf. Accessing Your HSA Funds Three easy ways to access your HSA money: Debit card Draws directly from your HSA and can be used to pay for eligible expenses at your doctor s office, pharmacy, or other locations where you purchase health-related items or services. Online bill pay Pay eligible expenses directly from your HSA. You can manage, monitor, and schedule payments online, anytime. Online reimbursement Reimburse yourself for eligible expenses that you paid out of your pocket. Your HSA is an Individually Owned Account You own and administer your HSA. You determine how much you will contribute to your account and when to use the money to pay for eligible health care expenses. You can change your contribution at any time during the plan year without a qualifying event. Like a bank account, you must have a balance in order to pay for eligible health care expenses. Keep all receipts for tax documentation. An HSA allows you to save and roll over money from year to year. The money in the account is always yours, even if you change health plans or jobs. There are no vesting requirements or forfeiture provisions. Maximize Your Tax Savings Contributions to an HSA are tax free and can be made through payroll deduction on a pre-tax basis. The money in your HSA (including interest and investment earnings) grows tax free. As long as you use the funds to pay for qualified medical expenses, the money is spent tax free. 6
Dental Insurance Plans Oakley Transport offers two dental insurance plan options through Aetna. Both plans offer in- and out-ofnetwork benefits, providing you the freedom to choose any provider. However, you will pay less out of your pocket when you choose a network provider. Expenses from non-network providers are reimbursed based on reasonable and customary charges (R&C) charges. Any charges over the R&C amount will be your responsibility. Locate an Aetna network provider at www.aetna.com. The table below summarizes the key features of the dental plans. The coinsurance amounts listed reflect the amount you pay. Please refer to the official plan documents for additional information on coverage and exclusions. Low Plan High Plan In-Network Out-of-Network In-Network Out-of-Network Plan Year Deductible Individual/Family None/None $50/$150 None/None $50/$150 Plan Year Benefit Max $1,000 $750 $5,000 $5,000 Preventive Care Oral exams, cleanings, fluoride, sealants, bitewing images, full mouth series images, space maintainers. Basic Services Root canal therapy, amalgam (silver) fillings, composite fillings, uncomplicated extractions, general anesthesia Major Services Crowns (inlays/onlays), dentures (full/ partial), implants Plan pays 100% 0% after deductible Plan pays 100% 0% after deductible 20% after deductible 50% after deductible 10% after deductible 20% after deductible 50% after deductible 75% after deductible 50% after deductible 50% after deductible Orthodontia Services Not covered Not covered 50% 50% after deductible Orthodontia Lifetime Max N/A N/A $2,000 $2,000 Dental Plan Costs Listed to the right are the weekly costs for dental insurance. The amount you pay for coverage is deducted from your paycheck on a pre-tax basis. Dental Insurance Low Plan High Plan Employee Only $4.16 $7.27 Employee + Spouse $9.06 $15.56 Employee + Child(ren) $9.94 $17.43 Employee + Family $16.18 $27.62 7
Vision Insurance Plans Locate an EyeMed network provider at www.eyemed.com. Oakley Transport offers two vision insurance plan options through EyeMed. You have the freedom to choose any vision provider. However, you will maximize the plan benefits when you choose a network provider. Locate an EyeMed network provider at www.eyemed.com. The table below summarizes the key features of the vision plans. Please refer to the official plan documents for additional information on coverage and exclusions. Low Plan High Plan In-Network Out-of-Network In-Network Out-of-Network Eye Exam (every 12 months) $20 copay Up to $40 reimbursement $5 copay Up to $40 reimbursement Standard Plastic Lenses (every 12 months) Single Bifocal Trifocal Frames (every 24 months) Contact Lenses (every 12 months in lieu of standard plastic lenses) Elective Medically Necessary $20 copay $20 copay $20 copay $100 allowance + 20% off balance $100 allowance + 15% off balance Plan pays 100% Up to $30 reimbursement Up to $50 reimbursement Up to $70 reimbursement Up to $70 reimbursement Up to $100 reimbursement Up to $210 reimbursement $10 copay $10 copay $10 copay $150 allowance + 20% off balance $150 allowance + 15% off balance Plan pays 100% Up to $30 reimbursement Up to $50 reimbursement Up to $70 reimbursement Up to $105 reimbursement Up to $150 reimbursement Up to $210 reimbursement Vision Plan Costs Listed to the right are the weekly costs for vision insurance. The amount you pay for coverage is deducted from your paycheck on a pre-tax basis. Vision Insurance Low Plan High Plan Employee Only $1.17 $2.09 Employee + Spouse $2.33 $4.18 Employee + Child(ren) $1.97 $3.54 Employee + Family $3.25 $5.83 8
Life and AD&D Insurance Basic Life and AD&D Insurance Life and accidental death and dismemberment (AD&D) insurance is an important element of your income protection planning, especially for those who depend on you for financial security. For your peace of mind, Oakley Transport automatically provides basic life and AD&D insurance through Unum to all benefits-eligible employees at no cost. If you die as a result of an accident, your beneficiary would receive both the life benefit and the AD&D benefit. Benefits will reduce to 65% at age 65 and to 50% at age 70. CEO, CFO, president, and directors life and AD&D benefit: $50,000. All managers life and AD&D benefit: $25,000. All other employees life and AD&D benefit: $20,000. Please be sure to keep your beneficiary designations up to date. Supplemental Life and AD&D Insurance Oakley Transport provides you the option to purchase supplemental life and AD&D insurance for yourself, your spouse, and your dependent children through Unum. Supplemental life and AD&D insurance can be purchased separately. You must purchase supplemental coverage for yourself in order to purchase coverage for your spouse and/or dependents. Supplemental life rates are age-banded. Benefits will reduce to 65% at age 65 and to 50% at age 70. If you elect coverage when first eligible, you may purchase up to the guarantee issue amount(s) without completing a statement of health (evidence of insurability). If you do not enroll when first eligible, and choose to enroll during a subsequent annual open enrollment period, you will be required to submit evidence of insurability for any amount of coverage. Coverage will not take effect until approved by Unum. Employee: $10,000 increments up to $500,000 or 5x annual earnings, whichever is less. Guarantee issue: $150,000. Spouse: $5,000 increments up to $500,000 or 100% of the employee s election, whichever is less. Guarantee issue: $50,000 Dependent children: Live birth to 14 days: $1,000; 14 days to 6 months: $1,000; 6 months to age 19 (or 26 if full-time student): $2,000 increments up to $10,000 or 100% of the employee s election, whichever is less. Supplemental Life and AD&D Insurance Costs Listed below are the weekly rates for supplemental life and AD&D insurance. The amount you pay for supplemental life and AD&D insurance is deducted from your paycheck on a post-tax basis. Spouse life rates are based on the employee s age. Age Employee Weekly Rates $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $110,000 $120,000 $130,000 $140,000 $150,000 <29 $0.14 $0.28 $0.42 $0.55 $0.59 $0.83 $0.97 $1.11 $1.25 $1.38 $1.52 $1.66 $1.80 $1.94 $2.08 30 34 $0.18 $0.37 $0.55 $0.74 $0.92 $1.11 $1.29 $1.48 $1.65 $1.85 $2.03 $2.22 $2.40 $2.58 $2.77 35 39 $0.25 $0.51 $0.76 $1.02 $1.27 $1.52 $1.78 $2.03 $2.28 $2.54 $2.79 $3.05 $3.30 $3.55 $3.81 40 44 $0.30 $0.60 $0.90 $1.20 $1.50 $1.80 $2.10 $2.40 $2.70 $3.00 $3.30 $3.60 $3.90 $4.20 $4.50 45 49 $0.46 $0.92 $1.38 $1.85 $2.31 $2.77 $3.23 $3.69 $4.15 $4.62 $5.08 $5.54 $6.00 $6.46 $6.92 50 54 $0.74 $1.48 $2.22 $2.95 $3.69 $4.43 $5.17 $5.91 $6.65 $7.38 $8.12 $8.86 $9.60 $10.34 $11.08 55 59 $1,29 $2.58 $3.88 $5.17 $6.46 $7.75 $9.05 $10.34 $11.63 $12.92 $14.22 $15.51 $16.80 $18.09 $19.38 60 64 $1.80 $3.60 $5.40 $7.20 $9.00 $10.80 $12.60 $14.40 $16.20 $18.00 $19.80 $21.60 $23.40 $25.20 $27.00 65 69 $3.28 $6.55 $9.83 $13.11 $16.38 $19.66 $22.94 $26.22 $29.49 $32.77 $36.05 $39.32 $42.60 $45.88 $49.15 70+ $5.88 $11.77 $17.65 $25.54 $29.42 $35.31 $41.19 $47.08 $52.96 $58.85 $64.73 $70.62 $76.50 $82.38 $88.27 AD&D $0.06 $0.12 $0.18 $0.24 $0.30 $0.36 $0.42 $0.48 $0.54 $0.60 $0.66 $0.72 $0.78 $0.84 $0.90 Age Spouse Weekly Rates $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 <29 $0.07 $0.14 $0.21 $0.28 $0.35 $0.42 $0.48 $0.55 $0.62 $0.69 30 34 $0.09 $0.18 $0.28 $0.37 $0.46 $0.55 $0.65 $0.74 $0.83 $0.92 35 39 $0.13 $0.25 $0.38 $0.51 $0.63 $0.76 $0.89 $1.02 $1.14 $1.27 40 44 $0.15 $0.30 $0.45 $0.60 $0.75 $0.90 $1.05 $1.20 $1.35 $1.50 45 49 $0.23 $0.46 $0.69 $0.92 $1.15 $1.38 $1.62 $1.85 $2.08 $2.31 50 54 $0.37 $0.74 $1.11 $1.48 $1.85 $2.22 $2.58 $2.95 $3.32 $3.69 55 59 $0.65 $1.29 $1.94 $2.58 $3.23 $3.88 $4.52 $5.17 $5.82 $6.46 60 64 $0.90 $1.80 $2.70 $3.60 $4.50 $5.40 $6.30 $7.20 $8.10 $9.00 65 69 $1.64 $3.28 $4.92 $6.55 $8.19 $9.83 $11.47 $13.11 $14.75 $16.38 70+ $2.94 $5.88 $8.83 $11.77 $14.71 $17.65 $20.60 $23.54 $26.48 $29.42 AD&D $0.03 $0.06 $0.09 $0.12 $0.15 $0.18 $0.21 $0.24 $0.27 $0.30 Child Weekly Rates $2,000 $4,000 $6,000 $8,000 $10,000 Life $0.06 $0.12 $0.17 $0.23 $0.29 AD&D $0.01 $0.02 $0.04 $0.05 $0.06 9
Voluntary Disability Insurance Voluntary Short-Term Disability Insurance Oakley Transport provides you the option to purchase voluntary short-term disability (STD) insurance through Unum. Voluntary STD insurance is designed to help you meet your financial needs if you become unable to work due to an illness or injury. Benefits will be reduced by other income, including state-mandated short-term disability plans. Benefit: $100 to $2,000 available in $50 increments up to a maximum of 60% of the employee s weekly earnings or $2,0000 per week. Elimination period: 7 days for sickness or accident. Benefit duration: Up to 26 weeks. Voluntary Long-Term Disability Insurance Oakley Transport provides you the option to purchase voluntary long-term disability (LTD) insurance through Unum. Voluntary LTD insurance is designed to help you meet your financial needs if you become unable to work due to an illness or injury. Benefit: 60% of base monthly earnings up to $10,000 per month. Elimination period: 180 days; 30 days accumulation feature. Benefit duration: Social security normal retirement age. 10
Accident Insurance Oakley Transport provides you the option to purchase accident insurance through Unum. Accident insurance can pay benefits based on the injury you receive and the treatment you need, including emergency-room care and related surgery. The benefit can help offset the out-of-pocket expenses that medical insurance does not pay, including deductibles and co-pays. Family coverage is available. Employees must be a U.S. citizen or legally authorized to work in the U.S. to receive overage. Spouses and dependents must live in the U.S. to receive coverage. This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. For complete details of coverage and availability, please refer to policy form GA-1 or contact your Unum representative. See schedule of benefits for a full list of covered injuries and treatments. Critical Illness Insurance Oakley Transport provides you the option to purchase critical illness insurance through Unum. Critical illness insurance can help protect your finances from the expense of a serious health problem, such as a stroke or heart attack. Cancer coverage is also available. You choose a lump-sum benefit up to $20,000 that is paid directly to you at the first diagnosis of a covered condition. You can use the benefit any way you choose and you can use this coverage more than once. If you receive a full benefit payout for a covered illness, your coverage can be continued for the remaining covered conditions. The diagnosis of a new covered illness must occur at least 90 days after the most recent diagnosis. Each condition is payable once per lifetime. Employees must be a U.S. citizen or legally authorized to work in the U.S. to receive overage. Spouses and dependents must live in the U.S. to receive coverage. This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. For complete details of coverage and availability, please refer to policy form CI-1, or contact your Unum representative. Oakley Transport provides you the option to purchase a legal plan through LegalShield. LegalShield offers 3 different plans: Legal Plan, CDL Basic Plan, and Super CDL Plan. Legal Plan costs $15.95 per month, CDL Basic Plan costs $29.95 per month, and Super CDL plan costs $32.95 per month. For more information on each plan, please visit www.legalshield.com/info/legalplan. If you have any questions, call 800-654-7757 to speak with a LegalShield Customer Care Specialist, or email memberservices@legalshield.com. Legal Plan 11
Important Contact Information If you have any questions regarding your benefits or the material contained in this guide, please contact Human Resources. Oakley Transport Human Resources Department Phone: 863-638-1435 Website: www.oakleytransport.com Contact Number Website Medical Aetna 888-982-3862 www.aetna.com Dental Aetna 888-982-3862 www.aetna.com Vision EyeMed 866-804-0982 www.eyemed.com Health Savings Account HealthEquity Life and Voluntary Disability Insurance Unum Accident and Critical Illness Insurance Unum 866-346-5800 www.healthequity.com 800-421-0344 www.unum.com 800-635-5597 www.unum.com Legal Plan LegalShield 800-654-7757 www.legalshield.com Benefits Enrollment EMB 407-574-7889 Monday Friday; 9:00 a.m. to 5:00 p.m. (EST) www.explainmybenefits.biz/oakley This summary of benefits is not intended to be a complete description of the terms and Oakley Transport insurance benefit plans. Please refer to the plan document(s) for a complete description. Each plan is governed in all respects by the terms of its legal plan document, rather than by this or any other summary of the insurance benefits provided by the plan. In the event of any conflict between a summary of the plan and the official document, the official document will prevail. Although Oakley Transport maintains its benefit plans on an ongoing basis, Oakley Transport reserves the right to terminate or amend each plan, in its entirety or in any part at any time. Images 2016 istock 2016 Getty Images. All rights reserved. 12