2015 sample company guide 001

Your Benefits Guide

SAMPLECOMPANY

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Sample Company Your Benefits Guide for 2014

Your Benefits Guide for 2014

Table of Contents

3 Benefit Basics

4 Medical

5 SimplyEngaged®

6 Voluntary Dental

6 Voluntary Vision

7 Life and Accidental Death & Dismemberment (AD&D) Insurance

8 Disability Insurance

8 Flexible Spending Accounts

10 401(k) Retirement Plan

11 The Cost of Your Benefits

12 Important Contacts

This benefit summary provides selected highlights of the Sample Company employee benefits program. It is not a legal document and shall not be construed as a guarantee of benefits nor of continued employment at the Company. All benefit plans are governed by master policies, contracts and plan documents. Any discrepancies between any information provided through this summary and the actual terms of the policies, contracts and plan documents are governed by the terms of these policies, contracts and plan documents. Sample Company reserves the right to amend, suspend or terminate any benefit plan, in whole or in part, at any time. The Plan Administrator has the authority to make these changes.

SAMPLECOMPANY

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Benefit Basics


Sample Company offers a comprehensive suite of benefits to promote health and financial security for you and your family.

Benefit BasicsAs a Sample Company employee, you are eligible for benefits if you are a full-time employee regularly working 30 or more hours per week. Benefits are effective on the first day of the month following 30 days from your date of hire.

You may enroll your eligible dependents for coverage once you are eligible. Your eligible dependents include:

� Your legal spouse

� Your children (natural, adopted and step) up to age 26.

Once your benefit elections become effective, they remain in effect until the end of the plan year. You may only change coverage within 30 days of a qualified life event.

Qualified Life Events � Marriage, divorce, legal separation or annulment

� Birth, adoption or placement for adoption of eligible child

� Death of spouse or covered child

� Change in your or your spouse’s work status that affects eligibility

� Change in residence or worksite that affects coverage eligibility

� Significant cost or coverage changes in benefits plans

� Entitlement to Medicare or Medicaid

� Dependent employer’s Open Enrollment

� Receiving a Qualified Medical Child Support Order (QMCSO)

This booklet provides you

with a summary of your benefits. Please review it carefully so you can choose the coverage that’s

right for you.

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MedicalSample Company offers the following medical plans. These plans provide comprehensive health care benefits, including free preventive care services and coverage for prescription drugs.

NEW! If your spouse is eligible for group health coverage through his/her employer, they will not be eligible for coverage under the Sample Company plan. If they are covered under the Sample Company plan now, they will lose this coverage effective September 1, 2014. This will result in a Special Enrollment or Qualifying Event and allow them to enroll in their employer’s plan within 30 days of the event. You will be asked to sign a statement regarding your spouse’s eligibility for other coverage in the enrollment process.

Plan Provisions Buy-Up Plan Base Plan Buy-Down Plan

IN-NETWORKOUT-OF-

NETWORK IN-NETWORKOUT-OF-

NETWORK IN-NETWORKOUT-OF-

NETWORK

Calendar Year DeductibleIndividual $750 $1,500 $1,000 $2,000 $2,500 $5,000

Family $2,250 $4,500 $3,000 $6,000 $7,500 $15,000

Out-of-Pocket Maximum (Includes Deductible, Copays and Coinsurance)Individual $3,000 $6,000 $4,000 $8,000 $6,000 $12,000

Family $9,000 $18,000 $12,000 $24,000 $12,000 $36,000

Coinsurance 80% 50% 80% 50% 80% 50%

ServicesPreventive Care 100% 50%* 100% 50%* 100% 50%*

Primary Physician Office Visit $25 copay 50%* $30 copay 50%* $35 copay 50%*

Specialist Office Visit $50 copay 50%* $60 copay 50%* $70 copay 50%*

Lab, X-Rays & Nuclear Medicine Lab work X-rays MRI, CAT, PET & Nuclear Medicine

100% 100% 80%*

50%* 50%* 50%*

100% 100% 80%*

50%* 50%* 50%*

100% 100% 80%*

50%* 50%* 50%*

Inpatient Hospital Services 80%* 50%* + $500** 80%* 50%* + $500** 80%* 50%* + $500**

Urgent Care $75 copay 50%* $75 copay 50%* $75 copay 50%*

Emergency Room Care $150 copay $200 copay $250 copay

Prescription Drugs

Retail RX (31-day Supply)

Generic $10 copay $15 copay $20 copay

Formulary $30 copay $35 copay $40 copay

Non Formulary $50 copay $60 copay $75 copay

Mail-Order RX (90-day Supply)

Generic $30 copay $45 copay $60 copay

Formulary $90 copay $105 copay $120 copay

Non Formulary $150 copay $180 copay $225 copay

* After deductible ** Per occurrence deductible

Important notes: This is a synopsis of coverage only; the benefits summaries contains exclusions and limitations that are not shown here. Please refer to the benefits summaries for the full scope of coverage. In-network services are based on negotiated charges; out-of-network services are based on Reasonable & Customary (R&C) charges.

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SimplyEngaged®


SimplyEngaged®Take control of your health and wellness and get rewarded!SimplyEngaged® is a personal health and wellness program which allows you to earn valuable rewards when you participate in wellness activities. These include completing your health screening, completing an online health assessment*, and participating in and completing an online health coaching program—all designed to help you learn more about your current health and potential health risks for certain diseases and conditions. Once you’ve finished an activity, you’ll be rewarded with a gift card!

Reward yourself with a gift card from SimplyEngaged®Earn up to $175 for completing health and wellness activities! SimplyEngaged® is available for you and your spouse if enrolled in the UHC health plan.

� Complete Your Health ScreeningLearn more about the important health numbers such as your cholesterol, blood pressure and Body Mass Index (BMI) when you get screened by your doctor or a participating clinic.

� Complete an online health assessment and get a $75 gift card

� Participate in and complete an online health coaching program and get a $25 gift card

� Complete a telephone-based health coaching program* and get a $75 gift cardOnline health coaching provides targeted behavior modification programs that guide you to better health. The programs reinforce positive changes and provide ongoing support for lifestyle goals such as nutrition, exercise, weight management, tobacco cessation, stress management, diabetes and heart health.

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Voluntary VisionThe UHC vision plan covers routine eye exams and also pays for all or a portion of the cost of glasses or contact lenses if you need them.

Voluntary Vision

BENEFIT IN-NETWORK OUT-OF-NETWORK

Exam $10 copay Reimbursement up to $40

Hardware $25 copay See below

FrequencyExam 12 months 12 months

Lenses 12 months 12 months

Frames 24 months 24 months

Frames Retail allowance $100 Reimbursement up to $45

LensesSingle Vision Lenses Covered at 100% Reimbursement up to $40

Bifocal Lenses Covered at 100% Reimbursement up to $60

Trifocal Lenses Covered at 100% Reimbursement up to $80

Contact LensesMedically Necessary Contact Lenses

Covered at 100% Reimbursement up to $210

Elective Contact Lenses(in lieu of glasses) Retail allowance $105 Retail allowance $105

Voluntary DentalRegular dental exams can help you and your dentist detect problems in the early stages when treatment is simpler and costs are lower. Keeping your teeth and gums clean and healthy will help prevent most tooth decay and periodontal disease and is an important part of maintaining your medical health.

The Company offers two DPPO options through UHC, both with In- and Out-of-Network benefits.

Plan Provisions Buy-Up Plan DPPO Base Plan DPPO

IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK

Calendar Year Deductible (Individual/Family) $50/$150 $50/$150

Annual Maximum (Per Person) $1,500 $1,000

Diagnostic and Preventive Care: Includes cleanings, fluoride treatments, sealants and x-rays

100%, no deductible

100%, no deductible

100%, no deductible

100%, no deductible

Basic Services: Includes restorations, fillings, emergency treatment/general services and simple extractions

80%* 80%* 80%* 80%*

Major Services: Includes crowns, full and partial dentures (bridges), Periodontics and Endodontics. 50%* 50%* 50%* 50%*

Orthodontia: (Adults & Children -- up to age 26) 50%*, $1,500 lifetime maximum N/A

* After deductible

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Life and Accidental Death & Dismemberment (AD&D) Insurance


Life and Accidental Death & Dismemberment (AD&D) InsuranceLife insurance is an important part of your financial security, especially if others depend on you for support. Accidental Death & Dismemberment (AD&D) insurance is designed to provide a benefit in the event of accidental death or dismemberment. The Company provides Basic Life and AD&D insurance to all eligible employees at no cost to you in the amount of one times annual basic earnings, up to a maximum benefit of $250,000.

Voluntary Life and Accidental Death & Dismemberment Insurance CoverageYou may also purchase additional Life and AD&D insurance for yourself and covered dependents:

Coverage for: Coverage available:

Employee − Increments of $10,000 up to five times your salary or $500,000.

Spouse − Increments of $10,000 up to $250,000 – not to exceed 100% of Employee coverage. Available up to age 70.

Child(ren) − Increments of $2,000 to a maximum of $25,000.

− $250 for children 14 days to 6 months.

In order to cover dependents, Employee must elect coverage for self.

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Disability InsuranceThe goal of Sample Company’s Disability insurance plans is to provide you with income replacement should you become disabled and unable to work due to a non-work-related illness or injury. The Company provides eligible employees with disability income benefits at no cost to you.

Coverage Benefit

Short-Term Disability − 66.67% of your total weekly earnings

− Minimum weekly benefit of $25

− Maximum weekly benefit of $1,500

− Benefit begins after 14 days of disability

Long-Term Disability − Covers 60% of your base annual earnings, to a $5,000 maximum per month

− Benefit begins after 90 days of disability

Flexible Spending AccountsFlexible Spending Accounts (FSAs) are designed to save you money on your taxes. They work in a similar way to a savings account. Each pay period, funds are deducted from your pay on a pre-tax basis and are deposited in your Health Care and/or Dependent Care FSA. You then use your funds to pay for eligible health care or dependent care expenses.

Account Type Eligible Expenses Annual Contribution Limits Benefit

Health Care FSA − Most medical, dental and vision care expenses that are not covered by your health plan (such as copayments, coinsurance, deductibles, eyeglasses and doctor-prescribed over-the-counter medications)

− Maximum contribution is $2,500 per year

− Saves on eligible expenses not covered by insurance. Reduces your taxable income

Dependent Care FSA − Dependent care expenses (such as day care, after school programs or elder care programs) so you and your spouse can work or attend school full-time

− Maximum contribution is $5,000 per year ($2,500 if married and filing separate tax returns)

− Reduces your taxable income

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Disability Insurance


What Are the Advantages of an FSA?With an FSA, the money you contribute is never taxed—not when you put it in the account, not when you are reimbursed with the funds from the account and not when you file your income tax return at the end the year.You will also have the option to use a Debit Card to pay for eligible services and products.

What Are the Advantages of a Debit Card? � Less out-of-pocket expenses at the time of service

� No waiting for reimbursement

� Merchant is paid directly at the point of sale

� Increased use of funds, less chance to forfeit at the end of the year

FSAs Let You Save on Your TaxesHere is an example of how much you can save when you use the FSAs to pay for your predictable health care and dependent care expenses.

Account Type With FSA Without FSA

Your taxable income $50,000 $50,000

Pre-tax contribution to Health Care and Dependent Care FSA $2,000 $0

Federal and Social Security taxes $11,701 $12,355

After-tax dollars spent on eligible expenses $0 $2,000

Spendable income after expenses and taxes $36,299 $35,645

Tax savings with the Medical and Dependent Care FSA $654 N/A

This is an example only and may vary from your actual experience. It assumes a 25% federal income tax rate and a 7.7% FICA marginal rate. State and local taxes vary and are not included in this example. However, you will save on any state and local taxes as well.

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401(k) Retirement PlanThe Sample Company 401(k) Retirement Savings Plan offers a convenient way to save for your future through payroll deductions.

Eligibility You are eligible to participate in the plan if you are age 21 or older, as of the first day of the month following one month of service with the Company. You may begin participating in this plan at the beginning of the month anytime during the year.

Employee ContributionsYou may contribute up to 50% of your pay pre-tax, up to the IRS annual limit. Additionally the Plan allows for Roth, after Tax, contributions.

If you are 50 years of age or older (or if you will reach age 50 by the end of the year), you may make an additional catch-up contribution.

Employer ContributionsThe employer contribution is a Safe Harbor which matches up to the first 4% of deferred compensation.

VestingVesting refers to your right of ownership to the money in your account. The 401(k) has immediate vesting in the Safe Harbor matching employer contribution.

For More InformationFor additional details about the 401(k) Retirement Savings Plan or to enroll or change your contribution rates or investment elections, please contact Principal Financial Group.

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The Cost of Your Benefits


The Cost of Your BenefitsThe Company pays the full cost of some of your benefits; you share the cost for others. You pay the full cost for any voluntary benefits you elect.

Benefit Who Pays Tax Treatment

YOU THE COMPANY PRE-TAX AFTER-TAX

Medical Coverage l l l

Voluntary Dental Coverage l l

Voluntary Vision Coverage l l

Basic Life and Accidental Death & Dismemberment (AD&D) Insurance

l l

Voluntary Life and AD&D Insurance l l

Short and Long Term Disability Coverage l l

Flexible Spending Accounts l l

401(k) Retirement Savings Plan l l l

For more information about your benefits, please contact your Human Resources Department.

Important ContactsContact Phone Number Website

Medical Plan United Healthcare 866-633-2446 www.myuhc.com

Dental Plan United Healthcare 877-816-3596 www.myuhcspecialtybenefits.com

Vision Plan United Healthcare 800-638-3120 www.myuhcvision.com

Life / AD&D Insurance Sun Life 800-247-6875 www.sunlife.com/us

Short-Term & Long-Term Disability Insurance

Sun Life 800-247-6875 www.sunlife.com/us

Flexible Spending Accounts United Healthcare 888-355-2509 www.myuhc.com

401(k) Principal Financial Group 800-547-7754 www.principal.com

Human Resources Jane Doe 123-456-7890 [email protected]

SAMPLECOMPANY

2015 sample company guide 001

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