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Your Benefit Period:
October 1, 2022 - September 30, 2023
Medical: Moving from Allsavers to Aetna
Dental: Provided through Guardian with 100%/100%/60% in network coverage.
Vision: Provided through Guardian who utilizes a large network of providers.
Short Term Disability (STD): Provided through Guardian
Life and AD&D: Provided though Guardian
Do you plan to enroll an eligible dependent(s)?
If so, make sure to have their social security numbers and birthdates available. You cannot enroll your dependent(s) without this information.
Have you recently been married/divorced or had a baby?
If so, remember to add or remove any dependent(s) and/or update your beneficiary designation.
Did any of your covered children reach their 26th birthday this year?
If so, they may no longer be eligible for benefits, unless they meet specific criteria.
HSA 3000:
IN NETWORK
DEDUCTIBLE:
COINSURANCE (applies after deductible is met) & Out of Pocket Max (includes coinsurance and deductible)
?
MEMBER COPAYMENT(S):
PRESCRIPTION DRUGS:
Retail (30 days) (After deductible is met)
40% up to %500
Mail-Order (90 days)
*A refers to generic prescription
EMPLOYEE CONTRIBUTION - PER PAY:
4000 70/50:
IN NETWORK
DEDUCTIBLE:
COINSURANCE (applies after deductible is met) & Out of Pocket Max (includes coinsurance and deductible)
?
MEMBER COPAYMENT(S):
PRESCRIPTION DRUGS:
Retail (30 days)
40% up to %500
Mail-Order (90 days)
*A refers to generic prescription
EMPLOYEE CONTRIBUTION - PER PAY:
Value Plan:
You have the freedom to select the dentist of your choice; however, when you visit a participating PPO or Premier dentist, you will have lower out-of-pocket costs, no balance billing, and claims will be submitted by your dentist on your behalf.
IN NETWORK:
BENEFIT PERIOD: 2 years until 10/24
DEDUCTIBLE:
*Deductible applies when receiving Basic or Major services (Waived for Preventive Services)
CLASS I: - Covered at 100% (deductible waived)
Diagnostic and Preventive Services - Exams, cleanings, fluoride, space maintainers, sealants, x-rays.
CLASS II: - Covered at 100% (deductible waived)
Basic Services - Fillings, anesthesia, oral surgery, extractions
CLASS III: - Covered at 60% (deductible applies)
Major Services - Fixed bridgework, dentures, crowns, implants, endodontics (not root canals), periodontal services (gums), and orthodontia for children under age 19
ANNUAL MAXIMUM:
Calendar Year Maximum (Allowed per Benefit Period) - $1,000 per covered individual
EMPLOYEE CONTRIBUTION - PER PAY:
Employee - $4.11
Employee+Spouse - $8.65
Employee+Child(ren) - $10.37
Family - $14.91
NAP Plan:
You have the freedom to select the dentist of your choice; however, when you visit a participating PPO or Premier dentist, you will have lower out-of-pocket costs, no balance billing, and claims will be submitted by your dentist on your behalf.
IN NETWORK:
BENEFIT PERIOD: 2 years until 10/24
DEDUCTIBLE:
*Deductible applies when receiving Basic or Major services (Waived for Preventive Services)
CLASS I: - Covered at 100% (deductible waived)
Diagnostic and Preventive Services - Exams, cleanings, fluoride, space maintainers, sealants, x-rays.
CLASS II: - Covered at 80% (deductible applies)
Basic Services - Fillings, anesthesia, oral surgery, extractions
CLASS III: - Covered at 50% (deductible applies)
Major Services - Fixed bridgework, dentures, crowns, implants, endodontics (not root canals), periodontal services (gums), and orthodontia for children under age 19
ANNUAL MAXIMUM:
Calendar Year Maximum (Allowed per Benefit Period) - $1,000 per covered individual
EMPLOYEE CONTRIBUTION - PER PAY:
Employee - $4.11
Employee+Spouse - $8.65
Employee+Child(ren) - $10.37
Family - $14.91
Under this plan, you may use the eye care professional of your choice. However, when you visit a participating in-network provider, you receive higher levels of coverage. If you choose to receive services from an out-of-network provider, you will be required to pay that provider at the time of service and submit a claim form for reimbursement.
IN NETWORK:
Vision Exam (with dilation as necessary) - $10
Retinal Imaging - Up to $39
COVERED SERVICES – LENSES / FRAMES
Single Lenses - $25
Bifocals - $25
Trifocals - $25
Progressive - $50
Frames - Up to $130, then 20%
COVERED SERVICES - CONTACT LENSES
Contact Lenses - Up to $130
Contact Lens Evaluation Fitting - Include in allowance
BENEFIT FREQUENCY
Exams - Once every calendar year
Lenses or Contact Lenses - Once every calendar year
Frames - Once every calendar year
EMPLOYEE CONTRIBUTION - PER PAY:
Employee - $0.00
Employee+Spouse - $0.00
Employee+Child(ren) - $0.00
Family - $0.00
Your Voluntary Life Benefit
*Please refer to attached Benefit Summary for more complete plan details and exclusions*
Disability insurance covers a part of your income, so you can pay your bills if you're injured or sick and can't work.
Accidents happen, and you can't always anticipate if or when you'll become sick or injured. That's why it's important to have a disability policy that helps you pay your bills in the event of being unable to collect your normal paycheck.
Your Short-Term Disability Benefit:
*Please see attached Benefit Summary for more complete plan details*
Click the link below to download and print your Enrollment Form. Once complete, please deliver to your HR Manager.
Jeff Criscione
jcriscione@cvcclub.com
(440) 248-4310
Kevin Lurie
Producer / Sales Consultant
kevin.lurie@nfp.com
(216) 410-6751
Lindsey Walsh
Benefit Coordinator
lindsey.walsh@nfp.com
216-260-2404
Naomi Butze
Sr Account Manager
naomi.butze@nfp.com
1-216-659-3813