Plan Highlights

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.

Medical - Plan 1 - Aetna

HSA 3000:

IN NETWORK

DEDUCTIBLE:

Single Deductible - $3,000
Family Deductible - $6,000

COINSURANCE (applies after deductible is met) & Out of Pocket Max (includes coinsurance and deductible)

Plan Pays: 80%
Single Out of Pocket Maximum: $5,500
Family Out of Pocket Maximum: $11,000

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MEMBER COPAYMENT(S):

Preventative Exam - 100% no deductible
Primary Care (PCP) - Office Visit - $35 Copay
Specialist - Office Visit - $75 Copay
Urgent Care Facility - 80% after deductible
Emergency Room Visit - 80% after deductible

PRESCRIPTION DRUGS:

Retail (30 days) (After deductible is met)

Tier 1 - $3A*/$15
Tier 2 - $50
Tier 3 - $100
Tier 4 - 20% up to $250

40% up to %500

Mail-Order (90 days)

Tier 1 - $6A*/$30
Tier 2 - $100
Tier 3 - $200
Tier 4 - N/A

*A refers to generic prescription

EMPLOYEE CONTRIBUTION - PER PAY:

Employee - $64.22
Employee+Spouse - $145.96
Employee+Child(ren) - $128.10
Family - $198.20

Summary of Benefits Coverage (SBC)

Plan 1 - HSA 3000

Summary of Benefits Coverage (SBC)

Plan 1 - HSA 3000

Aetna Teledoc Flyer

Aetna Funding Advantage Flyer

Medical - Plan 2 - Aetna

4000 70/50:

IN NETWORK

DEDUCTIBLE:

Single Deductible - $4,000
Family Deductible - $8,000

COINSURANCE (applies after deductible is met) & Out of Pocket Max (includes coinsurance and deductible)

Plan Pays: 70%
Single Out of Pocket Maximum: $7,000
Family Out of Pocket Maximum: $14,000

?

MEMBER COPAYMENT(S):

Preventative Exam - 100% no deductible
Primary Care (PCP) - Office Visit - $40 Copay
Specialist - Office Visit - $80 Copay
Urgent Care Facility - $100
Emergency Room Visit - $100

PRESCRIPTION DRUGS:

Retail (30 days)

Tier 1 - $3A/$10
Tier 2 - $50
Tier 3 - $800
Tier 4 - 20% up to $250

40% up to %500

Mail-Order (90 days)

Tier 1 - $6A/$30
Tier 2 - $100
Tier 3 - $160
Tier 4 - N/A

*A refers to generic prescription

EMPLOYEE CONTRIBUTION - PER PAY:

Employee - $68.75
Employee+Spouse - $156.77
Employee+Child(ren) - $137.53
Family - $213.01

Summary of Benefits Coverage (SBC)

Plan 2 - 4000 70/50

Summary of Benefits Coverage (SBC)

Plan 2 - 4000 70/50

Aetna Teledoc Flyer

Aetna Funding Advantage Flyer

Dental - Plan 1 - Guardian

Dental Benefit Summary

Page 3

Dental Benefit Summary

Page 3

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:

Single Deductible - $50
Family Deductible - $150

*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

Dental - Plan 2 - Guardian

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:

Single Deductible - $50
Family Deductible - $150

*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

Dental Benefit Summary

Page 3

Dental Benefit Summary

Page 3

Vision - Guardian

Vision Benefit Summary

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Vision Benefit Summary

Page 9

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

Basic Life and AD&D - Guardian

Life and AD&D Benefit Summary

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Life and AD&D Benefit Summary

Page 13

Your Voluntary Life Benefit

Premiums: Covered by your employer if you meet eligibility requirements
Employee Benefit: Up to $10,000
Portability: Allows you to take coverage with you if you terminate employment
Conversion: Allows you to continue your coverage after your group plan has
Waiver of Premium: for employees disabled prior to age 60, premium waived to age 65, if conditions are met

*Please refer to attached Benefit Summary for more complete plan details and exclusions*

Short Term Disability (STD) - Guardian

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:

Coverage Amount: Choose weekly benefit amount from $100 - $1,500 (see cost illustration on page 19 of the Benefit Summary)
Maximum Payment Period: 13 weeks
Accident Benefit Begin: Day 1
Illness Benefits Begin: Day 8

*Please see attached Benefit Summary for more complete plan details*

Short Term Disablity Benefit Summary

Page 17

Short Term Disablity Benefit Summary

Page 17

Enrollment Form

Click the link below to download and print your Enrollment Form. Once complete, please deliver to your HR Manager.

Enrollment Form

Guardian Kit

Guardian kit

Guardian Kit

Guardian kit

Contact Us

Client Contacts

JC

Jeff Criscione

jcriscione@cvcclub.com

(440) 248-4310

Account Team Contacts

KL

Kevin Lurie

Producer / Sales Consultant

kevin.lurie@nfp.com

(216) 410-6751

Additional Contacts

LW

Lindsey Walsh

Benefit Coordinator

lindsey.walsh@nfp.com

216-260-2404

NB

Naomi Butze

Sr Account Manager

naomi.butze@nfp.com

1-216-659-3813

Chagrin Valley Country Club

Table of Content

Plan Highlights

Medical - Plan 1 - Aetna

Summary of Benefits Coverage (SBC)

Summary of Benefits Coverage (SBC)

Aetna Teledoc Flyer

Aetna Teledoc Flyer

Aetna Funding Advantage Flyer

Aetna Funding Advantage Flyer

Medical - Plan 2 - Aetna

Summary of Benefits Coverage (SBC)

Summary of Benefits Coverage (SBC)

Aetna Teledoc Flyer

Aetna Teledoc Flyer

Aetna Funding Advantage Flyer

Aetna Funding Advantage Flyer

Dental - Plan 1 - Guardian

Dental Benefit Summary

Dental Benefit Summary

Dental - Plan 2 - Guardian

Dental Benefit Summary

Dental Benefit Summary

Vision - Guardian

Vision Benefit Summary

Vision Benefit Summary

Basic Life and AD&D - Guardian

Life and AD&D Benefit Summary

Life and AD&D Benefit Summary

Short Term Disability (STD) - Guardian

Short Term Disablity Benefit Summary

Short Term Disablity Benefit Summary

Enrollment Form

Enrollment Form

Enrollment Form

Guardian Kit

Guardian Kit

Contact Us

Client Contacts

Account Team Contacts

Additional Contacts