Transcript YOUR BENEFITS AT A GLANCE 12/1/2015 * 11/30/2016

PARTNERS BENEFITS AT A GLANCE
11/1/2015 – 10/31/2016
Our Commitment To You: Plans designed for your needs
Our benefit plans are designed to recognize the diverse needs of our workforce. Our goal is to offer you competitive benefit options that allow
you to design your own plan based on your individual needs.
We encourage you to review all of your options before making your benefit elections. Please visit https://www.fisherbroyles.com/welcomeaboard/ to access your employment forms, carrier enrollment forms and vital plan documents .
BENEFIT BASICS
Once you elect your Fisher Broyles benefit options, your elections remain in effect for the plan year 11-1-2015 through 10-31-2016. You may
only change coverage due to a qualifying life event and must do so within 30 days of the event.
QUALIFYING LIFE EVENT
• Change in status, which includes: marriage, birth/adoption of a child, employment changes, changes in residence, dependent
satisfies or ceases to satisfy eligibility requirements
• Dependent’s Open Enrollment through their employer
• Significant cost or coverage changes
• HIPAA special enrollment rights
• FMLA special requirements
• Changes due to a judgment, decree or court order
• Entitlement to Medicare or Medicaid
ELIGIBILITY
Fisher Broyles employees are eligible for benefits the first day of active employment. Following the date of hire. Eligible dependents are
defined as spouses, domestic partners, and/or dependent children up to age 26. Employee coverage must be elected in order for dependent
coverage to be valid.
About this guide This document is a summary of the benefits provided under a group insurance plan. The summary is an outline only and is not a
contract. This plan contains certain exclusions and limitations as well as terms under which coverage may be continued or discontinued. Please refer to
the certificate of insurance for a complete description of actual plan benefits and terms of coverage.
MEDICAL PLAN OPTIONS
BENEFITS
HNOPTION 1500 100
In Network
OAMC 1500 100
In Network
OAMC 3000 80
In Network
HNOption 5000 Choice
In Network
OAMC 5000 EQHD
In Network
Calendar Year Deductible
$1,500/Single
$3,000/Family
80% Reimbursement
$4,500/Single
$9,000/Family
$1,500/Single
$3,000/Family
80% Reimbursement
$4,500/Single
$9,000/Family
$3,000/Single
$6,000/Family
80% Reimbursement
$6,000/Single
$12,000/Family
$5,000/Single
$10,000/Family
100% Reimbursement
$6,500/Single
$13,000/Family
$5,000/Single
$10,000/Family
80% Reimbursement
$6,450/Single
$12,900/Family
$35 Copay
$60 Copay
100% Reimbursement
$35 Copay
$60 Copay
100% Reimbursement
$30 Copay
$60 Copay
100% Reimbursement
$30 Copay
$60 Copay
100% Reimbursement
*$25 Copay
*$50 Copay
100% Reimbursement
$100 Copay/Admission
100% Reimbursement
Deductible Applies;
100% Reimbursement
$100 Copay
100% Reimbursement
Deductible Applies;
100% Reimbursement
$300 Copay
Waived if admitted
$75 Copay
$100 Copay/Admission
100% Reimbursement
Deductible Applies;
100% Reimbursement
$100 Copay
100% Reimbursement
Deductible Applies;
100% Reimbursement
$300 Copay
Waived if admitted
$75 Copay
Deductible Applies;
80% Reimbursement
Deductible Applies;
80% Reimbursement
Deductible Applies;
100% Reimbursement
Deductible Applies:
100% Reimbursement
$500 Copay
Waived if admitted
$75 Copay
$250 Copay/Admission
100% Reimbursement
Deductible Applies:
100% Reimbursement
$250 Copay
100% Reimbursement
Deductible Applies;
100% Reimbursement
$500 Copay
Waived if admitted
$75 Copay
$3/$15
$35
$65
30%/$250 Maximum
2.5 x Copay
$3/$15
$35
$65
30%/$250 Maximum
2.5 x Copay
$3/$15
$45
$75
30%/$250 Maximum
2.5 x Copay
$3/$15
$45
$75
30%/$250 Maximum
2.5 x Copay
*$3/$15
*$35
*$65
*30%/$250 Maximum
*2.5 x Copay
$685.79
$586.29
$435.57
$435.57
$1,371.57
$1,268.70
$1,954.49
$1,172.57
$1,084.63
$1,670.91
$871.16
$805.82
$1,241.39
$871.16
$805.82
$1,241.39
Coinsurance Reimbursement
Out of Pocket
Calendar Year Maximum
(Excludes deductible)
Physician Services
 Office Visit
 Specialists
 Routine Physicals
Inpatient Hospital Services
 Facility
 Physician Services
Outpatient Hospital Services
 Facility
 Physician Services
 Emergency Room
 Urgent Care
Prescription Drugs
 Generic
 Brand
 Non Formulary
 Specialty
Mail Order (90 Days)
Monthly Employee Cost
Employee Only
Employee plus Spouse
Employee plus Child(ren)
Employee plus Family
Deductible Applies;
80% Reimbursement
Deductible Applies;
100% Reimbursement
*$300 Copay
Waived if admitted
*$75 Copay
*You must pay all costs up to the deductible amount before this plan begins to pay for covered services you use. The copays will only apply once the deductible has been met.
DENTAL & VISION PLANS
Dental Principal
PPO DENTAL BENEFITS
Preventive Services
PAID AT 100%, NO DEDUCTIBLE
Routine Cleanings | Sealants | X-Rays
100% EMPLOYER PAID
PAID AT 80%
Composite Fillings| Endodontics| Periodontics
Employee Benefit:
PAID AT 50%
$15,000 Crowns | Dentures| Inlays | Onlays | Bridges
Basic Services
Major Services
Orthodontic Services
(Children under age 19)
N/A
Calendar Year Maximum
$1,500
Annual Deductible
Individual / Family
$50 / $150
Monthly Employee Contributions
Employee Only
$46.58
Employee + Spouse
$89.00
Employee + Child(ren)
$96.00
Family
$144.00
In Network Shown – See summary for complete Out of Network Reimbursement Schedule
Vision Principal
Eye Exam / Materials
(every 12 months)
Plan pays 100% after $10 copay
Lenses (every 12 months)
Plan pays 100% after $25 copay
Frames (every 24 months)
Plan pays $130 retail allowance, then 20% off remaining balance
Contact Lenses (every 12 months in lieu of lenses/frames)
- Medically Necessary
$150 allowance, then 20% off remaining balance Plan pays up to $60 for fitting
$25 Copay
Monthly Employee Contributions
Employee Only
$9.51
Employee + Spouse
$18.00
Employee + Child(ren)
$19.00
Family
$30.00
LONG TERM DISABILITY & EAP
Long Term Disability Principal
Eligible Members
All active, full time employees (except seasonal, temporary, or contract workers) who work at least 30
hours per week
Primary Monthly Benefit
Benefit Amount/Definition of Earnings
Orthodontic Services
(Children under age 19)
60%PAID
or your predisability earnings up to $10,000
100% EMPLOYER
Primary monthly benefit less other income sources/ Base Wage
Employee
Benefit:
$15,000
N/A
Calendar Year Maximum
$1,500
Annual Deductible
Individual / Family
$50 / $150
Monthly Employee Contributions are based on the Employee’s Age
Employee Assistance Program - Magellan Healthcare
www.magellanHealth.com/member
1-800-450-1327
Benefits / Enrollment / Claims Questions
Questions about Claims or Utilizing your Health
Benefits?
Contact Kerri Ortiz at The Benefit Company
678-904-9352 or Sloane Murray at 678-904-9314 or
email [email protected]
In some cases, a HIPAA Authorization form may be requested
to allow us to serve as your advocate