KOONCE PFEFFER BETTIS

2013 EMPLOYEE PACKET
BRIEF SUMMARIES OF EMPLOYEE BENEFITS
PLEASE REFER TO BOOKLETS FOR DETAIL
prepared by
1.907.522.2229
1.888.533.9669 (in ak)
COLVILLE INC. / BROOKS RANGE SUPPLY
BENEFITS SUMMARIES
TABLE OF CONTENTS
MEDICAL BENEFITS SUMMARY
Premera Blue Cross Blue Shield of Alaska
Group #1016686
1.800.508.4722 or
1.866.224.8550 (in AK)
HEALTH REIMBURSEMENT ARRANGEMENT SUMMARY (HRA)
Flex Plan Services
ID: Colville/Brooks
1.866.897.1996
DENTAL BENEFITS SUMMARY
Premera Blue Cross Blue Shield of Alaska
Group #1016686
1.800.508.4722 or
1.866.224.8550 (in AK)
VISION BENEFITS SUMMARY
Premera Blue Cross Blue Shield of Alaska
Group #1016686
1.800.508.4722 or
1.866.224.8550 (in AK)
HEARING BENEFITS SUMMARY
Premera Blue Cross Blue Shield of Alaska
Group #1016686
1.800.508.4722 or
1.866.224.8550 (in AK)
LIFE AND AD&D BENEFITS SUMMARY
USAble Life
Group #50013295
1.800.370.5856
VOLUNTARY LIFE BENEFITS SUMMARY
USAble Life
Group #50013295
1.800.370.5856
SHORT TERM DISABILITY BENEFITS SUMMARY
USAble Life
Group #50013295
1.800.370.5856
LONG TERM DISABILITY BENEFITS SUMMARY
USAble Life
Group #50013295
1.800.370.5856
WELLNESS PROGRAM
Contact your Employer
for Information
COLVILLE INC. / BROOKS RANGE SUPPLY
SUMMARY OF MEDICAL INSURANCE BENEFITS
PREMERA BLUE CROSS BLUE SHIELD OF ALASKA
Group #1016686
Deductible
$3,000* you only pay $750, then
Colville pays 100% of the next
$2,250
Office Visit Co-pay (6/calendar yr)
Outpatient Mental Health (unlimited)
Inpatient Mental Health (unlimited)
Chemical Dependency (unlimited)
Acupuncture (12/calendar yr)
Naturopathic Care (unlimited)
Manipulations (12/cal. yr)
Rehab (PT, Massage, etc. – 45/cal.yr)
Preventive Office Visit (unlimited)
Preventive Care (including most preventive lab &
pathology) - Immunizations, PAP smears,
mammograms, PSA, etc., covered)
$30**, then ded. & coinsurance
$30**
Deductible & coinsurance
$30***
$30**
$30**
$30**
$30***
No Cost to You!
Diabetic Health Education (unlimited)
No Cost to You!
Have provider verify which
procedures are covered at 100%
vs. go to deductible
Lab and pathology notes
No Cost to You!
Diagnostic services including lab and pathology unless
noted otherwise
Prescription Drugs Co-pay
1 month supply, retail pharmacy (unlimited)
Prescription Drugs Co-pay
Mail order, 3 month supply (unlimited)
Coinsurance Maximum
(point at which Premera begins paying 100% of
eligible expenses for remainder of calendar year)
Deductible & coinsurance
Air or ground ambulance
Additional Hospital Deductible
ER ($100 Co-Pay waived if admitted)
Ambulance
Lifetime Maximum (no lifetime maximum)
Phone
Website
$100 then ded. & coinsurance
None
$100 then ded. & coinsurance
$100 then ded. & coinsurance
$2,000,000 per year maximum
1.800.224.8550
www.premera.com
*
$10 generic/$30 other** no max.
$25 generic/$75 other** no max.
$3,000 in your 20%
plus your deductible expenses.
You will not begin paying 20% until
after you have had over $3,000 in
deductible expenses!
Colville, via the HRA, will pay $2,250 of deductible related charges after you have paid $750.
If you exceed $3,000, Premera will begin paying 80%
** Co-pays are not subject to or subtracted from the deductible
*** Only if billed separately by credentialed provider otherwise deductible &
coinsurance
This is a highlight of your plan based on seeing a preferred provider,
For specifics please go to website or your booklet
Preventive office visits, preventive imaging (lab, pathology, etc.), immunizations and mammograms are paid 100% by Premera. If
there is a diagnosis, the charges will go toward your deductible and coinsurance (other than office visit which remains $30)
Highlights of your Health Care Coverage
Colville Inc
Group Number: 1016686
Premera Blue Cross Blue Shield of Alaska believes this plan is a "grandfathered health plan" under the Affordable
Care Act. For more information, please refer to your Benefit Booklet. Any deductibles, copays, and coinsurance
percentages shown are amounts for which you're responsible.
Effective date: 11/1/2012
HPE $3,000/20%/$6,000/$30
MEDICAL PLAN - GRANDFATHERED
IN-NETWORK
MEDICAL COST SHARE OPTIONS
OUT-OF-NETWORK
Individual Deductible PCY (Family Deductible 3x
Individual)
Coinsurance (Member's percentage of costs after
deductible based on allowable charges)
$3,000 PCY
Shared with In-Network Deductible
20%
Individual Out of Pocket Maximum PCY, Excludes
Copay (Family OOP Max 3x Individual)
Office Visit Cost Share (First six visits include office and
home visits combined)
$6,000 PCY
Hospital/CD Facility & MD/DO/DPM: 50%; Other
Facilities & Professionals: Same as In-Network
Cost Share
Not Applicable
First 6 visits $30 Copay; then
Deductible/Coinsurance ²
MD/DO/DPM: 50%; Other Professionals: Same as
In-Network Cost Share
COVERED SERVICES
PREVENTIVE CARE OPTIONS AND HEALTH EDUCATION
Preventive Office Visit (Unlimited)
Covered in Full ¹
Immunizations (Unlimited)
Covered in Full ¹
Diabetes Health Education (DE) (Unlimited)
Covered in Full ¹
MD/DO/DPM: Deductible/Coinsurance; Other
Facilities: Same as In-Network Preventive Office
Visit Cost Share
MD/DO/DPM: Deductible/Coinsurance; Other
Facilities: Same as In-Network Immunization Cost
Share ³
Covered in Full
PROFESSIONAL CARE
Professional Office Visit Including Urgent Care
Inpatient Professional Services
First 6 visits $30 Copay; then
Deductible/Coinsurance ²
Deductible/Coinsurance
MD/DO/DPM: 50%; Other Professionals: Same as
In-Network Cost Share
Hospital/CD Facility & MD/DO/DPM: 50%; Other
Facilities & Professionals: Same as In-Network
Cost Share
Covered in Full ¹
Hospital/CD Facility & MD/DO/DPM:
Deductible/Coinsurance; Other Facilities &
Professionals: Same as In-Network Cost Share
Hospital/CD Facility & MD/DO/DPM:
Deductible/Coinsurance; Other Facilities &
Professionals: Same as In-Network Cost Share
Hospital/CD Facility & MD/DO/DPM:
Deductible/Coinsurance; Other Facilities &
Professionals: Same as In-Network Cost Share
DIAGNOSTIC SERVICE OPTIONS
Preventive Professional Diagnostic Imaging and
Laboratory Services - Including PAP/PSA
Other Professional Diagnostic Imaging and Laboratory
Services
Mammography
Deductible/Coinsurance
Covered in Full ¹
FACILITY CARE OPTIONS
Inpatient Facility
Deductible/Coinsurance
Outpatient Surgery Facility
Deductible/Coinsurance
Skilled Nursing Facility (60 days PCY)
Deductible/Coinsurance
Hospital/CD Facility: 50%; Other Facilities: Same
as In-Network Cost Share
Hospital/CD Facility: Deductible/Coinsurance; Other
Facilities: Same as In-Network Cost Share
Hospital/CD Facility: 50%; Other Facilities: Same
as In-Network Cost Share
¹ Benefits provided at 100% of allowable charges; not subject to deductible or coinsurance.
² The 6-visit limit is a combined total of all specified in-network visits PCY; deductible waived. Above is only a partial list. The full list can be found in your
Master Group Contract.
³ Seasonal immunizations provided at a pharmacy will be covered in full up to maximum allowable amount.
PCY = Per calendar year. Balance billing may apply if a provider is not contracted with Premera Blue Cross Blue Shield of Alaska. Members are
responsible for amounts in excess of the allowable charge.
This is not a complete explanation of covered services, exclusions, limitations, reductions or the terms under which the program may be continued in force.
This benefit highlight is not a contract. For full coverage provisions, including a description of waiting periods, limitations and exclusions please contact
Customer Service.
Document ID: CTR0142.400 - 325889
An Independent Licensee of the Blue Cross Blue Shield Association
10/22/2012 5:25 pm
Page 1 of 3
Highlights of your Health Care Coverage
Colville Inc
Group Number: 1016686
Premera Blue Cross Blue Shield of Alaska believes this plan is a "grandfathered health plan" under the Affordable
Care Act. For more information, please refer to your Benefit Booklet. Any deductibles, copays, and coinsurance
percentages shown are amounts for which you're responsible.
EMERGENCY CARE OPTIONS
Emergency Care (Waive copay if admitted, always
subject to deductible and coinsurance)
Ambulance Transportation
Air Ambulance (Unlimited)
Air or Surface Transportation
IN-NETWORK
Effective date: 11/1/2012
OUT-OF-NETWORK
$100 Copay,
Deductible/Coinsurance
$100 Copay,
Deductible/Coinsurance
$100 Copay,
Deductible/Coinsurance
Deductible/Coinsurance
$100 Copay, Subject to In-Network
Deductible/Coinsurance
$100 Copay, Subject to In-Network
Deductible/Coinsurance
$100 Copay, Subject to In-Network
Deductible/Coinsurance
Same as In-Network Deductible/Coinsurance
$30 Copay
MD/DO/DPM: 50%; Other Professionals: Same as
In-Network Cost Share
Covered as Any Other Service
OTHER SERVICES
Acupuncture (12 visits PCY)
Chemical Dependency (Unlimited)
Covered as Any Other Service
Home Health Care (130 visits PCY)
Deductible/Coinsurance
Hospice (Inpatient: 10 days; Respite: 240 hours; 6 month
limit)
Deductible/Coinsurance
Manipulations (spinal and other) (12 visits PCY)
Medical Supplies (MS), Equipment (ME), Prosthetics
(Pro) and Orthotics (Orth) ()
Mental Health Inpatient Facility Care(Unlimited)
Mental Health Outpatient Professional Care(Unlimited)
Naturopathy (Unlimited)
Rehab Inpatient Facility (30 days PCY)
Rehab Outpatient Care, Including Physical,
Occupational, Speech and Massage Therapy; Cardiac &
Pulmonary Rehab.; and Chronic Pain (45 visits PCY)*
Transplants (Unlimited up to the member annual
maximum; $75,000 donor and $7,500 travel and lodging
limits)
$30 Copay
Deductible/Coinsurance
Same as In-Network Medical
Inpatient Cost Share
Same as In-Network Medical Office
Visit Cost Share
First 6 visits $30 Copay; then
Deductible/Coinsurance ²
Deductible/Coinsurance
Covered as Any Other Service
Covered as Any Other Service
Hospital/CD Facility & MD/DO/DPM: 50%; Other
Facilities & Professionals: Same as In-Network
Cost Share
Hospital/CD Facility & MD/DO/DPM: 50%; Other
Facilities & Professionals: Same as In-Network
Cost Share
MD/DO/DPM: 50%; Other Professionals: Same as
In-Network Cost Share
Deductible/Coinsurance
Same as Out-of-Network Medical Inpatient Cost
Share
Same as Out-of-Network Medical Office Visit Cost
Share
MD/DO/DPM: 50%; Other Professionals: Same as
In-Network Cost Share
Hospital/CD Facility: 50%; Other Facilities & All
Professionals: Same as In-Network Cost Share
MD/DO/DPM: 50%; Other Professionals: Same as
In-Network Cost Share
Not Covered
SUPPLEMENTAL BENEFITS
Routine Vision Exam (1 PCY)
Waive Deductible/20%
Waive Deductible/20%
Vision Hardware (1 set of lenses PCY/1 frame every 2
consecutive calendar years)
Routine Hearing Exam (1 every 3 years to combined max
of $800 limit every 3 consecutive years)
Hearing Hardware (Combined $800 limit every 3
consecutive years)
Waive Deductible/20%
Waive Deductible/20%
Waive Deductible/20%
Waive Deductible/20%
Waive Deductible/20%
Waive Deductible/20%
LIFETIME MAXIMUM
Unlimited Lifetime Max, $2,000,000 Aggregate Annual Max
² The 6-visit limit is a combined total of all specified in-network visits; deductible waived. Above is only a partial list. The full list can be found in your
Master Group Contract.
* Massage Therapy must be billed by a licensed physician.
PCY = Per calendar year. Balance billing may apply if a provider is not contracted with Premera Blue Cross Blue Shield of Alaska. Members are
responsible for amounts in excess of the allowable charge.
This is not a complete explanation of covered services, exclusions, limitations, reductions or the terms under which the program may be continued in force.
This benefit highlight is not a contract. For full coverage provisions, including a description of waiting periods, limitations and exclusions please contact
Customer Service.
Document ID: CTR0142.400 - 325889
An Independent Licensee of the Blue Cross Blue Shield Association
10/22/2012 5:25 pm
Page 2 of 3
Highlights of your Health Care Coverage
Colville Inc
Group Number: 1016686
Pharmacy Benefits
Tier 1 = Generic
Tier 2 = Brand
Below is a brief overview of what you can expect to pay for a prescription drug, depending on which "tier" category it falls
under in the Preferred Drug List for your plan when using an In-Network Pharmacy. For more information on your pharmacy
benefits, including Out-of-Network benefits, see your benefit booklet. To find out what tier applies to a specific medication,
see our Preferred Drug List in your pharmacy packet or at www.premera.com.
Effective date: 11/1/2012
Any deductibles, copays, and coinsurance percentages shown are amounts for which you're responsible.
PHARMACY PLAN
C RX $0-$10/$30
Cost Share Category
Tier 1/ Tier 2
OUTPATIENT PRESCRIPTION DRUGS
Retail Cost Shares
Up to 90 day supply per prescription, 1 Copay required for
each 30-day supply; 30 day supply for specialty
Mail Cost Shares
Up to 90 day supply per prescription, 1 Copay per
prescription; 30 day supply for specialty
Individual Deductible PCY
$10/$30
Out of Pocket Max
Unlimited
Annual Benefit Max
Unlimited
$25/$75
$0
This is not a complete explanation of covered services, exclusions, limitations, reductions or the terms under which the program may be continued in force.
This benefit highlight is not a contract. For full coverage provisions, including a description of waiting periods, limitations and exclusions please contact
Customer Service.
Document ID: CTR0142.400 - 325889
An Independent Licensee of the Blue Cross Blue Shield Association
10/22/2012 5:25 pm
Page 3 of 3
COLVILLE INC. / BROOKS RANGE SUPPLY
SUMMARY OF HEALTH REIMBURSEMENT
ARRANGEMENT (HRA)
FLEX PLAN SERVICES
Grandfathered
Purpose of Plan
Uses
Preferred Providers
HRA Balance
Contact
Telephone
Fax (for claims)
E-mail (for claims)
Colville funds $2,250 into your HRA
account each year to reimburse you any
deductible expenses beyond $750.
Any expenses that go toward your
deductible beyond $750 will be reimbursed
to you by Colville at 100% via your HRA
until you reach $3,000 in eligible claims.
If you exceed $3,000 in eligible deductible
expenses, Premera will begin paying 80%
until your 20% payments total $3,000, then
Premera will pay 100% of eligible
expenses for the remainder of the year.
If you elect to go to a non-preferred
provider, you pay the additional costs, the
HRA does not pay those charges.
Every January 1, Colville/Brooks will add
money to your HRA account up to the
$2,250 point, even if you have used every
penny from the previous year.
www.flex-plan.com
1.866.897.1996
1.866.831.6222
[email protected]
COLVILLE INC. / BROOKS RANGE SUPPLY
HEALTH REIMBURSEMENT ARRANGEMENT CLAIM FORM
PLAN YEAR 2013 through DECEMBER 31, 2013
Section I – Employee Information
Employee SSN
Last Name, First Name, MI
__________-__________-__________
Day Phone (
)
Address
City
 Address Change
St
Zip
Email
Instructions
1.
Complete Section I – Employee Information. This form can only be used for services incurred during the plan year shown
above.
2.
Do not staple any documentation to claim form, please tape to separate sheet or include loosely in envelope. Do not
send originals (all claims are stored electronically and paper copies will be shredded).
3.
Complete Section II – Claims. Attach proper documentation showing the date(s) of service, type(s) of service and cost (No
cancelled checks, balance forwards or bank card receipts). Itemize all expenses to prevent delays in reimbursement. If your
expense is covered by your insurance, you must submit a copy of your explanation of benefits (EOB).
4.
Complete Section III - Signing the claim form. Fax or mail a signed claim form, but do not do both. Claims must be submitted
at least two (2) full business days prior to the scheduled reimbursement date
***Deductible expenses associated with the employer sponsored group medical plan are
eligible for reimbursement. An Explanation of Benefits (EOB) is required***
Section II – List Claimed Expenses
Service Dates
Type of Service
-
-
-
-
-
-
-
-
-
-
-
-
Name of Provider
For Whom
Total Request
Net Cost
$
Does the claimant have secondary coverage?
__Y
__N
If Yes, please provide an Explanation of Benefits (EOB) from both carriers.
Section III – Signature
To the best of my knowledge and belief, my statements on this claim form are complete and true. I understand that I am solely responsible for the validity of claims submitted to
this Plan. I am claiming reimbursement only for eligible expenses incurred by myself, spouse and/or dependents. Note: The IRS does not recognize Domestic Partners for
purposes of receiving tax-favored health benefits. For further information please contact your employer. I certify that these expenses have not been reimbursed under this plan
or by any other source and that they will not be reimbursed by any other source or insurance. By providing my email address, I am requesting that all possible communications
regarding this claim may be sent via email. I hereby authorize my HRA to be reduced by the amount(s) shown above.
Participant’s Signature X
Date
Fax completed form and documentation to:
FAX: (425) 709-7125 or (866) 831-6222
Email:
[email protected]
Mail forms and documentation to: Flex-Plan Services, Inc.
PO Box 53250 Bellevue, WA 98015-3250
Customer Service Line: (425) 452-3421 or (866) 897-1996
Visit our Web site at www.flex-plan.com
COLVILLE INC. / BROOKS RANGE SUPPLY
Health Reimbursement Arrangement (HRA)
Flex-Plan Services, Inc. is proud to be the claims administrator for your Health
Reimbursement Arrangement. This plan has been established by Colville, Inc. to reimburse
you and your family for medical deductible expenses
Plan Information
• Plan Year: January 1, 2013 – December 31, 2013
• Benefit: The HRA will reimburse deductible expenses as indicated below for each
enrolled participant:
Deductible Benefit
o 0% of the first $750
o 100% of the next $2,250
Maximum HRA Reimbursement
Employee only: $2,250
Employee plus one: $4,500
Employee plus family: $6,750
• Eligible Expenses: Deductible expenses associated with the employer sponsored
group medical plan.
• How it Works: Get treatment from a provider. The provider will bill your medical
insurance. You will receive an Explanation of Benefits (EOB) from the insurance
carrier. If you have secondary insurance, wait until you also receive the secondary
EOB before submitting both of the EOB’s and a completed claim form to Flex-Plan
Services for reimbursement. It is then your responsibility to pay the provider.
HRA Claims Submission
1) Fill out a claim form, make sure to write legibly and sign the bottom.
2) Include an Explanation of Benefits (EOB) from your insurance carrier.
If you have dual coverage, also include EOB from the secondary insurance carrier.
3) Fax, email or mail your claim to Flex-Plan Services.
4) Your reimbursement will be distributed to you by your employer. Reimbursements are
processed on the 15th and last day of each month.
5) You will have 90 days to turn in claims at the end of the plan year.
Customer Service Line: (425) 452-3421 or (866) 897-1996
Visit our Web site at www.flex-plan.com
COLVILLE INC. / BROOKS RANGE SUPPLY
HRA AND INSURANCE
INSTRUCTIONS FOR EMPLOYEES
WHO HAVE OTHER COVERAGE
If you have other insurance coverage, you need to wait until
both the Premera and your other source of coverage pay
BEFORE turning a claim into Flex Plan. In many cases,
whatever Premera does not pay, the other coverage will, so
any claim that is submitted to Flex Plan would be an
overpayment to you.
All you need to do is wait until you receive an Explanation of
Benefits (EOB) from Premera 1st and then your other
insurance showing the payments from Premera AND the
other carrier or coverage. In the case of Indian Health Care,
most medical expenses are covered 100% after Premera
pays. If there are outstanding amounts after both insurance
companies pay on your claim, you would then file a claim with
Flex Plan for your HRA. With the claim form, you would need
to provide proof that both Premera and your other source
have been billed and paid the maximum they will pay.
COLVILLE INC. / BROOKS RANGE SUPPLY
SUMMARY
OF DENTAL PLAN BENEFITS
PREMERA BLUE CROSS BLUE SHIELD OF ALASKA
GROUP #1016686
Preventive Services
Cleanings, exams,
Routine x-rays …
No deductible
Basic Services
Fillings, root canals …
Paid at 80% after ded.
$50 deductible
Major Services
Bridges, crowns,
in/onlays …
Paid at 50% after ded.
Calendar Year
Maximum
Preferred Providers
Website
Contact
$1,500
You may go to any dentist and get
100%, 80% or 50% of reasonable
charges paid by Premera. If you go to a
Preferred dentist (under Provider
Search on website), you will never have
charges that exceed what Premera
considers to be reasonable.
www.premera.com
1.800.224.8550
Highlights of your Health Care Coverage
Colville Inc
Group Number: 1016686
Any deductibles, copays, and coinsurance percentages shown are amounts for which you're responsible.
DENTAL PLAN
Effective date: 11/1/2012
DOPT $50/0%/20%/50%/$1500
COVERED SERVICES
Individual/Family Deductible PCY
$50 PCY / $150 PCY
DIAGNOSTIC/PREVENTIVE
-cleanings (limited to 2 PCY)
-emergency & non-routine exams (limited to 1 PCY)
-fluoride treatments (limited to 2 applications PCY for
members under age 20)
-routine oral exams (limited to 2 PCY)
-sealants (for members under age 19)
-space maintainers (for members under age 20)
-x-rays (including bitewing x-rays; complete series or
panoramic X-ray once per 36 consecutive months)
BASIC
-emergency palliative treatment
-fillings (limited to once per tooth surface every 24
consecutive months)
-general anesthesia (limited to covered dental procedures
at a dental-care provider's office when dentally necessary)
-oral surgery (including simple and surgical extractions)
-periodontal maintenance (limited to 4 visits per calendar
year)
MAJOR
-implants, dentures, partial & fixed bridges (replacements
for dentures, partials & fixed bridges limited to once every 5
calendar years)
-endodontic (root canal) treatment (limited to 2 per arch
when performed in conjunction with overdentures)
-full mouth debridement (limited to once every 3 calendar
years)
-inlays, onlays & crowns (replacements limited to once per
tooth every 5 years)
-periodontal scaling (limited to once per quadrant every 2
calendar years)
-periodontal surgery
-recementing & repair of crowns, inlays, bridgework &
dentures
Annual Maximum
0%
20%
50%
$1,500 PCY
Diagnostic and Preventive Care Services aren't subject to the calendar year deductible. PCY = Per calendar year. Balance billing may apply if a provider
is not contracted with Premera Blue Cross Blue Shield of Alaska. Members are responsible for amounts in excess of the allowable charge.
This is not a complete explanation of covered services, exclusions, limitations, reductions or the terms under which the program may be continued in force.
This benefit highlight is not a contract. For full coverage provisions, including a description of waiting periods, limitations and exclusions please contact
Customer Service.
Document ID: CTR0142.400 - 325872
An Independent Licensee of the Blue Cross Blue Shield Association
10/22/2012 5:27 pm
Page 1 of 1
COLVILLE INC. / BROOKS RANGE SUPPLY
VISION BENEFITS SUMMARY
PREMERA BLUE CROSS BLUE SHIELD OF ALASKA
GROUP #1016686
Shown in Medical highlights
Deductible
None
Vision Exams
Premera pays 80% of reasonable charges once
per year
Lenses
Premera pays 80% of reasonable charges
once per year
Frames
Premera pays 80% of reasonable charges
once every 2 years
Phone
1.800.224.8550
Website
www.premera.com
You also will receive a 45% discount at LensCrafters when you tell them
you are covered by Premera Blue Cross Blue Shield of Alaska under the
"Extras" plan!
COLVILLE INC. / BROOKS RANGE SUPPLY
HEARING BENEFITS SUMMARY
PREMERA BLUE CROSS BLUE SHEILD OF ALASKA
GROUP #1016686
Shown in Medical Highlights
Deductible
Routine Exam
Hearing Hardware
None
$800 1x every 3 years Combined
Phone
1.800.224.8550
Website
www.premera.com
COLVILLE INC. / BROOKS RANGE SUPPLY
SUMMARY OF LIFE AND ACCIDENTAL DEATH &
DISABILITY INSURANCE BENEFITS
USAble Life
GROUP #50013295
Deductible
None
Amount of Life coverage
$20,000 (employee only)
Amount of AD&D coverage
$20,000 (employee only)
Benefit Reduction
Full benefit to “normal Social
Security retirement age” (65
– 67) then benefit schedules
down
(see certificate for details)
Phone
1.800.370.5856
Website
www.usablelife.com
[email protected]
e-mail
If there is an accidental death, both plans pay out to the
beneficiary(s)
COLVILLE INC. / BROOKS RANGE SUPPLY
SUMMARY OF VOLUNTARY (EMPLOYEE
PAID) LIFE AND ACCIDENTAL DEATH &
DISABILITY INSURANCE BENEFITS
USAble Life
GROUP #50013295
Deductible
None
Amount of Voluntary Live Coverage
$10,000-$100,000 Employee
$5,000-$50,000 Spouse
$2,000,$4,000,$6,000,$8,000 or $10,000
Child(ren) over 14 days old
Amount of Voluntary AD&D
Coverage
SAME
Benefit Reduction
Full benefit schedules down
beginning age 65
(see certificate for details)
Phone
1.800.370.5856
No health questions if apply when first
eligible for coverage
Website
e-mail
www.usablelife.com
[email protected]
Voluntary Life and AD&D Premium Cost Worksheet - Colville, Inc.
Effective Date: November 1, 2012
Voluntary Life and AD&D for Employees
Monthly Rate
for Voluntary
Life & AD&D
AGE
<30
30-34
35-39
40-44
45-49
50-54
55-59
60-64
Monthly Premium (Based on Level Coverage) Example
(per $1,000 of benefit)
$10,000
$20,000
$30,000
$50,000
$70,000
$80,000
$100,000 $150,000
$200,000
$300,000
$400,000
$500,000
$0.11
$0.11
$0.15
$0.24
$0.36
$0.59
$0.99
$1.34
$1.10
$1.10
$1.50
$2.40
$3.60
$5.90
$9.90
$13.40
$2.20
$2.20
$3.00
$4.80
$7.20
$11.80
$19.80
$26.80
$3.30
$3.30
$4.50
$7.20
$10.80
$17.70
$29.70
$40.20
$5.50
$5.50
$7.50
$12.00
$18.00
$29.50
$49.50
$67.00
$7.70
$7.70
$10.50
$16.80
$25.20
$41.30
$69.30
$93.80
$8.80
$8.80
$12.00
$19.20
$28.80
$47.20
$79.20
$107.20
$11.00
$11.00
$15.00
$24.00
$36.00
$59.00
$99.00
$134.00
$22.00
$22.00
$30.00
$48.00
$72.00
$118.00
$198.00
$268.00
$33.00
$33.00
$45.00
$72.00
$108.00
$177.00
$297.00
$402.00
$44.00
$44.00
$60.00
$96.00
$144.00
$236.00
$396.00
$536.00
$55.00
$55.00
$75.00
$120.00
$180.00
$295.00
$495.00
$670.00
$16.50
$16.50
$22.50
$36.00
$54.00
$88.50
$148.50
$201.00
Voluntary Life and AD&D for Spouses
Monthly Rate
for Voluntary
Life & AD&D
AGE
<30
30-34
35-39
40-44
45-49
50-54
55-59
60-64
Monthly Premium (Based on Level Coverage) Example
(per $1,000 of benefit)
$5,000
$10,000
$15,000
$25,000
$35,000
$40,000
$50,000
$75,000
$100,000
$150,000
$200,000
$250,000
$0.11
$0.11
$0.15
$0.24
$0.36
$0.59
$0.99
$1.34
$0.55
$0.55
$0.75
$1.20
$1.80
$2.95
$4.95
$6.70
$1.10
$1.10
$1.50
$2.40
$3.60
$5.90
$9.90
$13.40
$1.65
$1.65
$2.25
$3.60
$5.40
$8.85
$14.85
$20.10
$2.75
$2.75
$3.75
$6.00
$9.00
$14.75
$24.75
$33.50
$3.85
$3.85
$5.25
$8.40
$12.60
$20.65
$34.65
$46.90
$4.40
$4.40
$6.00
$9.60
$14.40
$23.60
$39.60
$53.60
$5.50
$5.50
$7.50
$12.00
$18.00
$29.50
$49.50
$67.00
$8.25
$8.25
$11.25
$18.00
$27.00
$44.25
$74.25
$100.50
$11.00
$11.00
$15.00
$24.00
$36.00
$59.00
$99.00
$134.00
$16.50
$16.50
$22.50
$36.00
$54.00
$88.50
$148.50
$201.00
$22.00
$22.00
$30.00
$48.00
$72.00
$118.00
$198.00
$268.00
$27.50
$27.50
$37.50
$60.00
$90.00
$147.50
$247.50
$335.00
Employee and Spouse benefit costs are calculated from their respective ages.
Benefits are available for employees and spouses who are age 65 or greater. Please contact your Human Resources Department for rates.
You may elect increments of $10,000 to a maximum of $500,000 not to exceed seven times your annual salary.
If you are insured for Voluntary Life and AD&D, you may also elect coverage for your spouse in increments of $5,000 to a maximum of $250,000. Your spouse benefit may not
exceed 50% of your benefit amount.
Voluntary Life and Voluntary AD&D are a packaged benefit and may not be purchased independent of each other.
Child(ren) Voluntary Life and AD&D
If you are insured for Voluntary Life and Voluntary AD&D, you may also elect coverage for your child(ren) in $2,000 increments to a maximum of $10,000. The child(ren)
benefit may not exceed 50% of your Voluntary Life and Voluntary AD&D amount.
Monthly Rate
(per $2,000 of benefit per
family unit)
07/21/2008
Monthly Premium (Based on Level of Coverage)
$2,000
$4,000
$6,000
$8,000
$10,000
COLVILLE INC. / BROOKS RANGE SUPPLY
SUMMARY OF SHORT TERM DISABILITY
INSURANCE BENEFITS
USAble Life
GROUP #50013295
Deductible
How long before Short Term
Disability benefits begin?
Amount of income
replacement
Maximum
Benefit Duration
Phone
Website
e-mail
None
Immediately for injury;
No cap after 7 days of disability
for sickness
Up to 60% of your pre-disability
basic salary /pay
$1,000/week
13 weeks to dovetail with your
long term disability benefits (see
next page)
1.800.370.5856
www.usablelife.com
[email protected]
Your short term disability benefits may cover pregnancy, even if it
is not high risk
Benefit will never exceed 100% of pre-disability income, such as if
income is received due to auto insurance, judgments/settlements,
etc.
COLVILLE INC. / BROOKS RANGE SUPPLY
SUMMARY OF LONG TERM DISABILITY
INSURANCE BENEFITS
USAble Life
GROUP #50013295
Deductible
How long before LTD
benefits kick in
None
After 90 days of disability (short
term plan, when applicable,
covers from either 1st or 8th day
until the long term plan kicks in)
Up to 60% of your pre-disability
basic salary/pay
$5,000/month
Yes, up to 24 months
Amount of income
replacement
Maximum
Own occupation coverage
Mental health or substance
abuse, along with some other Limited to 24 months of income
specific conditions (please
replacement
refer to your certificate for
details)
Phone
1.800.370.5856
www.usablelife.com
Website
e-mail
[email protected]
Benefit will never exceed 100% of pre-disability income, such as if
income is received due to Workers’ Compensation, auto
insurance, judgments/settlements, etc.
COLVILLE INC.
Your employee benefits summary
USAble Life is proud to make the following benefits available to you as an employee of COLVILLE INC.:
Group Term Life/ Accidental Death &
Dismemberment
Voluntary Group Term Life (VGTL)
Group Short Term Disability
Group Long Term Disability
Voluntary Accidental Death &
Dismemberment (VAD&D)
$20,000.00
Benefits reduce to 65% at your age 65, and to 50% at your age 70, and to 30% at age 75, and to 20% at age 80.
Terminate when you are no longer eligible or your retirement whichever occurs first.
Employee: If you are age 69 or younger, you may purchase coverage in units of $10,000 to a maximum of $100,000
without medical evidence of insurability. Coverage over these amounts to a maximum of $500,000 is available with
medical evidence of insurability.
Spouse: You may purchase coverage for your eligible spouse, through the spouse’s age 69, in units of $5,000 to a
maximum of $50,000 without evidence of medical insurability. Coverage over these amounts to $250,000 is available
with medical evidence of insurability.
Children: You may purchase coverage for your eligible children between the ages of 14 days and over in the amount
of $2,000, $4,000, $6,000, $8,000 or $10,000.
Benefits reduce to 65% at age 65, and to 50% at age 70, to 30% at age 75, and to 20% at age 80. Spouse reduces to
65% at employee’s age 65 and to, 50% at employee’s age 70, to 30% at employee’s age 75, and to 20% at
employee’s age 80. Terminate when you or your spouse is no longer eligible or your retirement, whichever occurs
first. Children’s coverage terminates when they are no longer eligible or the termination of your eligibility, whichever
occurs first.
Pays a benefit of 60% of your Weekly Earnings to a maximum of $1,000 per week [less offsets for other income].
Benefits begin on the first day of covered disability resulting from an accident, and on the 8th day of a covered
disability resulting from sickness, and are payable up to a maximum of 13 weeks for any one covered disability.
Pays a benefit of 60% of your Basic Monthly Earnings to a maximum of $5,000 per month [less offsets for other
income]. Benefits begin on the 91st day of a covered disability and are payable for two (2) years if you are disabled
from your own occupation or to your Social Security Normal Retirement age (SSNR) for any occupation.
Employee: If you are age 69 or younger, you may purchase coverage in units of $10,000 to a maximum of $500,000.
Spouse: You may purchase coverage for your eligible spouse, through the spouse’s age 69, in units of $5,000 to a
maximum of $250,000.
Children: You may purchase coverage for your eligible children between the ages of 14 days and over in the amount
of $2,000, $4,000, $6,000, $8,000 or $10,000.
Employee Benefits reduce to 65% at age 65 and to 50% at age 70, to 30% at age 75, and to 20% at age 80. Spouse
Reduces to 65% at employee’s age 65, and to 50% at employees age 70, to 30% at employees age 75, and to 20% at
employee’s age 80. Terminate when you or your spouses are no longer eligible or your retirement, whichever occurs
first.
Important Note: If you are not actively at work on the date your insurance or any increase in insurance is scheduled to take effect, the coverage or increase in coverage will take effect on the
day you return to active work. This benefit summary provides a very brief description of USAble Life’s insurance products. This is not an insurance policy and only the actual provisions of an
issued policy control. USAble Life’s policies set forth the rights and obligations of covered persons and USAble Life. Please be aware that certain limitations and exclusions may apply, and
certain coverage may reduce or terminate due to age or lack of eligibility. If you enroll and are approved for coverage, you will be furnished with a policy or certificate of insurance. Please
read your insurance documents carefully.
Group Term Life Insurance is designed to provide benefits to your designated beneficiary for loss of life.
Group Term Life coverage also includes the following benefits:
Accelerated Benefit
Extended Life Insurance Benefit (Waiver of Premium)
Accidental Death and Dismemberment (AD&D) is payable, if within 365 days of a covered accident, you suffer loss of life or
dismemberment. AD&D provides protection for losses occurring on or off the job.
AD&D coverage also includes the following benefits:
Seat Belt/ Air Bag Rider Benefit
Coma Benefit
Exposure & Disappearance Benefit
Repatriation Benefit
Paralysis Rider
GRPNM-BENESUM(2-13)
COLVILLE INC.
Your employee benefits summary (continued)
Long Term Disability (LTD) is designed to provide partial income replacement for you should you become disabled as the result of a
covered sickness or injury.
Long Term Disability coverage includes the following benefits:
Return to Work Incentive
Survivor Benefit
Voluntary Group Term Life (VGTL) If you need additional term life protection for you and your eligible family members, think about USAble
Life’s low cost Voluntary Group Term Life coverage. You select the benefit amounts to suit your specific situation, and premium payments
are made through payroll deduction.
VGTL coverage includes the following benefits:
Accelerated Benefits Rider
Portability
Extended Life Insurance Benefit (Waiver of Premium)
Voluntary Accidental Death & Dismemberment (VAD&D) coverage allows you to purchase benefits to provide protection in the event of an
unexpected loss of accidental death or dismemberment. Protection is issued on a 24-hour basis for you and your eligible family members
and covers you as the result of a covered accident anywhere in the world.
VAD&D coverage includes the following benefits:
Seat Belt/ Air Bag Rider Benefit
Coma Benefit
Exposure & Disappearance Benefit
Repatriation Benefit
Speech & Hearing Benefit
Paralysis Rider
Additional Services from USAble Life
With Group Term Life Coverage:
Assist America is a global emergency medical travel assistance company. Anytime you, your spouse and/or minor dependent children are
traveling 100 miles or more away from home or in another country—with or without you present, they are protected by Assist America’s vast
assistance resources. A single phone call is all it takes to put Assist America in motion on your behalf.
Online Will Prep is a will preparation service. Living will documents are also available at no cost. Go to www.estateguidance.com to create
a simple or living will and use Promotional Code USW.
PO Box 1650
Little Rock, Arkansas 72203
(800) 648-0271
Conditions & Exclusions
About
Assist America, Inc., formed in 1990, is the nation’s largest
provider of global emergency services through employee benefit
plans. Assist America responds when any eligible member
becomes ill or injured while traveling just 100 miles or more away
from home or abroad.
Conditions
Assist America will not provide services in the following instances:
• Travel undertaken specifically for securing medical treatment
• Injuries resulting from participation in acts of war
or insurrection
• Commission of unlawful act(s)
• Attempt at suicide
• Incidents involving the use of drugs unless prescribed by
a physician
• Transfer of member from one medical facility to another
medical facility of similar capabilities and providing a similar
level of care
Assist America will not evacuate or repatriate a member:
• Without medical authorization
• With mild lesions, simple injuries such as sprains, simple
fractures, or mild sickness which can be treated by local
doctors and do not prevent the member from continuing
his/her trip or returning home
• With a pregnancy over six months
• With mental or nervous disorders unless hospitalized
Exclusions
Please detach card and carry with you at all times.
• Travel by a member’s spouse when it is for the benefit
of the spouse’s employer (spouse business travel)
• Trips exceeding 90 days from legal residence without prior
notification to Assist America (Separate purchase of Expatriate
coverage is available)
While assistance services are available worldwide, transportation
response time is directly related to the location/jurisdiction where an
event occurs. Assist America is not responsible for failing to provide
services or for delays in the delivery of services caused by strikes or
conditions beyond its control, including by way of example and not by
limitation, weather conditions, availability of airports, flight conditions,
availability of hyperbaric chambers, communications systems, or
where rendering of service is limited or prohibited by local law or edict.
All consulting physicians and attorneys are independent contractors
and not under the control of Assist America. Assist America is not
responsible or liable for any malpractice committed by professionals
rendering services to a member.
This is not a medical insurance card. Claims for reimbursement for services not provided by
Assist America will not be accepted.
ATTENTION
Le titulaire de cette carte est membre d’Assist America et a droit à
l’assistance médicale et aux services personnels d’Assist America.
El portador de esta tarjeta es miembro de Assist America y tiene derecho
a los servicios personales y de asistencia médica de Assist America.
The holder of this card is a member of Assist America and is entitled
to its medical and personal services.
or via e-mail: [email protected]
Outside the U.S.A.
Toll free inside the U.S.A.
+1-609-986-1234
800-872-1414
If you require medical assistance and are more than 100 miles from your
permanent residence or abroad, call Assist America’s Operations Center at:
For questions regarding the program, contact:
GLOBAL EMERGENCY SERVICES
Reference Number 01-AA-USA-06081
Name
USAble Life
320 West Capitol Avenue, Suite 700
Little Rock, AR 72201
Telephone: 1-800-648-0271
www.usablelife.com
202 Carnegie Center l Suite 302A l Princeton, NJ 08540
609-921-0868
www.assistamerica.com
is a registered service mark of Assist America, Inc.
05.08.300M
Global
Emergency
Services
Provided by
Global Emergency Services
Congratulations! As part of your policy with USAble Life you now have
a unique global emergency services program from Assist America. This
program immediately connects you to doctors, hospitals, pharmacies
Key Services
Medical Consultation, Evaluation & Referral
Calls to Assist America’s Operations Center are evaluated by medical
personnel and referred to English-speaking, Western-trained doctors
and/or hospitals.
Assist America’s Operations Center is
staffed 24 hours a day, 365 days a
year with trained multilingual and
medical personnel, including nurses
and doctors, to advise and assist you
quickly and professionally in a medical
emergency.
Assist America will render every possible assistance in the event of
a member’s death. This service includes arranging the preparation
of the remains for transport, procuring required documentation,
providing the necessary shipping container as well as paying
for transport.
Emergency Trauma Counseling
and other services when faced with a medical emergency while traveling
100 miles or more away from your permanent residence or abroad.
Return of Mortal Remains
Hospital Admission Guarantee
Assist America will guarantee hospital admission outside the United
States by validating a member’s health coverage or by advancing
funds to the hospital.
Assist America will provide initial telephone-based counseling and
referrals to qualified counselors as needed or requested.
Lost Luggage or Document Assistance
Assist America will help members locate lost
luggage, documents or personal belongings.
Emergency Medical Evacuation
If adequate medical facilities are not available locally, Assist America
will use whatever mode of transport, equipment and personnel
necessary to evacuate a member to the nearest facility capable
of providing a high standard of care.
Interpreter & Legal Referrals
Assist America will refer members to interpreters
and/or legal personnel, as necessary.
Pre-trip Information
One simple phone call to the number on your Assist America
identification card will connect you to:
l
l
Critical Care Monitoring
A global network of pre-qualified medical providers
Assist America’s medical personnel will maintain regular
communication with the member’s attending physician and/or
hospital and relay information to the family.
A state-of-the-art Operations Center with worldwide
response capabilities
Medical Repatriation
l
Experienced crisis management professionals
l
Air and ground ambulance service providers
If a member still requires medical assistance upon being discharged
from a hospital, Assist America will repatriate him/her home or to
a rehabilitation facility with a medical or non-medical escort,
as necessary.
Assist America offers members web-based
country profiles that include visa requirements,
immunization and inoculation recommendations, as
well as security advisories for any travel destination.
Please detach card and carry with you at all times.
CALL ASSIST AMERICA WHEN TRAVELING 100 MILES OR
MORE AWAY FROM HOME OR IN ANOTHER COUNTRY AND:
• You require medical or counseling assistance
Assist America completely arranges and pays for all of the assistance
services it provides without limits on the covered cost. This alleviates
many of the obstacles and potential expenses that can be caused by
medical emergencies away from home.
Prescription Assistance
If a member needs a replacement prescription while traveling, Assist
America will help in filling that prescription.
• You require legal assistance
• You experience local language problems
Emergency Message Transmission
It is important to keep your identification card with you at all times so
that you can call for services whenever you need them.
Assist America will receive and transmit emergency messages
for members.
Assist America is not travel or medical insurance, rather it is a provider
of global emergency services.* Assist America’s services do not replace
medical insurance during medical emergencies away from home. All
medical costs incurred should be submitted to your health plan and
are subject to the policy limits of your health coverage.
Compassionate Visit
If a member is traveling alone and will be hospitalized for more than
seven days, Assist America will provide economy, round-trip, common
carrier transportation to the place of hospitalization for a designated
family member or friend.
Care of Minor Children
*All services must be arranged and
provided by Assist America. No claims
for reimbursement will be accepted.
Assist America will arrange for the care
of children left unattended as the result
of a medical emergency and pay for
any transportation costs involved in
such arrangements.
All services must be arranged and provided
by Assist America. No claims for
reimbursement will be accepted.
PLEASE PROVIDE THE FOLLOWING INFORMATION WHEN
YOU CALL:
• Your name, telephone number and relationship to the patient
• Patient’s name, age, gender, reference number and employer
• A description of the patient’s condition
• Name, location and telephone number of hospital or treating
doctor, if applicable
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