Gemma & Sachet Benefits Booklet - Online Version 2019

Gemma | Sachet

Gemma / Sachet Employee
Benefits Overview

Effective March 1, 2019

General Plan Information

Congratulations on being part of the Gemma / Sachet Employee Benefits Plan. This guide will help you
make the most of your benefits package and provide important information regarding your plan(s).
Should you have additional questions about this benefit package, please contact our agent, AIA Benefit
Advisors, Inc. Helpful contact information can be found in the back of this booklet.

ENROLLING IN THE PLAN

New To The Plan?

If you are a new employee and would like to enroll in benefits, it is important that you take action during
your enrollment period. Your enrollment period is the time between when you are hire and when benefits
become effective. If you do not enroll in benefits by that deadline, you will not be able to enroll in these
benefits until the next open enrollment period, unless you experience a Qualifying Event.

You benefits become effective on the 1st of the month following 60 days of service.

Next Steps: Read this benefits guide to understand plan benefits, eligibility, and enrollment guidelines.
Then decide which benefits are right for you. Once you have decided, your employer will guide you
through the enrollment process. If your company offers online enrollment, please see the online
enrollment guide in the back of this booklet.

Existing Employees

Your benefit elections are locked in until next year’s open enrollment. You may be able to add, drop, or
change benefits outside of open enrollment if you experience a Qualifying Event

Qualifying Events Include: Birth, Marriage, Death, Divorce, Loss of Coverage, Overage Child, Change in
work hours, Court mandate (other qualifying events may apply. Please contact AIA or your plan
administrator for more information)

Benefits Eligibility

You are eligible to participate in the plan if you are a full-time employee working a regular schedule of at
least 30 hours per week.

You can cover eligible dependents on some or all of the plans offered to you. Eligible dependents
include:

1) Your Spouse or same gender domestic/civil union partner (unless legally separated or divorced
from you)..

2) Your own biological or legally adopted children under the age of 26 (or those age 26 and older
who are mentally or physically handicapped and depend on you for support).

List of Benefits Offered

Below is a list of benefits included in this package. Details on these plans can be found throughout this
booklet and on the detailed plan summaries and plan documents. For additional information, please
contact AIA Benefit Advisors, Inc.

BENEFIT Plan Provider When you can enroll
Medical Plan Aetna AFA Open enrollment or as a new hire

Telemedicine Teladoc Open enrollment or as a new hire

Dental Plan Principal Financial Open enrollment or as a new hire

Vision Plan Principal Financial Open enrollment or as a new hire

Employer Paid Life Principal Financial Automatically enroll as new hire

For Guaranteed Issue, as a new

Voluntary Life Plan Principal Financial hire (changes can be made with

evidence of insurability)

This chart is a general guide. Please contact your plan administrator for more details.

GEMMA / SACHET PREMIUM CONTRIBUTION
Your employer contributes a significant amount to the premium of most insurance plans offered in this
benefit program. The rates listed in this guide reflect the employer contribution and therefore list what will
be coming out of your paycheck.

Please note that Medical, Dental and Vision premiums are deducted on a Pre-Tax basis. Voluntary Life
Insurance premiums are deducted post-tax.

Medical Benefits Overview

Plan 1 Plan 2 Plan 3 Plan 4
$3,500 / 80% $6,750 / 80%
Plan Code $6,750 / 100% $3,500 / 100% Copay Plan Copay Plan
Local Network
Network Integrated Rx Integrated Rx Open Access
Network Type* EPO TX Health
Plan Type Open Access Open Access Copay EPO
EPO EPO Copay
Deductible (Cal Yr) In Network
Individual Integrated Rx Integrated Rx In Network
Family In Network In Network

Co-Insurance $6,750 $3,500 $3,500 $6,750
Max Out-of-Pocket
$13,500 $7,000 $7,000 $13,500
Individual
Family 100% 100% 80% 80%
Primary Care Visit
Out-of-Pocket Maximum Includes Calendar Year Deductible
Specialist Office Visit
$7,350 $6,500 $6,500 $7,150
Preventive Care
Hospital Care $14,700 $13,000 $13,700 $14,300

$35 Copay $25 Copay $30 Copay $40 Copay

Applies to Applies to $60 Copay $80 Copay
Deductible Deductible $0 $0

$0 $0

In-Patient Stay 100% After 100% After 80% After 80% After
Deductible Deductible Deductible Deductible

Out-Patient Surgery 100% After 100% After 80% After 80% After
Deductible Deductible Deductible Deductible

Out-Patient Diagnostic 100% After 100% After 80% After 80% After
Deductible Deductible Deductible Deductible

Emergency Room Deductible + Deductible + $300 Copay $350 Copay
$500 $250

Urgent Care $100 Copay $75 Copay $75 Copay $100 Copay

Mental Health

In-Patient 100% After 100% After 80% After 80% After

Deductible Deductible Deductible Deductible

Out-Patient See Summary See Summary See Summary See Summary

Pharmacy

Generic Drugs $3 / $10 / $45 / $3 / $10 / $45 / $3 / $10 / $45 / $3 / $10 / $45 /

$70 $70 $70 $70

Brand Drugs Applies to Applies to $45 / $70 $45 / $70
Deductible Deductible

Specialty Drugs Applies to Applies to 20% up to 20% up to

Deductible Deductible $250 $250

Copays apply toward plan out-of-pocket maximum

*Network Type(s): EPO – In network benefits listed above. Out of network claims are not covered

Medical Benefits Overview

HEALTH PLAN INFORMATION

The health plan offered to you in this package is designed to provide you and your dependents with
access to quality healthcare that is comprehensive and cost-conscious.

To enroll dependents in this plan, you must enroll yourself in the plan. If multiple plans are offered, your
dependents must enroll in the same plan as you.

Your Provider Network:

Plans 1 through 3 utilize the Aetna Open Access Network. This is Aetna’s large national network. Plan 4
utilizes the Texas Health Network, which is a local network and is smaller than the Open Access. Rates
are reduced because of this. Please reference the Network Information Handout to learn how to search
each network directory to find the right choice for you. Both networks are EPO networks, meaning there
are no out of network benefits

Medical Plan Employee Rates Plan 2 (OA Plan 3 (OA Plan 4 (TX
3500/100 Int 3500/80 Copay) Health 6750/80
Plan 1 (OA
Bi-Weekly Rates 6750/100 Int Rx) $134.61 Copay)

Rx) $86.63

Employee Only $64.99 $110.96

Employee & $291.51 $410.79 $472.12 $347.63
Spouse $309.94
$597.14
Employee & $215.32 $358.59 $259.84
Child(ren)

Employee & $432.30 $681.89 $509.85
Family

Rates listed are per pay period (Bi-weekly)

Carrier Website Network Information
https://goo.gl/i6hNJr Open Access is the large national Aetna
Create an account & view claims information network. TX Health is a local, smaller
network.
Medical ID Cards
Employees enrolled in the medical plan will TeleMedicine
receive ID cards that include unique ID Telephonic Office Visits are available through
numbers and a list of covered dependents. Teladoc. Visit www.teladoc.com for more
information.

Dental Plan Overview

Dental coverage is available through this benefits program. The dental carrier has a network made up of
a national group of providers who have contracted to deliver their services at a reduced cost.
Participating providers are screened and selected by the carrier and must meet pre-established
certification standards.

The dental PPO Network is a “passive” PPO. This means that you can go to any dentist you choose.
However, if you go out of network, there is a possibility that you could pay more for services by being
balance billed.

Access the online provider directory to determine which providers are in your network. The website of the
online directory is: www.principal.com

Plan Name Plan 1 Plan 2
Network Choice Dental Choice Dental
Out of Network Claims Principal PPO Principal PPO
Calendar Year Deductible
MAC 90th UCR
Individual
Family $50 $50
Ded. Waived For $150 $150
Benefit Tiers Preventive Services Preventive Services

Preventive 100% 100%

Basic 90% 80%

Major 60% 50%
Not Covered
Orthodontia Not Covered
$1,500
Annual Maximum $1,500
Plan 2 (90th UCR Plan) – Use
MAC/UCR Plan – MAC plan dentists must be in network Any Dentist
$12.18
Dental Plan Employee Rates

Bi-Weekly Rates Plan 1 (MAC Plan) – Use In-
Network Dentist!

Employee Only $12.18

Employee & Spouse $27.42 $27.42

Employee & Child(ren) $27.07 $27.07

Employee & Family $43.74 $43.74

Rates listed are per pay period (Bi-weekly)

Vision Plan Overview

Vision coverage is available through this benefits program. If you utilize an in-network provider, the plan
will cover either a portion or all of the cost. If you stay in the network, you pay less than if you go outside
the network. In addition, in-network providers will take care of all of your paperwork – there are no claims
to file.

If you do not use an in-network provider, you will receive an allowance toward your incurred expenses.
You pay for services when you receive them, then submit a claim for reimbursement from the plan.
Claims must be filed within 6 month of the date of service.

Access the online provider directory to determine which providers are in your network. The website for
the online directory is: www.vsp.com

Participating Provider Non-Participating Provider
VSP
Network

Eye Exams $10 Copay Out of Network Schedule
(Once Per 12 Months)

Lenses $25 Copay Out of Network Schedule
(Once Per 12 Months) Out of Network Schedule
Frames
Contact Lenses $25 Copay
(Once Per 24 Months)

$150 Allowance*

Medically Necessary 100% Out of Network Schedule
(In lieu of glasses)

Elective $150 Allowance Out of Network Schedule
(In lieu of glasses)

*After allowance, you receive a discount of 20% of the remainder of the cost of frames.

Vision Plan Employee Rates Vision Plan

Per Pay Period Rates

Employee Only $4.14

Employee & Spouse $8.01

Employee & Child(ren) $7.93

Employee & Family $12.76
Rates listed are per pay period (Bi-weekly)

Life Insurance Plan Overview

Base Life Insurance

Your employer has purchased life insurance for you. You are automatically enrolled in this coverage and
it will cost you nothing to have.
Amount of Base Life Insurance: $20,000
Amount of AD&D Included: $20,000

Voluntary Life Insurance

If you wish to increase the amount of life insurance you have, you may purchase additional coverage
through this company benefit program.

EMPLOYEE VOLUNTARY LIFE INSURANCE
⇒ Insurance may be purchased in increments of $10,000
⇒ Purchase up to $300,000 of Insurance (Evidence of Insurability may be required)
⇒ Max. Guarantee Issue Amount: $100,000 (Evidence of Insurability required for more)
⇒ Age Reductions: 65% at age 65; 50% at age 70

SPOUSE VOLUNTARY LIFE INSURANCE
⇒ You must purchase life insurance on yourself to insure your spouse
⇒ You may purchase up to 100% of the amount you have on yourself
⇒ Max. Guarantee Issue Amount: $30,000 (Evidence of Insurability required for more)
⇒ Age Reductions: 65% at age 65; 50% at age 70

CHILD VOLUNTARY LIFE INSURANCE
⇒ You must purchase life insurance on yourself to insure your child(ren)
⇒ You may purchase insurance in the amount(s) of: $10,000
⇒ Price is the same regardless of how many children you have

Voluntary Life payroll deductions will be made on a post-tax basis
For pricing information, please refer to the rate table in this booklet.

Voluntary Life Rate Table (Monthly)
Rates apply for Employee & Spouse

$10,000 29 & 30 - 34 35 - 39 40 - 44 45 - 49
$20,000 Under $0.94 $1.16 $1.70 $2.82
$30,000 $0.76 $1.88 $2.32 $3.40 $5.64
$40,000 $1.52 $2.82 $3.48 $5.10 $8.46
$50,000 $2.28 $3.76 $4.64 $6.80 $11.28
$60,000 $3.04 $4.70 $5.80 $8.50 $14.10
$70,000 $3.80 $5.64 $6.96 $10.20 $16.92
$80,000 $4.56 $6.58 $8.12 $11.90 $19.74
$90,000 $5.32 $7.52 $9.28 $13.60 $22.56
$100,000 $6.08 $8.46 $10.44 $15.30 $25.38
$150,000 $6.84 $9.40 $11.60 $17.00 $28.20
$200,000 $7.60 $14.10 $17.40 $25.50 $42.30
$250,000 $11.40 $18.80 $23.20 $34.00 $56.40
$300,000 $15.20 $23.50 $29.00 $42.50 $70.50
$19.00 $28.20 $34.80 $51.00 $84.60
$22.80

$10,000 50 - 54 55 - 59 60 - 64 65 - 69 70 & over
$20,000 $4.45 $7.87 $12.09 $14.41 $23.32
$30,000 $8.90 $15.74 $24.18 $28.82 $46.63
$40,000 $13.35 $23.61 $36.27 $43.23 $69.95
$50,000 $17.80 $31.48 $48.36 $57.64 $93.26
$60,000 $22.25 $39.35 $60.45 $72.05 $116.58
$70,000 $26.70 $47.22 $72.54 $86.46 $139.89
$80,000 $31.15 $55.09 $84.63 $100.87 $163.21
$90,000 $35.60 $62.96 $96.72 $115.28 $186.52
$100,000 $40.05 $70.83 $108.81 $129.69 $209.84
$150,000 $44.50 $78.70 $120.90 $144.11 $233.15
$200,000 $66.75 $118.05 $181.35 $216.16 $349.73
$250,000 $89.00 $157.40 $241.80 $288.21 $466.30
$300,000 $111.25 $196.75 $302.25 $360.26 $582.88
$133.50 $236.10 $362.70 $432.32 $699.45

Child Coverage: $0.92 Per Pay Period per Family

Need Help?

Questions About: Eligibility Service Issues
Benefits Enrolling in the Plan Claims Issues
Benefit Summaries Adding/Dropping Dependents Coverage Questions
Carrier Information Plan Changes Prescription Question
Provider Directories Ordering ID Cards

AIA Benefit Advisors, Inc. is your insurance agent. Should you have any questions, please contact AIA.
Most information can be found at www.aiabenefits.com/gemmasachet

AIA Benefit Advisors, Inc.
Phone: 972-519-0721
Fax: 972-596-9266
Agent: Kallen McCoy

Email: [email protected]

Insurance Company Contact Information
Your insurance carriers can offer valuable assistance. Most of the time company phone numbers are
listed on the back of your ID card. Please contact your insurance company with questions.

Insurance Group Number Website Phone Number
Company

Aetna AFA 0288129 www.aetna.com On ID Card

Principal Financial 1051974 www.principal.com 800-986-3343
Group

Carrier websites can also be found on your employee portal at the address below.

Benefits Website:
Many questions can be answered by visiting your benefits program website. Here you can find detailed
plan summaries, plan forms, carrier contact and website information, provider directories, etc. Please
visit your site for more information:

www.aiabenefits.com/gemmasachet

You May Also Enroll in Benefits at this site.

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