Diversified Well Logging 2023 Benefit Guide : simplebooklet.com

T A B L E O F C O N T E N T S3If you have questions, please contactHuman Resources.BENEFIT CONTACTS4ELIGIBILITY & ENROLLMENT5SUMMARY OF MEDICAL PLAN OPTIONS62024 MEDICAL PLANS7PREVENTIVE CARE BENEFITS9WHERE SHOULD I GO FOR CARE10DENTAL11VISION12LIFE AND AD&D13SUPPLEMENTAL PLANSGLOSSARY1415Our employees are our most valuableassets. Therefore, Diversified Well Loggingis committed to providing a comprehensiveemployee benefits program that helps ourteam members stay healthy, feel secure,and maintain a productive work-lifebalance.This book is designed to provide you withinformation to make enrollment decisionsthat best meet your needs. It highlightskey features of the benefits program andwill answer many of your immediatequestions. We encourage you to take timeto educate yourself about your options andchoose the best coverage for you and yourfamily. Please review this booklet carefullyand refer to carrier documents for details.

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E L I G I B I L I T Y & E N R O L L M E N T5Who is Eligible and When?If you are a full-time employee (working 30 ormore hours per week), you are eligible to enroll inthe benefits described in this guide. Your spouseor domestic partner and dependent children (upto age 26) are eligible to enroll in these benefitsas well.New Hire EnrollmentNew employees hired after the Annual OpenEnrollment period are eligible for benefits on thefirst day of the month following 60 days.Employees must complete benefit electionsusing Navigator within 60 days of the enrollmenteligibility date.Failure to submit your elections within the designated timeframe will result in no coverage for the entire plan year unless you experience a qualifying life event that meets requirement and timeframeAnnual Enrollment PeriodDuring Annual Open Enrollment, all employeesare required to complete their elections byaccessing the Employee Navigator portal. If youdo nothing, your elections will NOT roll over to the2024 benefit plans.Mid-Year Change in Status EventGenerally, once you enroll in your benefits, youcannot change your elections until the next openenrollment period. There are, however, someexceptions. The Health Insurance Portability andAccountability Act of 1996 (HIPAA) requires grouphealth plans[1]to provide a special enrollmentopportunity to an employee (or COBRA enrollee)upon the occurrence of specific events.Examples include: Acquisition of new dependent(s) due tomarriage Acquisition of new child dependent(s) due tobirth or adoption (including placement foradoption) Gain eligibility for premium assistancesubsidy under Medicaid or CHIP Loss of other health coverage if due to:• Loss of eligibilityo Death of spouse; divorceo Child loses status (e.g., reaches agelimit)o Employment change (e.g., termination,reduction in hours, unpaid FMLA)• Expiration of COBRA maximum period• Other employer terminates its plan (ordiscontinues employer contributions)• Loss of eligibility under Marketplace policyor individual market policy• Loss of Medicaid or CHIP Coverage

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M e d i c a lOnly In-Network benefits are shown as a summary of your medical plan benefits offered to you.For details and limitations, please refer to your summary of benefits for specific requirements regarding pre-authorizations, coverage limits, and out-of-network costs.CHOICE PLUS BCYHCHOICE PLUS BCX9Out-of-Network(Individual / Family) In-Network(Individual / Family) Out-of-Network(Individual / Family) In-Network(Individual / Family) You Pay In-Network$5,000/ $10,000$3,000/ $6,000$5,000/ $10,000$3,000/$6,000Deductible50%20%30%0%Coinsurance$10,000/ $20,000$6,000/ $12,000$10,000/$20,000$4,500/$9,000Out-of-Pocket MaximumsIn-NetworkIn-NetworkCoinsurance/CopaysCovered 100%Covered 100%Preventive Care$30$30Primary CareIncludedIncludedTelemedicine$30 for Designated Network/$60 for Network$30 for Designated Network/$60 for NetworkSpecialist Care$75$75Urgent Care$250 copay+ 20% coinsurance$300 copayEmergency Room Care20% after deductible0% after deductibleOutpatient Surgery 20% after deductible0% after deductibleInpatient HospitalizationPharmacy Retail RX (only 30-day supply shown)Preferred: $10/$25Non-Preferred: $10/$25Preferred: $10/$25Non-Preferred: $10/$25Preferred/Non-Preferred Generic(Tier 1)$35/$87.50$35/$87.50Preferred Brand (Tier 2) - Preferred/Non-Preferred$60/$150$60/$150Non-Preferred Brand (Tier 3) - Preferred/Non-PreferredNANASpecialty (Tier 4) - Preferred/Non-Preferred

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M e d i c a lOnly In-Network benefits are shown as a summary of your medical plan benefits offered to you.For details and limitations, please refer to your summary of benefits for specific requirements regarding pre-authorizations, coverage limits, and out-of-network costs.CHOICE PLUS HSAOut-of-Network(Individual / Family) In-Network(Individual / Family) You Pay In-Network$5,000/ $10,000$5,000/ $10,000Deductible50%20%Coinsurance$10,000/ $20,000$6,350/ $12,700Out-of-Pocket MaximumsIn-NetworkCoinsurance/CopaysCovered 100%Preventive Care20% coinsurancePrimary CareIncludedTelemedicine20% coinsuranceSpecialist Care20% coinsuranceUrgent Care20% coinsuranceEmergency Room Care20% coinsuranceOutpatient Surgery 20% coinsuranceInpatient HospitalizationPreferred: $10/25Non-Preferred: $10/$25Preferred/Non-Preferred Generic(Tier 1)$35/$87.50Preferred Brand (Tier 2) - Preferred/Non-Preferred$60/$150Non-Preferred Brand (Tier 3) - Preferred/Non-PreferredNASpecialty (Tier 4) - Preferred/Non-Preferred

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P R E V E N T I V E C A R E B E N E F I T S9Annual Physicals and Preventive CarePreventive Care doctor visits are covered undereach of our health plans at 100%. This meansthat you will not have copays, coinsurance, ordeductible expenses when you visit an in-network provider for your preventive care visits.Preventive care visits include services such asannual physicals, routine well-woman visits, andwell-child exams.Important: Services will not be consideredpreventive and will not be covered 100% if theyare part of a visit to diagnose, monitor, or treatan already existing symptom, illness, or injury; or,if you utilize an out-of-network provider and/orfacility for part of the visit or tests.To help you make sure that your preventive visitis covered 100%, we have provided the followingtips when scheduling your next preventive carevisit and/or while you are at the physician’soffice.1. Confirm your physician is in-network withyour health plan.2. When you schedule your appointment,explain you are coming in for your annualpreventive care physical and that it shouldbe covered 100% by your insurance.Remember, not all screening and tests areconsidered medically necessary and somehave age limits before they arerecommended for preventive care andcovered 100%.3. Each member is allowed one (1) preventivephysical every 12 months. Confirm withyour doctor that it has been at least 12months since your last physical.4. While at your visit, if you mention to yourphysician that you are experiencing specificsymptoms or issues, the purpose of yourvisit could change from preventive todiagnosing a symptom and/or illness. Ifnecessary, schedule a separateappointment for any current symptoms toensure the testing is coded as preventivecare and covered 100%. Do not ignorecurrent symptoms or issues and schedulethat appointment as soon as possible orhave it addressed at your preventive visitknowing you may now need to pay for theoffice visit and/or tests.5. If the physician sends you to a separatefacility to have a preventive procedure ortest performed, ensure that the facility isin-network and ask your physician if theprocedure is covered 100%.

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W H E R E S H O U L D I G O F O R C A R E ?10The chart below is meant to be a general outline of your options of where to receive care, typicallyavailable services, and associated costs. Check with providers and your carrier’s website for details.Cost and TimeType of CareReason for UsageCare Center• Often requires a copayment and/or coinsurance• Normally requires an appointment• Little wait time with scheduled appointment• Routine checkups• Immunizations• Preventive services• Management of your general health• Routine care• Your doctor knows your health history• Your doctor can refer you to specialistsDoctor’s Office($)• HSA Plan - Deductible must be met with HDHP• No appointment necessary• Calls are usually returned in 30 minutes or less• Minor Illnesses• Minor Infections • Cold & flu symptoms• Bronchitis• Allergies• Mental Health• You need help on the weekend, after-hours or while travelling• Your condition is not an emergency• Convenient 24/7 availability via phone or web• Prescriptions can be sent to your local pharmacy if necessaryVirtual Visit($)• Often requires a copayment and/or coinsurance similar to office visit• Walk-in patients welcome with no appointments necessary• Wait times can vary• Common infections (e.g. strep throat)• Minor skin conditions (e.g. poison ivy)• Flu shots• Pregnancy tests• You can’t get to your doctor’s office• Your condition is not an emergency• Convenient locations in malls or retail storesConvenience Care($$)• Often requires a copayment and/or coinsurance usually higher than an office visit• Walk-in patients welcome, but may have long wait times• Sprains• Strains• Minor broken bones (e.g. finger)• Minor infections• Minor burns• You need care quickly• Your condition is not life-threateningUrgent Care($$)• Often requires a much higher copayment and/or coinsurance than an office visit or urgent care visit• Open 24/7, but waiting periods may be longer because patients with life-threatening emergencies will be treated first• Heavy bleeding• Large open wounds• Sudden change in vision• Chest pain• Sudden weakness or trouble walking• Major burns• Spinal injuries• You need immediate treatment of a very serious condition• Your situation is life-threateningDo not ignore an emergency. If a situation seems life-threatening, take action. Call 911 or your local emergency number right away.Emergency Room($$$)

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D E N T A L11Diversified Well Logging offers two dentalplan options administered by Ameritas.A Dental Preferred Provider Organization (DPPO)is designed to provide you the freedom to visitthe dentist of your choice, regardless of networkcoverage. However, when you visit a participatingin-network dentist, you will have lower out-of-pocket costs, no balance billing, and claims willbe submitted by your dentist on your behalf asopposed to you being required to submit theclaim for reimbursement.Low PlanHigh PlanPlan NameAmeritas NetworkAmeritas NetworkNetworkIn-NetworkIn-NetworkPlan Provisions (Calendar Year Basis)$50$50Individual Calendar Year Deductible$50 per person$150Family Calendar Year Deductible$10 per person, per visit YesDeductible Waived for Preventive?$750$1,500Calendar Year MaximumNoNoMaximum Waived for Preventive?N/A$1,500Orthodontia Lifetime Limit N/A19Orthodontia Dep Age LimitIn-NetworkIn-NetworkPlan Services0%0%Type I or A – Preventive20%20%Type II or B – Basic Restorative50%50%Type III or C – Major RestorativeNot Covered50%Type IV or D – Orthodontia50%20%Periodontics/Endodontic Maintenance50%20%Periodontics/Endodontic ProceduresMAC90thPercentileOut of Network ReimbursementImportant: The plan year is January-December. The deductible and out-of-pocket maximum for this plan run from Januarythrough December, which means these amounts reset every January 1st.Note: The chart above outlines the costs you pay for covered services.Ameritas Predetermination of BenefitsBefore making any decision on a recommended treatment for a dental issue, ask your dentist for aPredetermination of Benefits, which is provided to you at no cost by your dentist. It will tell youwhether and at what level the dental procedures recommended in the treatment plan will be coveredby your dental plan and detail the portion of costs you will need to pay out-of-pocket.

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V I S I O N12Ameritas Low PlanHigh PlanPlan NameVSP ChoiceVSP Choice NetworkIn-NetworkIn-NetworkPlan ProvisionsEvery 12 MonthsEvery 12 Months Exam/Lenses/Contact LensesEvery 24 MonthsEvery 24 Months FramesIn-NetworkIn-NetworkPlan Services$25 Copay$10 CopayEye Examination$25 Copay$25 CopayGlasses/Materials*$105 Allowance$150 Allowance Frame Allowance*$105 Allowance$150 AllowanceCosmetic Elective Lenses*Up to $60Up to $60Contact Lens FitCovered in fullCovered in full Medically Necessary Lenses5%-15%5%-15%Value Added/Discount ProgramNote: The chart above outlines the costs you pay for covered services.*Benefit includes coverage for glasses or contact lenses, not both.Diversified Well Logging offers two visionplan options through Ameritas.This plan provides coverage for professionalvision care, lenses, contacts, and frames througha broad network of optical specialists.Participants will receive richer benefits by usingnetwork providers. For a list of network providersgo to www.vsp.comIf you utilize a non-network provider, you will beresponsible for paying all charges at the time ofservice and will be required to file an itemizedclaim with our vision carrier for reimbursement.The chart below outlines your benefits for In-Network coverage. Refer to your plan documentsfor details about Out-of-Network coverage.

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L I F E A N D A D & D13Company Paid – Basic Life/AD&DDiversified Well Logging provides every eligibleemployee with a term life insurance policy at50% cost. You must elect the life coverage. Theaccidental death & dismemberment (AD&D) planpays in addition to the basic life policy for theloss of life or loss of limb due to the result of anaccident. See plan documents about conversion,portability, waiver of premium, and age reductionschedule for more details.Designating a BeneficiaryYou must name the person(s) or entity toreceive benefits in the event of your death.This information must be added during openenrollment or new hire enrollment using ouronline benefits portal. You may update yourlife insurance beneficiary at any timethroughout the year and as many times asneeded as well. To update beneficiariesoutside of open enrollment or new hireenrollment, contact Human Resources.Company Paid – Basic Life/AD&DBenefitsPlan ProvisionsClass 1 – Owners & OfficersClass 2 - All Active Full-Time Employees EligibilityClass 1 - $100,000Class 2 - $50,000Life AmountClass 1 - $100,000Class 2 - $50,000AD&D Amount35% at age 6550% at age 70Reduction Schedule Due to AgeLincoln FinancialDisclaimer: Coverage may be delayed or denied if a member is not actively at work, is confined tohome or a facility, or during a period of limited activity. See detailed eligibility & evidence ofinsurability rules in the plan document.

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S U P P L E M E N T A L P L A N S14ColonialWho is Eligible? All full-time, active employees Legal Spouse Dependent children up to age 26Your Cost:Employees are responsible for the entire cost ofWorksite Insurance. See the benefit materials forrate information.Benefits You Receive:Detailed information regarding these benefits isincluded in the Colonial benefit packetsavailable. The following policies are available toyou for consideration.Products available: Critical Illness Insurance– A seriousmedical event such as cancer, heart attackor stroke could leave you in a period offinancial difficulty. This plan features a lumpsum payment in the event of diagnosis witha critical illness. Employees can electcoverage in from $10K, $15K or $20K.Accident Insurance–Accident Insurancehelps you fill some of the gaps caused bydeductibles, co-payments and out-of-pocketcosts related to an accidental injury. If youqualify, Colonial will pay a lump sumpayment that is specific to the injury ortreatment required. Hospital Indemnity Insurance–HospitalIndemnity Insurance helps with financialgaps should you have an extended hospitalstay. They will pay a lump sum payment thatis specific to your hospital stay. Voluntary Term Life Insurance–Voluntary term life insurance is available topurchase if you would like to have more lifeinsurance above what the company providesor for your family members Short Term Disability Insurance–Shortterm disability insurance is available forpurchase to protect your paycheck in theinstance of being out of work due to aninjury or illness.BenefitAccident$150Emergency Room$150Urgent Care$1,000 per person per yearInitial Hospitalization Admission$1,750 per person per covered accidentInitial ICU Admission$200 - $7,500Fractures$1,500Open Surgery

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C o s t o f C o v e r a g eThe contributions listed below are monthly. Contributions are made from each paycheck toward the benefits.These are automatically deducted from your gross pay before Federal Income and Social Security taxes arecalculated. Since contributions are deducted before your pay is taxed, your taxes will be based on a lowergross pay, and you end up paying lower taxes on the same salary.Medical ContributionsCHOICE PLUS HSACHOICE PLUSBCYHCHOICE PLUSBCX9$ 56.64$ 156.15$ 248.91Employee Only$ 685.00$ 944.70$ 1,003.95Employee + Spouse$ 205.02$ 282.63$450.53Employee + Child(ren)$ 565.79$ 779.96$ 828.88Employee + FamilyDental Contributions Low Plan High Plan$ 16.00$ 35.12Employee Only$ 33.96$74.24Employee + Spouse$ 39.04$ 86.36Employee + Child(ren)$57.00$ 125.48Employee + FamilyVision Contributions Low Plan High Plan$ 6.48$ 8.46Employee Only$ 12.48$16.24Employee + Spouse$ 11.60$ 15.24Employee + Child(ren)$ 17.60$ 23.08Employee + Family

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G L O S S A R Y16Allowed AmountMaximum amount on which payment is based for covered healthcare services. This may be called “eligible expense,” “paymentallowance” or “negotiated rate.” If your provider charges morethan the allowed amount, you may have to pay the difference.(See Balance Billing.)Balance BillingWhen a provider bills you for the difference between theprovider’s charge and the allowed amount. For example, if theprovider’s charge is $100 and the allowed amount is $70, theprovider may bill you for the remaining $30. An in-networkprovider may NOT balance bill you for covered services.CoinsuranceYour share of the costs of a covered health care service,calculated as a percent (for example 20%) of the allowed amountfor the service. You pay coinsurance plus any deductibles youowe. For example, if the health insurance or plan’s allowedamount for an office visit is $100 and you’ve met your deductible,your coinsurance payment of 20% would be $20. The healthinsurance or plan pays the rest of the allowed amount.CopaymentA fixed amount (for example, $25) you pay for a covered healthcare service, usually when you receive the service. The amountcan vary by the type of covered health care service.DeductibleThe amount you owe for health care services your healthinsurance or plan covers before your health insurance or planbegins to pay. For example, if your deductible is $1,000, yourplan won’t pay anything until you’ve met your $1,000 deductiblefor covered health care services subject to the deductible. Thedeductible may not apply to all services.Durable Medical EquipmentEquipment and supplies ordered by a health care provider foreveryday or extended use. Coverage for DME may include: oxygenequipment, wheelchairs, crutches or blood testing strips fordiabetics.Emergency Medical ConditionAn illness, injury, symptom or condition so serious that areasonable person would seek care right away to avoid severeharm.Emergency Medical TransportationAmbulance services for an emergency medical condition.Emergency Room CareAn evaluation of an emergency medical condition and thetreatment to prevent the condition from getting worse in anemergency room.Evidence of Insurability (EOI)(Also known as “Proof of Good Health”) an application process inwhich you provide information on the condition of your health oryour dependent's health in order to be considered for certaintypes of insurance coverage.Excluded ServicesHealth care services that your health insurance or plan doesn’tpay for or cover.Health InsuranceA contract that requires your health insurer to pay some or all ofyour health care costs in exchange for a premium.HospitalizationCare in a hospital that requires admission as an inpatient andusually requires an overnight stay. An overnight stay forobservation could be outpatient care.Hospital Outpatient CareCare in a hospital that usually doesn’t require an overnight stay.In-Network CoinsuranceThe percent (for example, 20%) you pay of the allowed amount forcovered health care services to providers who contract with yourhealth insurance or plan. In-network coinsurance usually costsyou less than out-of-network coinsurance.In-Network CopaymentA fixed amount (for example, $25) you pay for covered services toproviders who contract with your health insurance or plan. In-network copayments usually are less than out-of-networkcopayments.In-Network ProviderA provider who has a contract with your health insurer or plan toprovide services to you at a discount. Check your policy to see ifyou can see all preferred providers or if your health insurance orplan has a “tiered” network and you must pay extra to see someproviders. Your health insurance or plan may have preferredproviders who are also “participating” providers. Participatingproviders also contract with your health insurer or plan, but thediscount may not be as great, and you may have to pay more.Medically NecessaryHealth care services or supplies needed to prevent, diagnose ortreat an illness, injury, condition, disease or its symptoms andthat meet accepted standards of medicine.NetworkThe facilities, providers and suppliers your health insurer or planhas contracted with to provide health care services.Out-of-Network CoinsuranceThe percent (for example, 40%) you pay of the allowed amount forcovered health care services to providers who do not contractwith your health insurance or plan. Out-of-network coinsuranceusually costs you more than in-network coinsurance.Out-of-Network DeductibleSee Balance Billing.

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G L O S S A R Y17Out-of-Network CopaymentA fixed amount (for example, $30) you pay for covered healthcare services from providers who do not contract with your healthinsurance or plan. Out-of-network copayments are usually higherthan in-network copayments.Out-of-Network ProviderA provider who doesn’t have a contract with your health insurer orplan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to allproviders who have contracted with your health insurance orplan, or if your health insurance or plan has a “tiered” networkand you must pay extra to see some providers.Out-of-Pocket LimitThe most you pay during a policy period (usually a year) beforeyour health insurance or plan begins to pay 100% of the allowedamount. This limit never includes your premium balance-billedcharges or health care your health insurance or plan doesn’tcover. Some health insurance or plans don’t count all of yourcopayments, deductibles, or coinsurance payments, out-or-network payments or other expenses toward this limit.Physician ServicesHealth care services a licensed medical physician (M.D. –Medical Doctor or D.O. – Doctor of Osteopathic Medicine)provides or coordinates.PreauthorizationA decision by your health insurer or plan that a health careservice, treatment plan, prescription drug or durable medicalequipment is medically necessary. Sometimes called priorauthorization, prior approval, or precertification. Your healthinsurance or plan may require preauthorization for certainservices before you receive them, except in an emergency.Preauthorization isn’t a promise your health insurance or plan willcover the cost.Predetermination of BenefitsA review by your insurer's medical staff to decide if they agreethat the treatment is right for your healthneeds. Predeterminations are done before you get care, so thatyou will know early if it is covered by your health insurance plan.PremiumThe amount that must be paid for your health insurance or plan.You and/or your employer usually pay it monthly, quarterly, oryearly.Prescription Drug CoverageHealth insurance or plan that helps pay for prescription drugs andmedications that by law require a prescription.Primary Care PhysicianA physician (M.D. – Medical Doctor or D.O. – Doctor ofOsteopathic Medicine) who directly provides or coordinates arange of health care services for a patient.Primary Care ProviderA physician (M.D. – Medical Doctor of D.O. – Doctor ofOsteopathic Medicine), nurse practitioner, clinical nursespecialist or physician assistant, as allowed under state law, whoprovides, coordinates or helps a patient access a range of healthcare services.ProviderA physician (M.D. – Medical Doctor of D.O. – Doctor ofOsteopathic Medicine), health care professional or health carefacility licensed, certified or accredited as required by state law.Reconstructive SurgerySurgery and follow-up treatment needed to correct or improve apart of the body because of birth defects, accidents, injuries ormedical conditions.Rehabilitation ServicesHealth care services that help a person keep, get back or improveskills and functioning for daily living that have been lost orimpaired because a person was sick, hurt or disabled. Theseservices may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in avariety of inpatient and/or outpatient settings.Skilled Nursing CareServices from licensed nurses in your own home or in a nursinghome. Skilled care services are from technicians and therapistsin your own home or in a nursing home.SpecialistA physician specialist focuses on a specific area of medicine or agroup of patients to diagnose, manage, prevent or treat certaintypes of symptoms and conditions. A non-physician specialist is aprovider who has more training in a specific area of health care.UCR (Usual, Customary and Reasonable)The amount paid for a medical service in a geographic areabased on what providers in the area usually charge for the sameor similar medical service. The UCR amount sometimes is used todetermine the allowed amount.Urgent CareCare for an illness, injury or condition serious enough that areasonable person would seek care right away, but not so severeas to require emergency room care.

Diversified Well Logging 2023 Benefit Guide

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