The benefits plan year runsDecember 1st through November 31st. Unless you have a qualified change-in-status event that impacts your eligibility and the change is allowed under the terms of the insurance contract or plan document, you cannot make changes to your benefits until the next Open Enrollment period.Benefit changes must be consistent with your qualified change-in-status event.Mid year changes must be submitted to Human Resources within 30 days of the event; documentation supporting the change will be required.Who is eligible for benefits?All full-time employees who work a minimum of 30 hours per week are eligible for benefits. For new hires, benefits are effective on the first of the month following 60 days of employment.In addition to enrolling yourself, you may also enroll any eligible dependents. Eligible dependents are defined below:• Spouse: a person to whom you are legally married by ceremony• Child(ren): Your biological, adopted, or legal dependents up to age 26 regardless of student, financial, and marital status; coverage for a dependent child will terminate at the end of the month in which the child turns age 26Change-in-Status EventsUnless you have a qualified change-in-status event that impacts your eligibility and the change is allowed under the terms of the insurance contract or plan document, you cannot make changes to the benefits you elect until the next Open Enrollment period. Some examples of qualified change-in-status events are highlighted below:Marriage or divorceBirth, adoption, or deathChange in employment, or employment status for you, your spouse, or your dependent childChange in coverage under another employer plan, such as a change made during your spouse’s Open EnrollmentLilyrain Jewelry takes pride in providing a comprehensive employee benefits program, and we recognize the important role employee benefits play as a critical component of your overall compensation. We strive to maintain a benefits program that is rewarding and competitive.WHAT’S INSIDEEmployee Resources Employee Contributions Medical Dental Vision Plan Highlights Life/AD&D Disability Employee Assistance Program Travel Assistance Program2
EMPLOYEE RESOURCESPlanPolicy Number Phone Number and Website/EmailMedicalBlue Cross Blue Shield2541811-800-521-2227www.bcbstx.com DentalPrincipal Financial1101143800.986.3343www.principal.com VisionPrincipal Financial1101143800.986.3343www.principal.com Life and Disability InsurancePrincipal Financial1101143800.986.3343www.principal.com Employee Assistance ProgramMagellan HealthLilyrain Jewelry800.588.8412www. magellanHealth.com/member.com Travel Assistance ProgramAXA AssistanceLilyrain Jewelry855.327.1441www.acatravelinsurance.com Many of our providers have mobile apps that provide personalized access to your benefits when and where you need it! There are also a variety of FREE health and fitness related apps available. Browse and download apps to your smartphone or tablet from the App Store or Google Play.THERE’S AN APP FOR THAT!EMPLOYEE CONTRIBUTIONS PER PAY PERIODBased on 26 pay periods per yearPlan FeaturesEmployee Employee + Spouse Employee + Child(ren) FamilyMEDICAL—BlueCross BlueShield$5,000 HDHP PPO (MTBCP608)$170.44$306.75$391.97$528.32$2,500 PPO (MTBCP709)$228.91$411.99$526.45$709.58$1,000 PPO (MTBCP803)$276.20$497.11$635.21$856.18DENTAL—PrincipalPPO Plan$5.91$13.33$11.40 $19.72VISION—PrincipalVSP Vision$1.48$3.15$2.69 $4.693
4We offer three PPO plans for you to choose from. To locate a participating, in-network provider, visit www.bcbstx.com. This chart is intended for summary purposes only. If there are any discrepancies, the official plan documents will always govern. Pre-certification may be required for certain services.MEDICAL & PRESCRIPTION PLAN HIGHLIGHTSPlan Features$5,000 HDHP PPO $2,500 PPO $1,000 PPO (MTBCP608) (MTBCP70922) (MTBCP80322)In-Network: YOU PAY In-Network: YOU PAY In-Network: YOU PAYAnnual Deductible$5,000 individual $2,500 individual $1,000 individualAmount you must pay before the plan will begin to pay for certain services.$10,000 family $7,500 family $3,000 familyCoinsurance Your responsibility after annual deductible has been met.0% 30% 20%Annual Out-of-Pocket Maximum $5,000 individual $5,500 individual$4,000 individualMaximum amount you pay per calendar year for covered expenses.$10,000 family $14,700 family$12,000 familyOFFICE VISITS, LABS, AND TESTINGPreventive Services (wellness visit) No charge No charge No chargePCP/Specialist Office Visits$0 after deductible $35 / $70 $30 / $60Virtual Visit$0 after deductible $35 $30 Diagnostic Test (x-ray, blood work) 0% after deductible 30% after deductible No chargeImaging (CT/PET scans, MRIs) 0% after deductible 30% after deductible 20% after deductibleHOSPITALInpatient/Outpatient0% after the deductible 30% after deductible 20% after deductibleURGENT AND EMERGENCY CAREUrgent Care Facility0% after deductible $75 copay $75 copayHospital Emergency Room0% after deductible$500 + 30% after deductible$500 + 20% after deductiblePRESCRIPTION DRUGSRetail Pharmacy, 30 day 0% after deductibleParticipation / Non-ParticipatingParticipation / Non-Participating$0 / $10 / $20 / $50 / $70 / $100 / $120 / $150 / $250$0 / $10 / $20 / $50 / $70 / $100 / $120 / $150 / $250Mail Order, 90 day0% after deductible 3x retail copay 3x retail copayOUT-OF-NETWORKAnnual Deductible$10,000 individual $5,000 individual $2,000 individual$20,000 family $15,000 family $6,000 family Coinsurance30% 50% 40%Annual Out-of-Pocket Maximum$20,000 individual $13,000 individual $8,000 individual$40,000 family $39,000 family $24,000 family
Health Savings Account (H.S.A.)The main purpose of a health savings account (HSA) is to help pay for qualified medical expenses when enrolled in a high deductible health plan (HDHP).Contributions to the HSA are made pre-tax, providing savings for your out-of-pocket healthcare expenses.You always own the money in your HSA, including contributions from your employer and interest. This account is yours to keep, even if you change jobs or retire.Once your HSA is established, money is contributed to your account by you and Lilyrain Jewelry, LLC. You can use the HSA to pay for qualified medical expenses such as doctors office visits, prescription drugs, vision expenses, and much more. Best of all you decide how and when to use your HSA dollars.IRS ANNUAL LIMITS2023 Max Contribution (Employee) 2024 Max Contribution (Employee)Single Only* $3,850 $4,150Employee + Family* $7,750 $8,300*Catch up contribution; Employees Age 55+ can contribute an additional $1,000to the max contributions above.Health Savings Account55
DentalWe are pleased to offer you a comprehensive dental PPO plan. You can visit any licensed dentist, but your costs are usually lowest with an in-network dentist. In-network dentists accept reduced fees for covered services; out-of-network dentists may balance bill you the difference between their usual fee and what the plan pays.Plan Features In-Network & Out-of-Network*NetworkPrincipal PPOCalendar Year Deductible Amount you must pay per calendar year before the plan begins to pay benefits waived for preventive$50 individual$150 familyPreventive and Diagnostic ServicesNo charge—no deductibleBasic ServicesDeductible, then 20%Major ServicesDeductible, then 50%Annual Benefit Maximum Maximum amount the plan will pay per calendar year$1,250 per person per calendar year, plus any maximum rollover benefitLimitations or waiting periods may apply for some benefits; some services may be excluded from your plan. These chart s are intended for summary purposes only. If there are any discrepancies, the plan document will always govern.*Dental Reimbursement for out-of-network services is based on the maximum contract allowances and not necessarily each dentist’s submitted fees. You will pay less money when you stay within the network. DENTAL & VISION PLAN HIGHLIGHTSPrevention first!Make sure you take advantage of your preventive dental visits. Preventive care services are not subject to the deductible and the plan covers 100% of the cost if you visit an in-network provider!Maximum RolloverWith Maximum Rollover, you are eligible to roll over a portion of your unused annual maximum. To qualify, you must have had a dental service performed within the calendar year and used less than the maximum threshold. The threshold is equal to the lesser of 50% of the maximum benefit, or $1,250. If the qualification is met, 50% of the threshold is carried over to next year’s maximum benefit. You can accumulate no more than four times the carry over amount. Please be sure to schedule your annual exams because your entire accumulated amount will be forfeited if no dental service is submitted within a calendar year.6VisionYour vision coverage provides a full range of vision care services. You may receive care from any provider you choose, but your benefits are greater when you see a participating provider in the network. If you choose to receive services from an out-of-network provider, you will be required to pay that provider at the time of service and submit a claim form for reimbursement.Plan Features In-NetworkOut-of-Network ReimbursementVision ExamOnce every 12 months$10 copay Up to $45Eyeglass FramesOnce every 12 months$130 plan allowance + 20% off balance Up to $70Eyeglass LensesOnce every 12 months SingleBifocal TrifocalLenticular$25 copay$125 copay$25 copay$25 copayUp to $30 Up to $50 Up to $65Up to $100Contact Lenses Once every 12 months in lieu of eyeglassesElective: $130 allowanceNecessary: $25 copayUp to $105Up to $210Additional Savings for Members:• 20-25 % off additional glasses and sunglasses, including lens options, from any VSP doctor.• Lasik or PRK: 15% off retail price or 5 % off promotional price.
Basic Term Life and AD&D Insurance (Company Paid)All full-time employees working 30 or more hours per week are automatically enrolled in the basic life benefit. While coverage is automatic, is critical that you complete a beneficiary form when first enrolling in benefits. You can change your beneficiary at any time and as frequently as needed. LIFE INSURANCEDuring your benefits enrollment, don’t forget to designate a beneficiary!7Life insurance helps protect your family from financial risk and sudden loss of income in the event of your death. Accidental death and dismemberment (AD&D) insurance provides an additional benefit if you lose your life, sight, hearing, speech, or limbs in an accident. Company Paid SummaryLife Benefit$25,000Accidental Death Benefit$25,000Reduction ScheduleBy 35% @ 65; 50% @ 70Additional BenefitsConversion, Accelerated Death Benefit, Waiver of PremiumVoluntary SummaryLife/AD&D Benefit-Employee-Spouse-Child(ren) [Term Life Only]$10,000 to $300,000100% of Employee Amount to $100,000$10,000Guaranteed Issue Coverage (no medical questions)-Employee-Spouse-Child(ren)$100,000$25,000$10,000Reduction ScheduleBy 35% @ 65; 50% @ 70Additional BenefitsConversion, Accelerated Death Benefit, Waiver of PremiumVoluntary Term Life and AD&D Insurance (Employee Paid)All full-time employees working 30 or more hours per week are eligible to enroll in additional voluntary life insurance above and beyond the employer paid benefits. Voluntary term life rates are offered at heavily discounted group rates. So long as you enroll when first eligible, guaranteed coverage is also available to you, regardless of your current health status.
DISABILITY INSURANCEEMPLOYEE ASSISTANCE PROGRAMTRAVEL ASSISTANCE PROGRAM8Short-Term Disability - 100% Employee PaidBenefit Percentage60%Weekly Maximum$1,200Benefits Begin7 daysBenefit Length12 weeks Pre-Existing Condition Exclusion3/12*Long-Term Disability - 100% Company PaidBenefit Percentage60%Monthly Maximum$6,000Benefits BeginAfter 90 daysBenefit LengthSSNRAPre-Existing Condition Exclusion3 / 12*Employee Assistance Program - 100% Company PaidLife isn’t always easy. Sometimes a personal or professional issue can affect your work, health, and general well-being. During these tough times, it’s important to have someone to talk with to let you know you’re not alone. We are pleased to offer an employee assistance program (EAP) for you and your immediate family members. Our EAP is a comprehensive resource providing access to professional assistance for a wide range of personal and work-related issues. This service is strictly confidential and available 24/7, 365 days per year. Services include unlimited phone counseling, online resources, and up to 3 face-to-face sessions with a counselor per year. Sample topics include:✓Legal and financial matters✓Work and lifestyle✓Child / elder care resources and referrals✓Stress, anxiety, depression✓Substance abuse and addiction Travel Assistance Program - 100% Company PaidTake comfort in knowing that travel assistance travels with you worldwide, offering access to a network of professionals who can help you with local medical referrals or provide emergency assistance services in foreign locations. Travel assistance can help you avoid unexpected bumps in the road anywhere in the world for you, your spouse, and dependent children on any single trip, more than 100 miles from home.Sample topics include:✓Pre-trip assistance✓Emergency travel support services✓Telephonic translation / interpreter services✓Document replacement✓Medical assistance✓Identity theft✓Prescription replacement assistance ✓Emergency medical evacuationWhy do you need Disability? How will you pay your bills if you were sick or injured? Even a short illness or injury could seriously impact your paycheck. What happens when your sick time runs out? Disability replaces part of your income if you are unable to work due to an accident, illness, or if you are expecting a new addition to your family. Maternity Leave is one of the most common uses for disability insurance. Fortunately, all full-time employees who work a minimum of 30 hours per week are automatically enrolled in Short-Term & Long-Term Disability benefits.