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2024FULL TIME MANAGERS SALARIED EMPLOYEES
IMPORTANT CONTACTSYour Open Enrollment journey starts here! Go to enroll.benefitsconnect.net/lupetortilla in your preferred web browser. Enter your username and password and click the sign in button. Your username is the first six characters of your last name (if applicable), followed by the first letter of your first name, which is then followed by the last four digits of your Social Security Number Your initial password is your Social Security Number (SSN). Please note, your SSN should contain no spaces or dashes.SET UP YOUR ONLINE ACCOUNTEXAMPLE:Name: John Smithson | Username: smithsj6789SSN: 123-45-6789 | Password: 123456789TECHNICAL ASSISTANCEGIS/Benefits Connect727.209.4227 x 0Monday - Friday 8:30am - 5:00pm ESLOGIN ASSISTANCEContact Your Representative866.400.7771patraservice@gisbenefits.netMEDICALUnited Healthcareuhc.com866.801.4409VIRTUAL CARESee Options on Page 5DENTALAmeritasameritas.com800.487.5553VISIONAmeritasvsp.com800.877.7195FLEXIBLE SPENDING ACCOUNT (FSA)Chard-Snyderchard-snyder.com800.982.7715LIFE and AD&D MetLifemetlife.com800.275.4638
If you are an active, full-time employee working at least 30 hours per week, you are eligible to enroll in the benefits described in this guide. The following family members are eligible for Medical, Dental, Vision, Voluntary Life and AD&D coverage: Legal Spouse Child(ren) up to age 26 - Extended coverage available for children with special needs. Please see policy for details.ELIGIBILITYQUALIFYING EVENTSUnder IRS Section 125 regulations after your Initial/Annual Enrollment period is closed, you cannot make changes to the benefits you elect/waive until the next annual enrollment period unless you experience a qualifying event. Events falling within the following categories are qualifying events: Marriage, divorce, death of spouse, legal separation, or annulment Birth, adoption, placement for adoption, death, qualified medical child support order (QMCSO), or dependent ceases to satisfy eligibility requirements Employee or spouse termination / commencement of employment Change from part-time to full-timeNEW HIRESBenefits will begin on the first day of the month following 60 days of employment.BENEFIT ENROLLMENTYOU MUST NOTIFY HUMAN RESOURCES WITHIN 30 DAYS OF AN EVENT IN ORDER TO BE ELIGIBLE TO MAKE CHANGESHR Benefits Coordinator Keila Olivares KOlivares@lupetortilla.com
Base PPO Plan Buy-Up PPO PlanIN-NETWORK (Nexus) IN-NETWORK (Premier Pro)Annual DeductibleIndividualFamily$6,000$12,000$2,000$4,000Coinsurance 80% 80%Annual Out-of-Pocket MaximumIndividualFamily$8,150 $16,300 $7,150$14,300 YOU PAYPreventive Services No Charge No ChargeOce VisitsDesignated Network In-Network Designated Network In-NetworkPrimary Care$15 copay $45 copay $10 copay* $10 copay **$0 dependent copay up to age 19Specialty Visit$50 copay $125 copay $40 copay $80 copayVirtual Visit$0 copay $0 copayLab, X-RayDiagnosticsMajor Diagnostics20% after deductible20% after deductible$40 copay$500 copayIn-Patient Hospital Services Designated Network - 20% after deductibleIn-Network - $500 + 40% after deductible 20% after deductibleEmergency Room $300 + 20% after deductible $300 + 20% after deductibleUrgent Care Center $50 copay $25 copayPrescription DrugsRetail - Tier 1Tier 2Tier 3Mail Order90 Day Supply$10 copay$35 copay$70 copay2.5x’s retail copay(specialty not included)$10 copay$35 copay$70 copay2.5x’s retail copay(specialty not included)This guide is a general description of coverage(s) provided. For a detailed description of policy terms and conditions, please refer to the policy itself. If a conflict exists between this guide and the policy, the policy will be controlling.Lupe Tortilla provides you with a choice of two medical plans through United Healthcare; a Base PPO plan and a Buy-Up PPO plan. The Base plan utilizes the NexusACO OAP Network and the Buy-Up plan utilizes the Choice+ Network. With both plans you can visit the physician of your choice, however, if you visit a non-network physician, you may be balance billed. To find a network physician, please visit www.uhc.com. Please carefully review the benefits below to decide what best suits you and your family’s needs.Create an Accountuhc.com | 866.801.4409MEDICAL
The UnitedHealtcare App helps you personalize, organize and access your important plan information on your phone or tablet. Use the app to make your life easier (and healthier) while you’re on the go. Download it today at www.uhc.com to get instant access to your health plan details, anytime, anywhere.TELEMEDICINEFinding time to get to the doctor can be dicult. You can have access to the care you need without leaving your home or oce; when, where and how it works best for you. Telemedicine is included at not cost with both medical plan options. Virtual providers oer 24/7/365 on-demand access to physicians that can diagnose, recommend treatment, and prescribe medication. VIRTUAL DOCTORS CAN HELP TREAT Allergies Asthma Nausea Sinus Infections Cold and Flu Bronchitis Ear Infections Joint Pain Pinkeye Respiratory Infections Anxiety/Depression And More!CHOOSE THE VIRTUAL CARE PROVIDER THAT’S BEST FOR YOUUNITED HEALTHCARE APPDOWNLOAD THE APP ON YOUR MOBILE DEVICEFind Care Find network care options for doctors, clinics and hospitals in your area. Talk to a doctor by video 24/7. See reviews and ratings for doctors.Stay On Top Of Costs Estimate the costs of common procedures. View your copay, annual deductible and out-of-pocket expenses. View your Health Reimbursement Account, Flexible Spending Account or Health Savings Account, if applicable.Manage Your Health Plan Details Generate and share digital ID cards. View claims and account balances. Manage prescription drugs and refills. patients.amwell.com optum.com/care/virtual-careteladoc.com doctorondemand.com
Preventive Services Exams, cleanings, x-rays, fluoride100% 100%Basic Services 80% after deductible 90% after deductibleMajor Services 50% after deductible 60% after deductibleEndodontics / Periodontics 50% after deductible 80% after deductibleOrthodontia Benefit Not Covered50% up to $1,000 lifetime maximumOrthodontia Eligibility N/A Children up to Age 26Low Plan High PlanIN-NETWORK IN-NETWORKAnnual DeductibleIndividualFamily$50$150$50$150Annual Benefit Maximum $1,000 $1,500Coverage Waiting Periods None NoneOut of Network ReimbursementMaximum Allowable Charge (MAC)90th Percentile of U&CLupe Tortilla provides you with a choice of two dental plans through Ameritas. You may receive care from any dentist of your choosing with either plan, however, choosing dental services from a dentist participating in your network will provide you with substantial savings. A non-participating provider may charge any amount and balance bill the enrollee for the dierence between the benefit allowance and the actual charge.DENTALThis guide is a general description of coverage(s) provided. For a detailed description of policy terms and conditions, please refer to the policy itself. If a conflict exists between this guide and the policy, the policy will be controlling.ameritas.com | 800.877.7195Visit ameritas.com to set up your secure member account. With an account you can review your benefits, find providers, and get estimates and coverage costs online.Create an Account
Lupe Tortilla oers vision coverage through Ameritas (utilizing the VSP Choice Network) for you and your family. There are “in network” providers (contracted with VSP’s Choice Network) and “out of network” providers (no contract). This means that you can obtain products or services through any provider you choose, although you’ll generally pay less with in network providers. When visiting an in network provider, you are responsible for paying any applicable copay and for items that are not covered, or that exceed your benefit limitations. When visiting out of network providers, you pay for all services in full, and then file a claim for reimbursement according to your out of network benefits schedule.VISIONThis guide is a general description of coverage(s) provided. For a detailed description of policy terms and conditions, please refer to the policy itself. If a conflict exists between this guide and the policy, the policy will be controlling.VSP Choice NetworkYOU PAY SERVICES FREQUENCYEye Exam $10 copay Once every 12 monthsLensesSingleBifocalTrifocal$10 copay$10 copay$10 copayOnce every 12 monthsFrames$130 allowance; then 20% o the balanceOnce every 24 monthsContact LensesElectiveMedically Necessary$130 allowance$10 copayOnce every 24 monthsLasik Discount Availablevsp.com 800.877.7195Visit vsp.com to set up your secure member account. With an account you can review your benefits, find providers, and get estimates and coverage costs online.Create an Account
VOLUNTARY LIFE AND AD&DAll eligible employees may purchase additional life coverage through MetLife. You may elect coverage for you, your spouse and child(ren) up to the guarantee issue with no evidence of insurability (EOI) “health questionnaire” as a newly eligible employee. If you have declined previously and are electing for the first time, are increasing your current benefit or exceeding the guarantee issue amount as a new hire EOI is required. MetLife will then either approve or deny coverage. The chart below is a brief description of the plan. Please see the summary plan description for complete details. (See “Deferred Eective Date” below)EMPLOYEE SPOUSE CHILDRENBenefit Amount5x’s annual earnings up to $500,00050% of employee amount up to $100,000Flat $1,000, $2,000, $4,000, $5,000, $10,000Benefit Increments $10,000 $5,000Guarantee Issue $150,000 $50,000 $10,000* Covered to age 26This guide is a general description of coverage(s) provided. For a detailed description of policy terms and conditions, please refer to the policy itself. If a conflict exists between this guide and the policy, the policy will be controlling.DEFERRED EFFECTIVE DATEIf you or your eligible dependent is totally disabled, his/her coverage will begin on the first of the month coincident with or the next following date he/she no longer is totally disabled. This provision does not apply to a newborn child while dependent insurance is in eect.CONVERSION PRIVILEGE & PORTABILITY OPTIONWhen you terminate employment, retire or lose insurance eligibility due to a status change, you have the Conversion Privilege / Portability Option available to continue your current group term life insurance. You have 31 days immediately following loss of your coverage to apply and submit first premium payment. Subject to the terms as described in the Certificate of Coverage.metlife.com | 800.275.4638Create an AccountIMPORTANT! MAKE SURE TO UPDATE YOUR BENEFICIARY INFORMATION
FLEXIBLE SPENDING ACCOUNT (FSA)A FLEXIBLE SPENDING ACCOUNT (FSA) IS A GREAT WAY TO STRETCH YOUR BENEFIT DOLLARSFor More Information Contact Your Representative askpenny@chard-snyder.comMANAGE YOUR PLAN ON-THE-GO!The Chard Snyder Mobile App provides 24/7 account access at your fingertips. The mobile app is the simplest way to view and manage your tax-free accounts. View account balances and transaction details Submit FSA claims with pictures of receipts Enter your bank account for seamless transfers Scan product bar codes for purchase eligibility Catalog past and current receiptsWHAT IS A FLEXIBLE SPENDING ACCOUNT?A Flexible Spending Account (FSA) allows you to set aside money from your paycheck before income taxes (Federal, Social Security, Medicare, state and local taxes, if applicable) are withheld. This money is available to pay for eligible expenses, such as your medical deductibles and co-payments, prescriptions, dental expenses, eyeglasses, contact lenses and other health related expenses that are not reimbursed by your health plan.2024 MAXIMUM$3,200HOW DOES IT WORK?You decide how much to contribute to your FSA on a calendar year basis, up to the maximum allowable amount. Your annual election will be divided by the number of pay periods and deducted evenly on a pre-tax basis from each paycheck throughout the plan year.Set up an account online at chard-snyder.com Download the App from the App Store or Google Play
EMPLOYEE MEDICAL BI-WEEKLY CONTRIBUTION Base Plan Buy-Up PlanEmployee Only$50.48 $116.25Employee + Spouse$353.34 $498.04Employee + Child(ren)$277.63 $402.59Employee + Family$605.74 $816.21EMPLOYEE VISION BI-WEEKLY CONTRIBUTIONVSP Choice NetworkEmployee Only$3.25Employee + Spouse$5.48Employee + Child(ren)$5.58Employee + Family$8.84EMPLOYEE DENTAL BI-WEEKLY CONTRIBUTIONLow Plan High PlanEmployee Only$10.74 $15.93Employee + Spouse$24.54 $32.51Employee + Child(ren)$26.89 $35.83Employee + Family$43.26 $58.38EMPLOYEE CONTRIBUTIONS
Example Amount of Insurance Divided by 1,000Multiplied by Rate (if age 32 for example)Example Cost$50,000 employee life ÷ 1,000 = 50 x $0.125 $6.25Volume of Insurance Divided by 1,000 Multiplied by Rate Your Cost$ ________________ ÷ 1,000 $ _____________ x $ _______________ $ ________________VOLUNTARY LIFE AND AD&D RATESEMPLOYEE & SPOUSE CHILD(REN)AGE Monthly Rate per $1,000 of Coverage< 30 $0.100$0.291 for $1,000$0.582 for $2,000$1.164 for $4,000$1.455 for $5,000$2.91 for $10,000All eligible children up to age 26 regardless of the number of children30 - 34 $0.12535 - 39 $0.13840 - 44 $0.17045 - 49 $0.24850 - 54 $0.38455 -59 $0.57560 - 64 $0.85165 - 69 $1.61370 + $2.600* Spouse rate based on employee’s age EMPLOYEE COST - You are responsible for paying the cost of Voluntary Life coverage through payroll deductions. Calculate your cost by dividing the elected benefit by 1,000 and multiplying the result by the appropriate rate above. Follow the example below to determine your cost.
This brochure of Employee Benefits is designed to provide basic information regarding employee benefit plans and programs available to eligible employees of Lupe Tortilla. It does not detail all of the terms, conditions, restrictions, and exclusions contained in the plan documents, carrier contracts or the Summary Plan Descriptions (SPD) for the various benefit plans and programs. This brochure merely summarizes the employee benefit plans and programs and does not create any contractual rights for any current or former employee of Lupe Tortilla, or for any other individual. The benefit provisions of the applicable plan document, contract or SPD will govern the determination of any individual’s rights under any employee benefit plan or program. This document does not constitute a plan document or SPD as defined by the Employment Retirement Income Security Act of 1974, as amended (ERISA). Lupe Tortilla reserve the right to amend or terminate any of its employee benefit plans and programs at any time and without notice or cause.