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The benefits plan year runsMarch 1st, 2024 throughFebruary 28th, 2025. Unless you have a qualified change-in-status event that impacts your eligibility and thechange is allowed underthe terms of the insurancecontract or plan document, you cannot make changes to your benefits until the nextOpen Enrollment period.Benefit changes must be consistent with yourqualified change-in-statusevent.Changes must besubmitted to HumanResources within 30 daysof the event;documentationsupporting the changewill 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 1st of the month following 60 days of your date 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 regardlessof 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 andthe 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 Enrollmentperiod. 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 EnrollmentNadine West takes pride in providing acomprehensive employee benefits program, andwe recognize the important role employeebenefits play as a critical component of youroverall compensation. We strive to maintain abenefits program that is rewarding andcompetitive.WHAT’S INSIDE2Employee ResourcesEmployee ContributionsMedicalHealth Savings Account (HSA) Dental VisionLife/AD&DVol. Life/AD&DVol. Short Term DisabilityEmployee Assistance Program (EAP)
EMPLOYEE RESOURCESPlanPolicy Number Phone Number and WebsiteMedicalBlueCross BlueShield292805(800) 521-2227www.bcbstx.com1.Find a Doctor or Hospital2.Select search as a guest3.PPO Plans: search using Blue Choice PPO4.HMO Plan: search using BlueAdvantage HMO [BAV]5.Enter zip code6.Search by category or type the nameDentalPrincipal Financial1125685(800) 247-4695www.principal.com/dentist1.Search for a Dentist (continue)2.Enter state and Principal plan PPO3.Enter search criteriaVisionPrincipal Financial / VSP 1125685(800) 877-7195www.principal.com/vspLife and AD&D InsurancePrincipal Financial1125685(800)245-1522www.principal.comVoluntary Short-Term Disability Principal Financial1125685(800)245-1522www.principal.comEMPLOYEE CONTRIBUTIONS PER PAY PERIODBased on 26 pay periods per yearPlan Features Employee Employee + Spouse Employee + Child(ren) FamilyMEDICAL—BlueCross BlueShield$3,000 60% PPO MTBCP029$179.85 $732.78 $520.07$1,073.09$5,000 80% HMO MTBPA042$89.07 $524.00 $356.69 $791.69$5,000 100% HMO HDHP w/ HSA MTBPA007H$27.28 $381.92 $245.50 $600.18DENTAL—PrincipalDental Value Option 1$2.57 $14.77 $20.69 $35.07Dental Plus Option 2$11.63 $30.78 $41.80 $64.56VISION—PrincipalVision Plan$0.92 $5.04 $5.00 $9.943
KEY TERMS TO REMEMBER & PLAN DETAILSANNUAL DEDUCTIBLEThe amount you must pay each year beforethe plan starts paying a portion of medicalexpenses. All family members’ expenses thatcount toward a health plan deductibleaccumulate together in the aggregate;however, each person also has a limit on theirown individual accumulated expenses (theamount varies by plan).OUT-OF-POCKET MAXIMUMThis is the total amount you can pay out ofpocket each calendar year before the planpays 100 percent of covered expenses forthe rest of the calendar year. Most expensesthat meet provider network requirementscount toward the annual out-of-pocketmaximum, including expenses paid to theannual deductible*, copays and coinsurance.*Except for Grandfathered medical plansCOPAYS AND COINSURANCEThese expenses are your share of cost paidfor covered health care services. Copays area fixed dollar amount and are usually due atthe time you receive care. Coinsurance isyour share of the allowed amount chargedfor a service and is generally billed to youafter the health insurance companyreconciles the bill with the provider.4PLAN TYPESPPO – A network of doctors, hospitals, andother healthcare providers. You havecoverage in and out of network.HMO – A network of doctors, hospitals, andother healthcare providers that offers onlyin-network coverage. A primary carephysician must be selected prior to renderingservices. There is no out-of-networkcoverage outside of a true emergency.HDHP – A plan that has higher deductiblesin exchange for lower premiums. HDHPs arecompatible with Health Savings Accounts(HSA).MEDICAL TERMS4
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 certainservices.MEDICAL & PRESCRIPTION PLAN HIGHLIGHTS IN NETWORK(you pay)Option 1:$3,000 MTBCP029 Blue Choice PPOOption 2:$5,000 MTBPA042 Blue Premier Access HMOOption 3:$5,000 HDHP w/ HSAMTBPA007H Blue Premier Access HMODeductibles(Individual / Family)$3,000 / $9,000 $5,000 / $14,700 $5,000 / $10,000Coinsurance40% after deductible 20% after deductible 0% after deductibleOut-of-Pocket Max(Individual / Family)$8,150 / $16,300 $8,150 / $16,300 $5,000 / $10,000Preventive CareNo Charge No Charge No ChargePrimary Care Visit$35 copay $45 copay $0 after deductibleVirtual Visits$35 copay $45 copay $0 after deductibleSpecialist Visit$70 copay $90 copay $0 after deductibleDiagnostic Test (X-Ray, blood work)No Charge 20% after deductible $0 after deductibleComplex Imaging40% after deductible 20% after deductible $0 after deductibleOutpatient Procedure40% after deductible 20% after deductible $0 after deductibleInpatient Visit40% after deductible 20% after deductible $0 after deductibleEmergency Room$500 copay +40% after deductible$500 copay + 20% after deductible$0 after deductibleUrgent Care$75 copay $75 copay $0 after deductibleRetail Pharmacy RX(30 Day)Preferred GenericNon-preferred GenericPreferred BrandNon-Preferred BrandPreferred SpecialtyNon-preferred SpecialtyParticipating/Non-Participating$0 / $10 copay$10 / $20 copay$50 / $70 copay$100 / $120 copay$150 copay$250 copayParticipating/Non-Participating$0 / $10 copay$10 / $20 copay$50 / $70 copay$100 / $120 copay$150 copay$250 copay$0 after deductibleOUT OF NETWORK $3,000 PPO $5,000 HMO $5,000 HDHP w/ HSA HMODeductibles (Individual / Family)$10,000 / $20,000N/A N/ACoinsurance 50% after deductibleOut-of-Pocket Max(Individual / Family)Unlimited / UnlimitedEmergency Room$500 copay +40% after deductible$500 copay + 20% after deductible$0 after deductible5
HEALTH SAVINGS ACCOUNT (HSA)How much can I contribute?IRS ANNUAL LIMITS2024 Max Contribution(Employer + Employee)2024 Maximum Employee Contribution Single Only$4,150 $3,850Employee + Spouse$8,300 $8,000Employee + Child(ren)$8,300 $8,000Employee + Family*$8,300 $8,000Catch-Up Contribution Employees Age 55+ may contribute an additional $1,000Who Is Eligible?* All three criteria must be met:• Enrolled in an IRS “qualified” High Deductible Health Plan (HDHP)• Not covered by another medical plan unless the other plans is also a “qualified” HDHP• Not enrolled in Medicare coverage*It is the employee’s responsibility to notify HR if you are not eligible for HSA.How does it work?The $5,000 HDHP HMO allows employees to set aside money on a pre-tax basis into a Health SavingsAccount (HSA). The HSA is an account established exclusively for the purpose of paying for qualified medicalexpenses for you and your eligible dependents on a tax-free basis.Contributions to the HSA are funded with pre-tax deductions withheld from your paycheck. The funds aredeposited into an interest-bearing account in your name. The money in the HSA can be used to reimburseeligible expenses not covered by your insurance plan, including the deductible, coinsurance, and copays.Any money not used for medical reimbursement remains in the account. In the event you leave Stor.ai, youown the account and the money therein. For a complete list of “qualified medical expenses, please refer toPublication 502 at www.irs.gov.6
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We are pleased to offer you comprehensive dental plans. You can visit any licensed dentist, but your costs are usually lowestwith an in-network dentist. In-network dentists accept reduced fees for covered services; out-of-network dentists may balancebill you the difference between their usual fee and what the plan pays.Need to locate a participating, in-network provider?To locate a participating provider, visit www.principal.com. Select “Find aDentist” and then “Search for a dentist.”DENTAL PLAN HIGHLIGHTSPrincipal Insurance Company Group #1125685Plan Features PPO Value Plan PPO Plus PlanProvider Network Principal Dental PPO NetworkIN-NETWORKCalendar Year Maximum $1,000 $2,000Annual Deductible (Individual / Family)$75 / $225 $50/$150Preventive Care•Routine Exam(once every 6 months)•Routine Cleanings (once every 6 months)•Bitewing X-ray0% (deductible waived) 0% (deductible waived)Basic Procedures•Simple extractions•Fillings•Stainless steel crowns20% after deductible 20% after deductible Major Procedures •Periodontics & Endodontics•Inlays & Onlays•Bridges•Dentures50% after deductible 50% after deductible Orthodontia50% 50%Lifetime Maximum$1,000 $2,000OUT-OF-NETWORKOut-of-NetworkClaim Payment Basis90th percentile8
Need to locate a participating, in-network provider?To locate a participating provider, visit www.vsp.com. Search by location, office or doctor.Your vision coverage provides a full range of vision care services. You may receive care from any provider you choose, but yourbenefits 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 ReimbursementProvider NetworkVSP ChoiceVision ExamOnceevery 12 months$10 copay Up to $45Eyeglass FramesOnceevery 12 months$150 plan allowance + 20% discount on balance over $150 Up to $70Eyeglass LensesOnce every 12 monthsSingleBifocalTrifocalLenticular$10 copay$10 copay$10 copay$10 copayUp to $30Up to $50Up to $65Up to $100ContactLenses Onceevery 12 months in lieu of eyeglassesElective: $150 allowanceNecessary: $0 copayUp to $105Up to $200Additional Discounts•Cosmetic Extras average of 20% off retail price.•Laser Correction Surgery: Up to 15% off usual and customary charge, or 5% off promotional price. Limitations or waiting periods may apply for some benefits; some services may be excluded from yourplan. These charts are intended for summary purposes only. If there are any discrepancies, the plandocument will always govern.Please refer to your plan documents for additional information.VISION PLAN HIGHLIGHTS9
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 todesignate a beneficiary!10Life insurance helps protect your family from financial risk and sudden loss of income in the event of yourdeath. Accidental death and dismemberment (AD&D) insurance provides an additional benefit if you loseyour life, sight, hearing, speech, or limbs in an accident. Company Paid SummaryLife Benefit$10,000Accidental Death Benefit$10,000Reduction ScheduleBy 35% @ 65; 50% @ 70Additional BenefitsConversion, Accelerated Death Benefit, Waiver of PremiumVoluntary SummaryLife/AD&D Benefit-Employee-Spouse (cannot exceed employee election)-Child(ren) [Term Life Only]$10,000 - $300,000$5,000 - $100,000$10,000Guaranteed Issue Coverage (no medical questions)-Employee (under age 70)-Spouse (under age 70)$150,000$30,000Reduction 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 aboveand beyond the employer paid benefits. Voluntary term life rates are offered at heavily discounted group rates. So long asyou enroll when first eligible, guaranteed coverage is also available to you, regardless of your current health status.Voluntary life/ad&d rates are provided when making your enrollment elections inside of Paycor.
VOLUNTARY DISABILITY INSURANCE11Short-Term Disability Plan Features Principal GroupEmployee Benefit Amount 60%Maximum Benefit Amount $1,500 per WeekElimination Period (Waiting Period) 14 DaysBenefit Duration 11 WeeksPre-Existing Condition Exclusion NoneWhy do you need Voluntary Short-Term Disability? (100% Employee Paid)How will you pay your bills if you were sick or injured? Even a short illness or injury couldseriously impact your paycheck. What happens when your sick time runs out? Disabilityreplaces part of your income if you are unable to work due to an accident, illness, or if youare expecting a new addition to your family. Maternity Leave is one of the most commonuses for disability insurance. Fortunately, all full-time employees who work a minimum of 30hours per week are eligible to elect Voluntary Short-Term benefits and take advantage of thegroup rate.Voluntary short term disability rates are provided when making your enrollment elections inside of Paycor.
ADDITIONAL BENEFITS12Employee Assistance Program - 100% Company PaidLifeisn’t always easy. Sometimes a personal or professional issue can affect your work, health, andgeneralwell-being. During these tough times, it’s important to have someone to talk with to let you know you’renotalone.Weare pleased to offer an employee assistance program (EAP) for you and your immediate familymembers.OurEAP is a comprehensive resource providing access to professional assistance for a wide range ofpersonalandwork-related issues.Theservice is provided by Nadine West, at no cost to you, and is available to you and your immediatefamilymemberstwenty-four hours a day, 365 days a year, and provides resources to help employees findsolutionstoeveryday issues.Servicesinclude 3 face-to-face counseling or video sessions per household, unlimited phone counselingwithmaster’s-level consultants to help with more serious issues, and online resources. Participation isvoluntaryandstrictly confidential.Sampletopics include:✓Legal and financial matters✓Work and lifestyle✓Child / elder care resources and referrals✓Stress, anxiety, depression✓Substance abuse and addiction
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