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The benefits plan year runsJanuary 1stthroug through December 31st have a qualified change-in-status event that impactsyour eligibility and the change is allowed underthe terms of the insurance contract or plan document,you cannot make changes toyour benefits until the nextOpen Enrollment period.Benefit changes must beconsistent with yourqualified change-in-statusevent.Mid year changes mustbe submitted to Human Resources within 30 daysof the event; documentation supporting 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 first of the month following 30days 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 willterminate 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, oremployment status for you, yourspouse, or your dependent childChange in coverage under anotheremployer plan, such as a changemade during your spouse’s Open EnrollmentProsource.it takes pride in providing a comprehensive employee benefits program,and we recognize the important roleemployee benefits play as a criticalcomponent of your overall compensation.We strive to maintain a benefits program that is rewarding and competitive.WHAT’S INSIDEEmployee Resources Employee Contributions Medical Health Savings Account (HSA) Flexible Spending Account (FSA) Dental Vision Life/AD&D Disability Employee Assistance Program Travel Assistance Program2
EMPLOYEE RESOURCESBCBS TX has a mobile app that provides personalized access to your benefits when and where you need it. Browse and download it to your smartphone or tablet from the App Store or Google Play, or text BCBSTX to 33633.THERE’S AN APP FOR THAT!EMPLOYEE CONTRIBUTIONS Based on 24 pay periods per yearPlan Features Employee Employee + SpouseEmployee + Child(ren)FamilyMEDICAL—BlueCross BlueShieldMTBCP013H $6,900-100% HDHP PPO $45.75 $240.76 $218.84 $350.51MTBCP018 $2K-60% PPO $50.36 $265.34 $241.06 $385.85MTBCP014 $1,500-80% PPO $91.51 $351.01 $313.51 $502.82DENTAL—BlueCross BlueShieldPPO Plan$0.00 $8.93 $12.26 $21.18VISION—BlueCross BlueShieldEyeMed Vision$0.00 $1.71 $1.90 $3.613PlanPolicy Number Phone Number and Website/EmailMedical358671(800) 521-2227BlueCross BlueShield www.bcbstx.com DentalVF028039800-521-2227BlueCross BlueShield www.bcbstx.com VisionVF028039(855) 875-6948BlueCross BlueShield www.eyemed.com Health Savings Account(800) 357-6246HSABankwww.hsabank.com Flexible Spending Account(281) 374-4928 Healthcare, Limited Purpose, & Dependent Care https://tco.summitfor.me Life and Voluntary Life InsuranceVF028039(800) 521-2227BlueCross BlueShieldwww.bcbstx.com Disability InsuranceVF028039(866) 899-0353BlueCross BlueShieldwww.bcbstx.com Employee Assistance ProgramVF028039(866) 899-1363BlueCross BlueShieldwww.bcbstx.com Human ResourcesUS.HR@prosource.it
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.KEY TERMS TO REMEMBER & HDHP/HSA PLAN DETAILSANNUAL DEDUCTIBLEThe amount you must pay each year before the plan starts paying a portion of medical expenses. All family members’ expenses that count toward a health plan deductible accumulate together in the aggregate; however, each person also has a limit on their own individual accumulated expenses (the amount varies by plan).OUT-OF-POCKET MAXIMUMThis is the total amount you can pay out of pocket each calendar year before the plan pays 100 percent of covered expenses for the rest of the calendar year. Most expenses that meet provider network requirements count toward the annual out-of-pocket maximum, including expenses paid to the annual deductible, copays and coinsurance.COPAYS AND COINSURANCEThese expenses are your share of cost paid for covered health care services. Copays are a fixed dollar amount and are usually due at the time you receive care. Coinsurance is your share of the allowed amount charged for a service and is generally billed to you after the health insurance company reconciles the bill with the provider.Medical4HSA PLAN DETAILSIf you are enrolled in the $6,900 HDHP PPO plan, you may contribute towards an HSA. There are many advantages to contributing to an HSA account including:· You are not taxed on the money you use to pay for eligible out-of-pocket medical expenses not covered by your medical plan such as deductibles, coinsurance for yourself, spouse, and/or dependent children.· Unused money is not forfeited at the end of the year. Balances are carried forward.· The account is yours to keep. You take it with you if you change jobs or retire.IRS Contribution Limits for HSA PlansThe IRS sets annual contribution limits for HSA plans. The 2024 contribution limit is $4,150 (for employee only coverage) and $8,300 (for employee plus one or more dependent coverage).If you are age 55 or older, you can make additional “catch-up” contributions up to $1,000 per year.According to the IRS, you cannot be covered by a medical plan that is not a High Deductible Health Plan (HDHP) and establish and/or contribute towards an HSA. E.g.: You cannot be covered by a non-HDHP separate individual medical plan, non-HDHP medical coverage through your spouse’s health plan, VA, Medicare, Medicaid, etc. PLAN TYPESPPO – A network of doctors, hospitals, and other healthcare providers. You have coverage in and out of network.HMO – A network of doctors, hospitals, and other healthcare providers that offers only in-network coverage. There is no out-of-network coverage outside of a true emergency. HDHP – A plan that has higher deductibles in exchange for lower premiums. HDHP’s are compatible with Health Savings Accounts (HSA).
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.MEDICAL & PRESCRIPTION PLAN HIGHLIGHTS5Plan Features BlueCross BlueShield of Texas Group # 358671IN-NETWORK$6,900 MTBCP013H HDHP PPO$2,000 MTBCP018 PPO $1,500 MTBCP014 PPOProvider NetworkBlueChoice PPO BlueChoice PPO BlueChoice PPOHSA Compatible?YES– EE & ER ContributionsNO NODeductibles
(Individual / Family)$6,900 / $13,800 $2,000 / $6,000 $1,500 / $4,500Coinsurance(Member Responsibility)0% after deductible 40% after deductible 20% after deductibleOut-of-Pocket Max
(Individual / Family)$6,900 / $13,800(Includes Deductible)$6,000 / $15,800(Includes Deductible,Coinsurance, & Copays)$4,500 / $13,500(Includes Deductible,Coinsurance, & Copays)Preventive CareNo Charge No Charge No chargePrimary Care Visit0% after deductible $35 copay $35 copayMDLive Virtual Visits0% after deductible $35 copay $35 copaySpecialist Visit0% after deductible $70 copay $70 copayDiagnosticLab & X-Ray 0% after deductible No charge No ChargeComplex Imaging0% after deductible 40% after deductible 20% after deductibleOutpatient ProcedureInpatientStayEmergency Room0% after deductible$500 per visit + 40%coinsurance after deductible$500 per visit + 20%coinsurance after deductibleUrgent Care0% after deductible $75 copay $75 copayRetail Pharmacy (30-day)
Preferred Generic
Non-Preferred Generic
Preferred Brand
Non-Preferred Brand
Preferred Specialty
Non-Preferred Specialty0% after deductiblePreferred / Non-Preferred$0 / $10 copay$10 / $20 copay$50 / $70 copay$100 / $120 copay$150 copay$250 copayPreferred / Non-Preferred$0 / $10 copay$10 / $20 copay$50 / $70 copay$100 / $120 copay$150 copay$250 copayMail Order Pharmacy (90-day)
*Excludes Specialty Drugs0% after deductible $0 / $30 / $150 / $300 $0 / $30 / $150 / $300OUT-OF-NETWORKDeductibles(Individual / Family)$13,800 / $27,600 $10,000 / $20,000 $3,000 / $9,000Out-of-Pocket Max(Individual / Family)Unlimited Unlimited UnlimitedCoinsurance(MemberResponsibility)30% after deductible 50% after deductible 50% after deductibleEmergencyRoom(must be true emergency)0% after deductible $500 per visit + 40% coinsurance$500 per visit + 20%coinsurance after deductible
6HEALTH SAVINGS ACCOUNTWho Is Eligible?*All three criteria must be met:• Enrolled in an IRS “qualified” High Deductible Health Plan• 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 HDHP allows employees to set aside money on a pre-tax basis into a Health Savings Account (HSA). The HSA is an account established exclusively for the purpose of paying for qualified healthcare expensesfor you and your eligible dependents on a tax-preferred 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 leaveemployment, you own the account and the money therein. For a complete list of “qualified” medical expenses, please refer to Publication 502 at www.irs.gov. How much can I contribute?
IRS ANNUAL LIMITSEmployer MonthlyContribution2024 Max Contribution(Employer + Employee)2024 MaximumEmployee ContributionSingle Only$188.09 $4,150.00 $1,892.92Employee + Spouse$435.92 $8,300.00 $3,891.80Employee + Child(ren)$367.35 $8,300.00 $3,068.60Employee + Family$591.66 $8,300.00 $1,200.08Catch-Up Contribution Employees Age 55+ may contribute an additional $1,000
Dental- BlueCross BlueShieldWe 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*NetworkBlueCare DentalCalendar Year DeductibleAmount you must pay per calendar year before the plan begins to pay benefits waived for preventive$50 individual$150 familyPreventive CareDeductible waivedBasic Services20%Major Services50%Annual Benefit MaximumMaximum amount the plan will pay per calendar year$1,500 per person per calendar yearOrthodontia (adults & children) 50%Lifetime Orthodontia Maximum $1,500Out of Network Processing MACLimitations 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. Need to locate a participating, in-network provider?To locate a participating provider, visit www.eyemedvision.com 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!7Vision- BlueCross BlueShieldYour 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 $30Eyeglass FramesOnce every 12 months$150 plan allowance + 20% off balance Up to $75Eyeglass Lenses Once every 12 months SingleBifocal TrifocalLenticular$25 copay$25 copay$25 copay$25 copayUp to $25Up to $40Up to $55Up to $55Contact Lenses Once every 12 months in lieu of eyeglassesElective: $150 allowance + 15% off balanceUp to $120
Basic Term Life and AD&D Insurance (Company Paid)All full-time employees working 30 or more hours per week you are automatically enrolled in the basic life benefit. Whilecoverage is automatic, is critical that you list a beneficiary designation when enrolling in benefits. You can change yourbeneficiary at any time and as frequently as needed.LIFE INSURANCEDuring your benefits enrollment, don’t forget to designate a beneficiary!8Life insurance helps protect your family from financial risk and sudden loss of income in the event of your death. Accidental deathand dismemberment (AD&D) insurance provides an additional benefit if you lose your life, sight, hearing, speech, or limbs in an accident.Company Paid SummaryLife BenefitFlat $100,000Accidental Death BenefitFlat $100,000Reduction ScheduleBy 35% @ 65; 50% @ 70Additional BenefitsConversion, Accelerated Death Benefit, Waiver of PremiumVoluntary SummaryLife Benefit-Employee-Spouse-Child(ren)$10,000 - $500,000 to a max of 5x annual salary$5,000 - $250,000 to a max of 100% of the employee benefitUp to $10,000Guaranteed Issue Coverage (no medical questions)-Employee-Spouse-Child$100,000 to a max of 5x annual salary$25,000Up to $10,000Reduction ScheduleBy 35% @ 65; 50% @ 70Additional BenefitsConversion, Accelerated Death Benefit, Waiver of PremiumVoluntary Term Life 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 asyou enroll when first eligible, guaranteed coverage is also available to you, regardless of your current health status. To enrollyour dependents, you as the employee must also have coverage.
9Other BenefitsFlexible Spending AccountsHealthcare FSAThe Healthcare FSA lets you pay for certain IRS-approved medical care expenses not covered by your insurance plan with pre-tax dollars. For example, cash that you now spend on deductibles, copayments, or other out-of-pocket medical expenses can instead be paid with funds that are pre-tax. The annual maximum contribution for is $3,200. Funds contributed towards the Healthcare FSA are front-loaded. Limited Purpose FSAEmployees are not allowed to contribute to both a health savings account (HSA) at the same time as a standard (non-limited) health flexible spending account (FSA). They are, however, eligible for an HSA if they use a limited-purpose FSA for their dental and vision care needs. This will allow you to maximize your savings and tax benefits. Funds contributed towards Limited Purpose FSAs are front-loaded. Dependent Care FSAYou can set aside up to $5,000 of pre-tax dollars to pay for qualified dependent care expenses such as the cost of licensed childcare facility, nursery or preschool, and the cost of an adult dependent’s care inside or outside of your household. Funds contributed towards Dependent Care FSA are not front-loaded and they do not rollover. “Use it or Lose it”According to IRS regulations, the money you contribute to the FSA must be used for expenses incurred during the plan year in which you make the election. You can rollover a maximum of $500 into the next Healthcare FSA plan year providing you keep an active account the following year; however, any money not used that exceeds $640 will be forfeited. Visit www.irs.gov for additional information about Flexible Spending Accounts. 401(k) PlanProsource.IT contributes 3% to your retirement plan. Employees are eligible to participate the first of the month following 30 days of employment and are 100% vested from the enrollment date.
DISABILITY INSURANCE10Why do you need Long-Term Disability? (Employee Paid)A lengthy disability can be devastating and is more common than you may think. Long-term disability may lead to a loss of income, independence, and financial security. A disability insurance policy can help provide security when you need it most. It pays you cash benefits when you’re sick or hurt and can’t work.Why do you need Short-Term Disability? (Company Paid)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 disability benefits.Plan FeaturesBlueCross BlueShieldEmployee Benefit Amount 60% of weekly earningsMaximum Benefit Amount $1,500 per weekElimination Period (Waiting Period) 7 DaysBenefit Duration 12 WeeksPre-Existing Condition Exclusion NonePlan FeaturesBlueCross BlueShieldEmployee Benefit Amount 60% of monthly earningsMaximum Benefit Amount $6,000 per monthElimination Period 90 days Own Occupation Period 2 YearsBenefit Duration<62: To age 65, SSNRA or 3.5 years, whichever is longest62+: Reduced Duration Schedule Pre-Existing Conditions Clause 3 / 12**Pre-Existing Condition 3/12 - is a Sickness or Injury for which you have received treatment within 3 months prior to your effective date. Any disability contributed to or caused by a Pre-Existing Condition within the first 12 months of your effective date will not be covered.
ADDITIONAL BENEFITS11Employee 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. An Employee Assistance Program (EAP) offers short-term counseling over the telephone to help you and members of your household manage everyday life issues. Professional counselors are available to assist you with:✓Everyday needs and life events✓Work and lifestyle concerns✓Relationship issues✓Stress, anxiety, depression✓Substance abuse and addiction✓Legal and financial matters Travel Assistance Program - 100% Company PaidFor free and confidential assistance, call 866-899-1363.Our Travel Resource Services provider, Assist America, offers around-the-clock emergency and information services that can help you access emergency assistance when you are traveling 100 or more miles away from home. Topics include:✓ Emergency travel support services✓ Foreign hospital admission assistance✓ Prescription assistance✓ Return of mortal remains✓ Care for minor children
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