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www.elitebenefitsgroup.comELITEBENEFITSGROUPENHANCE - EDUCATE - ENGAGE - ENROLL - EMPOWER
Pirtek is committed to a comprehensive employee benefit program that helps our employees stay healthy, feel secure and maintain a work/life balance.The benefits program was designed to provide you with a competitive level of standard coverage while allowing you the flexibility to choose benefits that reflect your needs and personal circumstances. In addition to receiving coverage for health insurance, you have the opportunity to choose other coverage that best meets your needs.www.elitebenefitsgroup.com
1. DEDUCTIBLEThe amount you must pay before your insurance company starts to pay for covered services each year.3. COPAYMENTSA fixed amount you pay for coveredservices such as doctor visit or diagnostic test.5. COVEREDSERVICESMedical services included in your insurance plan, such as doctor visits, hospital stays and diagnostic tests.7. OUT-OF-NETWORKA doctor or medical facility that is not contracted with your insurance company. Using out-of-network providers can result in you paying a higher portion of the medical bills or possibly the entire bill.2. COINSURANCEThe percentage of a medical expense you are responsible for paying. This usually kicks in after you have met your deductible.4. OUT-OF-POCKETMAXIMUMThe most you have to pay for covered services in a plan year.6. IN-NETWORKThe doctors, hospitals and other medical facilities and suppliers that contract with your insurance company to provide medical services.8. PROVIDERThe person or facility providing services to you, including doctors, hospitals and pharmacies.www.elitebenefitsgroup.comYOU SHOULD KNOW8TERMS
United Healthcare is our medical carrier. Below is a brief summary of the medical plan. Using In- Network facilities and physicians will result in significant cost savings to the member. Network facilities and physicians can be found at myallsavers.com or call 1-800-291-2634www.elitebenefitsgroup.comPlan 1 (Base Plan)NavE3000i60LX21BIN NETWORKOUT OF NETWORKParticipant60% 40%N/AN/ACaCaalelelndnddararYYeaear DeeDeductible (CYD)IndividualFamily$3,000$6,000N/AN/AMaximum mOuOt of PocoockeketIndividualFamily$8,150$16,300N/AN/AOffice VisisititPrimary Care Visits (non-surgical)Specialist Visit (non-surgical)Urgent Care VisitPreventive CareRetailPPrerescscription*Preferred Generic(PSOR\HH&RQWULEXWLRQ (Bi-WeeklyEmployee onlyEmployee and SpouseEmployee and Child (ren)Employee and Family$10 / $35 / $75 / $250$0.00$138.03$330.14PlanHospitalIn-Patient ServicesOut-Patient ServicesEmergency Room$190.68MEDICAL INSURANCE$25 Copay/visit. Deductible does not apply. $75 Copay/visit. Deductible does not apply.$50 Copay/visit. Deductible does not apply. No Charge. Deductible does not apply.40% Coinsurance40% Coinsurance40% Coinsurance
United Healthcare is our medical carrier. Below is a brief summary of the medical plan. Using In- Network facilities and physicians will result in significant cost savings to the member. Network facilities and physicians can be found at myallsavers.com or call 1-800-291-2634www.elitebenefitsgroup.comPlan 2 (Buy- Up Plan)E1000i80LX22BIN NETWORKOUT OF NETWORKParticipant80% 20%N/AN/ACaCaalelelndnddararYYeaear DeeDeductible (CYD)IndividualFamily$1,000$2,000N/AN/AMaximum mOuOt of PocoockeketIndividualFamily$3,000$6,000N/AN/AOffice VisisititPrimary Care Visits (non-surgical)Specialist Visit (non-surgical)Urgent Care VisitPreventive CareRetailPPrerescscription*Preferred Generic(PSOR\HH&RQWULEXWLRQ (Bi-WeeklyEmployee onlyEmployee and SpouseEmployee and Child (ren)Employee and Family$10 / $35 / $75 / $250$57.80$251.90$522.04PlanHospitalIn-Patient ServicesOut-Patient ServicesEmergency Room$325.93MEDICAL INSURANCE$25 Copay/visit. Deductible does not apply. $75 Copay/visit. Deductible does not apply.$50 Copay/visit. Deductible does not apply. No Charge. Deductible does not apply.20% Coinsurance 20% Coinsurance 20% Coinsurance
DENTALwww.elitebenefitsgroup.comCLASSTYPE OF SERVICEINSURANCE PAYSNetworkOur national dental network offers more than 323,000 access points. Members may choose any dentist but may receive additional savings by choosing an in-network dentist. Plus, services not covered by this plan may also still be eligible for in-network savings. Out-of-network benefits are paid at the network negotiated rate.Dental insurance can help preserve your smile with easy-to-use coverage that promotes overall wellness.Benefits can help with a variety of dental costs, from routine cleanings to more advanced procedures. Coverage is available for you, your spouse and dependent children.Plan detailsThe benefit year maximum for this plan is $2,000 per person.Class A, B and C services apply toward the benefit year maximum.This plan has a deductible of $50 per person.Families only pay the deductible for a maximum of three people. Applies only to class B and C services.The co-insurance for this plan is:INSURANCE(Network: UNUM) $2,000, 100%80% 50%Class AClass BClass CPreventive ServiceBasic ServiceMajor Service100%80%50%
Covered Procedures & waiting periodsRoutine exams and cleanings (twice every 12 months) One additional cleaning per 12 months if member is in second or third trimester of pregnancy4X-raysBitewing X-rays (up to four films; once every 12 months)Full mouth/panoramic x-rays(once every five years)Children’s services(up to age 14) Fluoride treatment (once every 12 months) Sealants (once every 36 months) Space maintainers (up to age 14; once every 24 months)Adjunctive pre-diagnostic oral cancer screening (for age 40 or older; once every 12 months).Simple restorative services(fillings)Simple extractionsEmergency treatmentRepair of crown, denture or bridgeOral surgery (extractions and impacted teeth)Anesthesia (subject to review; covered with complex oral surgery)Periodontics (gum treatments)Endodontics (root canals)Inlays and onlaysCrownsBridgesDenturesEndosteal implants (in lieu of an approved three-unit bridge)Preventive services (Class A): No waiting periodBasic services (Class B): No waiting periodMajor services (Class C): 12 - month waiting periodEmployee Contributions (Bi-Weekly)EmployeeEmployee and SpouseEmployee and Child (ren)Employee and Family$15.52$29.32$36.77$54.44www.elitebenefitsgroup.com
Dental insurance offers an optional vision rider to help pay for eye exams and materials, such as glasses and contact lenses. This coverage can help you maintain healthy vision and overall wellness, as well as provide valuable financial protection for you, your spouse and dependent children.www.elitebenefitsgroup.comVISION BENEFITSIN-NETWORKOUT OF NETWORK ALLOWANCECO-PAYSSTANDARD PLASTIC LENSES (once per 12 months)FRAMES (once per 12 months)CONTACT LENSES (once per 12 months) (Includes fit, follow-up and materials) in lieu of eyeglass lenses and frames.Exam (once per 12 months)Materials$10$25Up to $35See belowSingle visionBifocalTrifocalLenticularProgressivePolycarbonate lenses (for children to age 19)Covered by co-payCovered by co-payCovered by co-payCovered by co-pay$80 allowance$70 allowanceUp to $25Up to $40Up to $50Up to $50Up to $40N/Achoose any frame available at provider locations$120 allowanceUp to $50ElectiveMedically NecessaryUp to $120 allowanceUp to $210 allowanceUp to $100 allowanceUp to $210 allowanceVISIONEmployee Contributions (Bi-Weekly)EmployeeEmployee and SpouseEmployee and Child (ren)Employee and Family$2.88$5.70$6.00$9.39
BENEFITS & ELIGIBILITYAs an employee of Pirtek, you have access to the following benefits for the Plan Year February 1, 2024 – January31, 2025.Core Plan Benefits offered:United Healthcare+LU[HS/Vision7SHU :\WWSLTLU[HS)LULMP[Z[OYV\NO*VSVUPHS3PML)PY[O(KVW[PVU*OHUNLPU0UZ\YHUJL*V]LYHNL(KKYLZZ,TWSV`TLU[:[H[\Z+LH[OPU[OL-HTPS`+LWLUKLU[*OPSK9LHJOLZ3PTP[PUN(NL+P]VYJL(UU\STLU[-43(9LSH[LK3LH]L3LNHS:LWHYH[PVU4HYYPHNL:WV\ZL3VZZVM6[OLY*V]LYHNL,UYVSSTLU[PU4HYRL[WSHJL*V]LYHNLWHO IS ELIGIBLE AND WHENAll active full-time Employees, who work at least 30 hours per week. Employee benefits are effective the first of the month following 60 days of active employment.ELIGIBLE DEPENDENTSYou may enroll your eligible dependents in coverage. They include:-Legal Spouse.-Children up to age 26, regardless of student status or marital status, includingnatural children, stepchildren, and legally adopted children (including children living with you before the adoption is final) who are your dependents or for whom you arerequired to provide health care coverage under a Qualified Medical Child SupportOrder.CHANGING YOUR COVERAGE DURING THE YEARIf you need to change your coverage throughout the year, you may only do so if you experience an eligible change in status/life event, such as:You must make changes to your benefit coverage within 30 days of an eligible change in status/life event.WHAT HAPPENS IF I DON’T ENROLL?If you do not enroll in the benefits program, you will automatically receive “default” coverage, which is:No Coverage.If later on you decide to enroll in benefits, you may be subject to benefit waiting periods, require evidence of insurability, and/or be required to wait until the next Annual Enrollment.www.elitebenefitsgroup.com
The information in this Enrollment Guide is intended for illustrative purposes and informational purposes only. The information contained herein was taken from various summary plan descriptions, certificates of coverage and benefit information. Every effort was taken to accurately report your benefits however discrepancies and errors are always possible. It is not intended to alter or expand rights or liabilities set forth in the official plan documents or contracts. It is not an offer to contract nor are there any express or implied guarantees. In case of a discrepancy between this information and the actual plan documents, the actual plan documents will prevail. If you have any questions about this summary, please contact Human Resources or Elite Benefits GroupDENTAL/VISIONCOLONIAL LIFEELITE BENEFITS GROUPColonial Life Policieswww.colonialLife.com 800.325.4368713.575.3722CONTACT INFORMATIONwww.elitebenefitsgroup.comHUMAN RESOURCESSteven Marullostevenm@pirtekgulfgate.com888-400-9304 MEDICAL / PRESCRIPTIONS United Healthcare www.myUHC.com or call 1-800-291-2634www.colonialLifeDental.com