2025Saber Power ServicesEnrollment Guide Message
SABER POWER SERVICES BENEFITS GUIDE 2WHAT’S INSIDE2025 Benefits Enrollment Memo Page 3 Dental and Vision Benefits Page 11Important Contacts Page 4 Life and AD&D Plans Page 12Benefits & Eligibility Page 5 Life and AD&D Plan Costs Page 13Medical Benefits Page 6 Disability Page 14Flexible Spending Accounts Page 9 Additional Benefits Page 15Dental Plan Comparison Page 10 Legal Notices Page 23WELCOME TO YOUR BENEFITS ENROLLMENTAs a valued member of the Saber Power Services team, we want you to be well. That’s why we’re committed to offering a valuable, flexible benefits package to help you take care of your physical, financial and mental health. This guide includes information about the Saber Power Services benefits available to you. Read through the guide to learn more about how to get better use of your benefits, save money and take control of your health. 2025 BENEFITS ENROLLMENT
2025 BENEFITS ENROLLMENTSABER POWER SERVICES BENEFITS GUIDE 3To: All Eligible EmployeesFrom: Human ResourcesDate: November 18, 2024Re: 2025 Benefits EnrollmentWe are excited to announce that Open Enrollment for Saber Power Services benefits begins on Monday, November 18th, 2024 and will close on Friday, November 29th, 2024 at 11:59pm EST. This is your annual opportunity to review, update, or change your benefits elections for the upcoming year. This year’s enrollment is passive, meaning that your current elections will rollover into 2025 if you take no action. As a reminder, FSA plans must be elected new each year in compliance with IRS regulations. 2025 BENEFIT ENHANCEMENTS & ADDITIONSMedical• Saber is absorbing the increased medical costs for 2025; Employees will not see an increase in premium for the medical plans.• There are no Medical plan changes, employees will enjoy the same coverage at the same rate for 2025.Dental• Enhanced Dental Benefits through Unum at no additional cost• Expanded network of providers• Annual maximum increase from $1,500 in prior years to $2,500 in 2025• Adult orthodontia coverage is now includedVision• Enhanced Vision Benefits provided by Unum• Expanded network of providers through Unum• Employees will enjoy the same coverage at lower costsVoluntary Life and AD&D• Enhanced Voluntary Life Guaranteed Issue Amounts:• Higher Guaranteed Issue amounts. In 2024, the Guaranteed Issue amount was $150,000. In 2025 it will be increased to $180,000.• If an employee and their dependents enroll in at least the minimum amount of Voluntary Life when they are first eligible, they are able to increase up to the Guarantee Issue amount at a subsequent annual enrollment or within 31 days of a change in status without EOI.• One-time special enrollment for Voluntary Life:• Employee: You can purchase coverage from $20,000 to $500,000 in $10,000 increments, up to 7x your earnings. You can qualify for up to $180,000 of coverage with no medical underwriting (EOI). • Spouse: You can purchase coverage from $10,000 to $250,000 in increments of $5,000. Your spouse can get up to $50,000 of coverage with no medical underwriting (EOI). • Any amounts over the Guaranteed Issue Amounts will require Evidence of Insurability (EOI).• You may elect any Voluntary AD&D amount, up to the maximum benefit without EOI. Added Voluntary Benefits Available this Year• Accident, Critical Illness and Hospital Confinement. These products are available to all employees regardless of past health history and most conditions are covered immediately. These plans pay money directly to you, in addition to what health insurance pays doctors and hospitals, to assist with your out-of-pocket expenses. • Follow these links for more information: • Critical Illness - https://player.vimeo.com/video/652077546 • Accident - https://player.vimeo.com/video/638752488• Hospital Confinement - https://player.vimeo.com/video/652078910 YOUR RESPONSIBILITIES DURING OPEN ENROLLMENTPlease review your current benefits and beneficiary elections. Annual enrollment is your time to make changes to your current benefits elections to meet the needs of you and your family in 2025. As a reminder, the only way to make changes to your benefits during a calendar year is within 31 days of a Life Event.If you would like to make change to any of your benefit elections, you have two options:• Visit your ADP portal using the following link: https://workforcenow.adp.com to make changes directly -OR-• Schedule a call with an enrollment counselor at https://calendly.com/unumengageplus/saberpower?month=2024-11 or by calling 866-643-9404. Enrollment counselors are available to answer any questions and assist with the enrollment process.QUESTIONS If you have questions in the meantime, contact HR@saberpower.com.
CONTACT INFORMATIONSABER POWER SERVICES BENEFITS GUIDE 4BENEFIT VENDOR PHONE AND WEBSITEEnrollmentADP / UnumEnroll Yourself: https://workforcenow.adp.com To schedule an appointment:Call: 1.866.643.9404 or visit https://calendly.com/unumengageplus/saberpower?month=2024-11 Benefit Resource CenterUSI1.855.874.0110BRCSouthwest@usi.comMonday through Friday 8:00am to 5:00pm Eastern & Central Standard TimeMedical BenefitsBCBS TX1.800.521.2227bcbstx.comVirtual VisitsBCBS TX / MDLIVE1.888.680.8646MDLIVE.com/bcbstxBlueCard WorldwideBCBS TX 1.800.810.2583 Dental BenefitsUnum1.888.400.9304unumdentalcare.comVision BenefitsUnum / EyeMed Vision 1.888.400.9304unumvisioncare.comFlexible Spending AccountsWageWorks1.877.924.3967wageworks.comLife and DisabilityUnum1.866.679.3054unum.comEmployee Assistance ProgramUnum800.854.1446unum.com/lifebalanceLegal Assistance and Identity Theft AssistanceLegalShield / IDShieldShobi Raj832.672.7509shobi@legalshieldassociate.comVoluntary Hospital, Voluntary Accident & Voluntary Critical IllnessUnum1.800.635.5597unum.comLegal NoticesSaber Power Serviceshttps://www.flipsnack.com/5de6a5a7c6f/saber-power-services-2025-important-legal-notices/full-view.htmlHuman ResourcesSaber Power Services HR@saberpower.com
BENEFITS AND ELIGIBILITYWHO IS ELIGIBLE?You are eligible for benefits if you are a full-time employee regularly scheduled to work 30 or more hours per week. New Hires become eligible for coverage on your date of hire as a full-time employee. An eligible dependent includes: • Your legal spouse.• Your dependent child(ren) under the age of 26.• Your dependent child(ren) of any age who are dependent on you for support as a result of a physical or mental handicap, or disability.If a child becomes mentally or physically handicapped while covered under the benefits plan, the child’s coverage may be continued as long as the child remains handicapped and depends on you for support. Saber Power Services reserves the right to conduct an audit of dependent eligibility at any time. If you and your spouse are both employees of Saber Power Services, only one of you may elect coverage for your Dependent children. You cannot be covered as an employee and as a dependent under another Saber Power Services employee at the same time. More information is available from the Human Resources Department.MAKING CHANGES TO YOUR BENEFITS DURING THE YEARThe choices you make during enrollment remain in effect for the entire plan year. You cannot change coverage for yourself or add/drop dependents during the year unless you have a life status change event, including: • Change in legal marital status, • Birth or adoption of a child, • Death of a dependent, • Change in employment status, • Loss of other coverage under another plan, etc. • Change in cost or care provider (Dependent Care FSA only).IMPORTANT: If you feel you have experienced a life status change event, please visit https://workforcenow.adp.com or email HR@saberpower.com. BENEFITS GUIDE 5SABER POWER SERVICESIMPORTANT: You have 31 days, including your date of hire, to enroll in benefits. If you do not enroll within your 31-day window, you must wait until the next annual enrollment period or life status change event.
MEDICAL BENEFITS: BLUECROSS BLUE SHIELD OF TEXASSABER POWER SERVICES BENEFITS GUIDE 6EVERYONE’S HEALTH NEEDS ARE DIFFERENTSaber Power Services is committed to providing you and your family access to health care that fits your individual needs and budget. That is why we offer two different preferred provider organization (PPO) medical plans through Blue Cross Blue Shield of Texas (BCBSTX). 1. The Base PPO plan gives you the convenience of copays at the doctor’s office and pharmacy at a low monthly cost. 2. The Buy-Up PPO plan has higher monthly premiums but provides more coverage under the plan, in most cases. This means you will likely pay less at the doctor’s office or pharmacy. Neither plan requires a referral from a primary care physician for services provided by a specialty physician. However, in some instances, such as mental health and substance abuse care, you may be required to obtain approval for a service to be covered. Both plans cover preventive care at 100% and include access to the BCBSTX national network of providers. To locate an in-network doctor or pharmacy, call 1.800.521.2227 or go to bcbstx.com.BLUECARD WORLDWIDEAlways carry your BCBSTX ID card with you when you travel abroad. Through the BlueCard Worldwide program, you have access to medical assistance services, doctors and hospitals in more than 200 countries and territories around the world. The BlueCard Worldwide Service Center is available 24/7 toll-free at 1.800.810.2583 or by calling collect at 1.804.673.1177.Call the Service Center in these situations:• If you need to locate a doctor or hospital or need medical assistance services. A BlueCard assistance coordinator, in conjunction with a medical professional, will arrange a physician appointment or hospitalization, if necessary. • If you need to be hospitalized or you need inpatient care after calling the Service Center, you should also call BCBSTX customer service for pre-certification or pre-authorization. HOW THE PPO PLANS WORKYou pay a copay for in-network office visits and a percentage of the cost (coinsurance) for other types of care. You must meet your annual deductible before the plan pays its share of the coinsurance.If you reach your annual out-of-pocket maximum (including your deductible, coinsurance and medical copays), the plan pays 100% of any remaining eligible charges.
MEDICAL BENEFITS: BLUECROSS BLUE SHIELD OF TEXASSABER POWER SERVICES BENEFITS GUIDE 7BCBSTX RESOURCESWith a wide range of online tools and information, you can better manage every aspect of health and wellness • Check the status of a claim and your claims history• Confirm who is covered on your plan • View and print an Explanation of Benefits (EOB) for a claim • Locate an in-network doctor or hospital in your area • Sign up to receive claim status e-mail alerts• Request replacement member ID cards or print a temporary ID card• Find previous reviews, or write your own, on procedures previously performed in hospitalsIT’S EASY TO GET STARTEDStep 1: Go to bcbstx.comStep 2: Log on to Blue Access for Members. You will need your group and member ID numbers from your ID card. Step 3: Create a user ID and password. TELEHEALTH - MDLIVEMDLIVE provides you and your covered dependents with 24/7 virtual access to non-emergency medical care. You can speak to a board-certified doctor right from your mobile device or computer. MDLIVE doctors can diagnose and treat a variety of medical conditions, including: Allergies, Asthma, Sinus Infections, Flu, Cold, Nausea, Ear Problems and Pink Eye. Just like in-person visits, your doctor will review your symptoms, perform a virtual exam and recommend treatment. Prescriptions can even be sent to your pharmacy. MDLIVE also offers therapy. You can talk to a licensed counselor, therapist or psychiatrist to get help with things like anxiety, depression, trauma and relationship issues. Download the mobile app and get registered in minutes. Call (888) 680-8646 or visit www.MDLIVE.com/bcbstx for more information. BLUE365Blue365 offers exclusive health and wellness deals, keeping you healthy and happy every day of the year. Below are several examples of the deals available to you through Blue365: • Fitness deals, including waived enrollment fees at Lifetime Fitness facilities, workout gear and heart rate monitors. • Discounts on meal plans like Nutrisystem and other nutrition resources. • Discounts on hearing aids, elder care support resources, and support for health challenges. Create a username and password at blue365deals.com to start saving today.
MEDICAL PLAN COMPARISON: BLUECROSS BLUE SHIELD OF TEXASSABER POWER SERVICES BENEFITS GUIDE 8The table below is a brief overview of the medical plans available to you. To learn more, refer to your official plan documents. To find an in-network doctor, visit www.bcbstx.com.BCBSTX MEDICALBASE PLAN BUY UP PLANIN-NETWORKOUT-OF-NETWORKIN-NETWORKOUT-OF-NETWORKCalendar Year Deductible Individual | Family $3,000 | $9,000 $6,000 / $18,000 $1,500 / $4,500 $3,000 / $9,000Coinsurance20% 40% 20% 40%Annual Out-of-Pocket Max Individual | Family $5,000 | $10,200 $12,000 / $36,000 $5,000 | $10,200 $11,000 / $33,000Office Visits Virtual Care Preventive Care Physician and Specialist Office $10 copay$0 copay$30 copayNo Benefit40% after deductible40% after deductible$10 copay$0 copay$30 copayNo Benefit40% after deductible40% after deductibleUrgent Care$55 copay40% after deductible$55 copay40% after deductibleEmergency Room 20% and $200 copay(copay waived if admitted) 20% and $200 copay (copay waived if admitted) Hospital Services20% after deductible 40% after deductible20% after deductible 40% after deductibleLab / X-Ray $0 copay40% after deductible$0 copay40% after deductiblePrescription Benefits Retail GenericPreferred Brand NameNon-Preferred Brand Name$10 copay$40 copay$60 copay20% plus copay$10 copay$40 copay$60 copay20% plus copayMail Order (90 day supply) GenericPreferred Brand NameNon-Preferred Brand Name$30 copay$120 copay$180 copayNo Benefit$30 copay$120 copay$180 copayNo BenefitSpecialty DrugsCopay based on tier20% plus copayCopay based on tier20% plus copayMEDICAL COST Employee Only Employee + SpouseEmployee + Child(ren)Employee + FamilyBase Plan $31.50 $92.07 $77.54 $126.00Buy-up Plan $54.44 $134.84 $127.62 $183.18MEDICAL PLAN COSTSThe following charts show the per-paycheck amounts you will pay for medical coverage beginning January 1, 2025.
FLEXIBLE SPENDING ACCOUNTS (FSA): WAGEWORKSSABER POWER SERVICES BENEFITS GUIDE 9Saber Power Services offers two types of FSAs through WageWorks - health care FSA and dependent care FSA. You will not be able to make a new election or change until Open Enrollment for January 1st effective date, unless you have a life status change event. See page 5 for more information on life status change events. HEALTH CARE FSA The health care FSA allows you to elect an annual amount that is deposited into your account through pre-tax payroll deductions. Funds can be used throughout the year to pay for eligible expenses that are not covered or reimbursed through other plans, such as: • Medical, dental and vision expenses • Deductibles, coinsurance and copays • Prescription drugs expenses IMPORTANT: • Health Care FSA - Up to $660 of unused funds may be rolled over to the following year. • Dependent Care FSA - Any amount that is not used before the end of the year is forfeited.DEPENDENT Care FSA The dependent care FSA allows you to elect an annual amount that can be used to pay for qualified dependent care expenses for eligible dependents. Eligible dependents include: To be eligible, dependents must live with you and rely on you for more than half of his or her financial support, and must be claimed as a dependent on your federal tax return.A FEW THINGS TO KEEP IN MIND: • You may elect up to $3,300 annually.• If you and your spouse are both employees covered on the Saber Power Services plan, you and your spouse may both elect $3,300 annually, not to exceed $3,300 per person. • The elected amount is divided by the number of remaining payrolls in the year and deposited into your FSA account each pay period.• You cannot have a health care FSA if you or your spouse are contributing to an HSA.A FEW THINGS TO KEEP IN MIND: • You may elect up to $5,000 annually. If you are married and file separate income tax returns, the maximum amount each of you can contribute to the dependent care FSA is $2,500.• You may be reimbursed only for daycare that enables you to work, not occasional babysitters. If you are married, your spouse must also work, be a full-time student or be disabled. Eligible care includes care provided in your home, someone else’s home, or a licensed daycare facility.• Children under age 13 • Disabled dependents of any age (such as your disabled spouse, older child or parents)
DENTAL PLAN COMPARISON: UNUMSABER POWER SERVICES BENEFITS GUIDE 10Saber Power Services’ employees are offered comprehensive dental coverage through Unum. Good dental health is just as important as your annual physical, which is why preventive dental care is covered at 100% with no deductible. You can visit any dentist you choose. However, just like with the medical plan, you will spend significantly less if you choose an in-network dentist.Choosing the Right Dental Plan The chart below can help you decide which dental plan is right for you and any dependents you may cover. Remember, you must stay in whichever plan you choose until next year’s annual enrollment period.UNUM888.400.9304www.unumdentalcare.comUNUMPASSIVE MAC PLAN PASSIVE PPO PLANOut-of-networkBenefits are based on the discounted fee schedules agreed upon by network dentists. Any amount that is charged over the fee schedule is your responsibility. Benefits are based on usual, customary and reasonable (UCR) charges that dentists in your area charge for each procedure. CoinsurancePreventive services are covered at 100%. Coverage for other in-network services is higher than the PPO Plan. Preventive services are covered at 100%. Coverage for other in-network services is lower than the MAC. Save money using network providersIf you always use in-network providers, consider the MAC Plan. With higher coinsurance levels, your out-of-pocket costs are reduced for in-network dentists. If you want freedom to choose between in-network and out-of-network providers, consider the PPO Plan. Coverage out-of-network is not limited to the discounted fees our in-network dentists charge. Maximum RolloverMembers who take care of their teeth, but use only part of their annual maximum benefit during a benefit period are rewarded with extra benefits in future years! Carryover benefits will be accrued and stored in the insured’s carryover account to be used in the next benefit year. The limits for this policy/certificate are:Passive MACPassive PPOCarryover benefit$400 $400Threshold limit$800 $800Carryover account limit$1,500 $1,500IMPORTANT: Each benefit year a member must have: One cleaning, One regular exam, and Total dental claims for preventive, basic and major covered procedures paid during the year below the threshold limit. If all three criteria above are met, a portion of the annual maximum will carry over to the next year. Group carryover benefit rider must be in effect for one benefit year before any members can utilize carryover benefits. A member must be on the plan for a minimum of three months before accruing carryover benefits.Carryover benefit may be used toward preventive, basic and major covered services only. A member’s carryover account will be eliminated, and the accrued carryover benefits lost if the insured has a break in coverage for any length of time or any reason.
DENTAL & VISION BENEFITS AND COST: UNUMSABER POWER SERVICES BENEFITS GUIDE 11VISION PLANYou will receive comprehensive benefits and great discounts on services and supplies like eye exams, glasses and contact lenses if you enroll in the vision plan through Unum utilizing the EyeMed Insight network. ID cards will be mailed to your home address. DENTAL AND VISION PLAN COSTSThe following charts show the per-paycheck amounts you will pay for dental and vision coverage beginning January 1, 2025.UNUM DENTALPASSIVE MAC PLANPASSIVE PPO PLANCalendar Year Deductible(Individual/Family) $50 / $150 $50 / $150Calendar Year Maximum Benefit $2,500 per individual $2,500 per individualDiagnostic & Preventive Services - Deductible Waived (cleanings, exams and x-rays) You pay 0% You pay 0%Basic Dental Services(fillings, extractions, periodontics and root canals) You pay 0% You pay 20%Major Dental Services (crowns, inlays, onlays, bridges and implants) You pay 40% You pay 50%Orthodontia Services (Adult & Child) You pay 50% You pay 50%Orthodontia Lifetime Maximum $1,500 per person $1,500 per personUNUM VISIONEYEMED INSIGHT NETWORKOUT-OF-NETWORKExam (once every 12 months) $20 copay Covered up to $40Frames (once every 24 months) $130 allowance Covered up to $91Lenses (once every 12 months) Single Vision Lined Bifocals Lined Trifocals $20 copay$20 copay$20 copayCovered up to $30Covered up to $50Covered up to $70Contact Lenses (instead of glasses) Elective Medically Necessary Covered up to $130Copay then 100%Covered up to $130Covered up to $210DENTAL AND VISION COST Employee Only Employee + SpouseEmployee + Child(ren)Employee + FamilyMAC Dental Plan$4.62 $9.23 $13.85` $18.46PPO Dental Plan$4.62 $9.23 $13.85` $18.46Unum EyeMed Vision$2.46 $4.14 $4.22 $6.68DENTAL PLANSYou will receive comprehensive benefits and great discounts on dental services if you enroll in the dental plans through Unum utilizing the Unum Dental network. ID cards will be mailed to your home address.
LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT (AD&D): UNUMSABER POWER SERVICES BENEFITS GUIDE 12Life insurance pays a benefit to your beneficiary (whomever you designate to receive the benefit) upon your death resulting from an accident or illness. If the death is the result of an accident, the payment may be increased based on a schedule found within the policy. BASIC LIFE AND AD&DSaber Power Services provides you with basic life and AD&D insurance (company provided) in the amount of $50,000 at no cost to you. In addition to the benefit we provide to you, the company also provides basic life insurance for your spouse in the amount of $5,000 and for each of your dependent child(ren) in the amount of $3,000 per child. Your dependent children are covered under basic life if they are under the age of 26. Additional age limitations may apply. You are automatically the beneficiary on your dependents. VOLUNTARY LIFE AND AD&DYou may purchase additional voluntary life insurance and voluntary AD&D insurance for yourself and your dependents at group rates (see page 13). The rates for the employee and spouse are based on their own age. The chart below shows more details regarding the voluntary benefits. VOLUNTARY LIFE INSURANCE AND VOLUNTARY AD&D ARE SEPARATE ELECTIONS. Voluntary Life: This is a one-time special open enrollment. You may elect up to the Guaranteed Issue amounts without EOI (evidence of insurability). Amounts over the Guaranteed Issue amounts will be subject to EOI. Voluntary AD&D: EOI is not required for any amounts.UNUMVOLUNTARY LIFE AND AD&DEMPLOYEE SPOUSE CHILD(REN)Life coverage Amount$10,000 increments $5,000 increments $1,000 incrementsMinimum Amount$20,000$10,000$1,000Guaranteed Issue Amount Enhanced to $180,000 Enhanced to $50,000 $10,000Life Maximum Benefit Lesser of 7 times your earnings or $500,000Lesser of 50% of employee coverage or $250,000Birth to 6 months:$1,0006 months to age 26: $10,000The above benefits reduce from the original amount to 65% at age 65; to 40% at age 70; to 25% at age 75, and to 15% at age 80. The age reduction is based on the covered person’s own age. If you decline Voluntary Life coverage now and later decide to enroll as a late entrant, you must answer some medical questions (EOI) to help Unum assess your insurability. This coverage will not be effective until approved by a Unum underwriter. If you are approved for Voluntary Life Insurance coverage, you should receive formal confirmation from Unum. If you have not received formal confirmation, but are having payroll deductions taken for Voluntary Life Insurance, you should contact the payroll department immediately to ensure that coverage is in effect, as payroll deductions are not formal evidence of coverage. LIFE AND AD&D INSURANCE ENHANCEMENTS• Enhanced Voluntary Life Guaranteed Issue Amounts:• Higher Guaranteed Issue amounts. In 2024, the Guaranteed Issue amount was $150,000. In 2025 it will be increased to $180,000.• If you enroll in at least the minimum amount of Voluntary Life, you can increase up to the Guarantee Issue amount at a subsequent annual enrollment without medical underwriting (EOI).• One-time special enrollment for Voluntary Life:• Employee: You can purchase coverage from $20,000 to $500,000 in $10,000 increments, up to 7x your earnings. You can qualify for up to $180,000 of coverage with no medical underwriting (EOI). • Spouse: You can purchase coverage from $10,000 to $250,000 in increments of $5,000. Your spouse can get up to $50,000 of coverage with no medical underwriting (EOI). • Any amounts over the Guaranteed Issue Amounts will require Evidence of Insurability (EOI).• You may elect any Voluntary AD&D amount, up to the maximum benefit without EOI.
VOLUNTARY LIFE AND AD&D EMPLOYEE CONTRIBUTIONSSABER POWER SERVICES BENEFITS GUIDE 13EMPLOYEEmonthly rateSPOUSECHILD(REN)Rate per $1,000AGE Per $1,000 of coveragePer $1,000 of coverage$0.171 per $1,000 of coverage<34$0.07 $0.0735-39 $0.10 $0.1040-44 $0.15 $0.1545-49 $0.24 $0.2450-54 $0.36 $0.3655-59 $0.60 $0.6060-64 $0.95 $0.9565-69 $1.48 $1.4870-74 $2.45 $2.4575+$4.23 $4.23AD&D monthly ratesCoverage Amount RateEmployeeper $1,000 of coverage $0.040Spouse per $1,000 of coverage $0.040Childper $1,000 of coverage $0.040AD&D 1 2 3 4Employee$_____,000 divided by $1,000 = $___________X $0.040 = $___________Spouse $_____,000 divided by $1,000 = $___________X $0.040 = $___________Child$_____,000 divided by $1,000 = $___________X $0.040 = $___________Total CostCalculate your AD&D costs1. Enter the AD&D coverage amount you want.2. Divide by the amount shown. 3. Multiply by the rate. Use the AD&D rate table to find the rate. 4. Enter your cost LIFE1 2 3 4Employee$_____,000 divided by $1,000 = $___________X ______ = $___________Spouse $_____,000 divided by $1,000 = $___________X ______ = $___________Child$_____,000 divided by $1,000 = $___________X ______ = $___________Total CostCalculate your Life Insurance costs1. Enter the coverage amount you want.2. Divide by the amount shown. 3. Multiply by the rate. Use the rate table to find the rate. Choose the age you will be on 1/1/2025. To determine your spouse rate, choose the age you will be on 1/1/2025.4. Enter your cost. Voluntary Life and Voluntary AD&D are separate elections. You may elect either Voluntary Life, Voluntary AD&D or both. The rates for the employee and spouse are based on their own age.
Disability covers a portion of your income if you are unable to work due to accident or illness. Saber Power Services pays the full cost of both Short-Term Disability and Long-Term Disability coverage for eligible employees. SHORT TERM DISABILITY (STD)What happens if you have an unexpected injury or illness that leaves you unable to work or earn a paycheck? Few people believe it will happen to them, but the truth is your risk of becoming disabled is far greater than you may think. If you are disabled according to the policy’s definition of disability, you will be eligible to receive a weekly benefit of 60% of your basic weekly earnings, up to a maximum benefit of $3,000 per week. Benefits begin the first (1) day of injury and the eighth (8) day of illness. Benefits are paid up to thirteen (13) weeks, as long as you remain disabled according to the terms of the plan. If you have a Cesarean section, you will be considered disabled for a minimum period of eight weeks unless you return to work before the end of the time. DISABILITY: UNUMSABER POWER SERVICES BENEFITS GUIDE 14IMPORTANT: Unum determines eligibility for payment. Pre-existing limitations apply to the LTD plan. UNUMSHORT TERM DISABILITY (STD)Elimination Period0 days for Accidents7 days for SicknessWeekly Benefit60% of your base weekly earnings Maximum Weekly Benefit$3,000Maximum Benefit Duration13 weeksLONG TERM DISABILITY (LTD)If your disability continues beyond 90 days and you are still deemed disabled by Unum, you may receive a benefit of 60% of your annual earnings to a maximum monthly benefit of $5,000 per month. The LTD plan provided to you contains exclusions and limitations. Please refer to the contract for details. UNUMLONG TERM DISABILITY LTD)Elimination Period90 days or the date your short-term disability ends (if elected)Monthly Benefit60% of your base monthly earnings Maximum Monthly Benefit$5,000Maximum benefit periodPayments will last for as long as you are disabled or until you reach age 65, whichever is sooner.
SABER POWER SERVICES BENEFITS GUIDE 15YOU ENROLL IN HOSPITAL INDEMNITY INSURANCEWhen coverage is active, you are admitted to a hospital for any reasonWhile in the hospital charges start to add upPays you a lump sum for every day you are in the hospital up to the plan maximumYou enroll in Hospital Indemnity Insurance1234This plan design was created to be compatible with Health Savings Accounts (HSAs). However, if you have or plan to open an HSA, please consult your tax and legal advisors to determine which supplemental benefits may be purchased by employees with an HSA.Hospital Indemnity Insurance pays a daily benefit if you have a covered stay in a hospital or critical care unit. The benefit amount is determined based on the type of facility and the number of days you stay. You use the money as you see fit. This plan also includes Health Champion - Administrative & clinical support following serious illness or injuryUNUMVOLUNTARY HOSPITAL PLANHospital AdmissionUp to 1 day per year$1,000ICU AdmissionUp to 1 day per year$1,000Hospital Daily StayUp to 365 days$100ICU Daily StayUp to 30 days$100Short StayUp to 1 day per year$250Be Well BenefitEvery year, each covered member can receive a benefit for getting a covered Be Well screening test$50VOLUNTARY HOSPITAL COSTEMPLOYEE ONLY$4.90EMPLOYEE + SPOUSE$14.82EMPLOYEE + CHILD(REN)$8.23EMPLOYEE + FAMILY$18.15VOLUNTARY HOSPITAL PLAN COSTSThe following chart shows the per-paycheck amounts you will pay for coverage beginning January 1, 2025.ADDITIONAL BENEFITS: VOLUNTARY HOSPITAL ADDITIONAL BENEFITS: UNUM VOLUNTARY HOSPITAL
ADDITIONAL BENEFITS: UNUM VOLUNTARY CRITICAL ILLNESSSABER POWER SERVICES BENEFITS GUIDE 16When coverage is active, you are diagnosed with a covered critical illnessCharges start to add upPays you a lump sum depending on the diagnosisYou enroll in Critical Illness Insurance1234Critical Illness Insurance can help you by paying a lump sum cash benefit to help cover your out-of-pocket medical costs, including deductibles, copays, and cost-shares or pay daily living expenses such as grocery bills, mortgage payments, transportation costs, etc.UNUMVOLUNTARY CRITICAL ILLNESS PLANCRITICAL ILLNESSES•Heart Attack•Stroke•Major organ failure•End-stage kidney failure•Sudden cardiac arrest•Coronary artery disease Major (50%): Coronary artery bypass graft or valve replacement Minor (10%): Balloon Angioplasty or stent placementCANCER CONDITIONS•Invasive cancer – all breast cancer is considered invasive•Non-Invasive cancer (25%)•Skin Cancer - $500PROGRESSIVE DISEASES•Amyotrophic Lateral Sclerosis•(ALS)•Dementia, including Alzheimer’s disease•Multiple Sclerosis (MS)•Parkinson’s disease•Functional loss•Huntington’s Disease•Lupus•Muscular Dystrophy•Myasthenia Gravis•Systemic Sclerosis (Scleroderma)•Addison’s Disease•Loss of sight, hearing or speech•Benign brain tumor•Coma•Permanent Paralysis•Occupational HIV, Hepatitis B, C or D•Occupational PTSD Paid at 25%•Infectious Diseases•Pulmonary Embolism•Transient Ischemic Attack (TIA)•Bone Marrow/Stem CellBe Well BenefitEvery year, each covered member can receive a $50 benefit for getting a covered Be Well screening test.
ADDITIONAL BENEFITS: UNUM VOLUNTARY CRITICAL ILLNESSSABER POWER SERVICES BENEFITS GUIDE 17AGEEmployee Coverage: $10,000Spouse Coverage: $5,000Employee Spouse<25$1.62 $1.1325-29$1.94 $1.2930-34$2.31 $1.4835-39$2.82 $1.7340-44$3.78 $2.2245-49$5.45 $3.0550-54$8.22 $4.4355-59$11.31 $5.9860-64$19.98 $10.3265-69$27.09 $13.8770-74$36.83 $18.7475-79$49.48 $25.0680-84$65.54 $33.0985+$94.62 $47.63The following charts show the per-paycheck amounts you will pay for coverage beginning January 1, 2025.AGEEmployee Coverage: $20,000Spouse Coverage: $10,000Employee Spouse<25$3.23 $2.2625-29$3.88 $2.5830-34$4.62 $2.9535-39$5.63 $3.4640-44$7.57 $4.4345-49$10.89 $6.0950-54$16.43 $8.8655-59$22.62 $11.9560-64$39.97 $20.6365-69$54.18 $27.7470-74$73.66 $37.4875-79$98.95 $50.1280-84$131.08 $66.1885+$189.23 $95.26AGEEmployee Coverage: $30,000Spouse Coverage: $15,000Employee Spouse<25$4.85 $3.3925-29$5.82 $3.8830-34$6.92 $4.4335-39$8.45 $5.1940-44$11.35 $6.6545-49$16.34 $9.1450-54$24.65 $13.2955-59$33.92 $17.9360-64$59.95 $30.9565-69$81.28 $41.6170-74$110.49 $56.2275-79$148.43 $75.1880-84$196.62 $99.2885+$283.85 $142.89
ADDITIONAL BENEFITS: UNUM VOLUNTARY ACCIDENTSABER POWER SERVICES BENEFITS GUIDE 18Accident Insurance provides a set benefit amount based on the type of injury you have and the type of treatment you need. It covers accidents that occur on and off the job. And it includes a range of incidents, from common injuries to more serious events. Every year, each covered member can receive a $50 benefit for getting a covered Be Well screening test.UNUMAccidental Death & DismembermentInjuryUpper Jaw, Maxilla (other than alveolar process) - $375Employee - $50,0002nd Degree Burns – at least 5%, but less than 20% - $500Ankle (lower tibia or fibula) - $450Spouse - $25,0002nd Degree Burns – 20% or greater - $1,000Collarbone (clavicle, sternum) or Shoulder Blade (scapula) - $450Children - $12,5003rd Degree Burns - at least 5%, but less than 20% - $5,000Foot or Heel (other than Toes) - $450Common Carrier Benefit3rd Degree Burns – 20% or greater - $10,000Forearm (olecranon, radius, or ulna), Hand, orWrist (other than Fingers) - $450Employee - $50,000ConcussionKneecap (patella) - $450Spouse - $25,000Concussion - $200Lower Jaw, Mandible (other than alveolar process) - $450Children - $12,500Connective Tissue DamageVertebral Processes - $450DismembermentOne Connective Tissue - $90Rib - $450Both feet - $50,000Two or more Connective Tissues - $150Tailbone (coccyx), Sacrum - $450Both hands - $50,000DislocationsFinger or Toe (Digit) - $225One foot - $25,000Knee joint (other than patella) - $1,650Chip Fracture – 25%One hand - $25,000Ankle bone or bones of the foot (other than toes) - $1,650Same bone maximum incurred per accident – 1 fractureThumb and Index finger of the same hand - $12,500Hip Joint - $3,375Maximum payable multiplier for multiple bones – 2 timesComaCollarbone (sternoclavicular) - $825Internal InjuriesComa - $10,000Elbow Joint - $500Internal Injuries - $200Home & Vehicle ModificationsHand (other than Fingers) - $500LacerationsHome & Vehicle Modifications - $1,500Lower Jaw - $500No Repair - $50Loss of UseShoulder - $500Repair < 2 inches - $150Hearing (one ear) - $12,500Wrist joint - $500Repair 2-6 inches - $300Hearing - $12,500Collarbone (acromioclavicular and separation) - $325Repair < 2 inches - $600Sight of one Eye - $25,000Finger or Toe (Digit) - $150Loss of a DigitSight of both Eyes - $20,000Kneecap (patella) - $500One Digit (other than a Thumb or Big Toe) - $750Speech - $25,000Incomplete Dislocation – 25%One Digit (a Thumb or Big Toe) - $1,125ParalysisEye InjuryTwo or more Digits - $1,500Uniplegia - $12,500Eye Injury - $200Knee CartilageHemi/Paraplegia - $25,000FracturesKnee Cartilage (Meniscus) Injury - $150Triplegia - $37,500Skull (except bones of Face or Nose), Depressed - $4,500Ruptured or Herniated DiscQuadriplegia - $50,000Hip or Thigh (femur) - $3,375One Disc - $150HospitalizationSkull (except bones of Face or Nose), Non-depressed - $2,250Two or more Discs - $250Admission - $1,000Vertebrae, body of (other than Vertebral Processes) - $1,350RecoveryAdmission – ICU - $1,000 (added)Leg (mid to upper tibia or fibula) - $1,350Acquired Brain Injury - $25Daily Stay (365 days) - $300Pelvis - $1,350At-Home Care - $100Daily Stay – ICU - $300 (added)Bones of the Face or Nose (other than Lower Jaw, Mandible or Upper Jaw, Maxilla) - $675Physician Follow-Up Visits (2 max) - $75Short Stay - $200Upper Arm between Elbow and Shoulder (humerus) - $675Prescription Drug - $25
ADDITIONAL BENEFITS: UNUM VOLUNTARY ACCIDENTSABER POWER SERVICES BENEFITS GUIDE 19UNUMRehabilitationor Subacute Rehabilitation Unit - $100Ruptured or Herniated Disc Surgery:Exploratory without Repair - $125One Disc - $675Two or more Discs - $1,000Treatment:Emergency Room Treatment - $100Injections to Prevent or Limit Infection (tetanus, rabies, antivenom, immune globulin) - $50Pain Management Injections (epidural, cortisone, steroid) - $100Transfusions - $400Transportation (per trip) - $100Family Care - $50Pet Boarding (per day) - $30Treatment in a Physician’s Office or Urgent Care Facility (initial) - $75Behavior Health Therapy (15 visits) - $20TreatmentTelehealth Service - $25Organized Sports – 10%Therapy Services (chiro, speech, PT, occ, acupuncture/alternative) (15 days) - $20Ambulance:Air - $1,000Ground - $300SurgeryDurable Medical Equipment:Tier 1 (arm sling, cane, medical ring cushion) - $50Tier 2 (bedside commode, cold therapy system, crutches) - $100Dislocations:Surgical Repair – 100%Tier 3 (back brace, body jacket, continuous passive movement, electric scooter) - $200Anesthesia:Epidural or Regional Anesthesia - $100General Anesthesia - $250Emergency Dental Repair:Dental Crown - $350Dental Extraction - $115Filling or Chip Repair - $90Connective Tissue:Exploratory without Repair - $100Repair for One Connective Tissue - $800Repair for Two or more Connective Tissues - $1,200Imaging:Tier 1: X-rays or Ultrasound - $50Tier 2: Bone Scan, CAT, CT, EEG, MR, MRA, or MRI - $200Eye Surgery:Eye Surgery, Requiring Anesthesia - $300Lodging:Lodging (per night) - $150Fractures:Fractures, Surgical Repair - 100%Prosthetic Device:One Device or Limb - $750Two or more Devices or Limbs - $1,500General Surgery: Abdominal, Thoracic, or Cranial - $1,500Exploratory - $150Hernia Surgery - $150Knee Cartilage (Meniscus) Exploratory without Repair - $150Knee Cartilage (Meniscus) Exploratory with Repair - $750Outpatient Surgical Facility - $300Skin Grafts:For Burns – 50%Not Burns - Less than 20% of skin surface - $250Not Burns - 20% or greater of skin surface - $500VOLUNTARY ACCIDENT COSTEMPLOYEE ONLY$5.12EMPLOYEE + SPOUSE$9.06EMPLOYEE + CHILD(REN)$11.34EMPLOYEE + FAMILY$15.28VOLUNTARY ACCIDENT PLAN COSTSThe following chart shows the per-paycheck amounts you will pay for coverage beginning January 1, 2025.
ADDITIONAL BENEFITS: UNUMSABER POWER SERVICES BENEFITS GUIDE 20EMPLOYEE ASSISTANCE PROGRAM (EAP)With your Employee Assistance Program and Work/Life Balance services, confidential assistance is as close as your phone or computer.Your EAP is designed to help you lead a happier and more productive life at home and at work. Call for confidential access to a Licensed ProfessionalCounselor who can help you. A Licensed Professional Counselor can help you with:• Stress• Depression• Anxiety• Relationship issues• DivorceYou can also reach out to a specialist for help With balancing work and life issues. Just call and one of our Work/Life Specialists cananswer your questions and help you findresources in your community.Will Prep / Estate Planningwww.unum.com/lifebalancePhone: 1-800-854-1446WILL PREP/ESTATE PLANNINGVisit www.unum.com/lifebalance for state-specific templates and step-by-step instructions on creating a will. Your Personalized Legal Center also contains state-specific templates for power of attorney, trusts, estateplanning, and more as well as access to a legal library. You have access to a variety of personal and business-related topics:Saber Power Services provides these benefits to you at no costEAPwww.unum.com/lifebalancePhone: 1-800-854-1446 Online and Phone support: Unlimited, confidential 24/7• Anger, grief and loss• Job stress, work conflicts• Family and parenting problems• And more• Wills• Living Trusts• Personal Service Agreements• Promissory Notes• Copyright & Trademark• Power of Attorney• Landlord/Tenant Agreement• Name Change• Incorporation• Premarital AgreementsYou will be able to create your legal form or document instantly and ready it for printing. Educational content, definitions, and help prompts are available for each form or document. Your documents can be stored on a secure server and accessible 24/7 via a unique username and password.
ADDITIONAL BENEFITS: LEGALSHIELD & IDSHIELDSABER POWER SERVICES BENEFITS GUIDE 21
ADDITIONAL BENEFITS: USIBENEFIT RESOURCE CENTEROur Benefits Specialists can help you and your family translate confusing jargon, answer questions about which benefits are on your plan and which aren’t, work directly with insurance carriers to resolve tricky issues regarding claims and denials of service—and more! Our Benefits Specialists can help you with:• Benefit plan & policy questions• Eligibility & claim problems with carriers• Information about claim appeals & process• Allowable family status election changes• Transition of care when changing carriers• Claim escalation, appeal & resolution• Medicare basics with your employer plan • Coordination of benefits• Finding in-network providers• Access to care issues• Obtaining case management services• Group disability claims• Filing claims for out-of-network servicesBE NE FIT R ES O URC E C EN TE R BRCSouthwest@usi.com | Toll Free: 855-874-0110Monday through Friday 8:00am to 5:00pm Eastern & Central Standard TimeMyBenefits2Go MOBILE APPThe MyBenefits2GO app gives you on-the-go access to your benefit and insurance policy details, HR contact information and more! The app is a quick and simple way for you and your enrolled dependents to access benefit summaries and other important information about our group plans. Store photos of ID cards in the app and easily locate carrier and HR contact information—all in one place. The MyBenefits2GO app is free for iPhone and Android. HIGHLIGHTS OF THE MyBenefits2GO APP:• Access benefits information on the go• Convenient contact information for Carriers and HR• Organized plan information in one place• View the most updated plan information • Store your ID cards in the appSearch for ‘MyBenefits2GO’ and download our free app. Enter this code when prompted: W55070
SABER POWER SERVICES BENEFITS GUIDE 23IMPORTANT PATIENT PROTECTION AND AFFORDABLE CARE ACT NOTICES, ERISA NOTICES AND CONTACTS FOR MORE INFORMATIONThe legal notices describe important rights that you have under the terms of the Saber Power Services Health Plan. They are accessible at:https://www.flipsnack.com/5de6a5a7c6f/saber-power-services-2025-important-legal-notices/full-view.htmlIf you need a printed copy of these notices or have any questions about them, you may contact: Your Employer Representative Human ResourcesHR@saberpower.comor by mail atSaber Power Services9841 Saber Power LaneRosharon, TX 77583IMPORTANT NOTICE: The legal notices are provided to help employers understand the compliance obligations for Health & Welfare benefit plans, but it may not take into account all the circumstances relevant to a particular plan or situation. It is not exhaustive and is not a substitute for legal advice. Important Legal Notices• Fixed Indemnity Notice• CHIPRA Notice (Children’s Health Insurance Program Reauthorization Act)• WHCRA Notice (Women’s Health and Cancer Rights Act)• Wellness Program Disclosure (ADA & HIPAA)• Newborns Act Disclosure• HIPAA Special Enrollment Rights Notice• Medicare Creditable Coverage Notice• Statement of ERISA Rights• Notice of Privacy Practices
This guide is designed to help you make informed decisions. These Enrollment Materials (“Materials”) in accordance with the Employee Retirement Income Security Act of 1974 (ERISA), as amended, also serve as a Summary of Material Modifications (“SMM”). It is not a detailed description, nor is it a contract of employment or a guarantee of benefits. This SMM is effective January 1, 2025 and describes the changes (if any) to the Plan in very general terms. The specific terms and conditions of these plans are governed by legal plan documents, insurance contracts, and service agreements. In the event of a conflict between this SMM and the terms of those documents, contracts, and agreements, the documents, contracts, and agreements will at all times govern plan operation and payment of all plan benefits. In the event of an ambiguity in this SMM, the terms of the official plan documents will govern. Saber Power reserves the right to amend or terminate the program in whole or in part at any time. If you have any questions about this summary, contact Human Resources.