ThebenefitsplanyearrunsJanuary1stthroughDecember31st.Unlessyouhaveaqualifiedchange-in-statuseventthatimpactsyoureligibilityandthechangeisallowedunderthetermsoftheinsurancecontractorplandocument,youcannotmakechangestoyourbenefitsuntilthenextOpenEnrollmentperiod.Benefitchangesmustbeconsistentwithyourqualifiedchange-in-statusevent.ChangesmustbesubmittedtoHumanResourceswithin30daysoftheevent;documentationsupportingthechangewillberequired.Whoiseligibleforbenefits?Allfull-timeemployeeswhoworkaminimumof30hoursperweekareeligibleforbenefits. For new hires, benefits are effective on the first of the month followingyourdateofhire.In addition to enrolling yourself, you may also enroll any eligible dependents.Eligibledependentsaredefinedbelow:• Spouse:apersontowhomyouarelegallymarriedbyceremony• Child(ren):Yourbiological,adopted,orlegaldependentsuptoage26regardlessof student, financial, and marital status; coverage for a dependent child willterminateattheendofthemonthinwhichthechildturnsage26Change-in-StatusEventsUnlessyou have aqualifiedchange-in-statuseventthat impactsyoureligibilityandthechangeisallowedunderthetermsoftheinsurancecontractorplandocument,youcannot make changes to the benefitsyouelectuntilthenext Open Enrollmentperiod.Someexamplesofqualifiedchange-in-statuseventsarehighlightedbelow:MarriageordivorceBirth,adoption,ordeathChangeinemployment,oremploymentstatusforyou,yourspouse,oryourdependentchildChangeincoverageunderanotheremployerplan,suchasachangemadeduringyourspouse’sOpenEnrollmentTeal Energi takesprideinproviding acomprehensiveemployee benefits program, and we recognize theimportant role employee benefits play as a criticalcomponent of your overall compensation. We striveto maintain a benefits program that is rewarding andcompetitive.WHAT’SINSIDEEmployeeResourcesEmployeeContributionsMedicalDentalVisionPlanHighlightsLife/AD&DDisabilityEmployeeAssistanceProgramTravelAssistanceProgram2
EMPLOYEERESOURCESPlan PolicyNumber PhoneNumberandWebsite/EmailMedicalBlueCrossBlueShield359914(800) 521-2227 www.bcbstx.comDentalPrincipalFinancial1163013-10001(800) 247-4695www.principal.com/dentistVisionPrincipalFinancial1163013-10001(800) 877-7195www.principal.com/vsp LifeandDisabilityPrincipalFinancial1163013-10001(800) 245-1522www.principal.comEmployeeAssistanceProgram(EAP)PrincipalFinancial1163013-10001(800) 450-1327www.magellanhealth.com/memberTravelAssistanceProgramPrincipalFinancial1163013-10001(888) 647-2611www.principal.com/travelassistanceManyofourprovidershavemobileappsthatprovidepersonalizedaccesstoyourbenefitswhenandwhereyouneedthem!TherearealsoavarietyofFREEhealthandfitnessrelatedappsavailable.BrowseanddownloadappstoyoursmartphoneortabletfromtheAppStoreorGooglePlay.THERE’SANAPPFORTHAT!3
4WeofferthreePPOplansforyoutochoosefrom.To locateaparticipating,in-networkprovider,visitwww.bcbstx.com.Thischartisintendedforsummarypurposesonly.Ifthereareanydiscrepancies,theofficialplandocumentswillalwaysgovern.Pre-certificationmayberequiredforcertainservices.MEDICAL&PRESCRIPTIONPLANHIGHLIGHTSPPOPLANS(InandOut-of-Network;NoPCPRequired)PlanFeaturesPlanOption1 PlanOption2 PlanOption3$6,350HDHP $4,000HDHP $1,500PPO(B660CHC) (G656CHC) (G653CHC)IN-NETWORKProviderNetwork BlueChoicePPO BlueChoicePPO BlueChoicePPOHSACompatible? YES YES NOAnnualDeductibleAmountyoumustpaybeforetheplanwillbegintopayforcertainservices$6,500individual$13,000family$4,000individual$12,000family$1,500individual$4,500familyAnnualOut-of-PocketMaximumMaximumamountyoupayperyearforcoveredexpenses$7,250individual$14,500family$4,000individual$12,000family$6,000individual$12,000familyPREVENTIVESERVICESWell-childvisitsandimmunizations,routineGYNvisit,annualadultphysical,andotherappropriatescreeningsasoutlinedintheACANocharge Nocharge NochargeOFFICEVISITS,LABS,ANDTESTINGPCP&SpecialistOfficeVisits 30%afterdeductible 0%afterdeductible $40Copay/$80CopayDiagnosticTest(x-ray,bloodwork) 30%afterdeductible 0%afterdeductibleLab:20%afterdeductibleX-Rays:$50pertest+ 20%afterdeductibleImaging(CT/PETscans,MRIs)(pre-authorizationmayberequired)30%afterdeductible 0%afterdeductible$100copaypertest+ 20%afterdeductibleHOSPITALInpatient/Outpatient 30%afterdeductible 0%afterdeductible 20%afterdeductibleURGENTANDEMERGENCYCAREUrgentCare 30%afterdeductible 0%afterdeductible $75copayEmergencyRoom$650pervisit+30%afterdeductible0%afterdeductible$500copaypervisit+ 20%afterdeductiblePRESCRIPTIONDRUGSRetailPharmacy(30-daysupply)GenericNon-PreferredGenericBrandNameNon-PreferredBrandNamePreferredSpecialtyNon-PreferredSpecialty10%-50%afterdeductible(refertoSBCpharmacytiers)0%afterdeductiblePreferred/Non-PreferredPharmacy$0/$10$10/$20$50/$70$100/$120$150$250MailOrder(90-daysupply)SpecialtyRXnotcovered10%-50%afterdeductible 0%afterdeductible $0/$30/$150/$300 OUT-OF-NETWORKAnnualDeductible$13,000individual$26,000family$8,000individual$24,000family$3,000individual$9,000familyAnnualOut-of-PocketMaximum Unlimited$8,000individual$24,000familyUnlimited
5HEALTHSAVINGSACCOUNTWhoIsEligible?*Allthreecriteriamustbemet:• EnrolledinanIRS“qualified”HighDeductibleHealthPlan• Notcoveredbyanothermedicalplanunlesstheotherplanisalsoa“qualified”HDHP• NotenrolledinMedicarecoverage*Itistheemployee’sresponsibilitytonotifyHRifyouarenoteligibleforHSA.Howdoesitwork?The HDHP allows employees to set aside money on a pre-tax basis into a Health Savings Account (HSA).TheHSAisanaccountestablishedexclusivelyforthepurposeof payingforqualifiedmedicalexpensesforyouandyoureligibledependentsonatax-freebasis.ContributionstotheHSAarefundedwithpre-taxdeductionswithheldfromyourpaycheck.Thefundsaredeposited into an interest-bearingaccount in your name. The money in the HSA can be used to pay foreligible expenses not covered by your insurance plan, including the deductible, coinsurance, and copays.Any money not used for qualified medical expenses remains in the account. In the event you leave TealEnergi,youowntheaccountandthemoneytherein.Foracomplete listof“qualified” medical expenses,pleaserefertoPublication502atwww.irs.gov.HowmuchcanIcontribute?IRSANNUALLIMITS 2024MaximumContributionSingleOnly $4,150Employee+Dependents $8,300Catch-UpContribution Employeesage55+maybeeligibletocontributeanadditional$1,000
Dental-PrincipalWearepleasedtoofferyouacomprehensivedentalPPOplan.Youcanvisitanylicenseddentist,butyourcostsareusuallylowestwithanin-networkdentist.In-networkdentistsacceptreducedfeesforcovered services;out-of-network dentistsmaybalancebillyouthedifferencebetweentheirusualfeeandwhattheplanpays.Limitationsorwaitingperiodsmayapplyforsomebenefits;someservicesmaybeexcludedfrom your plan.Thesechartsareintendedforsummarypurposesonly.Ifthereareanydiscrepancies,theplandocumentwillalways govern. Dental Reimbursement for out-of-network services is based on the maximum contractallowancesandnotnecessarilyeachdentist’ssubmittedfees.Youwillpaylessmoneywhenyoustaywithinthenetwork.Needtolocateaparticipating,in-networkprovider?Visitwww.principal.com/vspDENTAL&VISIONPLANHIGHLIGHTSPreventionfirst!Make sure you take advantage of yourpreventive dental visits. Preventive careservicesarenotsubjecttothedeductibleandthe plan covers100%of the cost ifyouvisitanin-networkprovider!6Vision-PrincipalYour vision coverage provides a full range of vision care services. You may receive care from any provider you choose, but yourbenefitsaregreaterwhenyouseeaparticipatingproviderinthenetwork.Ifyouchoosetoreceiveservicesfromanout-of-networkprovider, youwillberequiredtopaythatprovideratthetimeofserviceandsubmitaclaimformforreimbursement.MaximumAccumulation(RolloverBenefit)1Threshold2$750Carry-over350%ofthresholdtoamaximumof$3751. This allows for a portion of unusedmaximumbenefittocarryovertonextyear'smaximum benefit amount. To qualify, youmust have had a dental service performedwithin the Calendar year and used less thanthemaximumthreshold.2. Thethresholdisequaltothelesserof50%ofthemax benefit or$1,000.Ifqualificationismet,50%ofthethresholdwillcarryovertonextyear’smaxbenefit.3. You can accumulate no more than 4Xcarryoveramount.PlanFeaturesIn-Network&Out-of-NetworkNetworkPrincipalDentalPPOCalendarYearDeductibleAmountyoumustpaypercalendaryearbeforetheplanbeginstopaybenefits.Thedeductibleiswaivedforpreventiveservices.$50individual$150familyPreventiveandDiagnosticServicesNocharge—nodeductibleBasicServicesDeductible,then20%MajorServicesDeductible,then50%AnnualBenefitMaximum$1,500perpersonpercalendaryear,plus,anymaximumrolloverbenefitMaximumamounttheplanwillpaypercalendaryearOrthodontiaNotCoveredOutofNetworkProcessing90thPercentilePlanFeatures In-NetworkOut-of-NetworkReimbursementVisionExam(Onceevery12months)$10copay Upto$45EyeglassFrames(Onceevery12months)$130planallowance+ 20%offbalanceUpto$70EyeglassLenses(Onceevery12months)Single$25copay Upto$30LinedBifocal$25copay Upto$50LinedTrifocal$25copay Upto$65Lenticular$25copay Upto$100ContactLenses Elective:$130allowance Upto$105(Onceevery12months)Necessary:$25copay Upto$210* Benefitallowanceincludescoverageforglassesframesorcontactlenses,notboth.
BasicTermLifeandAD&DInsurance(CompanyPaid)Allfull-timeemployeesworking30ormorehoursperweekareautomaticallyenrolledinthebasiclifebenefit.Whilecoverageisautomatic,iscriticalthatyoudesignateabeneficiarywhenfirstenrollinginbenefits.Youcanchangeyourbeneficiaryatanytimeandasfrequentlyasneeded.LIFEINSURANCEDuringyourbenefitsenrollment,don’tforgettodesignateabeneficiary!7Lifeinsurancehelpsprotectyourfamilyfromfinancialriskandsuddenlossofincomeintheeventofyourdeath.Accidentaldeathanddismemberment (AD&D)insurance provides an additionalbenefit ifyoulose your life, sight, hearing, speech, orlimbsin anaccident.CompanyPaidSummaryLifeBenefitFlat$50,000AccidentalDeathBenefitFlat$50,000ReductionScheduleBy35%@65;50%@70AdditionalBenefitsConversion,AcceleratedDeathBenefit,WaiverofPremiumVoluntarySummaryLife/AD&DBenefit- Employee- Spouse- Child(ren)[TermLifeOnly]$10,000-$300,000$5,000-$100,000(cannotexceed100%ofemployeeamount)$5,000or$10,000GuaranteedIssueCoverage(nomedicalquestions)- Employee(Underage70)- Spouse(Underage70)$100,000$20,000ReductionScheduleBy35%@65;50%@70AdditionalBenefitsConversion,AcceleratedDeathBenefit,WaiverofPremiumVoluntaryTermLifeandAD&D Insurance(EmployeePaid)Allfull-timeemployeesworking30ormorehoursperweekareeligibletoenrollinadditionalvoluntarylifeinsuranceaboveandbeyondtheemployerpaidbenefits.Voluntarytermliferatesareofferedatheavilydiscountedgrouprates.Solongasyouenrollwhenfirsteligible,guaranteedcoverageisalsoavailabletoyou,regardlessofyourcurrenthealthstatus.
DISABILITYINSURANCE8EmployerpaidShort-TermDisabilityPlanFeaturesPrincipalLifeInsuranceCompanyEmployeeBenefitAmount 60%MaximumBenefitAmount $2,000perweekEliminationPeriod(WaitingPeriod) 14DaysBenefitDuration 11WeeksPre-ExistingConditionExclusion NoneVoluntaryLong-TermDisabilityPlanFeaturesPrincipalLifeInsuranceCompanyEmployeeBenefitAmount 60%MaximumBenefitAmount $10,000permonthOwnOccupationPeriod 2YearsEliminationPeriod(WaitingPeriod) 90DaysBenefitDuration SocialSecurityNormalRetirementAgePre-ExistingConditionExclusion 3/12*WhydoyouneedVoluntaryLong-TermDisability?(EmployeePaid)Alengthydisabilitycanbedevastatingandismorecommonthanyoumaythink.Long-termdisabilitymayleadtoalossofincome,independence,andfinancialsecurity.Adisabilityinsurancepolicycanhelpprovidesecuritywhenyouneeditmost,anditpaysyoucashbenefitswhenyou’resickorhurtandcan’twork.Asanactive,full-timeemployee,youareeligibletoelectLTDandtakeadvantageofthegrouprate.WhydoyouneedShort-TermDisability?(CompanyPaid)Howwillyou payyourbillsifyouwere sickorinjured? Evenashort illnessorinjurycould seriouslyimpactyourpaycheck.What happens when yoursick time runsout? Disabilityreplaces part of your income ifyou are unableto work due to anaccident,illness,orifyouareexpectinganewadditiontoyourfamily. MaternityLeaveisoneofthemostcommonusesfordisabilityinsurance.Fortunately, allfull-timeemployeeswhoworkaminimumof30hoursperweekareautomaticallyenrolledinShort-Termdisability.*Apre-existingconditionisoneforwhichyouhavereceivedmedicaltreatment,consultation,careorservicesincludingdiagnosticmeasures,orifyouwereprescribedortookprescriptionmedicationsinthepredeterminedtimeframepriortoyoureffectivedateofcoverage.Thepre-existingconditionunderthisplanis3/12whichmeansanycondition(includingpregnancy)thatyoureceivemedicalattentionforinthe3monthspriortoyoureffectivedateofcoveragethatresultsinadisabilityduringthefirst12monthsofcoveragewouldnotbecovered.
ADDITIONALBENEFITS9EmployeeAssistanceProgram-100%CompanyPaidLifecanbeunpredictable.Andit’snotalwayseasy. Thereishelpavailablewhenyouneedit.Thatiswhattheemployeeassistanceprogram(EAP),providedbyMagellanHealthcare,isallabout.WithanEAP, youandyourfamilyhaveaccess tofree,confidentialresources tohelphandle life’s everyday- and notsoeveryday-challenges.You might use your EAPtohelp:manage stress,handlerelationshipissues,balance workandlife, workthroughgrief,copewithanxiety,andmore.Sampleservicesinclude:ü In-personorvirtualcounselingü Legal,financial,andidentitytheftservicesü Work-lifewebservicesTravelAssistanceProgram-100%CompanyPaidWhetheryou’retravelingrighthereintheUnitedStatesorleavingthecountry,youcanrelyonAXAtohelpyourtravelexperiencegooff without a hitch. And because you’re covered by group term life insurance from Principal®, you have access to many travelassistanceservicesforfree—nomatterifyou’retravelingforbusinessorpleasure.Sampletopicsinclude:ü Lostorstolenitemsü Medicalassistanceü Telephonictranslation/interpreterservicesü Prescriptionreplacementassistanceü Emergencymedicalevacuation
2022BENEFITSENROLLMENTBOOKLETBookletDevelopedinPartnershipWith