PowerPoint Presentation

BENEFITS GUIDE OPEN ENROLLMENT 2023

What's new this year?

What's new this year?

We will continue offering only one plan for all employees. Innovation Health PPO plan for local employees and Aetna PPO plan for out-of-state employees. For 2023, Four Points Technology will continue paying 75% for Employee Only coverage and 75% for Employee and dependents for medical plans and 80% for Employee Only coverage and 80% for Employee and dependents for vision plans.

MEDICAL

VA-22 PPO $20/$40 100/80 Rx1 Out-of-state employees

VA 22 IH PPO $20/$40 100/80 Rx 1 Local employees

IN NETWORK* Doctor CoPay (PCP/Spec.) Deductible (Ind/Fam) Coinsurance (Insurance) Inpatient Hospital Out of Pocket Max (Ind/Fam) OUT OF NETWORK* Deductible (Ind/Fam) Coinsurance (Insurance) Inpatient Hospital Out of Pocket Max (Ind/Fam) EMERGENCY SERVICES Emergency Room PRESCRIPTIONS Retail EMPLOYEE MONTHLY DEDUCTIONS Employee Employee/Spouse Employee/Child(ren) Family

$20 / $40

$20/$40

$0

$0

100% $500

100% $500

$2,500/$5 000

$2,500/$5,000

$0

$0

80% 80%

80% 80%

$5,000/$10,000

$5,000/$10,000

$250

$250

$5/$10/$45/$85/20% to $150/$250 $5/$10/$45/$85/20% to $150/$250

$193.67 $488.79 $389.13 $672.05

$184.26 $465.06 $370.34 $639.35

DENTAL

DENTAL Delta Dental PPO PLUS PREMIER – High Option

IN NETWORK Diagnostic and Preventive

100%/100%/100% 90%/80%/80%

Basic Dental Care Major Dental Care

60%/50%/50% 50%/50%/50% $50/$50/$50

Orthodontics Deductible Annual Max

$2,500/$2500/$2500 $2,500/$2,500/$2,500

Orthodontic Lifetime Max Annual MaxOver Amount

$625

$2,500

Maxover Account Limit

EMPLOYEE MONTHLY DEDUCTIONS Employee

$8.91

Employee/Spouse Employee/Child(ren)

$19.212 $19.344 $34.754

Family

DENTAL Delta Dental PPO PLUS PREMIER – Low Option

IN NETWORK Diagnostic and Preventive

100%/100%/100%

Basic Dental Care Major Dental Care

90%/80%/80% 0%/0%/0% 0%/0%/0% $50/$50/$50

Orthodontics Deductible Annual Max

$2,500/$2500/$2500

Orthodontic Lifetime Max

N/A

Annual Max Over MaxOver Account Limit

$625

$2,500

EMPLOYEE MONTHLY DEDUCTIONS Employee

$4.70 $10.03 $10.38 $16.01

Employee/Spouse Employee/Child(ren)

Family

VISION

VISION Delta VISION Plan # 130

IN NETWORK Eye Examination - Once every 12 months Frame Allowance - Once every 24 months Prescription Glasses - Once every 12 months Contact Lenses fitting and evaluation OUT OF NETWORK Eye Examination - Once every 12 months Frame Allowance - Once every 24 months Prescription Glasses – Once every 12 months Contact Lenses fitting and evaluation

$10 Copay

Covered up to $130

$25 Copay

Member pays up to $60

Member pays up to $45 Member pays up to $70

Member pays up to $30/$50/$65

Member pays up to $105

EMPLOYEE MONTHLY DEDUCTIONS Employee

$1.00 $2.02 $2.16 $3.44

Employee/Spouse Employee/Child(ren)

Family

2023

Open Enrollment Requirements

What do you need to do during the open-enrollment period?

If you do not want to make any changes to your current medical benefit elections, no action is needed. All of your current benefit elections will automatically carry over and remain effective for 2023. If you want to change any of your current benefit elections, you will need to complete a new enrollment form to be returned to Lori Constantino within 30 days of the qualifying event . Examples of needing new enrollment forms are: • Current enrollees who now wish to waive coverage. • Current enrollees who are changing enrollment status (i.e., adding/removing spouse or dependents). • Employees not currently enrolled who now wish to do so.

Open Enrollment Requirements

After the Open Enrollment Period, you cannot make changes to your coverage during the year unless you experience a change in family status, such as: • Loss or gain of coverage through your spouse

• Loss of eligibility of a covered dependent • Death of your covered spouse or child • Birth or adoption of a child • Marriage, divorce or legal separation • Switch from part-time employment to full-time employment.

REMINDER:

Open Enrollment forms are due to:

Lori Constantino by EOB Wednesday, December 7th

Summary of Benefits & Coverage

Aetna IH PPO 22 VA 100/80

20/40

Summary of Benefits & Coverage

Aetna PPO 22 VA 100/80

20/40

Delta Dental PPO Plus Premier Low Plan Benefit Summary

Benefit Summary

Delta Dental PPO Plus Premier

High Plan

Benefit Summary

Delta Dental Vision-130