Yearbook - PIBT Benefits Yearbook/… · Yearbook Since 1989 The Printing Industry Benefits Trust has been offering and supporting employee benefits insurance for companies from 2

Yearbook

Since 1989 The Printing Industry Benefits Trust has been offering and supporting employee benefits insurance for companies

from 2 to 500 employees in the printing, graphic arts and web media

industries. Our mission is to present solutions that help control costs

while delivering meaningful healthcare benefits and to be a trusted

source of support and assistance.

• Industry leading service center - one call for service and support

• No cost COBRA Administration

• No cost Section 125 Premium Only Plan Document

• Access to full Flexible Spending Account (Section 125 Cafeteria

Plan)

20 -202 PIAG Yearbook

Benefits at a Glance

Kaiser

Plan Name KP HMO 20/30 (115) KP HMO 40/50 (116)

Network Full Full

Calendar Year Deductible

(Individual/Family)

Not Applicable Not Applicable

Out-of-pocket maximum

(Individual/Family)

$6,350 / $12,700 $6,350 / $12,700

Office Visit (PCP) $20 Copay $40 Copay

Specialist Visit $30 Copay $50 Copay

Outpatient Surgery/Treatment $200 Copay $200 Copay

Hospital Admission $750 Copay per admission $1,000 per admission

X-ray No Charge [41] No Charge [41]

Laboratory No Charge [41] No Charge [41]

Urgent Care $40 per visit $60 Copay per visit

Emergency Room $200 per visit $200 Copay per visit

Preventive Care No Charge No Charge

Mental Health Office Visit $20 Copay $40 Copay

Prescription Drugs Generic / Brand / Specialty Generic / Brand / Specialty

Separate calendar year

deductible

Not Applicable $100 Individual / $300 Family (Brand only)

Rx out-of-pocket maximum

(Individual/Family)


Retail prescriptions

(30 day supply)

$25 / $40 / Not Covered $25 / $40 / Not Covered

Mail order

(up to 90-day supply)

$50 / $80 / Not Covered $50 / $80 / Not Covered

Dental Coverage

Pediatric dental coverage Not Covered Not Covered

Vision

Routine exam $30 Copay (at Kaiser facility) $50 Copay (at Kaiser facility)

Frames and lenses $150 allowance every 12 months (with

EyeMed Network)

$150 allowance every 12 months (with

EyeMed Network)

Plan ID 6423 6951

IMPORTANT NOTICE: This benefit comparison is provided to help you quickly compare plans and is not intended to be

a comprehensive description of plans and benefits. Refer to the Summary of Benefits, Summary of Benefits and

Coverage (SBC) and Evidence of Coverage for a detailed description of coverage and benefits limitations. In the event

of a discrepancy on this comparison, Evidence of Coverage and Plan contract shall prevail. (Please visit www.pibt.org -

Forms and Documents.)

• Prescription drug benefits listed are for participating pharmacies only.[41] $200 in outpatient settings.



Kaiser

Plan Name KP HMO 50/55 (117)

Network Full


(Individual/Family)

Not Applicable


(Individual/Family)

$6,350 / $12,700

Office Visit (PCP) $50 Copay

Specialist Visit $55 Copay

Outpatient Surgery/Treatment $250 Copay

Hospital Admission $1,500 per admission

X-ray No Charge [42]

Laboratory No Charge [42]

Urgent Care $70 Copay per visit

Emergency Room $250 Copay per visit

Preventive Care No Charge

Mental Health Office Visit $50 Copay

Prescription Drugs Generic / Brand / Specialty


deductible

$100 Individual / $300 Family (Brand only)


(Individual/Family)

Not Applicable


(30 day supply)

$35 / $45 / Not Covered

Mail order


$70 / $90 / Not Covered

Dental Coverage

Pediatric dental coverage Not Covered

Vision

Routine exam $55 Copay (at Kaiser facility)


EyeMed Network)

Plan ID 6952






• Prescription drug benefits listed are for participating pharmacies only.[42] $250 in outpatient settings.



Kaiser

Plan Name KP Ded HMO 1000/30 (121) KP Hi Ded HMO 2000 (S77)

Network Full Full


(Individual/Family)

$1,000 [2] / $2,000 [2] $2,000 [2] / $4,000 [2]


(Individual/Family)

$2,000 / $4,000 $2,000 / $4,000

Office Visit (PCP) $30 Copay (No Deductible) No Charge after Deductible

Specialist Visit $40 Copay (No Deductible) No Charge after Deductible

Outpatient Surgery/Treatment No Charge after Deductible No Charge after Deductible

Hospital Admission No Charge after Deductible No Charge after Deductible

X-ray No Charge (No Deductible) No Charge after Deductible

Laboratory No Charge (No Deductible) No Charge after Deductible

Urgent Care $50 Copay No Charge after Deductible

Emergency Room $200 Copay per visit (No Deductible) No Charge after Deductible

Preventive Care No Charge (No Deductible) No Charge (No Deductible)

Mental Health Office Visit $30 Copay (No Deductible) No Charge after Deductible

Prescription Drugs Generic / Brand / Specialty Generic / Brand / Specialty


deductible

$250 Individual / $750 Family (Brand only) Subject to Plan Deductible


(Individual/Family)



(30 day supply)

$20 / $40 / Not Covered No Charge after Deductible

Mail order


$40 / $80 / Not Covered No Charge after Deductible

Dental Coverage


Vision

Routine exam $40 Copay (at Kaiser facility) No Charge after Deductible (at Kaiser facility)


EyeMed Network)

$150 allowance every 12 months (with

EyeMed Network)

Plan ID 7886 7885






• Prescription drug benefits listed are for participating pharmacies only.[2] A calendar year deductible is the amount you pay each calendar year before the carrier pays for covered services under the benefit

plan.


-FAQThis Q&A answers the most frequently asked questions about the new PIBT Freedom Plans . If you

are interested in these plans and would like more information, please watch the videos we have

prepared for you, or plan to attend one of the Freedom Plans webinars.

1. PIBT Freedom Plans the right choice for me?

These plans are a good choice for you if:

• You want to lower your costs

• You prefer to choose your provider

• You like the idea of having an advocate to help

you navigate the healthcare system

• You are willing to be engaged with your health

plan occasionally

2. How do the Freedom Plans control rising

health insurance costs?

GPA and ELAP-the companies that administer the

PIBT Freedom Plans-audit all hospital and outpatient

claims for excessive and incorrect charges to ensure

that you're paying a fair price for the services

received and that the provider is getting a fair

reimbursement.

The result is lower cost, lower payroll deductions and

lower out-of-pocket costs for members.

3. What doctors and other healthcare providers

can I use?

Virtually all practitioners accept this plan. Although

these plans use a national network that includes

physicians, labs, urgent care and similar types of

providers, you are not restricted to this network and

your benefits are the same whether you seek care

from an in-network or out-of-network practitioner.

If you are looking for a new doctor, we

recommend that you check the PHCS Practitioner

and Ancillary network and select a suitable doctor

from the list. You may also ask GPA's Nurse

Navigator to find the top practitioners in your area for

the medical issue you have.

If you know which doctor you want to see and

they are not in the network, bring along your new

ID card and your GPA Practitioner Guidance Flyer. If

they still have questions, ask them to call GPA. We

will explain how our plan works and get you seen. It

is very rare that we are unsuccessful.

For facilities-like hospitals, outpatient facilities, and

surgical centers-there is no network. You may go to

virtually any facility you choose. If they need to

contact GPA to confirm your coverage, the

information for them to contact us is on your ID card.

If you like, you may contact GPA prior to any

appointments, and we will contact the doctor or

facility to make sure there are no problems when you

arrive for your appointment.

Note that certain healthcare providers and facilities,

Kaiser for example, only treat patients who are part

of their health system. Kaiser will typically not accept

these plans except for emergency medical

conditions.

4. What if a healthcare provider says they don't

recognize my insurance plan?

Give them the GPA Practitioner Guidance Flyer

which should answer their questions. If they still

have questions, ask them to call GPA at the number

on your ID card. We are almost always able to work

out a solution for you and get you seen and treated.

Although very rare, if a solution can’t be found with

your provider, a Nurse Navigator will locate other

top-tier provider options for you to select from for

your medical services.


5. What if a healthcare provider asks me to pay

upfront?

Call GPA immediately, even if you are in the

provider’s office. You should not pay any amounts

higher than your plan copay, coinsurance or

deductible, depending on the type of treatment you

are receiving. We will explain to the provider how

our plan works and get you seen without an upfront

payment higher than these amounts. Again, it is very

rare that we are unsuccessful.

6. Who can I turn to with questions or for help?

The staff at PIBT can answer many of your questions

related to eligibility, benefits and various

administrative issues. GPA also has Member

Services Professionals who are available to answer

more detailed questions.

One of the most valued resources provided under

these Freedom Plans is GPA’s Nurse Navigator.

These advocates are available to help you:

• Navigate the complex healthcare system

• Find the best healthcare providers in your area

• Better understand a diagnosis and learn about

treatment options

• Ensure your physician’s office understands the

plan and you get seen

• And much more

7. What happens if a healthcare provider doesn't

accept the payment amount and bills me for the

balance?

Balance billings do not happen very often but, if you

receive a balance bill, send it to GPA or ELAP as

soon as possible. You will be contacted within 24

hours by an ELAP Member Advocate who will work

closely with you until the balance billing is resolved.

GPA and ELAP's commitment to you is that, if you

follow our process, you will only be responsible for

copays, deductibles and co-insurance based on your

chosen health insurance plan.

If the bill is sent to collections, your assigned legal

representative will contact the collection agency to

remove you from the process, and then work with

the collection agency to resolve the billing so that

your credit is not impaired.

8. Are these plans HMOs, PPOs or POS plans?

These plans are PPO level benefits, but you can

seek care at virtually any provider -There is no

out-of-network! The PHCS Practitioner and Ancillary

network gives you an excellent starting point. You

can check to see if your current doctor is there, or

you can find a new doctor, but ultimately you are free

to seek care at any provider that you choose.



PIBT Freedom

Plan Name PIBT 25/500 PIBT 35/1000

Network Not Applicable [37] Not Applicable [37]


(Individual/Family)

$500 / $1,000 [2] $1,000 / $2,000 [2]


(Individual/Family)

$3,000 / $6,000 $4,500 / $9,000

Office Visit (PCP) $25 (No Deductible) $35 (No Deductible)

Specialist Visit $25 (No Deductible) $35 (No Deductible)

Outpatient Surgery/Treatment 10% per visit 20% per visit

Hospital Admission $100 copay + 10% per admission $100 copay + 20% per admission

X-ray $25 per visit [40] $35 per visit [40]

Laboratory $25 per visit [40] $35 per visit [40]

Urgent Care $25 (No Deductible) $35 (No Deductible)

Emergency Room $100 copay + 10% per visit $150 copay + 20% per visit (No Deductible) [8]


Mental Health Office Visit $25 (No Deductible) $35 (No Deductible)

Prescription Drugs Generic/Brand/Non-Pref. Brand/Specialty Generic/Brand/Non-Pref. Brand/Specialty


deductible

$250 per member (Except Generic) [5] $250 per member (Except Generic) [5]


(Individual/Family)



(30-90 day supply)

$15 / $30 / $50 / 30% (up to $200 max) [6] $15 / $30 / $45 / 30% (up to $200 max) [6]

Mail order

(30-90-day supply)

$30 / $60 / $100 / 30% (up to $400 max)

[6]

$30 / $60 / $90 / 30% (up to $400 max) [6]

Dental Coverage


Vision

Routine exam Not Covered Not Covered

Frames and lenses Not Covered Not Covered

Plan ID 11184 11183







plan. [5] Accrues toward the calendar year out-of-pocket maximum. [6] Some drugs require prior authorization for medical necessity, or

when effective, lower cost alternatives are available. [8] Deductible will apply to physician services only. [37] Some services require

pre-authorization. If these services are rendered by providers as a facility, please refer to the appropriate category under level I of the

Benefit Summary for the benefit. [40] For outpatient department of a Hospital, copay may differ.



PIBT Freedom


Network Not Applicable [37] Not Applicable [37]


(Individual/Family)

$2,500 / $5,000 [2] $4,000 / $8,000 [2]


(Individual/Family)

$6,000 / $12,000 $7,000 / $14,000

Office Visit (PCP) $40 (No Deductible) $45 (No Deductible)

Specialist Visit $40 (No Deductible) $45 (No Deductible)

Outpatient Surgery/Treatment 20% per visit 30% per visit

Hospital Admission $100 copay + 20% per admission $100 copay + 30% per admission

X-ray $40 per visit [40] $45 per visit [40]

Laboratory $40 per visit [40] $45 per visit [40]

Urgent Care $40 (No Deductible) $45 (No Deductible)

Emergency Room $100 copay + 20% per visit $100 copay + 30% per visit


Mental Health Office Visit $40 (No Deductible) $45 (No Deductible)

Prescription Drugs Generic/Brand/Non-Pref. Brand/Specialty Generic/Brand/Non-Pref. Brand/Specialty


deductible

$250 per member (Except Generic) [5] $250 per member (Except Generic) [5]


(Individual/Family)



(30-90 day supply)

$15 / $30 / $45 / 30% (up to $200 max) [6] $15 / $30 / 50% $100 max / 30% (up to

$200 max)

Mail order

(30-90-day supply)

$30 / $60 / $90 / 30% (up to $400 max) [6] $30 / $60 / 50% $200 max / 30% (up to

$400 max)

Dental Coverage


Vision

Routine exam Not Covered Not Covered

Frames and lenses Not Covered Not Covered

Plan ID 11185 11186








when effective, lower cost alternatives are available. [37] Some services require pre-authorization. If these services are rendered by

providers as a facility, please refer to the appropriate category under level I of the Benefit Summary for the benefit. [40] For outpatient

department of a Hospital, copay may differ.



PIBT Freedom

Plan Name PIBT HSA 5500

Network Not Applicable [37]


(Individual/Family)

$5,500 / $11,000 [2]


(Individual/Family)

$6,650 / $13,300

Office Visit (PCP) 20%

Specialist Visit 20%

Outpatient Surgery/Treatment 20% per visit

Hospital Admission $100 + 20% per admission

X-ray 20% [40]

Laboratory 20% [40]

Urgent Care 20%

Emergency Room $150 + 20% per visit

Preventive Care No Charge (No Deductible)

Mental Health Office Visit 20%

Prescription Drugs Generic/Brand/Non-Pref. Brand/Specialty


deductible

Subject to the calendar year deductible [5]


(Individual/Family)

Not Applicable


(30-90 day supply)

$10 / $25 /$40 / 30% (up to $200 max) [6]

Mail order

(30-90-day supply)

$20 / $50 / $80 / 30% (up to $400 max) [6]

Dental Coverage

Pediatric dental coverage Not Covered

Vision

Routine exam Not Covered

Frames and lenses Not Covered

Plan ID 11187








when effective, lower cost alternatives are available. [37] Some services require pre-authorization. If these services are rendered by

providers as a facility, please refer to the appropriate category under level I of the Benefit Summary for the benefit. [40] For outpatient

department of a Hospital, copay may differ.


Kaiser Monthly Rates by age, effective 12/1/2020Dependent monthly rates do not include the employee portion.

Plan Name KP HMO 20/30 (115), Plan ID #6423

Age/Tier Under 30 Under 40 Under 50 Under 55 Under 60 Under 65 65 & Over

Employee 362.50 416.54 524.63 704.75 884.88 1,083.03 1,083.03

+Spouse 423.75 484.99 611.08 820.04 1,032.58 1,266.75 1,266.75

+Child(ren) 289.09 332.32 418.77 562.88 706.98 858.29 858.29

+Spouse & Child(ren) 761.02 876.31 1,103.27 1,481.55 1,859.83 2,274.12 2,274.12



Employee 341.66 392.57 494.39 664.10 833.81 1,020.49 1,020.49

+Spouse 399.35 457.05 575.85 772.72 972.97 1,193.58 1,193.58

+Child(ren) 272.63 313.34 394.81 530.57 666.35 808.89 808.89

+Spouse & Child(ren) 717.25 825.87 1,039.70 1,396.08 1,752.47 2,142.80 2,142.80



Employee 333.58 383.28 482.68 648.34 814.02 996.24 996.24

+Spouse 389.91 446.24 562.19 754.37 949.86 1,165.23 1,165.23

+Child(ren) 266.24 306.00 385.51 518.05 650.59 789.76 789.76

+Spouse & Child(ren) 700.29 806.32 1,015.05 1,362.95 1,710.87 2,091.91 2,091.91

Plan Name KP Ded HMO 1000/30 (121), Plan ID #7886


Employee 354.65 407.52 513.24 689.45 865.66 1,059.48 1,059.48

+Spouse 414.57 474.47 597.82 802.22 1,010.15 1,239.22 1,239.22

+Child(ren) 282.89 325.18 409.76 550.72 691.68 839.70 839.70

+Spouse & Child(ren) 744.55 857.33 1,079.35 1,449.39 1,819.41 2,224.69 2,224.69

Plan Name KP Hi Ded HMO 2000 (S77), Plan ID #7885


Employee 307.01 352.74 444.17 596.56 748.94 916.57 916.57

+Spouse 358.83 410.64 517.31 694.08 873.91 1,072.00 1,072.00

+Child(ren) 245.25 281.83 354.97 476.88 598.80 726.80 726.80

+Spouse & Child(ren) 644.52 742.04 934.04 1,254.06 1,574.08 1,924.58 1,924.58


PIBT Freedom Monthly Rates by age, effective 12/1/2020Dependent monthly rates do not include the employee portion.


Plan ID 11184 11183

Region 100 100

Emp. Age Employee +Spouse +Child(ren) +Family Employee +Spouse +Child(ren) +Family

18 388.92 505.59 272.24 738.94 346.86 450.92 242.80 659.03

19 400.85 521.10 280.59 761.60 357.50 464.75 250.24 679.24

20 413.20 537.16 289.24 785.07 368.52 479.07 257.96 700.18

21 425.98 553.77 298.18 809.36 379.91 493.89 265.94 721.84

22 425.98 553.77 298.18 809.36 379.91 493.89 265.94 721.84

23 425.98 553.77 298.18 809.36 379.91 493.89 265.94 721.84

24 425.98 553.77 298.18 809.36 379.91 493.89 265.94 721.84

25 427.68 555.99 299.37 812.59 381.43 495.87 267.01 724.73

26 436.20 567.06 305.35 828.78 389.04 505.74 272.31 739.16

27 446.42 580.35 312.50 848.21 398.15 517.60 278.70 756.49

28 463.03 601.95 324.13 879.78 412.96 536.86 289.08 784.64

29 476.67 619.67 333.67 905.67 425.13 552.66 297.58 807.73

30 483.49 628.52 338.43 918.61 431.20 560.56 301.85 819.29

31 493.71 641.82 345.59 938.04 440.32 572.41 308.23 836.60

32 503.93 655.11 352.75 957.47 449.44 584.28 314.60 853.94

33 510.32 663.42 357.22 969.61 455.14 591.67 318.59 864.76

34 517.14 672.28 361.99 982.56 461.22 599.58 322.84 876.30

35 520.55 676.71 364.38 989.03 464.25 603.53 324.98 882.09

36 523.96 681.14 366.77 995.51 467.29 607.48 327.11 887.86

37 527.36 685.57 369.16 1,001.99 470.33 611.43 329.23 893.63

38 530.77 690.00 371.54 1,008.46 473.37 615.39 331.36 899.40

39 537.58 698.86 376.31 1,021.41 479.46 623.28 335.61 910.95

40 544.40 707.72 381.08 1,034.35 485.53 631.19 339.87 922.51

41 554.63 721.01 388.23 1,053.78 494.65 643.04 346.25 939.83

42 564.42 733.74 395.09 1,072.39 503.38 654.40 352.38 956.44

43 578.05 751.47 404.64 1,098.30 515.55 670.20 360.87 979.53

44 595.09 773.61 416.56 1,130.67 530.74 689.96 371.51 1,008.40

45 615.12 799.65 430.58 1,168.70 548.60 713.17 384.01 1,042.33

46 638.96 830.66 447.28 1,214.04 569.87 740.82 398.91 1,082.75

47 665.81 865.54 466.06 1,265.02 593.80 771.94 415.66 1,128.23

48 696.48 905.41 487.53 1,323.30 621.16 807.50 434.81 1,180.20

49 726.72 944.73 508.70 1,380.76 648.13 842.58 453.69 1,231.45

50 760.79 989.04 532.56 1,445.51 678.53 882.08 474.96 1,289.20

51 794.45 1,032.78 556.11 1,509.45 708.54 921.10 495.98 1,346.22

52 831.51 1,080.96 582.06 1,579.86 741.59 964.07 519.11 1,409.02

53 869.00 1,129.69 608.29 1,651.09 775.02 1,007.54 542.52 1,472.54

54 909.46 1,182.30 636.62 1,727.98 811.11 1,054.45 567.78 1,541.12

55 949.93 1,234.91 664.95 1,804.86 847.21 1,101.37 593.05 1,609.69

56 993.80 1,291.95 695.66 1,888.23 886.34 1,152.24 620.44 1,684.04

57 1,038.11 1,349.54 726.68 1,972.41 925.85 1,203.61 648.10 1,759.12

58 1,085.39 1,411.01 759.77 2,062.24 968.02 1,258.42 677.61 1,839.24

59 1,108.82 1,441.47 776.18 2,106.76 988.91 1,285.60 692.24 1,878.94

60 1,156.10 1,502.93 809.27 2,196.60 1,031.09 1,340.41 721.76 1,959.06

61 1,197.00 1,556.10 837.89 2,274.29 1,067.56 1,387.83 747.29 2,028.36

62 1,223.83 1,590.98 856.68 2,325.28 1,091.49 1,418.94 764.04 2,073.84

63 1,257.49 1,634.72 880.24 2,389.22 1,121.50 1,457.95 785.06 2,130.86

64+ 1,277.94 1,661.31 894.55 2,428.07 1,139.74 1,481.67 797.82 2,165.51




Plan ID 11185 11186

Region 100 100

Emp. Age Employee +Spouse +Child(ren) +Family Employee +Spouse +Child(ren) +Family

18 304.82 396.26 213.38 579.16 275.68 358.39 192.98 523.80

19 314.17 408.42 219.92 596.93 284.13 369.38 198.90 539.86

20 323.85 421.00 226.69 615.32 292.90 380.76 205.02 556.49

21 333.87 434.03 233.70 634.35 301.95 392.54 211.36 573.71

22 333.87 434.03 233.70 634.35 301.95 392.54 211.36 573.71

23 333.87 434.03 233.70 634.35 301.95 392.54 211.36 573.71

24 333.87 434.03 233.70 634.35 301.95 392.54 211.36 573.71

25 335.20 435.77 234.64 636.89 303.16 394.11 212.21 576.00

26 341.88 444.45 239.32 649.57 309.20 401.96 216.44 587.48

27 349.89 454.87 244.93 664.80 316.45 411.39 221.51 601.25

28 362.91 471.79 254.04 689.54 328.22 426.69 229.76 623.62

29 373.60 485.68 261.52 709.84 337.88 439.25 236.52 641.99

30 378.94 492.63 265.26 719.99 342.72 445.53 239.89 651.15

31 386.95 503.04 270.87 735.21 349.97 454.95 244.97 664.92

32 394.96 513.46 276.48 750.44 357.21 464.37 250.05 678.70

33 399.97 519.97 279.98 759.95 361.74 470.26 253.21 687.30

34 405.31 526.92 283.73 770.10 366.57 476.54 256.61 696.49

35 407.98 530.39 285.60 775.18 368.99 479.68 258.29 701.08

36 410.65 533.86 287.46 780.25 371.40 482.82 259.98 705.66

37 413.33 537.33 289.33 785.33 373.81 485.97 261.68 710.25

38 416.00 540.80 291.21 790.41 376.23 489.10 263.36 714.85

39 421.35 547.74 294.93 800.55 381.07 495.38 266.74 724.01

40 426.69 554.69 298.68 810.70 385.90 501.66 270.13 733.20

41 434.70 565.10 304.28 825.92 393.14 511.09 275.20 746.97

42 442.38 575.09 309.66 840.51 400.09 520.11 280.06 760.16

43 453.06 588.98 317.14 860.81 409.75 532.67 286.82 778.52

44 466.42 606.34 326.49 886.18 421.83 548.38 295.29 801.48

45 482.11 626.74 337.47 916.01 436.02 566.82 305.21 828.44

46 500.80 651.05 350.56 951.53 452.93 588.81 317.05 860.57

47 521.84 678.39 365.29 991.49 471.95 613.55 330.37 896.71

48 545.87 709.64 382.12 1,037.17 493.69 641.80 345.58 938.01

49 569.58 740.45 398.71 1,082.21 515.13 669.67 360.60 978.75

50 596.29 775.17 417.39 1,132.95 539.29 701.08 377.50 1,024.65

51 622.67 809.46 435.87 1,183.06 563.14 732.08 394.20 1,069.97

52 651.71 847.22 456.19 1,238.25 589.41 766.24 412.59 1,119.88

53 681.09 885.42 476.77 1,294.08 615.98 800.78 431.19 1,170.37

54 712.81 926.65 498.97 1,354.34 644.67 838.07 451.27 1,224.87

55 744.52 967.89 521.18 1,414.61 673.35 875.37 471.35 1,279.38

56 778.92 1,012.59 545.24 1,479.93 704.45 915.80 493.12 1,338.47

57 813.64 1,057.73 569.55 1,545.91 735.86 956.61 515.10 1,398.13

58 850.70 1,105.90 595.49 1,616.33 769.37 1,000.19 538.56 1,461.82

59 869.06 1,129.78 608.34 1,651.22 785.98 1,021.77 550.19 1,493.37

60 906.12 1,177.96 634.29 1,721.63 819.50 1,065.35 573.66 1,557.05

61 938.18 1,219.62 656.71 1,782.52 848.49 1,103.03 593.94 1,612.13

62 959.21 1,246.96 671.44 1,822.48 867.51 1,127.77 607.26 1,648.28

63 985.58 1,281.26 689.91 1,872.61 891.36 1,158.78 623.96 1,693.59

64+ 1,001.61 1,302.09 701.12 1,903.05 905.86 1,177.62 634.10 1,721.14



Plan Name PIBT HSA 5500

Plan ID 11187

Region 100

Emp. Age Employee +Spouse +Child(ren) +Family

18 244.55 317.91 171.18 464.64

19 252.05 327.66 176.44 478.89

20 259.82 337.76 181.87 493.65

21 267.85 348.21 187.50 508.92

22 267.85 348.21 187.50 508.92

23 267.85 348.21 187.50 508.92

24 267.85 348.21 187.50 508.92

25 268.92 349.61 188.25 510.95

26 274.28 356.56 191.99 521.13

27 280.71 364.93 196.50 533.35

28 291.15 378.50 203.81 553.19

29 299.73 389.64 209.81 569.48

30 304.01 395.22 212.81 577.62

31 310.44 403.57 217.31 589.84

32 316.87 411.93 221.80 602.05

33 320.88 417.15 224.62 609.68

34 325.17 422.73 227.62 617.82

35 327.32 425.51 229.11 621.89

36 329.46 428.29 230.62 625.97

37 331.60 431.07 232.12 630.04

38 333.74 433.86 233.62 634.11

39 338.03 439.44 236.62 642.26

40 342.31 445.01 239.61 650.40

41 348.74 453.37 244.13 662.61

42 354.90 461.37 248.43 674.32

43 363.47 472.52 254.43 690.60

44 374.18 486.45 261.94 710.96

45 386.78 502.81 270.74 734.88

46 401.78 522.31 281.25 763.37

47 418.65 544.25 293.06 795.44

48 437.94 569.32 306.56 832.07

49 456.95 594.05 319.87 868.22

50 478.38 621.90 334.87 908.93

51 499.54 649.41 349.69 949.13

52 522.85 679.70 365.99 993.41

53 546.41 710.34 382.49 1,038.20

54 571.86 743.42 400.31 1,086.54

55 597.30 776.50 418.12 1,134.89

56 624.90 812.37 437.43 1,187.30

57 652.75 848.59 456.93 1,240.24

58 682.48 887.23 477.74 1,296.72

59 697.22 906.38 488.05 1,324.71

60 726.95 945.03 508.86 1,381.20

61 752.66 978.46 526.86 1,430.06

62 769.54 1,000.40 538.67 1,462.12

63 790.69 1,027.91 553.49 1,502.33

64+ 803.55 1,044.62 562.49 1,526.75


Dental DPO Benefits at a Glance

Plan Features

Plan Name Delta DPO Plan 1 Delta DPO Plan 2

Services Rendered At In Network Out of Network In Network Out of Network


(Individual/Family)

$25 / $75 $50 / $150 [24] $50 / $150 [24]

Calendar Year Maximum $1,500 per person $1,500 per person [38]

Waiting Period/Major Services None [25] None [25]

Benefit Levels Contracted Rate / Contracted Allowance Contracted Rate / Contracted Allowance

Preventative Services

Oral Exams No Charge (No Deductible) No Charge (No Deductible)

Cleanings No Charge (No Deductible) No Charge (No Deductible)

Bitewing X-rays No Charge (No Deductible) No Charge (No Deductible)

Complete X-rays No Charge (No Deductible) No Charge (No Deductible)

Basic Services

Fillings (composite resin) 10% 20% 20%

Oral Surgery 10% 20% 20%

Major Services

Crowns (high noble) 40% 50% 50%

Orthodontics

Lifetime Maximum $1,000 $1,000

Children up to 19th Birthday 50% (No Deductible) [21] 50% (No Deductible) [21]

Adults 50% (No Deductible) [21] Not Covered

Monthly Rates, effective 12/01/2020

Employee 58.84 47.34

+Spouse 54.87 44.11

+Child 73.28 62.61

+Children 73.28 62.61

+Family 145.37 121.40Plan ID 10424 10425






[21] In order to be covered, orthodontic treatment must be received in one continuous course of treatment; must be received in

consecutive months and must not exceed 24 consecutive months. [24] Non-participating dentist can bill you for charges above the

amount covered by your dental plan. To ensure you do not receive additional charges , visit a participating PPO network dentist. [25]

Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on

Delta Dental maximum contract allowances and not necessarily each dentist's submitted fees. [38] Non-Delta Dental PPO dentists:

$1,000 per person each calendar year.



Plan Features

Plan Name CIGNA PPO GA GA Humana Trad PPO 1

Services Rendered At In Network Out of Network In Network Out of Network


(Individual/Family)

$25 / $75 [24] $50 / $150 [24]

Calendar Year Maximum $1,000 $1,000

Waiting Period/Major Services None None

Benefit Levels Customary & Reasonable Customary & Reasonable


Oral Exams No Charge (2 per calendar year) (No Deductible) No Charge (No Deductible)

Cleanings No Charge (2 per calendar year) (No Deductible) No Charge (No Deductible)

Bitewing X-rays No Charge (2 per calendar year) (No Deductible) No Charge (No Deductible)

Complete X-rays No Charge (1 per 36 months) (No Deductible) No Charge (No Deductible)

Basic Services

Fillings (composite resin) 20% 20%

Oral Surgery 20% 20%

Major Services

Crowns (high noble) 50% 50%

Orthodontics

Lifetime Maximum $1,000 per child $1,000 per child

Children up to 19th Birthday 50% (No Deductible) 50% (No Deductible)

Adults Not Covered Not Covered



+Spouse 62.90 57.84

+Child 62.90 57.84

+Children 98.46 105.95

+Family 98.46 105.95Plan ID 4143 6984






[24] Non-participating dentist can bill you for charges above the amount covered by your dental plan. To ensure you do not receive

additional charges, visit a participating PPO network dentist.



Plan Features

Plan Name GA Humana Trad PPO 2

Services Rendered At In Network Out of Network


(Individual/Family)

$50 / $150 [24]

Calendar Year Maximum $1,000

Waiting Period/Major Services None

Benefit Levels Customary & Reasonable


Oral Exams No Charge (No Deductible)

Cleanings No Charge (No Deductible)

Bitewing X-rays No Charge (No Deductible)

Complete X-rays No Charge (No Deductible)

Basic Services

Fillings (composite resin) 30%

Oral Surgery 30%

Major Services

Crowns (high noble) 60%

Orthodontics

Lifetime Maximum Not Covered

Children up to 19th Birthday Not Covered

Adults Not Covered


Employee 34.52

+Spouse 32.66

+Child 32.66

+Children 68.67

+Family 68.67Plan ID 6985






[24] Non-participating dentist can bill you for charges above the amount covered by your dental plan. To ensure you do not receive

additional charges, visit a participating PPO network dentist.


Dental DMO Benefits at a Glance

Plan Features

Plan Name GA Humana EPO 2S GA Humana EPO 1S


(Individual/Family)


Calendar Year Maximum None None


Benefit Levels Fee Schedule Fee Schedule


Oral Exams No Charge (1 every 6 months) No Charge (1 every 6 months)

Cleanings No Charge (1 every 6 months) No Charge (1 every 6 months)

Bitewing X-rays No Charge (1 every 6 months) No Charge (1 every 6 months)

Complete X-rays No Charge (1 every 36 months) No Charge (1 every 36 months)

Basic Services

Fillings (composite resin) No Charge $24 Copay

Oral Surgery No Charge $26 Copay [20]

Major Services

Crowns (high noble) $466 Copay [29] $466 Copay [29]

Orthodontics

Lifetime Maximum Refer to Schedule of Benefits Refer to Schedule of Benefits

Children up to 19th Birthday $2,100 Copay [21] $2,100 Copay [21]

Adults $2,300 Copay [21] $2,300 Copay [21]



+Spouse 25.22 21.00

+Child 25.22 21.00

+Children 50.12 41.58

+Family 50.12 41.58Plan ID 6986 6987






[20] Surgical removal of erupted tooth, impacted tooth, and tooth root. [21] In order to be covered, orthodontic treatment must be

received in one continuous course of treatment; must be received in consecutive months and must not exceed 24 consecutive months.

[29] Limit one per tooth every eight years.



Plan Features

Plan Name Cigna DMO W1-09 Cigna DMO F1-09


(Individual/Family)

None None





Oral Exams No Charge No Charge

Cleanings No Charge (limit 2 per calendar year) No Charge (2 per calendar year)

Bitewing X-rays No Charge (limit 2 per calendar year) No Charge (2 per calendar year)

Complete X-rays No Charge (1 every 36 months) No Charge (1 every 36 months)

Basic Services

Fillings (composite resin) $22 Copay No Charge

Oral Surgery $53 Copay [20] $12 Copay [20]

Major Services

Crowns (high noble) $470 Copay $380 Copay

Orthodontics


Children up to 19th Birthday $2,472 Copay [21] $2,184 Copay [21]

Adults $3,336 Copay [21] $2,904 Copay [21]



+Spouse 15.06 25.39

+Child 15.06 25.39

+Children 32.80 63.28

+Family 32.80 63.28Plan ID 34 3276






[20] Surgical removal of erupted tooth, impacted tooth, and tooth root. [21] In order to be covered, orthodontic treatment must be

received in one continuous course of treatment; must be received in consecutive months and must not exceed 24 consecutive months.



Plan Features

Plan Name Delta USA 13A Delta USA 15A


(Individual/Family)

None None





Oral Exams No Charge No Charge

Cleanings No Charge (every six months) $5 (every six months)

Bitewing X-rays No Charge No Charge

Complete X-rays No Charge (limit 1 per 24 months) No Charge (limit 1 per 24 months)

Basic Services

Fillings (composite resin) No Charge $22 Copay

Oral Surgery $5 Copay [20] $14 Copay [20]

Major Services

Crowns (high noble) $355 Copay $395 Copay

Orthodontics


Children up to 19th Birthday $1,900 Copay $1,900 Copay

Adults $2,100 Copay $2,100 Copay



+Spouse 18.18 16.98

+Child 19.52 18.44

+Children 19.52 18.44

+Family 42.17 39.65Plan ID 10426 10427






[20] Surgical removal of erupted tooth, impacted tooth, and tooth root.


Vision Benefits at a Glance

Plan Features

EyeMed BaseEyeMed HighPlan Name

Plan ID 10423 8763

Provider EyeMed Provider EyeMed Provider

Eye Exam $5 Copay $5 Copay

Frames $0 Copay. $200 allowance, 20% off on balance over

$200

$0 Copay. $130 allowance, 20% off on balance over

$130

Lenses

Single $15 Copay $15 Copay

Bifocal $15 Copay $15 Copay

Trifocal $15 Copay $15 Copay

Contact Lenses

(instead of glasses)

$0 Copay. $200 plan allowance 15% off balance over

$200


$130

Frequency

Examination Once every 12 months Once every 12 months

Frame Once every 12 months Once every 12 months

Lenses or Contact Lenses Once every 12 months Once every 12 months


Employee 8.23 6.45

+Spouse 7.39 5.79

+Child 7.39 5.79

+Children 11.54 14.70

+Family 14.70 11.54

Plan ID 10423 8763








Plan Features

VSP PremiumEyeMed KaiserPlan Name

Plan ID 8764 10884

Provider Kaiser Faciliy and EyeMed Provider [34] VSP Provider [30]

Eye Exam Plan office visit copay at Kaiser facility $10 Copay

Frames $150 plan allowance, 20% off on balance over $150

for frames, lens and lens options

$20 Copay. $200 plan allowance, 20% off balance

over allowance

Lenses

Single $150 plan allowance, 20% off on balance over $150 $20 Copay

Bifocal $150 plan allowance, 20% off on balance over $150 $20 Copay

Trifocal $150 plan allowance, 20% off on balance over $150 $20 Copay

Contact Lenses



$150

$200 plan allowance [31]

Frequency

Examination Once every 12 months Every 12 months

Frame Once every 12 months Every 12 months

Lenses or Contact Lenses Once every 12 months Every 12 months


Employee 0.00 11.66

+Spouse 0.00 3.53

+Child 0.00 3.53

+Children 13.41 0.00

+Family 0.00 13.41

Plan ID 8764 10884






[30] 20% off for certain materials and services accessed through a VSP provider . [31] Allowance for contacts and contact lens exam

(fitting and evaluation). [34] Benefits apply for Kaiser participants only. Plan cannot be added to your plan menu.



Plan Features

VSP StandardPlan Name

Plan ID 10883

Provider VSP Provider [30]

Eye Exam $10 Copay

Frames $20 Copay. $150 plan allowance, 20% off balance

over allowance

Lenses

Single $20 Copay

Bifocal $20 Copay

Trifocal $20 Copay

Contact Lenses


$150 plan allowance [31]

Frequency

Examination Every 12 months

Frame Every 24 months

Lenses or Contact Lenses Every 12 months


Employee 9.39

+Spouse 2.24

+Child 2.24

+Children 9.86

+Family 9.86

Plan ID 10883






[30] 20% off for certain materials and services accessed through a VSP provider . [31] Allowance for contacts and contact lens exam

(fitting and evaluation).


Basic Group Life and AD&D Benefits at a GlanceDistributed by PIA-SC, Insurance Services Inc.

Plan Features

Accelerated Death Benefit If an employee has been diagnosed as terminally ill, Symetra Life Insurance

Company may pay a portion of the death benefit in advance to the member.

Conversion A conversion benefit is available that allows you to convert your group coverage to

an individual policy if certain conditions apply.

Portability This coverage may be continued at group rates upon termination of employment.

Certain restrictions apply.

AD&D Riders Includes Seat Belt, Airbag, Repatriation, Child Education, Day Care and Spouse

Education benefits.

Value Added Services

Beneficiary Companion Support services for beneficiaries who have experienced a loss.

Travel Assist Travel assistance services for employees and eligible dependents traveling more

than 100 miles from home.


Basic Life $10K 3.80





IMPORTANT NOTICE: This comparison is provided to help you compare coverage benefits at a glance only. Before

making your plan choice, you should refer to the Evidence of Coverage and Plan Contract for a detailed description of

coverage benefits and limitations. In the event of any difference between this summary versus the Evidence of Coverage

or Plan Contract, the Evidence of Coverage and Plan Contract shall prevail.


Voluntary Life and AD&D Benefits at a Glance

Distributed by PIA-SC, Insurance Services Inc.

Plan Features

Amount Increments of $10,000

Maximum Amount Lesser of $500,000 or 10 x Earnings

Guarantee Issue (GIA) $120,000 (New Hires only)

Age Reduction (Original

Benefit Amount reduced to)

65% at age 70

50% at age 75

Eligibility Full time employee (of participating employer) and their eligible dependents

Evidence of Insurability (EOI) EOI is required for all amounts of insurance selected after the initial 31-day eligibility

period and for any amount in excess of the GIA.

Accelerated Death Benefit If an employee has been diagnosed as terminally ill, Symetra Life Insurance

Company may pay a portion of the death benefit in advance to the member.

Spouse

Amount Increments of $5,000

Maximum Amount $250,000 not to exceed 100% of employee coverage

Guarantee Issue $25,000

Child

Child Amount (Birth to 26 yrs.) $5,000 or maximum of $10,000

Monthly Employee Rates, effective 1/1/2021Benefit $10,000 $50,000 $80,000 $120,000

Under 25 0.76 3.80 6.08 9.12

25-29 0.76 3.80 6.08 9.12

30-34 0.86 4.30 6.88 10.32

35-39 1.14 5.70 9.12 13.68

40-44 1.62 8.10 12.96 19.44

45-49 2.76 13.80 22.08 33.12

50-54 4.66 23.30 37.28 55.92

55-59 8.27 41.35 66.16 99.24

60-64 10.36 51.80 82.88 124.32

65-69 17.77 88.85 142.16 213.24

70-74 31.54 157.70 252.32 378.48

75+ 31.54 157.70 252.32 378.48


Employee Assistance Program Benefits at a Glance

Plan Features

Plan Name EAP MHN

Employee Assistance Program Counseling services for various life management problems for employees and dependents

Office Visits $0 copay with authorization

Deductible None

Clinical Counseling

Visits

As needed

As needed

6 visits per incident per plan period, unlimited incidents

Telephone Couseling

Web Video Couseling

Monthly Rates, effective 12/01/2020, Employer Sponsored Plan

Employee 5.37

Plan ID 3715







The Ultimate Health Coverage plan is an innovative and convenient way to give an extra level of coverage for employees.

It reimburses for many medical expenses not covered by the employer-sponsored base health plan. For more

information contact Evie Bañaga at 800.449.4898 ext. 224.

Supplemental Medical

Benefits

Samples of What is Eligible

(Not a Complete List)*

Platinum Diamond Diamond Plus

(Requires 15+ to enroll)

Per-Occurrence (each

injury, condition or illness)

for medical out-of-pocket

costs

Deductibles, co-pays, balance bills

and other out-of-pocket costs for

medically necessary services

$2,500 $3,000 $10,000

Per Covered Person per

Year


Year


Year

Other Supplemental

Benefits

$10,000$3,000$2,500Co-pays, brand name and lifestyle

prescriptions

Prescriptions

$10,000$3,000$2,000Counseling and substance abuse

programs

Mental Health

$10,000$5,000$2,000Durable medical equipment,

wigs, hearing aids, orthotics

Medical Equipment

$10,000$1,500$1,000Acupuncture, massage therapy and

chiropractic care

(if not covered by primary plan)

Wellness Treatments

$10,000 each$2,500 each$2,000 eachComprehensive physicals for the

primary member and enrolled spouse

Executive Physicals

Per Covered Person per YearAncillary Benefits

$10,000$5,000$4,000Routine care, child and adult

orthodontia, crowns and bridges

Dental Treatments

$10,000$1,500$1,000LASIK, contact lenses and

prescription glasses & sunglasses

Vision Treatments

$100,000$50,000$50,000Annual Family Maximum

The levels are for each covered person, whether that person is the enrolled employee or his/her enrolled family member. All the reimbursed

expenses across the benefit categories, including medical per occurrences, roll up to the overall annual family maximum, which is the same for a

family of one or a family of six.

*These are examples of 213(d)- eligible expenses that are typically covered by the Ultimate Health plan. We cannot pre-certify specific medical

treatments or procedures. A claim must be submitted for review before a claim will be accepted or denied for reimbursement.


&

PIAG Insurance has partnered with Aflac to offer an extensive voluntary

benefits portfolio of a broad range of financial protection options with multiple

ways to enroll. Employees may quote out personal lines for themselves and

their family/friends, and employers may add coverage to cover their

employees.

A Selection of Voluntary Personal Benefits through Aflac

Accident Insurance

(benefits for unexpected injuries)

• Accident - A guaranteed-issue, composite-rated,

guaranteed-renewable accident product that offers

several coverage levels to fit all budgets

• Gunshot Wound - A guaranteed-issue product that

provides lump-sum benefits for injury due to non-fatal

gunshot wounds

Disability Insurance

(income protection)

• Disability - A short-term disability product that replaces

a portion of your income

Supplemental Health Insurance

(lump sum hospital confinement)

• MedicalBridge - A hospital confinement

indemnity product that supplements your core

medical coverage

Special Risk Insurance

(treatment & recovery from serious illness)

• Cancer - A cancer product that pays indemnity-based

benefits to help cover medical and non-medical

expenses related to a cancer diagnosis and treatment

• Critical Illness - A critical illness product that provides a

lump-sum benefit for the diagnosis of a critical illness

Life Insurance

(family financial protection)

• Universal Life - A universal life product with

flexibility that allows the employee to adapt to

changing needs by varying amounts and premiums

• Whole Life - A permanent whole life insurance

product that provides guaranteed level premiums,

guaranteed cash values, and guaranteed death

benefits as long as premiums are paid when due and

no loans are taken

and more!

Contact us today to learn about all the ways we can help you plan for the unexpected.

www.piaginsurance.com | (770) 433-3050

[email protected]


It’s said that you protect what’s important to you,

so what are you insuring?

call us today at (770) 433-3050

www.piaginsurance.com

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