Annual Benefits Enrollment - Pinnacle PEO › media › 2013-Pinnacle-Ancillary... · 2013-07-02 · We have some exciting changes this Annual Enrollment with brand new products including

2013-2014

Annual Benefits Enrollment Employee Benefit Options

Supplemental Guide

We have some exciting changes this Annual Enrollment with brand new products including Ternian HealthSelect which replaces the Cigna Starbridge Limited Medical and MetLife Dental which replaces the Aetna and United Concordia Dental. We think you will be pleased with these changes that give you more value in your benefit offerings at a lower cost.

The Benefits Enrollment period is from June 28th through July 28th. During this time you have the opportunity to review your benefit choices and enroll, cancel or make changes. Any benefit changes made during this time will become effective August 1st and will remain in effect until the next Benefit Enrollment period. Your premium for each benefit will be divided and deducted from your paycheck(s) each month, according to your specified pay period. Keep in mind that all employees are eligible as long as you are considered a full time employee and working 30+ hours a week. For new hires, your benefits will become effective the 1st of the month following your 90 day probationary period.

Under Federal regulations, after a plan year (August 1st through July 31st) has started, employees may not change their benefit elections except under certain qualifying events deemed as exceptions (see box below). These regulations do not affect all insurance enrollment changes. Please contact benefits department no later than 31 days after the event for detailed discussion of your event and related enrollment possibilities. Allowable changes must be made within 31 days of the qualifying event.

Qualifying Events: Marriage, divorce, or death

Birth, or adoption Change in employment (part time to full time, full time to part time)

With the new laws of Health Care Reform, understanding your options has become more complex. Rest assured that Pinnacle is preparing for the upcoming changes and will be able to assist you with timely information.

If you have any questions, feel free to contact your Benefits Department. You can use the following resources listed below:

Office (210) 344-2088 Fax (210) 344-2777

Email: [email protected]

Kind Regards,

The Benefits Department

EMPLOYEE BENEFITS

Supplemental Plans

Table of Contents: Page

1. Ternian Limited Medical 1

2. Gap Plan Reimbursement Benefit 6

3. Cigna Dental 8

4. MetLife Dental High Plan 9

5. MetLife Dental Low Plan 11

6. VSP Vision Benefit 13

7. UNUM Basic and Optional Life Summary 14

8. UNUM Optional Life Rates 15

9. Principal Short Term Disability 16

10. Aflac – Call for details

11. Retirement Plan Options – Call for details (the plan is customized for each client)

Enroll Now! Time is limited.

Search PHCS network providers at: my.ternian.com or call 1-866-750-7427

(You DO NOT need to use these providers – they provide discounts should you choose to visit them. You can visit ANY licensed physician and present your insurance card – you may qualify for a discount. But regardless, you still have insurance coverage as outlined in this brochure.) Who can enroll?

All Full-time employees (30+ hours) When can I enroll?

During the annual open enrollment period or within 90 days of your hire date. When will coverage begin?

The 1st of the month following 90 days of employment When will coverage end?

The earlier of: 1. The date the Policy terminates; 2. The employee’s Active Service ends; or 3. The period ends for which premium has been paid. NOTICE: The Limited Medical Plans are fixed indemnity insurance plans which do not provide Major Medical or Comprehensive Medical coverage. NOTICE: These plans DO NOT fulfill the Individual Mandate for Health Insurance

Coverage required under the Affordable Care Act (ACA) starting 01/01/2014.

HealthSelect:

$10 Doctor Visit Pre-Pay*

Inpatient Hospital Coverage

Outpatient Accident Coverage

Emergency Room Coverage

Accidental Death & Dismemberment Coverage

Prescription Drug Coverage Also Available:

CriticalMed Plans Ternian Services:*

$10 Doctor Visit Pre-Pay

Consult A Doctor Telephonic Doctor Office Visits

New Directions Nurseline and EAP

PHCS PPO Network Discounts The insurance described in this guide provides limited benefits. Limited benefits plans are insurance products with reduced benefits intended to supplement comprehensive health insurance plans. This insurance is not an alternative to comprehensive coverage. It does not provide major medical or comprehensive medical coverage and is not designed to replace major medical insurance. Further, this insurance is not minimum essential benefits as set forth under the Patient Protection and Affordable Care Act.

An Affordable Limited Medical

Plan is Available to You!

PAPER Enrollment: Turn your form in to your HR Department

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Benefits at a Glance This information is a brief description of the important features of the insurance plan. It is not a contract of insurance. The terms and conditions of coverage are set forth in the policies issued in the state of Texas. Complete details may be found in the policies on file at your

employer’s office. The policy is subject to the laws of the state of Texas, and is available to employees nationwide. Please keep this information as a reference.

Ternian HealthSelect Indemnity Plans

Monthly

Employee Only Employee + 1 Family

Plan 1 - Basic

$79.22 $174.06 $253.18

Plan 2 - Choice

$168.81 $363.72 $529.93

Plan 3 - Max

$258.94 $553.68 $810.02

INPATIENT(1)

Day 1 hospital confinement benefit amount per day Day 2+ hospital confinement benefit amount per day Maximum Benefit Surgery benefit amount (incl. maternity) per surgery Anesthesia benefit amount – per surgery

$2,000 x 1 day $750 thereafter 5 days per year

$1,000 x 1 surgery 25% surgical amount

$2,500 x 1 day

$1,500 thereafter 5 days per year

$2,000 x 2 surgeries 25% surgical amount

$3,000 x 1 day

$2,000 thereafter 10 days per year

$2,500 x 2 surgeries 25% surgical amount

OUTPATIENT(1)

Physician Office Visit Pre-pay(2) Benefit amount per day Wellness benefit amount per day Well child care (age 4 or below) benefit amount Accident maximum benefit amount per year up to Benefit % payable Deductible per accident Emergency Room (sickness) benefit amount per visit Surgery benefit amount per surgery Anesthesia benefit amount - per surgery Diagnostic, X-ray, Lab - benefit amount per day Class I: Laboratory - Blood work, CMP, Lipid Panel Maximum number of days for laboratory test including blood work, comprehensive metabolic panel, lipid panel, all other lab per Plan Year Class II: X-ray, ECG, Pap/PSA tests, all other diagnostic Class III: Ultrasound, Mammogram Class IV: CT, PET, MRI

$10

$65 x 5 days $100 x 1 day

N/A $5,000 per year

80% U&C $0

$300 x 1 days N/A N/A

$30 x 2 days

$50 x 2 days $75 x 1 days

N/A

$10

$75 x 5 days $100 x 1 day

N/A $7,500 per year

80% U&C $0

$500 x 1 days $1,000 x 1 surgery

25% surgical amount

$30 x 2 days

$75 x 2 days $125 x 1 days

N/A

$10

$85 x 5 days $100 x 1 day

N/A $10,000 per year

80% U&C $0

$750 x 1 days $1,750 x 1 surgery

25% surgical amount

$30 x 2 days

$175 x 2 days $200 x 1 days $750 x 1 day

PRESCRIPTION(3)

Retail – Generic RX co-pay Retail – Preferred Brand RX co-pay Mail Order – Generic RX co-pay Mail Order – Preferred Brand RX co-pay Monthly benefit maximum – INDIVIDUAL Monthly benefit maximum – FAMILY

Discount Only(2)

$10 $30 $30 $90

$200 $400

$10 $30 $20 $60

$300 $600

AD&D Accidental Death & Dismemberment (1) benefit

amount* *Benefit amounts listed are for:

Employee/Spouse/Child(ren)

$10,000/5,000/1,000

$15,000/5,000/1,000

$25,000/5,000/1,000

continued on next page

HealthSelect A fixed indemnity medical plan which provides limited coverage for accidents, illness, and specified disease to help cover basic, minor-medical expenses. The HealthSelect benefits outlined below do not have a pre-existing condition limitation.

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Ternian HealthSelect Indemnity Plans

Plan 1 - Basic Plan 2 - Choice Plan 3 - Max

OTHER SERVICES (4)

Consult A Doctor: Telephonic Doctor Office Visits - $38 Fee New Directions Behavioral Health: EAP PHCS PPO Discounts

Yes Yes Yes

Yes Yes Yes

Yes Yes Yes

(1)The Fixed Indemnity, Outpatient Accidental-Only, Critical Illness and AD&D Benefit Plans (are underwritten by AXIS Insurance Company. HealthSelect is a limited medical plan. It is not considered creditable coverage under HIPAA, is not major medical insurance, and is NOT designed to replace, provide, or modify major medical insurance. This information is a brief description of the important features of the insurance plan. It is not a contract of insurance. The terms and conditions of coverage are set forth in the policy issued in the state in which the policy is delivered. The policy is subject to the laws of the state in which it is issued. Coverage may not be available in all states or certain terms may be different if required by state law. This insurance does not apply to the extent that trade or economic sanctions or regulations prohibit us from providing insurance, including, but not limited to, the payment of claims. (2) The office visit pre-pay is a service through the PHCS PPO Network. (3)The prescription copay is underwritten by Companion Life Insurance Company. (4)These services are not insurance and are not provided by the underwriting companies shown here.

Ternian HealthSelect Indemnity Plans

Bi-Weekly

Employee Only Employee + 1 Family

$45,000 Plan

$47.81 $104.73 $152.34

$75,000 Plan

$73.81 $162.38 $236.18

INPATIENT

Hospital Confinement benefit amount per day Additional ICU benefit amount per day

$1,000 x 10 days $1,000 x 5 days

$1,500 x 10 days $1,000 x 10 days

OUTPATIENT Accident Only Coverage

Benefit Maximum, per year up to Benefit % Payable Deductible per year

$15,000

80% $1,500

$25,000

80% $2,500

Accidental Death & Dismemberment $15,000 Emp $10,000 Sp $1,000 Ch

$25,000 Emp $10,000 Sp $1,000 Ch

CRITICAL ILLNESS*

Benefit Maximum Payable for 10 conditions: Cancer, Heart Attack, Renal Failure,

Stroke, Major Organ Transplant, Multiple Sclerosis, Coronary Artery

Bypass Surgery, Alzheimer’s, ALS, Terminal Illness

$15,000 $25,000

OTHER SERVICES (4)

New Directions Behavioral Health: EAP PHCS PPO Discounts

Yes Yes

Yes Yes

(4) These services are not insurance and are not provided by AXIS Insurance Company * Pre-existing condition exclusions apply to this component. Please see Exclusions & Limitations as outlined on the following pages.

CriticalMed Plan

A buy-up fixed indemnity option if you enroll in HealthSelect and are looking for enhanced coverage for catastrophic events, OR, a stand-alone option (instead of HealthSelect) if you are willing to self-pay your day-to-day medical expenses because you are more concerned about major events.

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What’s Not Covered For HealthSelect and CriticalMed we will not pay benefits for any

loss, injury or sickness that is caused by, or results from:

Intentionally self-inflicted injury, suicide or attempted suicide.

War or any act of war, whether declared or not.

Service in the military, naval or air service of any country or international organization.

Piloting or serving as a crew member or riding in any aircraft except as a fare-paying passenger on a regularly scheduled or charter airline.

Commission of, or attempt to commit, a felony.

Commission of or active participation in a riot, or insurrection.

Bungee cord jumping, parachuting, skydiving, parasailing, hang-gliding.

flight in, boarding or alighting from any aircraft except as a fare-paying passenger on a regularly scheduled commercial airline.

An accident if the covered person is the operator of a motor vehicle and does not possess a valid motor vehicle operator’s license, except while participating in Driver’s Education Program.

Medical or surgical treatment, diagnostic procedure, administration or anesthesia, or medical mishap or negligence, including malpractice. (This exclusion applies to the Accidental Death and Dismemberment benefit only.)

Travel or activity outside the United States, Canada or Mexico, except for a Medical Emergency.

Travel in any aircraft owned, leased or controlled by the Policyholder, or any of its subsidiaries or affiliates. An aircraft will be deemed to be “controlled” by the Policyholder if the aircraft may be used as the Policyholder wishes for more than 10 straight days, or more than 15 days in any year.

Alcoholism, drug addiction or the use of any drug or narcotic except as prescribed by a Doctor unless specifically provided herein.

Repair or replacement of existing dentures, partial dentures, braces, fixed or removable bridges, or other artificial dental restoration.

Repair, replacement, examinations for, prescriptions, or the fitting of eyeglasses or contact lenses.

While the covered person is legally intoxicated (as determined by that state’s laws) or while under the influence of any drug unless administered under the advice and consent of a Doctor.

Elective Abortion. Elective Abortion means an abortion for any reason other than to preserve the life of the female upon whom the abortion is performed.

Mental and Nervous Disorders.

Cosmetic surgery, except for reconstructive surgery needed as the result of an injury or sickness.

Experimental or Investigational drugs, services, supplies or any procedure held to be experimental or investigatory by Us at the time the procedure is done.

treatment for being overweight, gastric bypass or stapling, intestinal bypass, and any related procedures, including complications.

sexual reassignment surgery, sexual transformation surgery, sexual transgendering surgery.

services related to sterilization, reversal of a vasectomy or tubal ligation; in vitro fertilization and diagnostic treatment of infertility or other problems related to the inability to conceive a child, unless such infertility is a result of a covered Injury or Sickness.

treatment or services provided by a private duty nurse, unless provided for in the Policy.

organ or tissue transplants and related services.

personal comfort or convenience items.

rest or custodial cures.

hearing aids.

radial keratotomy.

treatment by a family member or member of the Covered Person’s household.

routine dental care and treatment, except for treatment of Injury as specified in the Policy.

For HealthSelect and CriticalMed, we will not pay benefits for any

loss, injury or sickness that is caused by, or results from:

1. Suicide or attempted suicide, intentionally self-inflicted injury. 2. War or any act of war, whether declared or not. 3. A Covered Accident that occurs while on active duty service in

the military, naval or air force of any country or international organization. Upon Our receipt of proof of service, We will refund any premium paid for this time. Reserve or National Guard active duty training is not excluded unless it extends beyond 31 days.

4. Sickness, disease, or any bacterial infection, except one that results from an accidental cut or wound or pyogenic infections that result from accidental ingestion of contaminated substances.

5. Piloting or serving as a crew member or riding in any aircraft except as a fare-paying passenger on a regularly scheduled or charter airline.

6. Injury that occurs while the Covered Person is legally intoxicated (as determined by that state’s law) or while under the influence of any drug unless administered under the advice and consent of a Doctor.

7. Medical or surgical treatment, diagnostic procedure, administration of anesthesia, or medical mishap or negligence, including malpractice.

8. Commission of, or attempt to commit, a felony. 9. Aggravation or re-injury of a prior Injury the Covered Person

suffered prior to his or her coverage effective date, unless We receive a written medical release from the Covered Person’s Doctor.

In addition to the above Exclusions, We will not pay Accident Medical

Expense Benefits for any loss, treatment or services resulting from or

contributed to by:

treatment by persons employed or retained by the Policyholder, or by any Immediate Family or member of the Covered Person’s household.

treatment of sickness, disease or infections except pyogenic infections or bacterial infections that result from the accidental ingestion of contaminated substances.

treatment of hernia, Osgood-Schlatter’s Disease, osteochondritis, appendicitis, osteomyelitis, cardiac disease or conditions, pathological fractures, congenital weakness, detached retina unless caused by an Injury, or mental disorder or psychological or psychiatric care or treatment (except as provided in the Policy), whether or not caused by a Covered Accident.

pregnancy, childbirth, miscarriage, abortion or any complications of any of these conditions.

mental and nervous disorders (except as provided in the Policy).

damage to or loss of dentures or bridges, or damage to existing orthodontic equipment (except as specifically covered by the Policy).

expenses incurred for treatment of temporomandibular or craniomandibular joint dysfunction and associated myofacial pain (except as provided by the Policy).

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Injury covered by Workers’ Compensation, Employer’s Liability Laws or similar occupational benefits or while engaging in activity for monetary gain from sources other than the Policyholder.

cosmetic surgery, except for reconstructive surgery needed as the result of an Injury.

any elective treatment, surgery, health treatment, or examination, including any service, treatment or supplies that: (a) are deemed by us to be experimental; and (b) are not recognized and generally accepted medical practices in the United States.

eyeglasses, contact lenses, hearing aids, examinations or prescriptions for them, or repair or replacement of existing artificial limbs, orthopedic braces, or orthotic devices.

expenses payable by any automobile insurance Policy without regard to fault. (This exclusion does not apply in any state where prohibited.)

conditions that are not caused by a Covered Accident.

participation in any activity or hazard not specifically covered by the Policy.

any treatment, service or supply not specifically covered by the Policy.

In addition, Critical Illness Benefits will not be paid for:

Injury or Sickness, other than one of the Covered Illnesses, even though such Injury or Sickness may have been complicated by one of the Covered Illnesses;

Any complication of Human Immunodeficiency Virus (HIV) infection or any variance thereof including AIDS and AIDS Related Complex;

The use, existence or escape of nuclear weapons, material or ionizing radiation from or contamination by radioactivity from any nuclear fuel or waste from the combustion of nuclear fuel;

Misuse of medication or the abuse of drugs or intoxicants;

Any Preexisting Condition, except where coverage has been in effect for a period of twelve (12) consecutive months following the covered person’s effective date of coverage. “Preexisting Condition” means a Sickness suffered by a covered person for which he or she sought or received medical advice, consultation, investigation, or diagnosis, or for which treatment was required or recommended by a Doctor during the 12 months immediately prior to the covered person’s effective date of coverage, that directly or indirectly causes the condition to occur within the first 12 months from the covered person’s most recent effective date of coverage.

No Prescription Drug Benefits will be paid for:

All over-the-counter products and medications unless shown in the definition of Prescription Drug. This includes, but is not limited to, electrolyte replacement, infant formulas, miscellaneous nutritional supplements, and all other over-the-counter products and medications.

Blood glucose meters and insulin injecting devices.

Depo-Provera; condoms, contraceptive sponges, and spermicides; sexual dysfunction drugs.

Biologicals (including allergy tests); blood products; growth hormones; hemophiliac factors; MS injectables; immunizations; and all other injectables unless shown in the definition of Prescription Drug.

Medical supplies and durable medical equipment.

Liquid nutritional supplements; pediatric Legend Drug vitamins; prescribed versions of Vitamins A, D, K, B12, Folic Acid, and Niacin – used in treatment verses as a dietary supplement; and all other Legend Drug vitamins and nutritional supplements.

Anorexiants; any cosmetic drugs including, but not limited to, Renova and skin pigmentation preps; any drugs or products used for the treatment of baldness; and topical dental fluorides.

Refills in excess of that specified by the prescribing Doctor, or refills dispensed after one year from the original date of the prescription.

Any drug labeled “Caution – limited by Federal Law for Investigational Use” or experimental drugs.

Any drug which the Food and Drug Administration has determined to be contraindicated for the specific treatment.

Drugs needed due to conditions caused, directly or indirectly, by a covered person taking part in a riot or other civil disorder; or the covered person taking part in the commission of a felony.

Drugs needed due to conditions caused, directly or indirectly, by declared or undeclared war or any act of war; or drugs dispensed to a covered person while on active duty service in any armed forces.

Any expenses related to the administration of any drug.

Drugs or medicines taken while in or administered by a Hospital or any other health care facility or office.

Drugs covered under Worker’s Compensation, Medicare, Medicaid or other governmental program.

Drugs, medicines or products which are not medically necessary.

Diaphragms; erectile dysfunction Legend Drugs; and infertility Legend Drugs.

Epi-Pen, Epi-Pen Jr., Ana-Kit, Ana-Guard; Glucagon-auto injection; and Imitrex-auto injection.

Smoking deterrents, Legend or over-the-counter drugs.

Replacement of stolen medication (except under circumstances approved by us), or lost, spilled, broken or dropped Prescription Drugs.

Vacation supplies of Prescription Drugs (except under circumstances approved by us).

All newly marketed pharmaceuticals or currently marketed pharmaceuticals with a new FDA approved indication for a period of one year from such FDA approval for its intended indication.

Frequently Asked Questions Q: When will I get my ID Card?

A: You will get your ID card within 10 business days of your

employer approved enrollment. You will receive a separate ID card for each product you enroll in. Q: How do I find a PHCS network provider?

A: Please visit www.myternian.com or call 1-866-750-7427.

Q: Is this major medical or comprehensive medical coverage?

A: No. This Limited Medical Plan is a fixed indemnity medical

plan which provides limited coverage for accidents, illness, and specified diseases to help cover basic, minor-medical expenses.

Claims Administered by:

Administrative Concepts, Inc. (ACI) 994 Old Eagle School Road, Ste. 1005

Wayne, PA 19087 1-800-964-7096

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THE GAP PLAN REIMBURSEMENT PROCEDURES

What is the Gap Plan?

The Gap Plan is a first dollar benefit program that reimburses the insured for charges

accruing towards their annual deductible and coinsurance.

Base Plan

In-Patient Benefit Up to $1,000 (per calendar year)

Out-Patient Benefit Up to $1,000 (per condition: 4 / family per calendar year)

Buy Up Plan

In-Patient Benefit Up to $2,000 (per calendar year)

Out-Patient Benefit Up to $2,000 (per condition: 4 / family per calendar year)

What does an insured need to submit a claim for reimbursement?

1. Claim Form- A completed claim form is required one time per year. If your

address or phone number has changed since your last claim you will need to send

in a new claim form with the updated information. Sign and date the

authorization section (the insured must sign and date the claim form for dependent

children).

2. Explanation of Benefits ( EOB ) from your primary insurance company. This

is the statement from the primary carrier that lists what charges they are paying,

denying or applying to deductibles, etc. This is sent to your home address

following activity on your health insurance account.

3. Itemized Provider Bill- Attach copies of the original bills showing the

diagnosis and procedure codes, date of service, name and address of the provider

and the provider tax identification number.

(REGULAR BILLING STATEMENTS NOT ACCEPTED)

What should I know about claim payment?

1. If you submit all of the information necessary to process your claim it will

take 5-10 days to issue payment.

2. Payment will be made directly to the provider if there is a balance due on the

claim form. Special Insurance Services will reimburse you directly if the

documentation you submitted shows that you have already paid the account in

full and the account balance is $0.

What is not reimbursed by the Gap Plan?

1. Copays for doctor visits or Prescriptions

2. Durable Medical equipment

3. Outpatient mental health

4. Wellness / Annual Exams (usually covered by office visit copay)

Where do I submit my paperwork?

Special Insurance Services, PO Box 250349, Plano, TX 75025-0349

For claim status please contact customer service at 1-800-767-6811.

You may fax your paperwork directly to Special Insurance Services at 1-972-960-0377.

Please make sure your name, social security number, group name and policy number is

on all correspondence.

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Plan: 1/1 Plan 2/2 Plan

In-Patient Benefit: $1,000 $2,000

Out-Patient Benefit: $1,000 $2,000

Maximum # of Occurrences 4 per family per year 4 per family per year

Pre-Existing Conditions Clause: No No

Type of Coverage Monthly Monthly

Under 40 - Insured Only $21.54 $30.96

Under 40 - Insured plus Children $52.11 $73.02

Under 40 - Insured plus Spouse $38.78 $55.75

Under 40 - Insured plus Family $69.31 $97.75

40-49 - Insured Only $27.32 $39.19

40-49 - Insured plus Children $54.27 $87.82

40-49 - Insured plus Spouse $49.12 $70.56

40-49 - Insured plus Family $76.10 $115.92

50 and Older - Insured Only $57.85 $80.31

50 and Older - Insured plus Children $98.94 $136.82

50 and Older - Insured plus Spouse $104.13 $144.51

50 and Older - Insured plus Family $145.17 $200.96

First Dollar Reimbursement Plan - NEXSTEP - Special Insurance Services & Fidelity

PINNACLE CORPORATION

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CIGNA DENTAL DHMO

Diagnostic/Preventive All covered by plan 100%

Consultation

Office Visit for Observation

Periodic and Limited Oral Evaluation

All X-Rays Cleanings covered every 6 months Call Cigna or Pinnacle for a Charge Schedule on the following:

Restorative (Fillings)

Crown and Bridge (All charges for crown and bridge are per unit) (Each replacement or supporting tooth equals one unit – replacement limit 1 every 5 years)

Endodontics (Root canal treatment, excluding final restorations)

Periodontics (Treatment of supporting tissues [gum and bone] of the teeth)

Prosthetics (Removable tooth replacement – dentures) (Includes up to 4 adjustments within first 6 months after insertion – replacement limit 1 every 5 years)

Repair to Prosthetics

Denture Relining (Limit 1 every 36 months)

Interim Dentures (Limit 1 every 5 years)

Oral Surgery (Includes routine post-operative treatment)

Orthodontics (Tooth movement)

General Anesthesia/I.V. Sedation

Emergency Services In- network benefits only No deductibles No annual dollar maximum

Select a dentist from a list of network providers on www.cigna.com.

Customer Service toll free #: 1-800-244-6224

NOTE: A dentist must be selected on application. Please log on or call customer service for a list of providers.

CIGNA DENTAL MONTHLY RATES

Employee Only $18.69

Employee & Spouse $49.92

Employee & Child(ren) $49.92

Family $49.92

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Pinnacle PEO Corporation Dental Plan Benefits- High Plan (Contrib)

For the savings you need, the flexibility you want and service you can trust.

Benefit Summary Coverage Type PDP In-Network Out-of-Network Type A – Preventative 100% of PDP Fee* 100% of PDP Fee* Type B – Basic 90% of PDP Fee* 90% of PDP Fee* Type C – Major 60% of PDP Fee* 60% of PDP Fee* Type D- Orthodontia 50% of PDP Fee* 50% of PDP Fee* Deductible† In-Network Out-of-Network Individual $50.00 $50.00 Family $150.00 $150.00 Annual Maximum Benefit In-Network Out-of-Network Per Person $2,000 $2,000 Orthodontia Lifetime Maximum In-Network Out-of-Network Per Person $2,000 $2,000 Late Enrollment Waiting Period:

Preventive Services No waiting period Basic Restorative Services (Fillings) 6 month waiting period Basic – All Other Services 12 month waiting period Major Services 24 month waiting period Orthodontic Services 24 month waiting period

* PDP Fee refers to the fees that participating PDP dentists have agreed to accept as payment in full, subject to any co-payments, deductibles, cost sharing and benefits maximums. †Applies only to Type B & C Services. Monthly Rates

Eligibility Options Employee Only $35.98 Employee + Spouse $73.17 Employee + Child(ren) $89.56 Employee + Family $136.70

MetLife®

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10

Pinnacle PEO Corporation Dental Plan Benefits- Low Plan (Voluntary)

For the savings you need, the flexibility you want and service you can trust.

Benefit Summary Coverage Type PDP In-Network Out-of-Network Type A – Preventative 100% of PDP Fee* 100% of PDP Fee* Type B – Basic 80% of PDP Fee* 80% of PDP Fee* Type C – Major 50% of PDP Fee* 50% of PDP Fee* Type D- Orthodontia 50% of PDP Fee* 50% of PDP Fee* Deductible† In-Network Out-of-Network Individual $50.00 $50.00 Family $150.00 $150.00 Annual Maximum Benefit In-Network Out-of-Network Per Person $1,250 $1.250 Orthodontia Lifetime Maximum In-Network Out-of-Network Per Person $1,250 $1,250 Late Enrollment Waiting Period:

Preventive Services No waiting period Basic Restorative Services (Fillings) 6 month waiting period Basic – All Other Services 12 month waiting period Major Services 24 month waiting period Orthodontic Services 24 month waiting period

* PDP Fee refers to the fees that participating PDP dentists have agreed to accept as payment in full, subject to any co-payments, deductibles, cost sharing and benefits maximums. †Applies only to Type B & C Services. Monthly Rates

Eligibility Options Employee Only $27.27 Employee + Spouse $55.53 Employee + Child(ren) $70.41 Employee + Family $106.68

MetLife®

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0699562 - 11/18/11

PINNACLE CORPORATION and VSP provide you anaffordable eyecare plan. Sign up today.Doctor Network..................................... VSP Signature

Your Coverage with a VSP Doctor

WellVision Exam® focuses on your eye health and overallwellness

• $10.00 copay......................................every 12 months

Prescription Glasses

• $25.00 copay

Lenses..................................................every 12 months• Single vision, lined bifocal and lined trifocal lenses

• Polycarbonate lenses for dependent childrenFrame................................................... every 24 months• $120 allowance for a wide selection of frames

• 20% off amount over your allowance

~OR~

Contact Lens Care

No copay applies..................................every 12 months

$120.00 allowance for contacts and the contact lens exam(fitting and evaluation)

Current soft contact lens wearers may qualify for a specialprogram that includes a contact lens exam and initial supplyof lenses.

Extra Discounts and Savings

Glasses and Sunglasses •Average 35 - 40% savings on all non-covered lens options •30% off additional glasses and sunglasses, including lensoptions, from the same VSP doctor on the same day asyour WellVision Exam. Or get 20% off from any VSP doctorwithin 12 months of your last WellVision Exam

Contacts •15% off cost of contact lens exam (fitting and evaluation)

Laser Vision Correction •Average 15% off the regular price or 5% off the promotionalprice. Discounts only available from contracted facilities. •After surgery, use your frame allowance (if eligible) forsunglasses from any VSP doctor.

VSP guarantees service from VSP doctors only. In the eventof a conflict between this information and your organization'scontract with VSP, the terms of the contract will prevail.

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UUNNUUMM PPRROOVVIIDDEENNTT LLIIFFEE IINNSSUURRAANNCCEE

Plan Description: Basic Life & AD&D Insurance

Employee Life Benefit Amount Overall Maximum

1 X annual earnings rounded to the next higher $1,000 $100,000

Employee Life Benefit Reduction Formula Life Benefit Reduces to: - 65% at age 65; and - 50% at age 70

One Time Basic Annual Earnings (BAE)

Calculate: 1x BAE is .53 per 1,000

Example: $30,000 x .53 = $15.90 per month

Important: Premiums are adjusted throughout the year according to current base salary changes. Maximum of 100,000.

Plan Description: Optional Term Life Insurance

Employee Life Benefit Amount Overall Maximum

Amounts in $10,000 benefit units as applied for The lesser of 5 X annual earnings by the employee and approved by UnumProvident or $500,000

Employee Life Benefit Reduction Formula

Life Benefit Reduces to: - 65% at age 65; and - 50% at age 70

Dependent Life Benefit Amount Overall Maximum

Spouse: Amounts in $5,000 benefit units The lesser of 100% of the employee life amount not to exceed 50% of the employee’s or $250,000 coverage amount

Child: - Live birth to 14 days: $1,000 The lesser of 100% of the employee life amount - 14 days to 6 months: $1,000 or $10,000 - 6 months to 19 years (26 years if full-time student): $10,000 Amounts in $2,000 benefit units

Child(ren): Available in increments of $2,000 up to 10,000, cost is $0.76 up to $3.80 per month whether it’s one child or five children.

SEE NEXT PAGE FOR RATE CHART

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AGE 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000 100,000 200,000 300,000 400,000 500,000

15-29 $1.47 $2.94 $4.41 $5.88 $7.35 $8.82 $10.29 $11.76 $8.82 $14.70 $29.40 $44.10 $58.80 $73.5030-34 $1.49 $2.98 $4.47 $5.96 $7.45 $8.94 $10.43 $11.92 $13.41 $14.90 $29.80 $44.70 $59.60 $74.5035-39 $1.83 $3.66 $5.49 $7.32 $9.15 $10.98 $12.81 $14.64 $16.47 $18.30 $36.60 $54.90 $73.20 $91.5040-44 $2.37 $4.74 $7.11 $9.48 $11.85 $14.22 $16.59 $18.96 $21.33 $23.70 $47.40 $71.10 $94.80 $118.5045-49 $3.54 $7.08 $10.62 $14.16 $17.70 $21.24 $24.78 $28.32 $31.86 $35.40 $70.80 $106.20 $141.60 $177.0050-54 $5.21 $10.42 $15.63 $20.84 $26.05 $31.26 $36.47 $41.68 $46.89 $52.10 $104.20 $156.30 $208.40 $260.5055-59 $8.24 $16.48 $24.72 $32.96 $41.20 $49.44 $57.68 $65.92 $74.16 $82.40 $164.80 $247.20 $329.60 $412.0060-64 $12.91 $25.82 $38.73 $51.64 $64.55 $77.46 $90.37 $103.28 $116.19 $129.10 $258.20 $387.30 $516.40 $645.5065-69 $22.36 $44.72 $67.08 $89.44 $111.80 $134.16 $156.52 $178.88 $201.24 $223.60 $447.20 $670.80 $894.40 $1,118.0070-74 $40.02 $80.04 $120.06 $160.08 $200.10 $240.12 $280.14 $320.16 $360.18 $400.20 $800.40 $1,200.60 $1,600.80 $2,001.0075+ $80.62 $161.24 $241.86 $322.48 $403.10 $483.72 $564.34 $644.96 $725.58 $806.20 $1,612.40 $2,418.60 $3,224.80 $4,031.00

AGE 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 50,000 100,000 150,000 200,000 250,000

15-29 $0.73 $1.46 $2.19 $2.92 $3.65 $4.38 $5.11 $5.84 $6.57 $7.30 $14.60 $21.90 $29.20 $36.5030-34 $0.75 $1.50 $2.25 $3.00 $3.75 $4.50 $5.25 $6.00 $6.75 $7.50 $15.00 $22.50 $30.00 $37.5035-39 $0.95 $1.90 $2.85 $3.80 $4.75 $5.70 $6.65 $7.60 $8.55 $9.50 $19.00 $28.50 $38.00 $47.5040-44 $1.27 $2.54 $3.81 $5.08 $6.35 $7.62 $8.89 $10.16 $11.43 $12.70 $25.40 $38.10 $50.80 $63.5045-49 $1.86 $3.72 $5.58 $7.44 $9.30 $11.16 $13.02 $14.88 $16.74 $18.60 $37.20 $55.80 $74.40 $93.0050-54 $2.78 $5.56 $8.34 $11.12 $13.90 $16.68 $19.46 $22.24 $25.02 $27.80 $55.60 $83.40 $111.20 $139.0055-59 $4.15 $8.30 $12.45 $16.60 $20.75 $24.90 $29.05 $33.20 $37.35 $41.50 $83.00 $124.50 $166.00 $207.5060-64 $6.93 $13.86 $20.79 $27.72 $34.65 $41.58 $48.51 $55.44 $62.37 $69.30 $138.60 $207.90 $277.20 $346.5065-69 $11.68 $23.36 $35.04 $46.72 $58.40 $70.08 $81.76 $93.44 $105.12 $116.80 $233.60 $350.40 $467.20 $584.0070-74 $20.64 $41.28 $61.92 $82.56 $103.20 $123.84 $144.48 $165.12 $185.76 $206.40 $412.80 $619.20 $825.60 $1,032.0075+ $41.12 $82.24 $123.36 $164.48 $205.60 $246.72 $287.84 $328.96 $370.08 $411.20 $822.40 $1,233.60 $1,644.80 $2,056.00

2,000 4,000 6,000 8,000 10,000

$0.76 $1.52 $2.28 $3.04 $3.80

UNUM PROVIDENT OPTIONAL LIFE

EMPLOYEE RATES-MONTHLY COST PER COVERAGE AMOUNT

CHILD RATES-MONTHLY COST PER COVERAGE AMOUNT

SPOUSE RATES-MONTHLY COST PER COVERAGE AMOUNT

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PRINCIPAL DISABILITY PLAN

Your group short term disability benefits All Members

Eligible Employees All active, full-time employees (except part-time, seasonal, temporary or contract employees) who work at least 30 hours per week

B E N E F I T Q U A L I F I C A T I O N

Definition of Disability Zero day residual disability

Income Loss Requirement 20%

Elimination Period Benefits begin on: The 1st day for disability due to injury The 8th day for disability due to sickness

B E N E F I T S P A Y A B L E

Benefit Percentage 60% of predisability earnings

Definition of Earnings Weekly average of W-2 earnings for the prior 2 calendar year(s)

Maximum Weekly Benefit $1,500

Minimum Weekly Benefit $15

Coordination of Benefits Direct integration

Social Security Integration Primary and family

Benefit Duration 13 weeks R E H A B I L I T A T I O N B E N E F I T S

Reasonable Accommodation Benefit $500

A D D I T I O N A L F E A T U R E S

Coverage for non work-related disabilities Mandatory rehabilitation The policy does not provide state mandated disability benefits in CA, NY, NJ, RI or HI.

RATE SHEET (EXAMPLES)

ANNUAL SALARY WEEKLY BENEFIT

APPROXIMATED MONTHLY COST

$10,000.00 $115.38 $13.23

$15,000.00 $173.08 $19.85

$20,000.00 $230.77 $26.47

$25,000.00 $288.46 $33.09

$30,000.00 $346.15 $39.70

$40,000.00 $461.54 $52.94

$50,000.00 $576.92 $66.17

$60,000.00 $692.31 $79.41

$100,000.00 $1,153.85 $132.35

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0813ANC

Pinnacle PEO Corporation

9311 San Pedro Ave. Ste 700 San Antonio, TX. 78216 Phone (210) 344-2088 Fax (210) 344-2777

www.pinnaclepeo.com