Benefit Guide 2021 Sinai Union
BenefitGuide 2021
Sinai Union
Welcome to Your BenefitsWith CARE BRAVELY at our core, LifeBridge Health team members care for our
patients, their families and communities day in and day out. But, we also need to
be sure we’re taking care of ourselves and our own families.
LifeBridge Health is excited to be able to provide competitive benefits packages
for our team members to ensure their loved ones are covered, no matter the
circumstance. And as we face a “new normal” with the COVID-19 pandemic, now it is
more important to ensure you’re getting the most out of your benefits coverage.
Please use this benefits guide as a resource for the plans offered by LifeBridge
Health for the 2021 calendar year. We want to ensure you understand the
benefits and the packages we offer, so you can get the most out of them.
Take the time to review the options outlined in this guide and select coverage
that works best for you and your family. Typically, unless you have a qualified
status change, the selections that you make will stay in place for the entire
2021 calendar year.
If you have any questions, please visit http://www.lifebridgehealth.org/benefits
for more information.
As a LifeBridge Health team member, your health and well-being are important
to us. We are excited to CARE BRAVELY for you.
Best,
Neil
Enrolling in Your Benefits
New Hires
You have 30 days to enroll in your benefits. If you do
not enroll during this time, you will not be eligible to
enroll until the next annual enrollment period unless
you experience a qualified life event.
What’s Inside: 3 Your Benefits 5 Medical Plan 6 Resources for Navigating Your Healthcare 7 Prescription Drug Coverage 8 Medical & Prescription Drug Rates 9 Health Savings Account (HSA) 10 Flexible Spending Accounts11 Dental Plan12 Vision Plan13 Life Insurance & Disability15 Additional Benefits16 Metlife Legal Plans with Plus Parents Option20 403(b) Retirement Savings Plan21 Dependent Verification Process22 Glossary of Terms23 Special Notices24 Contact Information
Review this guide and the information on the
Benefits Website.
Collect any dependent/spouse documentation
required and submit to the Benefits Team at
[email protected] or via fax
at 410-469-5161.
Make your benefit elections and enroll in GHR.
Review and print your benefits confirmation
statement.
Pay close attention to your first paycheck with
your new payroll deductions.
About Your Benefits
2 | 2021 OPEN ENROLLMENT: OCTOBER 26 – NOVEMBER 6, 2020
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Covering Yourself and Your FamilyWhen Coverage Begins
Medical, prescription, dental and Spending Account benefits are
effective 60 days after the day of hire (effective 61st day). All other
benefits are effective the first of the month following 60 days
of employment.
The following dependents are eligible:• Your legal spouse
• Children up to age 26 (regardless of their student status or if they are
claimed as a dependent for income tax purposes), or your disabled
children if disabled before age 26* *Note: Voluntary benefits may have different age requirements so please review the
materials carefully.
When Coverage Ends
For Medical, Dental, Vision, and Life Insurance, coverage will end on the
last day of the month in which your employment ends or you move to
a position not eligible for benefits. All other voluntary benefits coverage
ends on the last day of employment or on date you move to a position
not eligible for benefits.
For Flexible Spending Accounts (Health, Dependent and Limited
Purpose) coverage ends on the last day of employment. You have
60 days to spend your contributed funds. After 60 days the funds are
forfeited unless you elect to continue coverage under COBRA.
If you have a Health Savings Account the monthly fee will become your
responsibility at the beginning of the month after your benefits end.
You will see this reflected on your monthly statement from Health
Equity. All funds posted to your account are yours to continue using for
qualified expenses until exhausted.
Your dependent coverage ends when your coverage ends or on the
last day of the month in which your dependent turns age 26.
Are You Providing Coverage to a New Dependent?If you enroll a new dependent for benefits, you will be required to provide
documentation to confirm their eligibility. All documentation should be
submitted to the Benefits Team at [email protected].
If you do not provide the required documents within 30 days,
your dependents will not have coverage. View page 20 for
detailed requirements.
You and the Affordable Care ActUnder the Affordable Care Act (ACA), an employee who works an
average of 30 hours per work (1,560 hours annually) are eligible for
medical coverage. Employees who have hours that vary from week
to week are referred to as “variable hour” (under 0.6 FTE) employees
and all variable hour employees have a 12-month “measurement period”
to determine the average number of hours worked per week. If your
average is 30 hours or more per week, you’ll be eligible for LifeBridge
Health’s medical coverage for the full 2021 plan year. If your average is
less than 30 per week, you won’t be eligible for the LifeBridge Health’s
medical coverage and will need to find other coverage elsewhere,
such as through a spouse, parent, or the Health Insurance Marketplace.
The measurement period occurs annually, so your eligibility could change
each plan year. Employees eligible for medical coverage under ACA will
receive a separate enrollment letter notifying them of their eligibility.
Making Changes During the Plan YearThe IRS provides strict regulations about changes to pre-tax elections
during the plan year. If you experience a qualified IRS family status
change mid-year, you are permitted to make a change within 30 days of
the event. If the change request is not completed within 30 days of the
event, you will not be able to change your elections until the following
year’s benefits annual enrollment period or you experience another
qualified life event. Below is a list of some of the more commonly known
qualified status changes:
• Marriage, divorce or legal separation
• Birth or adoption of a child
• Death of your spouse or dependent child
• Change in employment status of team member, spouse or
dependent child
• Loss or gain of insurance coverage
To make changes, contact the Benefits Team within 30 days of a
qualifying life event. You may need to provide proof of the event,
such as a marriage license. If you don’t take action, you’ll have to
wait until the next enrollment period to make changes unless you
experience another qualifying life event.
Your BenefitsYour 2021 Benefits Are Effective January 1 Through December 31
LifeBridge Health pays the full cost of many of your benefits. For others, LifeBridge Health and you share the cost or you pay the full cost.
Pretax means the cost comes out of your pay before taxes are deducted. After-tax means your cost comes out of your pay after taxes are deducted.
The chart shows who pays for each benefit and the related tax treatment.
Benefit Who Pays Tax Treatment
Medical LifeBridge Health/You Pretax
Dental LifeBridge Health/You Pretax
Vision You Pretax
Basic Life and Accidental Death & Dismemberment (AD&D) Insurance
LifeBridge HealthN/A, except on
Life Insurance greater than $50,000
Short-Term Disability Coverage LifeBridge Health N/A
Buy-up Short-Term Disability Coverage You After-tax
Voluntary Benefits (Accident, Critical Illness, ie.)
You After-tax
Employee Assistance Plan LifeBridge Health N/A
403(b) Retirement Savings Plan LifeBridge Health/You Pretax
About Your Benefits
4 | 2021 OPEN ENROLLMENT: OCTOBER 26 – NOVEMBER 6, 2020
Medical PlanLifeBridge Health offers two medical plan options - administered by CareFirst BlueCross BlueShield (CareFirst). Each plan offers comprehensive
health care benefits, including free preventive care services and coverage for prescription drugs. Here’s how the plans compare.
Plan ProvisionHealth Saver Plan (with HSA) Premium Health Plan
LBH Network
CareFirst In-Network
Out-of-Network
LBH Network
CareFirst In-Network
Out-of-Network
Company Contribution to HSA1 Individual Family
$7001 $1,4001 N/A
Calendar Year Deductible Individual Family
$2,800 $5,200
$3,000 $6,000
$3,000 $6,000
$100 $300
$600 $1000
$600 $1000
Annual Out-of-Pocket Maximum (Includes deductible, copays and coinsurances)Individual Family
$4,000 $8,000
$5,000 $10,000
$6,600 $13,200
$1,000 $3,000
$2,000 $6,000
$5,600 $11,200
You Pay
Primary Physician Office Visit 20%* 40%* 50%* $25 30%* 40%*
Specialist Office Visit 20%* 40%* 50%*$35 for first6 visits then
100%30%* 40%*
Preventive Care – one per calendar year (includes annual physicals, immunizations, routine cancer screenings and well child visits)
$0Plan pays
100%
$0Plan pays
100%50%*
$0Plan pays
100%
$0Plan pays
100%40%*
Diagnostic Service (includes Advanced imaging (PET, MRI, CT), other imaging (X-ray, sonogram), Lab and other services)
20%* 40%* 50%*$02
Plan pays 100%
30%* 40%*
Emergency Care3 20%* 20%* 20%* $100 copay per visit
$100 copay per visit
$100 copay per visit
Urgent Care 20%* 40%* 50%* $25 copay $35 copay 40%
Outpatient Facility and AmbulatorySurgical Facility 20%* 40%* 50%* $0* 30%* 40%*
Inpatient Hospitalization4 20%* 40%* 50%* $0* $500 copay + 30%*
$500 copay + 40%*
*After Deductible. 1 If enrolling in the Health Saver Plan; the first half of funding is provided in January and the second half is provided in July as long as you are still enrolled in the plan.2 Must be performed by LifeBridge Health Provider, designated LifeBridge health Lab or Facility.3 Emergency Room copay waived only if admitted; Emergency services available out-of-network.4 Pre-authorization required.
Important Considerations• You may use in- or out-of-network providers. You will always pay the least if you use the LifeBridge Provider Network. Using a provider in the CareFirst
network, instead of an out-of-network provider, will also help you save.• You must meet an annual deductible before the medical plan begins to cover a portion of the cost for most care. • Deductibles and Out-of-Pocket Maximums cross apply. Anything spent in either the LifeBridge Health Network, CareFirst In-Network or Out-of-Network
levels will accumulate toward all deductibles and out-of-pocket maximums for the year.• Out-of-pocket maximums apply to both plans. This is the maximum amount you will pay for health care costs in a calendar year. Your bi-weekly
contribution rates will continue.• You may be required to obtain pre-authorization from the plan prior to receiving certain services. If either you or your provider does not pre-authorize
care when necessary, you may not have coverage for that service.
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Blue Rewards This program, sponsored by CareFirst, leverages a digital health
company – Sharecare – to help you live a healthier lifestyle and earn
rewards for healthy behavior, all customized to your needs and goals.
Blue Rewards has a RealAge® test, quarterly challenges and biometric
screenings that will earn you up to $200 in reward money by the end
of 2021.
Wellness Resources:
Access motivating digital resources anytime, anywhere:
• RealAge®: Learn the physical age of your body, compared to your
calendar age with the online health assessment
• A personalized health timeline: Receive recommendations,
content and programs
• Trackers: Connect your wearable devices or enter your own data to
monitor sleep, steps, nutrition and more
• Challenges: Provide extra motivation for achieving your health goals
• A health profile: Access your important health data all in one place
• Inspirations and Relax 360°: Break free from stress, unwind at the
end of the day or ease into a restful night of sleep with meditation,
streaming music and videos
As part of your wellness program, you have access to additional
support resources like:
• Health coaching
• Tobacco cessation
• Weight management
• Financial well-being
If you have questions about the program or incentive, please email
Ready to Get Started?
Visit carefirst.com/sharecare
You’ll need to:
• Enter your CareFirst My Account username and password .
• Complete the one-time registration with Sharecare.
Locating A Medical Provider Searching for a medical provider and/or service has never been easier.
Utilize our provider locator tool listed below to help you find a provider
and/or facility that is in the LifeBridge Health (Tier 1) Network.
https://member.carefirst.com/mos/#/fadsdpublic/search/lifebridge
• All LifeBridge Health (Tier 1) providers and facilities are identified
as Best Value $
• CareFirst In-Network (Tier 2) are identified as Better Value $$
• Out-of-Network (Tier 3) are identified as Good Value $$$
Using the LifeBridge Health (Tier 1) Network will always save you
money by offering a lower deductible and co-pays.
Blue Cross Blue Shield Global As a Blue Cross and Blue Shield member, you take your healthcare
benefits with you when you are abroad. Through the Blue Cross Blue
Shield Global® Core program, you have access to doctors and hospitals
around the world.
Before you travel, contact your Blue Cross and Blue Shield company for
coverage details. Coverage outside the United States may be different.
If you need to locate a doctor or hospital, call the Service Center for
Blue Cross Blue Shield Global Core at 1.800.810.2583 or collect at
1.804.673.1177, 24 hours a day, seven days a week. An assistance
coordinator, in conjunction with a medical professional, will arrange a
physician appointment or hospitalization if necessary.
Elevation of Services When the LifeBride Health medical plan does not offer or provide eligible
services or providers an elevation of services may be requested. You can
submit your inquires to [email protected].
Resources for Navigating Your Healthcare
Preventive CareRemember, your preventive care with an in-network provider is
at no cost to you.
• Annual adult physical
• Routine immunizations
• Well child exams
• Annual GYN check up
• Routine cancer screenings (mammogram, cervical cancer screening,
prostate cancer screening, colonoscopy, skin cancer screening)
• Routine prenatal maternity services
About Your Benefits
6 | 2021 OPEN ENROLLMENT: OCTOBER 26 – NOVEMBER 6, 2020
Prescription Drug CoverageThis chart provides information about your prescription drug coverage. You can save on your prescriptions by using a LifeBridge Health Pharmacy
(Sinai Pharmacy, Northwest Outpatient Pharmacy or Anchor Pharmacy, the on-site location at Carroll Hospital) or Mail Order.
Save With a LifeBridge Health Pharmacy No Cost Preventive Medications: There is no copay ($0) for generics
used to treat high blood pressure, cholesterol, depression and diabetes
if the prescription is filled at a LifeBridge Health Pharmacy.
Long-term Medications: You have two options to receive a 90-day
supply if you are taking a long-term medication. Long-term
medications are those taken regularly for chronic conditions such as
high blood pressure, asthma, diabetes or high cholesterol, and must
be filled using one of these options:
• Option 1: A LifeBridge Health Pharmacy, including Sinai Outpatient
Pharmacy, Northwest Outpatient Pharmacy or Anchor Pharmacy, the
on-site location at Carroll Hospital.
• Option 2: Mail Order through a LifeBridge Health Pharmacy or CVS
Caremark. For LifeBridge Health, please call 410-601-7100 or visit
lifebridgehealth.org/outpatientpharmacy. For CVS Caremark,
call 866-294-2110 or visit www.caremark.com.
Definitions Generic – A drug that offers equivalent uses, doses, strength, quality
and performance as a brand-name drug, but is not trademarked.
Formulary – A drug with a patent and trademark name that is
considered “preferred” by the drug plan administrator because it is
appropriate to use for medical purposes and is usually less expensive
than other brand-name drugs.
Non-formulary – This type of drug is “not preferred” and is usually
more expensive than generic and formulary brand drugs.
Specialty – These drugs are typically the most expensive options,
may require special handling, can be difficult to administer and often
require additional clinical monitoring.
Plan ProvisionHealth Saver Plan (With HSA) Premium Health Plan
Retail and Mail Order LBH Pharmacy1 CVS/Other Retail Pharmacies
Annual Deductible
Individual Family
Included in Medical (see page 5)
$75 per person$225 per family
Annual Out-of-Pocket Maximum
Individual Family
Included in Medical (see page 5)
$1,000 per person$2,000 per family
Retail Prescription Drugs (30-day supply)
• Generic• Formulary• Non-formulary• Specialty
20%* 30%*40%*
50%* (LifeBridge Health Pharmacy only)
$10*2 $30*$50* $0*
$10*$40*$70*
Not Covered
Mail Order Prescription Drugs (90-day Supply)3
• Generic • Formulary• Non-formulary• Specialty
20%* 30%*40%*
50%* (LifeBridge Health Pharmacy only)
$20*2
$60*$100*
$0*
$20*$80*
$140*Not Covered
*After deductible. 1 LifeBridge Health Pharmacies: Sinai, Northwest, and Anchor Pharmacy (at Carroll Hospital Location only).2 $0 copay for generics to treat high blood pressure, cholesterol, depression and diabetes, if the prescription is filled at LifeBridge Health Pharmacy.3 Long Term Medications (Maintenance) must be filled at a LifeBridge Health Pharmacy or through CVS Mail Order.
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Medical & Prescription Drug RatesBi-Weekly Rates Associate Only Employee + Child Employee + Spouse Family
Premium Health Plan
Full Time $72.92 $117.23 $162.00 $205.85
Part-Time $150.92 $240.92 $330.00 $420.92
Health Saver Plan
Full Time $37.85 $60.00 $83.08 $105.23
Part Time $51.23 $82.15 $112.15 $143.08
Surcharges If applicable, there are two surcharges:
• Smoker Surcharge – $30 per pay period
• Spousal Surcharge – $30 per pay period, if your spouse has access to other health coverage through their employer and that employer is not
LifeBridge Health. Note: Surcharges are applicable only to enrollments in the Medical Plans.
About Your Benefits
8 | 2021 OPEN ENROLLMENT: OCTOBER 26 – NOVEMBER 6, 2020
Health Savings Account (HSA) A Health Savings Account (HSA) provides additional options for paying medical expenses with tax-free savings. LifeBridge contributes to your
account to help offset some of your eligible expenses.
Account Type Health Savings Account (HSA)
Eligibility You must be enrolled in the Health Saver Plan with HSA and meet these requirements: • Not be claimed as a dependent on another person’s tax return.• Not be covered under another medical plan that is not HSA-eligible. • Not be enrolled in Medicare Part A or B, or be in receipt of VA medical or prescription benefits within the previous three months.
Your contributions You contribute on a pretax basis and you can change how much you contribute from each paycheck. The IRS maximum annual contribution is $3,600 for individual coverage and $7,200 for family coverage. If you are age 55 or older, you may make a “catch-up” contribution of $1,000.
Company’s contributions LifeBridge Health contributes to your account (the first half is paid in January and the second half is paid in July as long as you are still enrolled in the plan).• $700 for individual coverage• $1,400 for family coverageThe combination of your contribution and the company contribution cannot exceed the IRS maximum for 2021 of $3,600 for individual coverage and $7,200 for family coverage.
Eligible expenses Medical, dental, vision and prescription drug expenses incurred by you and your covered family members.
If you also wish to enroll in a Health Care FSA, you will only be eligible for a Limited-Purpose Health Care Flexible Spending Account (FSA).
Using your account Use the debit card linked to your HSA or submit a claim form to cover the expenses, or pay the expenses out-of-pocket and save your HSA money for future health care expenses.
Remaining Funds Any money left in your HSA at the end of the year will roll over to the next year — you’ll never lose your HSA dollars.
If you leave LifeBridge Health or retire, you can take your HSA with you so you can continue to pay and save for eligible health care expenses.
Fees There is a monthly fee of $2 for the HSA. As long as you are enrolled in the Health Saver Plan, LifeBridge Health pays the fee for you.
Setting Up Your HSATo set up your HSA, log on to HealthEquity and register your account. To view your balance, submit claims and more log on to https://healthequity.com/.
Once you pass the CIP process, you will receive a debit card from HealthEquity in the mail. To view your balance, submit claims and more, set up a
HealthEquity account at https://healthequity.com/.
Remember to set up your beneficiary directly with HealthEquity.
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Flexible Spending AccountsA Flexible Spending Account (FSA) helps you pay for eligible health care costs using tax-free dollars. You decide how much money you would like
to contribute to the account on a pretax basis.
Provision Limited Purpose (FSA)
BenefitsSpecifically for associates enrolled in the Health Saver Plan. Saves on eligible expenses not covered by insurance; reduces your taxable income.
Your contributions* Maximum contribution is $2,750.
Eligible expenses Eligible expenses are limited to qualifying dental and vision expenses.
Using your accountWhen you incur expenses, you can access account funds in your account to pay for eligible expenses.
Use the debit card linked to your HSA to cover the expenses, or pay the expenses out of pocket and submit a claim to be reimbursed by your FSA.
Use It or Lose It Reimbursable expenses must be incurred between January 1 and December 31. Claims for reimbursement must be submitted by March 31, of the following year. Please plan your contributions carefully. FSA elections do not automatically contribute from year to year, you must actively enroll each year.
*You are not able to make changes to your annual contribution unless you experience a qualified life event.
About Your Benefits
10 | 2021 OPEN ENROLLMENT: OCTOBER 26 – NOVEMBER 6, 2020
Dental Plan
ProvisionSilver Plan Gold Plan
In-Network Out-of-Network In-Network Out-of-Network
Annual Deductible N/A N/A N/A N/A
Annual Maximum N/A N/A N/A $1,000 combined
Periodic Oral Evaluation $5 copay N/A $5 copay $12 allowance
Dental Bi-weekly Rates Silver Plan Gold Plan
Individual $0.00 $8.80
Employee + Child $0.00 $15.45
Employee + Spouse $0.00 $17.59
Family $0.00 $24.16
Regular dental care is an important part of caring for your overall
health. Your dental plan is the United Concordia Dental Plan.
Detailed information regarding benefit coverage can be found on
the Schedule of Benefits posted on the Benefits Website,
http://www.lifebridgehealth.org/benefits.
Please note: You must select a United Concordia Primary Dental Office
(PDO) to receive covered services.
Treatment by an Out-of-Network Dentist is covered as described in the
Certificate of Coverage and Point of Service (POS) Rider, subject to a
maximum of $1,000 per Member per Contract year.
Only procedures listed on the Schedule of Benefits are Covered Services.
For services not listed (not covered), you are responsible for the full fee
charged by the dentist. Procedure codes and member Copayments may
be updated to meet American Dental Association (ADA) Current Dental
Terminology (CDT) in accordance with national standards.
For a complete description of your plan, please refer to the Certificate
of Coverage and the Schedule of Exclusions and Limitations.
If you have any questions about your United Concordia dental plan,
please call UCCI’s Customer Service Department toll-free at
1-866-357-3304 or access their website at www.UnitedConcordia.com.
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Vision PlanGetting your eyes checked every year can help maintain your vision and identify the early signs of certain health conditions, including diabetes.
Benefit Description Copay Frequency
Your Coverage with a VSP Provider
WellVision Exam Focuses on your eyes and overall wellness $0 Every calendar year
Prescription Glasses
Frame • $150 allowance for a wide selection of frames• $170 allowance for featured frame brands• 20% savings on the amount over your allowance• $80 Costco® frame allowance
$0 Every calendar year
Lenses • Single vision, lined bifocal, and lined trifocal lenses Polycarbonate lenses for dependent children
$0 Every calendar year
Lens Enhancements • Standard progressive lenses • Premium progressive lenses Custom progressive lenses• Average savings of 35-40% on other lens enhancements
$0$80–$90
$120–$160
Every calendar year
Contacts (instead of glasses)
• $130 allowance for contacts; copay does not apply Contact lens exam (fitting and evaluation)
Up to $60 Every calendar year
Diabetic Eyecare Plus Program
Services related to diabetic eye disease, glaucoma and age-related macular degeneration (AMD). Retinal screening for eligible members with diabetes. Limitations and coordination with medical coverage may apply. Ask your VSP doctor for details.
$20 As needed
Computer Vision Care
Computer Vision Exam Evaluates your needs related to computer use $0 Every calendar year
Frame • $100 allowance for a wide selection of frames• $120 allowance for featured frame brands• 20% savings on the amount over your allowance
$0 Every calendar year
Lenses Single vision, lined bifocal, lined trifocal, and occupational lenses $0 Every calendar year
Extra Savings Glasses and Sunglasses• Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details.• 30% savings on additional glasses and sunglasses, including lens enhancements, from the same VSP provider on the same day as your WellVision Exam. Or get 20% from any VSP provider within 12 months of your last WellVision Exam.
Retinal ScreeningNo more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam
Laser Vision Correction• Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities • After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor
Vision Bi-weekly Rates Full or Part Time
Individual $4.11
Associate & Child(ren) $7.70
Associate & Spouse $7.26
Family $11.73
Your Coverage with Out-of-Network Providers Get the most out of your benefits and greater savings with a VSP
network doctor. Call Member Services for out-of-network plan details.
Krieger Eye DiscountsAs a LifeBridge Health team member you still have access to discounts with Krieger Eye at the Quarry Lake and Northwest Hospital locations. Be sure to
contact their office directly for applicable discounts.
To locate a VSP provider for In-Network Coverage please visit - https://www.vsp.com/eye-doctor
About Your Benefits
12 | 2021 OPEN ENROLLMENT: OCTOBER 26 – NOVEMBER 6, 2020
Company-Provided InsuranceLifeBridge Health automatically provides the following insurance
benefits at no cost to you.1 You do not need to enroll.
Account Type Benefit
Basic Life Insurance • 1x your base annual earnings, up to a maximum benefit of $50,000
Basic Accidental Death and Dismemberment (AD&D) Insurance
• 1x your base annual earnings, up to a maximum benefit of $50,000
Short-Term Disability for you
• 66.7% of your weekly earnings, up to $350 per week
• 14 calendar day elimination period • Benefits begin on the 15th day of
disability due to a non-work related injury and illness, and are payable up to the 26 weeks, if approved
Associate Paid Insurance
Account Type Benefit
Buy-up Short-Term Disability for you
• Ability to purchase buy up to a maximum of $700 per week.
• Benefits begin on the 15th day of disability due to injury or illness, and are payable up to 26 weeks.
Life Insurance & DisabilityWhat would your family do if your income was lost due to death or disability? Life and disability insurance are important for you and your family’s
financial security.
Reminder regarding Life Insurance: Keep your beneficiary information up-to-date in GHR.
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Important Considerations For Your Disability Plans• If approved by the carrier, your disability payments begin
after the benefit waiting period. The benefit waiting period is
the period of time an employee must be continuously disabled
before disability benefits may be payable through Cigna. Employees
are able to use available earned paid time off to cover time out of
work while they are satisfying the benefit waiting period. Disability
benefits may begin being paid out at the end of benefit waiting
period.
• Short Term Disability for maternity leave is supported for
six weeks’ postpartum for normal deliveries and eight weeks’
postpartum for cesarean section deliveries. Cigna’s claim managers
review pregnancies with complications on a case by case basis.
Please note that before disability benefits are payable for maternity
leave, you must satisfy the benefit waiting period.
• Benefits may be reduced by other income, such as Social Security.
• To place a disability claim please contact Cigna directly.
Life Insurance & DisabilityBasic Life Insurance:As a benefit eligible employee, you are automatically enrolled into the employer paid Basic Life insurance. This plan provides you with access to a
number of services at no additional cost! For any questions, please contact MetLife directly.
• Grief Counseling - Provides you and your dependents up to five private counseling sessions, in-person or by phone, with a professional grief counselor—
per event—to help cope with a loss, no matter the circumstances, whether it’s a death, an illness or divorce.
• Life Settlement Account - The Total Control Account (TCA) is a settlement option that provides your loved ones with a safe and convenient way to
manage life insurance proceeds. They’ll have the convenience of immediate access to any or all of their proceeds through an interest-bearing account
with unlimited check-writing privileges. The Total Control Account also allows beneficiaries time to decide what to do with their proceeds.
• Funeral Discounts and Planning Services - Helps alleviate the burden of making funeral arrangements from your loved ones. Get access to the
largest network of funeral homes and cemeteries to pre-plan with a counselor and receive discounts on funeral services.
Important Life Insurance Considerations: To open a claim for life insurance please contact Human Resources
About Your Benefits
14 | 2021 OPEN ENROLLMENT: OCTOBER 26 – NOVEMBER 6, 2020
Additional Benefits
Employee Assistance Program – CareBridge If you find yourself in need of professional support to deal with
personal, work, financial or family issues, the Employee Assistance
Program (EAP) can help. You and your immediate family
(spouse, dependent children) can use the EAP for help with: • Marriage and family problems
• Job-related issues
• Stress, anxiety and depression
• Parent and child relationships
• Legal and financial counseling
• Identity theft counseling
• Financial planning
• Various other issues
The program is available 24/7, is completely confidential and offered
at no cost. If you need help or guidance, call a CareBridge counselor at
800-437-0911 or visit www.myliferesource.com, access code: KKNH3.
Make Emotional Well-Being A Priority
Confidential Mental Health Assistance
Access to 24/7 guidance and counseling with licensed clinicians to assist
with concerns such as stress, anxiety, depression, grief, substance abuse,
and relationship conflicts. Support options include six in-person or
telehealth referrals, text and chat.
Life Management Solutions
Experienced life management specialists can provide qualified referrals
and resources for everyday concerns including child and eldercare, legal,
wellness support groups, transportation, relocation, and pet care.
Personal Money Management
Financial experts can provide you with the educational information and
resources you need to create a budget, pay off debt and establish savings.
Your mental health contributes towards happiness in your personal life. It also enhances your ability to be productive at work. At times, particular
life experiences and conditions can challenge one’s emotional and mental well-being. Present day conditions caused by the pandemic and social
injustices may have influenced feelings of fear, anxiety, and sadness, as well as, relationship conflicts. Your Employee Assistance Program (EAP) benefit
provides confidential consultations and referrals for counseling at no expense to you and members of your immediate family. Work-life support is
available to help you with information and resources for childcare, eldercare, personal money management, convenience services including pet
services, and education planning. Carebridge can help. Call 800.437.0911, 24/7. Educational resources are available on myliferesource.com and the
Carebridge EAP App. You will need to use the access code, KKNH3, during your first visit to the website.
Education Planning
Useful educational guidance and information to assist from infancy
through retirement. Obtain support to help your child learn while also
identifying programs to develop your personal interests and skills.
Virtual Resources and Support
Carebridge EAP App and mylifersource.com make it easy for you to access
a wide array of mental health and life management resources including
articles, trainings, calculators, self-care tips, mindfulness practices, discount
shopping program, and more.
| 15
MetLife Legal Plans with Plus Parents Option Metlife Legal Plans helps you navigate life’s planned and unplanned events Attorney fees can be expensive. With this plan, attorney fees for the legal services listed below are fully paid for when you use a network attorney. There
are no waiting periods, no deductibles, and no claim forms when using a network attorney for a covered matter.
With network attorneys available in person, by phone, or by email and online tools to do-it-yourself or plan your next move – MetLife makes it easy
to get legal help. And, you will always have a choice in which attorney to use. You can choose from their network of prequalified attorneys or use an
attorney outside of the network and be reimbursed some of the cost.1
Best of all, you have unlimited access to the MetLife attorneys for all legal matters covered under the plan. All services below are to available
employees, spouses, and eligible dependents. Services highlighted in bold are available to parents and parents-in-law.
Money Matters • Debt Collection Defense • Identity Theft Defense • Identity Management Services2
• Negotiations with Creditors• Personal Bankruptcy
• Promissory Notes• Tax Audit Representation• Tax Collection Defense
Home & Real Estate • Boundary & Title Disputes • Deeds • Eviction Defense • Foreclosure
• Home Equity Loans • Mortgages • Property Tax Assessments • Refinancing of Home
• Sale or Purchase of Home • Security Deposit Assistance • Tenant Negotiations • Zoning Applications
Estate Planning • Codicils • Complex Wills • Healthcare Proxies • Living Wills
• Powers of Attorney (Healthcare, Financial, Childcare, Immigration)• Revocable & Irrevocable Trusts • Simple Wills
Family & Personal • Adoption • Affidavits • Conservatorship • Demand Letters • Divorce - 20 hours • Garnishment Defense • Guardianship• Immigration Assistance
• Juvenile Court Defense, • Including Criminal Matters • Name Change • Parental Responsibility • Matters • Personal Property Protection• Prenuptial Agreement
• Protection from Domestic Violence • Review of ANY Personal Legal Document • School Hearings
Civil Lawsuits • Administrative Hearings • Civil Litigation Defense
• Disputes Over Consumer Goods & Services • Incompetency Defense
• Pet Liabilities • Small Claims Assistance
Elder-Care Issues Consultation & Document for your parents: • Deeds • Leases
• Medicaid • Medicare • Notes • Nursing Home Agreements
• Powers Of Attorney • Prescription Plans • Wills
Vehicle & Driving • Defense of Traffic Tickets3 • Driving Privileges Restoration
• License Suspension Due to DUI • Repossession
Bi-weekly Rate
MetLife Legal Plans with Parent Plus $8.50
1You will be responsible to pay the difference, if any, between the Plan’s payment and the out-of-network Attorney’s charge for services.2This benefit provides the Participant with access to LifeStages Identity Management Services provided by CyberScout, LLC. CyberScout is not a corporate affiliate of MetLife Legal Plans.3Does not cover DUI.
About Your Benefits
16 | 2021 OPEN ENROLLMENT: OCTOBER 26 – NOVEMBER 6, 2020
Group Voluntary Critical Illness CoverageGroup Voluntary Critical Illness coverage through MetLife pays benefits
for non-medical, critical illness-related expenses that your medical
plan might not cover. Benefits are in the form of a lump sum payment,
which is paid after a diagnosis is made.
Your initial benefit provides a lump-sum payment upon the first
diagnosis of a covered condition. Your plan also pays a recurrence
benefit for the certain covered conditions. The maximum amount that
you can receive through your Critical Illness Insurance is three times
the amount of your initial benefit.
Attained Age Employee Employee/Spouse Employee/Children Family
<25 $0.36 $0.72 $0.68 $1.05
25-29 $0.38 $0.78 $0.70 $1.10
30-34 $0.47 $1.00 $0.80 $1.32
35-39 $0.62 $1.34 $0.94 $1.66
40-44 $0.68 $1.90 $1.18 $2.23
45-49 $1.22 $2.75 $1.54 $3.07
50-54 $1.67 $3.88 $1.99 $4.21
55-59 $2.24 $5.40 $2.57 $5.73
60-64 $3.16 $7.81 $3.48 $8.13
65-69 $0.67 $11.61 $4.99 $11.93
70+ $7.20 $17.31 $7.52 $17.64
Employee Only Coverage, Age 55 with $10,000 coverage: • $10,000/1000 = 10
• 10 * $2.24 = $22.40 Monthly Rate
• $22.40 * 12 (months in the year) = $268.80/26 (pays in the year) =
$10.34 per pay
Family Coverage, Age 30 with $20,000 coverage:• $20,000/1000 = 20
• $20* $1.32 = $26.40 Monthly Rate
• $26.40 * 12 (months in the year) = $316.80/26 (pays in the year) =
$12.18 per pay
MetLife will provide an annual benefit of $50 per calendar year for
taking one of the eligible screening/prevention measures. MetLife
will pay only one health screening benefit per covered person per
calendar year. More details can be found on BridgeNet.
Eligible Individual Initial Benefit
Coverage Options
Employee $10,000 or $20,000
Spouse 100% of the employees Initial Benefit
Dependent Children3 50% of the employee's Initial Benefit
Insurance RatesMetLife offers competitive group rates and convenient payroll deduction, so you don’t have to worry about a check or missing a payment!
Your employee rates are outlined below.
Monthly Premium/ $1,000 of Coverage
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Group Voluntary Accident Coverage Group Voluntary Accident coverage through MetLife can pay benefits for off-the-job accidents, plus some benefits that correspond with medical
care. The coverage can be used on its own or to fill a gap left by other coverage. It pays a benefit up to a specified amount for dislocation/fracture,
initial hospitalization confinement, hospitalization confinement, intensive care, ambulance service, medical expenses, outpatient physician’s
treatment and more.
The below chart shows a range of potential payment amounts for a given category of covered conditions. Actual payments are determined by the
benefit type.
Covered BenefitsLow Plan High Plan
MetLife Accident Insurance Pays You MetLife Accident Insurance Pays You
Injuries – 12 covered injury types Ranging from $25 – $5,000 per injury Ranging from $50 – $10,000 per injury
Medical Services & Treatment – 15 covered types
Ranging from $15 – $1,000 per medical service/treatment type
Ranging from $25 – $2,000 per medical service/treatment type
Hospital Coverage (Accident) $500 (non-ICU) or $1,000 (ICU) per accident $1,000 (non-ICU) or $2,000 (ICU) per accident
Admissions $100 per day (non-ICU), up to 31 days $200 per day (non-ICU), up to 31 days
Confinement $200 per day (ICU), up to 31 days $400 per day (ICU), up to 31 days
Inpatient Rehab$100 per day, up to 15 days per accident and 30 days per calendar year
$200 per day, up to 15 days per accident and 30 days per calendar year
Accidental Death$25,000 $75,000 is passenger in common carrier
$50,000 $150,000 is passenger in common carrier
Dismemberment, Loss & Paralysis $250 - $10,000 per injury $500 – $50,000 per injury
Lodging$100 per night, up to 31 nights; up to $3,100 in total lodging benefits available per calendar year
$200 per night, up to 31 nights; up to $6,200 in total lodging benefits available per calendar year
Health Screening (Wellness)$50 payable 1x per covered insured per calendar year, if covered insured takes a covered test
$50 payable 1x per covered insured per calendar year, if covered insured takes a covered test
Bi-Weekly Group Voluntary Accident Rates Low Plan High Plan
Employee Only $3.30 $5.46
Employee Plus Spouse $6.94 $11.63
Employee Plus Child $6.92 $11.40
Family $8.34 $14.34
About Your Benefits
18 | 2021 OPEN ENROLLMENT: OCTOBER 26 – NOVEMBER 6, 2020
PetFirst Pet Insurance, a MetLife CompanyPet Insurance through PetFirst helps
offset the cost of caring for your dog or
cat, and covers everything from preventive
care to accidents and illness, as well as the
costs of X-rays, office visits, medications,
surgeries and hospital stays.
Please note: To enroll in Petfirst Pet Insurance you need to contact
Petfirst directly.
Home and Auto Discount Program You can receive special group discounts on auto, home, and renter’s
insurance through Liberty Mutual. The policies are tailored to suit your
needs. Please contact Liberty Mutual to inquire and/or enroll.
Please note: Liberty Mutual will bill you directly. No payroll
deduction is offered.
Identity Theft Protection This service through Allstate is designed to protect your identity and
assets through identity, credit and social media monitoring. Allstate also
extends dependent coverage to any dependent who lives in the same
household as the employee or who is financially dependent on them,
with no age limit.
Allstate Identity Protection is available in two comprehensive plans to
fit your needs with Allstate Identity Protection Pro and Allstate Identity
Protection Pro Plus. Both products include:
• Identity and credit monitoring
• Annual credit report and monthly credit score tracking
• Threshold monitoring
• Social media reputation monitoring
• Digital wallet storage and monitoring
• Full-service identity restoration
• $1,000,000 identity theft insurance policy
• A digital exposure report
Note: If you are newly enrolling, you need to set up an account with
Allstate. You will receive a home mailer and an email to your work
email address.
Learn more at www.myaip.com
Questions? Contact Allstate
Allstate Identity Protection Pro
Allstate Identity Protection Pro Plus
$3.66 per Individual per Paycheck $4.59 per Individual per Paycheck
$6.43 per Family per Paycheck $8.28 per Family per Paycheck
FeatureAllState Identity Protection Pro
Allstate Identity Protection Pro Plus
Credit Monitoring
Tri-Bureau Credit Monitoring
Annual Credit Report
Monthly Credit Score Tracking
Social Media Reputation Monitoring
Digital Wallet Storage & Monitoring
Full-Service Identity Restoration
Privacy Advocate Assistance
$1,000,000 Identity Theft Insurance Policy
Expanded Data Sources for Transactions on Financial Accounts
Additional Proactive Alerts on Financial Account Transactions
Threshold Monitoring on all Financial Accounts
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403(b) Retirement Savings PlanLifeBridge Health offers 403(b) Retirement Savings Plan giving you an easy way to save for your future through payroll deductions.
For More InformationFor additional details about the 403(b) Retirement
Savings Plan or to enroll or change your contribution
rates or investment elections, please refer to
Transamerica Retirement Solutions at 800-755-5801,
or Transamerica.com/portal/lbh.
Remember: you can make changes to your 403(b)
plan at anytime during the plan year.
EligibilityYou are eligible to participate in the plan on your date of hire.
Your ContributionsContributions from your pay are made on a pretax basis up to the
IRS annual limit ($19,500 for 2020). If you are 50 years of age or older,
(or if you will reach age 50 by the end of the year), you may make
an additional catch-up contribution of $6,500, in addition to the
IRS annual limit.
Vesting Vesting refers to your right of ownership to the money in your
account. You are immediately vested in all of your contributions and
earnings on your contributions.
About Your Benefits
20 | 2021 OPEN ENROLLMENT: OCTOBER 26 – NOVEMBER 6, 2020
Dependent Verification Process You are required to complete the Dependent Verification Process for any dependent or spouse that will be newly covered with LifeBridge Health Benefits.
If you are not sure if you have the required dependent verification on file, please contact the Benefits Team. Your dependent(s) will not have coverage until
you complete this process.
As part of our commitment to control health care costs, LifeBridge Health (LBH) is taking steps to ensure that only eligible dependents are covered under
our medical, dental and/or vision plans. To accomplish this, LBH has implemented a dependent verification program. This process is intended to ensure
that each dependent enrolled in the LBH medical, dental and/or vision plans is accurately listed and eligible for coverage.
There are three (3) steps to the verification program clearly detailed below. Please complete all 3 steps for the dependents you enrolled in benefits,
if applicable.
1. Make sure that you provide legible copies of all required documentation.
2. Write your name and employee ID number on each piece of documentation.
3. Write “Not For Official Use” on each document and cross out the first five digits of any social security number.
Disabled Dependent:• A copy of the child’s birth certificate,
naming you or your legally married spouse
as the child’s parent, or appropriate court
order/adoption decree naming you or your
legally married spouse as the child’s legal
guardian AND
• A copy of a physician certification confirming
the child’s disability status.
Required Documentation:
Spouse:• A copy of your marriage certificate AND
• One form of documentation establishing
current marital status such as a joint
household bill, joint bank/credit account,
joint mortgage or lease, or front page of
your jointly filed federal tax return.
Child:• A copy of the child’s birth certificate,
naming you or your legally married spouse
as the child’s parent, or appropriate court
order/adoption decree naming you or
your legally married spouse as the child’s
legal guardian.
All required documentation must be received by the Benefits Team as soon as possible. You can submit documentation via email at
Your dependent(s) will not have coverage until we receive the documentation. If documentation is not received within 30 days of your hire date,
your dependent will not be eligible for coverage until the next open enrollment period unless they experience a qualifying life event.
If you have any questions regarding this process please contact your site HR team or the Benefits Team at [email protected].
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Glossary of TermsAfter-tax – The contributions you make for benefits such as Life and AD&D insurance and Disability insurance are subject to Social Security tax, federal income tax and, in most cases, state and local income taxes.
Calendar Year Maximum – The benefit amount paid each year for each family member enrolled in the dental plan.
Coinsurance – The sharing of cost between you and the plan. For example, 80 percent coinsurance means the plan covers 80 percent of the cost of service after a deductible is met, and you will be responsible for the remaining 20 percent of the cost.
Copay – A fixed amount (for example $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
Deductible – The amount you have to pay for covered health care services before your health plan begins to pay.
Benefit Waiting Period – The benefit waiting period is the period of time an employee must be continuously disabled before disability benefits may be payable through Cigna. Employees are able to use available earned paid time off to cover time out of work while they are satisfying the benefit waiting period. Disability benefits may begin being paid out at the end of benefit waiting period.
Health Savings Account (HSA) – An HSA is a personal health care account for those enrolled in an HDHP. You may use your HSA to pay for qualified medical expenses such as doctor’s office visits, hospital care, prescription drugs, dental care, and vision care. You can use the money in your HSA to pay for qualified medical expenses now, or in the future. Your HSA can be used for your expenses and those of your spouse and dependents, even if they are not covered by the HDHP.
High Deductible Health Plan (HDHP) – A qualified High Deductible Health Plan (HDHP) is defined by the Internal Revenue Service (IRS) as a plan with a minimum annual deductible and a maximum out-of-pocket limit. These minimums and maximums are determined annually and are subject to change.
In-network – A designated list of health care providers (doctors, dentists, etc.) with whom the health insurance provider has negotiated special rates. Using in-network providers lowers the cost of services for you and the Company.
LifeBridge Health (LBH) Network – LifeBridge Health Provider Network.
Out-of-network – Health care providers that are not in the Plan’s network and who have not negotiated discounted rates. The cost of services provided by out-of-network providers is much higher for you and the Company. Additional deductibles and higher coinsurance will apply.
Out-of-pocket maximum – The most you will pay of your own money before services are 100 percent covered by the medical plan. Your annual deductible is included in your out-of-pocket maximum.
Pretax – The contributions you make for medical, dental, vision, HSA, FSA health care spending and FSA dependent care spending are not subject to Social Security tax, federal income tax or, in most cases, state and local income taxes.
Reasonable & Customary Charges (R&C) – Prevailing market rates for services provided by health care professionals within a certain area for certain procedures. Reasonable and Customary rates apply to out-of-network charges.
About Your Benefits
22 | 2021 OPEN ENROLLMENT: OCTOBER 26 – NOVEMBER 6, 2020
Special NoticesAccess these LifeBridge Health Special Notices at http://www.lifebridgehealth.org/benefitsCertificate of Credible Coverage for Medicare Part D This notice has information about your current prescription drug coverage with LifeBridge Health and about your options under Medicare’s prescription drug coverage.
Women’s Health and Cancer Act of 1998 If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA).
CHIPRA Notice If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs.
Mental Health Parity Act The Mental Health Parity law applies to group health insurers and to fully insured and self-insured ERISA groups of 51 or more employees that include mental health/substance use disorder benefits. It mandates equalization of copays, coinsurance, deductibles and the elimination of day and visit limits and financial maximums.
Healthcare Reform Notification This notice includes information about the Patient Protection and Affordable Care Act that was recently passed and provides you with important information that you need to know.
Newborn’s Act Disclosure The Newborns’ and Mothers’ Health Protection Act requires that group health plans and health insurance issuers who offer childbirth coverage generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section.
LifeBridge Health 2018 PN501 Summary Annual Report This is a summary of the annual report of the LifeBridge Health, Inc., a health, life insurance, dental, vision, temporary disability and longterm disability plan.
Notice of Special Enrollment Rights If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage).
| 23
Contact InformationPlan Provider Phone Number Website
Medical CareFirst 866-595-6245 www.carefirst.com
Prescription Drugs CVS 866-294-2110 http://caremark.com/wps/portal
Dental UCCI 866-357-3304 www.unitedconcordia.com
Vision VSP 800-877-7195 www.vsp.com
Flexible Spending Accounts WageWorks 877-924-3967 www.wageworks.com
FMLA/LOA Requests FMLA Source 877-462-3652 www.fmlasource.com
Credit Union First Financial Federal
Credit Union410-321-6060 www.firstfinancial.org
Health Savings Account (HSA) HealthEquity 877-924-3967 https://healthequity.com/
Life Insurance and AD&D MetLife 800-438-6388 www.mybenefits.metlife.com
Disability Cigna 800-781-2006 www.cigna.com
Employee Assistance Program Carebridge800-437-0911
Company Access Code: KKNH3www.myliferesource.com
Critical Illness/Accident Insurance MetLife 800-438-6388 www.mybenefits.metlife.com
Legal Assistance MetLIfe Legal 800-821-6400
Company access code: 9900019info.legalplans.com
Identity Theft Protection Allstate 800-789-2720 www.myaip.com
Home and Auto Insurance Liberty Mutual 800-295-3549 www.libertymutual.com
Pet Insurance PetFirst 866-937-7387 www.petfirst.com/lifebridge
403(b) Retirement Savings PlanTransamerica Retirement
Solutions800-755-5801 Transamerica.com/portal/lbh
Additional Resources Service Phone Number Website
Mobile Wallet Card
Provides you access to plan contact information,
group numbers and benefit guides anywhere from your computer or mobile phone
— mymobilewalletcard.com/lifebridge
Enrollment Counselors
Additional support in understanding your
benefits and/or to make enrollment elections
855-736-1446 —
Global Human Resources (GHR)
Access online the enrollment area and view your current
benefit elections throughout the year
—https://lbhprd-law.cloud.infor.com/
SitePages/InforSuite.aspx
*Must be within the LBH Network to access the Benefit area. *Must use updated Microsoft Edge Browser.
Provider Locating Tool
Carefirst United Concordia Vision Services Plan
https://member.carefirst.com/mos/#/fadsdpublic/search/lifebridge
http://www.unitedconcordia.com/ https://www.vsp.com/eye-doctor
About Your Benefits
24 | 2021 OPEN ENROLLMENT: OCTOBER 26 – NOVEMBER 6, 2020
About this Guide: This benefit summary provides selected highlights of the LifeBridge Health employee benefits program. It is not a legal document and shall not be construed as a guarantee of benefits nor of continued employment at the company. All benefit plans are governed by master policies, contracts and plan documents. Any discrepancies between any information provided through this summary and the actual terms of such policies, contracts and plan documents shall be governed by the terms of such policies, contracts and plan documents. LifeBridge Health reserves the right to amend, suspend or terminate any benefit plan, in whole or in part, at any time. The authority to make such changes rests with the Plan Administrator.