enrollment guide [template]

Enrollment Guide [Template]

Know your benefits.

Protingent Employee Benefits Guide

2021 Benefits – Effective 9/1/2021 through 8/31/2022

2021 Open Enrollment Learn more information at protingentbenefits.com

[Protingent|protingentbenefits.com | 2021]

Learn more on the Protingent benefits website:protingentbenefits.com

Health Savings Account (HSA)

Your 2021-2022 Benefits

Medical Benefits Medical Network

Pharmacy Benefits

Long-term, Short-term Disability, Life and Voluntary Life, Dental Vision Benefits

What you need to know:

Learn more:

• Healthcare Definitions

• Who’s Eligible to Enroll

• Changing Your Benefits

• Your Medical Plan

• Your Prescription Plan

• Your Telemedicine Plan

• Your EAP Plan

• Your HSA Plan

• Your Dental Plan

• Your Voluntary Vision Plan

• Your Voluntary Life & Disability Plan

• Resources and Contact Information

• Required Notices

Protingent provides employees and their eligible dependents a vital program of benefits designed to keep you healthy, protect your financial security, and help you balance your life at work and home.

This guide highlights your benefits. Official plan and insurance documents govern your rights and benefits under each plan. For more details about your benefits, including covered expenses, exclusions, and limitations, please refer to the individual Summary Plan Description (SPD), plan document, or certificate of coverage for each plan, which can be found in our company’s designated office. If any discrepancy exists between this guide and the official documents, the official documents will prevail.

What’s inside?

What’s inside?


Learn more:

In-Network vs. Out-of-Network – Our plans are designed to give you the freedom to use the healthcare provider of your choice. However, when

you use an in-network provider, the percentage you pay out of pocket will be based on a set fee, which is usually lower than the actual charge. If

you use a provider who is out-of-network, you may be responsible for paying the difference between the reasonable and customary (R&C) charges

and what the provider charges. R&C is the amount that is generally considered reasonable based on the average that most providers charge for a

particular service in a geographic region.

Preventive Care Services – These are services that are generally linked to routine wellness exams and screenings. Non-preventive services are

those that are considered treatment or diagnosis for an illness, injury, or other medical condition. Preventive care is covered at 100% in-network.

Copayments and Coinsurance – A copayment (or copay) is the fixed dollar amount you pay for certain in-network services. In some cases, you

may be responsible for coinsurance after the copay is made. Coinsurance is the percentage of covered expenses shared by you and the plan. In

some cases, coinsurance is paid after you meet a deductible. For example, if the plan pays 80% of an in-network covered charge, you pay the

remaining 20%.

Annual Deductible – The amount of money you must first pay out of pocket before your plan begins paying for services covered by coinsurance is

your annual deductible. After you meet your deductible, the plan pays for a percentage of eligible expenses (coinsurance) until you meet your out-

of-pocket maximum. If you receive services from an out-of-network provider, the plan has a higher deductible and pays a lower percentage of

coinsurance.

Out-of-Pocket Maximum – The amount of coinsurance you will be required to pay for eligible health care expenses is limited. Once you reach the

maximum amount, the plan begins to pay 100% of eligible expenses. Please note that there may be separate in-network and out-of-network annual

out-of-pocket maximums.

Summary Plan Description (SPD) – The SPD is an important document that tells participants what the plan provides and how it operates,

including when an employee can begin to participate in the plan, how service and benefits are calculated, when benefits become vested, and how

to file a claim for benefits. Employers are legally obligated by The Employee Retirement Income Security Act (ERISA) to provide employees SPDs

for each benefit plan offered by the employer.

Health Savings Account (HSA) – An HSA is a savings account used in conjunction with a high deductible health plan (HDHP) that allows users to

save money tax-free for IRS-qualified medical expenses. An HSA allows the employer to make contributions to the account, and the account

balance rolls over from year to year. For a complete list of IRS-qualified medical expenses, consult IRS Pub 502

(https://www.irs.gov/pub/irspdf/p502.pdf).

Definitions


Learn more:

Who is eligible?

A full-time Employee of the Employer who regularly

works 30 Hours of Service per week will be eligible

to enroll for coverage under this plan.

Participation in the plan will begin as of the first day

of the month following the date he or she completes

at least one (1) hour of service with the Employer

provided all required election and enrollment forms

are properly submitted to the Plan Administrator. You

must enroll for benefits within 31 days of your hire

date.

You are not eligible to participate in the Plan if you

are a part-time, temporary, leased or Seasonal

Employee, an independent contractor or a person

performing services pursuant to a contract under

which you are designated an independent contractor

(regardless of whether you might later be deemed a

common law employee by a court or governmental

agency).

Eligible dependents include your:

Legally married spouse

Same- or opposite sex spouse

Children up to age 26 (health plan) with

integral dental and/or vision*

Children under the age of 20; or to age 26

if a fulltime student (stand-alone dental or

standalone vision)


Learn more:

Certain Qualified Life Events (QLEs) may enable you to change your benefit elections at a time other

than during open enrollment. You can change your benefit elections during the year if you experience a

qualified life event.

Generally, your benefits election change must be consistent with the QLE. If you experience a QLE, you

must generally notify Protingent within 31 days of the change. You may need to provide proof of the

change. If you do not make contact within 31 days, you will have to wait until the next annual open

enrollment period to make changes, unless you have another QLE.

QLEs include: Marriage

Divorce, annulment, or legal separation

Birth of your child

Death of your spouse or dependent child

Adoption of/placement for adoption of your child

Termination or commencement of your spouse’s

employment

Change of employment status by you or your

spouse, or another dependent

A significant change in your or your spouse’s

health coverage due to your spouse’s employment

Qualification by the Plan Administrator of a

Medical Child Support Order

Entitlement to Medicare or Medicaid

Commencement of or return from an unpaid leave

of absence

A change in the place of residence of you, your

spouse, or your dependent

Your dependent satisfies or ceases to satisfy

eligibility requirements

Changing your benefits


Medical BenefitsKnowing your health plan

Learn more on the Protingent benefits website:

protingentbenefits.com

Medical Benefits

Medical BenefitsFinding the right doctor for you is

very important for your overall health.

Our Group Medical plans make it

easier to prioritize your health. You

can minimize out-of-pocket costs by

taking advantage of our large

network of providers.

Learn more about your benefits on

the Protingent Benefits website:


Plan Network Plan Administrator

YOUR HEALTH PLAN 1. POS Choice Plus Plan

IN-NETWORK / OUT-OF-NETWORK

2. HDHP / HSA Plan

IN-NETWORK / OUT-OF-NETWORK

PLAN-YEAR DEDUCTIBLE

Individual / Family

$2,000 individual (in network)

$4,000 family (in network)

$4,000 individual (out of network)

$8,000 family (out of network)





PLAN-YEAR OUT-OF-

POCKET MAX

Individual / Family







$15,000 individual (out network)


Coinsurance 80% (in network)

40% (out of network)

80% (in network)

80% (out of network)

Outpatient care IN-NETWORK / OUT-OF-NETWORK IN-NETWORK / OUT-OF-NETWORK

Preventive care 100% deductible waived (in network)

60% after deductible (out of network)

100% Deductible Waived (in network)


Physicians Office visits $30 (in network)

60% after deductible (out of network)80% after deductible (in network)


Urgent Care $50 (in network)

60% after deductible (out of network)80% after deductible (in network)


Emergency Room $200, then 100% (in network, out of network) 80% after deductible (in network, out of network)

Prescription Drug Card Retail (30 days supply)

Generic - $15

Preferred - $45

Non-preferred $75

Mail Order (up to 90 days supply)

Generic - $30

Preferred - $90

Non-preferred - $150

Retail (30 days supply)

Generic – 20%

Brand Name – 20%

Mail Order (up to 90 days supply)

Generic – 20%

Brand Name – 20%

This is a brief outline of your benefits. It is not a Summary Plan Description or intended to replace the Schedule of Benefits contained within the Plan Document. If any provision is inconsistent with the language of the Plan Document, the Plan Document will govern.

Your Medical Plan Options

2021-2022 Medical Rates

Monthly Rates HDHP POS

EmployeeNo cost $175

Employee + Spouse$750 $1,100

Employee + Children$300 $550

Employee + Family$1,050 $1,480

Sign Up For TelaDoc Today!!TELADOC - 24/7 Healthcare

www.teladoc.comPPO - $15 Copay then 100%, Deductible waived

HSA - Consult fee of $47 then 100% after Deductible N/A

Protingent offers you access to Teladoc!24/7 Online Access to a Medical Professional!

TELADOC TREATS & PRESCRIBES MEDICATION FOR A WIDE RANGE OF CONDITIONS:• COLD AND FLU• BRONCHITIS• PINK EYE• AND MORE

Find support for all of life’s challenges.

1-855-283-1917www.resourcesforliving.comUsername: ProtingentPassword: eap

Program features • Legal (30-minute consultation per

issue/60-minute ID Theft Consultation for victims of ID theft)

• Financial (30-minute telephonic consultation per issue)

• Daily life assistance provides personalized guidance and referrals for childcare, parenting, elder care, caregiver support, special needs, home repair and improvement, school and financial aid research, etc.

• Online resources include articles, videos, myStrength, legal/financial tools, webinars, discount center, etc.

Pharmacy Benefits Manager

Maximize Your BenefitYour decisions play a key role in the effectiveness of your prescription benefit. Here are a few tips to help you maximize your benefit.

Request Generics• Generic medications provide quality, cost-effective alternatives to brand medications and may help reduce costs to you and your plan. • Ask your local pharmacy if they offer any low-cost generic programs. Use your prescription benefit card to process your order and receive the lower priced alternative, whether it is the pharmacy’s generic program price or your copay

Take Your Medications As Directed • Taking medications exactly as prescribed is one of the most important things you can do to enhance your health and prevent medical complications. • Missing doses, stopping medication early or swapping medications with other people can lead to serious problems that may negatively impact health outcomes.

Helping you achieve the best possible health outcomes Promoting the use of safe, cost-effective and clinically appropriate medications Helping you save money and providing convenient access to your prescription medications

Take Advantage of Over-The-Counter (OTC) Products • Some medications that used to only be available by prescription (e.g., Claritin®, Prilosec®, and Zyrtec®) are now available over-the-counter without a prescription. • Ask your doctor if any OTC alternatives are available to effectively treat your condition. Switching to an OTC product could save both you and your plan money.

Take Advantage of Over-The-Counter (OTC) Products - $0 !!

Helping you achieve the best possible health outcomes Promoting the use of safe, cost-effective and clinically appropriate medications Helping you save money and providing convenient access to your prescription medications

Zero Co-Pay OTC ProgramALAVERT • ALLEGRA • ALLEGRA-D

AXID AR • CETIRIZINE • CIMETIDINE CLARITIN • CLARITIN-D • FAMOTIDINE

FEXOFENADINE • FEXOFENADINE PSEUDOEPHEDRINE • LORATADINE NEXIUM 24HR OTC • OMEPRAZOLE

PEPCID COMPLETE • PEPCID AC PREVACID 24 HR CAP • PRILOSEC OTC

RANITIDINE • TAGAMET HB • XYZAL OTC ZANTAC • ZEGERID OTC • ZYRTEC

To take advantage of this zero co-pay OTC program, please follow these 3 easy steps once you and your doctor agree that an OTC product is right for you:

1. Ask your physician to write (or telephone in) a prescription for the specific OTC product. • Make sure your physician writes “OTC” on the prescription.

2. Take the prescription to your local pharmacy (not available through mail service) and ensure that your pharmacist:

• Uses your prescription benefit card to fill the OTC prescription.• Fills the prescription just like any other prescription medicine, making sure to include

your doctor’s name and instructions on the label.• Charges you no co-pay as a result of this program.

3. Make sure to follow your doctor’s instructions for use when taking the medication.

Home delivery by Magellan Rx Pharmacy Save time and money with a 90-day supply of your medications by mail

If you take maintenance medications for long-term conditions like arthritis, asthma, diabetes, high blood pressure or high cholesterol, you could save with home delivery through Magellan Rx Pharmacy.

How to get started First, ask your doctor to write two prescriptions: 1. 30-day supply to fill at your local pharmacy 2. 90-day supply plus refills to fill by mail

Next, you may either: Ask your doctor to e-prescribe to Magellan Rx Pharmacy, LLC (Mail-ORL) or fax your prescription to 888-282-1349.

Faxed prescriptions may only be sent by a doctor’s office and must include patient information and diagnosis. • For prompt delivery, please provide your payment information by mailing in your completed home

delivery order form or by calling 800-424-8274.• Mail us your 90-day prescription and completed order form with payment to Magellan Rx

Pharmacy, P.O. Box 620968, Orlando, FL 32862. • Home delivery order forms are available at www.magellanrx.com/member/forms

Healthcare Savings Account (HSA)


What is an HSA?

If you enroll in Protingent Staffing's High

Deductible Health Plan (HDHP), then you

may be eligible to open and HSA. An HSA

is a bank account where you can set aside

money to pay for expenses that your

health plan does not cover. The money in

your HSA is not considered income, so it is

not subject to taxes.

Healthcare Savings Account (HSA)


An HSA is designed to work with a qualifying high-deductible health plan (HDHP). The money goes in tax-free, grows income tax-free and comes out income tax-free when you use it for qualified medical expenses.You can carry over unused funds from year to year and the account is yours to keep even if you change jobs, change health plans or retire.

Group: 911736Customer Service: 866-234-8913www.optumbank.com

Please notify payroll if you enrolled in a previous employer’s HSA program this year.


Dental BenefitsYour Dental Plan



Dental Benefits

METLIFE DENTAL

Good dental care is key to your overall

health and wellness. Find an in-network

dentist on the MetLife mobile app or online

at www.metlife.com/mybenefits




BENEFIT IN-NETWORK OUT OF NETWORK

Annual Calendar-Year $3000 $3000

Calendar-Year Deductible/Combined for Basic and Major

$50 (Type B & C) $50 (Type B & C)

A. Preventive Services 100% 100%

B. Basic Services 80% 80%

C. Major Services 50% 50%

Orthodontia Coinsurance $1000 $1000

Orthodontia Lifetime Maximum Ortho applies to Adult and Child (Up to dependent age limit)

Your Dental Plan

Type A · Oral Examinations 1 in 6 months. · Cleanings 1 in 6 months

Type B · Periodontal Maintenance 4 in 1 year less the number of teeth cleanings. · Space Maintainers For dep

Type C · Crowns 1 in 84 months. · Dentures 1 in 84 months. · Bridges 1 in 84 months. · Periodontal Surgery 1 in 36 months

Orthodontia· Dependent children are covered up to their 26th birthday.

2021-2022 Dental Rates

Monthly Dental Rates

Employee $45.08

Employee + Spouse $89.61

Employee + Children $94.48

Employee + Family $148.13


Vision Benefits



Vision Benefits

To find a vision provider, you can use the search tool on the VSP provider search tool:

vsp.com/eye-doctor

Vision care - Voluntary




Covered Charges VSP Network Copay

Eye Exam Focuses on your eyes and overall wellness $10 copay

Frames $130 allowance for a wide selection of frames

$150 allowance for featured frame brands 20%

savings on the amount over your allowance

$70 Walmart®/Costco® frame allowance

$25 copay

Lenses Single vision, lined bifocal, and lined trifocal

lenses

$25 copay

Contact Lenses $130 allowance for contacts; copay does not

apply

Up to $60

Your Vision Plan

Extra $20 to spend on featured frame brands. Go to vsp.com/offers 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.

2021-2022 VSP Vision Rates

Monthly Vision Rates

Employee $7.46

Employee + Spouse $11.93

Employee + Children $12.18

Employee + Family $19.64


Additional Benefits



Short-term Disability

The elimination period is as follows:For Injury: 14 daysFor Sickness (includes pregnancy): 14 days

Benefits continue for as long as you are disabled up to a maximum duration of 11 weeks of Disability.

The Benefit amount is 60% of your predisability weekly earnings subject to the plan's maximum weekly benefit of $2,500.

Benefits begin after the end of the elimination period. The elimination period begins on the day you become disabled and is the length of time you must wait, while disabled, before you are eligible to receive a benefit.

Learn more about benefit offerings and rates on the Protingent Employee Benefits website:


Voluntary Long-term Disability

Long Term Disability: The Long-Term Disability benefit replaces a portion of your predisability monthly earnings, less other income you may receive from other sources during the same Disability (e.g., Social Security, Workers’ Compensation, vacation pay etc.).

The Benefit amount is 60% of your predisability monthly earnings.



Voluntary Term Life

Build Your Benefit With MetLife's Supplemental Term Life insurance, your employer gives you the opportunity to buy valuable life insurance coverage for yourself, your spouse and

your dependent children -- all at affordable group rates.

With Met Life's Supplemental Term Life insurance, Protingent gives you the opportunity to buy valuable life insurance coverage for yourself (up to $100K-in 10K increments-with no

medical exam needed), your spouse (up to $25K) and your dependent children. All at affordable group rates.

With no medical underwriting.



Employee Contributions Per Month

Monthly Cost MedicalHDHP

Medical PPO

Dental Vision

EmployeeNo cost $175 $45.08 $7.46

Employee / Partner $750 $1,100 $89.61 $11.93

Employee / Children $300 $550 $94.48 $12.18

Employee + Family $1,050 $1,480 $148.13 $19.64

Contact Information and Resources

BENEFIT PROVIDER WEBSITE / EMAIL PHONE

Medical Admin Meritain meritain.com 800-925-2272

Medical Network Aetna aetna.com 877-204-9186

Pharmacy Magellan Rx magellanrx.com 800-424-0472

Dental Life and AD&D MetLife metlife.com 800-275-4638

Vision VSP vsp.com 800-877-7195

HR Human Resources Department at Protingent

[email protected] 425-284-7777

Benefit Advocate Kris Kirkpatrick [email protected] 425-778-2800

mailto:[email protected]

mailto:[email protected]

The U.S. government requires companies offering

certain employee benefit plans to inform covered

employees and their dependents about

laws/provisions that affect the governance and/or

coverage within those plans. The company has full

details available for you concerning the following

laws/provisions:

Summaries of each can be found in the Your

Required Notices brochure. For complete

information and more detailed explanations about

any of these notices, contact Protingent’s Human

Resources department. Also, from time to time,

you may receive detailed explanations directly

from the company via letter or email.

• Wellness Program Disclosure Notice of

Alternative Standard

• Medicare Part D Notice

• Children’s Health Insurance Program

(CHIP) Notice

• Grandfather Status

• Notice of Patient Protection Provisions

• COBRA Notice

• Medical Child Support Order Notice

• Women’s Health and Cancer Rights Act

• Summary of Benefits and Coverage

• Mental Health Parity and Addiction Equity Act

(MHPAEA) Notice

Required Notices

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