1. health and fitness
2. drugs

Employee
Benefits
Guide
LHD Benefit Advisors
We’re happy to provide you and your family one of the most comprehensive benefit programs. Our benefits
program provides a variety of plans that can enhance the lives of you and your family, both now and in the future.
As part of this benefits program, you will be asked to make decisions about the employee benefits described in this
booklet. Please study the information carefully and complete the enrollment forms promptly so that you can begin
enjoying the benefits that are available.
Highlights of Our Benefits
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Dual Option Medical Plans
Prescription Drug Plan
Dental Plan
Voluntary Vision Plan
Life / AD&D Insurance
Short Term Disability
Long Term Disability
Eligibility
All full-time employees regularly scheduled to work at least
30 hours per week and are on the regular payroll of the
employer. For new hires your benefits for the medical,
dental, vision and life programs begin on the first day of
the month following 30 days of employment. Covered
dependents include your spouse and children to age 26 for
medical and 24 for dental.
Medical
The medical coverage is provided by Anthem. You have
two medical plans from which to choose (Please see inside
for benefit details). Both group medical plans use a
network of doctors and hospitals who have agreed to
provide services at discounted rates. You are covered at
the highest level if you receive care through the Blue
Access PPO network. While it is not required that you
utilize the PPO network, the service outside the network
will be at a greater cost to you. To obtain the most current
participating provider listing, log onto www.anthem.com
and pick the Blue Access Network.
Dental
The dental program is administered by Delta Dental. They
provide benefits for Preventive, Basic and Major dental
care. Orthodontia benefits are also covered under this
program, which has a separate annual maximum of $1,000.
Voluntary Vision
LHD Benefit Advisors is also offering a voluntary vision
program provided by VSP. Please see inside and benefit
summary for detailed information. For a listing of
network providers please log onto www.vsp.com and pick
the Choice Network.
Life Insurance
LHD Benefit Advisors provides you a Basic Life and
AD&D benefit of 1.5 x salary to a maximum of $100,000
at no cost to you through Met Life. Also a benefit of
$20,000 is proved to you at no cost through Anthem.
Income Protection
LHD Benefit Advisors provides at no cost to you, both
Short Term Disability Income Protection and Long Term
Disability Income Protection. These programs provide
financial protection by paying you a portion of your
income while you are disabled due to sickness or injury.
Please see Plan Certificate for important plan features.
Both income protection plans are provided by Met Life.
Medical & Prescription Drug Benefits
Administered By:
Dual Option Offering
Plan Summaries
Buy Up Plan
Network Benefits
Lifetime Maximum
Calendar Year Deductible
Single
Family
Coinsurance
Out of Pocket Max. (include
deductible)
Single
Family
Office Visits
Primary Care Physician
Specialty Care Physician
Inpatient/Outpatient Hospital
Emergency Room
Urgent Care Facility
Preventive Care
Medical history, mammograms, pelvic
exams, Pap tests, immunizations,
routine & diabetic eye exams, and
hearing exams
Vision Exam - (Discount on
Materials)
Prescription Drugs –
Retail (30 day supply)
Tier 1
Tier 2
Tier 3
Tier 4 (30 Day Supply)
Prescription Drugs
Mail Order or (90 day supply)
Tier 1
Tier 2
Tier 3
Tier 4 (30 Day Supply)
Core Plan
Non-Network
Benefits
Non-Network
Benefits
Network Benefits
Unlimited
Unlimited
$1,000
$3,000
80%/20%
$2,000
$6,000
60%/40%
$1,000
$3,000
70%/30%
$2,000
$6,000
50%/50%
$4,000
$8,000
$8,000
$16,000
$4,000
$8,000
$8,000
$16,000
$20 Copay; 100%
40% after Deductible
$20 Copay; 100%
40% after Deductible
20% after Deductible
40% after Deductible
$250 copay + 20% Coinsurance
$75 copay
40% after Deductible
0%
40% after Deductible
(Anthem pays at 100%)
30% after Deductible
50% after Deductible
30% after Deductible
50% after Deductible
30% after Deductible
50% after Deductible
30% Coinsurance
30% after Deductible
50% after Deductible
0%
50% after Deductible
(Anthem pays at 100%)
$5 Exam Only
Reimbursed up to
$42
$5 Exam Only
Reimbursed up to $42
$10 copay
$30 copay
$60 copay
50% Min $60
50% Min $60
50% Min $60
$10 copay
$30 copay
$60 copay
50% Min $60
50% Min $60
50% Min $60
25% to $200 Max
up to $2500
50% Min $60
25% to $200 Max
up to $2500
50% Min $60
$10 copay
$75 copay
$180 copay
Not Covered
Not Covered
Not Covered
$10 copay
$75 copay
$180 copay
Not Covered
Not Covered
Not Covered
25% to $200 max
up to $2500
Not Covered
25% to $200 max
up to $2500
Not Covered
The above is a brief outline to communicate the benefit programs offered. Please refer to the Plan Certificate to determine level of coverage.
Additional Benefits
Dental Benefit Summary
Plan Effective Dates: 2/1/2014 – 1/31/2014
Network/NonNetwork
Administered By:
Deductible
Basic Life / AD&D
1.5 X Base Annual Earnings to a
maximum of $100,000
All Employees
You Pay
Individual
$50
Family
$150
Annual Plan Max(Per Individual)
Preventive Services
Deductible Waived
Exam, Cleanings, Fluoride and Space Maintainers
X-rays, Sealants, Brush Biopsy
Emergency Palliative Treatment
Basic Services
$1,500
You Pay 0%/0%
Minor Restorative Services,
You Pay 20%/20%
Relines and Repairs to Bridges and
You Pay 20%/20%
Dentures, Oral Surgery, Fillings
You Pay 20%/20%
Major Services
Major Restorative Services,
You Pay 50%/50%
Prosthodontic Services
You Pay 50%/50%
Crowns, Full/Partial Dentures,
You Pay 50%/50%
Bridges, Endosteal Implants
You Pay 50%/50%
Endodontic and Periodontic Services
You Pay 50%/50%
Orthodontia
You Pay 50%/50%
Separate Ortho Deductible
Ortho Lifetime Max Per Child
No
Short Term Disability
Full-Time Employees
Benefit Duration
Paid by LHD
0 Day Accident
7 Day Illness
26 Weeks
Benefit
60% of earnings
Elimination Period
Maximum Weekly Benefit
$500
Long Term Disability
Full-Time Employees
Paid by LHD
Own Occupation
24 Months
Elimination Period
180 Days
Benefit
60% or pre-disability earnings
Maximum Monthly Benefit
$5,000
Basic Life / AD&D
Administered By:
All Employees
$20,000
Plan Pays $1,000
Ortho Eligibility
To Age 19
Visit www.deltadentalin.com to find a participating
PPO Standard dental provider.
Voluntary Vision Benefit
Administered By:
2013-2014 Employee Per Pay Contributions
All Eligible Full-Time Employees
Employee Only
$4.33
Employee & Spouse
$7.30
Employee + Child(ren)
$7.45
Family
$12.01
Vision Exam (1 per 12 Months)
$10 Copay
Lenses (1 per 12 Months)
Frames (1 per 12 Months)
$130 Allowance
Contact Lenses (1 per 12 Months)
$25 Copay
$25 Copay
Elective $25 Copay
www.vsp.com (Choice Network)
See full plan details for cost allowance for in and
out of Network Coverage's.
The above is a brief outline to communicate the benefit programs offered. Please refer to the Plan Certificate to determine level of coverage.