Employee Benefit Statements: Health Care Protection

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This Employee Benefit Statement Prepared for: Henry H. Hemma

Medical Benefits:Co-Pay Plan - - A PPO/Indemnity Plan administered by Pacific Life and Annuity Company (formerly PM Group). PPO office visits (except surgery, lab charges, psychiatric and substance abuse) are paid at 100%, once a $15 co-payment is made. There is a $400 deductible for charges not covered by the $15 PPO office visit co-payment. These charges are paid at 80% if a PPO provider is utilized and 50% if a non-PPO provider is utilized. The Annual Out-Of-Pocket Maximum is $2,000 per person for PPO and $4,400 for non-PPO charges. Once the maximum is met, the Plan pays 100% of all charges for the remainder of the year. The lifetime maximum benefit is $2,000,000 for each covered individual. The Plan includes a prescription drug program administered by PCS Recap. Your cost varies based on the drug utilized, generic vs. brand name. Generic drugs cost $5 while brand name drugs cost $10 plus 20% of the total drug charge.

Under the Advance Plan, you have elected the following coverage for yourself and two or more dependents:

Dental Benefits:

PacifiCare - - an HMO There is no annual deductible.Each office visit has a small copayment. Most benefits are paid at 100% after the copayment.You must use a PacifiCare physician or hospital for non-emergency care.PacifiCare’s prescription drug program has a $5 copayment for generic drugs and a $10 copayment for brand name drugs. You must use a PacifiCare pharmacy. Non-formulary drugs must be pre-authorized.

Delta Dental - - A Managed Care Dental Plan administered by Pacific Life and Annuity Company (formerly PM Group). The annual deductible for basic and major services is $50 per person.The deductible is waived for preventive and diagnostic dentistry, and these services are paid at 100%.After you have met your deductible, basic services are paid at 80% and major services are paid at 50%.The calendar year maximum is $2,000 per person.Because the dentists contracted with Delta Dental have agreed to charge you lower set fees, dental services will cost you less. When you do not use a Delta Dental dentist, you may be subject to higher fees and a lower covered amount.

The variable data was in the orange blocks.
In retrospect, there is 'too much text'.Some of the detail should have been placed on a separate web page.

Introduction TotalCompensationPackage HealthCareProtection ReimbursementAccounts DisabilityInsurance SurvivorProtection Other Work& FamilyBenefits RISP, 401(k),& SocialSecurity Employees'RetirementPlan