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FSA
ADMINISTERED BY ADMIN AMERICA
Annual Healthcare Contribution up to $2,650, with $500 rollover benefit; Annual Dependent Care Contribution $5,000
Vision
GUARDIAN
FREQUENCIES OF SERVICES:
Examination, Lenses or Contact Lenses – Once every 12 months
Frames – Once every 12 months
EXAM COPAY:
$10 Copay
LENSES COPAY:
$10 Copay
FRAMES:
$10 Copay, then $130.00 allowance, plus 20% discount on amount over $130.00
CONTACT LENSES:
$130 Allowance
OUT-OF-NETWORK BENEFITS:
Available – See benefit summary for further details on vision benefits
NETWORK:
VSP Choice Network
Life/AD&D
GUARDIAN
100% of annual earnings to $200,000
Guarantee Issue up to $200,000
Short Term Disability
GUARDIAN
WAITING PERIODS:
Benefits begin on the 5th Day Accident –5th Day Illness
WEEKLY VOLUME:
100% of weekly earnings
MAXIMUM PAYMENT PERIOD:
13 Weeks
Long Term Disability
GUARDIAN
WAITING PERIODS:
Benefits begin on the 91st Day Accident – 91st Day Illness
MONTHLY VOLUME:
60% of monthly earnings
MAXIMUM AMOUNT:
$10,000
MAXIMUM PAYMENT PERIOD:
To age 65, standard ADEA
EAP
GUARDIAN
3 FACE TO FACE VISITS
This overview is a brief summary of medical, dental, vision, life, short and long term disability. If there is any difference in the information in this overview
and the plan documents and contracts, the official documents will govern.
12/2017
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