2015 Charts & Rates Comparison Charts & Rates
Medical Options This is not the complete Medical Comparison Chart. Refer to the Medical Summary Plan Description or the Legal Notices on the enclosed CD for full information. 2015 Medical Option Employee Contributions (Monthly) Coverage Tier Blue Option White Option Out-of-Area Option Employee Only $47 $120 $97 Employee + Spouse $77 $218 $176 Employee + Child(ren) $64 $173 $140 Meritain Health, Mutual Health Services (OH only) and Piedmont Community Health Plan (VA only) Blue Option White Option Out-of-Area Option $91 $278 $224 Annual Deductible: Employee Only Annual Deductible: Employee + Spouse Employee + Child(ren) Annual Out-of-Pocket Maximum: 2 Employee Only Annual Out-of-Pocket Maximum: 2 Employee + Spouse Employee + Child(ren) In-Network Out-of-Network In-Network Out-of-Network Out-of-Network $2,000 $4,000 $1,750 $3,500 $1,500 $4,000 $8,000 $3,500 1 $7,000 1 $3,000 $4,000 $8,000 $6,350 $12,700 $3,200 $8,000 $16,000 $12,700 3 $25,400 3 $6,400 Note: As applicable, the $50 tobacco surcharge and the $50 condition management surcharge will be added to the monthly employee contributions listed above. Prescription Drug Coverage Prescription drug coverage is included as part of the Medical. Blue Option White Option Out-of-Area In-Network Out-of-Network In-Network Out-of-Network Out-of-Network Lifetime Maximum Unlimited Unlimited Unlimited Health Reimbursement Account (HRA) Health Savings Account (HSA) 4 Preventive Care Exams If you complete the wellness activities: Employee + Child(ren), If you complete the wellness activities: Employee + Child(ren), If you complete the wellness activities: Employee + Child(ren), Physician s Office Visits 5 20% after deductible 50% after deductible $30 50% after deductible 20% after deductible Prescription Drug Coverage - 30-day Supply RETAIL Generic 20% after deductible $10 copay $10 copay Preferred Brand 30% after deductible Non-Preferred Brand 45% after deductible 25% of cost with $30 min /$75 max 35% of cost with $45 min /$110 max Prescription Drug Coverage - 90-day Supply MAIL ORDER or RETAIL Maintenance at Walgreens Only 25% of cost with $30 min /$75 max 35% of cost with $45 min /$110 max Generic 20% after deductible $25 $25 Preferred Brand 30% after deductible $100 25% of cost with $75 min /$150 max Specialist s Office Visits 5 20% after deductible 50% after deductible $45 50% after deductible 20% after deductible Non-Preferred Brand 45% after deductible $150 35% of cost with $125 min /$225 max 1 One person can meet the individual annual deductible, or a combination of covered family members can meet the annual deductible for these coverage tiers. 2 The out-of-pocket maximum includes the medical deductible. Medical and prescription drug copays and coinsurance also accumulate toward the out-of-pocket maximum. 3 One person can meet the individual annual out-of-pocket maximum, or a combination of covered family members can meet the annual out-of-pocket maximum for these coverage tiers. 4 If you are not eligible for a Health Savings Account, your earned company contribution will be deposited into a Health Reimbursement Account. Specialty (30-day supply) 20% after deductible 20% of cost up to maximum $125 copay 5 Copay covers the general office visit. You will also pay co-insurance for additional medical services your doctor may prescribe during your visit. 1 2 20% of cost up to maximum $125 copay
Dental The Dental is designed to help you maintain dental health. You have two dental options - Dental Basic or Dental Plus. In most states the Dental is administered by MetLife. Features Dental Basic Dental Plus Annual Maximum $1,000/person $1,500/person Vision The Vision is administered by UnitedHealthcare Vision, which offers services through a network of providers at a lower cost. The benefit provides coverage once every 12 months for routine eye exams and glasses or contacts. When you visit an in-network provider, most services will be covered at 100 percent after you pay a copay. You may go to an out-of-network provider, but you will incur higher out-of-pocket costs and you may have to file your own claims. Orthodontia Lifetime Maximum for children under age 19 $1,500/person 2015 Vision Employee Contributions (Monthly) Deductible $50/person $150/family $25/person $75/family Covered Services Preventive and diagnostic care $0, no deductible $0, no deductible Basic and restorative care 20% after deductible 20% after deductible Major care 50% after deductible 40% after deductible Orthodontia for children under age 19 2015 Dental Employee Contributions (Monthly) 50%, no deductible Coverage Tier Dental Basic Dental Plus Employee Only $30 $37 Employee + Spouse $57 $74 Employee + Child(ren) $66 $88 $94 $121 Virginia Residents Only Your benefits are the same, but you must choose between the Cost-Efficient or Standard Network: The discounts are better in the Cost-Efficient network MetLife administers the Cost-Efficient network Anthem administers the Standard network Coverage Tier VA Only 2015 Dental Employee Contributions (Monthly) Dental Basic Dental Plus Cost-Efficient Network Standard Network Cost-Efficient Network Standard Network Employee Only $30 $31 $37 $38 Employee + Spouse $57 $59 $74 $76 Employee + Child(ren) $66 $68 $88 $90 $94 $97 $121 $125 Coverage Tier Vision Coverage Employee Only $6.30 Employee + Spouse $12.61 Employee + Child(ren) $13.20 $16.79 Features In-Network Pays: Out-of-Network Pays: Eye Exam 100% after $10 copay Up to $45 Glasses - Lenses Single Vision 100% after $25 copay Up to $30 Lined Bifocal 100% after $25 copay Up to $50 Lined Trifocal 100% after $25 copay Up to $65 Lenticular 100% after $25 copay Up to $100 Glasses - Frames Covered-in-Full 100% after $25 copay Up to $70 Wholesale Up to $50 Up to $70 Retail Allowance Up to $130 Up to $70 Contact Lenses Covered-in-Full Elective Contacts* 100% after $25 copay Up to $105 All Other Elective Contacts* Up to $125 Up to $105 Necessary Contacts 100% after $25 copay Up to $210 *If you select elective covered-in-full contact lenses from an in-network provider, the fitting/evaluation fees, contacts and two follow-up visits are covered (after $25 copay). For all other elective contacts, a $125 allowance is applied toward the fitting/evaluation fees and purchase of contact lenses ($25 materials copay does not apply). Toric, gas permeable and bifocal contacts are all examples of contacts that are not considered covered-in-full. 3 4
Income Protection B&W offers a variety of income protection benefits you can customize for your personal needs. No one enjoys thinking about it, but it s important to protect your loved ones in case of an accident, disability or your death. Provider/Administrator Contact Information Provider/Administrator Website Phone Number Description Coverage General Questions and Enrollment FlexChoice Service Center www.babcock.com/enrollment 1-877-222-4015 Outside the U.S.: 1-972-720-3985 Basic Life Coverage: $50,000 Provided by company to all eligible full-time and part-time employees Supplemental Life Coverage: Medical and Prescription Drug Information Care Coordinators www.mybwhealthtools.com 1-888-563-6766 Health Savings Account (HSA) Optum Health Bank www.optumhealthbank.com 1-866-234-8913 Life Insurance Long-Term Disability (LTD) Insurance Personal Accident Insurance Pays your beneficiary if you should die Monthly benefit if you are unable to work because of an accident or illness Pays a lump-sum benefit if an accidental injury results in a catastrophic loss or death Full-time employees can elect supplemental coverage in $50,000 increments, up to the lesser of 10 times per pay or $2,500,000 Part-time employees can elect coverage of $50,000, $100,000 or $150,000 Spouse Life Coverage: All employees can elect spouse coverage of $10,000, $25,000, $50,000, $75,000 or $100,000; up to 50% of the employee supplemental life coverage amount Child(ren) Life Coverage: All employees can elect $5,000, $10,000 or $15,000 life insurance coverage per child 40% Basic LTD: Provided by company to all eligible full-time employees at no cost to employee 60% Buy-Up Option: Paid by employee Minimum monthly benefit of $100; Maximum monthly benefit of $10,000 Pays up to 10 times of base pay: Employee: $50,000 to $1,000,000 Spouse: 70% of the employee coverage amount without insured child(ren); 65% with insured child(ren) Child(ren): 25% of the employee coverage amount without insured spouse; 20% with insured spouse Health Reimbursement Account PayFlex ID: 119176 www.healthhub.com 1-800-284-4885 Flexible Spending Accounts PayFlex ID: 119176 www.healthhub.com 1-800-284-4885 Dental Vision MetLife Anthem BlueCross BlueShield United Healthcare Vision Group # 718582 www.metlife.com/dental www.anthem.com 1-800-942-0854 1-866-470-7250 www.myuhcvision.com 1-800-839-3242 Life Insurance MetLife Group # 145035 www.metlife.com 1-800-638-6420 Long-Term Disability Cigna Group #FLK-980181 www.mycigna.com (once a claim is filed) 1-800-238-2125 Personal Accident Insurance Chubb Group www.chubb.com 1-877-222-4015 Hospital Income Continental American (Aflac) www.caicworksite.com 1-800-433-3036 Critical Illness Group Legal American Heritage Life Insurance Company Hyatt Legal Family: 634/0010 Single: 633/0010 www.allstateatwork.com Enroll: 1-866-828-1384 Claims: 1-800-348-4489 www.legalplans.com 1-800-821-6400 Hospital Income* Flat dollar amount per day to help you pay your share of hospital expenses, such as deductibles and coinsurance Options: $100 per day $200 per day Thrift Plan Vanguard www.vanguard.com 1-800-523-1188 Charles Schwab Schwab Participant Services http://eac.schwab.com 1-800-654-2593 Critical Illness* Supplements your other coverage by paying you a lump-sum benefit to be used at your discretion upon the diagnosis of a serious illness, such as stroke, heart attack, organ transplant or paralysis Options: $10,000 $15,000 $30,000 Retirement s (hourly and salaried employees except NFS) Retirement s (NFS employees only) B&W Retirement Service Center 1-877-580-3299 B&W Retirement Service Center 1-866-587-4118 Group Legal Easy and low-cost access to a wide variety of personal legal services Access to a national network of more than 11,000 attorneys for a variety of legal needs Pension Retirement Planning Resource On-Point www.babcock.hrodb.com 1-877-580-3299 *To enroll in these benefits, contact the providers at the numbers indicated under Contact Information on the next page. 5 6
Your Enrollment Resources FlexChoice Service Center: For questions related to the enrollment process and all benefit programs except the Medical, call 1-877-222-4015. Customer service representatives are available weekdays, 8 a.m. to 6 p.m. Eastern time, except holidays. Outside the U.S. call 1-972-720-3985. Care Coordinators: For questions related to the Medical, call a Care Coordinator at 1-888-563-6766. Care Coordinators are available weekdays, 8:30 a.m. to 10 p.m. Eastern time, except holidays. www.babcock.com/enrollment 2015