The information in this Benefits Guide is presented for illustrative purposes only. The text contained in this Guide was taken
from various plan documents and/or benefit information. While every effort was taken to accurately report your benefits,
discrepancies or errors are always possible. In case of discrepancy between the Benefits Guide and the actual plan
documents the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability
and Accountability Act of 1996. If you have any questions about this guide, contact Human Resources. 08/03/2017 AD
Employee Benefits Guide
October 1, 2017 – September 30, 2018
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
TABLE OF CONTENTS
Open Enrollment 3
Making Changes To Your Benefits 3
Who Is Eligible? 3
Medical 4
Pre-tax Spending Accounts (FSA/DCA) 9
Dental 11
Vision 14
Life Insurance 15
Disability 18
Legal / ID Theft Services 19
Pet Insurance 21
Voluntary Products 22
Employee Assistance Program (EAP) 24
Individual Mandate 25
Marketplace Notice 26
Annual Notices 27Women’s Health & Cancer Rights Act of 1998
Newborns’ Act
Right to Receive a Notice of Privacy Practices
Addendum A – Medicaid and CHIP
Addendum B – Medicare Part D
Glossary 30
Contacts 31
Page 2
If you (and/or your dependent) have Medicare or
will become eligible for Medicare in the next 12
months, a Federal law gives you more choices
about your prescription drug coverage. Please
see Addendum B on page 29 for more details.
Ravago Americas, LLC is pleased to offer you the following
benefit options. This guide provides an overview of the
benefit plans and programs available to you as well as
informational tools to optimize your coverage. As you
consider your benefit options, take an active role in
understanding any changes to your needs and seize this
opportunity to make any necessary updates. If you have any
questions or require additional information please reference
the contacts page in this guide.
ENROLLMENT CHECKLIST
✓ Review your benefit options
✓ Verify your provider(s) are contracted in the network
✓ All employees are required to attend an enrollment
appointment with an Explain My Benefits counselor
by calling the appropriate number located on the
contacts page
✓ Complete Evidence of Insurability (EOI), if applicable
What’s New!• The Flexible Spending Account (FSA) vendor is
changing from ADP to MedCom
• The carrier for Accident, Critical Illness and Hospital
Indemnity is changing from Aflac to Voya
• New Benefit! – Pet insurance through ASPCA
• New Benefit! – Legal services through LegalShield
• New Benefit! – Identity theft services through
IDShield
Good News!We will continue to utilize United Healthcare for medical,
Cigna for dental and vision, Voya for life insurance and
disability.
Page 3
OPEN ENROLLMENT
Each year, during the open enrollment period, you will have the opportunity to enroll in or make changes to
your benefit elections and dependents without a qualifying event. Once you have made your elections you
will not be able to change them until the next open enrollment period, unless you experience a qualifying
event.
WHO IS ELIGIBLE?
Full-time employees (working 30+ hours per week)
New hires are eligible for benefits on the 1st of the month following 30 days of employment.
Family members eligible for dependent coverage include:
- Legal spouse
- Domestic partner (Same and Opposite sex) – Affidavit Required
- Natural, adopted, foster or step child(ren)
- Child(ren) for whom court appointed or legal guardianship has been awarded
Eligible dependent children may be covered until:
- Medical: end of the calendar year they turn age 26
- Dental: end of the calendar year they turn age 26
- Vision: end of the calendar year they turn age 26
- Voluntary life: they turn age 26 (coverage ends on birthday)
- Voluntary products: end of the month they turn age 26
A handicapped dependent child may continue coverage beyond the age limit if determined to meet plan requirements.
MAKING CHANGES TO YOUR BENEFITS DURING THE PLAN
YEAR (QUALIFYING EVENT)
Per IRS code Section 125, once your benefits are effective you may not make changes to
your benefits until the next open enrollment period unless you experience a qualifying
event. Qualifying events that permit mid-year changes include:
- Marriage - Divorce
- Death of spouse, child or other qualified dependent - Legal Separation
- Birth or adoption of child - Change of dependent status
- Loss of other group coverage
- Change in employment status (employee, spouse, domestic partner or dependent)
- Change in residence due to an employment transfer
If you do not make changes within 30 days of the ‘qualifying event,’ you must wait until the following
open enrollment period. It is your responsibility to notify Human Resources within 30 days of the
qualifying event.
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 4
MEDICAL INSURANCEUnited Healthcare – www.myuhc.com
Participating provider information can be found on the carrier’s website. For additional information concerning your
preventive care and what is covered please access www.uhcpreventivecare.com, enter your age and gender and
you will receive a full list of what is covered under preventive care.
IN-NETWORK BENEFITS Choice PlusPlan Coinsurance 90%
Calendar Year Deductible Embedded
Individual / Family $200 / $600
Out of Pocket Max
Individual / Family $2,000 / $4,000
Deductible Applies To Out of Pocket Yes
Medical / RX Copays & Coinsurance Applies to Out of Pocket Yes
Office Charges
Office / Specialist Visit $20 / $30
Virtual Visits $10
Referral Required No
Preventive $0
Facility Charges
Convenience Care (i.e. CVS Minute Clinic) $20
Urgent Care $35
Emergency Room (In or out of network) $200
Inpatient Hospital 10% after deductible
Outpatient Hospital 10% after deductible
Physician Fees 10% after deductible
Independent Facility Charges
Labs (LabCorp) / X-rays / Complex Diagnostic Imaging $0
Mental Health
Inpatient Facility 10% after deductible
Physician Visit $0
Prescription Drugs: Mandatory Generic
Deductible $0
Preventive $0
Tier 1 $6
Tier 2 $25
Tier 3 $40
Specialty (GH, Self Injectable, etc) Applicable Cost Share
Mail Order - 90 day supply 2 x retail copay
OUT-OF-NETWORK BENEFITS
Plan Coinsurance 70%
Calendar Year Deductible
Individual / Family $500 / $1,500
Out of Pocket Max
Individual / Family Unlimited
Office / Facility Charges 30% after deductible
Balance Billing Yes
BI-WEEKLY PAYROLL DEDUCTIONS
Annual Salary < $45,000$45,000 -
$75,000
$75,000 –
$125,000$125,000 +
Employee $27.69 $32.54 $40.66 $54.20
Employee + Spouse $60.51 $72.62 $90.77 $121.02
Employee + Child(ren) $50.24 $60.29 $75.34 $100.47
Employee + Family $73.37 $88.03 $110.05 $144.62
http://www.myuhc.com/http://www.uhcpreventivecare.com/
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
The United Healthcare NurseLine is a health services solution in which members are connected with a health
care expert, who helps guide them to resources and more effective use of care, including:
• Help answer clinical concerns, facilitate referrals to relevant health and wellness programs, and provide
condition management and treatment-decision counseling
• Identify premium providers and even schedule appointments
• Coaching on medication adherence and education on drug
interactions or medication alternatives
• Preventive care information, healthier lifestyle coaching and
referrals to wellness coaching and behavioral
When you enroll in the medical plan, you and your dependents will have
access to an experienced registered nurse, 24 hours a day, seven days a week. There is no additional cost
and it can give you the peace of mind you need.
Call the number on your medical card or login to www.myuhc.com to get in touch with a NurseLine.
Page 5
The more you know about health care costs and the options you have, the easier it may be for you to make
better decisions. When you register on www.myuhc.com, you will have access to tools and information to help
you manage and improve your health. You can download the UHC Health4Me mobile application and have
instant access to your health information – anytime / anywhere.
• Download ID Cards
• Find a provider
• Track your claims
• Compare and buy prescriptions
• Compare treatment costs
• Wellness information and much more
MYUHC.COM
NURSELINE
http://www.myuhc.com/http://www.myuhc.com/
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Use virtual visits when:• Your doctor is not available
• You become ill while traveling
• You are considering visiting a
hospital emergency room for a
non-emergency health condition
Not good for:• Anything requiring an exam or test
• Complex or chronic conditions
• Injuries requiring bandaging or
sprains/ broken bones
When you don’t feel well, or your child is sick, the last thing you want to do is leave the comfort of home to sit in a waiting
room. Now, you don’t have to. A virtual visit lets you see and talk to a certified medical professional from your mobile device
or computer without an appointment. Most visits take about 10-15 minutes and doctors can write a prescription, if needed,
that you can pick up at your local pharmacy. And, it’s part of your health benefits.
Conditions commonly treated through a virtual visit Doctors can diagnose and treat a wide range of non-emergency medical
conditions, including:
• Bladder infection/
Urinary tract infection
• Bronchitis
• Cold/flu
• Diarrhea
• Fever
• Migraine/headaches
• Pink eye
• Rash
• Sinus problems
• Sore throat
• Stomach ache
Access virtual visits
Log in to myuhc.com® and choose from provider sites where you can register
for a virtual visit. After registering and requesting a visit you will pay your portion
of the service costs according to your medical plan, and then you will enter a
virtual waiting room. During your visit you will be able to talk to a doctor about
your health concerns, symptoms and treatment options.
Get access to care online. Any where. Any time.
VIRTUAL VISITSUnited Healthcare – www.myuhc.com
Page 6
To learn more, login to myuhc.com or Health4Me
Accessing via www.myuhc.com
• Log in to www.myuhc.com
• You will see the Virtual Visit option on the home page
• Choose a Provider
Accessing via Health4Me
• Open Health4Me mobile application
• Click on Search
• Select Quick Care
• Click on Virtual Visits
http://www.myuhc.com/http://www.myuhc.com/http://www.myuhc.com/
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
WELLNESSUnited Healthcare – www.myuhc.com
Page 7
Real Appeal is included as part of your medical benefit plan and provided to you and your enrolled
dependents (18 and older) at no additional cost. It educates participants on eating healthy habits, staying
active – without turning their lives upside down.
Establish a plan for lasting weight loss. Nearly 7 out of 10 adults are considered overweight or obese.
UnitedHealthcare’s Real Appeal is working to reverse this trend, with tools and support to help participants lose
weight, feel good and prevent weight-related health conditions.
Real Appeal includes:
A personalized transformation coach for an entire year
Coaches guide participants through the program, step by step, customizing it to fit their needs, personal
preferences, goals and medical history
24/7 online support and mobile app.
Staying accountable to goals is easier than ever with:
• Customizable food, activity, weight and goal trackers
• Unlimited access to digital content, including streaming workout videos
• Success group support which lets participants chat with others who are doing the Real Appeal program
• The weekly Real Appeal All-Star Show featuring healthy tips from celebrities, athletes and health experts
• Weekly analysis, feedback and goal reporting
A success kit
All the gadgets participants need to help kick-start their weight loss and keep them going strong will be delivered
to their door after they attend their first group coaching session. It includes these helpful tools:
• Personal blender
• Digital food scale
• Measuring cups and spoons
• “Perfect” portion plate
• Resistance band
• Pedometer
• Real Appeal water bottle
• Electronic body weight scale
• Body tape measure
• Exercise DVD’s
• And more
http://www.myuhc.com/
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
GOOD HEALTH GATEWAY
Page 8
In just 4 Easy Steps, you can be on your way to better health and receive a monthly $45 Good HealthGateway Card which can be redeemed at over 60 premium retailers or used to make a charitabledonation.
Register on the Good Health Gateway Diabetes Care Rewards Program website.
Complete a brief phone interview with our Good Health Gateway Diabetes Nurse Educator to get your written Diabetes Health Action Plan® Care Guide to review and share with your doctor. Call (800) 643-8028 to schedule your interview.
Complete the basic requirements for managing your diabetes such as having important screenings and exams.
Have your health care provider complete the Good Health Gateway Provider
Confirmation Form and send to us, and you’ll receive your monthly reward every month you are up to date on the program requirements.
To learn more about the program and the basic requirements, call our HelpLine toll-free at (800) 643-8028, or register online at GoodHealthGateway.com.
Your participation is voluntary and confidential. The Good Health Gateway website is both private and secure. HIPAA privacy and security standards are used to ensure the security of your health care information.
(800) 643-8028GoodHealthGateway.com
Managing your diabetes has its own Rewards. Plus, we’ll give you a few more.
Improved health and well being
$45 monthly rewardsAvailable to members enrolled in a medical plan offered by RavagoAmericas LLC
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 9
PRE-TAX SPENDING ACCOUNTS (FSA/DCA)Medcom – www.mywealthcareonline.com/medcom
Ravago Americas, LLC offers employees the option of making deposits into separate spending accounts for eligible
healthcare (including Medical, Dental and Vision) expenses and dependent care (including child care) expenses.
Information regarding your FSA can be found on the carrier’s website or by calling (800) 523-7542.
Your deductions cannot be changed or discontinued during the plan year
unless you experience a qualifying event.
Healthcare Reimbursement FSA: You must enroll/re-enroll to participate
In addition to using this account to make co-pays, co-insurance payments or deductible payments this program lets
employees pay for certain IRS-approved medical care expenses. The annual maximum amount is $2,600.
Some examples of reimbursable expenses include:
✓ Hearing exams, hearing aids
✓ Vision expenses such as: laser eye surgery (Lasik), contact lenses, eye examinations, and eyeglasses
✓ Orthodontia
✓ Chiropractic services
✓ Acupuncture
✓ Physical therapy
✓ Diabetic Supplies
Under the Patient Protection and Affordable Care Act (PPACA): Over-the-counter drugs and medicines are NOT
eligible expenses unless you have a doctor’s prescription.
Dependent Care FSA: You must enroll/re-enroll to participate
The Dependent Care FSA enables employees to use pre-tax dollars
to pay for eligible dependent care expenses that are necessary for you
(and your spouse) to work, actively look for work, or attend school
full time. Dependent care FSA can be used for the caring of children
under the age of 13 or dependent elders who live with you. The
annual maximum contribution to the Dependent Care FSA is $5,000
($2,500 if married and filing separately).
Examples of eligible expenses include:
✓ The cost of child or adult dependent care
✓ The cost for an individual to provide care either in or out
of your house
✓ Nursery schools and preschools (excluding kindergarten)
You should only contribute the amount of money you expect to pay out
of pocket for eligible expenses for the plan year. If you do not use the
money within the plan year it will not be refunded to you or carried
forward to a future plan year.
Use it or lose it.
Without FSA With FSA
Gross income $30,000 $30,000
FSA contributions $0 -$5,000
Gross income $30,000 $25,000
Estimated taxes
Federal -$2,550* -$1,776*
State -$900* -$750*
FICA -$2,295 -$1,913
After-tax earnings $24,255 $20,561
Eligible out-of- pocket
medical and
dependent care
expenses
-$5,000 $0
Remaining spendable
income$19,255 $20,561
Spendable income
increase-- $1,306
Under the Health Care Reimbursement FSA employees may carry over up to $500 of unused funds
into the next plan year and must be used in that year.
*Estimated taxes are subject to change and do not
always apply.
www.FSAStore.com is the only one-stop-shop stocked exclusively with FSA-eligible
products and services so there are no guessing games as to what is and isn't
reimbursable which is what consumers face every time they walk into a drugstore.
http://www.mywealthcareonline.com/medcomhttp://www.fsastore.com/
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 10
www.NeedyMeds.org is a national non-profit
organization that maintains a website of free
information on programs that help people who need
assistance with the cost of medications and
healthcare costs.
Some resources available through NeedyMeds are:
• Patient Assistance Programs
• Free / Low Cost Clinics
• Diagnosis – Based Assistance
• State Programs
• Free Drug Discount Card
SAVINGS TIPS
Below are a few ideas on how to spend your dollars or save on prescriptions and medications.
Pharmacy discount programs. Before you pay for your
next prescription, check to see if they are available for
free or at a low cost. Pharmacies such as Walmart and
Costco offer prescription discount programs that allow
you to purchase medications for as low as $4 for a 30-
day supply. Publix pharmacies offer select free
antibiotics and diabetes medications.
Urgent Care vs Emergency Room (ER). The Emergency Room is meant for true emergencies such as life threatening
illnesses and injuries. The ER costs an average of three times more than a visit to the urgent care. In a non-life
threatening situation, you can most likely be treated at an urgent care. Urgent Care centers are available for non-life
threatening immediate care.Emergency Room Examples:
• Chest Pain
• Broken Bones
• Allergic Reactions
• Continuous Bleeding
• Head Injury
• Severe Shortness of Breath
• Deep Wounds
Urgent Care Examples:
• Coughs and Sore Throat
• Minor Injuries and Burns
• Ear / Sinus Infections
• Flu and Cold
• Sprains and Strains
• Fever
• Vaccinations
Convenience Care Clinic. Don’t pay more if you don’t
have to. Convenience care clinics are walk-in clinics
located in a supermarket, pharmacy or retail store, where
available, such as CVS Caremark, Walgreens and
Walmart. Services may be provided at a lower out-of-
pocket cost compared to urgent or emergency care as
they are subject to primary care office visit co-pays,
and/or coinsurance. Convenience care clinics are
available for non-life threatening immediate care.
Convenience Care Clinic Examples:
• Common Infections (e.g.: ear,
bladder, pink eye, strep throat)
• Flu Shots
• Minor Skin Conditions
• Pregnancy Tests
• Allergies
• Immunizations
• School Physicals
Good Rx. Stop paying too much for prescriptions. Start
saving now for free – no sign-up or credit card required.
Compare prices, print free coupons and save up to 80%
on your medications. Download the Mobile App or, visit
www.goodrx.com on any mobile phone.
www.Goodrx.com
Zenni Optical. Affordable, stylish frames starting at
$8.00. You can save on glasses with Zenni Optical.
Trendy, not spendy prescription glasses for men,
women and children as well as prescription sunglasses.
Find their selection and prices online at:
www.zennioptical.com.
http://www.needymeds.org/http://www.goodrx.com/http://www.zennioptical.com/
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 11
DENTAL INSURANCECigna – www.mycigna.com
Participating provider information can be found on the carrier’s website.
BENEFITS In-Network Out-Of-Network
Co-Insurance
Preventive 100% 100%
Basic 100% 80%
Major 60% 50%
Orthodontia 50% 50%
Benefits Based on Contracted Rates 80th percentileBalance Billing No Yes
Calendar Year Deductible (Individual / Family) $50 / $150
Deductible Waived for Preventive Service Yes
Calendar Year Maximum $1,500 (per person enrolled)
Lifetime Orthodontic Maximum $1,500
SCHEDULE OF BENEFITS
Routine Exams (2 per calendar year) Preventive
Cleaning (2 per calendar year) Preventive
X-Rays
Bitewing Preventive
Full Mouth Preventive
Sealants (under age16) Preventive
Fillings
Amalgam Basic
Composite Resin Basic
Oral Surgery* Basic
Repairs Basic
Root Canal Basic
Periodontal Maintenance* Basic
Periodontal Surgery* Basic
Endosteal Implants Major
Crowns Major
Fixed Bridges Major
Full And Partial Dentures Major
Orthodontia Children up to age 19
*Co-insurance based on complexity of procedure
POLICY PROVISIONS
Late Entrant Penalties NoneBI-WEEKLY PAYROLL DEDUCTIONS
Employee $1.56
Employee + Spouse $3.29
Employee + Child(ren) $4.41
Employee + Family $5.94
http://www.mycigna.com/
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 12
How to locate a provider.
If you currently have a Cigna plan and have registered,
log in to www.mycigna.com.
If you haven’t enrolled/registered yet, follow these easy steps to find a dentist near you.
• Go to www.cigna.com
• Click ‘Find a Doctor/Dentist’ at the top right of the screen
• Select the orange box that reads ‘If your insurance plan is offered through work’
• Choose which professional you are looking for: doctor, dentist or facility
• Enter the geographic location you want to search
• Select the appropriate plan:
Dental: Cigna Dental PPO
• Enter a name, specialty or other search word (Optional). Click SEARCH to see your results.
CIGNA.COM
http://www.mycigna.com/http://www.cigna.com/
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 13
MYCIGNA MOBILE APP
The myCigna Mobile App gives you a simple way to personalize, organize and access your important health
information – on the go.
little app. BIG Features.
Health care professional directory• Search for a doctor or health care facility from the Cigna national network and compare quality-
of-care ratings
• Access maps for instant driving directions
ID cards• Quickly view ID cards (front and back) for entire family
• Easily print, email or scan right from smartphone
Claims• View and search recent and past claims
• Bookmark and group claims for easy reference
Drug search• Look up and compare actual costs are over 60,000 pharmacies nationwide
• Find closest pharmacy location using GPS
• Research medications and dosages
• Speed-dial Cigna Home Delivery Pharmacy
Account balances• Access and view health fund balances
• Review plan deductibles and coinsurance
Health wallet• Store and organize all important contact info for doctors, hospitals and pharmacies
• Add health care professionals to contact list right from a claim or directory search
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 14
VISION INSURANCECigna – www.mycigna.com
Participating provider information can be found on the carrier’s website.
Members have access to a large
network of national independent
private practitioners and retail
providers, some of which include:
Independent practitioners and retail providers may not be available in all states or may change at anytime without notice.
IN-NETWORK BENEFITS
Vision Examination $20 copay
Single Lenses $0 copay
Bifocal Lenses $0 copay
Trifocal Lenses $0 copay
Progressive LensesProgressive lenses covered up to the bifocal lens
amount with 20% savings on the difference
Frame$150 retail allowance +
20% off over allowance
Contact Lens Exam & Fitting Deducted from contact allowance
Elective Contact Lenses – In lieu of frames $150 allowance
Laser Vision CorrectionHealthy Rewards program: 15% off standard pricing and
5% off promotional
Hearing AidsHealthy Rewards program includes hearing aids
discounts
OUT-OF-NETWORK BENEFITS Reimbursement up to:
Vision Examination $45
Single Lenses $32
Bifocal Lenses $55
Trifocal Lenses $65
Frame $83
Elective Contact Lenses – In lieu of frames $120
FREQUENCY – based on calendar year
Exams 12 months
Lenses/Contacts 12 months
Frames 24 months
BI-WEEKLY PAYROLL DEDUCTIONS
Employee $3.74
Employee + Spouse $7.49
Employee + Child(ren) $7.56
Employee + Family $11.91
http://www.mycigna.com/
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 15
LIFE INSURANCEVoya – www.voya.com
BASIC LIFE/AD&D INSURANCE (EMPLOYER PAID)
Ravago Americas, LLC provides Basic Life and Accidental Death & Dismemberment (AD&D) Insurance through
Voya to all full time employees at no cost. Employees receive 2 x annual salary, not to exceed $900,000. Please be
sure to review your beneficiary information and contact your Human Resources department should you have any
changes throughout the year. When you terminate employment or insurance eligibility, you may apply for an
individual policy by converting the current policy in force. This allows for the transfer of your current coverage to an
individual policy. You must notify Human Resources within 30 days of termination or insurance eligibility. Should
you apply, please note that your premium rate may be different than the current rate.
Benefit Reduction Schedule: 35% at age 70, 55% at age 75
VOLUNTARY LIFE INSURANCE
Employees who would like to supplement their basic life insurance benefits may purchase additional coverage. If
you purchase coverage for yourself, you may also purchase coverage for your spouse and/or your dependent
children. To be eligible for coverage you must be actively at work, you and your dependents must be able to
perform normal activities and not be confined (at home, in a hospital, or in any other care facility). When you enroll
yourself and/or your dependents in this benefit, you pay the full cost through payroll deductions. Be sure to review
your beneficiary information and contact your Human Resources department should you have any changes. When
you terminate employment or insurance eligibility, you may apply for an individual policy by either converting or
porting (included under age 70) the current policy in force. Both provisions allow for the transfer of your current
coverage. Conversion changes your coverage to an individual policy while porting allows continuation of your
current group policy, but on an individual basis. You must notify Human Resources within 30 days of termination or
insurance eligibility. Should you apply for either option, please note that your premium rate may be different than
the current rate.
The Voluntary Life Insurance coverage minimums, maximums and guarantee issue (G.I.) amounts are as follows:
Voluntary Life Insurance Benefit Description
Employee
• Maximum Benefit: Up to 5 x annual salary not to exceed $500,000
($10,000 increments)
• Minimum Benefit: $10,000
• Guarantee Issue: Up to 3 x annual salary not to exceed $360,000
Benefit Reduction Schedule: Reduces by 35% at age 70, to 55% at age 75
Spouse /
Domestic Partner
• Maximum Benefit: Up to 100% of employee’s benefit amount not to exceed $250,000
($5,000 increments)
• Minimum Benefit: $5,000
• Guarantee Issue: Up to 100% of employee’s benefit amount not to exceed $50,000
Benefit Reduction Schedule: Reduces by 35% at age 70, to 55% at age 75
Child(ren)
• Maximum & Minimum Benefit: $10,000
(Birth – 14 days: $1,000)
(14 days to age 26: Full Benefit)
http://www.voya.com/
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 16
LIFE INSURANCEVoya – www.voya.com
Below is the cost for the Voluntary Life Insurance coverage. The rates/premium are age banded based on the
employee’s and spouse’s own age as of the first day of the plan year.
If the benefit amount you would like to select is over $100,000, select the benefit amount from the first column
(Coverage Amount) that when multiplied by another number results in the benefit amount you want. For
example: If you would like to elect $150,000 in coverage, use the $50,000 row rate which applies to your age
band and multiply by 3.
Note: Your actual payroll deduction may vary slightly due to rounding.
EMPLOYEE BI-WEEKLY PAYROLL DEDUCTIONS (NON-SMOKER)
Coverage
Amounts< 29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69
$10,000 $0.44 $0.51 $0.61 $0.83 $1.27 $1.93 $3.26 $5.10 $9.33
$20,000 $0.88 $1.02 $1.22 $1.65 $2.54 $3.87 $6.52 $10.19 $18.66
$30,000 $1.32 $1.52 $1.83 $2.48 $3.81 $5.80 $9.78 $15.29 $27.98
$40,000 $1.75 $2.03 $2.44 $3.30 $5.08 $7.74 $13.03 $20.38 $37.31
$50,000 $2.19 $2.54 $3.05 $4.13 $6.35 $9.67 $16.29 $25.48 $46.64
$60,000 $2.63 $3.05 $3.66 $4.96 $7.62 $11.60 $19.55 $30.57 $55.97
$70,000 $3.07 $3.55 $4.26 $5.78 $8.88 $13.54 $22.81 $35.67 $65.29
$80,000 $3.51 $4.06 $4.87 $6.61 $10.15 $15.47 $26.07 $40.76 $74.62
$90,000 $3.95 $4.57 $5.48 $7.44 $11.42 $17.40 $29.33 $45.86 $83.95
$100,000 $4.38 $5.08 $6.09 $8.26 $12.69 $19.34 $32.58 $50.95 $93.28
EMPLOYEE BI-WEEKLY PAYROLL DEDUCTIONS (SMOKER)
Coverage
Amounts< 29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69
$10,000 $0.66 $0.80 $1.01 $1.43 $2.29 $3.57 $5.99 $8.83 $15.44
$20,000 $1.31 $1.60 $2.02 $2.86 $4.59 $7.14 $11.98 $17.66 $30.89
$30,000 $1.97 $2.40 $3.03 $4.29 $6.88 $10.72 $17.97 $26.49 $46.33
$40,000 $2.62 $3.19 $4.04 $5.72 $9.18 $14.29 $23.96 $35.32 $61.77
$50,000 $3.28 $3.99 $5.05 $7.15 $11.47 $17.86 $29.95 $44.15 $77.22
$60,000 $3.93 $4.79 $6.06 $8.58 $13.76 $21.43 $35.94 $52.98 $92.66
$70,000 $4.59 $5.59 $7.08 $10.02 $16.06 $25.01 $41.94 $61.80 $108.10
$80,000 $5.24 $6.39 $8.09 $11.45 $18.35 $28.58 $47.93 $70.63 $123.54
$90,000 $5.90 $7.19 $9.10 $12.88 $20.64 $32.15 $53.92 $79.46 $138.99
$100,000 $6.55 $7.98 $10.11 $14.31 $22.94 $35.72 $59.91 $88.29 $154.43
It is the EMPLOYEE’s responsibility to complete and submit an Evidence of Insurability (EOI) form.
An Evidence of Insurability (EOI) form is required for coverage elections above the Guarantee Issue (GI)
or if coverage was previously waived or not elected during the initial eligibility period.
Note: Benefit coverage & payroll deductions for newly elected amount will not take effect until EOI is approved by the carrier.
http://www.voya.com/
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 17
LIFE INSURANCEVoya – www.voya.com
Below is the cost for the Voluntary Life Insurance coverage. The rates/premium are age banded based on the
employee’s and spouse’s own age as of the first day of the plan year.
If the benefit amount you would like to select is over $100,000, select the benefit amount from the first column
(Coverage Amount) that when multiplied by another number results in the benefit amount you want. For
example: If you would like to elect $150,000 in coverage, use the $50,000 row rate which applies to your age
band and multiply by 3.
Note: Your actual payroll deduction may vary slightly due to rounding.CHILD(REN) BI-WEEKLY PAYROLL DEDUCTION*
$ 10,000 $0.92
*Regardless of how many children you have.
SPOUSE BI-WEEKLY PAYROLL DEDUCTIONS (NON-SMOKER)
Coverage
Amounts< 29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69
$1,000 $0.04 $0.05 $0.06 $0.08 $0.13 $0.19 $0.33 $0.51 $0.93
$2,000 $0.09 $0.10 $0.12 $0.17 $0.25 $0.39 $0.65 $1.02 $1.87
$3,000 $0.13 $0.15 $0.18 $0.25 $0.38 $0.58 $0.98 $1.53 $2.80
$4,000 $0.18 $0.20 $0.24 $0.33 $0.51 $0.77 $1.30 $2.04 $3.73
$5,000 $0.22 $0.25 $0.30 $0.41 $0.63 $0.97 $1.63 $2.55 $4.66
$6,000 $0.26 $0.30 $0.37 $0.50 $0.76 $1.16 $1.96 $3.06 $5.60
$7,000 $0.31 $0.36 $0.43 $0.58 $0.89 $1.35 $2.28 $3.57 $6.53
$8,000 $0.35 $0.41 $0.49 $0.66 $1.02 $1.55 $2.61 $4.08 $7.46
$9,000 $0.39 $0.46 $0.55 $0.74 $1.14 $1.74 $2.93 $4.59 $8.39
$10,000 $0.44 $0.51 $0.61 $0.83 $1.27 $1.93 $3.26 $5.10 $9.33
SPOUSE BI-WEEKLY PAYROLL DEDUCTIONS (SMOKER)
Coverage
Amounts< 29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69
$1,000 $0.07 $0.08 $0.10 $0.14 $0.23 $0.36 $0.60 $0.88 $1.54
$2,000 $0.13 $0.16 $0.20 $0.29 $0.46 $0.71 $1.20 $1.77 $3.09
$3,000 $0.20 $0.24 $0.30 $0.43 $0.69 $1.07 $1.80 $2.65 $4.63
$4,000 $0.26 $0.32 $0.40 $0.57 $0.92 $1.43 $2.40 $3.53 $6.18
$5,000 $0.33 $0.40 $0.51 $0.72 $1.15 $1.79 $3.00 $4.41 $7.72
$6,000 $0.39 $0.48 $0.61 $0.86 $1.38 $2.14 $3.59 $5.30 $9.27
$7,000 $0.46 $0.56 $0.71 $1.00 $1.61 $2.50 $4.19 $6.18 $10.81
$8,000 $0.52 $0.64 $0.81 $1.14 $1.84 $2.86 $4.79 $7.06 $12.35
$9,000 $0.59 $0.72 $0.91 $1.29 $2.06 $3.22 $5.39 $7.95 $13.90
$10,000 $0.66 $0.80 $1.01 $1.43 $2.29 $3.57 $5.99 $8.83 $15.44
It is the EMPLOYEE’s responsibility to complete and submit an Evidence of Insurability (EOI) form.
An Evidence of Insurability (EOI) form is required for coverage elections above the Guarantee Issue (GI)
or if coverage was previously waived or not elected during the initial eligibility period.
Note: Benefit coverage & payroll deductions for newly elected amount will not take effect until EOI is approved by the carrier.
http://www.voya.com/
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 18
STD SCHEDULE OF BENEFITS
Benefits Begin 8th day Accident / Sickness
Benefit Duration / Payable 25 weeks
Percentage of Income Replaced 60%
Maximum Weekly Benefit $2,000
Pre-Existing Condition Limitation None
SHORT TERM DISABILITY (EMPLOYER PAID)
Ravago Americas, LLC provides Short Term Disability (STD) insurance through Voya to all full time
employees at no cost. In the event you become disabled from a non work-related injury or sickness, disability
benefits are provided as a source of income. You must be actively at work on the day this coverage begins.
DISABILITY INSURANCEVoya – www.voya.com
LONG TERM DISABILITY (EMPLOYER PAID)
Ravago Americas, LLC provides Long Term Disability (LTD) insurance through Voya to all full time employees
at no cost. In the event you become disabled from an injury or sickness, disability benefits are provided as a
source of income. You must be actively at work on the day this coverage begins.
LTD SCHEDULE OF BENEFITS
Benefits Begin 181st day Accident / Sickness
Benefit Duration / Payable2 years (Own Occupation); Reducing Benefit Duration (RBD) to Social
Security Normal Retirement Age (SSNRA)
Percentage of Income Replaced 60%
Maximum Monthly Benefit $10,000
Pre-Existing Condition Limitation
Disabilities that occur during the first 12 months of coverage due to a
pre-existing condition that occurred during the 3 months prior to
coverage are excluded.
http://www.voya.com/
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 19
LEGAL SERVICESLegalShield
Through LegalShield employees can talk to a lawyer on any personal legal matter, no matter how trivial or
traumatic, all without worrying about high hourly costs. Services include:
FAMILY
• Administrative Hearing
• Adoption
• Child Custody
• Conservatorship
• Divorce
• Domestic Violence Protection
• Elder Care Assistance
• Guardianship
• Immigration Assistance
• Incompetency Defense
• Juvenile Court Defense
• Name Change
• Parental Responsibility
ESTATE PLANNING
• Codicils (Will Modification)
• Living W ills
• Power of At torney
• Probate
• Trusts
• W ills
• Prenuptial Agreements
• School Hearings
FINANCIAL
• Affidavits
• Bankruptcy
• Civil Litigation
• Consumer Pro tection
• Debt Collection
• Identity Theft
• Medical/Medicare Disputes
• Personal Property Disputes
• Promissory Notes
• Small Claims Assistance
• Social Security Disputes
• Tax Audit Pro tection
• Veterans Benefits Disputes
AUTO
• Driver’s License Restoration
• Motor Vehicle Property Damage
• Moving Traffic Violations
• Traffic Tickets
HOME
• Boundary/Title Disputes
• Contractor Disputes
• Deeds
• Foreclosure
• Home Equity Loans
• Landlord/Tenant Issues
• Mortgages
• Property Tax Assessments
• Purchase/Sale of Home(primary or secondary)
• Refinancing
• Zoning Applications
GENERAL
• 24/7 Emergency Access
• Document Review
• Mobile App
• Office Consultation
• Telephone Advice
BI-WEEKLY PAYROLL DEDUCTION
$8.54
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 20
IDENTITY THEFTIDShield
Have You Ever?
Worried about being a victim of identity
theft?
Worried about entering personal information
on-line
Been concerned about your child’s
identity?
Feared the security of your medical
information?
Lost your wallet? Been pursued by a collection agency
IDENTITY THEFT ISSUES ARE MORE COMMON THAN YOU THINK…
30 new identity theft victims per minuteIdentity thieves are hacking and stealing data at a
frightening rate—with 30 new victims of identity theft per
minute. Offer your employees coverage that will help
protect against and resolve identity theft issues.
Just 15% of identity theft activity is discoverableOnly 15% of the identity theft complaints received in 2014
would have created activity discoverable by credit
report monitoring, pointing to the importance of taking a
dual approach to help protect employees.
16 consecutive yearsIdentity theft was among the top consumer complaints
filed with the Federal Trade Commission for 16
consecutive years. Of the more than 2.5 million
consumer complaints logged, 13 percent were for
identity theft.
THE IDSHIELDSM
MEMBERSHIP INCLUDES:
Privacy MonitoringMonitoring your name, SSN, date of birth, email address
(up to 10), phone numbers (up to 10), driver license &
passport numbers, and medical ID numbers (up to 10)
provides you with comprehensive identity protection
service that leaves nothing to chance.
Security Monitoring / Social Media MonitoringSSN, credit cards (up to 10), and bank account (up to
10) monitoring, sex offender search, financial activity
alerts and quarterly credit score tracking keep you
secure from every angle. With the family plan, Minor
Identity Protection is included and provides monitoring
for up to 8 children under the age of 18.
ConsultationYour identity protection plan includes 24/7/365 live
support for covered emergencies, unlimited counseling,
identity alerts, data breach notifications and lost wallet
protection.
Full Service RestorationComplete identity recovery services by Kroll Licensed
Private Investigators and our $5 million service
guarantee ensure that if your identity is stolen, it will be
restored to its pre-theft status.IDShield Plans are available for Groups at individual or family plan rates. A family ratecovers the member, member’s spouse or domestic partner and up to 8 dependents up to theage of 26*.
*Dependents that are over 18, under 26, and either live at home or are a full timestudent, and have never been married will receive unlimited consultation and completerestoration by Kroll licensed private investigators. Monitoring is not available fordependents in this category.
BI-WEEKLY PAYROLL DEDUCTIONS
Employee $3.46
Employee + Family $6.58
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 21
PET INSURANCEASPCA
Pet’s medical emergencies never happen when you expect them. Pet insurance reimburses you for covered
vet bills, so you can give your pet the best care possible. All plans include the ability to visit any vet in the US
and Canada, emergency visits and specialist visits, prescription medication, diagnostic procedures and tests,
veterinary exam fees, surgeries and hospitalizations, MRI, CCT scans, X-rays and more!
HOW TO ELECT COVERAGE
www.aspcapetinsurance.com/ravago
CODE: EB17RAVAGO
1. Select your reimbursement percentage
2. Choose your deductible
3. Choose your annual limit
4. Select Accident – Only Coverage if desired
5. Add preventive care if desired
Annual Limit
Annual Deductible
(Plan Year)
Reimbursement
80% 90%
$100 $250 $500
$5,000
$10,000
$15,000
$20,000
Unlimited
WHY ASPCA?
✓ Discounts Are Available
✓ No Upper Age Limits
All cats and dogs 8 weeks and older are eligible.
✓ Fast Reimbursements
Get reimbursed by direct deposit or check.
✓ No Networks
Visit any vet, specialist, or emergency clinic.
✓ Online Claims Management
Simple online claim submission, claim tracking, and account management.
✓ Friendly, Experienced Staff
We're proud to be one of the largest and oldest providers around.
Your pets are important to us because we're pet parents, too.
70%
Monthly Price Range*
Accident Only: $12 – $25
Accident / Illness: $30 – $50
*Monthly costs are subject to change based on employee’s benefit selection
http://www.aspcapetinsurance.com/ravago
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 22
VOLUNTARY PRODUCTSVoya
ACCIDENT Accidents can happen to anyone, at any time. Accident Insurance will give you the freedom to spend the
benefit on what you need – medical costs after an accident, groceries, utilities, etc.
Key Features
- Benefits for common injuries like fractures and dislocations, burns, lacerations and concussions
- Benefits for emergency room visits, ambulance, hospital care, surgery and physical therapy
- Benefits paid regardless of any other insurance you may have
- Wellness Benefit
- Portable
HOSPITAL INDEMNITYEven with health insurance, hospital stays can be expensive. Hospital Confinement Indemnity Insurance
can help you pay for things like deductibles, transportation and rehabilitation costs that would usually come
out of your own pocket.
Key Features
- Benefits based on the number of days spent in a hospital, critical care unit or rehabilitation facility
- Benefits for outpatient and inpatient surgery, diagnostic tests and emergency room and rehabilitation
services
- Assistance with out-of-pocket expenses that may not be fully covered by health insurance
- Benefits paid regardless of any other insurance you may have
- Spend the benefits on what you need – coinsurance, lodging, child care
- Wellness Benefit
- Portable
BI-WEEKLY PAYROLL DEDUCTIONS
Employee $4.26
Employee + Spouse $6.96
Employee + Child(ren) $8.09
Employee + Family $10.79
BI-WEEKLY PAYROLL DEDUCTIONS
Employee $12.35
Employee + Spouse $27.92
Employee + Child(ren) $20.72
Employee + Family $36.29
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 23
VOLUNTARY PRODUCTSVoya
CRITICAL ILLNESS (Cancer Included)
Being diagnosed with a critical illness can be devastating both personally and financially. Breathe easier
knowing Critical Illness Insurance can help you pay your out-of-pocket expenses and allow you to focus on
your health. Rates based on employee and spouse’s own age.
Key Features
- Lump-sum benefit when you are diagnosed with a covered illness
- Benefits for heat attack, stroke, kidney failure, coronary artery bypass and several others
- Spend benefits on what you need – medical expenses, groceries, utilities
- Benefits paid regardless of any other insurance you may have
- Wellness Benefit
- Portable
EMPLOYEE BI-WEEKLY PAYROLL DEDUCTIONS
Coverage
Amounts< 29 30-39 40-49 50-59 60-64 65-69 70+
$10,000 $2.54 $2.86 $5.22 $11.17 $17.12 $21.28 $24.23
$20,000 $5.08 $5.72 $10.43 $22.34 $34.25 $42.55 $48.46
$30,000 $7.62 $8.58 $15.65 $33.51 $51.37 $63.83 $72.69
SPOUSE BI-WEEKLY PAYROLL DEDUCTIONS
Coverage
Amounts< 29 30-39 40-49 50-59 60-64 65-69 70+
$5,000 $1.18 $1.45 $2.70 $5.15 $7.71 $9.67 $16.80
$10,000 $2.35 $2.91 $5.40 $10.29 $15.42 $19.34 $33.60
$15,000 $3.53 $4.36 $8.10 $15.44 $23.12 $29.01 $50.40
CHILD(REN) BI-WEEKLY
PAYROLL DEDUCTIONS
Coverage
Amounts< 26
$2,500 $0.32
$5,000 $0.65
$10,000 $1.29
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 24
EMPLOYEE ASSISTANCE PROGRAM (EAP)
STAY AHEAD of Performance and Productivity Issues
The ComPsych EAP Difference
Also available through ComPsych:
Estate Guidance®
Helps you secure your future by overcoming the legal, financial and
emotional barriers to writing a will.
Family Source®
Provides help for a wide range of needs including child care, elder
care, education, adoption, pet care and personal convenience – all of
which, if left unaddressed, can distract you from your work
performance.
Financial Connect®
Professionals cover a broad range of personal financial issues
including debt management, family budgeting, tax questions,
retirement programs, real estate, investment options,
mortgages/loans/refinancing, money management, estate planning,
lease vs. buy, insurance, credit problems, bankruptcy.
IDResources®
Identity Theft restoration services to victims of ID theft.
Legal Connect ®
Provides immediate access to expertise and support services for
divorce, estate planning/wills, identity theft, lawsuits, bankruptcy,
personal injury, real estate, probate, adoption, landlord/tenant issues.
of Financial Concerns
of Work-Life Issues
of Legal Issues
> Free phone access 24 hours a
day to master’s and doctoral-
degreed clinicians
> Worldwide network of
psychologists, licensed clinical
social workers and other
master’s-degreed professionals
for in-person counseling
> Care management and follow up
on every case
> Award-winning Internet service
with full access to program
components
> Crisis intervention and support to
lessen the impact of traumatic
events
> Programs to address substance
abuse
(877) 533-2363
mailto:[email protected]
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Individual Mandate
OverviewBeginning in 2014, the Affordable Care Act included a mandate for most individuals to have health insurance or potentially pay a
penalty for noncompliance. Individuals are required to maintain minimum essential coverage for themselves and their dependents.
Some individuals are exempt from the mandate or the penalty, while others may be given financial assistance to help them pay for the
cost of health insurance.
What type of coverage satisfies the individual mandate?“Minimum essential coverage”
What is minimum essential coverage?Minimum essential coverage is defined as:
• Coverage under certain government-sponsored plans
• Employer-sponsored plans, with respect to any employee
• Plans in the individual market,
• Grandfathered health plans; and
• Any other health benefits coverage, such as a state health benefits risk pool, as recognized by the HHS Secretary.
Minimum essential coverage does not include health insurance coverage consisting of excepted benefits, such as dental-only
coverage.
How does “Minimum Essential Coverage” differ from “Essential Health Benefits”?Essential health benefits were required to be offered by certain plans starting in 2014 as a component of the essential health benefit
package. They are also the benefits that are subject to the annual and lifetime dollar limit requirements.
This is different than minimum essential coverage, which refers to the coverage needed to avoid the individual mandate
penalty. Coverage does not have to include essential benefits to be minimum essential coverage.
What is the penalty for noncompliance?The penalty is determined by calculating the greater amount of either a flat dollar amount or set percentage of income. Beginning in
2017, penalties may increase based on the cost of living.
Who is exempt from the mandate?Individuals who have a religious exemption, those not lawfully present in the United States, and incarcerated individuals are exempt
from the minimum essential coverage requirement.
Are there other exceptions to when the penalty may apply?Yes. A penalty will not be assessed on individuals who:
• cannot afford coverage based on formulas contained in the law,
• have income below the federal income tax filing threshold,
• are members of Indian tribes,
• were uninsured for short coverage gaps of less than three months;
• have received a hardship waiver from the Secretary, or are residing outside of the United States, or are bona fide residents of
any possession of the United States.
Tax
Year
Pay whichever is greater
Flat dollar amount
OR
Percentage of income
(over tax filing threshold)
Per AdultPer Child
(under age 18)
2015$325 $162.50
2.0%(maximum of $975 per family)
2016$695 $347.50
2.5%(maximum of $2,085 per family)
2017 Fees are the same as 2016
Page 25
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Health Insurance Marketplace Coverage Options
Page 26
Form ApprovedOMB No. 1210-0149
In 2014 a new option to buy health insurance began: the Health Insurance Marketplace. To assist you as you
evaluate options for you and your family, this notice provides some basic information about the Marketplace and
employment based health coverage offered by your employer.
What is the Health Insurance Marketplace?The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The
Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible
for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance
coverage through the Marketplace begins November 1, 2017 and ends on December 15, 2017. You can get coverage
through the Marketplace for 2017 if you qualify for a special enrollment period or are applying for Medicaid or the
Children’s Health Insurance Program (CHIP). Here are some important dates:
November 1, 2017: Open Enrollment starts
December 15, 2017: Last day to enroll or change 2018 health plan
January 1, 2018: 2018 Insurance coverage begins
Can I Save Money on my Health Insurance Premiums in the Marketplace?You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or
offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on
your household income.
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for
a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be
eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does
not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your
employer that would cover you (and not any other members of your family) is more than 9.69% of your household
income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the
Affordable Care Act, you may be eligible for a tax credit.1
Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your
employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer
contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for
Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax
basis.
How Can I Get More Information?For more information about your coverage offered by your employer, please check your summary plan description or
contact your Human Resources department.
The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the
Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health
insurance coverage and contact information for a Health Insurance Marketplace in your area.
1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan
is no less than 60 percent of such costs.
http://www.healthcare.gov/
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 27
Annual Notices
Women’s Health & Cancer Rights Act of 1998
Did you know that your medical plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for
mastectomy-related services, including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses,
and complications resulting from a mastectomy, including lymphedema? For more information regarding this benefit, contact customer
service at the number listed on the back of your medical ID card.
The Newborns’ and Mothers’ Health Protection Act (the Newborns’ Act)
Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in
connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours
following a cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after
consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case,
plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a
length of stay not in excess of 48 hours (or 96 hours).
Your Right to Receive a Notice of Privacy Practices
Ravago Americas, LLC is subject to the HIPAA privacy rules. In compliance with these rules, it maintains a Notice of Privacy
Practices. You have the right to request a copy of its Notice of Privacy Practices by contacting the medical insurance company. (See
telephone number on your medical ID card).
Addendum A – Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may
have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your
children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy
individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or
your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP
office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you
think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help
you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan,
your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment”
opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have
questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA
(3272).
If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list ofstates is current as of January 31, 2017. Contact your State for more information on eligibility.
ALABAMA – Medicaid FLORIDA – Medicaid
Website: http://myalhipp.com/
Phone: 1-855-692-5447
Website: http://flmedicaidtplrecovery.com/hipp/
Phone: 1-877-357-3268
ALASKA – Medicaid GEORGIA – Medicaid
The AK Health Insurance Premium Payment Program
Website: http://myakhipp.com/ Phone: 1-866-251-4861
Email: [email protected]
Medicaid Eligibility:
http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
Website: http://dch.georgia.gov/medicaid
- Click on Health Insurance Premium Payment (HIPP)
Phone: 404-656-4507
ARKANSAS – Medicaid INDIANA – Medicaid
Website: http://myarhipp.com/
Phone: 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479
All other Medicaid - Website: http://www.indianamedicaid.com
Phone 1-800-403-0864
COLORADO – Health First Colorado (Colorado’s Medicaid
Program) & Child Health Plan Plus (CHP+)IOWA – Medicaid
Health First Colorado Website:
https://www.healthfirstcolorado.com/
Health First Colorado Member Contact Center:
1-800-221-3943/ State Relay 711
CHP+: Colorado.gov/HCPF/Child-Health-Plan-Plus
CHP+ Customer Service: 1-800-359-1991/
State Relay 711
Website:
http://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp
Phone: 1-888-346-9562
http://www.healthcare.gov/http://www.insurekidsnow.gov/http://www.askebsa.dol.gov/http://myalhipp.com/http://flmedicaidtplrecovery.com/hipp/http://myakhipp.com/mailto:[email protected]://dhss.alaska.gov/dpa/Pages/medicaid/default.aspxhttp://dch.georgia.gov/medicaidhttp://myarhipp.com/http://www.in.gov/fssa/hip/http://www.indianamedicaid.com/https://www.healthfirstcolorado.com/http://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 28
Addendum A – Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) - CONTINUATION
To see if any other states have added a premium assistance program since January 31, 2017, or for more information on special enrollment rights,
contact either:
U.S. Department of Labor U.S. Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare & Medicaid Services
www.dol.gov/ebsa www.cms.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565
SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid
Website: http://dss.sd.gov
Phone: 1-888-828-0059
Website: http://www.hca.wa.gov/free-or-low-cost-health-
care/program-administration/premium-payment-program
Phone: 1-800-562-3022 ext. 15473
TEXAS – Medicaid WEST VIRGINIA – Medicaid
Website: http://gethipptexas.com/
Phone: 1-800-440-0493
Website:http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Page
s/default.aspx Phone: 1-877-598-5820, HMS Third Party Liability
UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP
Medicaid Website: https://medicaid.utah.gov/
CHIP Website: http://health.utah.gov/chip
Phone: 1-877-543-7669
Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf
Phone: 1-800-362-3002
VERMONT– Medicaid WYOMING – Medicaid
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
Website: https://wyequalitycare.acs-inc.com/
Phone: 307-777-7531
VIRGINIA – Medicaid and CHIP
Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924
CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282
KANSAS – Medicaid0 NEW HAMPSHIRE – Medicaid
Website: http://www.kdheks.gov/hcf/
Phone: 1-785-296-3512
Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP
Website: http://chfs.ky.gov/dms/default.htm
Phone: 1-800-635-2570
Medicaid Website:
http://www.state.nj.us/humanservices/
dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
LOUISIANA – Medicaid NEW YORK – Medicaid
Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331
Phone: 1-888-695-2447
Website: https://www.health.ny.gov/health_care/medicaid/
Phone: 1-800-541-2831
MAINE – Medicaid NORTH CAROLINA – Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html
Phone: 1-800-442-6003 TTY: Maine relay 711
Website: https://dma.ncdhhs.gov/
Phone: 919-855-4100
MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid
Website: http://www.mass.gov/eohhs/gov/departments/masshealth/
Phone: 1-800-462-1120
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 1-844-854-4825
MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP
Website: http://mn.gov/dhs/people-we-serve/seniors/health-
care/health-care-programs/programs-and-services/medical-
assistance.jsp Phone: 1-800-657-3739
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
MISSOURI – Medicaid OREGON – Medicaid
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
Phone: 573-751-2005
Website: http://healthcare.oregon.gov/Pages/index.aspx
http://www.oregonhealthcare.gov/index-es.html
Phone: 1-800-699-9075
MONTANA – Medicaid PENNSYLVANIA – Medicaid
Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP
Phone: 1-800-694-3084
Website:http://www.dhs.pa.gov/provider/medicalassistance/healthin
surancepremiumpaymenthippprogram/index.htm
Phone: 1-800-692-7462
NEBRASKA – Medicaid RHODE ISLAND – Medicaid
Website:
http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Page
s/accessnebraska_index.aspx
Phone: 1-855-632-7633
Website: http://www.eohhs.ri.gov/
Phone: 401-462-5300
NEVADA – Medicaid SOUTH CAROLINA – Medicaid
Medicaid Website: https://dwss.nv.gov/
Medicaid Phone: 1-800-992-0900
Website: https://www.scdhhs.gov
Phone: 1-888-549-0820
http://www.dol.gov/ebsahttp://www.cms.hhs.gov/http://dss.sd.gov/http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-programhttp://gethipptexas.com/http://www.dhhr.wv.gov/bms/Medicaid Expansion/Pages/default.aspxhttps://medicaid.utah.gov/http://health.utah.gov/chiphttps://www.dhs.wisconsin.gov/publications/p1/p10095.pdfhttp://www.greenmountaincare.org/https://wyequalitycare.acs-inc.com/http://www.coverva.org/programs_premium_assistance.cfmhttp://www.coverva.org/programs_premium_assistance.cfmhttp://www.kdheks.gov/hcf/http://www.dhhs.nh.gov/oii/documents/hippapp.pdfhttp://chfs.ky.gov/dms/default.htmhttp://www.state.nj.us/humanservices/dmahs/clients/medicaid/http://www.state.nj.us/humanservices/dmahs/clients/medicaid/http://www.njfamilycare.org/index.htmlhttp://dhh.louisiana.gov/index.cfm/subhome/1/n/331https://www.health.ny.gov/health_care/medicaid/http://www.maine.gov/dhhs/ofi/public-assistance/index.htmlhttps://dma.ncdhhs.gov/http://www.mass.gov/eohhs/gov/departments/masshealth/http://www.nd.gov/dhs/services/medicalserv/medicaid/http://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/medical-assistance.jsphttp://www.insureoklahoma.org/http://www.dss.mo.gov/mhd/participants/pages/hipp.htmhttp://healthcare.oregon.gov/Pages/index.aspxhttp://www.oregonhealthcare.gov/index-es.htmlhttp://dphhs.mt.gov/MontanaHealthcarePrograms/HIPPhttp://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htmhttp://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/accessnebraska_index.aspxhttp://www.eohhs.ri.gov/https://dwss.nv.gov/https://www.scdhhs.gov/
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 29
Addendum B - Medicare Part D Notice of Creditable Coverage
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to
show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).
Important Notice from Ravago Americas, LLC
About Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Ravago
Americas, LLC and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join
a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the
coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions
about your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare
Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans
provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
2. Ravago Americas, LLC has determined that the prescription drug coverage offered through United Healthcare is, on average for all plan
participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable
Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you
later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through December 7th. However, if you
lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment
Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?
If you decide to join a Medicare drug plan, your current coverage will not be affected. If you do decide to join a Medicare drug plan and drop your current
coverage, be aware that you and your dependents will be able to reenroll in our program during the next open enrollment period.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with Ravago Americas, LLC and don’t join a Medicare drug plan within 63 continuous
days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare
base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable
coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium
(a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.
For More Information About This Notice Or Your Current Prescription Drug Coverage…
Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a
Medicare drug plan, and if this coverage through Ravago Americas, LLC changes. You also may request a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug Coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the
handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.
For more information about Medicare prescription drug coverage:
• Visit www.medicare.gov
• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their
telephone number) for personalized help
• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help,
visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).
CMS Form 10182-CC Updated April 1, 2011
Date: 10/01/2017
Name of Entity/Sender: Ravago Americas, LLC
Contact--Position/Office: Donna Comey – Director of Human Resources
Address: 1900 Summit Tower Blvd, Suite 900
Orlando, FL 32810
Phone Number: (407) 475-9717
http://www.medicare.gov/http://www.socialsecurity.gov/
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 30
GLOSSARY OF TERMSBalance Billing – When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the
provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may
not balance bill you for covered services.
Coinsurance – The portion of the cost for care received for which an individual is financially responsible, which is usually calculated as a
percentage (such as 20%). Often coinsurance applies after a specific deductible has been met and may be subject to an individual
out-of-pocket. For example, if the plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance
payment of 20% would be $20. The plan pays the rest of the allowed amount.
Copayment – A payment you make at the time that selected services are rendered and no additional payment is required. Copayments
are typically flat amounts (for example, $15), covering such items as office visits, prescriptions, and emergency care.
Covered Expenses – Health Care expenses that are covered under your health plan.
Deductible – The amount of eligible expenses you must pay, out of pocket each plan year, before the plan begins to pay. The deductible
may not apply to all services.
Embedded Deductible: An embedded deductible is an individual deductible level within a family contract. For example, if there is a
family deductible of $3,000 with an individual embedded deductible of $1,500, when any one individual family member reaches
$1,500 in expenses, their benefit plan coverage takes effect.
Non-embedded Deductible: An non-embedded deductible requires that the entire family deductible be met before benefit plan
coverage takes effect by any one or combination of family members.
Evidence of Insurability – A medical questionnaire which is used to determine whether an applicant will be approved or declined
coverage.
Guarantee Issue - The amount which is available without providing an Evidence of Insurability (EOI). An EOI will be required for any
amounts above this, for late enrollees or increases in insurance.
In-Network – Care received from physicians, facilities or suppliers that are contracted with the insurer to provide services on a negotiated
discount basis.
Late Entrant – A member that becomes insured more than 30 days after initial eligibility or becomes insured again after previously
waiving coverage.
Mandatory Generic – When you request a brand name drug when there is a generic equivalent, you pay the generic copay plus the cost
difference between the brand and generic drug. Dispense as written (DAW) may be allowed. With DAW you will not be charged a
cost difference.
Out-of-Network – Care received from physicians, facilities or suppliers that are not contracted with the insurer to provide services on a
negotiated discount basis.
Out-of-Pocket Expense – Amount you must pay toward the cost of health care services. This may include deductibles, copayment and/or
coinsurance.
Out-of-Pocket Maximum – The maximum dollar amount a member is required to pay out of pocket during a benefit period. Plans may
vary but deductibles and coinsurance may apply toward meeting the out-of-pocket maximum.
Preferred Provider – A provider who has a contract with your carrier/vendor to provide services to you at a discount.
Pre-existing Condition – Any Injury or Sickness for which you received medical treatment, advice or consultation, care or services
including diagnostic measures, or had drugs or medicines prescribed or taken in the X months prior to the day you become insured.
For example: Disabilities that occur during the first 6 months of coverage due to a pre-existing condition that occurred during the 3
months prior to coverage are excluded.
Provider – A physician (medical, dental or vision), health care professional or health care facility licensed, certified or accredited as
required by state law.
Prior Authorization/Pre-Service Notification – The decision by the plan or health insurer that a health care service, treatment plan,
prescription drug, medical equipment, or other health care services defined in the certificate of coverage, is medically necessary. The
plan may require preauthorization for certain services before receiving them, except in an emergency.
UCR (Usual, Customary & Reasonable) – The amount paid for a service in a geographic area based on what providers in the area
usually charge for the same or similar service. The UCR amount is sometimes used to determine the allowed amount.
The information in this benefit guide is presented for illustrative purposes only. Please refer to the plan document for complete details.
Page 31
Benefit / Contact Carrier / Resource Phone Website / Email
Medical United Healthcare (866) 844-4864 www.myuhc.com
Dental Cigna (800) 244-6224
www.mycigna.com
Vision Cigna (800) 478-7557
Flexible Spending
Account (FSA)Medcom (800) 523-7542 www.mywealthcareonline.com/medcom
Life Insurance
Voya
(888) 238-4840
www.voya.com
Disability (800) 328-4090
Legal Services LegalShield (800) 654-7757 www.benefits.legalshield.com/ravago
Identity Theft Services IDShield (888) 494-8519 www.idshield.com
Pet Insurance ASPCA
(877) 343-5314
CODE:
EB17RAVAGO
www.aspcapetinsurance.com/ravago
Employee Assistance
Program (EAP)ComPsych (877) 533-2363 [email protected]
Voluntary Products Voya (877) 236-7564 https://claimscenter.voya.com
Danielle Donofrio Ravago Americas, LLC (407) 875-6697 [email protected]
Explain My Benefits
Open Enrollment (407) 329-3714
www.explainmybenefits.biz/ravagoOngoing Support after
August 31, 2017
(321) 296-8060
Option 1
Debbie Cox Brown & Brown of FL (321) 214-2399 [email protected]
CONTACTS
This guide is provided to you by:
http://www.myuhc.com/http://www.mycigna.com/http://www.mywealthcareonline.com/medcomhttp://www.voya.com/http://www.benefits.legalshield.com/ravagohttp://www.idshield.com/mailto:[email protected]://claimscenter.voya.com/mailto:[email protected]://www.mutualofomaha.com/mailto:[email protected]