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valuable options for you and your families. With that in mind, we are pleased to offer a Limited Medical Benefit Program through Standard Security Life Insurance Company of New York. Now is your time to enroll in this exciting program! Employees are eligible to enroll 30 days after date of hire and employees must complete enrollment within 60 days from hire date. We consider your hire date to be your first day of training. After the 60 days has passed, you will not be able to enroll until our next Open Enrollment period without a qualifying life event. Coverage begins on the first Friday in which you have a payroll deduction, after 30 days of employment.
Call 1-800-656-4577 to Enroll. Be sure to mention you are an Alpine Access employee!
The enclosed program brochure provides an overview of the available health plans. There are medical plans from which to choose as well as optional Dental, Life Insurance and Short Term Disability insurance so that you can select the program(s) that best suits your needs. Please call the Enrollment Center for more information at 1-800-656-4577. The Enrollment Center can answer your specific questions about the plan and coverage. ID Cards and plan information will be mailed to your home address. When calling to enroll, please identify the option you wish to elect and provide Social Security Numbers and birth dates for you and any dependents you wish to cover. Please see the information below before you call to make your elections.
Enrollment Instructions
Enrollment must be done through the Enrollment Center; you cannot enroll online. When you call the Enrollment Center, please be prepared to answer the following questions. A representative will take your information and answer any questions you may have regarding your benefits. The Enrollment Center is available from 7:00 AM to 7:00 PM Central Time, Monday through Friday. When you call the Enrollment Center, be ready to provide them the name of your employer (Alpine Access), along with your name, social security number, date of birth and full address. If you are enrolling dependents, please be prepared to provide your dependents full name, date of birth, social security number, and relationship (spouse or child). What level of coverage? __ Employee Only __ Employee Plus Child(ren) __ Employee Plus Spouse __ Family Would you like to elect a medical plan? Optional Coverage? __ Select Plan __ Dental Coverage __ Select Buy-Up Plan __ Vision Coverage __ Short Term Disability __ Life Insurance
When you are ready to enroll, or if you have questions about your coverage choices, call the Enrollment Center at 1-800-656-4577. If you decide to enroll, please save this brochure for future reference along with the plan information you will be receiving.
Si usted necesita la informacin o ayuda en espaol, llame por favor el centro de la inscripcin al 1-800-656-4577.
1120 Lincoln Street, Suite 1400, Denver, CO 80203 l phone 303.279.0585 l fax 303.279.0584 l www.alpineaccess.com
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PLAN YEAR
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Feeling Secure Disability Insurance Life and Accidental Death & Dismemberment
Contact Information
Refer to this list when you need to contact one of your benefit vendors. For general information contact Human Resources at benefits@alpineaccess.com. MEDICAL/RX: Page 4 First Health/Select Plan - Doctors only/Select Plus Plan - Doctors and Hospitals/Standard Security Life Insurance Company -Member Services 800-822-3906 WWW.YOURMEDBENEFITS.COM DENTAL: Standard Security Life Insurance Company - Member Services 800-822-3906 VISION: Standard Security Life Insurance Company - Member Services 800-822-3906 SHORT-TERM DISABILITY: Standard Security Life Insurance Company Member Services 800-822-3906 LIFE & ACCIDENTAL DEATH & DISMEMBERMENT: Standard Security Life Insurance Company - Member Services 800-822-3906 BENEFIT PREMIUMS: Page 6
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P age 7
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Substance Abuse
Accident Coverage Accidental Death & Dismemberment Critical Illness Benefit **Prescription Drug (Discount Plan)
* Employee is responsible for the remainder of the cost ** These benefits are not underwritten by Standard Security Life Insurance Company of New York
Substance Abuse
Accident Coverage Accidental Death & Dismemberment **Prescription Drug (Discount Plan)
* Employee is responsible for the remainder of the cost ** These benefits are not underwritten by Standard Security Life Insurance Company of New York
Dental Insurance
Dental Care Benefit
$50 deductible, $500 calendar year maximum This table provides a brief overview of the Dental Benefit. Exclusions and limitations apply.
Type of Service Percent paid by plan 80% 80% 50% Waiting period Deductible Applies No Yes Yes
Type IV (Ortho)
50%
12 months
Yes
Vision
Vision Care Benefit
Covered Vision Care expenses are paid at 80%. $300 maximum benefit per person per calendar year. One exam every 12 months. One pair of glasses/contacts every 24 months.
Disability Insurance
In the event you become disabled from a non work related injury or sickness, disability income benefits are provided as a source if income. You are not eligible to receive short term disability benefits if you are receiving workers compensation benefits.
Short-term Disability Benefits Begin Benefits Payable Percentage of Income Replaced Maximum Benefit After 15th day of sickness or injury $150 per week 66% of salary Pays up to 26 weeks
Benefit Premiums
Limited Medical Rates
Select Plan Rates Bi-Weekly Employee Only Employee + Spouse Employee + Child(ren) Family $52.60 $128.55 $80.35 $136.75 Select Buy Up Plan Rates Bi-Weekly $69.25 $172.26 $106.22 $188.95
Employee + Spouse
$20.21
$7.33
Employee + Child(ren)
$13.06
$4.46
Family
$22.44
$7.67
Employees are eligible for insurance benefits after completing 30 days of employment.
The information in this Benefits Summary is presented for illustrative purposes and is based on information provided by the employer. The text contained in this Summary was taken from various summary plan descriptions and 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 Summary 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 summary, contact Human Resources.