Post on 27-Jan-2021
Yearbook
Since 1989 The Printing Industry Benefits Trust has been offering and supporting employee benefits insurance for companies
from 2 to 500 employees in the printing, graphic arts and web media
industries. Our mission is to present solutions that help control costs
while delivering meaningful healthcare benefits and to be a trusted
source of support and assistance.
• Industry leading service center - one call for service and support
• No cost COBRA Administration
• No cost Section 125 Premium Only Plan Document
• Access to full Flexible Spending Account (Section 125 Cafeteria
Plan)
20 -202 PIAG Yearbook
Benefits at a Glance
Kaiser
Plan Name KP HMO 20/30 (115) KP HMO 40/50 (116)
Network Full Full
Calendar Year Deductible
(Individual/Family)
Not Applicable Not Applicable
Out-of-pocket maximum
(Individual/Family)
$6,350 / $12,700 $6,350 / $12,700
Office Visit (PCP) $20 Copay $40 Copay
Specialist Visit $30 Copay $50 Copay
Outpatient Surgery/Treatment $200 Copay $200 Copay
Hospital Admission $750 Copay per admission $1,000 per admission
X-ray No Charge [41] No Charge [41]
Laboratory No Charge [41] No Charge [41]
Urgent Care $40 per visit $60 Copay per visit
Emergency Room $200 per visit $200 Copay per visit
Preventive Care No Charge No Charge
Mental Health Office Visit $20 Copay $40 Copay
Prescription Drugs Generic / Brand / Specialty Generic / Brand / Specialty
Separate calendar year
deductible
Not Applicable $100 Individual / $300 Family (Brand only)
Rx out-of-pocket maximum
(Individual/Family)
Not Applicable Not Applicable
Retail prescriptions
(30 day supply)
$25 / $40 / Not Covered $25 / $40 / Not Covered
Mail order
(up to 90-day supply)
$50 / $80 / Not Covered $50 / $80 / Not Covered
Dental Coverage
Pediatric dental coverage Not Covered Not Covered
Vision
Routine exam $30 Copay (at Kaiser facility) $50 Copay (at Kaiser facility)
Frames and lenses $150 allowance every 12 months (with
EyeMed Network)
$150 allowance every 12 months (with
EyeMed Network)
Plan ID 6423 6951
IMPORTANT NOTICE: This benefit comparison is provided to help you quickly compare plans and is not intended to be
a comprehensive description of plans and benefits. Refer to the Summary of Benefits, Summary of Benefits and
Coverage (SBC) and Evidence of Coverage for a detailed description of coverage and benefits limitations. In the event
of a discrepancy on this comparison, Evidence of Coverage and Plan contract shall prevail. (Please visit www.pibt.org -
Forms and Documents.)
• Prescription drug benefits listed are for participating pharmacies only.[41] $200 in outpatient settings.
20 -202 PIAG Yearbook
Benefits at a Glance
Kaiser
Plan Name KP HMO 50/55 (117)
Network Full
Calendar Year Deductible
(Individual/Family)
Not Applicable
Out-of-pocket maximum
(Individual/Family)
$6,350 / $12,700
Office Visit (PCP) $50 Copay
Specialist Visit $55 Copay
Outpatient Surgery/Treatment $250 Copay
Hospital Admission $1,500 per admission
X-ray No Charge [42]
Laboratory No Charge [42]
Urgent Care $70 Copay per visit
Emergency Room $250 Copay per visit
Preventive Care No Charge
Mental Health Office Visit $50 Copay
Prescription Drugs Generic / Brand / Specialty
Separate calendar year
deductible
$100 Individual / $300 Family (Brand only)
Rx out-of-pocket maximum
(Individual/Family)
Not Applicable
Retail prescriptions
(30 day supply)
$35 / $45 / Not Covered
Mail order
(up to 90-day supply)
$70 / $90 / Not Covered
Dental Coverage
Pediatric dental coverage Not Covered
Vision
Routine exam $55 Copay (at Kaiser facility)
Frames and lenses $150 allowance every 12 months (with
EyeMed Network)
Plan ID 6952
IMPORTANT NOTICE: This benefit comparison is provided to help you quickly compare plans and is not intended to be
a comprehensive description of plans and benefits. Refer to the Summary of Benefits, Summary of Benefits and
Coverage (SBC) and Evidence of Coverage for a detailed description of coverage and benefits limitations. In the event
of a discrepancy on this comparison, Evidence of Coverage and Plan contract shall prevail. (Please visit www.pibt.org -
Forms and Documents.)
• Prescription drug benefits listed are for participating pharmacies only.[42] $250 in outpatient settings.
20 -202 PIAG Yearbook
Benefits at a Glance
Kaiser
Plan Name KP Ded HMO 1000/30 (121) KP Hi Ded HMO 2000 (S77)
Network Full Full
Calendar Year Deductible
(Individual/Family)
$1,000 [2] / $2,000 [2] $2,000 [2] / $4,000 [2]
Out-of-pocket maximum
(Individual/Family)
$2,000 / $4,000 $2,000 / $4,000
Office Visit (PCP) $30 Copay (No Deductible) No Charge after Deductible
Specialist Visit $40 Copay (No Deductible) No Charge after Deductible
Outpatient Surgery/Treatment No Charge after Deductible No Charge after Deductible
Hospital Admission No Charge after Deductible No Charge after Deductible
X-ray No Charge (No Deductible) No Charge after Deductible
Laboratory No Charge (No Deductible) No Charge after Deductible
Urgent Care $50 Copay No Charge after Deductible
Emergency Room $200 Copay per visit (No Deductible) No Charge after Deductible
Preventive Care No Charge (No Deductible) No Charge (No Deductible)
Mental Health Office Visit $30 Copay (No Deductible) No Charge after Deductible
Prescription Drugs Generic / Brand / Specialty Generic / Brand / Specialty
Separate calendar year
deductible
$250 Individual / $750 Family (Brand only) Subject to Plan Deductible
Rx out-of-pocket maximum
(Individual/Family)
Not Applicable Not Applicable
Retail prescriptions
(30 day supply)
$20 / $40 / Not Covered No Charge after Deductible
Mail order
(up to 90-day supply)
$40 / $80 / Not Covered No Charge after Deductible
Dental Coverage
Pediatric dental coverage Not Covered Not Covered
Vision
Routine exam $40 Copay (at Kaiser facility) No Charge after Deductible (at Kaiser facility)
Frames and lenses $150 allowance every 12 months (with
EyeMed Network)
$150 allowance every 12 months (with
EyeMed Network)
Plan ID 7886 7885
IMPORTANT NOTICE: This benefit comparison is provided to help you quickly compare plans and is not intended to be
a comprehensive description of plans and benefits. Refer to the Summary of Benefits, Summary of Benefits and
Coverage (SBC) and Evidence of Coverage for a detailed description of coverage and benefits limitations. In the event
of a discrepancy on this comparison, Evidence of Coverage and Plan contract shall prevail. (Please visit www.pibt.org -
Forms and Documents.)
• Prescription drug benefits listed are for participating pharmacies only.[2] A calendar year deductible is the amount you pay each calendar year before the carrier pays for covered services under the benefit
plan.
20 -202 PIAG Yearbook
20 -202 PIAG Yearbook
-FAQThis Q&A answers the most frequently asked questions about the new PIBT Freedom Plans . If you
are interested in these plans and would like more information, please watch the videos we have
prepared for you, or plan to attend one of the Freedom Plans webinars.
1. PIBT Freedom Plans the right choice for me?
These plans are a good choice for you if:
• You want to lower your costs
• You prefer to choose your provider
• You like the idea of having an advocate to help
you navigate the healthcare system
• You are willing to be engaged with your health
plan occasionally
2. How do the Freedom Plans control rising
health insurance costs?
GPA and ELAP-the companies that administer the
PIBT Freedom Plans-audit all hospital and outpatient
claims for excessive and incorrect charges to ensure
that you're paying a fair price for the services
received and that the provider is getting a fair
reimbursement.
The result is lower cost, lower payroll deductions and
lower out-of-pocket costs for members.
3. What doctors and other healthcare providers
can I use?
Virtually all practitioners accept this plan. Although
these plans use a national network that includes
physicians, labs, urgent care and similar types of
providers, you are not restricted to this network and
your benefits are the same whether you seek care
from an in-network or out-of-network practitioner.
If you are looking for a new doctor, we
recommend that you check the PHCS Practitioner
and Ancillary network and select a suitable doctor
from the list. You may also ask GPA's Nurse
Navigator to find the top practitioners in your area for
the medical issue you have.
If you know which doctor you want to see and
they are not in the network, bring along your new
ID card and your GPA Practitioner Guidance Flyer. If
they still have questions, ask them to call GPA. We
will explain how our plan works and get you seen. It
is very rare that we are unsuccessful.
For facilities-like hospitals, outpatient facilities, and
surgical centers-there is no network. You may go to
virtually any facility you choose. If they need to
contact GPA to confirm your coverage, the
information for them to contact us is on your ID card.
If you like, you may contact GPA prior to any
appointments, and we will contact the doctor or
facility to make sure there are no problems when you
arrive for your appointment.
Note that certain healthcare providers and facilities,
Kaiser for example, only treat patients who are part
of their health system. Kaiser will typically not accept
these plans except for emergency medical
conditions.
4. What if a healthcare provider says they don't
recognize my insurance plan?
Give them the GPA Practitioner Guidance Flyer
which should answer their questions. If they still
have questions, ask them to call GPA at the number
on your ID card. We are almost always able to work
out a solution for you and get you seen and treated.
Although very rare, if a solution can’t be found with
your provider, a Nurse Navigator will locate other
top-tier provider options for you to select from for
your medical services.
20 -202 PIAG Yearbook
5. What if a healthcare provider asks me to pay
upfront?
Call GPA immediately, even if you are in the
provider’s office. You should not pay any amounts
higher than your plan copay, coinsurance or
deductible, depending on the type of treatment you
are receiving. We will explain to the provider how
our plan works and get you seen without an upfront
payment higher than these amounts. Again, it is very
rare that we are unsuccessful.
6. Who can I turn to with questions or for help?
The staff at PIBT can answer many of your questions
related to eligibility, benefits and various
administrative issues. GPA also has Member
Services Professionals who are available to answer
more detailed questions.
One of the most valued resources provided under
these Freedom Plans is GPA’s Nurse Navigator.
These advocates are available to help you:
• Navigate the complex healthcare system
• Find the best healthcare providers in your area
• Better understand a diagnosis and learn about
treatment options
• Ensure your physician’s office understands the
plan and you get seen
• And much more
7. What happens if a healthcare provider doesn't
accept the payment amount and bills me for the
balance?
Balance billings do not happen very often but, if you
receive a balance bill, send it to GPA or ELAP as
soon as possible. You will be contacted within 24
hours by an ELAP Member Advocate who will work
closely with you until the balance billing is resolved.
GPA and ELAP's commitment to you is that, if you
follow our process, you will only be responsible for
copays, deductibles and co-insurance based on your
chosen health insurance plan.
If the bill is sent to collections, your assigned legal
representative will contact the collection agency to
remove you from the process, and then work with
the collection agency to resolve the billing so that
your credit is not impaired.
8. Are these plans HMOs, PPOs or POS plans?
These plans are PPO level benefits, but you can
seek care at virtually any provider -There is no
out-of-network! The PHCS Practitioner and Ancillary
network gives you an excellent starting point. You
can check to see if your current doctor is there, or
you can find a new doctor, but ultimately you are free
to seek care at any provider that you choose.
20 -202 PIAG Yearbook
Benefits at a Glance
PIBT Freedom
Plan Name PIBT 25/500 PIBT 35/1000
Network Not Applicable [37] Not Applicable [37]
Calendar Year Deductible
(Individual/Family)
$500 / $1,000 [2] $1,000 / $2,000 [2]
Out-of-pocket maximum
(Individual/Family)
$3,000 / $6,000 $4,500 / $9,000
Office Visit (PCP) $25 (No Deductible) $35 (No Deductible)
Specialist Visit $25 (No Deductible) $35 (No Deductible)
Outpatient Surgery/Treatment 10% per visit 20% per visit
Hospital Admission $100 copay + 10% per admission $100 copay + 20% per admission
X-ray $25 per visit [40] $35 per visit [40]
Laboratory $25 per visit [40] $35 per visit [40]
Urgent Care $25 (No Deductible) $35 (No Deductible)
Emergency Room $100 copay + 10% per visit $150 copay + 20% per visit (No Deductible) [8]
Preventive Care No Charge (No Deductible) No Charge (No Deductible)
Mental Health Office Visit $25 (No Deductible) $35 (No Deductible)
Prescription Drugs Generic/Brand/Non-Pref. Brand/Specialty Generic/Brand/Non-Pref. Brand/Specialty
Separate calendar year
deductible
$250 per member (Except Generic) [5] $250 per member (Except Generic) [5]
Rx out-of-pocket maximum
(Individual/Family)
Not Applicable Not Applicable
Retail prescriptions
(30-90 day supply)
$15 / $30 / $50 / 30% (up to $200 max) [6] $15 / $30 / $45 / 30% (up to $200 max) [6]
Mail order
(30-90-day supply)
$30 / $60 / $100 / 30% (up to $400 max)
[6]
$30 / $60 / $90 / 30% (up to $400 max) [6]
Dental Coverage
Pediatric dental coverage Not Covered Not Covered
Vision
Routine exam Not Covered Not Covered
Frames and lenses Not Covered Not Covered
Plan ID 11184 11183
IMPORTANT NOTICE: This benefit comparison is provided to help you quickly compare plans and is not intended to be
a comprehensive description of plans and benefits. Refer to the Summary of Benefits, Summary of Benefits and
Coverage (SBC) and Evidence of Coverage for a detailed description of coverage and benefits limitations. In the event
of a discrepancy on this comparison, Evidence of Coverage and Plan contract shall prevail. (Please visit www.pibt.org -
Forms and Documents.)
• Prescription drug benefits listed are for participating pharmacies only.[2] A calendar year deductible is the amount you pay each calendar year before the carrier pays for covered services under the benefit
plan. [5] Accrues toward the calendar year out-of-pocket maximum. [6] Some drugs require prior authorization for medical necessity, or
when effective, lower cost alternatives are available. [8] Deductible will apply to physician services only. [37] Some services require
pre-authorization. If these services are rendered by providers as a facility, please refer to the appropriate category under level I of the
Benefit Summary for the benefit. [40] For outpatient department of a Hospital, copay may differ.
20 -202 PIAG Yearbook
Benefits at a Glance
PIBT Freedom
Plan Name PIBT 40/2500 PIBT 45/4000
Network Not Applicable [37] Not Applicable [37]
Calendar Year Deductible
(Individual/Family)
$2,500 / $5,000 [2] $4,000 / $8,000 [2]
Out-of-pocket maximum
(Individual/Family)
$6,000 / $12,000 $7,000 / $14,000
Office Visit (PCP) $40 (No Deductible) $45 (No Deductible)
Specialist Visit $40 (No Deductible) $45 (No Deductible)
Outpatient Surgery/Treatment 20% per visit 30% per visit
Hospital Admission $100 copay + 20% per admission $100 copay + 30% per admission
X-ray $40 per visit [40] $45 per visit [40]
Laboratory $40 per visit [40] $45 per visit [40]
Urgent Care $40 (No Deductible) $45 (No Deductible)
Emergency Room $100 copay + 20% per visit $100 copay + 30% per visit
Preventive Care No Charge (No Deductible) No Charge (No Deductible)
Mental Health Office Visit $40 (No Deductible) $45 (No Deductible)
Prescription Drugs Generic/Brand/Non-Pref. Brand/Specialty Generic/Brand/Non-Pref. Brand/Specialty
Separate calendar year
deductible
$250 per member (Except Generic) [5] $250 per member (Except Generic) [5]
Rx out-of-pocket maximum
(Individual/Family)
Not Applicable Not Applicable
Retail prescriptions
(30-90 day supply)
$15 / $30 / $45 / 30% (up to $200 max) [6] $15 / $30 / 50% $100 max / 30% (up to
$200 max)
Mail order
(30-90-day supply)
$30 / $60 / $90 / 30% (up to $400 max) [6] $30 / $60 / 50% $200 max / 30% (up to
$400 max)
Dental Coverage
Pediatric dental coverage Not Covered Not Covered
Vision
Routine exam Not Covered Not Covered
Frames and lenses Not Covered Not Covered
Plan ID 11185 11186
IMPORTANT NOTICE: This benefit comparison is provided to help you quickly compare plans and is not intended to be
a comprehensive description of plans and benefits. Refer to the Summary of Benefits, Summary of Benefits and
Coverage (SBC) and Evidence of Coverage for a detailed description of coverage and benefits limitations. In the event
of a discrepancy on this comparison, Evidence of Coverage and Plan contract shall prevail. (Please visit www.pibt.org -
Forms and Documents.)
• Prescription drug benefits listed are for participating pharmacies only.[2] A calendar year deductible is the amount you pay each calendar year before the carrier pays for covered services under the benefit
plan. [5] Accrues toward the calendar year out-of-pocket maximum. [6] Some drugs require prior authorization for medical necessity, or
when effective, lower cost alternatives are available. [37] Some services require pre-authorization. If these services are rendered by
providers as a facility, please refer to the appropriate category under level I of the Benefit Summary for the benefit. [40] For outpatient
department of a Hospital, copay may differ.
20 -202 PIAG Yearbook
Benefits at a Glance
PIBT Freedom
Plan Name PIBT HSA 5500
Network Not Applicable [37]
Calendar Year Deductible
(Individual/Family)
$5,500 / $11,000 [2]
Out-of-pocket maximum
(Individual/Family)
$6,650 / $13,300
Office Visit (PCP) 20%
Specialist Visit 20%
Outpatient Surgery/Treatment 20% per visit
Hospital Admission $100 + 20% per admission
X-ray 20% [40]
Laboratory 20% [40]
Urgent Care 20%
Emergency Room $150 + 20% per visit
Preventive Care No Charge (No Deductible)
Mental Health Office Visit 20%
Prescription Drugs Generic/Brand/Non-Pref. Brand/Specialty
Separate calendar year
deductible
Subject to the calendar year deductible [5]
Rx out-of-pocket maximum
(Individual/Family)
Not Applicable
Retail prescriptions
(30-90 day supply)
$10 / $25 /$40 / 30% (up to $200 max) [6]
Mail order
(30-90-day supply)
$20 / $50 / $80 / 30% (up to $400 max) [6]
Dental Coverage
Pediatric dental coverage Not Covered
Vision
Routine exam Not Covered
Frames and lenses Not Covered
Plan ID 11187
IMPORTANT NOTICE: This benefit comparison is provided to help you quickly compare plans and is not intended to be
a comprehensive description of plans and benefits. Refer to the Summary of Benefits, Summary of Benefits and
Coverage (SBC) and Evidence of Coverage for a detailed description of coverage and benefits limitations. In the event
of a discrepancy on this comparison, Evidence of Coverage and Plan contract shall prevail. (Please visit www.pibt.org -
Forms and Documents.)
• Prescription drug benefits listed are for participating pharmacies only.[2] A calendar year deductible is the amount you pay each calendar year before the carrier pays for covered services under the benefit
plan. [5] Accrues toward the calendar year out-of-pocket maximum. [6] Some drugs require prior authorization for medical necessity, or
when effective, lower cost alternatives are available. [37] Some services require pre-authorization. If these services are rendered by
providers as a facility, please refer to the appropriate category under level I of the Benefit Summary for the benefit. [40] For outpatient
department of a Hospital, copay may differ.
20 -202 PIAG Yearbook
20 -202 PIAG Yearbook
Kaiser Monthly Rates by age, effective 12/1/2020Dependent monthly rates do not include the employee portion.
Plan Name KP HMO 20/30 (115), Plan ID #6423
Age/Tier Under 30 Under 40 Under 50 Under 55 Under 60 Under 65 65 & Over
Employee 362.50 416.54 524.63 704.75 884.88 1,083.03 1,083.03
+Spouse 423.75 484.99 611.08 820.04 1,032.58 1,266.75 1,266.75
+Child(ren) 289.09 332.32 418.77 562.88 706.98 858.29 858.29
+Spouse & Child(ren) 761.02 876.31 1,103.27 1,481.55 1,859.83 2,274.12 2,274.12
Plan Name KP HMO 40/50 (116), Plan ID #6951
Age/Tier Under 30 Under 40 Under 50 Under 55 Under 60 Under 65 65 & Over
Employee 341.66 392.57 494.39 664.10 833.81 1,020.49 1,020.49
+Spouse 399.35 457.05 575.85 772.72 972.97 1,193.58 1,193.58
+Child(ren) 272.63 313.34 394.81 530.57 666.35 808.89 808.89
+Spouse & Child(ren) 717.25 825.87 1,039.70 1,396.08 1,752.47 2,142.80 2,142.80
Plan Name KP HMO 50/55 (117), Plan ID #6952
Age/Tier Under 30 Under 40 Under 50 Under 55 Under 60 Under 65 65 & Over
Employee 333.58 383.28 482.68 648.34 814.02 996.24 996.24
+Spouse 389.91 446.24 562.19 754.37 949.86 1,165.23 1,165.23
+Child(ren) 266.24 306.00 385.51 518.05 650.59 789.76 789.76
+Spouse & Child(ren) 700.29 806.32 1,015.05 1,362.95 1,710.87 2,091.91 2,091.91
Plan Name KP Ded HMO 1000/30 (121), Plan ID #7886
Age/Tier Under 30 Under 40 Under 50 Under 55 Under 60 Under 65 65 & Over
Employee 354.65 407.52 513.24 689.45 865.66 1,059.48 1,059.48
+Spouse 414.57 474.47 597.82 802.22 1,010.15 1,239.22 1,239.22
+Child(ren) 282.89 325.18 409.76 550.72 691.68 839.70 839.70
+Spouse & Child(ren) 744.55 857.33 1,079.35 1,449.39 1,819.41 2,224.69 2,224.69
Plan Name KP Hi Ded HMO 2000 (S77), Plan ID #7885
Age/Tier Under 30 Under 40 Under 50 Under 55 Under 60 Under 65 65 & Over
Employee 307.01 352.74 444.17 596.56 748.94 916.57 916.57
+Spouse 358.83 410.64 517.31 694.08 873.91 1,072.00 1,072.00
+Child(ren) 245.25 281.83 354.97 476.88 598.80 726.80 726.80
+Spouse & Child(ren) 644.52 742.04 934.04 1,254.06 1,574.08 1,924.58 1,924.58
20 -202 PIAG Yearbook
PIBT Freedom Monthly Rates by age, effective 12/1/2020Dependent monthly rates do not include the employee portion.
Plan Name PIBT 25/500 PIBT 35/1000
Plan ID 11184 11183
Region 100 100
Emp. Age Employee +Spouse +Child(ren) +Family Employee +Spouse +Child(ren) +Family
18 388.92 505.59 272.24 738.94 346.86 450.92 242.80 659.03
19 400.85 521.10 280.59 761.60 357.50 464.75 250.24 679.24
20 413.20 537.16 289.24 785.07 368.52 479.07 257.96 700.18
21 425.98 553.77 298.18 809.36 379.91 493.89 265.94 721.84
22 425.98 553.77 298.18 809.36 379.91 493.89 265.94 721.84
23 425.98 553.77 298.18 809.36 379.91 493.89 265.94 721.84
24 425.98 553.77 298.18 809.36 379.91 493.89 265.94 721.84
25 427.68 555.99 299.37 812.59 381.43 495.87 267.01 724.73
26 436.20 567.06 305.35 828.78 389.04 505.74 272.31 739.16
27 446.42 580.35 312.50 848.21 398.15 517.60 278.70 756.49
28 463.03 601.95 324.13 879.78 412.96 536.86 289.08 784.64
29 476.67 619.67 333.67 905.67 425.13 552.66 297.58 807.73
30 483.49 628.52 338.43 918.61 431.20 560.56 301.85 819.29
31 493.71 641.82 345.59 938.04 440.32 572.41 308.23 836.60
32 503.93 655.11 352.75 957.47 449.44 584.28 314.60 853.94
33 510.32 663.42 357.22 969.61 455.14 591.67 318.59 864.76
34 517.14 672.28 361.99 982.56 461.22 599.58 322.84 876.30
35 520.55 676.71 364.38 989.03 464.25 603.53 324.98 882.09
36 523.96 681.14 366.77 995.51 467.29 607.48 327.11 887.86
37 527.36 685.57 369.16 1,001.99 470.33 611.43 329.23 893.63
38 530.77 690.00 371.54 1,008.46 473.37 615.39 331.36 899.40
39 537.58 698.86 376.31 1,021.41 479.46 623.28 335.61 910.95
40 544.40 707.72 381.08 1,034.35 485.53 631.19 339.87 922.51
41 554.63 721.01 388.23 1,053.78 494.65 643.04 346.25 939.83
42 564.42 733.74 395.09 1,072.39 503.38 654.40 352.38 956.44
43 578.05 751.47 404.64 1,098.30 515.55 670.20 360.87 979.53
44 595.09 773.61 416.56 1,130.67 530.74 689.96 371.51 1,008.40
45 615.12 799.65 430.58 1,168.70 548.60 713.17 384.01 1,042.33
46 638.96 830.66 447.28 1,214.04 569.87 740.82 398.91 1,082.75
47 665.81 865.54 466.06 1,265.02 593.80 771.94 415.66 1,128.23
48 696.48 905.41 487.53 1,323.30 621.16 807.50 434.81 1,180.20
49 726.72 944.73 508.70 1,380.76 648.13 842.58 453.69 1,231.45
50 760.79 989.04 532.56 1,445.51 678.53 882.08 474.96 1,289.20
51 794.45 1,032.78 556.11 1,509.45 708.54 921.10 495.98 1,346.22
52 831.51 1,080.96 582.06 1,579.86 741.59 964.07 519.11 1,409.02
53 869.00 1,129.69 608.29 1,651.09 775.02 1,007.54 542.52 1,472.54
54 909.46 1,182.30 636.62 1,727.98 811.11 1,054.45 567.78 1,541.12
55 949.93 1,234.91 664.95 1,804.86 847.21 1,101.37 593.05 1,609.69
56 993.80 1,291.95 695.66 1,888.23 886.34 1,152.24 620.44 1,684.04
57 1,038.11 1,349.54 726.68 1,972.41 925.85 1,203.61 648.10 1,759.12
58 1,085.39 1,411.01 759.77 2,062.24 968.02 1,258.42 677.61 1,839.24
59 1,108.82 1,441.47 776.18 2,106.76 988.91 1,285.60 692.24 1,878.94
60 1,156.10 1,502.93 809.27 2,196.60 1,031.09 1,340.41 721.76 1,959.06
61 1,197.00 1,556.10 837.89 2,274.29 1,067.56 1,387.83 747.29 2,028.36
62 1,223.83 1,590.98 856.68 2,325.28 1,091.49 1,418.94 764.04 2,073.84
63 1,257.49 1,634.72 880.24 2,389.22 1,121.50 1,457.95 785.06 2,130.86
64+ 1,277.94 1,661.31 894.55 2,428.07 1,139.74 1,481.67 797.82 2,165.51
20 -202 PIAG Yearbook
PIBT Freedom Monthly Rates by age, effective 12/1/2020Dependent monthly rates do not include the employee portion.
Plan Name PIBT 40/2500 PIBT 45/4000
Plan ID 11185 11186
Region 100 100
Emp. Age Employee +Spouse +Child(ren) +Family Employee +Spouse +Child(ren) +Family
18 304.82 396.26 213.38 579.16 275.68 358.39 192.98 523.80
19 314.17 408.42 219.92 596.93 284.13 369.38 198.90 539.86
20 323.85 421.00 226.69 615.32 292.90 380.76 205.02 556.49
21 333.87 434.03 233.70 634.35 301.95 392.54 211.36 573.71
22 333.87 434.03 233.70 634.35 301.95 392.54 211.36 573.71
23 333.87 434.03 233.70 634.35 301.95 392.54 211.36 573.71
24 333.87 434.03 233.70 634.35 301.95 392.54 211.36 573.71
25 335.20 435.77 234.64 636.89 303.16 394.11 212.21 576.00
26 341.88 444.45 239.32 649.57 309.20 401.96 216.44 587.48
27 349.89 454.87 244.93 664.80 316.45 411.39 221.51 601.25
28 362.91 471.79 254.04 689.54 328.22 426.69 229.76 623.62
29 373.60 485.68 261.52 709.84 337.88 439.25 236.52 641.99
30 378.94 492.63 265.26 719.99 342.72 445.53 239.89 651.15
31 386.95 503.04 270.87 735.21 349.97 454.95 244.97 664.92
32 394.96 513.46 276.48 750.44 357.21 464.37 250.05 678.70
33 399.97 519.97 279.98 759.95 361.74 470.26 253.21 687.30
34 405.31 526.92 283.73 770.10 366.57 476.54 256.61 696.49
35 407.98 530.39 285.60 775.18 368.99 479.68 258.29 701.08
36 410.65 533.86 287.46 780.25 371.40 482.82 259.98 705.66
37 413.33 537.33 289.33 785.33 373.81 485.97 261.68 710.25
38 416.00 540.80 291.21 790.41 376.23 489.10 263.36 714.85
39 421.35 547.74 294.93 800.55 381.07 495.38 266.74 724.01
40 426.69 554.69 298.68 810.70 385.90 501.66 270.13 733.20
41 434.70 565.10 304.28 825.92 393.14 511.09 275.20 746.97
42 442.38 575.09 309.66 840.51 400.09 520.11 280.06 760.16
43 453.06 588.98 317.14 860.81 409.75 532.67 286.82 778.52
44 466.42 606.34 326.49 886.18 421.83 548.38 295.29 801.48
45 482.11 626.74 337.47 916.01 436.02 566.82 305.21 828.44
46 500.80 651.05 350.56 951.53 452.93 588.81 317.05 860.57
47 521.84 678.39 365.29 991.49 471.95 613.55 330.37 896.71
48 545.87 709.64 382.12 1,037.17 493.69 641.80 345.58 938.01
49 569.58 740.45 398.71 1,082.21 515.13 669.67 360.60 978.75
50 596.29 775.17 417.39 1,132.95 539.29 701.08 377.50 1,024.65
51 622.67 809.46 435.87 1,183.06 563.14 732.08 394.20 1,069.97
52 651.71 847.22 456.19 1,238.25 589.41 766.24 412.59 1,119.88
53 681.09 885.42 476.77 1,294.08 615.98 800.78 431.19 1,170.37
54 712.81 926.65 498.97 1,354.34 644.67 838.07 451.27 1,224.87
55 744.52 967.89 521.18 1,414.61 673.35 875.37 471.35 1,279.38
56 778.92 1,012.59 545.24 1,479.93 704.45 915.80 493.12 1,338.47
57 813.64 1,057.73 569.55 1,545.91 735.86 956.61 515.10 1,398.13
58 850.70 1,105.90 595.49 1,616.33 769.37 1,000.19 538.56 1,461.82
59 869.06 1,129.78 608.34 1,651.22 785.98 1,021.77 550.19 1,493.37
60 906.12 1,177.96 634.29 1,721.63 819.50 1,065.35 573.66 1,557.05
61 938.18 1,219.62 656.71 1,782.52 848.49 1,103.03 593.94 1,612.13
62 959.21 1,246.96 671.44 1,822.48 867.51 1,127.77 607.26 1,648.28
63 985.58 1,281.26 689.91 1,872.61 891.36 1,158.78 623.96 1,693.59
64+ 1,001.61 1,302.09 701.12 1,903.05 905.86 1,177.62 634.10 1,721.14
20 -202 PIAG Yearbook
PIBT Freedom Monthly Rates by age, effective 12/1/2020Dependent monthly rates do not include the employee portion.
Plan Name PIBT HSA 5500
Plan ID 11187
Region 100
Emp. Age Employee +Spouse +Child(ren) +Family
18 244.55 317.91 171.18 464.64
19 252.05 327.66 176.44 478.89
20 259.82 337.76 181.87 493.65
21 267.85 348.21 187.50 508.92
22 267.85 348.21 187.50 508.92
23 267.85 348.21 187.50 508.92
24 267.85 348.21 187.50 508.92
25 268.92 349.61 188.25 510.95
26 274.28 356.56 191.99 521.13
27 280.71 364.93 196.50 533.35
28 291.15 378.50 203.81 553.19
29 299.73 389.64 209.81 569.48
30 304.01 395.22 212.81 577.62
31 310.44 403.57 217.31 589.84
32 316.87 411.93 221.80 602.05
33 320.88 417.15 224.62 609.68
34 325.17 422.73 227.62 617.82
35 327.32 425.51 229.11 621.89
36 329.46 428.29 230.62 625.97
37 331.60 431.07 232.12 630.04
38 333.74 433.86 233.62 634.11
39 338.03 439.44 236.62 642.26
40 342.31 445.01 239.61 650.40
41 348.74 453.37 244.13 662.61
42 354.90 461.37 248.43 674.32
43 363.47 472.52 254.43 690.60
44 374.18 486.45 261.94 710.96
45 386.78 502.81 270.74 734.88
46 401.78 522.31 281.25 763.37
47 418.65 544.25 293.06 795.44
48 437.94 569.32 306.56 832.07
49 456.95 594.05 319.87 868.22
50 478.38 621.90 334.87 908.93
51 499.54 649.41 349.69 949.13
52 522.85 679.70 365.99 993.41
53 546.41 710.34 382.49 1,038.20
54 571.86 743.42 400.31 1,086.54
55 597.30 776.50 418.12 1,134.89
56 624.90 812.37 437.43 1,187.30
57 652.75 848.59 456.93 1,240.24
58 682.48 887.23 477.74 1,296.72
59 697.22 906.38 488.05 1,324.71
60 726.95 945.03 508.86 1,381.20
61 752.66 978.46 526.86 1,430.06
62 769.54 1,000.40 538.67 1,462.12
63 790.69 1,027.91 553.49 1,502.33
64+ 803.55 1,044.62 562.49 1,526.75
20 -202 PIAG Yearbook
Dental DPO Benefits at a Glance
Plan Features
Plan Name Delta DPO Plan 1 Delta DPO Plan 2
Services Rendered At In Network Out of Network In Network Out of Network
Calendar Year Deductible
(Individual/Family)
$25 / $75 $50 / $150 [24] $50 / $150 [24]
Calendar Year Maximum $1,500 per person $1,500 per person [38]
Waiting Period/Major Services None [25] None [25]
Benefit Levels Contracted Rate / Contracted Allowance Contracted Rate / Contracted Allowance
Preventative Services
Oral Exams No Charge (No Deductible) No Charge (No Deductible)
Cleanings No Charge (No Deductible) No Charge (No Deductible)
Bitewing X-rays No Charge (No Deductible) No Charge (No Deductible)
Complete X-rays No Charge (No Deductible) No Charge (No Deductible)
Basic Services
Fillings (composite resin) 10% 20% 20%
Oral Surgery 10% 20% 20%
Major Services
Crowns (high noble) 40% 50% 50%
Orthodontics
Lifetime Maximum $1,000 $1,000
Children up to 19th Birthday 50% (No Deductible) [21] 50% (No Deductible) [21]
Adults 50% (No Deductible) [21] Not Covered
Monthly Rates, effective 12/01/2020
Employee 58.84 47.34
+Spouse 54.87 44.11
+Child 73.28 62.61
+Children 73.28 62.61
+Family 145.37 121.40Plan ID 10424 10425
IMPORTANT NOTICE: This benefit comparison is provided to help you quickly compare plans and is not intended to be
a comprehensive description of plans and benefits. Refer to the Summary of Benefits, Summary of Benefits and
Coverage (SBC) and Evidence of Coverage for a detailed description of coverage and benefits limitations. In the event
of a discrepancy on this comparison, Evidence of Coverage and Plan contract shall prevail. (Please visit www.pibt.org -
Forms and Documents.)
[21] In order to be covered, orthodontic treatment must be received in one continuous course of treatment; must be received in
consecutive months and must not exceed 24 consecutive months. [24] Non-participating dentist can bill you for charges above the
amount covered by your dental plan. To ensure you do not receive additional charges , visit a participating PPO network dentist. [25]
Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on
Delta Dental maximum contract allowances and not necessarily each dentist's submitted fees. [38] Non-Delta Dental PPO dentists:
$1,000 per person each calendar year.
20 -202 PIAG Yearbook
Dental DPO Benefits at a Glance
Plan Features
Plan Name CIGNA PPO GA GA Humana Trad PPO 1
Services Rendered At In Network Out of Network In Network Out of Network
Calendar Year Deductible
(Individual/Family)
$25 / $75 [24] $50 / $150 [24]
Calendar Year Maximum $1,000 $1,000
Waiting Period/Major Services None None
Benefit Levels Customary & Reasonable Customary & Reasonable
Preventative Services
Oral Exams No Charge (2 per calendar year) (No Deductible) No Charge (No Deductible)
Cleanings No Charge (2 per calendar year) (No Deductible) No Charge (No Deductible)
Bitewing X-rays No Charge (2 per calendar year) (No Deductible) No Charge (No Deductible)
Complete X-rays No Charge (1 per 36 months) (No Deductible) No Charge (No Deductible)
Basic Services
Fillings (composite resin) 20% 20%
Oral Surgery 20% 20%
Major Services
Crowns (high noble) 50% 50%
Orthodontics
Lifetime Maximum $1,000 per child $1,000 per child
Children up to 19th Birthday 50% (No Deductible) 50% (No Deductible)
Adults Not Covered Not Covered
Monthly Rates, effective 12/01/2020
Employee 63.98 48.16
+Spouse 62.90 57.84
+Child 62.90 57.84
+Children 98.46 105.95
+Family 98.46 105.95Plan ID 4143 6984
IMPORTANT NOTICE: This benefit comparison is provided to help you quickly compare plans and is not intended to be
a comprehensive description of plans and benefits. Refer to the Summary of Benefits, Summary of Benefits and
Coverage (SBC) and Evidence of Coverage for a detailed description of coverage and benefits limitations. In the event
of a discrepancy on this comparison, Evidence of Coverage and Plan contract shall prevail. (Please visit www.pibt.org -
Forms and Documents.)
[24] Non-participating dentist can bill you for charges above the amount covered by your dental plan. To ensure you do not receive
additional charges, visit a participating PPO network dentist.
20 -202 PIAG Yearbook
Dental DPO Benefits at a Glance
Plan Features
Plan Name GA Humana Trad PPO 2
Services Rendered At In Network Out of Network
Calendar Year Deductible
(Individual/Family)
$50 / $150 [24]
Calendar Year Maximum $1,000
Waiting Period/Major Services None
Benefit Levels Customary & Reasonable
Preventative Services
Oral Exams No Charge (No Deductible)
Cleanings No Charge (No Deductible)
Bitewing X-rays No Charge (No Deductible)
Complete X-rays No Charge (No Deductible)
Basic Services
Fillings (composite resin) 30%
Oral Surgery 30%
Major Services
Crowns (high noble) 60%
Orthodontics
Lifetime Maximum Not Covered
Children up to 19th Birthday Not Covered
Adults Not Covered
Monthly Rates, effective 12/01/2020
Employee 34.52
+Spouse 32.66
+Child 32.66
+Children 68.67
+Family 68.67Plan ID 6985
IMPORTANT NOTICE: This benefit comparison is provided to help you quickly compare plans and is not intended to be
a comprehensive description of plans and benefits. Refer to the Summary of Benefits, Summary of Benefits and
Coverage (SBC) and Evidence of Coverage for a detailed description of coverage and benefits limitations. In the event
of a discrepancy on this comparison, Evidence of Coverage and Plan contract shall prevail. (Please visit www.pibt.org -
Forms and Documents.)
[24] Non-participating dentist can bill you for charges above the amount covered by your dental plan. To ensure you do not receive
additional charges, visit a participating PPO network dentist.
20 -202 PIAG Yearbook
Dental DMO Benefits at a Glance
Plan Features
Plan Name GA Humana EPO 2S GA Humana EPO 1S
Calendar Year Deductible
(Individual/Family)
Not Applicable Not Applicable
Calendar Year Maximum None None
Waiting Period/Major Services None None
Benefit Levels Fee Schedule Fee Schedule
Preventative Services
Oral Exams No Charge (1 every 6 months) No Charge (1 every 6 months)
Cleanings No Charge (1 every 6 months) No Charge (1 every 6 months)
Bitewing X-rays No Charge (1 every 6 months) No Charge (1 every 6 months)
Complete X-rays No Charge (1 every 36 months) No Charge (1 every 36 months)
Basic Services
Fillings (composite resin) No Charge $24 Copay
Oral Surgery No Charge $26 Copay [20]
Major Services
Crowns (high noble) $466 Copay [29] $466 Copay [29]
Orthodontics
Lifetime Maximum Refer to Schedule of Benefits Refer to Schedule of Benefits
Children up to 19th Birthday $2,100 Copay [21] $2,100 Copay [21]
Adults $2,300 Copay [21] $2,300 Copay [21]
Monthly Rates, effective 12/01/2020
Employee 23.77 19.72
+Spouse 25.22 21.00
+Child 25.22 21.00
+Children 50.12 41.58
+Family 50.12 41.58Plan ID 6986 6987
IMPORTANT NOTICE: This benefit comparison is provided to help you quickly compare plans and is not intended to be
a comprehensive description of plans and benefits. Refer to the Summary of Benefits, Summary of Benefits and
Coverage (SBC) and Evidence of Coverage for a detailed description of coverage and benefits limitations. In the event
of a discrepancy on this comparison, Evidence of Coverage and Plan contract shall prevail. (Please visit www.pibt.org -
Forms and Documents.)
[20] Surgical removal of erupted tooth, impacted tooth, and tooth root. [21] In order to be covered, orthodontic treatment must be
received in one continuous course of treatment; must be received in consecutive months and must not exceed 24 consecutive months.
[29] Limit one per tooth every eight years.
20 -202 PIAG Yearbook
Dental DMO Benefits at a Glance
Plan Features
Plan Name Cigna DMO W1-09 Cigna DMO F1-09
Calendar Year Deductible
(Individual/Family)
None None
Calendar Year Maximum None None
Waiting Period/Major Services None None
Benefit Levels Fee Schedule Fee Schedule
Preventative Services
Oral Exams No Charge No Charge
Cleanings No Charge (limit 2 per calendar year) No Charge (2 per calendar year)
Bitewing X-rays No Charge (limit 2 per calendar year) No Charge (2 per calendar year)
Complete X-rays No Charge (1 every 36 months) No Charge (1 every 36 months)
Basic Services
Fillings (composite resin) $22 Copay No Charge
Oral Surgery $53 Copay [20] $12 Copay [20]
Major Services
Crowns (high noble) $470 Copay $380 Copay
Orthodontics
Lifetime Maximum Refer to Schedule of Benefits Refer to Schedule of Benefits
Children up to 19th Birthday $2,472 Copay [21] $2,184 Copay [21]
Adults $3,336 Copay [21] $2,904 Copay [21]
Monthly Rates, effective 12/01/2020
Employee 16.11 35.88
+Spouse 15.06 25.39
+Child 15.06 25.39
+Children 32.80 63.28
+Family 32.80 63.28Plan ID 34 3276
IMPORTANT NOTICE: This benefit comparison is provided to help you quickly compare plans and is not intended to be
a comprehensive description of plans and benefits. Refer to the Summary of Benefits, Summary of Benefits and
Coverage (SBC) and Evidence of Coverage for a detailed description of coverage and benefits limitations. In the event
of a discrepancy on this comparison, Evidence of Coverage and Plan contract shall prevail. (Please visit www.pibt.org -
Forms and Documents.)
[20] Surgical removal of erupted tooth, impacted tooth, and tooth root. [21] In order to be covered, orthodontic treatment must be
received in one continuous course of treatment; must be received in consecutive months and must not exceed 24 consecutive months.
20 -202 PIAG Yearbook
Dental DMO Benefits at a Glance
Plan Features
Plan Name Delta USA 13A Delta USA 15A
Calendar Year Deductible
(Individual/Family)
None None
Calendar Year Maximum None None
Waiting Period/Major Services None None
Benefit Levels Fee Schedule Fee Schedule
Preventative Services
Oral Exams No Charge No Charge
Cleanings No Charge (every six months) $5 (every six months)
Bitewing X-rays No Charge No Charge
Complete X-rays No Charge (limit 1 per 24 months) No Charge (limit 1 per 24 months)
Basic Services
Fillings (composite resin) No Charge $22 Copay
Oral Surgery $5 Copay [20] $14 Copay [20]
Major Services
Crowns (high noble) $355 Copay $395 Copay
Orthodontics
Lifetime Maximum Refer to Schedule of Benefits Refer to Schedule of Benefits
Children up to 19th Birthday $1,900 Copay $1,900 Copay
Adults $2,100 Copay $2,100 Copay
Monthly Rates, effective 12/01/2020
Employee 18.18 16.98
+Spouse 18.18 16.98
+Child 19.52 18.44
+Children 19.52 18.44
+Family 42.17 39.65Plan ID 10426 10427
IMPORTANT NOTICE: This benefit comparison is provided to help you quickly compare plans and is not intended to be
a comprehensive description of plans and benefits. Refer to the Summary of Benefits, Summary of Benefits and
Coverage (SBC) and Evidence of Coverage for a detailed description of coverage and benefits limitations. In the event
of a discrepancy on this comparison, Evidence of Coverage and Plan contract shall prevail. (Please visit www.pibt.org -
Forms and Documents.)
[20] Surgical removal of erupted tooth, impacted tooth, and tooth root.
20 -202 PIAG Yearbook
Vision Benefits at a Glance
Plan Features
EyeMed BaseEyeMed HighPlan Name
Plan ID 10423 8763
Provider EyeMed Provider EyeMed Provider
Eye Exam $5 Copay $5 Copay
Frames $0 Copay. $200 allowance, 20% off on balance over
$200
$0 Copay. $130 allowance, 20% off on balance over
$130
Lenses
Single $15 Copay $15 Copay
Bifocal $15 Copay $15 Copay
Trifocal $15 Copay $15 Copay
Contact Lenses
(instead of glasses)
$0 Copay. $200 plan allowance 15% off balance over
$200
$0 Copay. $130 plan allowance 15% off balance over
$130
Frequency
Examination Once every 12 months Once every 12 months
Frame Once every 12 months Once every 12 months
Lenses or Contact Lenses Once every 12 months Once every 12 months
Monthly Rates, effective 12/01/2020
Employee 8.23 6.45
+Spouse 7.39 5.79
+Child 7.39 5.79
+Children 11.54 14.70
+Family 14.70 11.54
Plan ID 10423 8763
IMPORTANT NOTICE: This benefit comparison is provided to help you quickly compare plans and is not intended to be
a comprehensive description of plans and benefits. Refer to the Summary of Benefits, Summary of Benefits and
Coverage (SBC) and Evidence of Coverage for a detailed description of coverage and benefits limitations. In the event
of a discrepancy on this comparison, Evidence of Coverage and Plan contract shall prevail. (Please visit www.pibt.org -
Forms and Documents.)
20 -202 PIAG Yearbook
Vision Benefits at a Glance
Plan Features
VSP PremiumEyeMed KaiserPlan Name
Plan ID 8764 10884
Provider Kaiser Faciliy and EyeMed Provider [34] VSP Provider [30]
Eye Exam Plan office visit copay at Kaiser facility $10 Copay
Frames $150 plan allowance, 20% off on balance over $150
for frames, lens and lens options
$20 Copay. $200 plan allowance, 20% off balance
over allowance
Lenses
Single $150 plan allowance, 20% off on balance over $150 $20 Copay
Bifocal $150 plan allowance, 20% off on balance over $150 $20 Copay
Trifocal $150 plan allowance, 20% off on balance over $150 $20 Copay
Contact Lenses
(instead of glasses)
$0 Copay. $150 plan allowance 15% off balance over
$150
$200 plan allowance [31]
Frequency
Examination Once every 12 months Every 12 months
Frame Once every 12 months Every 12 months
Lenses or Contact Lenses Once every 12 months Every 12 months
Monthly Rates, effective 12/01/2020
Employee 0.00 11.66
+Spouse 0.00 3.53
+Child 0.00 3.53
+Children 13.41 0.00
+Family 0.00 13.41
Plan ID 8764 10884
IMPORTANT NOTICE: This benefit comparison is provided to help you quickly compare plans and is not intended to be
a comprehensive description of plans and benefits. Refer to the Summary of Benefits, Summary of Benefits and
Coverage (SBC) and Evidence of Coverage for a detailed description of coverage and benefits limitations. In the event
of a discrepancy on this comparison, Evidence of Coverage and Plan contract shall prevail. (Please visit www.pibt.org -
Forms and Documents.)
[30] 20% off for certain materials and services accessed through a VSP provider . [31] Allowance for contacts and contact lens exam
(fitting and evaluation). [34] Benefits apply for Kaiser participants only. Plan cannot be added to your plan menu.
20 -202 PIAG Yearbook
Vision Benefits at a Glance
Plan Features
VSP StandardPlan Name
Plan ID 10883
Provider VSP Provider [30]
Eye Exam $10 Copay
Frames $20 Copay. $150 plan allowance, 20% off balance
over allowance
Lenses
Single $20 Copay
Bifocal $20 Copay
Trifocal $20 Copay
Contact Lenses
(instead of glasses)
$150 plan allowance [31]
Frequency
Examination Every 12 months
Frame Every 24 months
Lenses or Contact Lenses Every 12 months
Monthly Rates, effective 12/01/2020
Employee 9.39
+Spouse 2.24
+Child 2.24
+Children 9.86
+Family 9.86
Plan ID 10883
IMPORTANT NOTICE: This benefit comparison is provided to help you quickly compare plans and is not intended to be
a comprehensive description of plans and benefits. Refer to the Summary of Benefits, Summary of Benefits and
Coverage (SBC) and Evidence of Coverage for a detailed description of coverage and benefits limitations. In the event
of a discrepancy on this comparison, Evidence of Coverage and Plan contract shall prevail. (Please visit www.pibt.org -
Forms and Documents.)
[30] 20% off for certain materials and services accessed through a VSP provider . [31] Allowance for contacts and contact lens exam
(fitting and evaluation).
20 -202 PIAG Yearbook
Basic Group Life and AD&D Benefits at a GlanceDistributed by PIA-SC, Insurance Services Inc.
Plan Features
Accelerated Death Benefit If an employee has been diagnosed as terminally ill, Symetra Life Insurance
Company may pay a portion of the death benefit in advance to the member.
Conversion A conversion benefit is available that allows you to convert your group coverage to
an individual policy if certain conditions apply.
Portability This coverage may be continued at group rates upon termination of employment.
Certain restrictions apply.
AD&D Riders Includes Seat Belt, Airbag, Repatriation, Child Education, Day Care and Spouse
Education benefits.
Value Added Services
Beneficiary Companion Support services for beneficiaries who have experienced a loss.
Travel Assist Travel assistance services for employees and eligible dependents traveling more
than 100 miles from home.
Monthly Rates, effective 1/1/2021
Basic Life $10K 3.80
Basic Life $15K 5.70
Basic Life $20K 7.60
Basic Life $25K 9.50
Basic Life $40K 15.20
IMPORTANT NOTICE: This comparison is provided to help you compare coverage benefits at a glance only. Before
making your plan choice, you should refer to the Evidence of Coverage and Plan Contract for a detailed description of
coverage benefits and limitations. In the event of any difference between this summary versus the Evidence of Coverage
or Plan Contract, the Evidence of Coverage and Plan Contract shall prevail.
20 -202 PIAG Yearbook
Voluntary Life and AD&D Benefits at a Glance
Distributed by PIA-SC, Insurance Services Inc.
Plan Features
Amount Increments of $10,000
Maximum Amount Lesser of $500,000 or 10 x Earnings
Guarantee Issue (GIA) $120,000 (New Hires only)
Age Reduction (Original
Benefit Amount reduced to)
65% at age 70
50% at age 75
Eligibility Full time employee (of participating employer) and their eligible dependents
Evidence of Insurability (EOI) EOI is required for all amounts of insurance selected after the initial 31-day eligibility
period and for any amount in excess of the GIA.
Accelerated Death Benefit If an employee has been diagnosed as terminally ill, Symetra Life Insurance
Company may pay a portion of the death benefit in advance to the member.
Spouse
Amount Increments of $5,000
Maximum Amount $250,000 not to exceed 100% of employee coverage
Guarantee Issue $25,000
Child
Child Amount (Birth to 26 yrs.) $5,000 or maximum of $10,000
Monthly Employee Rates, effective 1/1/2021Benefit $10,000 $50,000 $80,000 $120,000
Under 25 0.76 3.80 6.08 9.12
25-29 0.76 3.80 6.08 9.12
30-34 0.86 4.30 6.88 10.32
35-39 1.14 5.70 9.12 13.68
40-44 1.62 8.10 12.96 19.44
45-49 2.76 13.80 22.08 33.12
50-54 4.66 23.30 37.28 55.92
55-59 8.27 41.35 66.16 99.24
60-64 10.36 51.80 82.88 124.32
65-69 17.77 88.85 142.16 213.24
70-74 31.54 157.70 252.32 378.48
75+ 31.54 157.70 252.32 378.48
20 -202 PIAG Yearbook
Employee Assistance Program Benefits at a Glance
Plan Features
Plan Name EAP MHN
Employee Assistance Program Counseling services for various life management problems for employees and dependents
Office Visits $0 copay with authorization
Deductible None
Clinical Counseling
Visits
As needed
As needed
6 visits per incident per plan period, unlimited incidents
Telephone Couseling
Web Video Couseling
Monthly Rates, effective 12/01/2020, Employer Sponsored Plan
Employee 5.37
Plan ID 3715
IMPORTANT NOTICE: This benefit comparison is provided to help you quickly compare plans and is not intended to be
a comprehensive description of plans and benefits. Refer to the Summary of Benefits, Summary of Benefits and
Coverage (SBC) and Evidence of Coverage for a detailed description of coverage and benefits limitations. In the event
of a discrepancy on this comparison, Evidence of Coverage and Plan contract shall prevail. (Please visit www.pibt.org -
Forms and Documents.)
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The Ultimate Health Coverage plan is an innovative and convenient way to give an extra level of coverage for employees.
It reimburses for many medical expenses not covered by the employer-sponsored base health plan. For more
information contact Evie Bañaga at 800.449.4898 ext. 224.
Supplemental Medical
Benefits
Samples of What is Eligible
(Not a Complete List)*
Platinum Diamond Diamond Plus
(Requires 15+ to enroll)
Per-Occurrence (each
injury, condition or illness)
for medical out-of-pocket
costs
Deductibles, co-pays, balance bills
and other out-of-pocket costs for
medically necessary services
$2,500 $3,000 $10,000
Per Covered Person per
Year
Per Covered Person per
Year
Per Covered Person per
Year
Other Supplemental
Benefits
$10,000$3,000$2,500Co-pays, brand name and lifestyle
prescriptions
Prescriptions
$10,000$3,000$2,000Counseling and substance abuse
programs
Mental Health
$10,000$5,000$2,000Durable medical equipment,
wigs, hearing aids, orthotics
Medical Equipment
$10,000$1,500$1,000Acupuncture, massage therapy and
chiropractic care
(if not covered by primary plan)
Wellness Treatments
$10,000 each$2,500 each$2,000 eachComprehensive physicals for the
primary member and enrolled spouse
Executive Physicals
Per Covered Person per YearAncillary Benefits
$10,000$5,000$4,000Routine care, child and adult
orthodontia, crowns and bridges
Dental Treatments
$10,000$1,500$1,000LASIK, contact lenses and
prescription glasses & sunglasses
Vision Treatments
$100,000$50,000$50,000Annual Family Maximum
The levels are for each covered person, whether that person is the enrolled employee or his/her enrolled family member. All the reimbursed
expenses across the benefit categories, including medical per occurrences, roll up to the overall annual family maximum, which is the same for a
family of one or a family of six.
*These are examples of 213(d)- eligible expenses that are typically covered by the Ultimate Health plan. We cannot pre-certify specific medical
treatments or procedures. A claim must be submitted for review before a claim will be accepted or denied for reimbursement.
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&
PIAG Insurance has partnered with Aflac to offer an extensive voluntary
benefits portfolio of a broad range of financial protection options with multiple
ways to enroll. Employees may quote out personal lines for themselves and
their family/friends, and employers may add coverage to cover their
employees.
A Selection of Voluntary Personal Benefits through Aflac
Accident Insurance
(benefits for unexpected injuries)
• Accident - A guaranteed-issue, composite-rated,
guaranteed-renewable accident product that offers
several coverage levels to fit all budgets
• Gunshot Wound - A guaranteed-issue product that
provides lump-sum benefits for injury due to non-fatal
gunshot wounds
Disability Insurance
(income protection)
• Disability - A short-term disability product that replaces
a portion of your income
Supplemental Health Insurance
(lump sum hospital confinement)
• MedicalBridge - A hospital confinement
indemnity product that supplements your core
medical coverage
Special Risk Insurance
(treatment & recovery from serious illness)
• Cancer - A cancer product that pays indemnity-based
benefits to help cover medical and non-medical
expenses related to a cancer diagnosis and treatment
• Critical Illness - A critical illness product that provides a
lump-sum benefit for the diagnosis of a critical illness
Life Insurance
(family financial protection)
• Universal Life - A universal life product with
flexibility that allows the employee to adapt to
changing needs by varying amounts and premiums
• Whole Life - A permanent whole life insurance
product that provides guaranteed level premiums,
guaranteed cash values, and guaranteed death
benefits as long as premiums are paid when due and
no loans are taken
and more!
Contact us today to learn about all the ways we can help you plan for the unexpected.
www.piaginsurance.com | (770) 433-3050
info@piag.org
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It’s said that you protect what’s important to you,
so what are you insuring?
call us today at (770) 433-3050
www.piaginsurance.com
Insurance
get a FREE quote on insurance at
Business Personal Property
Building
Workers Compensation
Commercial Auto
Cyber/Crime/Data Breach
Home
Personal Auto
Renters
Personal Umbrella
Individual Life
Group Health Group Dental Group Vision Group Disability*Group policies are for companies with 2 or more employees.
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