Employee Benefits Guide For Plan Year January 1, 2020 ......Life Insurance Plans 11 Contacts12...

Employee Benefits Guide For Plan Year January 1, 2020 - December 31, 2020

Welcome to your Butch’s Benefits Guide.

We take great pride in offering an excellent selection of benefits to all full-time employees. This guide provides quick access to information about your employee benefits program, which is an important part of your total compensation package. Please take a few moments to familiarize yourself with the benefit programs available to you as part of the Butch’s family.

Table of Contents

DISCLAIMER: The information in this Enrollment Guide is intended for illustrative and informational purposes only. The information contained herein was taken from various summary plan descriptions, certificates of coverage and benefit information. Every effort was taken to accurately report your benefits however discrepancies and errors are always possible. It is not intended to alter or expand rights or liabilities set forth in the official plan documents or contracts. It is not an offer to contract nor are there any express or implied guarantees. In case of a discrepancy between this information and the actual plan documents, the actual plan documents will prevail. If you have any questions about this summary, please contact Human Resources. © Marsh & McLennan Agency 2019. All Rights Reserved.

Eligibility & Enrollment Guidelines 3

Payroll Deduction Options 3

Medical Plans 4

Medical Plan Features 5

Telemedicine Services 8

tooth Dental Plan 9

Eye Vision Plan 10

Life Insurance Plans 11

Contacts 12

building Benefit Contacts 13

pen Notes 14

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Eligibility & Enrollment GuidelinesFull-time employees of Butch’s are eligible to enroll in the benefit plans on the first day of the month following 60 days of full-time employment. Employees who do not elect coverage at this initial eligibility date will only be able to enroll during the next open enrollment period, or if they experience an applicable qualifying event.

Open enrollment is the one opportunity during the year when you may make changes to your current benefit elections for both yourself and any eligible dependents without having a qualifying event. Examples of qualifying events include: marriage, divorce, birth or adoption of a child, loss of a dependent, court order, loss of other coverage, or significant change in employment status of you or your spouse. If you experience one of these qualifying events, please contact Human Resources within 30 days of the event.

The benefit elections you make will be effective January 1, 2020 through December 31, 2020.

Payroll Deduction OptionsAs a participant of the medical plan, dental and/or vision plans, you will have the option to pay for your portion of the plan premiums with pre-tax deductions or with post-tax deductions.

Pre-Tax Election:

◗Allows member to pay for plan premiums with pre-tax payroll deductions. This may decrease the member’s overall tax liability.

◗Requires the member to maintain coverage during the entire plan year, not allowing changes or cancellations of coverage unless there is a qualified family change.

Post-Tax Election:

◗Requires member to pay for plan premiums with post-tax payroll deductions.

◗Allows the member to cancel coverage at any time. The member could not re-enroll until the next open enrollment.

IMPORTANT: Your deductions for this plan will be AUTOMATICALLY taken Pre-Tax

unless you opt out in writing and submit to Human Resources prior to the start of

coverage.

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Medical PlansThe medical plans are offered through BlueCross and BlueShield of Texas. You can elect from three medical plans: HSA, Base PPO and Buy Up PPO.

IN-NETWORK BENEFITS HSA PLAN BASE

PPO PLANBUY-UP

PPO PLANCopays

Primary Care Physician 100% after deductible $30 $30

Specialist 100% after deductible $55 $55

Urgent Care 100% after deductible $50 $50

Prescription Drugs Prescription Deductible $0 $100 $0

Preferred Generic 100% after deductible $10 $10

Preferred Brand 100% after deductible $35 $35

Non-Preferred Brand 100% after deductible $60 $60

Specialty 100% after deductible 20% 20%

Calendar Year DeductibleIndividual $6,550 $5,000 $3,000

Family $13,100 $10,000 $6,000

Out of Pocket Limit (Includes Deductible)Individual $6,550 $6,350 $6,000

Family $13,100 $12,700 $12,000

Member CoinsurancePreventive Care Covered at 100% Covered at 100% Covered at 100%

Lab and X-ray 100% after deductible Covered at 100% Covered at 100%

Diagnostic Imaging (MRI, Pet Scans, CT Scans, etc.)

100% after deductible $250 copay $250 copay

Hospital Services 100% after deductible 30% after deductible 20% after deductible

Emergency Services 100% after deductible

$400 Copay, then 30% after deductible

$400 Copay, then 20% after deductible

HOURLY – Bi-weekly Employee Medical Contributions beginning 1/1/2020

Wellness Participation YES NO YES NO YES NOEmployee Only $44.14 $60.30 $60.22 $76.37 $109.21 $125.37

Employee + Child/ren $185.44 $201.60 $215.16 $231.32 $305.75 $321.91

Employee + Spouse $293.57 $309.72 $333.73 $349.89 $456.15 $472.30

Employee + Family $368.41 $384.56 $415.80 $431.95 $560.24 $576.39

SALARY – Semi-monthly Employee Medical Contributions beginning 1/1/2020

Employee Only $47.82 $65.32 $65.24 $82.74 $118.31 $135.81

Employee + Child/ren $200.90 $218.40 $233.09 $250.59 $331.23 $348.73

Employee + Spouse $318.03 $335.53 $361.54 $379.04 $494.16 $511.66

Employee + Family $399.11 $416.61 $450.45 $467.95 $606.93 $624.43

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Medical Plan FeaturesHSA PLAN FEATURESAs a participant in Butch’s HSA-compatible High Deductible Health Plan, you have the option to open a Health Savings Account (HSA) Bank Account to pay for qualified medical expenses tax-free.

HSA-compatible plans do not have office visit or prescription copays. While you do receive the BlueCross and BlueShield of Texas (BCBSTX) provider discount, you are responsible for all medical costs up to the deductible amount, after which the plan will pay at 100% for the remainder of the plan year. The only exception is preventive care services (i.e. baby well-checks, annual physical, annual women well-check, etc.) which the plan always covers at 100%. The plan allows you access to both In-Network and Out-of-Network providers, but utilizing In-Network maximizes the benefits of the plan.

Find BCBSTX PPO Network providers by visiting www.bcbstx.com and clicking “Find a Doctor,” selecting your state, then “BlueChoice PPO.” You can also call 800-521-2227 for assistance!

You can make contributions directly to the HSA bank account and can deduct the contributions (even if you do not itemize deductions) when completing your federal income tax return. The IRS determines the maximum amount that can be contributed to an HSA, and adjusts them annually for inflation. For 2020, the maximum contribution for Self-Only coverage is $3,550, and $7,100 for Family coverage. For individuals age 55 and older, the IRS permits an additional annual “catch-up” contribution of $1,000.

You can use the money in the HSA bank account for any “qualified medical expense” permitted under federal tax law. This includes most medical care and services, dental and vision care. Any amounts used for purposes other than to pay for “qualified medical expenses” are taxable as income and subject to an additional tax penalty.

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An HSA provides you triple tax savings: (1) contributions to your account are tax-deductible; (2) tax-free earnings through investment; and, (3) tax-free withdrawals for qualified medical expenses.

EMPLOYEES WHO ARE NOT ELIGIBLE TO OPEN A TAX-FREE ACCOUNT

• Those over 65 and have Medicare coverage

• Those who have received benefits from the VA in the 3 months prior

• Employees who are covered by another health plan that is NOT an

HSA-compatible High Deductible Health Plan

YOU RETAIN COMPLETE CONTROL OVER ALL ASPECTS OF THE HSA BANK ACCOUNT, INCLUDING:

• how much money you put into the account

• whether to use the account for current or future medical expenses

• which medical expenses to pay from the account

• whether to invest any of the money in the account

• which investments to make

PORTABILITYHSA Bank Accounts are completely portable, meaning you can keep your HSA even if you change jobs, change your medical coverage, become unemployed, move to another state, or change marital status. The funds remain in the account from year to year and are not subject to a “use it or lose it” rule.

PPO PLAN FEATURESPreferred Provider Organization (PPO) plans provide In-Network and Out-Of-Network benefits. The comprehensive PPO plans feature a lower deductible and a traditional office visit and prescription copay structure.

To obtain the highest benefit level, always try to find In-Network providers. Find PPO Network providers by visiting www.bcbstx.com and clicking “Find a Doctor,” selecting your state, then “BlueChoice PPO.” You can also call 800-521-2227 for assistance!

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Butch’s Health ManagementButch’s Health Management is an essential part of your benefits package. Our focus is helping our employees enjoy long, healthy, active lives. Annual wellness screenings are conducted in the fall and will provide a snapshot of your overall health. After your screening and throughout the year you will receive FREE access to valuable lifestyle and disease management coaching to help you reach your health goals.

BY COMPLETING A HEALTH SCREENING, YOU CAN SAVE UP TO $420 PER YEAR!

ANSWER THE CALL! Watch for a phone call from an iaWellness Lifestyle or Disease Management coach. Our coaches are here to help you understand your screening results and reach your health goals.

This FREE resource can help you with: N Medication questionsN Nutrition adviceN Exercise adviceN Goal settingN AccountabilityN Managing a chronic condition [Diabetes, heart disease, high blood pressure and more]

Participation is voluntary. Your health information is confidential and will not be shared with the company,only group-level information.

If you have any questions regarding the Butch’s wellness program, please contact iaWellness: P | 806-765-7265 Toll Free | 877-765-7265 E | [email protected]

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Telemedicine Services

091410E-101A

SET UP YOUR ACCOUNT

REQUEST A CONSULT

PROVIDE MEDICAL HISTORY

Your medical history provides Teladoc doctors with the information they need to make an accurate diagnosis.

Downloadthe app:Facebook.com/Teladoc Teladoc.com/mobile

Talk to a doctor anytime for Free

© 2016 Teladoc, Inc. All rights reserved. Teladoc and the Teladoc logo are trademarks of Teladoc, Inc. and may not be used without written permission. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services. © 2016 Teladoc, Inc. Todos los derechos reservados. Teladoc y el logotipo de Teladoc son marcas de Teladoc, Inc. y no pueden ser utilizados sin permiso por escrito. Teladoc no sustituye al médico de atención primaria. Teladoc no garantiza que una receta se escribe. Teladoc opera sujeta a la regulación estatal y pueden no estar disponibles en ciertos estados. Teladoc no prescribir sustancias controladas DEA, las drogas no terapéuticas y algunos otros medicamentos que pueden ser perjudiciales debido a su potencial de abuso. Médicos Teladoc reservamos el derecho de negar la atención por el mal uso potencial de los servicios.

Teladoc.com 1-800-Teladoc (835-2362)

It's quick and easy online. Visit the Teladoc website at Teladoc.com, click "Set up account" and provide the required information. You can also call Teladoc for assistance over the phone.

Once your account is set up, request a consult anytime you need care.

Online: Log into Teladoc.com and click "My Medical History". Mobile app: Log into your account and complete the "My Health Record" section. Visit Teladoc.com/mobile to download the app. Call Teladoc: Teladoc can help you complete your medical history over the phone.

Teladoc's U.S. board-certif ed doctors are available 24/7/365i to resolve many of your medical issues through phone or video consults. Set up your account today so when you need care now, a Teladoc doctor is just a call or click away.

Getting started with Teladoc®

Get started with Teladoc!

Medical plan participants and their dependents can start using the telemedicine services. You can set up your account online, on the mobile app or by phone. Remember, your consult fee is $0!

091410E-101A

SET UP YOUR ACCOUNT

REQUEST A CONSULT














091410E-101A

SET UP YOUR ACCOUNT

REQUEST A CONSULT














091410E-101A

SET UP YOUR ACCOUNT

REQUEST A CONSULT














091410E-101A

SET UP YOUR ACCOUNT

REQUEST A CONSULT














091410E-101A

SET UP YOUR ACCOUNT

REQUEST A CONSULT














091410E-101A

SET UP YOUR ACCOUNT

REQUEST A CONSULT














Medical plan participants and their dependents have FREE access to Teladoc services. You can register your account online, on the mobile app or by phone - just indicate you are a Butch’s Rat Hole employee. You get unlimited FREE consults!

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tooth Dental PlanButch’s provides all full-time employees with a dental insurance plan administered by BlueCross and BlueShield of Texas. Employees may elect to purchase coverage for themselves and their dependents. Below is a summary of benefits under the plan.

PLAN BENEFITSCalendar Year Deductible Individual $50

Preventive Care (e.g. Cleanings)

100%, Deductible waived

Basic Care (e.g. Fillings) 80%, After deductible

Major Care (e.g. Crowns, Dentures)

50%, After deductible

Orthodontia (Child Only Up To Age 19) 50%, After deductible

Annual Maximum Benefit $2,000 Per Covered Person

Orthodontia Lifetime Max $1,000 Per Covered Person

Employee Contributions Beginning first pay period after January 1, 2020

Coverage Tier Bi-Weekly Semi-Monthly

Employee Only $0.00 $0.00

Employee + Children $12.97 $14.06

Employee + Spouse $8.91 $9.65

Employee + Family $22.34 $24.21

The dental policy covers two routine cleanings per year at no cost to you when visiting in-network providers.

You may choose any dentist. However, if you elect to see an out-of-network provider, you may be balance billed for anything over the usual, reasonable and customary amount allowed by BlueCross and BlueShield of Texas. You can locate in-network dental providers at www.bcbstx.com or call 1.800.521.2227.

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Eye Vision PlanButch’s also provides a vision insurance plan to all employees and their dependents through Ameritas, utilizing the VSP network of providers. Employees may elect to purchase coverage for their dependents.

IN-NETWORK OUT-OF-NETWORKAnnual deductibles

Eye Exam Deductible $10 $10

Materials Deductible $25 $25

Eye Exam (Once every 12 months) Covered at 100% Up to $45 allowance

Glasses (Lenses: Once every 12 months, Frames: Once every 24 months)

Single Vision Lenses Covered at 100% Up to $30 allowance

Bifocal Lenses Covered at 100% Up to $50 allowance

Trifocal Lenses Covered at 100% Up to $65 allowance

Lenticular Lenses Covered at 100% Up to $100 allowance

Progressive Lenses See lens options N/A

Frames Up to $130 allowance Up to $70 allowance

Contact Lenses - in lieu of Glasses (Once every 12 months)

Exam and fitting 15% discount N/A

Elective Contacts Up to $130 allowance Up to $105 Allowance

Employee Contributions Beginning first pay period after January 1, 2020

Coverage Tier Bi-Weekly Semi-Monthly

Employee Only $0.00 $0.00

Employee + Children $2.23 $2.42

Employee + Spouse $3.45 $3.74

Employee + Family $5.70 $6.18

Locate an in network Vision provider at www.VSP.com or call 1.800.877.7195. If you use an out-of-network provider the benefits will be reduced and you will be required to submit a reimbursement to Ameritas along with the receipt for your related expenses.

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Life Insurance PlansBASIC TERM LIFE AND AD&D Butch’s provides employees with Basic Term Life and Accidental Death & Dismemberment coverage through BlueCross and BlueShield of Texas. This coverage is provided for all active full-time employees at no cost!

BASIC LIFE AND AD&D BENEFITS

Life Benefit $50,000

AD&D Benefit $50,000

Age Reduction Schedule35% at age 65

50% at age 70

VOLUNTARY TERM LIFE Butch’s also offers all active full-time employees the option to purchase Term Life Insurance coverage through BlueCross and BlueShield of Texas. This coverage would be in addition to the Basic Group Life coverage.

VOLUNTARY TERM LIFE BENEFITSGUARANTEE

ISSUE*

Employee Benefit In $10,000 increments, up to $500,000 or 5x annual earnings, whichever is less.

$150,000

Spouse BenefitUp to 100% of employee’s coverage

in increments of $5,000, not to exceed $500,000

$25,000

Child Benefit Up to 100% of employee’s coverage in increments of $2,000, not to exceed $10,000

$10,000

Voluntary Term Life premium rates are based on age and coverage amounts. See Plan Document for rate table. *Guarantee Issue amounts are only available at initial eligibility.

Please be sure you have a current designation of beneficiary form on file!

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Contacts

BUTCH’S RAT HOLE & ANCHOR SERVICE HR DEPARTMENTEddie Wilson

[email protected]

Lisa Vargas [email protected]

806.894.6294

MARSH & MCLENNAN AGENCYYanina Trejo Kiechler

Senior Account Manager [email protected]

806.794.3246

Pamela Hedrick Benefit Analyst

[email protected] 806.798.4327

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building Benefit Contacts

MY LIFE ADVISORS

ADP (English & Spanish support available)

1.855.547.8508 | [email protected]

MEDICAL, DENTAL & LIFE BENEFITSBlueCross and BlueShield of Texas 1.800.521.2227 | www.bcbstx.com

VISION BENEFITS

Ameritas Group/VSP 1.800.877.7195 | www.vsp.com

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pen Notes

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pen Notes

700 Austin StreetLevelland, TX 79336

806-894-6294

Employee Benefits Guide For Plan Year January 1, 2020 ......Life Insurance Plans 11 Contacts12...

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