BENEFITS GUIDE 2023
MEDICAL • DENTAL • VISION
Important Notice:
Read Carefully This benefit guide briefly describes your benefit choices and your options to enroll. All benefits, and your eligibility for benefits are subject to the terms and conditions of the benefit plans, including group insurance contracts. This guide is not intended to be a complete description of the benefit plans and is not a summary plan description or plan document. In the event of any conflict or discrepancy between this guide and the plan documents, the plan documents will govern. Ryzen Solutions reserves the right to modify or terminate any of the described benefits at any time and for any reason. This guide is not a guarantee of current or future employment or benefits.
Table of Contents ELIGIBILITY AND ENROLLMENT 3 MEDICAL 4 DENTAL 10 VISION 12 CONTACTS 13 GLOSSARY 14
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ELIGIBILITY WHO IS ELIGIBLE
Full‐time employees who work a minimum of 30 hours per week, and their eligible dependents can participate in Ryzen’s employee benefits. Eligible dependents include: Your spouse or registered domestic partner Children, including natural, stepchildren, adopted and those whom you are the legal guardian • Disabled children of any age if you support them Review the Ryzen Solution benefits plan document for additional details regarding eligibility. • •
PROOF OF DEPENDENT ELIGIBILITY You may be required to provide proof of eligibility for your dependents. Note that attempting to enroll an ineligible dependent could lead to disciplinary action up to and including termination of employment. If your dependent becomes ineligible for coverage during the year, you must notify Human Resources within 30 days.
ENROLLMENT WHEN YOU CAN ENROLL New hires are eligible for benefits on the first day of the month following their date of hire. You must enroll in benefits within 30 days of your date of hire for your elections to be approved. Elections are completed in the Employee Navigator Portal. To access the portal, please review the Employee Navigator Enrollment Guide.
QUALIFYING EVENT Changes outside of Open Enrollment or your initial eligibility period will only be allowed if you experience a qualified change-in-status or HIPAA special enrollment event. Qualifying Events that may allow you to make changes to your benefits include: marriage, divorce, death, childbirth, adoption or placement for adoption and changes in employment for you or your spouse and/or domestic partner. To make any changes to your benefit elections due to a Qualified Event, you must submit your requested changes within 30 days of the qualified event date.
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MEDICAL PREFERRED PROVIDER ORGANIZATION (PPO) PLAN
UNITEDHEALTHCARE SELECT PLUS CI7Y PPO
SELECT PLUS NETWORK Calendar Year Deductible (Individual / Family) Calendar Year Out-of-Pocket Limit (Individual / Family)
IN-NETWORK
OUT-OF-NETWORK
None
$1,000 / $2,000
$2,500 / $5,000
$7,500 / $15,000
Lifetime Maximum
Unlimited
IN THE OFFICE $15 / $30
50% coinsurance1
No charge
Adult Services: Not covered
No charge/10% coinsurance
50% coinsurance1
10% coinsurance
50% coinsurance1
Chiropractic Care (24 visits)
$15 per visit
50% coinsurance1
Urgent Care
$50 per visit
50% coinsurance1
10% coinsurance
50% coinsurance1
$500
50% coinsurance1
Office Visit Copay (PCP / Specialist) Preventive Care Diagnostic Lab & X-ray (Designated network/In-Network) Advanced Imaging (MRI / PET)
Outpatient Surgery (Ambulatory Surgical Center/Office) IN THE HOSPITAL Hospitalization EMERGENCY SERVICES Emergency Room
$250 copay
Ambulance RETAIL PRESCRIPTIONS
10% coinsurance 30-DAY SUPPLY
30-DAY SUPPLY
Tier 1
$10
Fee - $102
Tier 2
$35
Fee - $352
Tier 3
$70
Fee - $702
30-DAY SUPPLY
30-DAY SUPPLY
Tier 1
$10
Fee - $102
Tier 2
$150
Fee - $1502
Tier 3
$250
Fee - $2502
PREFERRED SPECIALTY RETAIL PRESCRIPTIONS
CONTRIBUTIONS PER MONTH
Employee Only
YOUR COST
$434.96
Employee + Spouse
$1,412.31
Employee + Child(ren)
$1,162.34
Employee + Family
$2,139.70
1 After
deductible. 2 If you use an out-of-network pharmacy, you may be responsible for any amount over the allowed amount.
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MEDICAL PREFERRED PROVIDER ORGANIZATION (PPO) PLAN
UNITEDHEALTHCARE SELECT PLUS CJKM PPO
SELECT PLUS NETWORK Calendar Year Deductible (Individual / Family) Calendar Year Out-of-Pocket Limit (Individual / Family)
IN-NETWORK
OUT-OF-NETWORK
$500 / $1,000
$5,000 / $10,000
$7,150 / $14,300
$10,000 / $20,000
Lifetime Maximum
Unlimited
IN THE OFFICE Office Visit Copay (PCP / Specialist) Preventive Care
$35 / $70
50% coinsurance1
No charge
Adult Services: Not covered
20% coinsurance1
50% coinsurance1
Advanced Imaging (MRI / PET)
20%
coinsurance1
50% coinsurance1
Chiropractic Care (24 visits)
20% coinsurance1
50% coinsurance1
$50 per visit
50% coinsurance1
20% coinsurance1
50% coinsurance1
$350 copay, 20% coinsurance1
$350 copay, 50% coinsurance1
Diagnostic Lab & X-ray
Urgent Care
Outpatient Surgery (Ambulatory Surgical Center/Office) IN THE HOSPITAL Hospitalization EMERGENCY SERVICES Emergency Room
$350 per visit, then 20% coinsurance1 (waived if admitted)
Ambulance RETAIL PRESCRIPTIONS
20% coinsurance1 30-DAY SUPPLY
30-DAY SUPPLY
Tier 1
$10
Fee - $102
Tier 2
$35
Fee - $352
Tier 3
$70
Fee - $702
30-DAY SUPPLY
30-DAY SUPPLY
Tier 1
$10
Fee - $102
Tier 2
$150
Fee - $1502
Tier 3
$250
Fee - $2502
PREFERRED SPECIALTY RETAIL PRESCRIPTIONS
CONTRIBUTIONS PER MONTH
Employee Only Employee + Spouse Employee + Child(ren) Employee + Family
YOUR COST
$293.06 $1,051.99 $857.89 $1,616.83
1 After
deductible. 2 If you use an out-of-network pharmacy, you may be responsible for any amount over the allowed amount.
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MEDICAL PREFERRED PROVIDER ORGANIZATION (PPO) PLAN
UNITEDHEALTHCARE SELECT PLUS CJKP PPO
SELECT PLUS NETWORK
IN-NETWORK
OUT-OF-NETWORK
Calendar Year Deductible (Individual / Family)
$3,000 / $6,000
$10,000 / $20,000
Calendar Year Out-of-Pocket Limit (Individual / Family)
$7,150 / $14,300
$20,000 / $40,000
Lifetime Maximum
Unlimited
IN THE OFFICE $35 / $70
50% coinsurance1
No charge
Adult Services: Not covered
Office Visit Copay (PCP / Specialist) Preventive Care Diagnostic Lab & X-ray
20%
coinsurance1
50% coinsurance1
Advanced Imaging (MRI / PET)
20% coinsurance1
50% coinsurance1
Chiropractic Care (24 visits)
20% coinsurance1
50% coinsurance1
$50 per visit
50% coinsurance1
20% coinsurance1
50% coinsurance1
$350 copay, 20% coinsurance1
$350 copay, 50% coinsurance1
Urgent Care Outpatient Surgery (Ambulatory Surgical Center/Office) IN THE HOSPITAL Hospitalization EMERGENCY SERVICES Emergency Room
$350 copay, 20% coinsurance1
Ambulance RETAIL PRESCRIPTIONS Tier 1
20% coinsurance1 30-DAY SUPPLY
30-DAY SUPPLY
$5
Fee - $52
Tier 2
$50
Fee - $502
Tier 3
$100
Fee - $1002
30-DAY SUPPLY
30-DAY SUPPLY
PREFERRED SPECIALTY RETAIL PRESCRIPTIONS Tier 1
$5
Fee - $52
Tier 2
$150
Fee - $1502
Tier 3
$250
Fee - $2502
CONTRIBUTIONS PER MONTH
YOUR COST
Employee Only
$205.36
Employee + Spouse
$829.31
Employee + Child(ren)
$669.72
Employee + Family
$1,293.67
After deductible 2 If you use an out-of-network pharmacy, you may be responsible for any amount over the allowed amount. 1
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MEDICAL **PLEASE NOTE** You can only enroll on the below plan if you live in one of the following counties: Alameda, Contra Costa, Marin, Santa Clara, Santa Cruz, San Francisco, San Mateo Solano or Sonoma. EXCLUSIVE PROVIDER ORGANIZATION (EPO) PLAN DOCTOR’S PLAN NETWORK
UNITEDHEALTHCARE DOCTOR’S PLAN CJFP IN-NETWORK
Calendar Year Deductible (Individual / Family)
$2,500 / $5,000
Calendar Year Out-of-Pocket Limit (Individual / Family)
$7,500 / $15,000
Lifetime Maximum
Unlimited
IN THE OFFICE Office Visit Copay (PCP / Specialist) Preventive Care
$30/$60 per visit No charge
Diagnostic Lab & X-ray
30% coinsurance1
Advanced Imaging (MRI / PET)
30% coinsurance1
Chiropractic Care (24 visits) Urgent Care Outpatient Surgery (Ambulatory Surgical Center/Office)
$30 per visit $50 per visit 30% coinsurance1
IN THE HOSPITAL Hospitalization
30% coinsurance1
EMERGENCY SERVICES Emergency Room
30% coinsurance1
Ambulance
30% coinsurance1
RETAIL PRESCRIPTIONS
30-DAY SUPPLY
Tier 1
$5
Tier 2
$50
Tier 3 /Specialty PREFERRED SPECIALTY RETAIL PRESCRIPTIONS
$100 30-DAY SUPPLY
Tier 1
$5
Tier 2
$150
Tier 3
CONTRIBUTIONS PER MONTH
$250
YOUR COST
Employee Only
$146.93
Employee + Spouse
$680.93
Employee + Child(ren) Employee + Family 1
$544.36 $1,078.38
After deductible.
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MEDICAL **PLEASE NOTE** You can only enroll on the below plan if you live in one of the following counties: Alameda, Contra Costa, Marin, Santa Clara, Santa Cruz, San Francisco, San Mateo Solano or Sonoma. EXCLUSIVE PROVIDER ORGANIZATION (EPO) PLAN DOCTOR’S PLAN NETWORK
UNITEDHEALTHCARE DOCTOR’S PLAN CJFT IN-NETWORK
Calendar Year Deductible (Individual / Family)
$5,000 / $10,000
Calendar Year Out-of-Pocket Limit (Individual / Family)
$8,000 / $16,000
Lifetime Maximum
Unlimited
IN THE OFFICE Office Visit Copay (PCP / Specialist) Preventive Care
$35/$70 per visit No charge
Diagnostic Lab & X-ray
30% coinsurance1
Advanced Imaging (MRI / PET)
30% coinsurance1
Chiropractic Care (24 visits)
$35 copay
Urgent Care
$50 per visit
Outpatient Surgery (Ambulatory Surgical Center/Office)
30% coinsurance1
IN THE HOSPITAL Hospitalization
30% coinsurance1
EMERGENCY SERVICES Emergency Room
30% coinsurance1
Ambulance
30% coinsurance1
RETAIL PRESCRIPTIONS
30-DAY SUPPLY
Tier 1
$5
Tier 2
$50
Tier 3 /Specialty PREFERRED SPECIALTY RETAIL PRESCRIPTIONS
$100 30-DAY SUPPLY
Tier 1
$5
Tier 2
$150
Tier 3
CONTRIBUTIONS PER MONTH
$250
YOUR COST
Employee Only
$116.02
Employee + Spouse
$602.44
Employee + Child(ren)
$478.04
Employee + Family
$964.48
1
After deductible.
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MEDICAL HOW TO FIND A MEDICAL PROVIDER If you are enrolled in one of the Select Plus medical plans: •
Visit www.myuhc.com and select ‘Find a Provider’
•
Select ‘Medical Directory’ then click ‘Employer and Individual Plans’
•
Click the ‘Select Plus’ network to begin your search
If you are enrolled in the Doctor’s Plan medical plan: •
Visit www.myuhc.com and select ‘Find a Provider’
•
Select ‘Medical Directory’ then click ‘Employer and Individual Plans’
•
Click the ‘Doctor’s Plan’ network to begin your search
MEDICAL MOBILE APP Download the UnitedHealthcare Mobile App for FREE on the Apple iTunes App Store and the Android Market. You will have instant access to the following features! •
Fina a Provider
•
Review your benefits
•
Check claim status
•
View your ID card
•
Contact UHC customer service
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DENTAL CA SELECT MANAGED CARE NETWORK
UNITED HEALTHCARE DHMO PLAN (CA ONLY)
EXAMS AND DIAGNOSTICS Annual Maximum Annual Deductible
None None
Oral Exam
No cost
Teeth Cleaning
No cost
Bitewing X-ray
No cost
RESTORATIVE Cavities - Amalgam, 1 surface
No cost
Cavities - Amalgam, 2 surfaces
No cost
CROWNS Resin with predominantly base metal
$175
Full cast predominantly base metal
$175
PERIODONTICS Gingivectomy Per Tooth Periodontal Scaling and Root Planning per quadrant
$115 (4+ Contiguous Teeth) $75 (1-3 Contiguous Teeth) $40 (4+ Teeth) $28(1-3 Teeth)
ENDODNTICS Anterior (Front) Tooth Root Canal
$75
Bicuspid Tooth Root Canal
$150
Molar Root Canal
$275
WAITING PERIODS
None
ORAL SURGERY Extraction
No charge ($25 Erupted Tooth Requiring Removal of the bone)
Removal of Impacted Tooth - Partial Bony
$75
Removal of Impacted Tooth - Completely Bony
$115
ORTHODONTICS Adolescent
$1,895
Adult
$1,895
PROSTHODONTICS
Complete Denture—Maxillary Complete Denture—Mandibular CONTRIBUTIONS PER MONTH
$225 $225 YOUR COST
Employee Only
$0.97
Employee + Spouse
$15.92
Employee + Child(ren)
$15.92
Family
$34.63
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DENTAL PREFERRED PROVIDER ORGANIZATION (PPO) PLAN DENTAL PPO 30 NETWORK Calendar Year Deductible (Individual / Family) Calendar Year Plan Maximum
UNITED HEALTHCARE DENTAL PLAN IN-NETWORK
OUT-OF-NETWORK
$50 / $150
$50 / $150
$1,500 per member
$1,500 per member
Diagnostic & Preventive Care
No charge (deductible waived)
Basic Care
20%
20%
Endodontics & Periodontics
20%
20%
Major Care
50%
50%
Orthodontia (Adult & Child)
50%
50%
Orthodontia Maximum
$1,500 Lifetime Maximum
CONTRIBUTIONS PER MONTH
$1,500 Lifetime Maximum YOUR COST
Employee Only
$33.24
Employee + Spouse
$62.25
Employee + Child(ren)
$78.60
Family
$160.84
The out-of-network percentage of benefits is based on the schedule of usual and customary fees in the geographic area in which the expenses are incurred.
HOW TO FIND A DENTAL PROVIDER United Healthcare —Dental •
To search for a UHC contracted dentist for the PPO plan you go to www.myuhc.com and select ‘Find a dentist’, then select ‘Employer and Individual Plans’, enter your zip code, then select ‘*National Options PPO 30’
•
To search for a UHC contracted dentist for the HMO plan, you go to www.myuhc.com and follow the same instructions as above, but select ‘CA Select Managed Care DHMO Plan’
•
Search for dentists, specialists, or enter a keyword or find by category
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VISION PREFERRED PROVIDER ORGANIZATION (PPO) PLAN UHC SPECTERA NETWORK
UNITEDHEALTHCARE VISION PLAN IN-NETWORK
FREQUENCY Exam
Every plan year
Lenses
Every plan year
Frames
Every other plan year
Contacts
Every plan year
COPAYS Eye Exam Materials Frames
$10 copay $25 copay $200 allowance
Standard Lenses Single Vision
Covered in full
Bifocal
Covered in full
Trifocal
Covered In full
Contact Lenses (in lieu of glasses) CONTRIBUTIONS PER MONTH
$200 allowance YOUR COST
Employee Only
$8.69
Employee + Spouse
$17.07
Employee + Child(ren)
$17.39
Family
$27.73
HOW TO FIND A VISION PROVIDER UHC Spectera Eyecare Network—Vision •
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Visit www.myuhcvision.com and select the ‘*UnitedHealthcare Vision Plans’ network, then enter your zip code
CONTACTS PLAN TYPE
GROUP NUMBER
TELEPHONE
WEBSITE
UnitedHealthcare Select Plus
922835
866.633.2446
www.myuhc.com
UnitedHealthcare Doctor’s Plan
922835
833.805.7677
www.myuhc.com
922835
800.445.9090
www.myuhc.com
922835
800.638.3210
www.myuhcvision.com
MEDICAL
DENTAL UnitedHealthcare VISION UnitedHealthcare BENEFITS INFORMATION WEBSITE Benefits Website
Password: ryzen2018
www.verusinsurance.com/ryzen
BENEFITS ENROLLMENT PORTAL Benefits Enrollment & Election Website
www.employeenavigator.com
BROKER SolV Independent Insurance Associates Benefits Advocacy Team (BAT)
Ryzen
833.476.5848
[email protected]
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GLOSSARY OF TERMS COBRA Federal law (Consolidated Omnibus Budget Reconciliation Act of 1985) requiring certain employers that offer group health plans to provide continuation coverage to employees and their dependents who incur certain qualifying events. Coinsurance or Cost Sharing The portion of covered health care costs for which the plan pays after the deductible is met. You pay the remainder, up to the out-of-pocket maximum. Copayment or Copay A set amount you pay out-of-pocket for a particular service. The plan pays the balance. Deductible The out-of-pocket amount you must pay each plan year before the plan pays for eligible benefits. Explanation of Benefits (EOB) A statement from a plan explaining how a claim was paid. HIPAA Authorization Under HIPAA, a document that authorizes the use or disclosure of an individual’s Protected Health Information by a Covered Entity for any purpose described in the document and meets specific requirements. In-Network Provider A provider who has contracted with a health care plan (a medical, dental or vision plan) and agreed to certain rates. In most cases, you pay less and receive a higher benefit when you use innetwork providers. Check with your plan for coverage details. Negotiated rates The costs for health care services negotiated between the insurance carrier and in-network health care providers. Negotiated rates are usually less than usual, customary and reasonable (UCR) charges. Out-of-Pocket Expenses Copays, deductibles, and other expenses that are not covered by the health plan. Out-of-Network Provider A state-licensed health care provider who has not contracted with a health care plan (medical, dental or vision plan) and has not agreed to certain rates. In most cases, you pay more and receive a lower level of benefits when you use out-of-network providers. See your plan for coverage details. Qualifying Life Event Certain events which may allow you to make changes to your benefits. Qualifying events include: marriage, divorce, death, birth, adoption or placement for adoption, and significant change in employment. Reasonable and Customary (R&C) or Usual, Customary & Reasonable (UCR) A term used in many health plans, defined as the price at or below which the majority of healthcare professionals of similar expertise charge for similar procedures within a specific geographic area. Tier 1 Prescriptions Represents the lowest cost drugs and usually includes generic medications. Tier 2 Prescriptions Represents the mid-range cost drugs and usually includes preferred brand name medications. Tier 2 medications considered if no Tier 1 medication is appropriate. Tier 3 Prescriptions Represents the next most costly brand drugs, often with Tier 1 or Tier 2 alternatives and includes many moderate to high-cost brand drugs. Specialty Drugs Specialty drugs are high-cost prescription medications used to treat complex, chronic conditions.
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SolV Independent Insurance Associates 4170 Douglas Blvd, Suite 100 Granite Bay, CA 95746 www.solvins.com I 833.476.5848