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Maredith Carter

/ Full Time
Start Date: 10/09/1999

Enrollment Window

Newly Eligible / Enrollment Status: In Progress

Window Closes on 09/29/2019

Elected Benefits

Product	Carrier	Plan	Coverage Level	Enrolled Members	Effective Date	Cost Per Pay
Medical	Anthem Blue Cross	Anthem Gold $1000 PPO	Employee	Maredith Carter	02/01/2021	$86.54
TOTAL PER PAY COST:	$86.54

Newly Eligible / Enrollment Status: In Progress

Window Closes in 28 Days

Elected Benefits

Product	Carrier	Plan	Coverage Level	Enrolled Members	Effective Date	Cost Per Pay
TOTAL PER PAY COST:	$0

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Unlock an enrollment window for current year plans, such as a new hire, newly benefit eligible (due to employment changes), and employee qualified life event.

Benefits Summary

Product	Carrier	Plan	Coverage Level	Enrolled Members	Effective Date	Benefit Amount	Pay Per Cost
Medical	Blue Shield of California	Active Choice 500 80/50	Family	Maredith Carter Brian Carter Noah Carter	10/01/2019		$98.08
Dental	Delta Dental Insurance Company	Delta Dental PPO	Employee	Maredith Carter	10/01/2019		$4.62
Vision	EyeMed	EyeMed Vision	Employee	Maredith Carter	10/01/2019		$3.46
Group Life AD&D	Guardian	Guardian Group Life/AD&D	Employee	Maredith Carter	01/01/2019	$50,000	$0
Group Life AD&D	Guardian	Guardian Group Life/AD&D	Employee	Maredith Carter	01/01/2019	$50,000	$0
Voluntary Life AD&D	Unum Group	2019 UNUM Voluntary Life/AD&D	Employee	Maredith Carter	10/01/2019	$250,000	$21.92
Voluntary Life AD&D	Unum Group	2019 UNUM Voluntary Life/AD&D	Employee	Maredith Carter	10/01/2019	$100,000 Pending Carrier Approval	$8.77
Voluntary Life AD&D	Unum Group	2019 UNUM Voluntary Life/AD&D	Spouse	Brian Carter	10/01/2019	$150,000	$13.15
Voluntary Life AD&D	Unum Group	2019 UNUM Voluntary Life/AD&D	Spouse	Brian Carter	10/01/2019	$35,000 Pending Carrier Approval	$3.07
Voluntary Life AD&D	Unum Group	2019 UNUM Voluntary Life/AD&D	Child(ren)	Noah Carter	08/01/2019	$10,000	$0.42
Group Short Term Disability	Guardian	Guardian Group STD	Employee	Maredith Carter	01/01/2019	$923	$0
Group Short Term Disability	Guardian	Guardian Group STD	Employee	Maredith Carter	10/01/2019	$923	$0
Group Long Term Disability	Guardian	Guardian Group LTD	Employee	Maredith Carter	01/01/2019	$4,000	$0
Group Long Term Disability	Guardian	Guardian Group LTD	Employee	Maredith Carter	10/01/2019	$4,000	$0
Total Per Pay Cost $141.65

Product	Carrier	Plan	Coverage Level	Enrolled Members	Effective Date	Pay Per Cost
Medical	Anthem Blue Cross	Anthem Gold $1000 PPO	Employee	Maredith Carter	01/01/2019	$86.54
Dental	Delta Dental Insurance Company	Delta Dental PPO	Employee	Maredith Carter	01/01/2019	$4.62
Vision	EyeMed	EyeMed Vision	Employee	Maredith Carter	01/01/2019	$3.46
Voluntary Life AD&D	Unum Group	2019 UNUM Voluntary Life/AD&D	Employee	Maredith Carter	08/01/2019	$21.92
Voluntary Life AD&D	Unum Group	2019 UNUM Voluntary Life/AD&D	Spouse	Maredith Carter Brian Carter	08/01/2019	$13.15
Total Per Pay Cost $129.69

Product	Waive Date	Enrollment Window
Commuter	10/15/2019	Newly Eligible
Dependent Care FSA	10/15/2019	Newly Eligible
Dependent Care FSA	09/23/2019	New Hire

Your Employer Pays: $213.46 per pay

Plan Description

This is an HMO plan with Blue Shield of California. HMO plans have lower premiums, but subscribers are limited to a specific network of doctors and facilities, and must designate a primary care physician.

Coverage

Services	In Network	Out of Network
Coverage Basic Annual Individual Deductible Annual Family Deductible Coinsurance	- 1500 3000 60%	- 3000 6000 20%
Physician / Medical Services Preventive Services Primary Care Physician Specialist	- 0% $35 copay $60 copay	- 0% 80% 80%
Hospital Services Inpatient Hospital Outpatient Hospital	- 60% 60%	- 80% 80%
Emergency Care Services Emergency Room Urgent Care	- $300 copay $60 copay	- $300 copay 80%
Extended Care Services Home Health Care Hospice Services	- $300 copay $60 copay	- $300 copay 80%
Prescription Drugs Prescription Deductible Retail Supply Limit Retail Generic Drugs Retail Preferred Brand Drugs Retail Specialty Drugs	- $0 30 Days $25 copay $50 copay $100 copay	- $0 30 Days 80% 80% 80%