Alaska Gateway

School District
Public Employees Health Trust
Insurance Plans

July 2020 to July 2021

Deductibles & out of pocket runs from January 1 – December 31

907.522.2229 1.888.533.9669
 TABLE OF CONTENTS
PEHT Medical/Rx Insurance
Group #000350 pehtak.com
Customer Service 1.907.274.7526
Bridgehealth http://pehtak.com/index.php/links

PEHT Dental Insurance

Group #000350 pehtak.com
Customer Service 1.907.274.7526

PEHT Vision (VSP) Insurance

Group #000350 vsp.com or pehtak.com
Customer Service 1.800.877.7195
UNUM Life Insurance and
Accidental Death/Dismemberment Insurance
Group #700032
www.askunum.com 1.877.851.7637
Customer Service

UNUM Long Term Disability Insurance

Group #700032
www.askunum.com 1.877.851.7637
Customer Service

gina@ginabosnakis.com
terri@ginabosnakis.com
ALASKA GATEWAY
SCHOOL DISTRICT

PEHT MEDICAL
Rx
and
DENTAL
 IT IS VERY IMPORTANT THAT YOU SEEK ANY
MEDICAL CARE “IN-NETWORK”
NOT OUT-OF- NETWORK

PEHT pays “Out-of-Network” claims at 125% of Medicare for medical treatment (not dental or VSP)
and there is no out of pocket dollar limit, unless the providers you go to are 50 miles or more
away from any In-Network providers. For reference, charges for care generally fall between 300%
and 800% of Medicare, so 125% of Medicare means that you would be responsible for a very large
doctor bill with no limit to how much you have to pay, and it doesn’t go toward your In-Network out of
pocket maximum.

1st THING TO TRY

Call PEHT at 907.274.7526 (or 1.888.685.6526 if you’re out of state) and ask them if the providers
you plan to go to are In-Network and, if not, ask them to give you names of providers in your area
who are In-Network. Don’t forget, this may be more than one provider.

2nd THING TO TRY

Go to either www.pehtak.com “links” page OR copy and paste this link:

www.aetna.com/docfind/home.do?site_id=asa&langprefer=en to find In-Network Providers.

You will need to know all providers that will be involved, including doctors, labs, anesthesiologists*,
etc.

*PEHT has included all Alaska anesthesiologists as In-Network, since you don’t’ always have a
choice

3rd THING TO TRY

If you are willing to leave the State for surgery, either call BridgeHealth at 1.855.265.2874;
e-mail BridgeHealth at PEHT@BridgeHealth.com; or log into your PEHT portal and register for
BridgeHealth with Code TVIBF to find out if your surgery qualifies.

If BridgeHealth approves your surgery, they will find you In-Network providers in, say, Seattle, then
your plan will pay for coach airfare for you and anyone you want to travel with you (does not need to
be family), they will pay you up to IRS limits for your hotel room and incidentals and PEHT will not
charge you your deductible or coinsurance – approved medical care will be paid 100%. If you
want to stay in the area to do something fun, that’s fine, you will be responsible for hotel and
incidentals after you’ve been given approval to come back home, but you can fly back whenever you
want (it does not have to be the day your surgeon says you can leave). This process can take up to 6
– 8 weeks so it is strictly for scheduled surgeries, not emergencies.
 ALASKA GATEWAY SCHOOL DISTRICT
BRIEF SUMMARY OF PEHT INSURANCE

If there is an In-Network Provider within 50 miles from where you receive care
from an Out-of-Network Provider
your plan covers expenses at 125% of Medicare with no out of pocket limit
__________________________________________________________________________________________
DESCRIPTION BENEFIT
MEDICAL Assumes In Network Provider Used
Deductible $100 Individual / $300 Family
Emergency Room Deductible $500 per incident (waived if admitted)
Inpatient Hospital Deductible $500 per admission (limited to 2/year/person)
In-Network Out of Pocket Maximum $1,000/Individual and $3,000/Family
Preventive Care 100% covered (please refer to booklet for limitations)
Office Visit Co-pays Deductible then 20% (Providence Express $25)
24/7 doctors available for diagnosis at no cost
Teledoc Rx can be ordered at your Rx co-pay amount
Spinal Manipulations 20 visits/year, subject to deductible and 20%
Massage Therapy 20 visits/year, subject to deductible and 20%
Physical Therapy 20 visits/year, subject to deductible and 20%
Mental Health/Substance Abuse Deductible and 20%, in and outpatient, no limit
Ground Ambulance Deductible then 20%
Emergency Air Transportation Deductible then 20%
100% paid, for surgeries that are pre-authorized for
this benefit.*
BridgeHealth Benefit
Travel for 2 people, hotel and incidentals up to IRS
limits. Takes 6-8 weeks for approval.
If pre-approved, you will receive $750
mi Choice
Same as BridgeHealth, including the $750
(If BridgeHeatlh not approved)
Medical Evacuation Deductible then 20%
Retail 30 Day Supply Rx Mail Order – 90 Day Supply 2x below
Generic Rx 25% ($10 min/$25 max)
Preferred Brand 25% ($20 min/$40 max)
Non-Preferred Brand 25% ($45 min/$85 max)
50% no Deductible
Specialty Rx $100/Rx Value; $400/Rx Formulary;
$600/Rx Non-Formulary
Hearing Benefit $2,500/ear every 36 months
 Benefit Highlights Page 2 of 2

PEDIATRIC DENTAL (under 18) Benefit is under medical 100% paid, no deductible
Examinations 2/calendar year/child
Cleanings 2/calendar year/child
Fluoride Treatments 2/calendar year/child
Bitewing Series Images 2/calendar year/child
Routine X-Rays (including panoramic) 5/ calendar year/child
Sealants (under 17 years old) 1/permanent tooth/5 calendar years
ADULT DENTAL
Deductible $50 individual /$150 family
Calendar Year Maximum $2,000/year/person
Lifetime Orthodontia Maximum $2,000/lifetime/person
Preventive 0% (does not count toward calendar year maximum)
Basic 20% to combined $2,000
Major 50% to combined $2,000
Orthodontia 50% Lifetime maximum up to $2,000 per person
VSP VISION (Assumes you see In-Network Panel Provider)
Examination $25/calendar year/person
Contact Lens Examination/Fitting $60/calendar year/person
Materials (Frames/Lenses or Contacts) $25/calendar year/person
Contact Lens Allowance $130 (medically necessary)
Frames in Lieu of Contacts $195/calendar year/person or 2 pair every other year
Costco Frame Allowance $105
Lenses for in Frames Covered in full after $25 co-pay
Please refer to your booklet for details

Children of a covered employee who are on the plan

will be covered for maternity costs
(the coverage ends after the birth
and release from birthing center or hospital)
 PEHT TRAVEL BENEFIT

Each member of the plan is able to utilize two non

emergency travel benefits in a calendar year. The travel
benefit is for the treatment of a medical injury or illness. The
benefit is not for preventative or dental/vision services.

The member and the physician will complete the non

emergency travel form which can be found on the
pehtak.com site under forms.

The ticket would need to be purchased 14 days* advance

and the form submitted to our office prior to the beginning
of travel. The benefit is subject to deductibles and copay
amounts. The travel benefit is to the nearest location where
services can be provided.

*If you do not have 14 days in avance of the required Medical

travel, please contact my office and I will arrange to have the 14
day requirement waived.
Planned Surgery Program
The Public Education Health Trust health plan expands your options with the BridgeHealth surgery program at no
additional cost to you. BridgeHealth saves you money and gives you access to top-rated hospitals, surgery centers
and doctors for planned, non-emergent procedures.

PPO PLANS HIGH DEDUCTIBLE PLANS

YOU PAY $ 0 No deductible

No coinsurance
$ 0 After you meet
your deductible
CARE
ALLOWANCE Receive a $750 incentive when you choose BridgeHealth

THE BEST EASY-TO-UNDERSTAND A TRUSTED

Care. Benefits. Guide.
We connect you with We’ve simplified surgery benefits with We handle all the details from
top-rated facilities and pre-negotiated bundled rates—one set finding a top-rated provider to
surgeons. cost for your procedure. plan approvals and scheduling.

MOST COMMON COVERED PROCEDURES

Bariatric Cardiac General Orthopedic Spine Women’s

Gastric bypass, Coronary artery bypass Gall bladder ACL repair, hip and knee Spinal fusion, Health
gastric sleeve, lap graft, valve repair and removal, replacement, shoulder artificial disc Hysterectomy
band removal replacement hernia repair repair and replacement replacement

Emergency, vision, dental and diagnostic procedures are not available through BridgeHealth. Call for a complete list of procedures.

Considering surgery?
CALL US TO LEARN ABOUT YOUR OPTIONS.

(855) 265-2874 | peht@bridgehealth.com | BridgeHealth.com

Register with company code: TVIBF
 For Services outside of BridgeHealth, miChoice can work for you!

Join the movement toward smarter healthcare

miChoice Know the hospital’s
quality prior to your
Know what
the charges
Avoid potential harm by choosing
a hospital and provider based on
lets you know scheduled procedure will be quality and costs
before you go:

and… receive enhanced benefits when you use miChoice

HOW I T WORKS

STEP 1 > STEP 2 > STEP 3 > STEP 4 >

When BridgeHealth A miChoice Concierge Your miChoice Your Clinical
options are not will walk you through Concierge will Coordinator, a
available miChoice your options for coordinate with your registered nurse, will
can work for you for quality, costs, and provider of choice. also support your
planned procedures. benefits associated Additionally, if travel medical journey both
with each possible is necessary, they will before and after your
hospital. handle all your travel procedure.
arrangements.

100,000 Preventable Average person has 9.2 medical procedures

2000 Deaths in Hospitals
in their lifetime and in 25% of these they will
be harmed by hospital medical errors.

250,000 Preventable
TODAY Deaths in Hospitals
New England Journal of Medicine, Marty Makary, Unaccountable: What
John T. James, JournalPatientSafety.com, Lippincott Williams & Wilkins, 2013 Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care

To find the best provider for your healthcare needs,

please call us at: 866.677.8745
 You’ve got this
Your online provider directory makes healthy simpler

Finding a doctor or other health care professional is an important part of staying healthy.
Our online directory helps make it simpler. It offers you up-to-date information about
providers — and it’s available online, anytime.

Provider details Narrowing your search

To visit our online directory, simply go to aetna.com/asa. Want to refine your search even further?
Begin searching for a doctor using your location — ZIP, city, Multiple options are available. You can easily:
county or state. You can use either the general or category • Filter by provider characteristics — such as:
search to see provider details that typically include:
- Specialty
• Board certification
- Languages spoken
• Hospital affiliation
- Gender
• Medical school/year of graduation
- Board certification
• Gender
- Hospital affiliation
• Website address (if available) - Accepting new patients
• Specialties - Performance — such as Aexcel** providers
• Languages spoken or Institutes of Excellence and Institutes of
You can also see additional provider information that can Quality® facilities
include: participation information*, other office locations, • Expand or reduce the geographic radius of
whether they’re accepting new patients, maps, driving your results
directions and more.
• Sort by best matched or distance

Additional features • View a map to see the locations of results

You’ll be able to find specialty care, too. Like a list
of transplant facilities or pediatric congenital heart
surgery facilities that are part of our Institutes of
Excellence™ network.
and get driving directions
• Print results
If you wish to view additional information about providers,
detail pages are available (on selected providers).

aetna.com/asa
72.03.598.1 (08/18)
 REGISTER
WITH
TELADOC
TODAY!
Once registered, you
can speak with a licensed
doctor.
Anytime. Anywhere.

3 WAYS TO REGISTER

OR OR During registration, you’ll complete

your medical history so when you
need Teladoc, it’ll be fast and easy.
Online Mobile App Phone

Teladoc is the easy, convenient, and affordable option for quality medical care. Our licensed doctors can treat
cold and flu symptoms, respiratory infections, sinus problems, ear infections, and more!

With your consent, Teladoc is happy to provide information about your Teladoc consult to your primary care physician.

Talk to a doctor anytime for free!

Teladoc.com 1-800-Teladoc
Facebook.com/Teladoc Teladoc.com/mobile

© 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. 10E-179
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, 0116
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.
 0
TELADOCw
Teladoc® Frequently Asked Questions
What is Teladoc?
Teladoc is the first and largest provider of
telehealth medical consults in the United
States, giving you 24/7 /365 access to
quality medical care through phone and
video consults.
Who are the Teladoc doctors?
Teladoc doctors are U.S. board certified
in Internal Medicine, Family Practice,
or Pediatrics. They average 20 years
practice experience, are licensed in your
state, and incorporate Teladoc into their
day-to-day practice as a way to provide
people with convenient access to quality
medical care.
Does Teladoc replace my doctor?
No. Teladoc does not replace your
primary care physician. Teladoc should
be used when you need immediate care
for non-emergent medical issues. It is
an affordable, convenient alternative to
urgent care and ER visits.
What kind of medical care
does Teladoc provide?
Teladoc provides adult and pediatric
general medical care.
What consult methods are available?
You can talk with a Teladoc doctor via a
phone consult, video consult within the
secure member portal, or video consult
within the Teladoc mobile app.
~ Teladoc.com
0 Facebook.com/Teladoc
© 2017 Teladoc, Inc. All rights reserved. Teladoc and the Teladoc logo are registered trademarks ofTeladoc, Inc. and may not be used without written permission. Teladoc does not replace the
will be written. Teladoc ope rates subject to state regulation and may nat be available in certain states. Teladoc does not
primary care physic:ian. Teladoc does not guarantee that a prescription
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
__ .. __ .. :_t-: .......... -•~--·=~~ ..
How do I set up my Teladoc account?
Setting up your account is a quick and
easy process on line. Visit the Teladoc
website and click "Set Up Account".
Follow the on line instructions.
How do I request a consult
to talk to a doctor?
Visit the Teladoc website, log into your
account and click "Request a Consult" .
You can also call Teladoc to request a
consult by phone.
How quickly can I talk to the doctor?
Median call back time is just 10 minutes.
If you miss the doctor's call, whether you
are away from the phone or you have
anonymous call blocker on, you will be
returned to the bottom of the waiting
list. The consult request is cancelled if
you miss three calls.
Is there a time limit
when talking with a doctor?
There is no time limit for consults.
Can Teladoc doctors
write a prescription?
Yes, Teladoc doctors can prescribe short-
term medication for a wide range of
conditions when medically appropriate.
Teladoc doctors do not prescribe
substances controlled by the DEA, non-
therapeutic and/or certain other drugs
which may be harmful because of their
potential abuse .
~ 1-800-Teladoc
~ Teladoc.com/mobile
How do I pay for a prescription
called in by Teladoc?
When you go to your pharmacy of choice
to pick up the prescription, you may use
your health/prescription insurance card
to help pay for the medication. You will
be responsible for the co-pay based on
the type of medication and your plan
benefits.
Is the consult fee the same price,
regardless of the time?
Yes! Teladoc charges one flat rate per
consult. There is no charge for PPO plans .
How do I pay for the consult?
You can pay with your HSA (health
savings account) card, credit card,
prepaid debit card or by PayPal.
If the Teladoc doctor recommends that
I see my primary care physician or a
specialist, do I still have to pay the
Teladoc consult fee?
Yes. Just like any doctor appointment,
you must pay for the consulting doctor's
time.
Can I provide consult information
to my doctor?
Yes. You have access to your electronic
medical record at anytime. Download
a copy on line from your account or call
Teladoc and ask to have your medical
record mailed or fa xed to you.
Dependent Children covered under your plan are now covered
for delivery of a child (your grandchild) - delivery only

MATERNITY MANAGEMENT

Are you or your spouse pregnant? If so, you can take advantage of the
Maternity Management program to get one-to-one support from a
registered nurse who can help you achieve a healthy pregnancy.

Through the Maternity Management program, a nurse will call you on

a regular basis to provide educational information and discuss ways to
minimize the risks to you and your baby. Your nurse, who is experienced
in all aspects of prenatal care, will also help you manage your diet
and exercise and discuss other ways to stay healthy throughout your
pregnancy. Even if you aren’t a first-time mom, your nurse can help
you through the changes that come with each unique pregnancy.

Questions regarding
Maternity Management?
Call 1-866-894-1505.
 •

• •

•
•
• •

•
•

•
•
•
ALASKA GATEWAY
SCHOOL DISTRICT

PEHT
VSP
VISION
 Protect
your vision
with VSP.

Get the best in eye care and eyewear

with PUBLIC EDUCATION HEALTH
TRUST and VSP® Vision Care.
At VSP, we invest in the things you value most—the best care
at the lowest out-of-pocket costs. Because we’re the only
national not-for-profit vision care company, you can trust that
we’ll always put your wellness first.
You’ll like what you see with VSP.
See why we’re consumers’ #1
Value and Savings. You’ll enjoy more value and the lowest out-of-pocket 2
costs.
choice in vision care .
High Quality Vision Care. You’ll get the best care from a VSP provider,
including a WellVision Exam®—the most comprehensive exam designed Contact us. 800.877.7195
to detect eye and health conditions. vsp.com
Choice of Providers. The decision is yours to make—choose a VSP doctor,
a participating retail chain, or any out-of-network provider.
Great Eyewear. It’s easy to find the perfect frame at a price that fits your
budget.

Using your VSP benefit is easy.

Create an account at vsp.com. Once your plan is effective, review your
benefit information.
Find an eye care provider who’s right for you. To find a VSP provider,
visit vsp.com or call 800.877.7195.
At your appointment, tell them you have VSP. There’s no ID card
necessary. If you’d like a card as a reference, you can print one on
vsp.com.
That’s it! We’ll handle the rest—there are no claim forms to complete when
you see a VSP provider.

Choice in Eyewear
From classic styles to the latest designer frames, you’ll find hundreds of
options. Choose from featured frame brands like bebe®, Calvin Klein,
1
Cole Haan, Flexon®, Lacoste, Nike, Nine West, and more . Visit vsp.com to
find a Premier Program location that carries these brands. Prefer to shop
online? Check out all of the brands at Eyeconic.com, VSP's online eyewear
store.
Your VSP Vision Benefits Summary
PUBLIC EDUCATION HEALTH TRUST and VSP provide you with an affordable eye
care plan.

VSP Provider Network: VSP Signature

Benefit Description Copay Frequency
Your Coverage with a VSP Provider
WellVision Exam Focuses on your eyes and overall wellness $25 Every calendar year

Prescription Glasses $25 See frame and lenses

$195 allowance for a wide selection of frames
Included in
$215 allowance for featured frame brands
Frame Prescription Every other calendar year
20% savings on the amount over your allowance
Glasses
$105 Costco® frame allowance
Included in
Single vision, lined bifocal, and lined trifocal lenses
Lenses Prescription Every calendar year
Polycarbonate lenses for dependent children
Glasses
Anti-reflective coating $0
Standard progressive lenses $50
Lens Enhancements Premium progressive lenses $80 - $90 Every calendar year
Custom progressive lenses $120 - $160
Average savings of 35-40% on other lens enhancements

Contacts (instead of $130 allowance for contacts; copay does not apply
Up to $60 Every calendar year
glasses) Contact lens exam (fitting and evaluation)

Additional Pairs of Eyewear

$195 allowance for a wide selection of frames
$215 allowance for featured frame brands $25 for frame
Frame Every other calendar year
20% savings on the amount over your allowance and lenses
$105 Costco® frame allowance
Single vision, lined bifocal, and lined trifocal lenses Combined with
Lenses Every calendar year
Polycarbonate lenses for dependent children Frame
Contacts (instead of $130 allowance for additional contacts
Up to $60 Every calendar year
glasses) Contact lens exam (fitting and evaluation)

Glasses and Sunglasses

Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details.
30% savings on additional glasses and sunglasses, including lens enhancements, from the same VSP provider on the
same day as your WellVision Exam. Or get 20% from any VSP provider within 12 months of your last WellVision Exam.
Extra Savings Retinal Screening
No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam
Laser Vision Correction
Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities
After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor

Your Coverage with Out-of-Network Providers

Visit vsp.com for details, if you plan to see a provider other than a VSP network provider.
Exam .............................................................................. up to $50 Lined Bifocal Lenses ........................................... up to $75 Progressive Lenses .............................................. up to $75
Frame ............................................................................ up to $70 Lined Trifocal Lenses ....................................... up to $100 Contacts .................................................................... up to $105
Single Vision Lenses ........................................... up to $50

Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details. Coverage information is subject to change. In the event of a conflict between this
information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location.

Contact us. 800.877.7195 | vsp.com

1
Brands/Promotion subject to change.
2
Blueocean Market Intelligence National Vision Plan Member Research, 2014
©
2014 Vision Service Plan. All rights reserved. VSP, VSP Vision care for life, and WellVision Exam are registered trademarks of Vision Service Plan. Flexon is a registered trademark of Marchon Eyewear,
Inc. All other company names and brands are trademarks or registered trademarks of their respective owners.
 ALASKA GATEWAY
SCHOOL DISTRICT

UNUM
Life, Accidental Death
and/or Dismemberment
and Voluntary Insurance
 Alaska Gateway School District
Policy #210843
Employer-paid Life and AD&D Benefit Summary
Who is eligible for this All actively employed employees working at least 6 hours each day for your
coverage? employer in the U.S. and their eligible spouses and children (up to age 19, or
to 26 if they are full-time students).

What is my Life Your employer is providing you with 2X times your annual earnings plus a flat
benefit amount? benefit amount of $2,000 rounded to the next higher $1,000; not to exceed
$102,000 of term life insurance.
Spouse Term Life Coverage: $1,000

Child Term Life Coverage:

- Live birth up to 14 days: $100
- 14 days to 6 months: $100
- 6 months to 19 years (26 years if full time student): $1,000

What is my AD&D Your employer is providing you with a flat amount of $105,000 of AD&D
benefit amount? insurance.
Accidental death and dismemberment coverage is not subject to health
questions.

Is it portable (can I If you retire, reduce your hours or leave your employer, you can continue
keep it if I leave my coverage at the group rate. Portability is not available for people who have a
employer)? medical condition that could shorten their life expectancy — but they may be
able to convert their term life policy to an individual life insurance policy.

Do my life insurance Coverage amounts will reduce according to the following schedule:
benefits decrease with Age: Insurance amount reduces to:
age? 65 65% of original amount
70 50% of original amount
Coverage may not be increased after a reduction.
When is my coverage Please see your plan administrator for your effective date.
effective?

What does my AD&D The full benefit amount is paid for loss of:
insurance pay for? - Life
- Both hands or both feet or sight of both eyes
- One hand and one foot
- One hand and the sight of one eye
- Speech and hearing
 Alaska Gateway School District
Voluntary Life and AD&D Insurance Plan Highlights
Policy #210844

Who is eligible All actively employed employees working at least 6 hours each week for your
for this employer in the U.S. and their eligible spouses and children (up to age 19, or to 26
coverage? if they are full-time students).

What are the Employee: up to 5 times salary in increments of $10,000; not to exceed $500,000.
coverage
amounts?
Spouse: up to 100% of employee amount in increments of $5,000; not to
exceed $500,000.

Child: up to 100% of employee coverage amount in increments of $2,000; not

to exceed $10,000. The maximum death benefit for a child between
the ages of live birth and six months is $1,000.

What are the Employee: up to 5 times salary in increments of $10,000; not to exceed $500,000.
AD&D coverage
amounts? Spouse: up to 100% of employee amount in increments of $5,000; not to
exceed $500,000.

Child: up to 100% of employee coverage amount in increments of $2,000; not

to exceed $10,000. The maximum death benefit for a child between
the ages of live birth and six months is $1,000.

Note: You may purchase AD&D coverage for yourself regardless of whether you
purchase term life coverage. In order to purchase life and AD&D coverage for your
dependents, you must buy coverage for yourself.

Can I be denied Current employees: If you and your eligible dependents are enrolled in the plan
coverage? and wish to increase your life insurance coverage, you may apply on or before
10/01/2019 for any amount of additional coverage up to $50,000 for yourself and
any amount of additional coverage up to $25,000 for your spouse. Any life
insurance coverage over the guaranteed amount(s) will be subject to answers to
health questions.

If you and your eligible dependents are not currently enrolled in the plan, you may
apply for coverage on or before 10/01/2019 and will be required to answer health
questions for any amount of coverage.

New employees: To apply for coverage, complete your enrollment within 31 days
of your eligibility period. If you apply for coverage after 31 days, or if you choose
coverage over the amount you are guaranteed, you will need to complete a medical
questionnaire which you can get from your plan administrator. You may also be
required to take certain medical tests at Unum’s expense.
How do I apply? Please see your plan administrator.

When is Please see your plan administrator for your effective date.
coverage
effective? Insurance coverage will be delayed if you are not in active employment because of
an injury, sickness, temporary layoff, or leave of absence on the date that insurance
would otherwise become effective.
 For your dependent spouse and children, insurance coverage will be delayed if that
dependent is totally disabled on the date that insurance would otherwise be
effective. Totally disabled means that as a result of an injury, sickness or disorder,
your dependent spouse and children: are confined in a hospital or similar institution;
are unable to perform two or more activities of daily living (ADLs) because of a
physical or mental incapacity resulting from an injury or a sickness; are cognitively
impaired; or have a life-threatening condition. Exception: Infants are insured from
live birth.
How much does Term life
the coverage Age band Employee rate Spouse rate
cost? per $10,000 per $5,000
<25 $0.800 $0.400
25-29 $0.900 $0.450
30-34 $1.100 $0.550
35-39 $1.600 $0.800
40-44 $2.500 $1.250
45-49 $3.800 $1.900
50-54 $5.900 $2.950
55-59 $7.800 $3.900
60-64 $11.900 $5.950
65-69 $18.000 $9.000
70-74 $36.000 $18.000
75+ $53.000 $26.500
Child life monthly rate is $0.700 per $2,000. One life premium covers all
children.

Term life calculation worksheet

Coverage amount Increment Rate Monthly cost
Employee $ ÷ $10,000 X $ = $
Spouse $ ÷ $5,000 X $ = $
Children $ ÷ $2,000 X $ = $

AD&D rate chart

AD&D cost Monthly Cost
Employee Per $10,000 $0.500
Spouse Per $5,000 $0.250
Child Per $2,000 $0.120

AD&D calculation worksheet

Coverage amount Increment Rate Monthly cost
Employee $ ÷ $10,000 X $ = $
Spouse $ ÷ $5,000 X $ = $
Children $ ÷ $2,000 X $ = $

Your rate is based on your age as of 10/01/2019 — your coverage-anniversary date.

Insurance age is calculated by subtracting your year of birth from the year your
coverage becomes effective or the current anniversary date.

Spouse rate is based on spouse’s insurance age.

Do my life Coverage amounts will reduce according to the following schedule:
insurance
benefits Age: Insurance amount reduces to:
70 65% of original amount
75 50% of original amount