SMALL EMPLOYER / GROUP AGREEMENT

BENEFIT SELECTIONS
1–50 EMPLOYEES
This form is part of the Small Employer / Group Agreement /

GROUP NAME

(Group / Producerto Complete)

GROUP ID

(LifeWise to Complete)
1. /

MEDICAL PLAN OPTIONS – CHOOSE BENEFIT PLAN BELOW

A. / Renewal Groups Only
Renew as is – no medical/RX benefit changes; form complete. Stop here.
Renew with changes –complete medical selection below:
(Consult your Producer or LifeWise Account Manager if you have questions concerning your plan’s grandfathering status)
B. / Passport PPO with PCP Designation (includes first 2 PCP visits at no charge)
PSTPlatinum PPO 500 / PSTSilver PPO 2000
PST Gold PPO 750 / PST Silver PPO 2500
PST Gold PPO 1000 / PST Silver PPO 3000
PST Gold PPO 1500 / PST Silver PPO 4000
C. / Passport PPO with PCP Designation (includes first 5 PCP visits at copay cost share)
PST Bronze PPO 5500 / PST Bronze PPO 6500
D. / Assure EPO with PCP Designation (includes first 2 PCP visits at no charge)
Assure Gold EPO 1500 / Assure Silver EPO 3000
E. / Passport HSA PPO
HSA Silver PPO 3000 / HSA Bronze PPO 4500
HSA BronzePPO 5500
F. / Standard Plans*
STND Silver $2500 / STND Bronze $5000
G. / No Medical Plan
No medical plan selected
2. / ADULT VISION BENEFIT OPTIONS– CHOOSE ONE BENEFIT PLAN BELOW
Vision exam/test $25 copay and hardware subject to $150 PCY

Not Covered

3. / PEDIATRIC DENTAL BENEFIT OPTIONS – CHOOSE ONE BENEFIT PLAN BELOW
LifeWise Pediatric Dental Plan: $65 Ded/90%/50%/50%
Not Covered. We certify that pediatric dental coverage has been purchased with another carrier.
4. / DENTAL BENEFIT OPTIONS – CHOOSE ONE BENEFIT PLAN BELOW
A. / Renewing Groups Only
Renew as is – no dental benefit changes. Stop here.
Renew with changes – complete one dental selection below
B. / LifeWiseFamilyDental Plans
LifeWise FamilyDental plans include pediatric dental benefits: $50 Ded / 100% / 60% / 50%.
LifeWise AdultDental PlanOptions
1. / Options only available to groups with 2 or more enrolled employees.
Note: For groups with 2 to 4 enrolled employees, LifeWise medical coverage must be selected.
DFP $50 / 0% / 40% / 50% / $1000 / DFP $50 / 20% / 50% / 50% / $1000
2. / Additional options available to groups with 5 or more enrolled employees.
DFP $50 / 0% / 20% / 50% / $1000 / DFP $50 / 0% / 20% / 50% / $2000
DFP $50 / 0% / 20% / 50% / $1500 / DFP $50 / 0% / 40% / 50% / $1500
C. / LifeWise Adult Dental Voluntary Plans
Note: Options only available to groups enrolling a minimum of 5 employees or 30% of all eligible employees, whichever is greater.
LifeWise Adult Dental Voluntary Plans do not include pediatric dental benefits.
DAV $50/ 0% / 20% / 50% / $1000 / DAV $50 / 0% / 40% / 50% / $1000 / DAV $50 / 20% / 50% / 50% / $1000
D. / No Dental Plan
No dental plan selected
5. / DENTAL PLAN ORTHODONTIA OPTION – CHOOSE ONE BENEFIT OPTION BELOW
Note: Option only available with FamilyDental Plans for groups with 26 or more enrolled employees.
Ortho $0 / 50% / $1500
Not Covered
LWO 2014 LATBS.SG / 014579 (Rev 01-2016) / SMALL EMPLOYER / GROUP AGREEMENT BENEFIT SELECTIONS
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