2022 COBRA Open Enrollment Guide - Wageworks
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
2022 COBRA
Open Enrollment
GuideAnnouncing 2022 Benefits Open Enrollment
November 29 – December 10, 2021
Caref ully review the information in this guide. As a reminder, Open Enrollment is your only opportunity to elect or change
benef it coverage under PFG’s COBRA plans for 2022, unless you experience a qualifying family status change. We hope
you will take this opportunity to familiarize yourself with the benefits PFG is offering for 2022, then actively participate in
the 2022 Open Enrollment process so you will have the coverage best suited to your needs and budget. For 2022, if you
do not enroll, your current coverages will automatically rollover.
What’s New in 2022
CONTRIBUTION RATES
• Medical Plan rates for all coverage levels will increase. Dental and vision rates remain the same.
NEW PROGRAMS
While plan design (deductibles, coinsurance, etc.) is not changing for 2022, there are some enhancements to the medical
plans . PFG is excited to offer the following enhancements to help you better manage your health:
• Hinge Health offers a program of education, coaching and exercise therapy for hip, knee, low back, neck or
shoulder conditions.
• AccordantCare™ provides one-on-one support from nurses who are specially trained in complex conditions.
Once enrolled, an Accordant Care nurse helps you manage your whole condition – not just adherence to
medication.
• PrudentRx allows you to purchase any medication on the specialty prescription drug listing at a $0 out-of-pocket
cost when filled by CVS Specialty®. This enhancement is only available to those enrolled in the HDHP, PPO and
Out-of -Area plans. Refer to page 6 for important information on how this plan impacts your costs for
specialty drugs.
Benefits Eligibility
You may enroll your eligible dependents in plans offering dependent coverage. The definition of eligible dependents for
PFG benefit plans is explained below.
If a plan offers a spouse coverage option, you may enroll:
• Your legal spouse as defined by Federal law (unless you are legally separated) who resides in the same country
of residence as you, including a same-sex spouse, or
• Your same- or opposite-sex domestic partner.
If a plan offers a child(ren) coverage option, you may enroll:
• Your child(ren) under age 26, including your biological child, step-child, foster child, child who has been legally
adopted or placed for adoption with you, or a child for whom you have been designated as the legal guardian,
your domestic partner’s or civil union partner’s child,
• Your child, age 26 or older, who is incapable of self-support due to a mental or physical disability which
commenced prior to age 26 or the time s/he would otherwise become ineligible for coverage as your dependent.
Qualifying Family Status Change Event
Af ter Open Enrollment, if you experience a qualifying family status change event, you may be eligible to change elections
consistent with the qualifying event, provided you do so within 31 days of the event. Your benefit elections will be effective
the f irst of the month following the date of the change in your family status. The only exceptions are if you experience a
birth or adoption; benefits will begin on the date of the birth or adoption. The type of qualifying event will determine the
type of change you are allowed to make and when the change in coverage takes effect. Qualifying family status change
events may occur when:
• You marry, divorce, or become legally separated, or your marriage is annulled.
• You have a new, eligible dependent child—by birth, adoption, placement for adoption, or for whom you have been
designated as the legal guardian.
• Your spouse/domestic partner or your dependent child dies.
1• You, your spouse/domestic partner, or your dependent child starts or stops working.
• You, your spouse/domestic partner, or your dependent child has a change in employment status or work
schedule.
• You, your spouse/domestic partner, or your dependent child has a significant increase in the cost of employer-
sponsored health care coverage or that person’s employer-sponsored health care coverage significantly changes
or ends (this includes COBRA coverage).
• You, your spouse/domestic partner, or your dependent child becomes eligible or ineligible for Medicare or
Medicaid.
• Your dependent child becomes eligible for—or is no longer eligible for—health care coverage due to age.
• Your spouse/domestic partner, or your dependent child’s coverage changes under their employer’s plan because
of a change in status event, eligibility requirements or an Open Enrollment.
• You, your spouse/domestic partner, or your dependent move to a new residence or change jobs and it affects
access to care within your current plan.
• Your domestic partnership ends.
Medical Plans Medical ID Cards
When making your elections, please keep in mind. You may choose from the You will only receive a new
f ollowing medical plans for 2022: Medical ID cards for 2022 if
you change plans or elect
• UHC High Deductible Health Plan (HDHP) medical coverage for the first
• UHC Consumer Driven Health Plan (CDHP) with an HSA
time.
• UHC Choice Plus Preferred Provider Option (PPO) Plan
• UHC Out-of-Area (OOA) Plan
To determine if you are eligible to enroll in the UHC Out-of-Area Plan, log on to www.whyuhc.com/pfg and select Search
f or a Provider, then enter your home zip code. If your zip code is not serviced by the UHC Choice Plus Provider Network,
you will only be able to enroll in the HDHP, CDHP or Out-of-Area PPO Plan. All plans are designed to cover the same
services; however, your total costs (including your premiums) may vary according to the plan and providers you select.
UHC High Deductible Health Plan (HDHP)
This plan is designed to offer associates a minimal safety net against high, unanticipated medical costs. Of the three plan
options PFG offers, this plan has the highest annual deductibles ($5,000 per individual; $10,000 if covering one or more
dependents). As a trade-off, it has the lowest per-pay-period payroll deductions. When weighing affordability, you’ll want
to f actor in more than the deductible and per-pay-period costs.
Under this medical plan, you are responsible to pay for most health care services, with the exception of a Primary Care
Physician (PCP) visit and prescriptions, until your annual deductible is met, then the coinsurance rate applies. With
coinsurance, you share a percentage of the cost with the plan until your annual out -of-pocket limit is reached; then the
plan pays 100% of additional medical costs incurred within the same year. The covered expenses you pay under the
medical benefits count towards the deductible and medical & prescription costs count towards the out-of-pocket
maximum. Plus, the deductible is included in the out-of-pocket maximum.
The deductible and out-of-pocket maximum work differently based on coverage level. If any covered member or more
than one member of the family incurs services, the family deductible must be met. Conversely, if any covered member of
the f amily reaches the individual maximum out-of-pocket, for that covered member you will not have to pay anything
f urther f or covered expenses for the remainder of the calendar year.
Certain routine preventive services, such as annual physical exams and immunizations, are covered 100% without
meeting the deductible or paying coinsurance. If you are used to paying a copayment for services such as specialist office
visits, please be aware that those services will be subject to the deductible and coinsurance under the HDHP. This plan
might be your best value if you typically have low medical costs and you are willing to assume the higher risk of paying the
high deductible (and possibly your out-of-pocket maximum) in the event that you have unexpected medical expenses.
Bef ore selecting this plan, you’ll want to consider not only your costs, but also those of family dependents (if applicable),
plus medical coverage that might be available through a spouse’s employment, Medicare/Medicaid, CHIP, etc.
2Consumer Driven Health Plan (CDHP)
A CDHP encourages consumers to carefully consider quality of care, cost, and other factors as they choose health care
providers and services to address health care needs. Our CDHP, administered by UnitedHealthcare (UHC), has a lower
premium than the PPO plans and higher than the HDHP. The trade-off is a higher deductible and out-of-pocket maximum
than the PPO and lower deductible than the HDHP. Under this medical plan, you are responsible to pay for most health
care services until your annual deductible is met, then the coinsurance rate applies. With coinsurance, you share a
percentage of the cost with the plan until your annual out-of-pocket limit is reached, then the plan pays 100% of additional
medical costs incurred within the same year. The covered expenses you pay under both the medical and prescription
benef its count towards the deductible and out-of-pocket maximum. Plus, the deductible is included in the out-of-pocket
maximum.
The deductible and out-of-pocket maximum work differently based on coverage level. If any covered member or more
than one member of the family incurs services, the family deductible must be met. Conversely, if any covered member of
the f amily reaches the individual maximum out-of-pocket, for that covered member you will not have to pay anything
f urther f or covered expenses for the remainder of the calendar year.
Certain routine preventive services, such as annual physical exams and immunizations, are covered 100% without
meeting the deductible or paying coinsurance. If you are used to paying a copayment for services such as office visits and
prescription drugs under other plans, please be aware that those services will be subject to the deductible and
coinsurance under the CDHP. Preventive medications are subject to coinsurance, but you do not have to meet the
deductible first. Check Caremark’s website (www.caremark.com) for a list of preventive medications to confirm if your
prescriptions are considered preventive or not.
Depending on your utilization and needs, the CDHP’s cost structure could save you money in the long run.
Health Savings Account (HSA)
A Health Savings Account (HSA) is a companion feature to the UHC CDHP and is administered through Optum Financial
Services (Optum). You must enroll in the CDHP in order to have the HSA. An HSA allows you to contribute tax-favored
dollars that can be used to pay certain out-of-pocket health care costs, such as deductibles and coinsurance. You choose
how much you wish to contribute (subject to plan limits). As you cannot contribute through pre-tax payroll contributions,
you would report to the IRS on your tax filing to get tax-favored treatment on your post-tax contributions.
If you are enrolled in the CDHP
Coverage Level 2022 Contribution Limit
Associate Only $3,650
Associate + Dependent (s) $7,300
Catch Up (if turning age 55+ in 2022)* +$1,000
*You cannot make contributions, including catch up contributions, if you are enrolled in Medicare.
You are not allowed to use your HSA to cover eligible medical expenses incurred before your account is established.
Also, your HSA will not reimburse expenses greater than your account balance. However, as c ontributions go into your
account, they can be withdrawn to cover any eligible expenses that were incurred after your account was established. You
are eligible to participate in an HSA if you are enrolled for the CDHP unless you are covered under another health plan
that is not considered a qualifying High Deductible Health Plan (such as your spouse’s plan), or if you are covered under a
general-purpose health FSA, Medicare, or you are eligible to be claimed as a dependent on someone else’s tax return.
While the Patient Protection and Affordable Care Act (PPACA) allows parents to add their adult children (up to age 26) to
their health plans, the IRS has not changed its definition of a dependent for HSAs. This means you cannot be reimbursed
f or expenses for your child who is age 24 or older.
There are complicated rules associated with an HSA. Please consult your tax advisor to determine if an HSA fits
your needs.
3PPO and Out-of-Area Plans
PPO or “Pref erred Provider Organization” plans provide you with the convenience of paying a specified copayment (or
sometimes a deductible) up front—at the time you receive medical services or fill prescriptions using one of the plan’s
designated (“preferred” or “network”) providers. In that way, a PPO can alleviate some of the concern and guesswork
because you generally know how much you will have to pay out of your own pocket for routine medical services and
prescriptions. However, the trade-off for this convenience is paying the highest premium of all medical plans. Covered
services that do not have a copayment, are subject to the deductible and coinsurance, such as lab work.
The UHC OOA Plan is offered only to those associates who live in a geographical area that is not serviced by UHC
Network providers. Theref ore, the benefit allowance is the same regardless of the provider used.
Using Network Providers = Cost Savings
With the HDHP, CDHP and PPO Plan, you’ll pay lower deductibles, coinsurance, copayments, and less out-of-pocket when you use
In-Network providers. Choice Plus is the UHC network for all medical plans.
Tip: Look for the United Healthcare Premium Tier 1 designation. These providers may save you even more as they have been
recognized for quality and cost efficiency.
In-Network providers have service agreements with UHC, so your share of the cost is based on a rate agreed upon between UHC
and the provider, known as the “maximum allowable amount.”
You’ll pay higher deductibles, coinsurance, and more out-of-pocket if you use Out-of-Network providers.
Since there is no maximum allowable amount with an Out-of-Network provider, you may also end up paying charges billed over and
above the allowable amount. You may also be required to pay up front and submit the insurance claim yourself for reimbursemen t.
Finally, you are responsible for meeting any pre-authorization requirements.
How to Find an In-Network Provider:
Log on to www.wyhuhc.com and select Search for a Provider or call 1-877-769-7001.
Diabetes Program
Hinge Health offers education, coaching and exercise therapy for hip, knee, low back, neck or shoulder conditions to help
increase mobility, decrease pain and improve overall wellbeing. Best of all, Hinge Health’s programs are provided at no
cost to you and your eligible dependents enrolled in a PFG medical plan. If you don’t have pain and are just looking to
stay healthy, you can sign up for the free Hinge Health app. Recommended exercises will be tailored to you based on
your job and lifestyle and each session can be completed in about 15 minutes. Your treatment can be done anywhere,
anytime – whenever works best for your schedule. No need to drive to an appointment or worry about more costly care!
Hinge Health provides all the tools you need to get moving again from the comfort of your home. Here are some of the
ways your treatment plan could be tailored to you:
• Get a personal care team, including a physical therapist and health coach.
• Schedule personal physical therapy sessions as needed.
• Receive wearable sensors that give live feedback on your form in the app.
• Get a second opinion on your recommended surgery and treatment plan.
For questions, you can call Hinge Health at 1-855-902-2777 or send an email to hello@hingehealth.com.
4Diabetes Program
Livongo is the administrator for PFG’s diabetes program. Associates and their family members with diabetes can join at
no cost if they are covered under one of PFG's medical plans. Once enrolled, you will receive:
• Connected Meter: Automatically uploads your blood glucose readings to your secure online account and
provides real-time personalized tips.
• Support from Coaches When You Need It: Communicate with a coach anytime about diabetes questions on
nutrition or lifestyle changes.
• Unlimited Strips and Lancets at No Cost to You: When you are about to run out, Livongo ships more supplies,
right to your door.
Diabetic patients will be required to register with Livongo and use a Livongo meter (or Continuous Glucose Monitoring
System (insulin pump) to receive free or reduced-cost prescriptions and supplies. The program is confidential and can be
reviewed only by professionals within Livongo. Inf ormation will not be shared with PFG. If you choose not to participate,
you will not be eligible for the savings associated with the program. Registration can be completed online at
welcome.livongo.com/PFG or by calling customer support 1-800-945-4355, which is available 24/7. You will also need a
registration code which is PFG.
Livongo-issued CGMS or glucometers
If you are
Diabetes-related prescriptions Glucometer, lancets and not issued by Livongo
enrolled in:
and supplies will be: testing strips will be: (In-network) will be:
Paid at 70%
HDHP Paid at 100% Paid at 100%
(deductible waived)
PPO or Paid at 80%
Paid at 100% Paid at 100%
Out-of-Area Plan (deductible waived)
Paid at 80%
CDHP Paid at 90% (deductible waived) Paid at 100%
(deductible waived)
Prescription Drug Coverage
When you enroll in medical coverage, you are automatically enrolled in prescription
drug coverage through Caremark (CVS Health). The cost of this coverage is Prescription ID
included with your medical premiums. Your medical plan’s design will determine
how you pay for prescriptions. If you are enrolled in the HDHP, PPO, or the Out-of- Cards
Area Plan, you’ll pay coinsurance at a participating pharmacy. If you are enrolled in You will not receive new
the CDHP, the deductible and coinsurance rules may apply. Caremark has a prescription ID cards from
pref erred arrangement with many independent pharmacies as well as nationwide Caremark unless you are
chains, including CVS, Walgreens and Walmart. newly electing coverage
Filling and Refilling Prescriptions with PFG for 2022.
You have access to both retail and mail order prescriptions. For prescriptions you need to fill immediately, go to any
participating retail pharmacy and present your Caremark ID card. Visit www.caremark.com or call Caremark Customer
Care at 1-888-790-4260 to f ind a participating retail pharmacy. If your doctor has authorized refills, contact your pharmacy
when you’ve used about 70% of your supply (e.g., 21 days of a 30-day supply).
For maintenance drugs (those you take on a long-term basis), you are required to use the Mail Order Program or a local
CVS pharmacy. The first time you use mail order, register with Caremark by visiting www.caremark.com or by calling 1-
888-790-4260. Then complete and return your mail service order form along with your prescription (request a duplicate
f rom your doctor) and payment. Refills are available when you’ve used about 60% of your supply and can be ordered
online or by phone with a credit card once you’re registered and your prescription is on file. For even greater convenience,
you may register for automatic refills with a credit card. Please allow 10-14 days for mail order prescriptions to arrive at
your home.
5Step Therapy
Step therapy is a process targeted at providing the most cost-effective prescription drugs for your needs. The f irst step
requires you to use a generic equivalent of a drug that is commonly prescribed for your condition, when a suitable generic
is available. Generic drugs will cost the least.
If a generic equivalent is not available or suitable (for example, if you’ve tried the generic medication without success or if
your doctor has deemed it unsuitable for treating you because of allergic reaction or possible drug interaction), the next
step uses a brand-name preferred drug. Your doctor may need pre-authorization to use a brand-name drug (call 1-877-
203-0003 f or more information). Brand-name drugs will cost you more.
If no suitable generic or brand-name preferred drugs can be found under the first two steps, the last step is a brand-name
non-preferred drug. Brand-name non-preferred drugs will cost you the most.
For certain exceptions to the Step Therapy program, your physician may request prior authorization for the use of a
brand-name drug by calling 1-877-203-0003.
AccordantCare
AccordantCare is a one-on-one nurse care management program that supports individuals with certain rare and complex
health conditions, such as Crohn’s disease, Epilepsy, Parkinson’s disease and more. The AccordantCare team provides a
dedicated, specially trained nurse and care team available by phone and online 24/7. They can help you:
• Understand your treatment plan
• Manage medication and side effects
• Provide tips for healthy nutrition and mental health
• Find local resources, medical equipment and more
• Sort out insurance and file claims
This is an outreach program so if you are eligible, AccordantCare will contact you by mail if you are eligible. If you would
like to learn more about this program, please call 1-800-375-2596.
PrudentRx (Only for those enrolled in the HDP or PPO Medical Plans)
PrudentRx allows you to get specialty medications on the prescription drug list at a $0 out-of-pocket cost when filled by
CVS Specialty. This program is designed to lower your out-of-pocket costs by assisting you with enrollment in drug
manuf acturers’ discount copay cards/assistance programs. If you enroll in the HDHP, PPO or Out-of-Area Plan, and you
or one of your covered dependents are prescribed specialty drugs in 2022, you’ll be eligible to participate in PrudentRx at
no extra cost to you. To enroll, call PrudentRx at 1-800-578-4403.
If I’m: I pay:
Enrolled in PrudentRx and taking a drug on the specialty
$0 copay
drug listing
NOT enrolled in PrudentRx and taking a drug on the
30% coinsurance with no min or max
specialty drug listing
Retail Pharmacy - 50% ($100 min, $150 max) for up to
a 30 day supply
Taking a specialty drug NOT on the specialty drug listing
Mail Order - 50% ($200 min, $300 max) for up to 90 day
supply
6Employee Assistance Program (EAP)
PFG’s EAP can help you navigate life’s ups and downs more effectively.
Conf idential assistance is available 24/7 by calling United Behavioral Health at 1-866-248-4094, or you can access a
variety of online and interactive resources by logging on to www.liveandworkwell.com (Access Codes PFG).
The program is designed to help you and your eligible dependents cope with a variety of issues. Whether you need
support through a personal or family crisis, financial or legal advice, stress management tips, or help finding resources to
deal with substance abuse and recovery, the EAP is a good place to start. When needed, the EAP will connect you with
licensed professionals who provide short-term counseling services and referrals.
You and your eligible dependents may each receive up to five face-to-face counseling sessions with an Optum provider or
via Talkspace, described below). Call Optum 24/7 at 1 866 248 4094 or visit www.liveandworkwell.com to access a variety
of resources.
Additional confidential support resources include:
• Talkspace is an effective alternative to in-person therapy using in-app chat, voice and video messaging. Choose
f rom among thousands of licensed, master-level or higher behavioral health clinicians. Register at
talkspace.com/connect, select EAP and enter your authorization code (available at www.liveandworkwell.com
using access code PFG). Or call UnitedHealthcare at 1-877-769-7001.
• Sanvello is the #1 app for stress, anxiety and depression with millions of users. Download Sanvello from the App
Store or Google Play. For free premium access, choose upgrade through insurance when you create your
account. (Have your medical plan ID card on hand.)
Af ter your five free EAP visits, you can continue your online Talkspace visits (subject to any coinsurance or deductible
under your plan) by selecting Use my Insurance Benefit. One week of unlimited messaging is equivalent to one in-person
behavioral health visit.
Your personal records are never shared with PFG, or anyone else, without your permission. EAP services are easy to use
and are completely confidential!
7Medical Plan Highlights
UHC HDHP UHC CDHP
Features In-Network Out-of-Network In-Network Out-of-Network
Annual Deductible
• Individual $ 5,000 $ 10,000 $1,500 $3,000
• Family (Associate + 1 or more) $10,000 $ 20,000 $3,000 $6,000
Annual Out-of-Pocket Maximum (includes
deductible)
• Individual $ 6,550 $13,100 $ 6,550 $13,100
$13,100 $26,200 $13,100 $26,200
• Family (Associate + 1 or more)
Coinsurance (percentage you pay) 30% 50% 20% 50%
PCP Office Visit (no charge for routine physicals,
$25 copay 50% after deductible 20% after deductible 50% after deductible
immunizations)
Specialist Office Visit 30% after deductible 50% after deductible 20% after deductible 50% after deductible
Virtual Visit (Telemedicine) $25 copay 50% after deductible 20% after deductible, up to $49 50% after deductible
Hospital Services
• Inpatient 30% after deductible 50% after deductible 20% after deductible 50% after deductible
• Outpatient 30% after deductible 50% after deductible 20% after deductible 50% after deductible
Emergency Services
• Hospital ER 30% after deductible 50% after deductible (if not 20% after deductible 50% after deductible (if not
emergency) emergency)
30% after deductible 30% after deductible 20% after deductible 20% after deductible
• Ambulance
Urgent Care Facility (freestanding) 30% after deductible 50% after deductible 20% after deductible 50% after deductible
Non-Routine Lab/X-rays (no charge for
30% after deductible 50% after deductible 20% after deductible 50% after deductible
preventive/routine lab/X-rays)
Mental Health & Substance Abuse
• Inpatient 30% after deductible 50% after deductible 20% after deductible 50% after deductible
• Outpatient $25 copay 50% after deductible 20% after deductible 50% after deductible
Durable Medical Equipment 30% after deductible 50% after deductible 20% after deductible 50% after deductible
Rx Retail* (30 day supply) After Deductible†
Generic $25 max 20% ($25 max)
Brand-name, preferred 30% ($50 min; $100 max) Not Covered 30% ($50 min; $100 max) Not Covered
Brand-name non-preferred 50% ($75 min; $150 max) 50% ($75 min; $150 max)
Specialty See PrudentRx on Page 6 50% ($100 min; $150 max)
Rx by Mail* (90 day supply or CVS Pharmacy)* After Deductible†
$50 max
Generic 20% ($50 max)
30% ($100 min; $200 max) Not Covered
Brand-name, preferred 30% ($100 min; $200 max)
50% ($150 min; $300 max) Not Covered
Brand-name non-preferred 50% ($150 min; $300 max)
See PrudentRx on Page 6
Specialty 50% ($200 min; $300 max)
*Not covered if you use a non-participating pharmacy.
8Medical Plan Highlights
UHC PPO Plan UHC Out-of-Area PPO Plan
Features In-Network Out-of-Network In-Network
Annual Deductible
• Individual $1,250 $2,500 $1,250
$2,250 $4,500 $2,250
• Family (Associate + 1 or more)
Annual Out-of-Pocket Maximum (includes deductible)
• Individual $ 6,000 $12,000 $ 6,000
• Family (Associate + 1 or more) $12,000 $24,000 $12,000
Coinsurance (percentage you pay) 20% 50% 20%
PCP Office Visit (no charge for routine physicals, $25 copay 50% after deductible $25 copay
immunizations)
Specialist Office Visit $40 copay 50% after deductible $40 copay
Virtual Visit (Telemedicine) $25 copay 50% after deductible $25 copay
Hospital Services
• Inpatient $150 copay per day (5 day max), 50% after deductible $150 copay per day (5 day max),
20% after deductible 20% after deductible
50% after deductible
• Outpatient 20% after deductible 20% after deductible
Emergency Services
• Hospital ER $250 copay (waived if admitted), 50% after deductible if not emergency $250 copay (waived if admitted),
20% after deductible 20% after deductible
50% (no deductible)
• Ambulance 20% (no deductible) 20% (no deductible)
Urgent Care Facility (freestanding) $40 copay 50% after deductible $40 copay
Non-Routine Lab/X-rays (no charge for 20% after deductible 20% after deductible
50% after deductible
preventive/routine lab/X-rays) $100 copay for MRI, MRA, CT & PET Scan $100 copay for MRI, MRA, CT & PET Scan
Mental Health & Substance Abuse
• Inpatient $150 copay per day (5 day max), 50% after deductible $150 copay per day (5 day max),
20% after deductible 20% after deductible
50% after deductible
• Outpatient $25 copay $25 copay
Durable Medical Equipment 20% after deductible 50% after deductible 20% after deductible
Rx Retail* (30 day supply)
Generic $25 max $25 max
Brand-name, preferred 30% ($50 min; $100 max) Not Covered 30% ($50 min; $100 max)
Brand-name non-preferred 50% ($75 min; $150 max) 50% ($75 min; $150 max)
Specialty See PrudentRx on Page 6 See PrudentRx on Page 6
Rx by Mail* (90 day supply or CVS Pharmacy)*
$50 max $50 max
Generic
30% ($100 min; $200 max) 30% ($100 min; $200 max)
Brand-name, preferred
50% ($150 min; $300 max) Not Covered 50% ($150 min; $300 max)
Brand-name non-preferred
See PrudentRx on Page 6 See PrudentRx on Page 6
Specialty
*Not covered if you use a non-participating pharmacy. 9Dental Coverage
PFG knows that good dental care contributes to your health and well-being. That’s why we offer dental coverage,
administered through Delta Dental of Virginia.
The chart below lists some highlights of the plan, assuming use of In-Network providers. If you choose an Out-of-Network
provider, benefits may be limited and your out-of-pocket costs may be higher. To find an In-Network provider, log on to
www.deltadentalva.com.
Plan Highlights Benefit
Deductible (basic & major services)
$50
Individual
$150
Family
Maximums:
$ 1,500
• Calendar Year Maximum Benefit
$ 2,000
• Orthodontic Lifetime Maximum Benefit (eligible children only)
• Temporomandibular Joint Disorder (TMJ) Lifetime Maximum $ 1,000
Preventive and Diagnostic Services
No charge, no deductible
(does not apply toward the annual maximum)
Basic Services - fillings, extractions, etc. 80% after deductible
Major Services - Crowns, dentures, bridges, implants, etc. 50% after deductible
Temporomandibular Joint Disorder (TMJ) - Diagnosis, occlusal
50% after deductible
adjustment, orthodontic appliance and orthognathic surgery
Orthodontic Benefits (eligible children only)
Complete orthodontic exam (including necessary x-rays), active orthodontic 50%
treatment
PPO and Premier Networks
You may use providers in the Delta Dental PPO and Delta Dental Premier Networks. You’ll generally pay less out of
pocket if you use the PPO Network, but using the Premier Network will still cost you less than going out of the network.
Choosing a PPO or Premier dentist:
Dental ID Cards
When you see an In-Network provider, there are many advantages for you: You will not receive a new
• Most importantly, yours and the company’s costs are lower. dental ID card from Delta
• There are no claim forms to file. Dental unless you are newly
• The provider will submit pre-approval for treatment upon your request. electing PFG coverage for
• All you are responsible for is your deductible and coinsurance (if 2022.
applicable)—PFG pays the rest, up to the annual plan maximum.
If you choose an Out-of-Network dentist:
Your benefits may be limited. You must pay the dentist in full when services are received. You may have to file your own
claim with Delta Dental, by:
• U.S. mail to Delta Dental of Virginia, 4818 Starkey Road, Roanoke, VA 24018, or
• Fax to 1-540-725-3880.
• Delta Dental will reimburse you for “allowable charges” only, based on Delta Dental’s criteria. If y our dentist
charges more than Delta Dental’s allowable charges, you are responsible to pay the extra amount your dentist
charges in addition to your coinsurance.
• Delta Dental does not require pre-authorization for services; however, some Out-of-Network providers will submit
predetermination forms on behalf of their patients. It is your responsibility to submit this if your provider does not.
10Vision Coverage
The vision plan, administered by VSP, helps you pay a portion of a wide range of vision expenses. Plus, you can take
advantage of exclusive member extras for additional savings. The f ollowing chart highlights the vision plan features with
in-network providers. To locate an in-network provider, visit http://pfgc.vspforme.com/. For out-of-network plan details,
contact VSP at 1-800-877-7195.
VISION PLAN FEATURES YOUR COSTS FOR IN-NETWORK SERVICES
Eye Exam one every calendar year Covered 100%
Prescription Glasses You may select either prescription glasses or contact lenses, but not both, during the same
coverage period.
Lenses one pair every calendar year
Covered 100%
Single vision, bifocal or trifocal
Lens Enhancements on one pair every calendar year
• Standard progressive lenses • Covered 100%
• Premium progressive lenses • $95 – $105 copay
• Custom progressive lenses • $150 – $175 copay
Up to a $150 allowance for a wide selection of frames. If your
Frames one pair every calendar year
f rames exceed the allowance, you will receive a 20% discount on
the dif ference.
Contacts You may select either prescription glasses or contact lenses, but not both, during the same coverage period.
• Contact Lens Fitting & Follow Up • Up to $55 copay
• Contact Lenses once every calendar year • Up to $120 allowance
ADDITIONAL SAVINGS FROM IN-NETWORK PROVIDERS
Diabetic Eyecare Plus Program – Services related to diabetic eye disease, glaucoma and age-related macular
degeneration (AMD) are covered 100%.
Glasses and Sunglasses • Receive an extra $50 allowance for featured frame brands. • Receive 20% off additional
glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your last eye exam.
Retinal Screening – An enhancement to your eye exam. • Up to $39 copay.
Laser Vision Correction – From contracted facilities only. • Receive 15% off the regular price or 5% off the promotional
price.
11You can also read
