Health Insurance Forms & Benefits

As an employee of Mission Yogurt we are pleased to oﬀer you a full selection of beneﬁts. You are eligible for medical, dental, vision, and life insurance.

Important - You may enroll only at certain times

During the annual open enrollment period, July 1st.
First of the month following 60 days of employment.
Change of life event within 31 days (married, divorce, have a baby, etc.)

Eligibility

Average/Minimum of 30 Hours per Week

Summary of Benefits

MEDICAL

2021 Medical (in Network)

Copay

Health Savings Account

Preventative / Wellness Copay

Primary / Specialist Copay

$0/ $5 / $80

0$/ 70% after deductible

Urgent Care / Emergency Room Copay

$75 / $350

70% after deductible

Prescription Drugs

$10 / $20 / $40 / 20%

70% after deductible

Deductible (individual/family)

$1,500 / $3,000

$5,000 / $6,850

Out-of-Pocket maximum

$6,000 / $12,000

$6,360 / $6,850

Coinsurance

80% after deductible

70% after deductible

Outpatient Facility Deductible

$500

Out-of-Network Coverage

Yes (refer to SBC)

Amount Per Pay Check

Employee Only

$10.00

$0.00

Employee + Spouse

$256.41

$202.57

Employee + Children

$211.76

$165.75

Employee + Family

$458.30

$368.30

Dental

2021 Dental (in Network)	PPO/Low	PPO/High
Cleanings 2x Per Year	$0	$0
Deductible (individual/family)	$50	$50
Basic/Major/Annual Max	80%/50%/$1,000	90%/60%/$1,000
Out-of-Network Coverage	Yes (reduced benefit)	Yes (90% UCR)
	Amount Per Pay Check
Employee Only	$11.31	$21.04
Employee + Spouse	$23.49	$44.65
Employee + Children	$26.49	$50.19
Employee + Family	$40.50	$76.77

Vision

2021 Vision (in Network)	Basic
Exam Copay (1x every 12 months)	$10
Lenses (1x every 12 months)	$25
Retail Frames Allowance (1x every 12 months)	$200
Covered Selection Contacts (1x every 12 months)	$200
	Amount Per Pay Check
Employee Only	$4.13
Employee + Spouse	$8.95
Employee + Children	$9.79
Employee + Family	$16.23

Term Life

	Employee Life Benefits	Spouse Life Benefits	Child Life Benefits
Benefit Amount	Choose benefits in increments of $10,000	Choose benefits in increments of $10,000.	Generally Options are: • $10,000, or • $20,000
Minimum	$10,000	$10,000	$10,000
Maximum	$500,000	$100,000	$20,000
Guaranteed Issue (up to age 65)	$160,000	$30,000	$20,000