Summary Plan Description Benefit Booklet
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Summary of Benefits This Summary of Benefits shows the amount you will pay for covered services under this Blue Shield of California plan. It is only a summary and it is part of the contract for health care coverage, called the Evi- dence of Coverage (EOC). Please read both documents carefully for details. ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE INDEPENDENCE AND SAFE MOBILITY WITH AAA - Your benefit is provided by American Automobile Associ- ation of Northern California, Nevada & Utah (AAA). The benefit is a Classic AAA membership and includes access to Independent and Safe Mobility tools and services. • Roadwise Driver • Educational Driving Resources • Roadside Assistance $0 First $250 each Calendar Year $250 Remainder of charges 20% plus 100% of additional charges over the $50,000 lifetime maximum BASIC GYM ACCESS THROUGH SILVERSNEAKERS® FITNESS $0 HEARING AID SERVICES – Your hearing aid services benefits are provided by EPIC Hearing Healthcare (EPIC). This benefit is designed for you to use EPIC network providers. EPIC Participating Providers are listed at xxxxxxxxxxxx.xxx/XxxxxxxXxxx. If you choose to use out-of-network providers, those services will not be covered. This benefit is separate from diagnostic hearing examinations and related charges as covered by Medi- care. Hearing aid benefits every year include: • One routine hearing exam • Hearing aid instrument o Choice of private-labeled Silver (mid-level) or Gold (premium level) tech- nology hearing aid models o Up to two hearing aids in the following styles: ▪ in-the-ear; ▪ in-the-canal; ▪ completely-in-canal; ▪ behind-the-ear; or ▪ receiver-in-the-ear. o All technology levels include: ▪ one consultation; ▪ two-year supply of batteries per hearing aid; and ▪ three-year extended warranty. o Silver technology level hearing aids include: ▪ one behind-the-ear hearing aid (non-ear mold model) delivered directly to your home; and $0 Silver Technology Level: $449 per hearing aid Gold Technology Level: $699 per hearing aid ▪ up to three virtual follow-up visits by a participating provider for hearing aid fitting, consultation, device check, and adjustment for no additional cost. o Gold technology level hearing aids include: ▪ one hearing aid delivered in-person by a participating provider; ▪ up to three in-person follow-up visits for hearing aid fitting, con- sultation, device check, and adjustment for no additional cost; and ▪ standard ear molds & impressions. ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE VISION SERVICES– Your vision benefits are provided by Vision Service Plan (VSP). This benefit offers one of the largest national network of independent doctors located in retail, neighborhood, medical and professional settings. You can lower any out-of-pocket costs by choosing network providers for covered services. VSP Participating Providers may be located through an online directory at xxxxxxxxxxxx.xxx. Click on Find a Doctor. Comprehensive eye exam once every 12 months $20 All costs above $50 Eyeglass frame once every 24 months All costs above $100 All costs above $40 Eyeglass lenses once every 12 months $25 Single vision: • Single vision• Bifocal• Trifocal• Aphakic or lenticular monofocal or multifocal All costs above $43 Bifocal:All costs above $60 Trifocal: All costs above $75 Aphakic or lenticular monofo- cal or multifocal: All costs above $104 Contact lenses (instead of eyeglass lenses) once every 12 months • Non-elective (medically necessary) – Hard or Soft – one pair • Elective (cosmetic/convenience) – Hard – one pair • Elective (cosmetic/convenience) – Soft – Up to a three- to six-month supply for each eye based on lenses selected Non-elective (hard or soft): $25 copay and all costs above $500 Elective (hard or soft): $25 copay and all costs above $120 Non-elective (hard or soft): All costs above $200 Elective (hard or soft): All costs above $100 ADDITIONAL BENEFITS – NOT COVERED BY MEDICARE PHYSICIAN CONSULTATION BY PHONE OR VIDEO THROUGH TELADOC $0 per consult OVER-THE-COUNTER ITEMS THROUGH CVS – Eligible over-the-counter (OTC) items are available through the OTC Items Catalog, at xxx.xxxxxxxxxxxx.xxx/xxxxxxxxXXX. Limitations may apply. Refer to the OTC Items Catalog for more information. Up to two orders per quarter All costs above the $100 Allow- ance per quarter No person has the right to receive the benefits of this plan for Services furnished following termination of coverage except as specifically provided under the extension of benefits, Part I.B. of this Agreement. Benefits of this plan are available only for Services furnished during the term it is in effect and while the individual claiming benefits is actually covered by this Agreement. Benefits may be modified during the term of this plan as specifically provided under the terms of this Agreement or upon renewal. If benefits are modified, the revised benefits (including any reduction in benefits or the elimination of benefits) apply to Services furnished on or after the effective date of the modification. There is no vested right to receive the benefits of this Agree- ment. I: CONDITIONS OF COVERAGE AND PAYMENT OF DUES
Description of Benefits The benefits available under this Plan will be as defined in Items F(1), F(3), and F(4) of the Adoption Agreement.
SERVICE LEVEL DESCRIPTION The Fund Accounting Agreement is hereby amended by deleting the Service Level Description attached thereto and replacing it in its entirety with the Service Level Description attached hereto.
Application for Benefits Requests for short-term leaves shall be in writing, upon the appropriate form prescribed and provided by the District, and shall be filed with the unit member's supervisor and the appropriate manager five (5) days in advance of the intended leave (except in emergency situations), unless otherwise stated by the provisions of the specific leave.
System Description The wet detention basin is designed to trap 80% of sediment in runoff and maintain pre-development downstream peak flows. The basin has two forebays (smaller ponds) located at the low end of two grass xxxxxx. In addition to runoff conveyance, the grass xxxxxx also allow infiltration and filtering of pollutants, especially from smaller storms. The forebays are each 4 feet deep. They are connected to the main pool by 18 and 24-inch metal pipes that outlet onto a rock chute. The forebays will trap coarse sediments in runoff, such as road sands, thus reducing maintenance of the main basin. The main pool will trap the finer suspended sediment. To do this, the pond size, water level and outlet structures must be maintained as specified in this Agreement (see Figures 1, 2 and 3). The main basin receives runoff from a 67.1 acre drainage area (41.2 acres within the subdivision and 25.9 acres off-site drainage coming from the east). During high rainfall or snow melt events, the water level will temporarily rise and slowly drain down to the elevation of the control structure. The water level is controlled by a 12-inch concrete pipe extending through the berm in the northwest corner of the basin (see Figures 1 and 3). On the face of the 12-inch pipe, there is metal plate with a 3-inch drilled hole (orifice) with stone in front of it. This orifice controls the water level and causes the pond to temporarily rise during runoff events. Washed stone (1- 2” diameter) is placed in front of the orifice to prevent clogging. High flows may enter the grated concrete riser or flow over the rock lined emergency spillway. “As-built” construction drawings of the basin, showing actual dimensions, elevations, outlet structures, etc. will be recorded as an addendum(s) to this agreement within 60 days after [Municipality Name] accepts verification of construction from the project engineer.
Flexible Work Schedule A flexible work schedule is any schedule that is not a regular, alternate, 9/80, or 4/10 work schedule and where the employee is not scheduled to work more than 40 hours in the "workweek" as defined in Subsections F. and H., below.
ITEM DESCRIPTION Equipment (include VIN, make, model, year, serial no., accessories, or other identifying features): 12. NO. OF OPERATORS PER SHIFT 13. HRLY/ DAILY/ MILEAGE SHIFT BASIS 14. SPECIAL 15. GUARANTEE (8 HOURS) Portable Toilet Rental – Serviced(Includes first day delivery/last day pickup and daily rental rate per unit) 1 $75 Daily Ea. Portable Toilet Rental – Unserviced(Rental only, no daily service call) 1 $45 Daily Ea. Accessible Portable Toilet Rental – Serviced(Includes first day delivery/last day pickup and daily rental rate per unit) 1 $95 Daily Ea. Accessible Portable Toilet Rental – Unserviced(Rental only, no daily service call) 1 $65 Daily Ea.
Compensation/Benefit Programs During the Term of Employment, the Executive shall be entitled to participate in all medical, dental, hospitalization, accidental death and dismemberment, disability, travel and life insurance plans, and any and all other plans as are presently and hereinafter offered by the Company to its executive personnel, including savings, pension, profit-sharing and deferred compensation plans, subject to the general eligibility and participation provisions set forth in such plans.
Budget Schedule Subrecipient agrees that the expenditures of any and all funds under this Contract will be in accordance with the Budget Schedule, a copy of which is attached hereto as Attachment C, and which by this reference is incorporated herein and made a part hereof as if fully set forth.
Benefit Level The primary care clinics available through each plan administrator are assigned a Benefit Level. The Benefit Levels are outlined in the benefit chart below. Primary care clinics may be in different Benefit Levels for different plan administrators. Family members may be enrolled in clinics that are in different Benefits Levels. Employees and their dependents may change to clinics in different Benefit Levels during the annual open enrollment. Employees and their dependents may also elect to move to a clinic in a different Benefit Level within the same plan administrator up to two (2) additional times during the plan year. Unless the individual has a referral from his/her primary care clinic, there are no benefits for services received from providers in Benefit Levels that are different from that of the primary care clinic in which the individual has enrolled.
