benefits guide - Staples Benefits

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BENEFITS GUIDE
PA R T- T I M E N O N - E X E M P T A S S O C I AT E S
This guide provides information
about the Staples benefit choices you
have as a part-time non-exempt
associate. Take a look for more about…
Eligibility | 1
Electing Your Coverage | 2
Your Benefits-At-a-Glance | 3
Medical | 4
Dental | 7
Vision | 8
Disability and Life | 9
Savings and Stock Plans | 10
Voluntary Programs | 12
Contact Information | 13
Rules and Limitations | 14
This guide summarizes the benefit plans in general terms only. Plan documents and summary plan descriptions determine
the plan provisions. You should go to www.staples.com/benefits or contact the vendors directly for more information.
eligibility
Eligibility
You are eligible for these benefits effective 60 days
after your hire date.
You may elect fixed benefit, dental, vision and life
insurance coverage for your dependents as well.
Eligible dependents include:
• Your legal spouse, including same-sex spouses
in states that recognize same-sex marriage
• Your same-sex domestic partner as well as his/
Important Note: The fixed benefit,
her children if you cover your domestic partner
dental, disability and life insurance plans
are underwritten by Aetna Life Insurance
• Your children under age 26 and
Company. Exclusions and limitations may
• Your children age 26 and older who are not able
apply. Please also see the state rules and
to care for themselves due to physical or mental
limitations on pages 14 and 15.
disability and are on SSDI.
For more details about same-sex domestic partner eligibility, go to www.staples.com/benefits.
Changing Your Coverage During the Year
You may only change or drop your fixed
benefit, dental or vision coverage if you have
a qualifying life event due to the gain/loss of
coverage, change in employment status (e.g.,
Note that the fixed benefit plan is not
available to associates who live in
Massachusetts, North Dakota or Washington
or who live and work in New Hampshire.
to full-time), marriage, divorce, birth/adoption or
death. You have 30 days from the date of the
event to make a change (60 days for a birth or
adoption). Complete a Benefit Change Form
(available on www.staples.com/benefits) and
submit it to HR Services to change coverage.
1
elect
· enroll
Electing Your Coverage
To be covered under the fixed benefit, dental,
How to Enroll
vision, disability, life or legal services plans, you
1.Go www.staples.com/benefits and select
must enroll during the annual open enrollment
“Part-time non-exempt.” Then, click “Associate
period or within 45 days of your hire date if you
Connection” in the upper right.
2.Enter your 7-digit Employee Number and
are a new associate. Your coverage becomes
effective as of the first Sunday following 53 days of
password. If you forget your password, click
service, provided your first payroll deduction
“Forgot Password” on the login page and
follow the prompts.
has been made. Any coverage you elect for your
3.Click “Benefits Enrollment.”
dependents begins when your coverage begins,
4.Click “Select” to see your current choices.
unless you enroll them at a later date due to a
5.Click “Edit” next to each benefit option to enter
qualifying life event.
your 2014-2015 plan year elections.
6.When you are done, click “Submit” at the
Before you enroll, read your Aetna Voluntary®
bottom of the screen.
enrollment kit, which explains the features,
7.Do a final review of your elections and click
limitations and exclusions of your plan. To
“Submit” again.
access your Aetna Voluntary enrollment kit,
8.When you see the message “Your enrollment is
go to www.staples.com/benefits or to
complete,” your elections have been saved.
www.aetna.com and follow the links to log in.
9.Print out your confirmation page for future
Your login is 777674 and your password is AAHC.
reference.
Follow the links to the Document Library, and click
on “Enrollment Kit.” You can also get a printed copy
If You Need Help. For enrollment assistance,
of the enrollment kit by calling 1-888-772-9682.
contact HR Services by calling 1-888-490-4747 or
submitting an eHelpDesk ticket.
Note: If you have a status change (e.g., full-time
You will receive a confirmation statement at your
to part-time), your coverage is effective the
home address documenting your elections. To
Sunday following the date of your status change.
make a correction to your elections, mark the
changes on your confirmation statement and fax it
to HR Services at 508-305-1300 within 14 days of
the issue date.
2
benefit summary
Your Benefits At-a-Glance
As a part-time associate, you have the following benefit options available from July 1, 2014 through June 30,
2015. Read this guide for more information about each plan or contact HR Services or the vendors directly if
you have questions. (See page 13 for phone numbers and websites.)
Plan/Benefits
Your Coverage Choices
Medical
• Aetna Fixed Benefit Plan
This plan does not provide creditable
coverage; for more, see page 4
•
•
•
•
Single
You plus child(ren)
You plus spouse/domestic partner
Family
Dental
• Aetna Dental Plan
•
•
•
•
Single
You plus child(ren)
You plus spouse/domestic partner
Family
Vision
• EyeMed Basic Plan
• EyeMed Enhanced Plan
•
•
•
•
Single
You plus child(ren)
You plus spouse/domestic partner
Family
Short-term
disability
• Option to buy coverage with:
— $50 benefit maximum/week
— $125 benefit maximum/week
• Whether to elect coverage for yourself
and what benefit maximum to choose
Life and • $20,000/life for yourself
• Whether to elect coverage for yourself
accidental • $20,000/accidental death for yourself
and/or your dependents
death insurance • Option to buy life insurance for your dependents
The above benefits must be elected during the annual open enrollment period, within 45 days of
your hire date if you are hired during the year, or within 20 days of your status change to part-time.
Our Savings and Stock Plans
Staples also gives you the opportunity to save and invest for the future with the following plans.
Plan Features
Your Choices
401(k) Savings Plan
• Option to set aside pre-tax dollars for the future – and receive a Staples matching
contribution
• Whether to participate
• How much to contribute
• How to invest your account
Employee Stock • Option to share in the company’s success by
Purchase Plan
purchasing Staples stock at a 15% discount
3
• Whether to participate
• How much to contribute to purchase stock
medical
Aetna Fixed Benefit Plan
Staples offers a fixed benefit plan through Aetna. You may use any licensed
You dec
ide…
whether to
elect cove
rage
through th
e fixed be
n
e
fi
t plan
and whic
h depend
ents to
cover.
provider and any certified hospital for medical care, but you are eligible for discounts if you
use an Aenta in-network provider. The plan also includes prescription drug benefits and discounts at more
than 59,000 retail pharmacies nationwide.
Important Notes
• Due to state regulations, this coverage is NOT available to associates who live in Massachusetts, North
Dakota or Washington or who live and work in New Hampshire.
• Your coverage is not effective until your first deduction is taken from your paycheck (on the second Friday
after your coverage becomes effective). For example, if you became eligible for coverage on Sunday, the
2nd, your first deduction would not be taken until Friday, the 14th. So, you would be reimbursed for
medical visits on or after Sunday, the 9th, but not for that first week when you became eligible. Keep this
in mind when you are making appointments.
• Also, if a deduction was not taken for a certain week (for example, you did not work or worked fewer hours),
the plan will not pay benefits incurred during that week unless you repay the deduction amount to Aetna
within 45 days.
The fixed benefit plan is not considered “creditable” coverage for the purposes of health care
reform. As a result – even if you have coverage through this plan – you may still be assessed
a federal penalty when you file your taxes (unless you have coverage under another medical
plan). To find out more about health care reform, the Health Insurance Marketplace plans and/
or the tax penalty, go to www.healthcare.gov.
Marketplace Plan Subsidies. Remember that you may have lower cost health care options through the
Health Insurance Marketplace. You may also be eligible for subsidies based on your household income.
Go to www.healthcare.gov for more information.
4
medical
How the Aetna Plan Works
Under the fixed benefit plan, the plan reimburses a set amount for the services you receive during the year. You do
not pay a deductible for medical services or prescription drugs. Any maximums are per visit or per day. See the
chart below to see how the plan pays benefits.
Plan Reimbursement
Physician office visit*
$80/visit (up to 7 visits/person/year)
Hospital admission
$800/admission (up to 2 admissions/person/year)
plus
$550/day for inpatient benefits or $1,100/day for ICU benefits
Outpatient services
• Diagnostic
• Surgery
• Emergency
$100 (up to 3/person/year)
$500 (up to 2/person/year)
$325 (up to 2/person/year)
Accident services
$300 (up to 2/person/year)
*includes diagnostic, chiropractic, maternity
You may go to any provider or facility for services. The difference is whether discounts may apply and how you
pay for the care.
Discounts
In-Network
Out-of-Network
Your cost is based on the negotiated discount for the service
Your cost is based on the full cost
for the service
You do not file a claim form
You must file a claim form
Claim forms
Payment for the service
You owe nothing at the time of service
You are responsible for the full cost
at the time of service
Physician Visit Example. We’ll assume that your
If you use an out-of-network provider:
physician visit costs $150.
• T
he cost is still $150.
If you use an in-network provider:
• Y
ou pay $150 at the time of the service and file
• The negotiated cost could be $100.
a claim form for the visit.
• Y
ou are ultimately reimbursed $80 from the plan,
• You don’t file a claim form and pay nothing at the
time of the service.
so your cost is $70.
As you can see, it’s always to your advantage to
use an in-network provider because you may pay
less and you do not need to pay at the time of the
service or file a claim form.
• You are billed for $20 – the $100 cost minus the
$80 reimbursement from the plan.
5
medical
Prescription Drug Benefits
Pre-tax Fixed Benefit Plan Weekly Rates
The fixed benefit plan pays $45 up to 12 days per
• Single$20.14
year for prescription drugs. That’s $540 per year!
• You plus child(ren)
Using generic drugs whenever possible and going
• You plus spouse/domestic partner $45.32
to a network pharmacy will save you money.
• Family$60.42
You do need to consider how and when you go to
$42.29
Healthy Living Programs
the pharmacy, so here are two examples.
Staples offers additional healthy living programs for
Example 1. Let’s say you have a generic
you and your family. We encourage you to take
prescription that costs $5. When you fill this
advantage of these programs to help you learn
prescription, the plan will pay $5 and you will
about and manage your health throughout the year.
receive $40 as reimbursement – for a total of $45
• Aetna’s Informed Health Line is available if
that day.
you are enrolled in the fixed benefit plan. Just
call to ask about any health topic or to get
Example 2. Now let’s assume you have a
advice on treating a health issue. Providers are
prescription that costs $75. In this case, the
available 24/7 by calling 1-800-556-1555.
plan pays $45 and you are responsible for the
The following programs are available to all
remaining $30.
associates:
The bottom line is that you can receive a total of
• Staples LifeScope Employee Assistance
$540 towards prescription costs but this is based
Plan (EAP) provides information on health
on receiving $45 on 12 different days during the
topics, as well as support and referrals to help
year. Also, you cannot combine prescriptions to
you meet your health goals. More importantly,
receive the $45. That is, in the first example, you
you’re eligible for THREE free consultations with a
could only get $45 that day no matter how many
counselor for each member of your family on any
prescriptions you fill. You receive the cost of one
topic. Call 1-800-227-2195 at any time (24/7).
prescription and get reimbursed for any
• Staples.CorporatePerks.com is an online
remaining amount.
resource for a wide range of nutrition and
wellness topics and includes fitness center
discounts. Go to the site to see what’s available.
To find a network doctor or get more information
about the fixed benefit plan, contact Aetna at:
• 1-888-772-9682
• www.aetna.com/docfind
6
dental
Aetna Dental Plan
You may elect dental coverage and use any licensed dentist for care. After you
pay a $50 deductible per person, the plan pays a percentage of the cost of
You dec
ide…
whether to
elect den
tal
coverage
and whic
h
dependen
ts to cove
r.
the service (up to $750 per year, per covered person). You receive additional
savings if you use a participating Aetna PPO network dentist.
Important Notes
• The dental PPO network is not available in Alabama, Arkansas, Hawaii, Idaho, Louisiana,
Mississippi or New Mexico.
• Your coverage is not effective until your first deduction is taken. That is, if you go to the dentist
before a deduction for dental coverage is taken from your paycheck, that visit will NOT be covered.
Keep this in mind when you are making dental appointments.
• Also, if a deduction was not taken for a certain week, the plan will not pay benefits incurred during that
week unless you submit the missed premium to Aetna within 45 days of its being missed.
The chart below shows the percentage the plan pays and the waiting period that applies before you can
receive services. That is, the plan requires you to be enrolled for a certain number of months before some
procedures are covered.
Minimum Percentage Plan Pays*
Waiting Period Before Plan Pays Check-ups/cleanings
80%None
Fillings
60%
3 months
Oral surgery
60%
3 months
Crown and bridge repair
60%
3 months
Periodontal and endodontic services
60%
12 months
Crowns and bridges
50%
12 months
Dentures50%
12 months
* Note that the cost you pay for a preferred provider is based on a negotiated charge. Your cost could be lower if you use
a participating PPO network dentist. The cost you pay for a non-preferred provider is based on the customary charge.
A non-preferred provider may require that you pay more than the customary charge and this additional amount is your
responsibility. Contact Aetna if you have any questions.
Pre-tax Dental Plan Weekly Rates
• Single$5.17
• You plus child(ren)
$10.74
• You plus spouse/domestic partner $11.43
• Family$14.81
To find a network dentist or get more information
about your dental benefits, contact Aetna at:
• 1
-888-772-9682
• w
ww.aetna.com/docfind
7
vision
EyeMed Vision Plans
Staples offers a choice of two EyeMed vision plans: the Basic Plan or the
Enhanced Plan. EyeMed has a national provider network for exams and
You dec
ide…
whether to
elect EyeM
ed covera
which pla
ge,
n you wan
t and whic
dependen
h
ts to cove
r.
eyewear at excellent discounts and savings. Participating providers include
LensCrafters, Pearle Vision and the vision centers at Target, Sears and
JC Penney.
See the chart below for a summary of what’s covered in-network and how.
Annual comprehensive exam
Basic Plan
Enhanced Plan
You pay a $20 copay
You pay a $5 copay
Eyeglass lenses You pay a $25 copay for single, You pay a $10 copay for single, bifocal,
(standard plastic and polycarbonate)
bifocal, trifocal and lenticular lenses trifocal, lenticular standard and premium
• Available once per plan year
progressives polychromatic (transitions)
Frames
• Available once every other plan year
You get a $130 allowance
towards frames
You get a $130 allowance
towards frames
Contact lenses
(instead of eyeglasses)
You get a $150 allowance
towards contacts
You get a $150 allowance
towards contacts
Retinal imaging
You pay up to a $39 copay
You pay up to a $39 copay
Laser eye surgery
You get 15% off retail price
You get 15% off retail price plus a
one-time $600 allowance
You may use out-of-network providers but will receive a lower benefit. Simply pay your provider and then
file for a reimbursement with EyeMed. See the Benefit Summary (available on www.staples.com/benefits)
for details.
Important Note: Unlike the fixed benefit and dental plans, the vision deductions are due whether or not you
receive services during that pay period. Any missed premiums will be deducted from future paychecks even if
you had no claims.
For more information about your vision
Pre-tax Vision Plan Weekly Rates
Basic
Enhanced
• Single
$1.05$2.41
• You plus child(ren)
$2.09
$5.03
• You plus spouse/domestic partner
$2.51
$5.89
• Family
$3.14$7.44
benefits, contact EyeMed at:
• 1-866-299-1358 (before you enroll) or
1-888-849-7297 (after you enroll)
• www.EnrollWithEyeMed.com (before you
enroll) or www.EyeMedVisionCare.com
(after you enroll)
Choose the “Select” network from the
“Find a Provider” dropdown box.
8
disability
· life
You dec
ide…
whether to
elect shor
t-term dis
coverage
ability
and what
weekly be
maximum
nefit
to choose
. You also
whether to
decide
elect life
insurance
yourself a
for
nd your d
ependents
.
Disability and Life Programs
Short-term disability pays you a weekly benefit if
you become disabled while you are employed with
Staples. Life insurance can provide a benefit if you
or your covered dependents were to die.
Short-term Disability Insurance
Life and
You may elect short-term disability (STD) coverage*
Accidental Death Insurance
for yourself. If you elect coverage, you are eligible
If you elect coverage for yourself, you will have:
for weekly benefits while you are disabled, for up to
• $20,000 of life insurance and
six months. You receive 50% of your base pay up
• $20,000 of accidental death insurance.
to the weekly benefit maximum. You choose your
You choose a beneficiary for these coverages. That
weekly benefit maximum: $50 or $125 per week.
is, if you were to die as the result of an accident,
Benefits begin after a 14-day waiting period (or
your beneficiary could receive up to $40,000 from
immediately, if hospitalized).
these plans. Note that benefits are reduced by
* Some states require employers to provide STD
50% when you reach age 70.
benefits. If you work in California, New Jersey,
You may also cover your dependents if you elect
New York or Rhode Island, you may not elect
coverage for yourself. Coverage levels are:
coverage through Aetna because you have state
• $2,500 of life insurance for any dependent at
coverage.
least six months old and
• $500 of life insurance for children from birth
Short-term Disability Example. If you elect the
through six months of age.
$50 weekly benefit maximum, you pay $1.62 per
week for the coverage (see below) and you receive
You are the beneficiary for any dependent
up to $50 per week if you become disabled. If you
coverage you elect. If a dependent dies, you
elect the $125 weekly benefit maximum, you pay
receive the benefit.
$3.50 per week and would receive up to $125 per
week during a disability.
After-tax Short-term Disability Weekly Rates
After-tax Life Insurance Weekly Rates
• $50 weekly benefit maximum
$1.62
• Associate only
$1.54
• $125 weekly benefit maximum
$3.50
• Associate plus dependents
$1.88
9
savings
· stocks
Savings and Stock Plans
Staples offers two plans that help you save for the future and share in the ownership of our company. The
chart below outlines the benefits of each plan.
401(k) Savings Plan
Employee Stock Purchase Plan (ESPP)
Your contributions
• From 1% to 50% of your pay on a pre-tax basis, to a maximum of $17,500
• Additional catch-up contributions if you are
at least age 50
• From 1% to 10% of your pay on an
after-tax basis
Staples incentives
• A Staples match equal to 50 cents for every dollar you save on the first 6% of pay
• 15% discount on Staples stock
purchased over a 6-month period
• No commission paid on purchase
• Dividends paid to your account in
Staples stock
Vesting – your right to your account
when you leave Staples
• Immediate 100% vesting of your
contributions and any rollover contributions
• 20% per year vesting of Staples matching
contributions (100% once you have five
years of vesting service)
• Not applicable
Investment options
• The option to choose individual investment funds (including a Staples stock fund) or target date funds for your contributions and
the Staples match
• Contributions that purchase
Staples stock
Taxes • No taxes apply until money is paid out
• Taxes are paid on any profits made
from the sale of stock
• The discount is taxable if you sell
shares before holding them for
18 months plus one day
• Dividends are taxable when paid
Changing participation
• Change or restart contributions each month; stop at any time
• Change investment fund mix at any time
• Two offering periods per year
Access to your savings
• A loan or hardship withdrawal while employed
• After you leave Staples, you can roll over your
account into another qualified account
(e.g. 401(k), IRA)
• Make withdrawals once you’re age 59-1/2
• Can sell shares at any time
• Can withdraw contributions at
any time
10
savings
· stocks
Participation
You may elect to participate in the 401(k) Savings Plan as of the first of the month following 60 days of
service as long as you are at least age 21. The Employee Stock Purchase Plan has two offering periods
per year: January through June and July through December. You are eligible to participate once you have
90 days of service.
401(k) Advantages
ESPP Advantages
A 401(k) plan can be one of your best tools for creating
With the ESPP, you don’t save on taxes but
a secure retirement. It provides you with two
do get a 15% discount when you purchase
important advantages:
Staples stock. Plus, you can sell your shares
• You don’t pay taxes on the contributions you make
or withdraw your contributions at any time.
or the earnings on your account – until you withdraw
money from your account.
• Staples adds a match of $.50 of every dollar you
contribute up to 6% of your annual eligible base pay.
The result is a retirement savings plan you cannot afford
to pass up. By contributing (even just a little), you’ll save
on taxes and get the Staples match!
For more information about the 401(k) Savings Plan
and the ESPP, go to www.staples.com/benefits.
Once you have an account in the 401(k) Savings Plan,
you can contact New York Life at:
1-800-294-3575
• www.mylife.newyorklife.com
Once you have an account in the Employee Stock
Purchase Plan, you can contact E*Trade at:
1-800-838-0908
• www.etrade.com/stockplans
11
other benefits
Voluntary Programs
Staples offers several voluntary programs through
You can enroll in the following benefits at any time:
Marsh@Work. You pay 100% of the cost and have
• Aflac Hospital Indemnity Plan – an individual
the convenience of automatic payroll deductions.
policy which gives you a lump sum dollar benefit
You can only enroll in MetLaw Legal Services
in the event you become hospitalized
during the annual open enrollment period or
• Aflac Supplemental Dental Coverage – an
when you are first eligible. (You can only drop
individual policy which gives you a lump sum
coverage during open enrollment). The cost
dollar benefit for dental services
is $21.25 per month. If you elect coverage, you
• Group home and auto insurance – offering
get advice and services for a wide range of legal
a group discount on premiums for auto,
matters, including document review, traffic ticket
homeowners, boat and renters insurance
defense, wills, family issues, real estate
• ID TheftSmart – designed to help you monitor
transactions and more.
your credit and restore your credit rating
You dec
ide…
whether to
elect cove
rage
under any
of these
voluntary
plans
• Veterinary pet insurance – providing coverage for most household pets for routine care
and more complex treatment
Marsh@Work can provide more information about
your coverage options and costs.
For more information, contact Marsh@Work at:
1-800-749-4217
staplesvoluntarybenefits.com (no “www”)
12
contacts
For More Information
Our benefits website, www.staples.com/benefits, can help with all of your benefit needs. You can find
information about your benefit plans and link to the vendor sites. Just select “Part-time non-exempt” as your
associate group. Visit today; it’s easy!
To contact a vendor directly or talk to HR Services, see the phone and website information in the table below.
Benefit/Vendor
By Phone
Via the Web
Aetna1-888-772-9682
www.aetna.com
• Fixed Benefit Plan
• Dental
To find a fixed benefit or dental network
• Life Insurance ($20,000)
provider, go to www.aetna.com/docfind
• Accidental Death ($20,000)
• Short-term Disability
EyeMed — Vision
Pre-enrollment
1-866-299-1358
Customer Service
1-888-849-7297
Pre-enrollment: www.EnrollWithEyeMed.com
Network: Select
Once enrolled: www.EyeMedVisionCare.com
Network: Select
New York Life — 401(k)
1-800-294-3575
www.mylife.newyorklife.com
E*Trade — ESPP
1-800-838-0908
www.etrade.com/stockplans
Marsh@Work — Voluntary Programs
1-800-749-4217
staplesvoluntarybenefits.com (no “www”)
LifeScope — EAP
1-800-227-2195
www.LifeScopeEap.com
(login and password: staples)
For a Staples contact for any/all benefits…
HR Services
1-888-490-4747
13
Submit an eHelpDesk ticket
rules
· disclosures
Rules and Limitations
Life Insurance Exclusions
• S
uicide or attempted suicide (while sane or
insane)
This section is a partial list of the rules and limitations that apply to your dental, short-term disability,
life insurance and accidental death insurance
coverages. However, your plan may contain
exceptions to this list based on state mandates
or the plan design purchased. Please refer to the
Aetna certificate you receive to determine which
services are covered and to what extent.
Accidental Death Benefit Exclusions
• U
se of alcohol, intoxicants or drugs, except as
prescribed by a physician
• S
uicide or attempted suicide (while sane or
insane)
Dental Exclusions
The following charges are not covered under the
dental plan and they will not be recognized toward
the satisfaction of any deductible amount (unless
mandated by law):
• A
n intentionally self-inflicted injury
• A
disease, ptomaine or bacterial infection except
for that which results directly from an injury
• M
edical or surgical treatment except for that
which results directly from an injury
• C
osmetic procedures unless needed as a result
of injury
• V
oluntarily inhalation of poisonous gases
• A
ny procedure, service or supplies that are
included as covered medical expenses under
another group medical expense benefit plan
• C
ommission of or attempt to commit a
criminal act
• P
rescribed drugs, premedication, analgesia or
general anesthesia
DISCLOSURES
Important Information About the Benefits
You Are Being Offered
• S
ervices provided for any type of temporomandibular (TMJ) or related structures or myofascial
pain
The Aetna Fixed Benefits Plan is a hospital confinement indemnity plan with other fixed indemnity
benefits. This plan provides LIMITED BENEFITS.
Benefits provided are supplemental and are not
intended to cover all medical expenses. This plan
pays you fixed dollar amounts regardless of the
amount that the provider charges. You are responsible for making sure the provider’s bills get paid.
These benefits are paid in addition to any other
health coverage you may have. This disclosure
provides a very brief description of the important
features of the benefits being considered. It is not
an insurance contract and only the actual policy
provisions will control. THIS PLAN DOES NOT
COUNT AS MINIMUM ESSENTIAL COVERAGE
UNDER THE AFFORDABLE CARE ACT.
• C
harges in excess of the recognized charge,
based on the 80th percentile of the Ingenix
Medical Data Research Tables
Short-term Disability Exclusions
• Attempted suicide, while sane or insane or
unintentional self-inflicted injury or sickness,
unless as the result of a medical condition
• C
ommission of or attempt to commit an act
which is a felony in the jurisdiction in which the
act occurred
• Substance abuse
• Occupational injury or sickness
14
rules
Notice to Texas Residents
THIS IS NOT A POLICY OF WORKERS’
COMPENSATION INSURANCE. THE EMPLOYER
DOES NOT BECOME A SUBSCRIBER TO THE
WORKERS’ COMPENSATION SYSTEM BY
PURCHASING THIS POLICY, AND IF THE
EMPLOYER IS A NON-SUBSCRIBER, THE
EMPLOYER LOSES THOSE BENEFITS WHICH
WOULD OTHERWISE ACCRUE UNDER THE
WORKERS’ COMPENSATION LAWS. THE
EMPLOYER MUST COMPLY WITH THE
WORKERS’ COMPENSATION LAW AS IT
PERTAINS TO NON-SUBSCRIBERS AND
THE REQUIRED NOTIFICATIONS THAT MUST
BE FILED AND POSTED.
· disclosures
Additional Disclosures
This material is for information only and is not an
offer or invitation to contract. Insurance plans
contain exclusions and limitations. Providers are
independent contractors and are not agents of
Aetna. Provider participation may change without
notice. Aetna does not provide care or guarantee
access to health services. Not all health services
are covered. See plan documents for a complete
description of benefits, exclusions, limitations
and conditions of coverage. Plan features and
availability may vary by location. Aetna receives
rebates from drug manufacturers that may be
taken into account in determining Aetna’s Preferred
Drug List. Rebates do not reduce the amount
a member pays the pharmacy for covered prescriptions. Discount programs provide access to
discounted prices and are not insured benefits.
Information is believed to be accurate as of the
production date; however, it is subject to change.
Notice to Missouri Residents
An optional rider for elective abortion has not been
purchased by the group contract holder pursuant
to VAMS section 376.805. An enrollee who is a
member of a group health plan with coverage for
elective abortions has the right to exclude and
not pay for coverage for elective abortions if such
coverage is contrary to his or her moral, ethical
or religious beliefs. Your plan sponsor does
not include coverage for elective abortions.
Policy forms issued include GR-9/GR-9N,
GR-29/GR-29N, GR96172, and GR96173.
IF YOU ARE ELIGIBLE FOR MEDICARE NOW
OR IN THE NEXT 12 MONTHS, YOU SHOULD
UNDERSTAND THAT:
• T
his IS NOT a Medicare Supplement Policy.
• T
his prescription drug benefit IS NOT creditable
coverage under Medicare Part D.
You can get a free Guide to Health Insurance for
People with Medicare at www.medicare.gov.
Aetna will pay benefits only for services provided
while coverage is in force, and only for medically
necessary, covered services. These benefits may
be modified where necessary to meet state
mandated benefit requirements.
The information in this document is a summary of the benefit plans available to eligible Staples associates for the 2014/2015 plan
year. Details are provided in the summary plan descriptions and other plan documents, which are available from Human Resources and
the applicable vendors. The plan documents contain the terms and conditions for each plan and govern the operation of the plans.
In the event that the content of this document or any oral representation made by any person regarding the plans conflicts with or is
inconsistent with the provisions of any plan document, the provisions of the plan document control. The provision of this document
and the contents thereof are not intended to and shall not create any contractual relationship or guarantee of employment for any
defined period of time between Staples and any recipients of this document, including, without limitation, Staples current and former
associates. Eligibility for and enrollment in Staples benefit plans are subject to all terms and conditions of the plans. Staples reserves
the right to amend, modify and/or terminate any or all of the plans at any time, in its sole discretion.
May 2014
15