Page 30 - 2021 Team Member Benefit Guide - English

Medical Gap Insurance

Benefits Provided Dependent Eligibility
The Gap Plan is a fully insured product If your dependents are eligible for coverage
offered through Sun Life Financial. This plan in the BCBS Medical Plan sponsored by the
provides payment to you for out of pocket Company, they are eligible for enrollment in
expenses due to hospital confinements and the Gap Plan. Individuals in your family on
outpatient treatment for a covered injury or whom you expect to receive reimbursement
sickness up to the plan’s annual calendar under the Gap Plan must also be enrolled in
year limits. the Medical Plan.
Sun Life looks only to the BCBS EOB to
substantiate your out-of-pocket costs in
determining your reimbursement under the
Gap Plan. It is permissible for you to claim
the same expense under a health flexible
spending account, if applicable. A medical
GAP claim form is located on the company
Intranet.

Cost of Coverage
The cost of coverage in the Gap Plan is
100 percent paid for by the employee.
The premiums are age-banded, based on
the employee’s age as of January 1, 2021.
Premiums are withheld on a pre-tax basis.
*Enrollment in the Medical Gap Plan is
contingent on enrollment in one of the
company sponsored medical plans where you
Rachael Wilson, Design Sales Specialist are NOT also contributing to a Health Savings
Kodiak, AK Account (HSA).

Weekly Rates Bi-Weekly Rates
<40 40-49 50+ < 40 40-49 50+
Employee $8.21 $11.24 $18.37 $16.41 $22.47 $36.73
Employee + $14.78 $20.22 $33.05 $29.56 $40.44 $66.10
Spouse
Employee +
Child(ren) $18.20 $20.73 $29.81 $36.40 $41.46 $59.62
Employee + Family $24.77 $29.71 $44.48 $49.53 $59.41 $88.96

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