Page 4 - PWH 2018 Plan Documents
P. 4
• Dental Care Plus Summary of Benefits
Claims Fiduciary: Custom Design Benefits
Claims Administrator: Custom Design Benefits
Benefit Program Year: January 1st through December 31st
List all Employers whose Employees participate in this Health Benefit Program:
Positrol Workholding
Dental
Elect One: This Benefit Program will be offered under the
Cafeteria Plan Arrangement; OR
This Benefit Program will not be offered under
the Cafeteria Plan Arrangement (or the Cafeteria
Plan Arrangement does not apply).
The documents that govern the operation and administration of the Benefit
Program include:
• Dental Care Plus Master Group Contract
• Dental Care Plus Summary of Benefits
• PPO Handbook
Claims Fiduciary: Dental Care Plus
Claims Administrator: Dental Care Plus
Benefit Program Year: January 1st through December 31st
List all Employers whose Employees participate in this Health Benefit Program:
Positrol Workholding
Vision
Elect One: This Benefit Program will be offered under the
Cafeteria Plan Arrangement; OR
This Benefit Program will not be offered under
the Cafeteria Plan Arrangement (or the Cafeteria
Plan Arrangement does not apply).
The documents that govern the operation and administration of the Benefit
Program include:
• Anthem Certificate of Coverage
• Anthem Benefit Summary
Claims Fiduciary: Anthem
Claims Administrator: Anthem
Benefit Program Year: January 1st through December 31st
List all Employers whose Employees participate in this Health Benefit Program:
Positrol Workholding
IV. The Fully Insured Benefit Programs listed below are offered under the Plan:
