2015 benefits enrollment booklet for new hires and newly ...€¦ · able to update it online later...

Important benefits information

2015 benefits enrollment booklet for new

hires and newly eligible team members

Action required Enroll before your enrollment period deadline

Welcome to Wells Fargo

Congratulations on your new position We value and

support our people as a competitive advantage We

strive to attract develop retain and motivate the most

talented people we can find These people become our

team members and are a treasured resource in whom

we invest

As part of that investment Wells Fargo is proud

to offer you a competitive benefits package with a

comprehensive selection of benefits

Our aim is to support you so you can learn about your

plans gain confidence when making benefits choices

plan for your future and reach your personal health

well-being and retirement goals

Using the booklet

Some benefits are provided at no additional cost to you

mdash and you are automatically enrolled when you become

eligible for benefits These benefits are noted in this

booklet by this symbol PAID FOR

You and Wells Fargo share the cost for most benefits

There are optional benefits in which you pay the

total cost if you elect them designated by this

symbol YOUR CHOICE

Use the Enrollment Worksheet on page 8 to keep track

of the coverage yoursquore interested in for you and your

eligible dependents

Keep in mind that this booklet is intended to provide

only an overview and does not contain all the

provisions of the Wells Fargo-sponsored benefits plans

It is very important that you refer to the Benefi ts Book

available on Teamworks which contains the provisions

of the Wells Fargo-sponsored benefit plans

3

Inside the booklet

Donrsquot miss your benefits enrollment period 4

How to enroll 5

Enrollment worksheet mdash optional 8

Medical coverage 10

Account-based medical plans overview 11

The HRA-Based Medical Plan 12

The HSA-based medical plans 14

Health and wellness dollars 17

Prescription drug coverage

under the account-based plans 18

Comparing the account-based medical plans 20

How does your account get funded 23

The Kaiser HMO and HDHP Kaiser medical plan 24

Health and well-being 28

Your medical plan resources 29

Flexible spending accounts 30

Dental and vision coverage 31

Financial protection Long-Term Care Plan 33

Financial protection Disability coverage 35

Financial protection Life insurance coverage 37

Financial protection Business Travel Accident

and Accidental Death and Dismemberment 39

Naming a beneficiary 40

Financial protection Legal Services Plan 41

Other benefits Commuter Benefit Program 42

Claims administrators contact info 43

Tools and resources 45

Important information and disclosures 46

4

Donrsquot miss your benefits enrollment period

If you want to elect certain benefits you must enroll

during your designated enrollment period

If you are hired rehired or become newly eligible from

You must enroll by Your benefits take effect on

January 2 to February 1 February 14 March 1

February 2 to March 1 March 14 April 1

March 2 to April 1 April 14 May 1

April 2 to May 1 May 14 June 1

May 2 to June 1 June 14 July 1

June 2 to July 1 July 14 August 1

July 2 to August 1 August 14 September 1

August 2 to September 1 September 14 October 1

September 2 to October 1 October 14 November 1

October 2 to November 1 November 14 December 1

November 2 to December 1 December 14 January 1

December 2 to January 1 January 14 February 1

Note Your designated enrollment period ends

at 1159 pm Central Time on the last day of the

enrollment period Please note that online enrollment

is unavailable on certain nights after 845 pm

Central Time

Why is electing your benefits during your enrollment period so important

Some benefits such as medical dental vision

Accidental Death and Dismemberment legal services

and flexible spending accounts may be elected only

during your designated enrollment period If you do

not enroll during your designated enrollment period

you must generally wait until the next Annual Benefits

Enrollment period to enroll yourself and your eligible

dependents unless you experience a Qualified Event

Other benefits such as life insurance optional long-

term disability and long-term care may be elected

without proof of good health only during this fi rst

designated enrollment period Changes to your life

insurance coverage optional long-term disability or

long-term care after your initial designated enrollment

period (or Qualified Event for life insurance) must be

approved under the applicable proof of good health or

evidence of insurability process

For additional details see the section titled Making

Changes after Your Designated Enrollment Period on

page 7 and the Benefits Book

5

How to enroll

Online

To enroll go to the Your Benefits tool on Teamworks or

Teamworks at Home (teamworkswellsfargocom) Sign

on to the Your Benefits tool using your Wells Fargo

username and password Click the help links if you

have ID or password questions For more detailed

help with the steps listed below click the Help Center

button in the Your Benefits tool at any time

Use the Enrollment Worksheet beginning on page 8 to

choose and keep track of your benefit elections

Enroll early for the best possible response time in the

online Your Benefits tool Delays or disruptions might

occur during evening hours when payroll functions are

running

Go to teamworkswellsfargo com

From work Click Pay amp Benefits then Benefits

Tools then Your Benefits

From home Click Your Benefits

1 On the Your Benefits tool home page click

Benefits Enrollment This link is active during your

enrollment and change periods only

2 Click Review Personal Information Check your

address and other information and update it if

necessary (You must do this only the first time you

view this site during a new enrollment period)

3 After reviewing your personal information you must

agree to the terms of the benefits enrollment before

you can proceed

4 When finished click Return to Benefits Enrollment

at the bottom of the page

Choose and save your plan elections

5 In the Enrollment Events table click Select The

Enrollment Summary page lists each benefit and

shows your current and new selections To make

changes to a benefits selection or to see all of that

benefit planrsquos choices and costs click Choose

6 On the enrollment page for each benefit click

one choice to elect a plan or waive coverage Add

dependent information if necessary (see If You Have

Eligible Dependents on page 6)

Note You can change elections at any time until your

designated enrollment period ends Any elections you

save will display when you return so you can verify or

make more changes

7 To save your election click Next review the

Confirmation page and click Save Yoursquoll return to

the Enrollment Summary page

Repeat steps 5 to 7 until you have selected all the plans

in which you want to enroll If you need to end your

session before completing all your benefits elections

complete step 7 and return later to finish enrolling

8 When yoursquove completed your benefits elections click

Finish The last page provides timing information for

the enrollment and change periods and a link to your

Benefi ts Confirmation Statement which you should

review for accuracy To exit the Your Benefits tool

click Sign Off at the top of the page

By phone

If you do not have online access from a computer or

have trouble signing on call the HR Service Center at

1-877-HRWELLS (1-877-479-3557) option 2 Monday

through Friday from 800 am to 500 pm in your time

zone The HR Service Center accepts relay service calls

TDDTTY users may call 1-800-988-0161

Confirm or correct your benefits elections

After you make your benefits elections you will receive

an email containing a link to access your Benefits

Confirmation Statement to review and print a copy for

your records This statement is also available from the

Your Benefits tool

Review your Benefits Confirmation Statement carefully

If you need to make changes to your benefits elections

follow the instructions on the statement If you make

corrections during your change period your benefits

administrators might not have a record of the changes

by the date on which your benefits become effective

your updated ID cards could be delayed as a result

Note If you receive your Benefits Confirmation

Statement by email (or similar electronic delivery)

you may request to have a paper copy sent to

you at no cost either by sending an email to

hrsddistributionfulfillmentwellsfargocom or by

calling the HR Service Center at 1-877-HRWELLS

(1-877-479-3557) option 2 The HR Service Center

accepts relay service calls TDDTTY users may call

1-800-988-0161

6

This paper copy will be the same version that you can

print from the Your Benefits tool If you donrsquot have

a valid Wells Fargo email address you will receive a

paper Benefi ts Confirmation Statement through the

US mail If you donrsquot have at-home or at-work access to

the Your Benefits tool call the HR Service Center with

your changes or corrections

If you have eligible dependents

You are eligible for benefits described in this booklet if

you are classified as either a regular team member who is

scheduled with standard hours of 30 or more hours per

week or a part-time team member who is scheduled with

standard hours of between 175 and 29 hours per week

In general your eligible dependents include

bull Your spouse or domestic partner

bull Your or your spouse or domestic partnerrsquos natural-

born or legally adopted child until his or her 26th

birthday

bull A child for whom you your spouse or your domestic

partner is the agency- or court-appointed legal

guardian or foster parent

See the Benefits Book on Teamworks and Teamworks

at Home (teamworkswellsfargocom) for complete

dependent eligibility requirements

Note Enrolling a dependent who does not meet

Wells Fargorsquos eligibility criteria is a violation of the

Code of Ethics and may result in disciplinary action

including termination of your employment with

Wells Fargo Wells Fargo reserves the right to conduct

audits and reviews of all dependent eligibility

To add eligible dependents

1 Click Add Dependent Details on the enrollment

page for any benefit that allows dependent

enrollment Note that you must enroll in the plan

yourself fi rst

2 On the DependentBeneficiary Personal Information

page enter the required information

3 Review the information carefully mdash you wonrsquot be

able to update it online later (except for a spouse or

domestic partnerrsquos smoker status) Click Save

4 The new dependent will be shown on the enrollment


enrollment Repeat steps 1 to 3 to list more

dependents

5 Any dependents you listed will now appear with

checkboxes that allow you to add them to your

benefi ts coverage

6 Check the Enroll checkboxes next to the names of

the dependents you want to enroll

7 Click Next Follow the certification instructions

To certify newly enrolled eligible dependents

If you enroll an eligible dependent in coverage

yoursquore required to complete a brief certifi cation of

benefits eligibility Certification is triggered for these

dependents after you select the Enroll checkbox and

click Next on the benefits enrollment page

1 Read the overview page and click Continue

2 The certification page includes the eligible

dependentrsquos name and the benefits eligibility

requirements specific to the eligible dependentrsquos

relationship to you Read it and enter any required

information If your dependent qualifi es click I

Certify For any who donrsquot qualify click I Do Not

Certify You will not be able to enroll an uncertified

dependent

bullensp If you have several eligible dependents to certify

yoursquoll see a page for each one

bullensp When certifying an eligible dependent child of

a domestic partner you may need to certify the

domestic partner first even if you arenrsquot enrolling

the domestic partner in benefits coverage

3 When you finish certifying yoursquoll see the enrollment

confirmation page Review it and click Save

Yoursquoll return to the Enrollment Summary page After

you certify an eligible dependent in one plan you

may enroll him or her in any additional benefits plans

without repeating the certification steps

Certification is not the same as enrollment mdash you will

still need to select the enrollment checkboxes for your

eligible dependents on every plan in which you want

them enrolled

7

Making changes after your designated enrollment period

If you experience a Qualified Event mdash such as a

change of marital or employment status or the birth or

adoption of a child mdash you may be able to change certain

benefits elections by calling the HR Service Center

within 60 days of the Qualified Event to update your

coverage

See the Benefits Book for more information about

Qualified Events If you donrsquot contact the HR Service

Center within 60 days of your Qualified Event yoursquoll

have to wait until the next Annual Benefits Enrollment

period to change your benefi ts elections

8

__________________________

______________________________________________

ensp ___

_______________________

___

_______________________

___

_______________________

_______________________

________________________________________

_______________

_______________ _______________________

_______________ _______________________

Enrollment worksheet mdash optional

About this page You will be able to select from

the benefits below during your designated benefi ts

enrollment period As you read through this booklet

you can use this worksheet to record your choices

This is not an enrollment form mdash you wonrsquot need

to send or fax it anywhere mdash but it may help you be

prepared for the decisions yoursquoll need to make when

you enroll online

My choices are From the Your Benefits tool my per-pay-period costs are

Medical

Waive

Enroll in plan name

Enroll eligible dependents (see list on next page)

$

Dental

Waive

Enroll in Delta Dental Standard

Enroll in Delta Dental Enhanced


$

Vision

Waive

Enroll in Vision Plan


$

Limited DentalVision

Flexible Spending Account

(FSA)

Note Consider this FSA if

you are enrolling in the HSA-

Based Medical Plan ndash Gold

the HSA-Based Medical Plan

ndash Silver or the HDHP Kaiser

medical plan

Waive

Contribute $ annually divided by the

number of pay checks remaining in the year

$

Full-Purpose Health Care

FSA

Note If you enroll in the HSA-




medical plan you cannot

enroll in this FSA Consider

enrolling in the Limited

DentalVision FSA instead

Waive



$

Day Care FSA

Waive



$

Optional Term Life

Waive

Enroll in coverage of (1 to 8) times

covered pay (coverage greater than 4 times your covered

pay requires proof of good health)

$

9

My choices are From the Your Benefi ts tool my per-pay-period costs are

ensp

_________________

_______________________

ensp

ensp _______________________

ensp

_______________________

ensp

ensp ensp

ensp

ensp

ensp

ensp

ensp

ensp

_______________________

ensp ensp

ensp

ensp

ensp

ensp _______________________

ensp

_______________________

ensp ensp

ensp

SpousePartner Optional

Term Life

Waive

Enroll spouse or domestic partner in coverage of

$ (multiples of $25000 coverage

over $25000 requires proof of good health)

$

Dependent Term Life

Waive

Enroll in coverage $

Accidental Death and

Dismemberment Plan

Waive

Enroll in coverage of

$75000 Me only

$150000 Me only

$300000 Me only

$600000 Me only

$75000 Me + family

$150000 Me + family

$300000 Me + family

$600000 Me + family

$

Long-Term Care Plan

Waive


$100 per day

$150 per day

$210 per day

$250 per day

$

Optional Long-Term

Disability (LTD) Plan

Waive


Legal Services Plan

Waive


Me only

Me + family

$

For more information on the proof of good health form for each type of coverage see that planrsquos chapter in the Benefits Book on Teamworks

The eligible dependents I want to enroll are

Name Birthdate Relationship Social Security Number

You will be asked to enter the Social Security Number for any dependents when you enroll them on Your Benefits However for security purposes

do not write down Social Security numbers where others may have access to them

10

Medical coverage YOUR CHOICE

All our medical plans offer

bull Eligible preventive care services covered at 100

when you use in-network providers

bull Comprehensive medical coverage that includes

routine care emergency care and mental health and

substance abuse services

bull Comprehensive prescription drug benefits

bull Annual limits on what you might pay to provide

fi nancial protection

bull A large network of doctors hospitals and other

providers that offer services at negotiated rates

bull Personalized one-on-one programs to help you and your

covered dependents improve or maintain your health

and well-being

Wells Fargo gives you a choice of three medical plans

that come with accounts mdash the Health Reimbursement

Account (HRA)-Based Medical Plan and two health

savings account (HSA)-based medical plans the

HSA-Based Medical Plan ndash Gold and the HSA-Based

Medical Plan ndash Silver Another account-based plan the

High-Deductible Health Plan (HDHP) Kaiser medical

plan is also available in select locations

If you live in These plans are available to you

Any state

except Hawaii

bullensp HRA-Based Medical Plan

bullensp HSA-Based Medical Plan ndash Gold

bullensp HSA-Based Medical Plan ndash Silver

Kaiser available in

the following service

areas within California

Colorado (Denver

and Colorado Springs

areas) Oregon

(Portland and Salem

areas) or Washington

(Vancouver Longview

and Kelso areas)

bullensp HDHP Kaiser medical plan

bullensp Kaiser HMO medical plan

Hawaii bullensp POS Kaiser Added Choice

Each medical planrsquos claims networks and provider fees are handled by a claims administrator For contact

information for the administrators see page 43

Medical Plan Claims administrator State or territory

HRA-Based

Medical Plan

HSA-Based

Medical Plan

UnitedHealthcare Alabama Arizona Arkansas Colorado District of Columbia Florida

Illinois Iowa Louisiana Maine Maryland Massachusetts Mississippi

Missouri Nebraska Nevada New Hampshire New Jersey New Mexico

Oregon Utah Wisconsin Wyoming

Anthem BCBS Alaska California Connecticut Delaware Georgia Idaho Indiana Kansas

Kentucky Michigan Montana New York North Carolina North Dakota

Ohio Oklahoma Pennsylvania Rhode Island South Carolina South

Dakota Tennessee Texas Vermont Virginia Washington West Virginia

HealthPartners Minnesota

Indemnity Medical

Plan mdash Anthem BCBS

Anthem BCBS Puerto Rico Guam and the Northern Mariana Islands (Saipan) Not

available in the 50 United States or in the District of Columbia

CVScaremark is the prescription drug administrator for all the medical plans listed above

Kaiser medical

plans

Kaiser Permanente Residents of Kaiser service areas within California Colorado (Denver

and Colorado Springs areas) Oregon (Portland and Salem areas) and

Washington (Vancouver Longview and Kelso areas)

POS Kaiser Added

Choice mdash Hawaii

Kaiser Permanente Hawaii

The Kaiser HMO HDHP Kaiser medical plan and the POS Kaiser Added Choice are fully insured medical plans under the Wells Fargo amp

Company Health Plan The benefits described in this booklet do not apply The descriptions of plan benefits for the various Kaiser medical

plans are provided in separate documentation that will be sent to you by Kaiser if you enroll in the applicable plan The information that

comprises the complete Summary Plan Description for the applicable Kaiser plan is noted in Chapter 1 of the Benefits Book

Note If you live in Puerto Rico Guam or the Northern Mariana Islands (Saipan) or are an expatriate view the plan

options shown on the Your Benefits tool

11

Account-based medical plans overview

Wells Fargo sponsors a choice of three national account-

based health plans in the continental United States

bull The HRA-Based Medical Plan

bull The HSA-Based Medical Plan ndash Gold

bull The HSA-Based Medical Plan ndash Silver

Our medical plans help you manage your health

care expenses with comprehensive medical and

prescription drug coverage and the advantages of a

health reimbursement or health savings account These

account-based medical plans allow you to use a health

reimbursement account (HRA) or a health savings

account (HSA) to plan and pay for qualifi ed medical

expenses

You are responsible for understanding how your plans

work how they pay for services and how your account

supports your benefi ts throughout the year

Check out the Quick Comparison Chart on page 20

for more information For additional details about the

medical plans see Chapter 2 of the Benefi ts Book

Thinking and acting like a health care consumer

Understand how your medical plan works you and

your plan share the responsibility of paying for eligible

medical services Wells Fargo pays the majority of your

costs for coverage mdash on average 75 of your medical

premiums mdash and you are responsible for the rest

Knowing what your plan covers and your share of the

cost can help you make informed decisions throughout

the year

bull Research each plan yoursquore considering to understand

all covered services and costs

bull Use the Medical Plan Comparison Tool and the CVS

caremark website to help guide your decisions

bull Take control of your important health care decisions

from choosing a plan to knowing where to go for care

when you need it

bull Save money and time by making sure that all your

providers are in your planrsquos network

bull Once yoursquove selected a plan use your claims

administratorrsquos online tools to research the cost of

any service you may need

bull Work closely with your doctor by following care

regimens seeking guidance on maintaining your

health and asking questions

bull Never avoid getting care when you need it

You can further manage your costs by considering the

fl exible spending account (FSA) options available to

you depending on the plan in which you enroll Also

if you complete the health and wellness activities you

and your covered spouse or domestic partner may

each be able to earn up to $800 in health and wellness

dollars for your HRA or HSA

Eligible preventive care benefi ts are covered at 100 in network

The Wells Fargo-sponsored medical plans cover 100

of the cost of eligible in-network preventive care

services such as the types of services listed in the

charts below To be covered at 100 your provider

must code the eligible service as preventive care

Read more about preventive care coverage in Chapter 2

of the Benefits Book

12

The HRA-Based Medical Plan

The HRA-Based Medical Plan is a comprehensive medical plan accompanied by a health reimbursement account

The HRA is designed to help you pay for your medical care including your deductible and eligible out-of-pocket

expenses

Your account is funded in two ways

1 Wells Fargo-contributed HRA dollars The amount of HRA dollars that Wells Fargo may contribute to your

HRA depends on your HRA-eligible compensation category and the coverage level you elect These dollars will

be available in your account as of the effective date of your HRA-Based Medical Plan coverage Sign on to the

Your Benefits tool on Teamworks to view your HRA compensation category

HRA annualized contribution amount for 2015

Coverage level HRA-eligible compensation category

Category 1

Less than $60000

Category 2

$60000 ndash less than

$100000

Category 3


$150000

Category 4

$150000 or more

You $700 $600 $200 $0

You + spouse $700 $600 $200 $0

You + children $1200 $1000 $400 $0

You + spouse + children $1200 $1000 $400 $0

HRA contributions are prorated for the months you are enrolled in the plan

Spouse includes your spouse or domestic partner

Note HRA allocations are prorated for the months you are enrolled in the plan Amounts allocated to an HRA

including health and wellness dollars are not vested and are subject to forfeiture Wells Fargo amp Company reserves

the unilateral right to amend or modify the HRA at any time for any reason with or without notice including

placing limitations or restrictions on amounts allocated to an HRA or terminating the HRA

2 Health and wellness dollars You and your spouse or domestic partner each have the opportunity to earn up to

$800 in health and wellness dollars by completing the health and wellness activities See page 17 to learn how to

earn health and wellness dollars in 2015 Health and wellness dollars are prorated for the months you are enrolled

in the plan

Key HRA-based medical plan terms

Annual

deductible

bullensp This is the amount that you must pay toward the eligible expenses for covered health services before the

plan begins to pay any portion of the cost of eligible medical expenses you have incurred

bullensp Available HRA dollars may help cover the cost of the deductible

bullensp If you use up your HRA dollars during the plan year you then pay your eligible medical expenses yourself

out of pocket until you reach your annual deductible

bullensp If you enroll midyear in the HRA-Based Medical Plan the annual deductible will be prorated for the months

you are enrolled in the plan

Coinsurance bullensp This is the percentage of charges that you are required to pay for most eligible medical expenses after your

annual deductible is met

bullensp After you have met the annual deductible you pay 20 of the cost of in-network expenses for covered health

services and the plan pays 80

13

Your responsibility

Plan pays

Annual

out-of-pocket

maximum

bullensp This is the annual maximum you pay each year for covered health services

bullensp When the combined total of your deductible and medical coinsurance payments reaches the annual out-of-pocket

maximum the plan then pays 100 of eligible in-network medical care through the rest of the plan year

bullensp Your annual out-of-pocket maximum amount includes costs for eligible medical expenses

bullensp If you enroll midyear in the HRA-Based Medical Plan the annual out-of-pocket maximum will be prorated

for the months you are enrolled in the plan

Primary care

mental health

and substance

abuse care

bullensp For primary care or mental health care in-network outpatient offi ce visits you pay 20 with no deductible

and this amount is deducted from your HRA if available

bullensp Additional services incurred during an offi ce visit may be subject to the annual deductible and coinsurance

bullensp A primary care provider is a family medicine physician general practice physician internal medicine

physician nurse practitioner obstetrician and gynecologist pediatrician or physician assistant

How the HRA-Based Medical Plan pays for in-network claims

January Benefit plan year December

Plan pays 100 for eligible preventive care

Deductible

Your HRA pays

You pay remaining

expenses out of pocket

bull HRA pays expenses to help satisfy the annual deductible

bull If expenses exceed HRA funds you pay out of pocket up to the annual deductible

Coinsurance

Plan pays 80

(90 for maternity)

You pay 20

(10 for maternity)

bull If you reach your annual deductible you and the plan share responsibility for payment

bull HRA funds help to pay coinsurance

Out-of-pocket maximum

Once reached

plan pays 100

If you reach your out-of-pocket annual maximum you pay nothing more for the rest of the year (Note Out-of-pocket maximums apply separately for medical and prescription drug expenses)

This summary does not cover all account-based plan

features and it does not show compatibility with the

flexible spending accounts Visit the Health amp Well-

Being website or see the Benefits Book for details Out-

of-network services are priced differently and could

result in more out-of-pocket costs to you

HRA-Based Medical Plan Out of Area where

applicable Benefits-eligible team members who live

outside the network area can elect HRA-Based Medical

Plan Out-of-Area coverage This coverage allows you to

choose any doctor or hospital For further details refer

to the applicable Summary of Benefits and Coverage

and rates provided with your benefits materials and

available on Teamworks

Save more with a Flexible Spending Account

You can use before-tax dollars in a Full-Purpose

Health Care Flexible Spending Account (FSA) to pay

for eligible medical dental vision and prescription

expenses that are not reimbursed by another source

For more information about FSAs see page 30

14

HSA-Based Medical Plans (Gold and Silver)

The HSA-Based Medical Plan ndash Gold and the HSA-

Based Medical Plan ndash Silver are comprehensive high-

deductible health plans that are compatible with health

savings accounts and are designed to help you save and

pay for your medical care mental health and substance

abuse services and prescription expenses You decide

when to use your available HSA balance to pay for

eligible services

Key HSA-based medical plan terms

Annual

deductible

bullensp This is the amount you pay each year toward the eligible expenses for covered health services before the

plan begins to pay any portion of the cost of eligible medical expenses

bullensp You pay 100 of health care costs including prescription drugs that are not on the preventive therapy

drug list from your HSA or out of pocket until you meet the annual deductible

Coinsurance bullensp The percentage of charges you are required to pay for most eligible medical expenses after your annual

deductible is met

bullensp The plan pays the rest for covered health services

Annual out-of-

pocket maximum

bullensp This is the annual maximum you would ever pay each year for covered health services

bullensp If your coinsurance payments reach the annual out-of-pocket maximum the plan then covers eligible

in-network medical care at 100 through the rest of the plan year

bullensp Your annual out-of-pocket maximum includes costs for eligible medical mental health and prescription drugs

Both the HSA-Based Medical Plan ndash Gold and the HSA-

Based Medical Plan ndash Silver

bull Cover 100 of your eligible in-network preventive

care subject to certain limitations

bull Cover 80 of costs for prescription drugs on the

Preventive Therapy Drug List purchased at in-

network pharmacies or from the CVScaremark Mail

Service pharmacy you pay only 20 and have no

deductible

The HSA-Based Medical Plan ndash Silver pays 80

(you pay only 20) of the cost of in-network medical

services and prescription drugs after you meet the in-

network deductible

The HSA-Based Medical Plan ndash Gold pays 80 (you

pay only 20) of the cost of in-network medical


network deductible

While still a high-deductible plan the HSA-Based

Medical Plan ndash Gold offers a lower annual deductible

and lower annual out-of-pocket maximum than the

HSA-Based Medical Plan ndash Silver

15

Your responsibility

Plan pays

How the HSA-Based Medical Plans (Gold and Silver) work to cover in-network expenses



Deductible

You pay 100

of deductible

HSA balance can be used

bull You choose to use your HSA to pay eligible expenses while you satisfy the annual deductible

bull Unused HSA balance can be saved for future qualified medical expenses

Coinsurance

Plan pays 80

(90 for maternity)

You pay 20 (10 for maternity)



bull You can pay your share from your available HSA balance or out of pocket mdash itrsquos up to you


Once reached

plan pays 100

If you reach your out-of-pocket maximum you pay nothing more for the rest of the year

This summary does not cover all account-based plan features nor show compatibility with the flexible spending accounts See the Benefits Book for

more details Out-of-network services are priced differently and could result in more out-of-pocket costs to you


You can use before-tax dollars in a Limited Dental

Vision Flexible Spending Account (FSA) to pay

for eligible dental and vision expenses that are not

reimbursed by another source For more information

about FSAs see page 30

Health savings account

A health savings account (HSA) is an individual

account that belongs to you Itrsquos not part of any

employee benefit plan sponsored or maintained by

Wells Fargo amp Company or any of its subsidiaries or

affi liates and is not subject to the Employee Retirement

Income Security Act (ERISA)

If you spend funds in your HSA on qualified medical

dental vision and prescription expenses mdash now in the

near future or in retirement mdash those funds generally

wonrsquot be subject to federal taxes

Use the money in your HSA to cover qualifi ed medical

dental vision and prescription expenses or save it for

future health care expenses You own the dollars in your

account from day one and you never lose them so you

get to choose when to use them

Your HSA is administered by Wells Fargo Health

Benefit Services (HBS) a division of Wells Fargo Bank

NA You own and control all funds in your HSA and

your account is subject to the terms and conditions of

the custodial agreement The custodial agreement is

provided by HBS

Visit the HBS website (wellsfargocominvestinghsa)

for information on

bull Receiving distributions from your HSA

bull How funds in your HSA roll over from one year

to the next

bull Understanding HSA fees

16

HSA eligibility

You must be enrolled in an HSA-based medical plan to

make payroll contributions to the HSA

In general you cannot contribute to an HSA if you

bull Are covered under any nonndashhigh-deductible health plan

bull Are entitled to benefits under Medicare (that is you

are enrolled in Medicare)

bull Are eligible to be claimed as a dependent on another

personrsquos tax return Please note that a spouse or

domestic partner is not considered a dependent for

this purpose

bull Have received medical benefits from the US

Department of Veterans Affairs at any time during

the preceding three months

bull Are enrolled in the Full-Purpose Health Care FSA

through Wells Fargo or your spouse or domestic

partnerrsquos employer

In addition individuals covered as dependents under a

parentrsquos Full-Purpose Health Care FSA are not eligible

to contribute to an HSA You must be enrolled in an

HSA-based medical plan in order to make payroll

contributions to your HSA Consult your tax advisor if

you have questions

Contributing to your HSA

Using the Your Benefits tool on Teamworks you choose

how often and how much you want to contribute to

your HSA per pay period You can make updates at

any time You can allocate certain dollar amounts on

specific paydays or adjust the timing of your annual

deductions You may also establish an annual HSA

payroll contribution by contacting the HR Service

Center at 1-877-HRWELLS (1-877-479-3557) option 2

Any contributions made by Wells Fargo count toward

your maximum annual contribution limit as set by

the IRS Because you have the opportunity to earn

health and wellness dollars the annual maximum HSA

contributions through Wells Fargo payroll for 2015 are

less than the IRS maximum

You only $3350

You + spouse $6650

You + children $6650

You + spouse + children $6650

Team member age 55+ catch-up $1000

Includes eligible spouse or domestic partner

Includes spousersquos or domestic partnerrsquos eligible children

Domestic Partner HSA information

When you enroll in any of the medical plans that are

compatible with an HSA your domestic partner will

have benefits coverage under the medical portion of

the plan In that case you will have a shared deductible

and out-of-pocket maximum for the medical plan when

you select employee plus spouse or domestic partner

coverage

Whether you can pay your domestic partnerrsquos medical

expenses with your HSA depends on whether your

domestic partner qualifies as a tax dependent If you

can claim your domestic partner as a dependent on

your federal income tax return distributions for his or

her medical expenses are tax-free

bull Any individual you can claim as a tax dependent as

defined by Internal Revenue Code is not eligible to

open or contribute to his or her own HSA

bull If your domestic partner is not a tax dependent

distributions from your HSA for his or her medical

expenses are not tax-free

ndash Wells Fargo offers an annual special wage payment

for team members who cover a same-sex domestic

partner (andor his or her children) designated as

after-tax dependents in Wells Fargo-sponsored

medical dental or vision coverage

bull A domestic partner whom you cannot claim as your

dependent may open and contribute to his or her own

HSA

Your covered domestic partner is eligible to open an

HSA through Wells Fargo Health Benefit Services

(HBS) or any other HSA administrator as long as

he or she is enrolled in a qualifying high-deductible

health plan If your domestic partner has his or her own

HSA you might need to divide the maximum HSA

contribution limit between the two of you If you have

questions about allocating contribution limits between

domestic partners consult a tax advisor

17

Health and wellness dollars

When you enroll in an account-based medical plan

(the HRA-Based Medical Plan one of the HSA-based

medical plans or the HDHP Kaiser medical plan) you

can earn health and wellness dollars for your HRA or

HSA by completing health and wellness activities and

educational programs

Depending on the activities completed you and your

covered spouse or domestic partner if he or she is also

enrolled could each earn up to $800 for your HRA or

HSA If you enroll midyear the amount of health and

wellness dollars that you can earn will be prorated

Note Only specified activities allow you to earn health

and wellness dollars for your account

As you complete the activities health and wellness

dollars will be deposited to your HRA or HSA in

approximately 30 days Health and wellness dollars

cannot be deposited either in the Full-Purpose Health

Care FSA or the Limited DentalVision FSA

Activities that allow you to earn health and wellness dollars

Before you can earn health and wellness dollars you

must register on the Optum website Optum is the

Wells Fargo provider for health and wellness activities

Registration takes only a few minutes and once yoursquore

registered you can use this same account for all of

the activities Note You and your spouse or domestic

partner may complete the health and wellness activities

only after your medical coverage effective date It may

take up to two weeks after your coverage effective date

before you are able to register on the Optum website

Visit the Health amp Well-Being website on Teamworks for

detailed registration instructions and helpful links or go

to the Optum website (wellnessmyoptumhealthcom)

and click Register in the upper right corner of the page

If you are unable to register online contact Optum at

1-877-543-4294

Health and wellness activity

Maximum health and wellness dollars for you

Maximum health and wellness dollars for your covered spouse or domestic partner

Time to complete activity How to complete the activity

Health

assessment

$150 $150 About 15 minutes Sign on to the Optum website

and fi ll out the confi dential

questionnaire

Biometric

screening

$250 $250 About 30 minutes at either an

event on site at a Wells Fargo

location or an appointment with

your doctor preferably at the time

of your annual preventive exam

Sign on to the Optum website

and register for an on-site

event or print a personalized

Health Provider Screening

Form for your personal doctor

to complete

Online

wellness

education

programs or

telephonic

wellness

coaching

program

$400 $400 6 to 8 weeks to complete one of

the following

bullensp Online Wellness Education

Program Complete 12 activities

and five weekly tracker entries

bullensp Telephonic Wellness Coaching

Program Complete two

outbound coaching calls

Online Wellness Education

Program Sign on to the

Optum website and complete

the program requirements

Telephonic Wellness

Coaching Program

Call Optum at

1-877-440-9402 to register

Summary $800 $800 30 days to deposit funds in

your HRA or HSA

Important dates for earning health and wellness dollars

Complete the health and wellness activities between your medical plan coverage effective date and November 15

2015 to earn health and wellness dollars in 2015

18

Prescription drug coverage under

the account-based plans

Comprehensive prescription drug benefits for the

account-based medical plans are administered by

CVScaremark The nationwide network of more than

64000 pharmacies includes most retail chains and

many independent pharmacies in addition to the CVS

caremark Mail Service Pharmacy

About 90 of team members in account-based plans

are already saving money by choosing generic versions

of their drugs You can cut your costs further by

switching to a 90-day supply of the prescriptions you

take regularly Call CVScaremark at 1-855-673-6197

and they will take care of switching to 90-day supplies

for you You can have your prescriptions mailed to you

or you can pick them up at a CVSpharmacy store

Visit the CVScaremark Prescription Benefits Preview

website at caremarkcomwf to

bull Check drug costs

bull See if your drug requires prior authorization requires

you to first try an alternative drug or has quantity

limits

bull View the Advance Formulary drug list

bull View the Preventive Therapy Drug List Drugs on this

list are not subject to the deductible for the HSA-

based medical plans

bull Learn how you can save time and money by

switching to 90-day supply prescriptions

Comparing the account-based plans (in network)

HRA-Based Medical Plan HSA-Based Medical Plan ndash Gold


Is there a copay

for generic

prescription

drugs

Yes $7 retail (up to a 30-day supply)

$14 mail service (up to a 90-day supply)

or CVSpharmacy stores

(84- to 90-day supplies only)

No coinsurance applies

You pay 20 after annual

deductible (or 20 with no

deductible for drugs on the

preventive therapy drug list)






Are prescription

drugs part of

the medical

out-of-pocket

maximum

No There is a separate annual out-of-

pocket maximum for prescriptions you

purchase at

bullensp CVScaremark Mail Service Pharmacy

(up to a 90-day supply)

bullensp CVSpharmacy stores


bullensp Other in-network retail pharmacies

(up to 30-day supply)

bullensp CVScaremark Specialty Pharmacy


Yes Yes

Benefits are determined using the plansrsquo allowed amounts for eligible covered expenses If you buy a brand-name drug when generic is available you also

pay the cost difference which is not applied to your deductible (HSA-based medical plans only) or out-of-pocket maximum Out-of-network prescriptions

are covered differently they have separate deductibles and out-of-pocket maximums and could result in more out-of-pocket costs to you

19

Additional requirements for some prescription drugs

Some drugs have additional requirements that must be

met before the plan will cover your prescription

bull Certain medications require prior authorization by

CVScaremark before your prescription can be fi lled

bull Some plans require step therapy This means that if

you are prescribed a drug you might be required to

first try a generic drug or other therapy before the

plan will cover certain drugs

bull Most specialty medications mdash typically medications

that are self-injectable or require special handling

mdash are available only through the CVScaremark

Specialty Pharmacy not through retail pharmacies

bull Some drugs are covered only for certain limited

quantities based on manufacturer and clinical

guidelines

For more information about additional requirements

visit the CVScaremark Prescription Benefits Preview

website (caremarkcomwf) and see Chapter 2 of the

Benefits Book


If you enroll in the HRA-based medical plan you can

use before-tax dollars in a Full-Purpose Health Care

Flexible Spending Account (FSA) to pay for eligible

prescription expenses that are not reimbursed by

another source For more information about FSAs see

page 30

20

Comparing the account-based medical plans

Quick comparison chart (in-network services)

Out-of-network services are priced differently and could result in more out-of-pocket costs to you

Plan feature HRA-Based Medical Plan HSA-Based Medical Plan ndash Gold


Per-pay-period premium High Medium Low

Deductible Low Low High

Coinsurance Same

Out-of-pocket maximum Medium Low High

Provider network Same

Associated account mdash

helps you pay for

eligible expenses

Health Reimbursement

Account (HRA) mdash

a feature of the plan

Health Savings Account (HSA) mdash you always own it

Associated account

funding provided by

Wells Fargo

HRA funding based on

compensation category

Earn health and wellness

dollars

Earn health and wellness dollars

The HRA-Based Medical Plan covers in-network primary care office visits and mental health outpatient visits at 80 no deductible you pay 20

coinsurance until you reach the in-network out-of-pocket maximum

The HRA-Based Medical Plan has two in-network out-of-pocket maximums one for eligible medical expenses and a separate one for eligible prescription

drug expenses For both the HSA-Based Medical Plan ndash Gold and HSA-Based Medical Plan ndash Silver both eligible prescription drugs and medical

expenses are applied toward the combined in-network out-of-pocket maximum




Prescription drugs on

the Preventive Therapy

Drug List

Does not apply Coinsurance no deductible

30-day supply

prescriptions

Copay for generic drugs

Coinsurance up to a maximum

for brand-name drugs

Coinsurance after deductible

90-day supply

prescriptions





In-network prescription

drug out-of-pocket

maximum

Separate out-of-pocket

maximum

Combined medical and prescription drug

out-of-pocket maximum

21

Additional detail

In network HRA-Based Medical Plan HSA-Based Medical Plan ndash Gold


Annual deductible You $2000

You + spouse or domestic

partner $3200



partner + children $3800

You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount

after the deductible

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

Eligible preventive care You pay $0 You pay $0 You pay $0

Mental health and

substance abuse office

visits

Mental health and substance

abuse office visits are not

subject to the deductible

This means that even if you

havenrsquot reached your annual

deductible limit the plan will

pay for 80 of the in-network

office costs

Your 20 share is paid directly

from your HRA if you have a

balance

Annual out-of-pocket

maximum includes costs for

eligible mental health and

substance abuse care

You pay 20 after the

deductible is met Use your

HSA to pay or pay out of

pocket Annual out-of-pocket











Primary care office visits Office visits are not subject to

the deductible

You pay 20 coinsurance that

is paid directly from your HRA

if funds are available



eligible primary care




pocket







pocket




Prescription drugs You pay a $7 to $14 copay

(generics) or coinsurance

(brand name)

Prescriptions on the preventive

therapy drug list You pay 20

no deductible




pay for 80 of the preventive

drug costs

Nonpreventive drugs You

pay 20 after the deductible

is met

Use your HSA to pay or pay out

of pocket Annual out-of-pocket


eligible prescription drugs



no deductible





drug costs



is met





22

Additional detail (continued)



Specialist HRA pays based on the

deductible or coinsurance




pocket




pocket

All other covered

medical services

including for example

laboratory services and

hospitalizations

HRA pays based on the





pocket




pocket


maximum for medical

(includes deductible)

You $4000


partner $6400




Note There is a separate

annual out-of-pocket

maximum for eligible in-

network prescription drug

costs

You $3000

You + spouse or domestic partner $4800


You + spouse or domestic partner + children $5700

You $5000





maximum for all in-

network prescriptions

You $1000


partner $1600




There is no separate annual

out-of-pocket maximum for

prescription drug costs




Are prescription drugs

part of the medical


maximum

No A separate out-of-

pocket maximum applies

to in-network prescription

purchases

Yes Yes

See Chapter 2 of the Benefits Book for more information

23

How does your account get funded

Depending on which plan you choose your account can be funded from a number of sources

HRA Funding HSA Funding

See page 12 to determine

your compensation category

bullensp Wells Fargo contribution

for team members in

compensation categories

1 to 3

bullensp Your earned health and

wellness dollars

bullensp Unused contributions from

previous years

bullensp Team member before-tax

payroll contributions


wellness dollars


previous years

Make your own before-tax

contributions up to the IRS

limits See page 16 for more

information

An HRA is a notional bookkeeping entry and no specific funds will be set aside in an account for purposes of funding an HRA Amounts allocated to

an HRA including health and wellness dollars are not vested and are subject to forfeiture

By completing the health and wellness activities you and your covered spouse or domestic partner may each be

able to earn up to $800 in health and wellness dollars for your HRA or HSA

Note regarding midyear enrollment

If you enroll midyear in the HRA-Based Medical Plan Wells Fargo may allocate a prorated amount of HRA dollars

to your HRA Your annual deductible annual out-of-pocket

maximums and earned health and wellness dollars will also be

prorated depending on the date your benefits take effect

If you enroll midyear in an HSA-based medical plan

(Gold or Silver)

You are required to meet the full-year annual deductible and

annual out-of-pocket maximum regardless of your effective

date of coverage during the year

24

The Kaiser HMO and HDHP Kaiser medical plan

The Kaiser HMO and the High-Deductible Health

Plan (HDHP) Kaiser medical plan are available to

benefits-eligible team members who reside within the

Kaiser service areas of California Colorado (Denver

and Colorado Springs areas) and the Northwest which

consists of Oregon (Portland and Salem areas) and


POS Kaiser Added Choice mdash Hawaii is available only

in Hawaii The plans are available in limited locations

because of the exclusive provider relationships

available only through the Kaiser network

The Kaiser HMO medical plans for California

Colorado and the Northwest

bull Provide medical care through a network of hospitals

doctors and other providers

bull Pay for medical care only if you use a Kaiser provider

or facility Note In most cases the Kaiser medical

plans will pay for expenses incurred at a non-Kaiser

provider or facility in the case of a life-threatening

emergency

bull Charge a deductible and coinsurance payments for

certain covered services

bull Require a copay for certain office visits

bull Pay 100 of the cost for preventive care visits

bull Offer prescription drug coverage and mental health

and substance abuse benefits

bull Will generally pay only for medical care that is

referred by your primary care physician (PCP) Verify

Kaiser medical plan specifics in your area

The HDHP Kaiser medical plan for California

Colorado and the Northwest is an HSA-compatible

plan that allows members in certain Kaiser regions

to contribute to an HSA and participate in health and

wellness activities The HDHP Kaiser medical plans

are comprehensive health plans that cover a range of

services prescription drug coverage and mental health

and substance abuse benefits The features listed below

are provided as examples

Visit the Kaiser medical plans website

(mykporgwf) and refer to the rates and the Summary

of Benefits and Coverage for the features available in

your area

Kaiser HMO amp POS features

California Colorado and the Northwest area only HMO

Hawaii only POS

Plan features You pay You pay in-network Kaiser doctors and facilities

General

Annual deductible $300 you

$600 two or more individuals

None

Annual out-of-pocket maximum (verify

to see what expenses apply in your

specific region)

$2500 you


$1500 you


Lifetime maximum No maximum No maximum

Outpatient services

PCP office visit $25 copay $15 copay

Annual adult physical exams (preventive) You pay $0 You pay $0

Well-child care (preventive) You pay $0 You pay $0

Immunizations (preventive) You pay $0 You pay $0

Outpatient surgery and services $50 copay for specialist office visits

20 after deductible for other outpatient

services including surgery

$15 copay

25


Hawaii only POS


Inpatient care

Hospital care 20 after deductible Covered 100 no copay

Urgent care California $25 copay

Colorado and the Northwest $50 copay

$15 copay at Kaiser Hawaii facility

Emergency care 20 after deductible $50 copay

Maternity care

Office visit prenatal California Northwest

Covered 100 no copay

Colorado 20 after deductible

(as part of the global bill)

$15 copay for first visit

then covered 100

Office visit postnatal California Northwest Covered 100 no

copay for first postpartum visit


(as part of global bill)


then covered 100

In-hospital delivery 20 after deductible Covered 100 no copay

Other medical services

Occupational therapy physical therapy

and speech therapy

California $25 copay after deductible no

limit must be medically necessary and

authorized by a Kaiser physician

Colorado Northwest $25 copay after

deductible limit 20 visits per therapy per

calendar year must be medically necessary

and authorized by a Kaiser physician

$15 copay limit 60 visits combined

per calendar year must be medically

necessary and authorized by a Kaiser

physician

Chiropractic care $15 copay (deductible does not apply)

limit 20 visits per calendar year

Not covered

26

High Deductible Health Plan Kaiser medical plan features

California Colorado and the Northwest area only HDHP

Plan features You pay

General


$3200 you + spouse or domestic partner

$2600 you + children

$3800 you + spouse or domestic partner + children

Annual out-of-pocket maximum

(verify to see what expenses apply in your

specific region on the Kaiser medical

plans website (mykporgwf)

$3000 you




(Includes deductible)

Lifetime maximum No maximum

Outpatient services

Primary care physician (PCP) 20 after deductible

PCP office visit 20 after deductible

Annual adult physical exams (preventive) You pay $0

Well-child care (preventive) You pay $0

Immunizations (preventive) You pay $0

Outpatient surgery and services 20 after deductible

Inpatient care

Hospital care 20 after deductible

Urgent care 20 after deductible

Emergency care 20 after deductible

Maternity care

Office visit prenatal California Northwest You pay $0


Office visit postnatal California 20 after deductible

Colorado Northwest 10 after deductible

In-hospital delivery 10 after deductible



and speech therapy

California 20 after deductible no limit must be medically necessary and

authorized by a plan physician

Colorado Northwest 20 after deductible limit 20 visits per therapy per year

must be medically necessary and authorized by a plan physician

Chiropractic care California $15 copay after deductible limit 20 visits per calendar year

Colorado Northwest 20 after deductible limit 20 visits per calendar year

27

Using a health savings account

The HDHP Kaiser medical plan is a comprehensive

medical plan that is compatible with a health savings

account designed to help you save money to pay for

future qualified medical dental vision and prescription

expenses You decide when to use your available HSA

balance to pay for eligible services





Use the money in your HSA to cover qualified medical






With the HDHP Kaiser medical plan you are eligible

to earn health and wellness dollars for your HSA

by completing health and wellness activities and

educational programs Depending on the activities

completed you and your covered spouse or domestic

partner if he or she is also enrolled could each earn

up to $800 for your HSA If you enroll midyear the

amount of health and wellness dollars that you can

earn will be prorated


and wellness dollars for your account See page 17 for

more information about health and wellness activities

Save more with a flexible spending account

If you enroll in a Kaiser HMO or POS option or if you

waive Wells Fargo medical plan coverage you can



medical dental vision and prescription expenses that

are not reimbursed by another source

If you enroll in the HDHP Kaiser medical plan you

can use before-tax dollars in a Limited DentalVision


dental and vision expenses that are not reimbursed by

another source


28

Health and Well-Being

Want help to get and stay motivated to make better lifestyle choices fi nd health-related information from a trusted

source or research treatment options If you elect coverage in the HRA-Based Medical Plan the HSA-Based

Medical Plan ndash Gold the HSA-Based Medical Plan ndash Silver or the HDHP Kaiser medical plan yoursquoll have access to

tools and resources that can help and support your overall good health and well-being See more on the Health amp

Well-Being website on Teamworks

Programs and services (account-based plans only)

wellnessmyoptumhealthcom A secure website for Wells Fargo team members with tools trackers videos articles and

other resources to help you focus on good health and well-being

Health assessment An online health and lifestyle questionnaire that takes about 15 minutes to complete and

gives you personal feedback about your lifestyle choices

Wellness coaching programs

by phone

Work over the phone with a personal health coach to set goals and make the changes needed

for a healthier lifestyle

Online wellness education

programs

Complete online activities and use weekly trackers to make progress toward a healthier

lifestyle

Treatment decision support An over-the-phone program to help you understand treatment options and make informed

decisions if yoursquore dealing with conditions such as low back pain joint pain or replacement or

breast or prostate cancer Note that these programs are not available to those enrolled in the

HDHP Kaiser medical plan

Note If you enroll in a Kaiser HMO visit mykporgwf to learn about resources and programs to support you

29

Your medical plan resources

Unsure how to treat a fever in the middle of the night what to expect when yoursquore expecting or how to cope with

a serious disease If you elect coverage in any of the Wells Fargo-sponsored medical plan options contact your

claims administrator to access these great resources See the Benefits Book for more information about specifi c

claims administrators

24-hour NurseLine Assistance with understanding medical problems evaluating self-care possibilities and

researching treatment options including where to get the right care at the right time

Health Advocate Team This group answers questions about whom to see what to do or which health care resource

you need

Maternity support Important information and resources in support of a healthy pregnancy

Disease management Support for chronic medical conditions such as asthma diabetes and heart disease to better

understand and manage those conditions

Complex case management Individual support for serious and complex health issues

Cancer support Individualized comprehensive coaching and education for people diagnosed with cancer

Bariatric surgery support Clinical support before and after weight-loss surgery

Note If you enroll in the Kaiser medical plans please visit mykporgwf to learn about resources and programs to

support you

30

Flexible spending accounts YOUR CHOICE

Stretch your dollars further with flexible spending

accounts (FSAs) which allow you to put aside before-

tax dollars to cover eligible expenses not reimbursed

by another source By setting aside before-tax money

for these expenses you can reduce your taxable

income pay less in taxes each pay period and be better

prepared for out-of-pocket expenses

FSAs are ldquouse-it-or-lose-itrdquo accounts designed to be

used during a current plan year and the grace period

This means if you donrsquot use all the funds in your FSA

during the plan year or corresponding grace period

you will lose the remaining funds

If you want to participate in an FSA in 2015 you must

enroll and elect your annual contribution amount

during your designated enrollment period FSA

elections do not carry over from one year to another

The FSAs are administered by WageWorks

For more information about eligible expenses see

Chapters 5 and 6 of the Benefits Book

If you You also can enroll in

You can contribute annually on a before-tax basis

And use the FSA to

bullensp Enroll in the HRA-

Based Medical Plan

bullensp Enroll in a Kaiser

HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions

bullensp Waive Wells Fargo

medical plan coverage

Full-Purpose Health

Care FSA

$130 to $2500 Pay for eligible out-of-pocket medical

dental vision and prescription expenses

that are not reimbursed by another source

bullensp Enroll in the HSA-

Based Medical Plan

ndash Gold the HSA-Based

Medical Plan ndash Silver

or the HDHP Kaiser

medical plan


FSA

$130 to $2500 Pay for eligible out-of-pocket dental or

vision expenses that are not reimbursed by

another source Medical and prescription

expenses are not eligible expenses for this

FSA instead you can use your HSA

bullensp Enroll in any

Wells Fargo medical

plan



Day Care FSA $130 to $5000 Certain

highly compensated team

members as defined by

the IRS may contribute

up to $2500 only

Pay for eligible dependent day care

expenses such as preschool summer day

camp after-school programs and elder

care expenses

Know whatrsquos eligible

Eligible expenses for FSAs are determined by IRS

guidelines Understand the types of expenses that

you can claim before determining how much you will

contribute in 2015 Keep in mind that you cannot use

an FSA for expenses that you claim on your tax return

Consult with a tax advisor For more information see


Estimating how much before-tax money to set aside

The dollars you contribute to FSAs are governed by

IRS rules Carefully estimate your eligible expenses

before setting the dollar amount yoursquod like to save

because if you enroll for 2015 but do not use all your

FSA dollars by March 15 2016 (and submit your

claims for reimbursement by April 30 2016) you

will lose any unused dollars To help you estimate

how much to set aside in an FSA visit WageWorks at

wageworkscom or call WageWorks customer service

at 1-877-WAGEWORKS (1-877-924-3967)

31

Dental and vision coverage

Dental coverage YOUR CHOICE

Good oral health is essential to overall health and

well-being and you have two options to choose from

for dental coverage Delta Dental Standard and Delta

Dental Enhanced Both options cover the same services

but at different coverage amounts annual maximum

benefits and orthodontia lifetime maximums With

either plan you can see any dentist or provider in

the Delta Dental PPO or Premier networks You can

find dental providers in your area using the Provider

Directory Service

For details about dental options see Chapter 3 of the

Benefits Book

Summary of coverage

Delta Dental Standard

Delta Dental Enhanced

Diagnostic and

preventive care

100 coverage 100 coverage

Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000

Advantages of using a Delta Dental in-network provider

While you can choose any dentist there are several

advantages to choosing a dentist who participates

in the Delta Dental PPO or Delta Dental Premier

networks

bull Negotiated discounts Network dentists agree to

rates that are often lower than their usual fees In

other words you might benefit from negotiated

savings

bull No balance billing With an in-network dentist you

wonrsquot be billed for the difference between the actual

procedure charge and what the plan allows When

you receive care from a dentist whorsquos not in the

network you are responsible for the balance of

the bill

bull No paperwork Dentists submit bills directly to Delta

Dental and are paid directly by Delta Dental If you

choose an out-of-network dentist your claim must be

fi led with Delta Dental and the payment will be made

directly to you you are responsible for paying the

out-of-network dentist

Save more with a Flexible Spending Account (FSA)

You can use before-tax dollars in an FSA to pay for

eligible dental expenses that are not reimbursed by


page 30

32

Vision coverage YOUR CHOICE

Eye exams are essential and caring for your eyes

should always be a part of your regular health care

routine Wells Fargo sponsors the Vision Plan from

Vision Service Plan (VSP) which includes the VSP

Choice Network of providers

The VSP Affiliate Provider Program another option

for selecting vision care providers includes individual

optometrists and well-known retailers Although not

contracted as a network provider an affiliate provider

agrees to bill VSP directly and accept contracted

rates To see if your provider is part of the VSP Choice

Network use the Provider Directory Service visit

vspcomgowf or call VSP at 1-877-861-8352

For complete plan details see Chapter 4 of the Benefits

Book

Plan features In-network provider

Out-of-network provider

Eye exams (once

per calendar year)

$10 copay Plan pays up to $45

Lenses (once per

calendar year)

Single vision $15 copay Plan pays up to $45

Bifocal $15 copay Plan pays up to $65

Trifocal $15 copay Plan pays up to $85

Lenticular $15 copay Plan pays up to $125

Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance

Plan pays up to $130

Medically

necessary



You can use before-tax dollars in a Flexible Spending

Account (FSA) to pay for eligible vision expenses

that are not reimbursed by another source For more

information about FSAs see page 30

33

Financial protection Long-Term Care Plan YOUR CHOICE

Long-term care is the extended personal care required

when because of chronic illness injury or old age

a person needs help with basic activities such as

dressing bathing or eating Many people think long-

term care means nursing home care but it is and can

be much more than that Long-term care can also

include home health care adult day care alternate care

facilities and assisted-living facilities

While most of us have medical and disability insurance

coverage that doesnrsquot mean we are covered for long-

term care services Long-term care is not covered by

medical or disability plans or by Medicare Medicaid

will cover long-term care services only after you have

exhausted your assets

Your long-term care benefits

You can choose from four levels of coverage under the

Long-Term Care (LTC) Plan $100 per day $150 per

day $210 per day or $250 per day as outlined in the

table below

Take advantage of your opportunity to enroll during

your new hire period You can enroll in any level of LTC

during your designated enrollment period when you

are first eligible without proof of good health If you do

not enroll in the LTC Plan when you are first eligible

you may enroll at a later date but you must meet the

eligibility requirements including proof of good health

and approval by the insurance carrier If you are not

actively at work when your coverage begins coverage

will start when you return to being actively at work

Note You might want to talk to your financial planner

about how this important benefit fits your overall

financial and retirement planning

You pay the full cost of the LTC Plan with after-tax

dollars Premiums are deducted each pay period

and the amount you pay depends on the coverage

level you select and your age as of the date coverage

begins The younger you are when you buy long-

term care insurance the lower your premium will

be After you enroll your premiums will not change

because of your age or your health status However the

insurance carrier may change the premium rates for all

participants from time to time

Long-Term Care Plan coverage per day

Benefi t coverage $100-per-day level

$150-per-day level

$210-per-day level

$250-per-day level

Maximum daily benefit for nursing home care or

alternate care facility

$100 per day $150 per day $210 per day $250 per day

Maximum daily benefit for community-based care $60 per day $90 per day $126 per day $150 per day


alternate care facility and community-based care

combined


Hospice care $100 per day $150 per day $210 per day $250 per day

Lifetime maximum benefi ts $182500 $273750 $383250 $456250

For more information about the LTC Plan see Chapter 10 of the Benefits Book

34

Return of premium benefit and portability

If you die before age 75 while covered by the LTC Plan

your designated beneficiary may receive a refund of

some or all of the premiums paid up to the date of

death The amount will be reduced by any plan benefits

that you have been paid or are payable at the time of

death You can designate only one primary beneficiary

for the LTC Plan

If you enroll in the benefit remember to designate a

beneficiary

In addition the LTC Plan is portable If you leave

Wells Fargo and wish to continue coverage you may do

so at the same rate directly with the insurance carrier

Coverage for eligible dependents

Your spouse or domestic partner parents or the

parents of your spouse or domestic partner may apply

for individual long-term care coverage at the group rate

by contacting CNA at 1-800-932-1132 Proof of good

health is required before they can purchase coverage

CNA will provide the necessary application forms and

will bill them directly after they enroll

A Proof of Good Health form for your spouse or

domestic partner is available on Teamworks and

Teamworks at Home (teamworkswellsfargocom)

35

Financial protection Disability coverage

Wells Fargo offers coverage to protect you from income

loss if a medically certified health condition caused by

an illness or injury prevents you from working

Short-Term Disability PAID FOR

This coverage is fully paid for by Wells Fargo and does

not require enrollment Short-Term Disability (STD)

coverage will begin on the first of the month following

one full calendar month of service with Wells Fargo

If you are not actively at work on the date coverage

normally starts your eligibility for STD coverage will

not begin until you return to being actively at work and

complete at least one full work day Actively at work

means that you are performing your customary duties

during your regularly scheduled hours at a Wells Fargo

location or at places Wells Fargo requires you to work

or travel or allows you to work You are also considered

to be actively at work during your normally scheduled

day off on an observed holiday or on paid time off

(PTO)

The STD benefit may pay you 65 or 100 of your

covered pay as defined in the Benefits Book if you canrsquot

work because of an injury or illness If you become

disabled the STD benefits begin after a waiting

period of seven consecutive calendar days You may

be required to use accrued unused PTO days for any

scheduled work days you miss during this waiting

period If you donrsquot have any PTO days left these days

may be unpaid unless your business group allows team

members to use unaccrued PTO from their current

yearrsquos unaccrued PTO If this is the case you may use

your PTO allowance in accordance with your business

grouprsquos policy See Chapter 11 of the Benefits Book for

more information about the STD waiting period

Your STD benefi t level is based on your completed

years of service as shown below

Short-Term Disability coverage

You may be eligible for STD benefits after you

complete the STD waiting period The waiting period is

the seven-consecutive-calendar-day period beginning

on the initial date of your medically certified health

condition After completing the waiting period the

benefit pays as follows

Completed years of service

100 covered pay

65 covered pay

Less than 1 year None 25 weeks

1 ndash 3 years 3 weeks 22 weeks



10 or more years 25 weeks 0 weeks

The STD Plan has a survivor benefit remember to elect

a beneficiary

For additional details concerning the STD Plan see

Chapter 11 of the Benefits Book

Basic Long-Term Disability PAID FOR

The Basic Long-Term Disability (LTD) coverage under

the Wells Fargo amp Company Long-Term Disability

(LTD) Plan is designed to provide replacement income

if you are disabled for more than 26 weeks This

coverage is fully paid for by Wells Fargo and does not

require enrollment

Basic LTD benefits may begin after 26 weeks if you

remain disabled (as defined under the LTD Plan) and

your claim for LTD benefits is approved The benefit

pays 50 of your monthly covered pay as defined in the

Benefits Book up to a maximum benefit of $20833 per

month

For additional details concerning the LTD Plan see


Optional Long-Term Disability YOUR CHOICE

In addition to the Basic LTD coverage under the

LTD Plan you have an option to purchase an

additional coverage of 15 of your covered pay

Basic and Optional LTD provide a total combined

income replacement of 65 of your covered pay up

to a maximum of $500000 per year The maximum

combined benefit amount is $27083 a month

If you choose to enroll in the Optional LTD coverage

you are responsible for the cost of the additional

coverage and premiums will be deducted from your

pay each pay period Deductions will be taken on an

after-tax basis Premiums are based on your age and

covered pay

For more information about the LTD Plan see Chapter

12 of the Benefits Book

36

Preexisting condition

The LTD Plan does not pay benefits for a disability

that contributed to was caused by or resulted from a

preexisting condition You have a preexisting condition

if you meet the following

bull You received medical treatment consultation care

or services took prescription medications or had

medications prescribed during the three months just

before your effective date of coverage

bull The disability begins in the first 12 months after your

effective date of coverage and you have been treated

for the disability during the three months before the

eff ective date However even though your condition

meets the definition of a preexisting condition under

the LTD Plan you might be eligible for LTD benefi ts

if you were previously covered under the LTD Plan

of a company acquired by Wells Fargo (a ldquoprior LTD

planrdquo)

For more information about the pre-existing limitation

see Chapter 12 of the Benefits Book

37

Financial protection Life insurance coverage

Wells Fargo provides several types of term life

insurance coverage to help give you peace of mind and

protect your family fi nancially if something were to

happen to you or to a covered dependent

Basic Term Life Plan PAID FOR

Wells Fargo provides all eligible team members

with the Basic Term Life Plan You are automatically

enrolled for this benefi t The Basic Term Life Plan

provides benefits to your beneficiary if you die The

amount of the benefit is one time your annual covered

pay as defined in the Benefits Book with a coverage

minimum amount of $10000 and a maximum of

$50000

Remember to elect a beneficiary for the Basic Term Life

Plan For additional details concerning Basic Term Life

insurance benefits and coverage under the Wells Fargo

amp Company Life Insurance Plan see Chapter 7 of the

Benefits Book for more information

Optional Term Life Plan YOUR CHOICE

The Optional Term Life Plan allows you to choose

additional life insurance coverage You can choose from

one to eight times your annual covered pay as defined

in Chapter 7 of the Benefits Book for your coverage

level up to a maximum of $3000000 subject to plan

provisions

Take advantage of your opportunity to enroll You

can enroll for one to four times your annual covered

pay as defined in the Benefits Book during your

designated enrollment period without proof of good

health Enrollment for fi ve to eight times your annual

covered pay as defined in Chapter 7 of the Benefits

Book requires proof of good health and is subject to

approval by the insurance carrier If you are not actively

at work on the day coverage begins Optional Term Life

coverage will begin when you are actively at work

Important You can sign up for the Optional Term Life

Plan at a later date but you must meet the eligibility

requirements including proof of good health and

approval by the insurance carrier unless you have

a Qualified Event such as birth of a child adoption

or placement for adoption of a child marriage or

creation of a domestic partnership death of a spouse

legal separation divorce or dissolution of a domestic

partnership

If you enroll in the Optional Term Life Insurance Plan

remember to elect a beneficiary

SpousePartner Optional Term Life Plan YOUR CHOICE

You can enroll in the SpousePartner Optional Term

Life Plan to provide financial protection if your spouse

or domestic partner dies You can enroll for benefits in

$25000 increments up to a total coverage of $250000

during your designated enrollment period subject to

plan provisions Important Enrollment at the $25000

level does not require proof of good health during your

designated enrollment period To enroll in this optional

plan you cannot be legally separated or divorced from

your spouse Enrollment in coverage amounts greater

than $25000 during your designated enrollment

period requires your spouse or domestic partner to

provide proof of good health and is subject to approval

by the insurance carrier

You are automatically the beneficiary for your Spouse

Partner Optional Term Life Plan

Optional Term Life premiums and nicotine use status

Premiums for the Optional Term Life Plan and the

SpousePartner Optional Term Life Plan are based

on the level of coverage you select and the insured

personrsquos age and nicotine use status You or your

spouse or domestic partner are considered a nicotine

user if you used tobacco andor nicotine in any form

including cigarettes electronic cigarettes cigars pipes

chewing tobacco nicotine gum or nicotine patches in

the 12 months before enrollment

For more information about the Optional Term Life

Plan under the Wells Fargo amp Company Life Insurance

Plan see Chapter 7 of the Benefits Book for more

information

Dependent Term Life YOUR CHOICE

You can also enroll in the Dependent Term Life Plan

during your designated enrollment period to help ease

the burden if your child (or children) dies Enrollment

in the Dependent Term Life Plan automatically covers

all of your eligible dependents and any future newly

eligible dependents Important Take advantage of

your opportunity to enroll If you enroll during your

designated enrollment period you do not need to

submit a proof of good health form You do not need

to enroll each individual dependent Your dependentrsquos

eligibility will be verified at the time the claim is fi led

and the claim will be denied if your dependent is

38

ineligible The coverage amount is $20000 per eligible

covered dependent

Make sure your child (or children) is eligible See

Chapter 1 of the Benefits Book for complete dependent

eligibility requirements

Note See the section titled If You Have Eligible

Dependents on page 6 for details on certification for

newly enrolled dependents

You are automatically the beneficiary of the Dependent

Term Life Plan

For more information about the Dependent Term Life

Plan see Chapter 7 of the Benefits Book

39

Financial protection Business Travel Accident and

Accidental Death and Dismemberment

Wells Fargo also offers two plans that provide insurance

coverage if you are in a covered accident and die

become paralyzed or suffer the loss of a limb speech

hearing or sight or if a coma commences within 365

days of the date of a covered accident that occurred

while eligible under the plans

Business Travel Accident Plan PAID FOR

All eligible regular and part-time team members are

automatically enrolled in the Business Travel Accident

(BTA) Plan You become eligible as soon as you begin

working for Wells Fargo You are covered while you are

traveling on Wells Fargo business

You are automatically covered in this plan Remember

to elect a beneficiary

For more information about the BTA Plan see Chapter


Accidental Death and Dismemberment Plan YOUR CHOICE

The Accidental Death and Dismemberment (ADampD)

Plan is an optional plan that helps provide fi nancial

protection for you or your family if you or a covered

family member are in a covered accident and die

become paralyzed or suff er the loss of a limb speech



while you were covered under the ADampD Plan You

pay the full cost for coverage through after-tax payroll

deductions if you enroll in the ADampD Plan If you are

not actively at work on the day coverage begins your

ADampD coverage will begin when you are actively at

work

If you enroll in the ADampD plan remember to elect a

benefi ciary

For more information about the ADampD Plan see

Chapter 9 of the Benefi ts Book

Business Travel Accident Plan and Accidental Death and Dismemberment Plan benefi ts

Your BTA Plan benefi t is fi ve times your covered pay

as defi ned in Chapter 8 of the Benefi ts Book up to a

maximum of $2000000

For the ADampD Plan you can enroll in individual or

family coverage based on the following individual

coverage levels $75000 $150000 $300000 and

$600000 If you elect family coverage the spouse

benefi t (the amount you get if your spouse dies) is

50 of your elected coverage amount (not to exceed

$300000) and your child benefi t is 15 of that amount

(not to exceed $45000)

For more information about benefi ts and coverage

under the BTA Plan or the ADampD Plan see Chapters 8

and 9 of the Benefi ts Book

40

Naming a beneficiary

A beneficiary is the person persons trust charitable

institution or estate that you choose to receive benefi ts if

you die At any time you can designate your benefi ciary

(or beneficiaries) for these plans using the Your Benefi ts

tool in Teamworks for the following plans

bull Company-paid plans Basic Term Life BTA and

Short-Term Disability

bull Voluntary plans Optional Term Life ADampD and LTC

For SpousePartner Optional Term Life and Dependent

Term Life you are automatically the designated

benefi ciary of your spouse or domestic partner and

dependent

Default beneficiary

If you do not designate a beneficiary or if the

designated beneficiary dies before you do and no

contingent beneficiary is named the benefit is paid

after death in the following order

1 Your surviving spouse or domestic partner

2 Equally among your surviving biological and

adopted children

3 Equally between your surviving parents

4 Equally among your surviving brothers and sisters

5 Your estate

If you are not the biological or adoptive parent of your

spousersquos or domestic partnerrsquos child but would like that

child to receive benefits in the event of your death you

must properly designate the child as your beneficiary

Your estate is the default beneficiary for the Long-Term

Care Plan

41

Financial protection Legal Services Plan YOUR CHOICE

Through the Legal Services Plan insured by

ARAGreg you can receive professional legal advice

representation and assistance for personal legal

matters During your designated enrollment period

you can enroll in individual or family coverage

ARAG manages a nationwide network of attorneys to

provide you with professional legal assistance As a

Legal Services Plan member yoursquore guaranteed access

to a Network Attorney within 30 miles of your home If

a Network Attorney is not available in your area ARAG

will provide you with a non-Network Attorney who will

provide you with in-network benefi ts

Network Attorney fees for the services provided are

100 paid in full unless otherwise stated in Chapter 14

in the Benefi ts Book

Visit the ARAG Legal Center at ARAGLegalCentercom

If you have questions contact the ARAG Customer

Care Center at 1-800-299-2345

Representation available through the Legal Services Plan

Legal advice available by telephone

Tools and resources accessible online

bullensp Consumer protection Contract

disputes or warranty issues

bullensp Court adoption proceedings contested

and uncontested

bullensp Divorce Contested and uncontested

(up to 20 hours is paid in full)

bullensp IRS audit protection and collection

defense

bullensp Juvenile court proceedings

bullensp Legal name change

bullensp Personal property protection

bullensp Property transfer

bullensp Real estate

bullensp Renterrsquos rights

bullensp Will preparation and estate planning

bullensp Document preparation and review

bullensp Follow-up calls and letters

bullensp General legal advice

bullensp Small claims assistance

bullensp Attorney Finder

bullensp DIYtrade Do-it-yourself legal documents

bullensp Education Center Access to

guidebooks and videos a law guide

the LawExpressoreg e-newsletter

Personal Information Organizer

and other educational resources that

off er tips and tools for dealing with

everyday legal issues

42

Other benefits Commuter Benefi t Program YOUR CHOICE

The Wells Fargo Commuter Benefit Program provides

tax savings to team members who commute by

qualified mass transit or pay to park Off ered through

WageWorks the program lets you pay for parking and

transit on a before-tax basis

You can

bull Purchase your transit pass online or by telephone

and have the pass delivered directly to your home

bull Pay your transit provider by using a WageWorks

Commuter Card

bull Elect to have your parking vendor paid directly

bull Pay your parking vendor by using a WageWorks

Parking Card

bull Designate the amount you will pay for daily parking

and get reimbursed after you submit a claim with

WageWorks

The amount you elect for these services will be

deducted from your paycheck on a before-tax basis up

to IRS limits (and on an after-tax basis thereafter)

Itrsquos not necessary to wait until your benefits-effective

date to enroll in the Commuter Benefit Program

However only active team members who are

commuting are able to participate

Unlike the flexible spending accounts you can enroll

change or cancel participation at any time during

the year subject to the monthly enrollment and

disenrollment date requirements To begin using

services for commuter expenses in the following

month generally you must enroll by the 10th of the

current month Some transit agencies might impose

an earlier deadline Go to wageworkscom to see if the

transit agency in your area is one of them

You cannot elect this benefit using the Your Benefi ts

tool To elect this benefit you can enroll any time

directly with WageWorks

To enroll

bull Go to Teamworks and enter ldquocommuter benefitrdquo in

the Search field

bull On the Commuter Benefit page click the

WageWorks Sign-On button

You can also call WageWorks at 1-877-WAGEWORKS

(1-877-924-3967) Additional information regarding

the Wells Fargo Commuter Benefit Program is available

on Teamworks

43

Claims administrators contact information

Claims administrators do more than just process claims set up the networks and negotiate provider fees Their

websites can help you and your dependents get the most out of your benefits To see the claims administrators for

your location go to the Explore Your Options page and choose your residence from the dropdown menu

Claims Administrator Phone Website and email address

Medical Plans

Anthem BCBS

bull HRA-Based Medical Plan

bull HSA-Based Medical Plan ndash Gold

bull HSA-Based Medical Plan ndash Silver

bull Indemnity Medical Plan mdash Anthem BCBS

(Puerto Rico Guam and Northern Mariana

Islands [Saipan])

1-866-418-7749 anthemcom

HealthPartners (Minnesota)




952-883-6677

outside the metro area 1-888-487-4442

healthpartners comwf

Kaiser Permanente mdash California

HMO

High-Deductible Health Plan

1-800-464-4000 mykporgwf

Kaiser Permanente mdash Colorado

HMO


1-800-632-9700

303-338-3800 mdash DenverBoulder

1-888-681-7878 mdash Colorado Springs

mykporgwf

Kaiser Permanente mdash Hawaii

POS Added Choice

Oahu 808-432-5955

neighbor islands 1-800-966-5955

mykporgwf

Kaiser Permanente mdash Northwest

HMO


1-800-813-2000

503-813-2000 mdash Portland

mykporgwf

Optum 1-877-543-4294 wellnessmyoptumhealth com

UnitedHealthcare




1-800-842-9722 myuhc com

UnitedHealthcare Global Solutions In the US or Canada

Call toll-free at 1-877-UHI-0280

(1-877-844-0280)

All countries except US and Canada

bull Call your local ATampT Direct number

bull When prompted dial 1-877-UHI-0280

(1-877-844-0280)

bull If your country is not listed dial

1-763-274-7362 (reversed charges accepted)

myuhc com

44


Prescription drugs for the following medical plans





CVScaremark 1-800-772-2301 caremark comwf

Dental

Delta Dental 1-877-598-5342 MinneapolisSt Paul metro

area 651-994-5342

deltadentalmnorgwf

Vision

Vision Service Plan (VSP) 1-877-861-8352 vsp comgowf

Flexible spending accounts

WageWorks 1-877-924-3967 wageworks com

Accidental Death amp Dismemberment Plan and Business Travel Accident

Life Insurance Company of North America

(LINA) a CIGNA company

1-800-238-2125

Short-Term and Long-Term Disability

Liberty Life Assurance Company of Boston 1-866-213-2937

Basic and Dependent Term Life Employee and Spouse Partner Optional Term Life

Minnesota Life Insurance Company 1-877-822-8308

Legal Services Plan

ARAG Legal Center 1-800-299-2345 ARAGLegalCenter com

(access code 16862wfc)

Long-Term Care

CNA 1-800-932-1132

45

Tools and resources

This booklet is your starting place for finding information about whatrsquos available to you But therersquos much more Use

these tools and resources to get the most out of your benefits year-round

Summary of Benefits and

Coverage

teamworkswellsfargocom Compare certain features of the medical plans available to

you such as the covered benefits cost-sharing provisions

and coverage limitations and exceptions

Medical Plan Comparison Tool wfchooserpbghorg Review and compare features services and programs for

all medical plan options Estimate the possible financial

impact of your premiums combined with the potential

out-of-pocket expenses of each plan based on your usage

levels for medical services and medication use Keep in

mind that the estimated costs are estimated costs only and

your actual out-of-pocket costs will vary In addition itrsquos

important to note that this tool provides no guarantee of

benefits or access to providers services or supplies

Provider Directory Service geoaccesscom

directoriesonlinewf

Find physicians labs hospitals and dental and vision

providers that have contracted to provide medical

(including mental health and substance abuse) services at

negotiated rates

Your Benefits teamworkswellsfargocom Update your beneficiary designations enroll online view

your Benefi ts Confirmation Statement and set up HSA

payroll deductions

Caremark caremarkcomwf Check drug costs see if your drug is on the CVScaremark

Advance Formulary find out if your drug has additional

requirements and view all your savings opportunities

including choosing a generic

Your claims administratorrsquos

website

See page 43 View your Explanations of Benefits and use tools such as

cost estimators to make eff ective health care decisions

Track your HRA balance if you are enrolled in the

HRA-Based Medical Plan

Wells Fargo Health Benefi ts

Services (HBS) website

wellsfargocominvestinghsa Track your HSA balance and find information on reducing

health costs lowering your taxes and investing in your

future

WageWorks wageworkscom Manage your FSA and commuter benefi t balances

Benefits Book teamworkswellsfargocom Read important details and provisions of each plan and

benefi t option

46

Important information and disclosures

The disclosures provided here contain important

information about the employee benefi t plans

sponsored by Wells Fargo amp Company We encourage

you to review them in addition to reviewing the other

benefi ts information provided to you

Offi cial plan documents

This guide is intended to provide a high-level

overview of the referenced employee benefi t plans The

information presented in this booklet does not contain

all the terms and provisions of the employee benefi t

plans sponsored by Wells Fargo amp Company Refer to

each planrsquos Summary Plan Description (SPD) contained

in the Benefi ts Book for applicable plan provisions

For fully insured plans or coverage options (including

health maintenance organizations [HMOs]) also refer

to the applicable insurance policy or group contract

provided by the insurer Additional plan details can

be found in the offi cial plan documents If there is a

discrepancy between the statements and information

contained in this benefi ts enrollment booklet and the

offi cial plan documents the offi cial plan documents will

govern

Wells Fargo amp Company reserves the unilateral right to

amend modify or terminate any of its benefi t plans (or

benefi t plan options) programs policies or practices

at any time for any reason with or without notice Any

such amendment modifi cation or termination may

apply to both current and future participants and their

dependents and benefi ciaries

Disclosure about health savings accounts (HSAs)

HSAs are not part of any Employee Retirement Income

Security Act (ERISA)-covered employee benefi t plan

sponsored or maintained by Wells Fargo amp Company

or any of its subsidiaries or affi liates It is Wells Fargo

amp Companyrsquos intention to comply with the US

Department of Labor guidance which specifi es that

an HSA is not subject to ERISA when the employerrsquos

involvement is limited Establishment of an HSA is

completely voluntary on your part

bull Wells Fargo amp Company does not limit your ability to

move your funds to another health savings account

or impose conditions on usage of such funds beyond

those permitted under the Internal Revenue Code

However Wells Fargo will only support payroll

deductions or provide funding of wellness dollars

and other employer contributions if applicable for

HSAs opened at Wells Fargo Health Benefi t Services

a division of Wells Fargo Bank NA

bull Wells Fargo amp Company does not make or infl uence

the investment decisions with respect to funds

contributed to an HSA Available HSA investment

funds are not guaranteed and you could lose money

bull Wells Fargo amp Company does not represent that the

HSA is an ERISA-covered employee benefi t plan

established or maintained by Wells Fargo amp Company

or any of its subsidiaries

An HSA is an individually owned account The HSA

will continue to be your account even if you leave

Wells Fargo or change health plan coverage

Disclosure about health reimbursement accounts (HRAs)

The HRA is a notional bookkeeping entry and no

specifi c funds will be set aside in an account for

purposes of funding an HRA No interest or earnings

will be credited to an HRA Amounts allocated to

an HRA including health and wellness dollars are

not vested and are subject to forfeiture Wells Fargo

amp Company reserves the unilateral right to amend

or modify the HRA at any time for any reason with

or without notice including placing limitations or

restrictions on amounts allocated to an HRA or

terminating the HRA

Optum

Optum administers the health and wellness activities

under the Wells Fargo amp Company Health Plan

including the online health assessment biometric

screenings online wellness education programs

and telephonic wellness coaching programs These

health and wellness activities are not a substitute

for and are not intended to provide medical care or

treatment Additionally the statements made in this

communication regarding biometric screenings are

for general information purposes only and do not

constitute individual medical advice or care You

should discuss specifi c questions about your individual

health care with your personal health care provider

Your participation in the health and wellness programs

administered by Optum is completely voluntary and

the information you share through your participation

will be kept strictly confi dential in accordance with

applicable law Only you Optum partners or affi liates

of Optum your medical planrsquos claims administrator

and your provider have access to your information and

results Wells Fargo will not receive any individually

identifi able information or results Wells Fargo will

receive only aggregate summary results which

47

combine the data of all team members who participate

in health and wellness programs in a de-identifi ed

format Applicable law prohibits Wells Fargo from

using any of this information for employment-related

actions or decisions

Privacy of your protected health information

Your privacy is important We encourage you

to read the Notice of HIPAA Privacy Rights for

the Wells Fargo-sponsored group health plans to

understand how your protected health information

may be used and disclosed by the group health plans

and your rights under HIPAA The Notice is available

to you on Teamworks (search for ldquoNotice of HIPAA

Privacyrdquo) or you can request a copy by contacting the

HR Service Center at 1-877-HRWELLS (1-877-479-

3557) option 2 The HR Service Center accepts relay

service calls TDDTTY users may call 1-800-988-0161

Authorization to deduct premiums from payroll

By making your benefi t elections (including default

elections) for yourself and your dependents as part

of the benefi ts enrollment process you authorize

your employer to deduct from your pay the necessary

contribution and premium amounts for the benefi t

coverage you elected under the various Wells Fargo amp

Company employee benefi t plans including deducting

from your pay any back contributions or premiums for

coverage for which you may be in arrears to the extent

permitted by applicable law

General Information

The information presented in this booklet is not

intended to provide medical advice Consult with

your health care provider to determine the services or

treatments that may be appropriate for your situation

The provisions governing your medical plan control

what if any benefi ts are available for the services

you receive The fact that a health care provider has

performed or prescribed a procedure or treatment

does not mean that it is a covered service under your

medical plan

Eligibility for or participation in the employee benefi t

plans does not constitute a contract or guarantee

of employment with Wells Fargo amp Company or its

subsidiaries or affi liates

C000000

From well-managed forests

100

HRS9597 (0115)copy 2015 Wells Fargo Bank NA All rights reserved ECG-1230483

2015 benefits enrollment booklet for new hires and newly eligible team members


Using the booklet

Inside the booklet

Donrsquot miss your benefits enrollment period

Why is electing your benefits during your enrollment period so important

How to enroll

Online


By phone

Confirm or correct your benefits elections






Medical coverage



Eligible preventive care benefi ts are covered at 100 in network




Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility






Prescription drug coverage under the account-based plans






Additional detail







Save more with a flexible spending account







Dental coverage



Vision coverage


Financial protection Long-Term Care Plan

Your long-term care benefits

Return of premium benefit and portability





Basic Long-Term Disability

Optional Long-Term Disability



Basic Term Life Plan

Optional Term Life Plan

SpousePartner Optional Term Life Plan


Dependent Term Life

Financial protection Business Travel Accident and Accidental Death and Dismemberment

Business Travel Accident Plan

Accidental Death and Dismemberment Plan

Business Travel Accident Plan and Accidental Death and Dismemberment Plan benefi ts

Naming a benefi ciary

Default benefi ciary

Financial protection Legal Services Plan

Other benefits Commuter Benefit Program


Tools and resources





Optum



General Information


Congratulations on your new position We value and

support our people as a competitive advantage We

strive to attract develop retain and motivate the most

talented people we can find These people become our

team members and are a treasured resource in whom

we invest

As part of that investment Wells Fargo is proud

to offer you a competitive benefits package with a

comprehensive selection of benefits

Our aim is to support you so you can learn about your

plans gain confidence when making benefits choices

plan for your future and reach your personal health

well-being and retirement goals

Using the booklet

Some benefits are provided at no additional cost to you

mdash and you are automatically enrolled when you become

eligible for benefits These benefits are noted in this

booklet by this symbol PAID FOR

You and Wells Fargo share the cost for most benefits

There are optional benefits in which you pay the

total cost if you elect them designated by this

symbol YOUR CHOICE

Use the Enrollment Worksheet on page 8 to keep track

of the coverage yoursquore interested in for you and your

eligible dependents

Keep in mind that this booklet is intended to provide

only an overview and does not contain all the

provisions of the Wells Fargo-sponsored benefits plans

It is very important that you refer to the Benefi ts Book

available on Teamworks which contains the provisions

of the Wells Fargo-sponsored benefit plans

3

Inside the booklet


How to enroll 5


Medical coverage 10

























4






















Central Time






















5

How to enroll

Online













running














you can proceed
















make more changes














By phone












Your Benefits tool
















1-800-988-0161

6


















birthday

















yourself fi rst









dependents



benefi ts coverage


















dependent
















them enrolled

7







coverage






8

__________________________

______________________________________________

ensp ___

_______________________

___

_______________________

___

_______________________

_______________________

________________________________________

_______________

_______________ _______________________

_______________ _______________________









you enroll online


Medical

Waive

Enroll in plan name


$

Dental

Waive




$

Vision

Waive



$



(FSA)






medical plan

Waive



$


FSA









Waive



$

Day Care FSA

Waive



$

Optional Term Life

Waive




$

9


ensp

_________________

_______________________

ensp

ensp _______________________

ensp

_______________________

ensp

ensp ensp

ensp

ensp

ensp

ensp

ensp

ensp

_______________________

ensp ensp

ensp

ensp

ensp

ensp _______________________

ensp

_______________________

ensp ensp

ensp


Term Life

Waive




$

Dependent Term Life

Waive



Dismemberment Plan

Waive


$75000 Me only

$150000 Me only

$300000 Me only

$600000 Me only

$75000 Me + family

$150000 Me + family

$300000 Me + family

$600000 Me + family

$

Long-Term Care Plan

Waive


$100 per day

$150 per day

$210 per day

$250 per day

$

Optional Long-Term


Waive


Legal Services Plan

Waive


Me only

Me + family

$






10















and well-being










Any state

except Hawaii




Kaiser available in



Colorado (Denver


areas) Oregon

(Portland and Salem


(Vancouver Longview

and Kelso areas)







HRA-Based

Medical Plan

HSA-Based

Medical Plan










Indemnity Medical





Kaiser medical

plans




POS Kaiser Added

Choice mdash Hawaii








11














expenses















the year







when you need it

























12




expenses








Category 1

Less than $60000

Category 2


$100000

Category 3


$150000

Category 4

$150000 or more

You $700 $600 $200 $0

You + spouse $700 $600 $200 $0

You + children $1200 $1000 $400 $0











in the plan


Annual

deductible












13

Your responsibility

Plan pays

Annual

out-of-pocket

maximum







Primary care

mental health

and substance

abuse care









Deductible

Your HRA pays

You pay remaining




Coinsurance

Plan pays 80

(90 for maternity)

You pay 20

(10 for maternity)




Once reached

plan pays 100






















14









eligible services


Annual

deductible






deductible is met


Annual out-of-

pocket maximum













deductible




network deductible




network deductible





15

Your responsibility

Plan pays




Deductible

You pay 100

of deductible




Coinsurance

Plan pays 80

(90 for maternity)






Once reached

plan pays 100































provided by HBS


for information on



to the next


16

HSA eligibility










this purpose












you have questions
















You only $3350

You + spouse $6650













coverage




















HSA










17




































1-877-543-4294





Health

assessment



questionnaire

Biometric

screening











to complete

Online

wellness

education

programs or

telephonic

wellness

coaching

program


the following











Telephonic Wellness

Coaching Program

Call Optum at

1-877-440-9402 to register


your HRA or HSA




18






















limits




based medical plans






Is there a copay

for generic

prescription

drugs















Are prescription

drugs part of

the medical

out-of-pocket

maximum



purchase at









Yes Yes




19
















guidelines




Benefits Book







page 30

20








Coinsurance Same




helps you pay for

eligible expenses


Account (HRA) mdash



Associated account

funding provided by

Wells Fargo




dollars












Drug List


30-day supply

prescriptions





90-day supply

prescriptions






drug out-of-pocket

maximum


maximum



21

Additional detail





partner $3200




You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount


You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)


Mental health and


visits








office costs



balance




















the deductible










pocket







pocket






(brand name)



no deductible





drug costs



is met







no deductible





drug costs



is met





22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

3

Inside the booklet


How to enroll 5


Medical coverage 10

























4






















Central Time






















5

How to enroll

Online













running














you can proceed
















make more changes














By phone












Your Benefits tool
















1-800-988-0161

6


















birthday

















yourself fi rst









dependents



benefi ts coverage


















dependent
















them enrolled

7







coverage






8

__________________________

______________________________________________

ensp ___

_______________________

___

_______________________

___

_______________________

_______________________

________________________________________

_______________

_______________ _______________________

_______________ _______________________









you enroll online


Medical

Waive

Enroll in plan name


$

Dental

Waive




$

Vision

Waive



$



(FSA)






medical plan

Waive



$


FSA









Waive



$

Day Care FSA

Waive



$

Optional Term Life

Waive




$

9


ensp

_________________

_______________________

ensp

ensp _______________________

ensp

_______________________

ensp

ensp ensp

ensp

ensp

ensp

ensp

ensp

ensp

_______________________

ensp ensp

ensp

ensp

ensp

ensp _______________________

ensp

_______________________

ensp ensp

ensp


Term Life

Waive




$

Dependent Term Life

Waive



Dismemberment Plan

Waive


$75000 Me only

$150000 Me only

$300000 Me only

$600000 Me only

$75000 Me + family

$150000 Me + family

$300000 Me + family

$600000 Me + family

$

Long-Term Care Plan

Waive


$100 per day

$150 per day

$210 per day

$250 per day

$

Optional Long-Term


Waive


Legal Services Plan

Waive


Me only

Me + family

$






10















and well-being










Any state

except Hawaii




Kaiser available in



Colorado (Denver


areas) Oregon

(Portland and Salem


(Vancouver Longview

and Kelso areas)







HRA-Based

Medical Plan

HSA-Based

Medical Plan










Indemnity Medical





Kaiser medical

plans




POS Kaiser Added

Choice mdash Hawaii








11














expenses















the year







when you need it

























12




expenses








Category 1

Less than $60000

Category 2


$100000

Category 3


$150000

Category 4

$150000 or more

You $700 $600 $200 $0

You + spouse $700 $600 $200 $0

You + children $1200 $1000 $400 $0











in the plan


Annual

deductible












13

Your responsibility

Plan pays

Annual

out-of-pocket

maximum







Primary care

mental health

and substance

abuse care









Deductible

Your HRA pays

You pay remaining




Coinsurance

Plan pays 80

(90 for maternity)

You pay 20

(10 for maternity)




Once reached

plan pays 100






















14









eligible services


Annual

deductible






deductible is met


Annual out-of-

pocket maximum













deductible




network deductible




network deductible





15

Your responsibility

Plan pays




Deductible

You pay 100

of deductible




Coinsurance

Plan pays 80

(90 for maternity)






Once reached

plan pays 100































provided by HBS


for information on



to the next


16

HSA eligibility










this purpose












you have questions
















You only $3350

You + spouse $6650













coverage




















HSA










17




































1-877-543-4294





Health

assessment



questionnaire

Biometric

screening











to complete

Online

wellness

education

programs or

telephonic

wellness

coaching

program


the following











Telephonic Wellness

Coaching Program

Call Optum at

1-877-440-9402 to register


your HRA or HSA




18






















limits




based medical plans






Is there a copay

for generic

prescription

drugs















Are prescription

drugs part of

the medical

out-of-pocket

maximum



purchase at









Yes Yes




19
















guidelines




Benefits Book







page 30

20








Coinsurance Same




helps you pay for

eligible expenses


Account (HRA) mdash



Associated account

funding provided by

Wells Fargo




dollars












Drug List


30-day supply

prescriptions





90-day supply

prescriptions






drug out-of-pocket

maximum


maximum



21

Additional detail





partner $3200




You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount


You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)


Mental health and


visits








office costs



balance




















the deductible










pocket







pocket






(brand name)



no deductible





drug costs



is met







no deductible





drug costs



is met





22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

4






















Central Time






















5

How to enroll

Online













running














you can proceed
















make more changes














By phone












Your Benefits tool
















1-800-988-0161

6


















birthday

















yourself fi rst









dependents



benefi ts coverage


















dependent
















them enrolled

7







coverage






8

__________________________

______________________________________________

ensp ___

_______________________

___

_______________________

___

_______________________

_______________________

________________________________________

_______________

_______________ _______________________

_______________ _______________________









you enroll online


Medical

Waive

Enroll in plan name


$

Dental

Waive




$

Vision

Waive



$



(FSA)






medical plan

Waive



$


FSA









Waive



$

Day Care FSA

Waive



$

Optional Term Life

Waive




$

9


ensp

_________________

_______________________

ensp

ensp _______________________

ensp

_______________________

ensp

ensp ensp

ensp

ensp

ensp

ensp

ensp

ensp

_______________________

ensp ensp

ensp

ensp

ensp

ensp _______________________

ensp

_______________________

ensp ensp

ensp


Term Life

Waive




$

Dependent Term Life

Waive



Dismemberment Plan

Waive


$75000 Me only

$150000 Me only

$300000 Me only

$600000 Me only

$75000 Me + family

$150000 Me + family

$300000 Me + family

$600000 Me + family

$

Long-Term Care Plan

Waive


$100 per day

$150 per day

$210 per day

$250 per day

$

Optional Long-Term


Waive


Legal Services Plan

Waive


Me only

Me + family

$






10















and well-being










Any state

except Hawaii




Kaiser available in



Colorado (Denver


areas) Oregon

(Portland and Salem


(Vancouver Longview

and Kelso areas)







HRA-Based

Medical Plan

HSA-Based

Medical Plan










Indemnity Medical





Kaiser medical

plans




POS Kaiser Added

Choice mdash Hawaii








11














expenses















the year







when you need it

























12




expenses








Category 1

Less than $60000

Category 2


$100000

Category 3


$150000

Category 4

$150000 or more

You $700 $600 $200 $0

You + spouse $700 $600 $200 $0

You + children $1200 $1000 $400 $0











in the plan


Annual

deductible












13

Your responsibility

Plan pays

Annual

out-of-pocket

maximum







Primary care

mental health

and substance

abuse care









Deductible

Your HRA pays

You pay remaining




Coinsurance

Plan pays 80

(90 for maternity)

You pay 20

(10 for maternity)




Once reached

plan pays 100






















14









eligible services


Annual

deductible






deductible is met


Annual out-of-

pocket maximum













deductible




network deductible




network deductible





15

Your responsibility

Plan pays




Deductible

You pay 100

of deductible




Coinsurance

Plan pays 80

(90 for maternity)






Once reached

plan pays 100































provided by HBS


for information on



to the next


16

HSA eligibility










this purpose












you have questions
















You only $3350

You + spouse $6650













coverage




















HSA










17




































1-877-543-4294





Health

assessment



questionnaire

Biometric

screening











to complete

Online

wellness

education

programs or

telephonic

wellness

coaching

program


the following











Telephonic Wellness

Coaching Program

Call Optum at

1-877-440-9402 to register


your HRA or HSA




18






















limits




based medical plans






Is there a copay

for generic

prescription

drugs















Are prescription

drugs part of

the medical

out-of-pocket

maximum



purchase at









Yes Yes




19
















guidelines




Benefits Book







page 30

20








Coinsurance Same




helps you pay for

eligible expenses


Account (HRA) mdash



Associated account

funding provided by

Wells Fargo




dollars












Drug List


30-day supply

prescriptions





90-day supply

prescriptions






drug out-of-pocket

maximum


maximum



21

Additional detail





partner $3200




You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount


You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)


Mental health and


visits








office costs



balance




















the deductible










pocket







pocket






(brand name)



no deductible





drug costs



is met







no deductible





drug costs



is met





22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

5

How to enroll

Online













running














you can proceed
















make more changes














By phone












Your Benefits tool
















1-800-988-0161

6


















birthday

















yourself fi rst









dependents



benefi ts coverage


















dependent
















them enrolled

7







coverage






8

__________________________

______________________________________________

ensp ___

_______________________

___

_______________________

___

_______________________

_______________________

________________________________________

_______________

_______________ _______________________

_______________ _______________________









you enroll online


Medical

Waive

Enroll in plan name


$

Dental

Waive




$

Vision

Waive



$



(FSA)






medical plan

Waive



$


FSA









Waive



$

Day Care FSA

Waive



$

Optional Term Life

Waive




$

9


ensp

_________________

_______________________

ensp

ensp _______________________

ensp

_______________________

ensp

ensp ensp

ensp

ensp

ensp

ensp

ensp

ensp

_______________________

ensp ensp

ensp

ensp

ensp

ensp _______________________

ensp

_______________________

ensp ensp

ensp


Term Life

Waive




$

Dependent Term Life

Waive



Dismemberment Plan

Waive


$75000 Me only

$150000 Me only

$300000 Me only

$600000 Me only

$75000 Me + family

$150000 Me + family

$300000 Me + family

$600000 Me + family

$

Long-Term Care Plan

Waive


$100 per day

$150 per day

$210 per day

$250 per day

$

Optional Long-Term


Waive


Legal Services Plan

Waive


Me only

Me + family

$






10















and well-being










Any state

except Hawaii




Kaiser available in



Colorado (Denver


areas) Oregon

(Portland and Salem


(Vancouver Longview

and Kelso areas)







HRA-Based

Medical Plan

HSA-Based

Medical Plan










Indemnity Medical





Kaiser medical

plans




POS Kaiser Added

Choice mdash Hawaii








11














expenses















the year







when you need it

























12




expenses








Category 1

Less than $60000

Category 2


$100000

Category 3


$150000

Category 4

$150000 or more

You $700 $600 $200 $0

You + spouse $700 $600 $200 $0

You + children $1200 $1000 $400 $0











in the plan


Annual

deductible












13

Your responsibility

Plan pays

Annual

out-of-pocket

maximum







Primary care

mental health

and substance

abuse care









Deductible

Your HRA pays

You pay remaining




Coinsurance

Plan pays 80

(90 for maternity)

You pay 20

(10 for maternity)




Once reached

plan pays 100






















14









eligible services


Annual

deductible






deductible is met


Annual out-of-

pocket maximum













deductible




network deductible




network deductible





15

Your responsibility

Plan pays




Deductible

You pay 100

of deductible




Coinsurance

Plan pays 80

(90 for maternity)






Once reached

plan pays 100































provided by HBS


for information on



to the next


16

HSA eligibility










this purpose












you have questions
















You only $3350

You + spouse $6650













coverage




















HSA










17




































1-877-543-4294





Health

assessment



questionnaire

Biometric

screening











to complete

Online

wellness

education

programs or

telephonic

wellness

coaching

program


the following











Telephonic Wellness

Coaching Program

Call Optum at

1-877-440-9402 to register


your HRA or HSA




18






















limits




based medical plans






Is there a copay

for generic

prescription

drugs















Are prescription

drugs part of

the medical

out-of-pocket

maximum



purchase at









Yes Yes




19
















guidelines




Benefits Book







page 30

20








Coinsurance Same




helps you pay for

eligible expenses


Account (HRA) mdash



Associated account

funding provided by

Wells Fargo




dollars












Drug List


30-day supply

prescriptions





90-day supply

prescriptions






drug out-of-pocket

maximum


maximum



21

Additional detail





partner $3200




You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount


You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)


Mental health and


visits








office costs



balance




















the deductible










pocket







pocket






(brand name)



no deductible





drug costs



is met







no deductible





drug costs



is met





22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

6


















birthday

















yourself fi rst









dependents



benefi ts coverage


















dependent
















them enrolled

7







coverage






8

__________________________

______________________________________________

ensp ___

_______________________

___

_______________________

___

_______________________

_______________________

________________________________________

_______________

_______________ _______________________

_______________ _______________________









you enroll online


Medical

Waive

Enroll in plan name


$

Dental

Waive




$

Vision

Waive



$



(FSA)






medical plan

Waive



$


FSA









Waive



$

Day Care FSA

Waive



$

Optional Term Life

Waive




$

9


ensp

_________________

_______________________

ensp

ensp _______________________

ensp

_______________________

ensp

ensp ensp

ensp

ensp

ensp

ensp

ensp

ensp

_______________________

ensp ensp

ensp

ensp

ensp

ensp _______________________

ensp

_______________________

ensp ensp

ensp


Term Life

Waive




$

Dependent Term Life

Waive



Dismemberment Plan

Waive


$75000 Me only

$150000 Me only

$300000 Me only

$600000 Me only

$75000 Me + family

$150000 Me + family

$300000 Me + family

$600000 Me + family

$

Long-Term Care Plan

Waive


$100 per day

$150 per day

$210 per day

$250 per day

$

Optional Long-Term


Waive


Legal Services Plan

Waive


Me only

Me + family

$






10















and well-being










Any state

except Hawaii




Kaiser available in



Colorado (Denver


areas) Oregon

(Portland and Salem


(Vancouver Longview

and Kelso areas)







HRA-Based

Medical Plan

HSA-Based

Medical Plan










Indemnity Medical





Kaiser medical

plans




POS Kaiser Added

Choice mdash Hawaii








11














expenses















the year







when you need it

























12




expenses








Category 1

Less than $60000

Category 2


$100000

Category 3


$150000

Category 4

$150000 or more

You $700 $600 $200 $0

You + spouse $700 $600 $200 $0

You + children $1200 $1000 $400 $0











in the plan


Annual

deductible












13

Your responsibility

Plan pays

Annual

out-of-pocket

maximum







Primary care

mental health

and substance

abuse care









Deductible

Your HRA pays

You pay remaining




Coinsurance

Plan pays 80

(90 for maternity)

You pay 20

(10 for maternity)




Once reached

plan pays 100






















14









eligible services


Annual

deductible






deductible is met


Annual out-of-

pocket maximum













deductible




network deductible




network deductible





15

Your responsibility

Plan pays




Deductible

You pay 100

of deductible




Coinsurance

Plan pays 80

(90 for maternity)






Once reached

plan pays 100































provided by HBS


for information on



to the next


16

HSA eligibility










this purpose












you have questions
















You only $3350

You + spouse $6650













coverage




















HSA










17




































1-877-543-4294





Health

assessment



questionnaire

Biometric

screening











to complete

Online

wellness

education

programs or

telephonic

wellness

coaching

program


the following











Telephonic Wellness

Coaching Program

Call Optum at

1-877-440-9402 to register


your HRA or HSA




18






















limits




based medical plans






Is there a copay

for generic

prescription

drugs















Are prescription

drugs part of

the medical

out-of-pocket

maximum



purchase at









Yes Yes




19
















guidelines




Benefits Book







page 30

20








Coinsurance Same




helps you pay for

eligible expenses


Account (HRA) mdash



Associated account

funding provided by

Wells Fargo




dollars












Drug List


30-day supply

prescriptions





90-day supply

prescriptions






drug out-of-pocket

maximum


maximum



21

Additional detail





partner $3200




You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount


You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)


Mental health and


visits








office costs



balance




















the deductible










pocket







pocket






(brand name)



no deductible





drug costs



is met







no deductible





drug costs



is met





22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

7







coverage






8

__________________________

______________________________________________

ensp ___

_______________________

___

_______________________

___

_______________________

_______________________

________________________________________

_______________

_______________ _______________________

_______________ _______________________









you enroll online


Medical

Waive

Enroll in plan name


$

Dental

Waive




$

Vision

Waive



$



(FSA)






medical plan

Waive



$


FSA









Waive



$

Day Care FSA

Waive



$

Optional Term Life

Waive




$

9


ensp

_________________

_______________________

ensp

ensp _______________________

ensp

_______________________

ensp

ensp ensp

ensp

ensp

ensp

ensp

ensp

ensp

_______________________

ensp ensp

ensp

ensp

ensp

ensp _______________________

ensp

_______________________

ensp ensp

ensp


Term Life

Waive




$

Dependent Term Life

Waive



Dismemberment Plan

Waive


$75000 Me only

$150000 Me only

$300000 Me only

$600000 Me only

$75000 Me + family

$150000 Me + family

$300000 Me + family

$600000 Me + family

$

Long-Term Care Plan

Waive


$100 per day

$150 per day

$210 per day

$250 per day

$

Optional Long-Term


Waive


Legal Services Plan

Waive


Me only

Me + family

$






10















and well-being










Any state

except Hawaii




Kaiser available in



Colorado (Denver


areas) Oregon

(Portland and Salem


(Vancouver Longview

and Kelso areas)







HRA-Based

Medical Plan

HSA-Based

Medical Plan










Indemnity Medical





Kaiser medical

plans




POS Kaiser Added

Choice mdash Hawaii








11














expenses















the year







when you need it

























12




expenses








Category 1

Less than $60000

Category 2


$100000

Category 3


$150000

Category 4

$150000 or more

You $700 $600 $200 $0

You + spouse $700 $600 $200 $0

You + children $1200 $1000 $400 $0











in the plan


Annual

deductible












13

Your responsibility

Plan pays

Annual

out-of-pocket

maximum







Primary care

mental health

and substance

abuse care









Deductible

Your HRA pays

You pay remaining




Coinsurance

Plan pays 80

(90 for maternity)

You pay 20

(10 for maternity)




Once reached

plan pays 100






















14









eligible services


Annual

deductible






deductible is met


Annual out-of-

pocket maximum













deductible




network deductible




network deductible





15

Your responsibility

Plan pays




Deductible

You pay 100

of deductible




Coinsurance

Plan pays 80

(90 for maternity)






Once reached

plan pays 100































provided by HBS


for information on



to the next


16

HSA eligibility










this purpose












you have questions
















You only $3350

You + spouse $6650













coverage




















HSA










17




































1-877-543-4294





Health

assessment



questionnaire

Biometric

screening











to complete

Online

wellness

education

programs or

telephonic

wellness

coaching

program


the following











Telephonic Wellness

Coaching Program

Call Optum at

1-877-440-9402 to register


your HRA or HSA




18






















limits




based medical plans






Is there a copay

for generic

prescription

drugs















Are prescription

drugs part of

the medical

out-of-pocket

maximum



purchase at









Yes Yes




19
















guidelines




Benefits Book







page 30

20








Coinsurance Same




helps you pay for

eligible expenses


Account (HRA) mdash



Associated account

funding provided by

Wells Fargo




dollars












Drug List


30-day supply

prescriptions





90-day supply

prescriptions






drug out-of-pocket

maximum


maximum



21

Additional detail





partner $3200




You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount


You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)


Mental health and


visits








office costs



balance




















the deductible










pocket







pocket






(brand name)



no deductible





drug costs



is met







no deductible





drug costs



is met





22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

8

__________________________

______________________________________________

ensp ___

_______________________

___

_______________________

___

_______________________

_______________________

________________________________________

_______________

_______________ _______________________

_______________ _______________________









you enroll online


Medical

Waive

Enroll in plan name


$

Dental

Waive




$

Vision

Waive



$



(FSA)






medical plan

Waive



$


FSA









Waive



$

Day Care FSA

Waive



$

Optional Term Life

Waive




$

9


ensp

_________________

_______________________

ensp

ensp _______________________

ensp

_______________________

ensp

ensp ensp

ensp

ensp

ensp

ensp

ensp

ensp

_______________________

ensp ensp

ensp

ensp

ensp

ensp _______________________

ensp

_______________________

ensp ensp

ensp


Term Life

Waive




$

Dependent Term Life

Waive



Dismemberment Plan

Waive


$75000 Me only

$150000 Me only

$300000 Me only

$600000 Me only

$75000 Me + family

$150000 Me + family

$300000 Me + family

$600000 Me + family

$

Long-Term Care Plan

Waive


$100 per day

$150 per day

$210 per day

$250 per day

$

Optional Long-Term


Waive


Legal Services Plan

Waive


Me only

Me + family

$






10















and well-being










Any state

except Hawaii




Kaiser available in



Colorado (Denver


areas) Oregon

(Portland and Salem


(Vancouver Longview

and Kelso areas)







HRA-Based

Medical Plan

HSA-Based

Medical Plan










Indemnity Medical





Kaiser medical

plans




POS Kaiser Added

Choice mdash Hawaii








11














expenses















the year







when you need it

























12




expenses








Category 1

Less than $60000

Category 2


$100000

Category 3


$150000

Category 4

$150000 or more

You $700 $600 $200 $0

You + spouse $700 $600 $200 $0

You + children $1200 $1000 $400 $0











in the plan


Annual

deductible












13

Your responsibility

Plan pays

Annual

out-of-pocket

maximum







Primary care

mental health

and substance

abuse care









Deductible

Your HRA pays

You pay remaining




Coinsurance

Plan pays 80

(90 for maternity)

You pay 20

(10 for maternity)




Once reached

plan pays 100






















14









eligible services


Annual

deductible






deductible is met


Annual out-of-

pocket maximum













deductible




network deductible




network deductible





15

Your responsibility

Plan pays




Deductible

You pay 100

of deductible




Coinsurance

Plan pays 80

(90 for maternity)






Once reached

plan pays 100































provided by HBS


for information on



to the next


16

HSA eligibility










this purpose












you have questions
















You only $3350

You + spouse $6650













coverage




















HSA










17




































1-877-543-4294





Health

assessment



questionnaire

Biometric

screening











to complete

Online

wellness

education

programs or

telephonic

wellness

coaching

program


the following











Telephonic Wellness

Coaching Program

Call Optum at

1-877-440-9402 to register


your HRA or HSA




18






















limits




based medical plans






Is there a copay

for generic

prescription

drugs















Are prescription

drugs part of

the medical

out-of-pocket

maximum



purchase at









Yes Yes




19
















guidelines




Benefits Book







page 30

20








Coinsurance Same




helps you pay for

eligible expenses


Account (HRA) mdash



Associated account

funding provided by

Wells Fargo




dollars












Drug List


30-day supply

prescriptions





90-day supply

prescriptions






drug out-of-pocket

maximum


maximum



21

Additional detail





partner $3200




You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount


You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)


Mental health and


visits








office costs



balance




















the deductible










pocket







pocket






(brand name)



no deductible





drug costs



is met







no deductible





drug costs



is met





22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

9


ensp

_________________

_______________________

ensp

ensp _______________________

ensp

_______________________

ensp

ensp ensp

ensp

ensp

ensp

ensp

ensp

ensp

_______________________

ensp ensp

ensp

ensp

ensp

ensp _______________________

ensp

_______________________

ensp ensp

ensp


Term Life

Waive




$

Dependent Term Life

Waive



Dismemberment Plan

Waive


$75000 Me only

$150000 Me only

$300000 Me only

$600000 Me only

$75000 Me + family

$150000 Me + family

$300000 Me + family

$600000 Me + family

$

Long-Term Care Plan

Waive


$100 per day

$150 per day

$210 per day

$250 per day

$

Optional Long-Term


Waive


Legal Services Plan

Waive


Me only

Me + family

$






10















and well-being










Any state

except Hawaii




Kaiser available in



Colorado (Denver


areas) Oregon

(Portland and Salem


(Vancouver Longview

and Kelso areas)







HRA-Based

Medical Plan

HSA-Based

Medical Plan










Indemnity Medical





Kaiser medical

plans




POS Kaiser Added

Choice mdash Hawaii








11














expenses















the year







when you need it

























12




expenses








Category 1

Less than $60000

Category 2


$100000

Category 3


$150000

Category 4

$150000 or more

You $700 $600 $200 $0

You + spouse $700 $600 $200 $0

You + children $1200 $1000 $400 $0











in the plan


Annual

deductible












13

Your responsibility

Plan pays

Annual

out-of-pocket

maximum







Primary care

mental health

and substance

abuse care









Deductible

Your HRA pays

You pay remaining




Coinsurance

Plan pays 80

(90 for maternity)

You pay 20

(10 for maternity)




Once reached

plan pays 100






















14









eligible services


Annual

deductible






deductible is met


Annual out-of-

pocket maximum













deductible




network deductible




network deductible





15

Your responsibility

Plan pays




Deductible

You pay 100

of deductible




Coinsurance

Plan pays 80

(90 for maternity)






Once reached

plan pays 100































provided by HBS


for information on



to the next


16

HSA eligibility










this purpose












you have questions
















You only $3350

You + spouse $6650













coverage




















HSA










17




































1-877-543-4294





Health

assessment



questionnaire

Biometric

screening











to complete

Online

wellness

education

programs or

telephonic

wellness

coaching

program


the following











Telephonic Wellness

Coaching Program

Call Optum at

1-877-440-9402 to register


your HRA or HSA




18






















limits




based medical plans






Is there a copay

for generic

prescription

drugs















Are prescription

drugs part of

the medical

out-of-pocket

maximum



purchase at









Yes Yes




19
















guidelines




Benefits Book







page 30

20








Coinsurance Same




helps you pay for

eligible expenses


Account (HRA) mdash



Associated account

funding provided by

Wells Fargo




dollars












Drug List


30-day supply

prescriptions





90-day supply

prescriptions






drug out-of-pocket

maximum


maximum



21

Additional detail





partner $3200




You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount


You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)


Mental health and


visits








office costs



balance




















the deductible










pocket







pocket






(brand name)



no deductible





drug costs



is met







no deductible





drug costs



is met





22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

10















and well-being










Any state

except Hawaii




Kaiser available in



Colorado (Denver


areas) Oregon

(Portland and Salem


(Vancouver Longview

and Kelso areas)







HRA-Based

Medical Plan

HSA-Based

Medical Plan










Indemnity Medical





Kaiser medical

plans




POS Kaiser Added

Choice mdash Hawaii








11














expenses















the year







when you need it

























12




expenses








Category 1

Less than $60000

Category 2


$100000

Category 3


$150000

Category 4

$150000 or more

You $700 $600 $200 $0

You + spouse $700 $600 $200 $0

You + children $1200 $1000 $400 $0











in the plan


Annual

deductible












13

Your responsibility

Plan pays

Annual

out-of-pocket

maximum







Primary care

mental health

and substance

abuse care









Deductible

Your HRA pays

You pay remaining




Coinsurance

Plan pays 80

(90 for maternity)

You pay 20

(10 for maternity)




Once reached

plan pays 100






















14









eligible services


Annual

deductible






deductible is met


Annual out-of-

pocket maximum













deductible




network deductible




network deductible





15

Your responsibility

Plan pays




Deductible

You pay 100

of deductible




Coinsurance

Plan pays 80

(90 for maternity)






Once reached

plan pays 100































provided by HBS


for information on



to the next


16

HSA eligibility










this purpose












you have questions
















You only $3350

You + spouse $6650













coverage




















HSA










17




































1-877-543-4294





Health

assessment



questionnaire

Biometric

screening











to complete

Online

wellness

education

programs or

telephonic

wellness

coaching

program


the following











Telephonic Wellness

Coaching Program

Call Optum at

1-877-440-9402 to register


your HRA or HSA




18






















limits




based medical plans






Is there a copay

for generic

prescription

drugs















Are prescription

drugs part of

the medical

out-of-pocket

maximum



purchase at









Yes Yes




19
















guidelines




Benefits Book







page 30

20








Coinsurance Same




helps you pay for

eligible expenses


Account (HRA) mdash



Associated account

funding provided by

Wells Fargo




dollars












Drug List


30-day supply

prescriptions





90-day supply

prescriptions






drug out-of-pocket

maximum


maximum



21

Additional detail





partner $3200




You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount


You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)


Mental health and


visits








office costs



balance




















the deductible










pocket







pocket






(brand name)



no deductible





drug costs



is met







no deductible





drug costs



is met





22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

11














expenses















the year







when you need it

























12




expenses








Category 1

Less than $60000

Category 2


$100000

Category 3


$150000

Category 4

$150000 or more

You $700 $600 $200 $0

You + spouse $700 $600 $200 $0

You + children $1200 $1000 $400 $0











in the plan


Annual

deductible












13

Your responsibility

Plan pays

Annual

out-of-pocket

maximum







Primary care

mental health

and substance

abuse care









Deductible

Your HRA pays

You pay remaining




Coinsurance

Plan pays 80

(90 for maternity)

You pay 20

(10 for maternity)




Once reached

plan pays 100






















14









eligible services


Annual

deductible






deductible is met


Annual out-of-

pocket maximum













deductible




network deductible




network deductible





15

Your responsibility

Plan pays




Deductible

You pay 100

of deductible




Coinsurance

Plan pays 80

(90 for maternity)






Once reached

plan pays 100































provided by HBS


for information on



to the next


16

HSA eligibility










this purpose












you have questions
















You only $3350

You + spouse $6650













coverage




















HSA










17




































1-877-543-4294





Health

assessment



questionnaire

Biometric

screening











to complete

Online

wellness

education

programs or

telephonic

wellness

coaching

program


the following











Telephonic Wellness

Coaching Program

Call Optum at

1-877-440-9402 to register


your HRA or HSA




18






















limits




based medical plans






Is there a copay

for generic

prescription

drugs















Are prescription

drugs part of

the medical

out-of-pocket

maximum



purchase at









Yes Yes




19
















guidelines




Benefits Book







page 30

20








Coinsurance Same




helps you pay for

eligible expenses


Account (HRA) mdash



Associated account

funding provided by

Wells Fargo




dollars












Drug List


30-day supply

prescriptions





90-day supply

prescriptions






drug out-of-pocket

maximum


maximum



21

Additional detail





partner $3200




You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount


You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)


Mental health and


visits








office costs



balance




















the deductible










pocket







pocket






(brand name)



no deductible





drug costs



is met







no deductible





drug costs



is met





22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

12




expenses








Category 1

Less than $60000

Category 2


$100000

Category 3


$150000

Category 4

$150000 or more

You $700 $600 $200 $0

You + spouse $700 $600 $200 $0

You + children $1200 $1000 $400 $0











in the plan


Annual

deductible












13

Your responsibility

Plan pays

Annual

out-of-pocket

maximum







Primary care

mental health

and substance

abuse care









Deductible

Your HRA pays

You pay remaining




Coinsurance

Plan pays 80

(90 for maternity)

You pay 20

(10 for maternity)




Once reached

plan pays 100






















14









eligible services


Annual

deductible






deductible is met


Annual out-of-

pocket maximum













deductible




network deductible




network deductible





15

Your responsibility

Plan pays




Deductible

You pay 100

of deductible




Coinsurance

Plan pays 80

(90 for maternity)






Once reached

plan pays 100































provided by HBS


for information on



to the next


16

HSA eligibility










this purpose












you have questions
















You only $3350

You + spouse $6650













coverage




















HSA










17




































1-877-543-4294





Health

assessment



questionnaire

Biometric

screening











to complete

Online

wellness

education

programs or

telephonic

wellness

coaching

program


the following











Telephonic Wellness

Coaching Program

Call Optum at

1-877-440-9402 to register


your HRA or HSA




18






















limits




based medical plans






Is there a copay

for generic

prescription

drugs















Are prescription

drugs part of

the medical

out-of-pocket

maximum



purchase at









Yes Yes




19
















guidelines




Benefits Book







page 30

20








Coinsurance Same




helps you pay for

eligible expenses


Account (HRA) mdash



Associated account

funding provided by

Wells Fargo




dollars












Drug List


30-day supply

prescriptions





90-day supply

prescriptions






drug out-of-pocket

maximum


maximum



21

Additional detail





partner $3200




You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount


You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)


Mental health and


visits








office costs



balance




















the deductible










pocket







pocket






(brand name)



no deductible





drug costs



is met







no deductible





drug costs



is met





22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

13

Your responsibility

Plan pays

Annual

out-of-pocket

maximum







Primary care

mental health

and substance

abuse care









Deductible

Your HRA pays

You pay remaining




Coinsurance

Plan pays 80

(90 for maternity)

You pay 20

(10 for maternity)




Once reached

plan pays 100






















14









eligible services


Annual

deductible






deductible is met


Annual out-of-

pocket maximum













deductible




network deductible




network deductible





15

Your responsibility

Plan pays




Deductible

You pay 100

of deductible




Coinsurance

Plan pays 80

(90 for maternity)






Once reached

plan pays 100































provided by HBS


for information on



to the next


16

HSA eligibility










this purpose












you have questions
















You only $3350

You + spouse $6650













coverage




















HSA










17




































1-877-543-4294





Health

assessment



questionnaire

Biometric

screening











to complete

Online

wellness

education

programs or

telephonic

wellness

coaching

program


the following











Telephonic Wellness

Coaching Program

Call Optum at

1-877-440-9402 to register


your HRA or HSA




18






















limits




based medical plans






Is there a copay

for generic

prescription

drugs















Are prescription

drugs part of

the medical

out-of-pocket

maximum



purchase at









Yes Yes




19
















guidelines




Benefits Book







page 30

20








Coinsurance Same




helps you pay for

eligible expenses


Account (HRA) mdash



Associated account

funding provided by

Wells Fargo




dollars












Drug List


30-day supply

prescriptions





90-day supply

prescriptions






drug out-of-pocket

maximum


maximum



21

Additional detail





partner $3200




You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount


You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)


Mental health and


visits








office costs



balance




















the deductible










pocket







pocket






(brand name)



no deductible





drug costs



is met







no deductible





drug costs



is met





22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

14









eligible services


Annual

deductible






deductible is met


Annual out-of-

pocket maximum













deductible




network deductible




network deductible





15

Your responsibility

Plan pays




Deductible

You pay 100

of deductible




Coinsurance

Plan pays 80

(90 for maternity)






Once reached

plan pays 100































provided by HBS


for information on



to the next


16

HSA eligibility










this purpose












you have questions
















You only $3350

You + spouse $6650













coverage




















HSA










17




































1-877-543-4294





Health

assessment



questionnaire

Biometric

screening











to complete

Online

wellness

education

programs or

telephonic

wellness

coaching

program


the following











Telephonic Wellness

Coaching Program

Call Optum at

1-877-440-9402 to register


your HRA or HSA




18






















limits




based medical plans






Is there a copay

for generic

prescription

drugs















Are prescription

drugs part of

the medical

out-of-pocket

maximum



purchase at









Yes Yes




19
















guidelines




Benefits Book







page 30

20








Coinsurance Same




helps you pay for

eligible expenses


Account (HRA) mdash



Associated account

funding provided by

Wells Fargo




dollars












Drug List


30-day supply

prescriptions





90-day supply

prescriptions






drug out-of-pocket

maximum


maximum



21

Additional detail





partner $3200




You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount


You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)


Mental health and


visits








office costs



balance




















the deductible










pocket







pocket






(brand name)



no deductible





drug costs



is met







no deductible





drug costs



is met





22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

15

Your responsibility

Plan pays




Deductible

You pay 100

of deductible




Coinsurance

Plan pays 80

(90 for maternity)






Once reached

plan pays 100































provided by HBS


for information on



to the next


16

HSA eligibility










this purpose












you have questions
















You only $3350

You + spouse $6650













coverage




















HSA










17




































1-877-543-4294





Health

assessment



questionnaire

Biometric

screening











to complete

Online

wellness

education

programs or

telephonic

wellness

coaching

program


the following











Telephonic Wellness

Coaching Program

Call Optum at

1-877-440-9402 to register


your HRA or HSA




18






















limits




based medical plans






Is there a copay

for generic

prescription

drugs















Are prescription

drugs part of

the medical

out-of-pocket

maximum



purchase at









Yes Yes




19
















guidelines




Benefits Book







page 30

20








Coinsurance Same




helps you pay for

eligible expenses


Account (HRA) mdash



Associated account

funding provided by

Wells Fargo




dollars












Drug List


30-day supply

prescriptions





90-day supply

prescriptions






drug out-of-pocket

maximum


maximum



21

Additional detail





partner $3200




You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount


You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)


Mental health and


visits








office costs



balance




















the deductible










pocket







pocket






(brand name)



no deductible





drug costs



is met







no deductible





drug costs



is met





22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

16

HSA eligibility










this purpose












you have questions
















You only $3350

You + spouse $6650













coverage




















HSA










17




































1-877-543-4294





Health

assessment



questionnaire

Biometric

screening











to complete

Online

wellness

education

programs or

telephonic

wellness

coaching

program


the following











Telephonic Wellness

Coaching Program

Call Optum at

1-877-440-9402 to register


your HRA or HSA




18






















limits




based medical plans






Is there a copay

for generic

prescription

drugs















Are prescription

drugs part of

the medical

out-of-pocket

maximum



purchase at









Yes Yes




19
















guidelines




Benefits Book







page 30

20








Coinsurance Same




helps you pay for

eligible expenses


Account (HRA) mdash



Associated account

funding provided by

Wells Fargo




dollars












Drug List


30-day supply

prescriptions





90-day supply

prescriptions






drug out-of-pocket

maximum


maximum



21

Additional detail





partner $3200




You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount


You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)


Mental health and


visits








office costs



balance




















the deductible










pocket







pocket






(brand name)



no deductible





drug costs



is met







no deductible





drug costs



is met





22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

17




































1-877-543-4294





Health

assessment



questionnaire

Biometric

screening











to complete

Online

wellness

education

programs or

telephonic

wellness

coaching

program


the following











Telephonic Wellness

Coaching Program

Call Optum at

1-877-440-9402 to register


your HRA or HSA




18






















limits




based medical plans






Is there a copay

for generic

prescription

drugs















Are prescription

drugs part of

the medical

out-of-pocket

maximum



purchase at









Yes Yes




19
















guidelines




Benefits Book







page 30

20








Coinsurance Same




helps you pay for

eligible expenses


Account (HRA) mdash



Associated account

funding provided by

Wells Fargo




dollars












Drug List


30-day supply

prescriptions





90-day supply

prescriptions






drug out-of-pocket

maximum


maximum



21

Additional detail





partner $3200




You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount


You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)


Mental health and


visits








office costs



balance




















the deductible










pocket







pocket






(brand name)



no deductible





drug costs



is met







no deductible





drug costs



is met





22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

18






















limits




based medical plans






Is there a copay

for generic

prescription

drugs















Are prescription

drugs part of

the medical

out-of-pocket

maximum



purchase at









Yes Yes




19
















guidelines




Benefits Book







page 30

20








Coinsurance Same




helps you pay for

eligible expenses


Account (HRA) mdash



Associated account

funding provided by

Wells Fargo




dollars












Drug List


30-day supply

prescriptions





90-day supply

prescriptions






drug out-of-pocket

maximum


maximum



21

Additional detail





partner $3200




You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount


You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)


Mental health and


visits








office costs



balance




















the deductible










pocket







pocket






(brand name)



no deductible





drug costs



is met







no deductible





drug costs



is met





22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

19
















guidelines




Benefits Book







page 30

20








Coinsurance Same




helps you pay for

eligible expenses


Account (HRA) mdash



Associated account

funding provided by

Wells Fargo




dollars












Drug List


30-day supply

prescriptions





90-day supply

prescriptions






drug out-of-pocket

maximum


maximum



21

Additional detail





partner $3200




You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount


You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)


Mental health and


visits








office costs



balance




















the deductible










pocket







pocket






(brand name)



no deductible





drug costs



is met







no deductible





drug costs



is met





22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

20








Coinsurance Same




helps you pay for

eligible expenses


Account (HRA) mdash



Associated account

funding provided by

Wells Fargo




dollars












Drug List


30-day supply

prescriptions





90-day supply

prescriptions






drug out-of-pocket

maximum


maximum



21

Additional detail





partner $3200




You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount


You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)


Mental health and


visits








office costs



balance




















the deductible










pocket







pocket






(brand name)



no deductible





drug costs



is met







no deductible





drug costs



is met





22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

21

Additional detail





partner $3200




You $2000


partner $3200




You $3000


partner $4800




Coinsurance amount


You pay 20

(10 for maternity)

You pay 20

(10 for maternity)

You pay 20

(10 for maternity)


Mental health and


visits








office costs



balance




















the deductible










pocket







pocket






(brand name)



no deductible





drug costs



is met







no deductible





drug costs



is met





22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

22









pocket




pocket

All other covered

medical services



hospitalizations






pocket




pocket


maximum for medical


You $4000


partner $6400








costs

You $3000




You $5000





maximum for all in-


You $1000


partner $1600











part of the medical


maximum




purchases

Yes Yes


23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

23







for team members in


1 to 3


wellness dollars


previous years




wellness dollars


previous years




information











(Gold or Silver)




24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

24





















emergency






















your area



Hawaii only POS


General



None



specific region)

$2500 you


$1500 you



Outpatient services








$15 copay

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

25


Hawaii only POS


Inpatient care






Maternity care






then covered 100






then covered 100




and speech therapy











physician



Not covered

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

26




General









$3000 you






Outpatient services







Inpatient care




Maternity care








and speech therapy







27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

27









































another source


28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

28













by phone




programs


lifestyle






29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

29









you need








support you

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

30























And use the FSA to


Based Medical Plan


HMO or POS option

bullensp Enroll in

UnitedHealthcare

Global Solutions



Full-Purpose Health

Care FSA





Based Medical Plan



or the HDHP Kaiser

medical plan


FSA







Wells Fargo medical

plan







up to $2500 only




care expenses



















at 1-877-WAGEWORKS (1-877-924-3967)

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

31












Directory Service


Benefits Book

Summary of coverage



Diagnostic and

preventive care


Fillings and

periodontal

You pay 20

after $50 annual

deductible

You pay 10

after $50 annual

deductible

Composite

(white) fillings on

posterior teeth

You pay 30

after $50 annual

deductible

You pay 20

after $50 annual

deductible

Major restorative

services

You pay 50

after $50 annual

deductible

You pay 40

after $50 annual

deductible

Annual

maximum benefit

$1500 $2000

Orthodontia

lifetime

maximum benefit

$1500 $2000





networks




savings






the bill











page 30

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

32
















Book



Eye exams (once

per calendar year)


Lenses (once per

calendar year)





Frames (once per

calendar year)

Plan plays up

to $130 plan

allowance

Plan pays up to $50

Contact lenses

(once per

calendar year

instead of glasses)

Plan pays up

to $130 plan

allowance


Medically

necessary







33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

33




















table below


























$150-per-day level

$210-per-day level

$250-per-day level







combined





34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

34








for the LTC Plan


beneficiary















35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

35




















(PTO)

























100 covered pay

65 covered pay







a beneficiary









require enrollment






month
















covered pay



36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

36


















planrdquo)



37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

37














$50000












provisions



















partnership

































information














38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

38


covered dependent








Term Life Plan



39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

39
































work


benefi ciary






maximum of $2000000












40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

40













dependent

Default beneficiary







adopted children



5 Your estate






Care Plan

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

41


























and uncontested




defense





















42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

42







You can




Commuter Card



Parking Card



WageWorks




















To enroll


the Search field






on Teamworks

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

43






Medical Plans

Anthem BCBS






Islands [Saipan])

1-866-418-7749 anthemcom





952-883-6677




HMO


1-800-464-4000 mykporgwf


HMO


1-800-632-9700



mykporgwf


POS Added Choice

Oahu 808-432-5955


mykporgwf


HMO


1-800-813-2000


mykporgwf


UnitedHealthcare




1-800-842-9722 myuhc com



(1-877-844-0280)




(1-877-844-0280)



myuhc com

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

44








Dental


area 651-994-5342

deltadentalmnorgwf

Vision







1-800-238-2125





Legal Services Plan



Long-Term Care

CNA 1-800-932-1132

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

45

Tools and resources




Coverage














directoriesonlinewf




negotiated rates



payroll deductions






website









future



benefi t option

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

46























govern

















































terminating the HRA

Optum
























47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

47





























General Information










medical plan





C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

C000000


100




Using the booklet

Inside the booklet



How to enroll

Online


By phone







Medical coverage







Deductible

Coinsurance






Deductible

Coinsurance




HSA eligibility












Additional detail














Dental coverage



Vision coverage

















Dependent Term Life










Tools and resources





Optum



General Information

2015 benefits enrollment booklet for new hires and newly ...€¦ · able to update it online later...

Documents