2017 benefits - peterson health · wellness revolution retirement –mass mutual viverae...

5900 Southwest Parkway | Building 2, Suite 200, Austin, TX 78735Tel: (512) 366 ‐3745 Fax: (866) 315‐2353 www.healthsure.com

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2018 BENEFITS ENROLLMENT GUIDE

Table of Contents

Contacts Page 1

Benefit Basics

Monthly Premium Contributions Page 3

Medical Insurance Page 4

Prescription Drug Benefit Schedule Page 13

Dental Insurance Page 14

Vision Insurance Page 15

Basic Life & Voluntary Life Insurance Coverage Page 16

Short & Long Term Disability Page 18

Critical Illness Page 19

Accident Page 21

Cancer Page 23

Flexible Spending Accounts Page 25

Employee Assistance Program Page 27

Will Prep Services Page 28

Wellness Program Page 29

401K Savings and Profit Sharing Program Page 31

Important Notices Page 35

1

Contacts

Peterson Human Resources PlanSource Online Enrollment

https://benefits.plansource.com

User name: (up to 6 characters of last name, last 4 of social security)

Sandra PattersonHR Benefits Coordinator

830‐258‐7441

[email protected] Password: Your birthdate in YYYYMMDD format

Medical Dental

WebTPA ‐ Group #2012PRMC

www.webtpa.com

800‐953‐2015

WebTPA – Group #2012PRMC

PPO PHCS Plan

www.webtpa.com

800‐678‐7427

Guardian Flexible Spending Accounts (FSA)

Vision, Life, Disability, Critical Illness, Cancer & Accident

Pension Concepts & Administration

Group #: 00490572 Jan Holmes

www.guardiananytime.com [email protected]

888‐600‐1600 806‐745‐9781 X 4

Employee Assistance Program Will Prep Services

Work Life Matters Available to members enrolled in voluntary life

800‐386‐7055 877‐433‐6789

www.ibhworklife.com www.ibhwillprep.com

User Name: Matters User Name: WillPrep

Password: wlm70101 Password: GLIC09

Wellness Revolution Retirement – Mass Mutual

Viverae www.retiresmart.com

www.PRMCWellness.com 800‐743‐5274

888‐848‐3723

2

Benefit Basics

Qualified Life Event

Peterson Regional Medical Center offers a comprehensive suite of benefits to promote health and financial security for you and your family. This booklet provides you with a summary of your benefits. Please review it carefully so you can choose the coverage that’s right for you.

As a Peterson employee, you are eligible for benefits if you work at least 30 hours per week.

Benefits are effective on the first day of the month following 60 days of full‐time employment.

If the spouse of an eligible employee is eligible for coverage through their employer, they are not eligible to participate in this plan.

Generally, you may change your benefit elections only during the annual enrollment period. However, you may change your benefit elections during the year if you experience a qualified life event, including:• Marriage• Divorce or legal separation• Death of your spouse or dependent child• Birth of your child• Adoption of or placement for adoption of your

child• Change in employment status of employee,

spouse or dependent child• Qualification by the Plan Administrator of a child

support order for medical coverage• Entitlement to Medicare or MedicaidYou must notify Human Resources within 30 days of the qualified life event. Depending on the type of event, you may be asked to provide proof of the event.

If you do not contact Human Resources within 30 days of the qualified event, you will have to wait until the next annual enrollment period to make changes (unless you experience another qualified life event).

For more information about your benefits, please contact your HR Department.

Notice of Privacy PracticesPeterson Regional Medical Center understands that information about you and your health is personal and we are committed to protecting this information. Peterson Regional Medical Center maintains a Notice of Privacy Practices that explains how we may disclose your health information. The Notice of Privacy Practices also describes your rights and our obligations regarding the use and disclosure of this information

Plans at a Glance

This brochure is intended to provide a convenient summary of benefit plans. It is not intended to be a legal document. If there are any inconsistencies between the information in this brochure and the plan Summary of Benefit documents or contracts, the plan documents and contracts will prevail.

Terms and Descriptions

The information in this Enrollment Guides is presented for illustrative purposes and is based on information provided by the employer. The text contained in this Guide was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of discrepancy between the Guide and the actual plan documents, the actual plan documents will prevail. If you have any questions about your Guide, contact your Human Resources Department.

Reasonable & Customary (R&C) and /or Usual & Customary (U&C)

When using out‐of‐network providers for medical or dental benefit, payments from insurance carriers are based on what is considered reasonable. Everything not included as reasonable is considered the member’s responsibility to pay to the provider, and the member is not credited for any of these expenses towards their deductible or coinsurance maximums.

Benefit Payments

For benefits received in the Network, you are responsible only for your co‐payment or deductible amount and coinsurance. Your provider will file the claim. Benefits for Non‐Network visits are payable on a reimbursement basis only. You can be subject to additional charges over the reasonable and customary allowed amount.

3

MEDICAL BENEFITS - BASE PLAN

BASE PLANPRMC NETWORK

PROVIDERS NON-NETWORK

PROVIDERS Lifetime Maximum Unlimited

MAXIMUM BENEFIT AMOUNT: Aggregate

Annual Limit Unlimited

DEDUCTIBLE, PER CALENDAR YEAR - THE TIER 1 AND TIER 2 DEDUCTIBLE AMOUNTS ACCUMULATE TOGETHER, NOT SEPARATELY

BASE PLAN Per Covered Person $3,000 $3,000 N/A

Per Family Unit $6,000 $6,000 N/A

MAXIMUM OUT-OF-POCKET AMOUNT, PER CALENDAR YEAR - TTHHEE OOUUTT--OOFF--PPOOCCKKEETT AAMMOOUUNNTTSS FFOORR TIER 1 AND TIER 2 NNEETTWWOORRKKSS AACCCCUUMMUULLAATTEE TTOOGGEETTHHEERR..

Any applicable Prescription Drug Plan copayments and/or coinsurance percentages are integrated with the Medical Plan’s Out-of-Pocket Maximums.

BASE PLAN Per Covered Person $6,850 $6,850 N/A


The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts are reached, at which time the Plan will pay 100% of the remainder of Covered Charges for the rest of the

Calendar Year unless stated otherwise. The following charges do not apply toward the out-of-pocket maximum and are never paid at 100%:

Cost containment penalties Amounts over Usual and Reasonable Charges

Non-covered expenses Othognathic Conditions & Surgery

Smoking Cessation Program COVERED CHARGES Benefits are payable as shown below. However, to the extent that a service is specifically described in the Summary of Benefits and Coverage and it is not specifically addressed below, benefits will be payable at the levels shown in the Summary of Benefits and Coverage.

PLEASE NOTE: THERE IS NO OUT-OF-NETWORK COVERAGE EXCEPT FOR EMERGENCY SITUATIONS, WHICH ARE PAYABLE BASED UPON USUAL AND

REASONABLE ALLOWANCES Hospital Services Note: The following services are NOT available at PRMC: Bariatric Surgery, Cardiac Catherizations

(interventional), Cardiac Surgery, Multiple Trauma, Neonatal ICU, Pediatric ICU, PET Scans and Neurosurgery.

Room and Board semiprivate room rate

100%, deductible waived 75% after deductible Not Covered

Intensive Care Unit 100%, deductible waived 75% after deductible Not Covered

Rehabilitation Facility 100%, deductible waived 75% after deductible Not Covered

Emergency Room (true emergency)

75%, deductible waived 75%, deductible waived 75%, deductible waived

Emergency Room (non-emergency)

75% after deductible 75% after deductible Not Covered

Urgent Care $30 copayment 75% after deductible Not Covered 23 Hour Observation 100%, deductible waived 75% after deductible Not Covered

Members must use PRMC for health services unless the service is not available at PRMC. If service is not available member must use an in-network provider.

5



PROVIDERS Radiation Therapy, Inhalation Therapy,

Chemotherapy 75% after deductible 75% after deductible

Not Covered

Outpatient Dialysis 75% after deductible 75% after deductible Not Covered Please see the Covered Charges section for more information on Outpatient Dialysis coverage.

Cardiac Rehabilitation 75% after deductible 75% after deductible Not Covered Outpatient Surgery 75% after deductible 75% after deductible Not Covered Independent Lab Not Available 75% after deductible Not Covered

Diagnostic Imaging/ X-ray Services


Diagnostic Laboratory Services


Sleep Studies 75% after deductible 75% after deductible Not Covered Mammograms (non-routine)


Colonoscopy/ Sigmoidoscopy

(Routine or non-routine)

100% deductible waived


Not Covered

Pre-admission Testing 75% after deductible 75% after deductible Not Covered Note: Occupational, Speech and Physical Therapy visit maximums are separate.

Occupational Therapy 60 day Calendar Year

maximum 75% after deductible 75% after deductible Not Covered

Speech Therapy 60 day Calendar Year


Physical Therapy 60 day Calendar Year


Skilled Nursing Facility Must be within 7 days of

related Hospital confinement

Not Available 75% after deductible Not Covered

Physician Services Inpatient visits Not Available 75% after deductible Not Covered

Emergency room visit (true emergency)


Emergency room visit (non emergency)


Urgent Care – Physician visit

$30 copayment 75% after deductible Not Covered

Office visits Primary Care Physician

(PCP) $30 copayment $30 copayment Not Covered

Office visits Specialist $60 copayment $60 copayment Not Covered

All other services rendered during the

visit except laboratory test and x-rays


Diagnostic Laboratory Services - office 75% after deductible 75% after deductible

Not Covered

6



PROVIDERS Diagnostic X-ray Services - office 75% after deductible 75% after deductible

Not Covered

Interpretation of Diagnostic Services


Surgery – inpatient, outpatient or office


Allergy testing, injections and serums

Office visit copay applies if billed


Other Covered Charges Pregnancy Same as any other Illness

Dependent daughters not covered. Breast Pumps

Rental or purchase Limited to 1 pump per

Calendar Year rented or purchased within 30

days of delivery

100%, deductible waived 100%, deductible waived Not Covered

Depo Provera Shot Routine Diagnosis

Covered for Employees & spouses only.


Depo Provera Shot: Medically Necessary DX


Birth Control Pills Covered under the Prescription Plan

Birth Control Devices 100%, deductible waived 100%, deductible waived Not Covered

See the Medical Benefits and Prescription Drug Benefits sections for more details on contraceptive coverage.

Home Health Care 75% after deductible 75% after deductible Not Covered

Note: Pharmacy charges will be paid at 80% after deductible when a Peterson Regional Medical Center covered Employee diagnosed with Hepatitis C receives services rendered at Peterson Regional

Medical Center Home Health facility. Private Duty Nursing

Inpatient only 75% after deductible 75% after deductible Not Covered

Hospice Care Bereavement Counseling


Ambulance Service 75% after deductible 75% after deductible Not Covered Durable Medical

Equipment 75% after deductible 75% after deductible Not Covered

Diabetic Education/Training


Prosthetics 75% after deductible 75% after deductible Not Covered Orthotics 75% after deductible 75% after deductible Not Covered

Spinal Manipulation Chiropractic

$1,500 Calendar Year Maximum


7



PROVIDERS Mental Disorders and Substance Abuse

Inpatient 100%, deductible waived 75% after deductible Not Covered

Outpatient Treatment Facility


Partial Day Treatment Facility


Office visits Not Available $60 copayment Not Covered Preventive Care See the Covered Charges section for more details on Preventive Care benefits.

Routine Well Adult Care



Not Covered

Includes: Standard Preventive Care, office visits, pap smear, mammogram, prostate screening, gynecological exam, routine physical examination, x-rays, laboratory tests, hearing tests,

immunizations/flu shots, bone density scans, stress tests,colonoscopies, sigmoidoscopies and diagnostic procedures.

Frequency limits for mammogram……………………….One per Calendar Year Frequency limits for routine colonoscopy……………… . A routine colonoscopy is available

for a Covered Person age 50 or older, once per 130 months (or more frequently if recommended by a Physician, provided that such person has a positive family history).

Frequency limits for routine sigmoidoscopy…………… . A routine sigmoidoscopy is available for a Covered Person age 50 or older, once per 60 months (or more frequently if recommended

by a Physician, provided that such person has a positive family history).

Shingles vaccine will be covered through the Occupational Health Nurse at 100%. Please call 830-285-7459 to make an appt to get the vaccine. Shingles vaccines received anywhere else will not be covered.

Routine Well Child Care

100% (if services available)


Not Covered

Includes: Standard Preventive Care, office visits, routine physical examination, laboratory tests, x-rays, immunizations and other preventive care and services required by applicable law if provided by

a Panel/Network/Participating Provider through age 18. Hearing Exams

(with diagnosis) Routine hearing exams covered under Preventive Care

75% after deductible (if services available)

75% after deductible Not Covered

Smoking Cessation Services Outpatient

Limited to 2 courses per Calendar Year



Not Covered

Diabetes Education outpatient


Jaw Joint/TMJ Office visit


Jaw Joint/TMJ Diagnostic Testing

75%after deductible 75% after deductible Not Covered

Jaw Joint/TMJ Inpatient/Outpatient Surgery Physician

Charges


TMJ Inpatient/Outpatient facility charges paid the same as any other Illness

8

BUY-UP PLANPRMC NETWORK


PROVIDERS Lifetime Maximum Unlimited

MAXIMUM BENEFIT AMOUNT: Aggregate

Annual Limit Unlimited

DEDUCTIBLE, PER CALENDAR YEAR - THE TIER 1 AND TIER 2 DEDUCTIBLE AMOUNTS ACCUMULATE TOGETHER, NOT SEPARATELY

BUY-UP PLAN Per Covered Person $2,000 $2,000 N/A


MAXIMUM OUT-OF-POCKET AMOUNT, PER CALENDAR YEAR - TTHHEE OOUUTT--OOFF--PPOOCCKKEETT AAMMOOUUNNTTSS FFOORR TIER 1 AND TIER 2 NNEETTWWOORRKKSS AACCCCUUMMUULLAATTEE TTOOGGEETTHHEERR..

Any applicable Prescription Drug Plan copayments and/or coinsurance percentages are integrated with the Medical Plan’s Out-of-Pocket Maximums.

BUY-UP PLAN Per Covered Person $6,850 $6,850 N/A


The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts are reached, at which time the Plan will pay 100% of the remainder of Covered Charges for the rest of the

Calendar Year unless stated otherwise. The following charges do not apply toward the out-of-pocket maximum and are never paid at 100%:

Cost containment penalties Amounts over Usual and Reasonable Charges

Non-covered expenses Othognathic Conditions & Surgery

Smoking Cessation Program COVERED CHARGES Benefits are payable as shown below. However, to the extent that a service is specifically described in the Summary of Benefits and Coverage and it is not specifically addressed below, benefits will be payable at the levels shown in the Summary of Benefits and Coverage.

PLEASE NOTE: THERE IS NO OUT-OF-NETWORK COVERAGE EXCEPT FOR EMERGENCY SITUATIONS, WHICH ARE PAYABLE BASED UPON USUAL AND

REASONABLE ALLOWANCES Hospital Services Note: The following services are NOT available at PRMC: Bariatric Surgery, Cardiac Catherizations

(interventional), Cardiac Surgery, Multiple Trauma, Neonatal ICU, Pediatric ICU, PET Scans and Neurosurgery.

Room and Board semiprivate room rate

100%, deductible waived

$2,000 copayment, then 50% after deductible NOTE: Copayment

waived and coinsurance increased to 75% if

services not available at PRMC.

Not Covered

Intensive Care Unit 100%, deductible waived




Not Covered

MEDICAL BENEFITS - BUY UP PLAN

Members must use PRMC for health services unless the service is not available at PRMC. If service is not available member must use an in-network provider.

9



PROVIDERS Rehabilitation Facility 100%, deductible waived $2,000 copayment, then

50% after deductible NOTE: Copayment



Not Covered

Emergency Room (true emergency)


Emergency Room (non-emergency)


Urgent Care - facility $30 copayment 75% after deductible Not Covered 23 Hour Observation 100%, deductible waived 75% after deductible Not Covered

Radiation Therapy, Inhalation Therapy,

Chemotherapy 75% after deductible 75% after deductible

Not Covered

Outpatient Dialysis 75% after deductible 75% after deductible Not Covered Please see the Covered Charges section for more information on Outpatient Dialysis coverage.

Cardiac Rehabilitation 75% after deductible 75% after deductible Not Covered Outpatient Surgery 75% after deductible 75% after deductible Not Covered Independent Lab Not Available 75% after deductible Not Covered

Diagnostic Imaging/ X-ray Services


Diagnostic Laboratory Services


Sleep Studies 75% after deductible 75% after deductible Not Covered Mammograms (non-routine)


Colonoscopy/ Sigmoidoscopy

(Routine or non-routine)



Not Covered

Pre-admission Testing 75% after deductible 75% after deductible Not Covered Note: Occupational, Speech and Physical Therapy visit maximums are separate.

Occupational Therapy 60 day Calendar Year


Speech Therapy 60 day Calendar Year


Physical Therapy 60 day Calendar Year


Skilled Nursing Facility Must be within 7 days of

related Hospital confinement


Physician Services Inpatient visits Not Available 75% after deductible Not Covered

Emergency room visit (true emergency)


10



PROVIDERS Emergency room visit

(non emergency) 75% after deductible 75% after deductible Not Covered

Urgent Care – Physician visit

$30 copayment 75% after deductible Not Covered

Office visits Primary Care Physician

(PCP) $25 copayment $25 copayment Not Covered

Office visits Specialist $50 copayment $50 copayment Not Covered

All other services rendered during the

visit except laboratory test and x-rays


Diagnostic Laboratory Services - office 75% after deductible 75% after deductible

Not Covered

Diagnostic X-ray Services - office 75% after deductible 75% after deductible

Not Covered

Interpretation of Diagnostic Services


Surgery – inpatient, outpatient or office


Allergy testing, injections and serums

Office visit copay applies if billed


Other Covered Charges Pregnancy Same as any other Illness

Dependent daughters not covered. Breast Pumps

Rental or purchase Limited to 1 pump per

Calendar Year rented or purchased within 30

days of delivery


Depo Provera Shot Routine Diagnosis

Covered for Employees & spouses only.


Depo Provera Shot: Medically Necessary DX


Birth Control Pills Covered under the Prescription Plan

Birth Control Devices 100%, deductible waived 100%, deductible waived Not Covered

See the Medical Benefits and Prescription Drug Benefits sections for more details on contraceptive coverage.

Home Health Care 75% after deductible 75% after deductible Not Covered

Note: Pharmacy charges will be paid at 80% after deductible when a Peterson Regional Medical Center covered Employee diagnosed with Hepatitis C receives services rendered at Peterson Regional

Medical Center Home Health facility.

11



PROVIDERS Private Duty Nursing

Inpatient only 75% after deductible 75% after deductible Not Covered

Hospice Care Bereavement Counseling


Ambulance Service 75% after deductible 75% after deductible Not Covered Durable Medical

Equipment 75% after deductible 75% after deductible Not Covered

Diabetic Education/Training


Prosthetics 75% after deductible 75% after deductible Not Covered Orthotics 75% after deductible 75% after deductible Not Covered

Spinal Manipulation Chiropractic

$1,500 Calendar Year Maximum


Mental Disorders and Substance Abuse

Inpatient

100%, deductible waived




Not Covered

Outpatient Treatment Facility


Partial Day Treatment Facility


Office visits Not Available $50 copayment Not Covered Preventive Care See the Covered Charges section for more details on Preventive Care benefits.

Routine Well Adult Care



Not Covered

Includes: Standard Preventive Care, office visits, pap smear, mammogram, prostate screening, gynecological exam, routine physical examination, x-rays, laboratory tests, hearing tests,

immunizations/flu shots, bone density scans, stress tests,colonoscopies, sigmoidoscopies and diagnostic procedures.

Frequency limits for mammogram……………………….One per Calendar Year Frequency limits for routine colonoscopy……………… . A routine colonoscopy is available

for a Covered Person age 50 or older, once per 130 months (or more frequently if recommended by a Physician, provided that such person has a positive family history).

Frequency limits for routine sigmoidoscopy…………… . A routine sigmoidoscopy is available for a Covered Person age 50 or older, once per 60 months (or more frequently if recommended

by a Physician, provided that such person has a positive family history).

Shingles vaccine will be covered through the Occupational Health Nurse at 100%. Please call 830-285-7459 to make an appt to get the vaccine. Shingles vaccines received anywhere else will not be covered.

Routine Well Child Care

100% (if services available)


Not Covered

12



PROVIDERS Includes: Standard Preventive Care, office visits, routine physical examination, laboratory tests, x-

rays, immunizations and other preventive care and services required by applicable law if provided by a Panel/Network/Participating Provider through age 18.

Hearing Exams (with diagnosis) Routine hearing exams covered under Preventive Care

75% after deductible (if services available)


Smoking Cessation Services Outpatient

Limited to 2 courses per Calendar Year



Not Covered

Diabetes Education outpatient


Jaw Joint/TMJ Office visit


Jaw Joint/TMJ Diagnostic Testing


Jaw Joint/TMJ Inpatient/Outpatient Surgery Physician

Charges


TMJ Inpatient/Outpatient facility charges paid the same as any other Illness Orthognathic

Conditions and Surgery 50% after deductible (if services available)


Note: Outpatient X-ray and Laboratory services for Orthognathic Conditions will be covered as specified under “DIAGNOSTIC X-RAY AND LABORATORY SERVICES”.

Medical Weight Loss Surgery

$30,000 Lifetime maximum (including

complications)


Organ Transplants 75% after deductible (if services available)

Interlink In-Network Benefit:

75% after deductible

Not Covered

Covered transplants include: Heart, lung, Bone Marrow, Liver, Heart/Lung, Pancreas, Kidney, Kidney/Pancreas, and Multivisceral/Small Bowel. Please see the transplant section in the Covered

Charges section for more details on transplant benefits and limitations.

13

PRESCRIPTION DRUG BENEFIT SCHEDULE

SCOTT & WHITE PRESCRIPTION SERVICES

APPLIES TO BASE AND BUY-UP PLANS

Any applicable Prescription Drug Plan deductible, copayments and/or coinsurance percentages are integrated with the Medical Plan’s Out-of-Pocket Maximums.

$50 Calendar Year deductible applies to Preferred & Non-Preferred Brand Name Drugs

Pharmacy Option (33 Day Supply) Generic Drugs $10 copayment

Preferred Brand Name Drugs $55 copayment Non- Preferred Brand Name

Drugs $85 copayment

Specialty Drugs $80 copayment High Dollar Copayment (cost over $500)

Preferred Brand Name Drugs 15% Non- Preferred Brand Name

Drugs 25%

Mail Order Option (100 Day Supply) Generic Drugs $20 copayment

Brand Name Drugs $110 copayment Non- Preferred Brand Name

Drugs Not Applicable

Refer to the Prescription Drug Section for details on the Prescription Drug benefit.

14

DENTAL CARE BENEFIT SCHEDULE

DENTAL CARE BENEFIT

DENTAL CARE DEDUCTIBLE, PER CALENDAR YEAR

Per Covered Person $50 Per Family Unit $150

Calendar Year Deductible applies to these classes of services: Class B Services - Basic and Class C Services - Major

MAXIMUM BENEFIT AMOUNT BENEFIT

For Class A – Preventive, Class B - Basic and Class C - Major Services

Per Covered Person per Calendar Year

$1500

For Class D - Orthodontia (benefit available for Dependents under age 19)

Lifetime maximum per Covered Person $1500

Implants

Lifetime maximum per Covered Person $3,000 COVERED CHARGES

Dental Percentage Payable Class A Services - Preventive

Class B Services - Basic (6 month waiting period) Class C Services- Major (12 month waiting period)

Class D Services - Orthodontia

100% 80% 50% 50%

Note: The waiting period applies only to Late Enrollees from the Covered Person’s effective date of dental coverage before dental benefits are payable (a Late Enrollee is a person who enrolls other than

during the initial enrollment period or a special enrollment period as provided under the eligibility requirements of the Plan.)

15

About Your Benefits:

Eye care is a vital component of a healthy lifestyle. With vision insurance, having regular exams and purchasing contacts or glasses issimple and affordable. The coverage is inexpensive, yet the benefits can be significant! Guardian provides rich, flexible plans thatallow you to safeguard your health while saving you money. Review your plan options and see why vision insurance may be a greatbenefit for you.

Vision Benefit Summary

Visit any doctor with your Full Feature plan, but save by visiting any of the 50,000+ locations in the nation's largest visionnetwork.

Group Number: 00490572

Your Vision Plan Full Feature

Your Network is VSP Choice Network

Your Semi-monthly premium $ 4.78You and spouse $ 9.56You and child(ren) $ 8.23You, spouse and child(ren) $ 13.01Copay

Exams Copay $ 10

Materials Copay (waived for elective contact lenses) $ 25

Sample of Covered Services You pay (after copay if applicable):

In-network Out-of-network

Eye Exams $0 Amount over $55

Single Vision Lenses $0 Amount over $40

Lined Bifocal Lenses $0 Amount over $80

Lined Trifocal Lenses $0 Amount over $80

Lenticular Lenses $0 Amount over $80

Frames 80% of amount over $130¹ Amount over $65

Contact Lenses (Elective) Amount over $130 Amount over $105

Contact Lenses (Medically Necessary) $0 Amount over $210

Contact Lenses (Evaluation and fitting) 15% off UCR No discounts

Cosmetic Extras Avg. 20-25% off retail price No discounts

Glasses (Additional pair of frames and lenses) 20% off retail price** No discounts

Laser Correction Surgery Discount Up to 15% off the usual charge or 5%

off promotional price

No discounts

Service Frequencies

Exams Every calendar year

Lenses (for glasses or contact lenses)‡‡ Every calendar year

Frames Every two calendar years‡‡‡

Network discounts (cosmetic extras, glasses and contact lensprofessional service)

Limitless within 12 months of exam.

Dependent Age Limits 26

Visit www.GuardianAnytime.com and click on “Find a Provider”

16

Life Benefit SummaryGroup Number: 00490572


Your family depends on you in many ways and you’ve worked hard to ensure their financial security. But if something happened to

you, will your family be protected? Will your loved ones be able to stay in their home, pay bills, and prepare for the future. Life

insurance provides a financial benefit that your family can depend on. And getting it at work is easier, more convenient and more

affordable than doing it on your own. If you have financial dependents- a spouse, children or aging parents, having life insurance is a

responsible and a smart decision. Enroll today to secure their future!

What Your Benefits Cover:

BASIC LIFE VOLUNTARY TERM LIFE

Employee Benefit Your employer provides Basic Life

Coverage for all full time

employees in the amount of 200%

of your annual salary, to a

maximum of $350,000.

$10,000 increments to a

maximum of $500,000. See Cost

Illustration page for details.

Accidental Death and Dismemberment Your Basic Life coverage includes

Accidental Death and

Dismemberment coverage equal

to one times the employee's life

benefits.

Employee, Spouse & Child(ren)

coverage. Maximum 1 times life

amount.

Spouse‡ Benefit N/A $5,000 increments to a maximum

of $250,000. See Cost Illustration

page for details.

Child Benefit N/A Your dependent children age 14

days to 26 years.

$1,000 increments to a maximum

of $10,000. Subject to state limits.

See Cost Illustration page for

details.

Guarantee Issue: The ‘guarantee’ means you are not required to

answer health questions to qualify for coverage up to and including

the specified amount, when you sign up for coverage during the initial

enrollment period.

Guarantee Issue coverage up to

$350,000 per employee

We Guarantee Issue coverage up

to:

Employee $200,000.

Spouse $50,000.

Dependent children $10,000.

Premiums Covered by your company if you

meet eligibility requirements

Increase on plan anniversary after

you enter next five-year age

group

Portability: Allows you to take your coverage with you if you

terminate employment.

No Yes, with age and other

restrictions

Conversion: Allows you to continue your coverage after your group

plan has terminated.

Yes, with restrictions; see

certificate of benefits

Yes, with restrictions; see

certificate of benefits

17

BASIC LIFE VOLUNTARY TERM LIFE

Accelerated Life Benefit: A lump sum benefit is paid to you if you

are diagnosed with a terminal condition, as defined by the plan.

Yes Yes

Waiver of Premiums: Premium will not need to be paid if you are

totally disabled.

For employees disabled prior to

age 60, with premiums waived

until age 65, if conditions are met

For employees disabled prior to

age 60, with premiums waived

until age 65, if conditions met

Benefit Reductions: Benefits are reduced by a certain percentage as

an employee ages.

50% at age 70, 75% at age 75 50% at age 70, 75% at age 75

Subject to coverage limits� Spouse coverage terminates at age 70.

Manage Your Benefits:

Go to www.GuardianAnytime.com to access secure information about

your Guardian benefits. Your on-line account will be set up within 30

days after your plan effective date.

Need Assistance?

Call the Guardian Helpline (888) 600-1600, weekdays, 8:00 AM to 8:30

PM, EST. Refer to your member ID (social security number) and your

plan number: 00490572

18


You probably have insurance for your car or home, but what about the source of income that pays for it? You rely on your

paycheck for so many things, but what if you were suddenly unable to work due to an accident or illness? How will you put food

on the table, pay your mortgage or heat your home? Disability insurance can help replace lost income and make a difficult time a

little easier. Protect your most valuable asset, your paycheck-enroll today!


Disability Benefit Summary


Short-Term Disability Long-Term Disability

Plan 1 Plan 2.

Coverage amount60% of salary to maximum

$1500/week

60% of salary to maximum

$1500/week

60% of salary to maximum

$6000/month

Maximum payment period: Maximum length of

time you can receive disability benefits.13 weeks 9 weeks

Social Security Normal

Retirement Age

Accident benefits begin: The length of time you

must be disabled before benefits begin.Day 8 Day 30 Day 91

Illness benefits begin: The length of time you must

be disabled before benefits begin.Day 8 Day 30 Day 91

Evidence of Insurability: A health statement

requiring you to answer a few medical history

questions.

Health Statement not

required


required


required

Minimum work hours/week: Minimum number of

hours you must regularly work each week to be

eligible for coverage.

Planholder Determines Planholder Determines Planholder Determines

Pre-existing conditions: A pre-existing condition

includes any condition/symptom for which you, in the

specified time period prior to coverage in this plan,

consulted with a physician, received treatment, or

took prescribed drugs.

Not Applicable Not Applicable12 months look back; 12

months after exclusion

Premium waived if disabled: Premium will not

need to be paid when you are receiving benefits.Yes Yes Yes

UNDERSTANDING YOUR BENEFITS—DISABILITY (Some information may vary by state)

l Disability (long-term): For first two years of disability, you will receive benefit payments while you are unable to work in

your own occupation. After two years, you will continue to receive benefits if you cannot work in any occupation based on

training, experience and education.

l Earnings definition: Your covered salary excludes bonuses and commissions.

19

Critical Illness Benefit Summary



It takes a lot to beat a serious illness. Unfortunately, it can also cost a lot. When you or a family member suffers a serious illness like

a stroke or heart attack, Critical Illness Insurance can help with expenses that medical insurance doesn't cover like deductibles or

out of pocket costs, or services like experimental treatment. Critical Illness supplements your medical and your disability income

insurance. The lump sum benefit is paid when you need it most, upon diagnosis, so you can rest assured that you will have funds to

offset upcoming out of pocket costs, and that you'll have the flexibility to elect treatments with less worry about the cost. Review

your options and enroll today!


Option 1 Option 2

Benefit Amount(s)Employee may choose a lump sum benefit of

$5,000 to $50,000 in $5,000 increments.

Employee may choose a lump sum benefit of

$5,000 to $50,000 in $5,000 increments.

CONDITIONS

Cancer 1st OCCURRENCE 2nd OCCURRENCE 1st OCCURRENCE 2nd OCCURRENCE

Invasive Cancer Not Applicable Not Applicable 100% 50%

Carcinoma In Situ Not Applicable Not Applicable 30% 0%

Benign Brain Tumor Not Applicable Not Applicable 75% 0%

Skin Cancer Not Applicable Not Applicable $250 per lifetime Not Covered

Vascular

Heart Attack 100% 50% 100% 50%

Stroke! 100% 50% 100% 50%

Heart Failure## 100% 50% 100% 50%

Coronary Arteriosclerosis# 30% 0% 30% 0%

Other

Organ Failure*** 100% 50% 100% 50%

Kidney Failure** 100% 50% 100% 50%

ADDITIONAL CONDITIONS 1st OCCURRENCE ONLY 1st OCCURRENCE ONLY

Accute Respiratory Distress Syndrome 30% 30%

Addison's Disease 30% 30%

ALS (Lou Gehrig's Disease) 100% 100%

Alzheimer's Disease 50% 50%

Coma 100% 100%

Huntington's Disease 30% 30%

Loss of Hearing 100% 100%

Loss of Sight 100% 100%

Loss of Speech 100% 100%

Multiple Sclerosis 30% 30%

Parkinson's Disease 100% 100%

Permanent Paralysis 50% for 1 limb, 100% for 2 limbs 50% for 1 limb, 100% for 2 limbs

Severe Burns 100% 100%

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Option 1 Option 2

Childhood Conditions 1st OCCURRENCE ONLY 1st OCCURRENCE ONLY

Cerebral Palsy 100% 100%

Cleft Lip/Palate 100% 100%

Club Foot 100% 100%

Cystic Fibrosis 100% 100%

Down's Syndrome 100% 100%

Muscular Dystrophy 100% 100%

Spina Bifida 100% 100%

Type 1 Diabetes 100% 100%

Spouse Benefit

May choose a lump sum benefit up to $50,000.

Please see your cost illustration for a full list of

available benefit amounts.

May choose a lump sum benefit up to $50,000.

Please see your cost illustration for a full list of

available benefit amounts.

Child Benefit- children age Birth to 26 years 25% of employee's lump sum benefit 25% of employee's lump sum benefit

Benefit Reductions: Benefits are reduced by

a certain percentage as an employee ages50% at age 70 50% at age 70

Guarantee Issue: The ‘guarantee’ means you

are not required to answer health questions to

qualify for coverage up to and including the

specified amount, when you sign up for

coverage during the initial enrollment period.

We Guarantee Issue up to:

Less than age 70 $20,000

For a spouse:


For a child: All Amounts

Health questions are required if the

elected amount exceeds the Guarantee

Issue, as well as for all applicants age 70+

regardless of elected amount.

We Guarantee Issue up to:


For a spouse:


For a child: All Amounts

Health questions are required if the

elected amount exceeds the Guarantee

Issue, as well as for all applicants age 70+

regardless of elected amount.

Portability: Allows you to take your Critical

Illness coverage with you if you terminate

employment.

Included Included

Pre-Existing Condition Limitation: A

pre-existing condition includes any condition

for which you, in the specified time period

prior to coverage in this plan, consulted with a

physician, received treatment, or took

prescribed drugs.

3 months prior/6 months treatment free/12

months after

3 months prior/6 months treatment free/12

months after

Cancer Vaccine Benefit Not Applicable $50 per lifetime for receiving a cancer vaccine

Occupational HIV/Hepatitis Benefit100% of employee benefit for the first

occurrence.

100% of employee benefit for the first

occurrence.

WELLNESS BENEFIT

Employee Per Year Limit $50 $50

Spouse Per Year Limit $50 $50

Child Per Year Limit $50 $50

• ! Stroke: Stroke must be severe enough to cause neurological deficits at least 30 days after the event.

• ## Heart Failure: An insured must be placed on an organ transplant list in order to be eligible for the Heart failure benefits.

• # Coronary Arteriosclerosis: Coronary Arteriosclerosis must be severe enough to require a coronary artery bypass graft.

• *** Organ Failure: Organ failure includes both lungs, liver, pancreas or bone marrow and requires the insured to be placed on an organ

transplant list.

• ** Kidney Failure: An insured must be placed on an organ transplant list in order to be eligible for the Kidney failure benefits.

21

Accident Benefit Summary


Accidents happen every day. Did you know almost 39 Million emergency room visits a year are due to an injury?¹ If you wereinjured from an accident, chances are you will have expenses that you were not anticipating-will you be prepared? AccidentInsurance can help you deal with those expenses. Benefit payments can help you with your medical deductibles and co-pays, andcover household expenses like groceries, mortgage payments and childcare, which can begin to pile up if you have to take sometime off from work. You are guaranteed coverage, so please enroll today!1Injury Facts, 2011 Edition, National Safety Council.



ACCIDENT

COVERAGE - DETAILS

Your Semi-monthly premium $9.46

You and Spouse $14.71

You and Child(ren) $12.40

You, Spouse and Child(ren) $17.65

Accident Coverage Type On and Off Job

Portability - Allows you to take your Accident coverage with you if you terminate

employment. Ported Accident plan terminates at age 70.

Included

ACCIDENTAL DEATH AND DISMEMBERMENT

Benefit Amount(s)

Employee $25,000

Spouse $12,500

Child $5,000

Catastrophic LossQuadriplegia, Loss of speech & hearing (both ears),

Loss of Cognitive function: 100% of AD&D

Hemiplegia & Paraplegia: 50% of AD&D

Common Carrier 200% of AD&D benefit

Common Disaster 200% of Spouse AD&D benefit

Dismemberment - Hand, Foot, SightSingle: 50% of AD&D benefit

Multiple: 100% of AD&D benefit

Dismemberment - Thumb/Index Finger Same Hand, Four Fingers Same Hand, All

Toes Same Foot

25% of AD&D benefit

Seatbelts and Airbags Seatbelts: $10,000 & Airbags: $15,000

Reasonable Accommodation to Home or Vehicle $2,500

WELLNESS BENEFIT - Per Year Limit $50

Child(ren) Age Limits Children age birth to 26 years

FEATURES

Accident Emergency Room Treatment $175

Accident Follow-Up Visit - Doctor $50 up to 6 treatments

Air Ambulance $1,000

Ambulance $150

Appliance - Wheelchair, leg or back brace, crutches, walker, walking boot that

extends above the ankle or brace for the neck.

$125

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FEATURES (Cont.)

Blood/Plasma/Platelets $300

Burns (2nd Degree/3rd Degree)9 sq inches to 18 sq inches: $0/$2,000

18 sq inches to 35 sq inches: $1,000/$4,000

Over 35 sq inches: $3,000/$12,000

Burn - Skin Graft 50% of burn benefit

Child Organized Sport - Benefit is paid if the covered accident occurred while your

covered child is participating in an organized sport that is governed by an

organization and requires formal registration to participate.

20% increase to child benefits

Chiropractic Visits $25 per visit up to 6 visits

Coma $10,000

Concussions $75

Dislocations Schedule up to $4,400

Diagnostic Exam (Major) $150

Emergency Dental Work $300/Crown, $75/Extraction

Epidural pain management $100, 2 times per accident

Eye Injury $300

Family Care $20/day up to 30 days

Fracture Schedule up to $5,500

Hospital Admission $1,000

Hospital Confinement $225/day - up to 1 year

Hospital ICU Admission $2,000

Hospital ICU Confinement $450/day - up to 15 days

Initial Physician's office/Urgent Care Facility Treatment $75

Joint Replacement (hip/knee/shoulder) $2,500/$1,250/$1,250

Knee Cartilage $500

Laceration Schedule up to $400

Lodging - The hospital must be more than 50 miles from the insured's residence. $125/day, up to 30 days for companion hotel stay

Occupational or Physical Therapy $25/day up to 10 days

Prosthetic Device/Artificial Limb1: $500

2 or more: $1,000

Rehabilitation Unit Confinement $150/day up to 15 days

Ruptured Disc With Surgical Repair $500

SurgerySchedule up to $1,250

Hernia: $150

Surgery - Exploratory or Arthroscopic $250

Tendon/Ligament/Rotator Cuff1: $500

2 or more: $1,000

Transportation - Benefit is paid if you have to travel more than 50 miles one way to

receive special treatment at a hospital or facility due to a covered accident.

$500, 3 times per accident

X - Ray $30

UNDERSTANDING YOUR BENEFITS:

• Common Carrier – Benefit is paid if an insured's death occurs due to an accident while riding as a fare-paying passanger in a

public conveyance. If this is paid, we do not pay the Accidental Death benefit.

• Common Disaster – Benefit is paid if both you & your spouse die in a covered accident or separate covered accidents

within the same 24 hour period.

• Reasonable Accomodation – Benefit is payable if a modification is required to an insured's place of residence or vehicle due

to an Accidental Dismemberment or Catastrophic loss.

This handout is for illustrative purposes only and is an approximation. If any discrepancies between this handout and your paycheck stub exist, your paycheck stub prevails.

23

Cancer Benefit Summary


Cancer is a terrible disease, but fortunately, more and more people are beating it through earlier diagnosis and the ever improvingtreatments available. However, treatment can be costly. Did you know an average out-of-pocket cost for cancer care is more than$1200 per month.¹ That’s where Cancer insurance can help. It supplements your medical and disability income insurance and helpsprotect you and your family from the financial hardship you may face while fighting the disease. Cancer Insurance pays benefits toyou based on the treatments you receive related to a covered cancer diagnosis. The benefit payment is paid in addition to yourmedical insurance plan. Coverage is surprisingly affordable, so enroll today and get covered!

¹Duke University Medical Center, 2011 http://clearhealthcosts.com/tag/duke-university-medical-center/



CANCER

COVERAGE - DETAILS

Your Semi-monthly premium $9.16

You and Spouse $15.22

You and Child(ren) $10.59

You, Spouse and Child(ren) $16.65

INITIAL DIAGNOSIS BENEFIT - Benefit is paid when you are diagnosed with Internal cancer for the first time while insured under this Plan.

Benefit Amount(s)

Employee $5,000

Spouse $5,000

Child $5,000

Benefit Waiting Period - A specified period of time after your effective date

during which the Initial Diagnosis benefits will not be payable.30 Days

CANCER SCREENING

Benefit Amount $100; $100 for Follow-Up screening

RADIATION THERAPY OR CHEMOTHERAPY

BenefitSchedule amounts up to a $5,000 benefit year

maximum.

Pre-Existing Conditions Limitation: A pre-existing condition includes any condition

for which you, in the specified time period prior to coverage in this plan, consulted with

a physician, received treatment, or took prescribed drugs.

3 months prior/ 6 months treatment free/ 12 months

after.

Portability: Allows you to take your Cancer coverage with you if you terminate

employment. Ported Cancer plan terminates at age 70.

Included with Evidence

Child(ren) Age Limits Children age birth to 26 years

FEATURES

Air Ambulance $1,500/trip, limit 2 trips per hospital confinement

Ambulance $200/trip, limit 2 trips per hospital confinement

Anesthesia 25% of surgery benefit

Anti-Nausea $50/day up to $150 per month

Attending Physician $25/day while hospital confined. Limit 75 visits.

Blood/Plasma/Platelets $100/day up to $5,000 per year

24

FEATURES (Cont.)

Bone Marrow/Stem Cell

Bone Marrow: $7,500

Stem Cell: $1,500

50% benefit for 2nd transplant. $1,000 benefit if a

donor

Experimental Treatment $100/day up to $1,000/month

Extended Care Facility/Skilled Nursing care $100/day up to 90 days per year

Government or Charity Hospital $300 per day in lieu of all other benefits

Home Health Care $50/visit up to 30 visits per year

Hormone Therapy $25/treatment up to 12 treatments per year

Hospice $50/day up to 100 days/lifetime

Hospital Confinement$300/day for first 30 days; $600/day for 31st day

thereafter per confinement

ICU Confinement$400/day for first 30 days; $600/day for 31st day

thereafter per confinement

Immunotherapy $500 per month, $2500 lifetime max

Inpatient Special Nursing $100/day up to 30 days per year

Medical Imaging $100/image up to 2 per year

Outpatient and family member lodging - Lodging must be more than 50 miles from

your home.

$75/day, up to 90 days per year

Outpatient or Ambulatory Surgical Center $250/day, 3 days per procedure

Physical or Speech Therapy $25/visit up to 4 visits per month, $400 lifetime max

ProstheticSurgically Implanted: $2,000/device, $4,000 lifetime max

Non-Surgically: $200/device, $400 lifetime max

Reconstructive Surgery

Breast TRAM Flap $2,000

Breast reconstruction $500

Breast Symmetry $250

Facial reconstruction $500

Second Surgical Opinion $200/surgery procedure

Skin Cancer

Biopsy Only: $100

Reconstructive Surgery: $250

Excision of a skin cancer: $375

Excision of a skin cancer with flap or graft: $600

Surgical Benefit Schedule amount up to $4,125

Transportation/Companion Transportation - Benefit is paid if you have to travel

more than 50 miles one way to receive treatment for internal cancer.

$0.50/mile up to $1,000 per round trip/equal benefit

for companion

Waiver of Premium - If you become disabled due to cancer that is diagnosed after

the employee's effective date, and you remain disabled for 90 days, we will waive the

premium due after such 90 days for as long as you remain disabled.

Included

UNDERSTANDING YOUR BENEFITS :

• Cancer – Cancer means you have been diagnosed with a disease manifested by the presence of a malignant tumor

characterized by the uncontrolled growth and spread of malignant cells in any part of the body. This includes leukemia,

Hodgkin's disease, lymphoma, sarcoma, malignant tumors and melanoma. Cancer includes carcinomas in-situ (in the natural or

normal place, confined to the site of origin, without having invaded neighboring tissue). Pre-malignant conditions or conditions

with malignant potential, such as myelodyplastic and myeloproliferative disorders, carcinoid, leukoplakia, hyperplasia, actinic

keratosis, polycythemia, and nonmalignant melanoma, moles or similar diseases or lesions will not be considered cancer.

• Experimental Treatment – Benefits will be paid for experimental treatment prescribed by a doctor for the purpose of

destroying or changing abnormal tissue. All treatment must be NCI listed as viable experimental treatment for Internal

Cancer.

25

Flexible Spending AccountsFlexible Spending Accounts (FSAs) are

designed to save you money on your

taxes. They work in a similar way to a

savings account. Each pay period, funds

are deducted from your pay on a pre-tax

basis and are deposited to your Health

Care and/or Dependent Care FSA. You

then use your funds to pay for eligible

health care or dependent care expenses.

Please note, in order to receive

employer contributions to an HSA

account, or contribute yourself, you

cannot participate in the Health Care

FSA.

Account Type Eligible ExpensesAnnual Contribution

LimitsBenefit

Health Care FSA

Most medical, dental and vision care expenses that are not covered by your health plan (such as copayments, coinsurance, deductibles, eyeglasses and doctor-prescribed over the counter medications)

Minimum contribution-$500Maximum contribution-$2,550 per year

Saves on eligible expenses not covered by insurance; reduces your taxable income

Dependent Care FSA

Dependent care expenses (such as day care, after school programs or elder care programs) so you and your spouse can work or attend school full-time

Maximum contribution is $5,000 per year ($2,500 if married and filing separate tax returns)

Reduces your taxable income

Important Information About FSAs

Your FSA elections will be in effect

from January 1st through December

31st. Claims incurred between January

1st and March 31st may be submitted

under the previous plan year. If you do

not use all of the funds in your FSA by

then, you forfeit any unused funds.

Please plan your contributions

carefully. Note that FSA elections do

not automatically continue from year

to year; you must actively enroll each

year.

The Advantages of an FSA

With an FSA, the money you

contribute is never taxed—not when

you put it in

the account, not when you are

reimbursed with the funds from the

account, and not when you file your

income tax return at the end of the

year.

Save on Your Taxes

Here is an example of how much you

might save when you use the FSAs to

pay for your predictable health care

and dependent care expenses.

With FSA Without FSA

Your taxable income $50,000 $50,000

Pre-tax contribution to Health Care and Dependent Care FSA $2,000 $0

Federal and Social Security taxes* $11,701 $12,355

After-tax dollars spent on eligible expenses $0 $2,000

Spendable income after expenses $36,299 $35,645

Tax savings with the Medical and Dependent Care FSA $654

*This is an example only, and may not reflect your actual experience. It assumes a 25% federal income tax rate marginal rate and a 7.7% FICA marginal rate. State and local taxes vary, and are not included in this example. However, you will also save on any state and local taxes as well.

26

FSA/HSA Eligible and Non-Eligible Expenses

FSA/HSA Eligible Health Care Expenses Please note that this list is not intended to be comprehensive tax advice. For more detailed

information, please consult IRS Publication 502 or see your tax advisor.

Acupuncture Psychiatric care, psychologists, Alcoholism treatment Home health and/or hospice care psychotherapists, counselors

Hospital services Radial keratotomy Ambulance (ground or air) Insulin Schools (special, relief, or handicapped)

Laboratory fees Blind services and equipment LASIK/LASEK eye surgery Car controls for handicapped* Medical alert (bracelet, necklace) Surgical fees Chiropractor services Television or telephone for the hearing

Nursing services impaired Contact lenses Obstetrical expenses Therapy treatments* Crutches, wheelchairs, walkers Occlusal guards

medical care; limits apply) aid animal & care, lip reading expenses, Optometrists

Vitamins* Dental treatment Orthopedic services Weight loss programs* Dentures Osteopaths X-rays

Oxygen/oxygen equipment ailment or

Doctor’s fees Physical exams (except for employment-

related physicals) Physical therapy

Important Notice About Over-the-Counter (OTC) Medications

OTC medications require a doctor’s prescription to be eligible for FSA/HSA reimbursement. For that reason, OTC

medications cannot be purchased using the mySourceCard® unless dispensed by a pharmacy the same as

a standard prescription (with an Rx number). If a manual claim is submitted for purchase of an OTC medication,

both a copy of the prescription and the purchase receipt must be included to receive reimbursement.

Non-medicated OTC products (diabetes test strips, saline solution, bandages, etc.) do not require a prescription.

You can use either the mySourceCard® to purchase these items or submit the purchase receipt for reimbursement

Under PPACA (health reform

law), the Maximum

Annual Election is capped at $2,600 per employee.

FSA/HSA Eligible OTC Medications and Products

COPY OF PRESCRIPTION AS WELL AS DETAILED ELIGIBLE FOR REIMBURSEMENT WITH RECEIPT REQUIRED FOR REIMBURSEMENT: suppositories, etc.) DETAILED RECEIPT ONLY (NO PRESCRIPTION

Eczema & psoriasis remedies REQUIRED): Eye drops, ear drops, nasal sprays Breast pumps for nursing mothers

syrups, cough drops, nasal sprays, medicated First aid kits Braces & supports

rubs, etc.) Hydrogen peroxide, rubbing alcohol CPAP equipment & supplies Antacids & acid controllers (tablets, liquids,

capsules) Medicated bandaids & dressings Durable medical equipment (power chairs,

ointments walkers, wheelchairs, etc.)

Pain relievers (aspirin, ibuprofen, kits, thermometers, blood pressure acetaminophen, naproxen, etc.) monitors, etc.)

Non-medicated bandaids, rolled bandages & Wart removal remedies, corn patches dressings

Baby care (diaper rash ointments, teething gel, Reading glasses

All OTC items listed are examples

2018 FORM FURNISHED BY PENSION CONCEPTS AND ADMINISTRATION, INC.

27

WorkLifeMatters

Your Confidential Employee Assistance Program – Helping find balance between work and homelife.

WorkLifeMatters provides guidance for personal issues that you might be facing and information about other concerns thataffect your life, whether it’s a life event or on a day-to-day basis.

• Unlimited free telephonic consultation with an EAP counselor available 24/7 at 800-386-7055

• Referrals to local counselors — up to three sessions free of charge

• State-of-the-art website featuring over 3,400 helpful articles on topics like wellness, training courses, and a

legal and financial center

WorkLifeMatters can offer help with:

Education Dependent Care & Care Giving Legal and financial▪ Admissions testing & procedures ▪ Adoption Assistance ▪ Basic tax planning▪ Adult re-entry programs ▪ Before/after school programs ▪ Credit & collections▪ College Planning ▪ Day Care/Elder Care ▪ Debt Counseling▪ Financial aid resources ▪ Elder care ▪ Home buying▪ Finding a pre-school ▪ In-home services ▪ Immigration

Lifestyle & Fitness Management Working Smarter▪ Anxiety & depression ▪ Career development▪ Divorce & separation ▪ Effective managing▪ Drugs & alcohol ▪ Relocation

For more information about WorkLifeMatters, go to www.ibhworklife.com; User Name: Matters; Password: wlm70101

WorkLifeMatters Program services are provided by Integrated Behavioral Health, Inc., and its contractors. Guardian does not provide any part of WorkLifeMattersProgram services. Guardian is not responsible or liable for care or advice given by any provider or resource under the program. This information is for illustrativepurposes only. It is not a contract. Only the Administration Agreement can provide the actual terms, services, limitations and exclusions. Guardian and IBH reservethe right to discontinue the WorkLifeMatters Program at any time without notice. Legal services provided through WorkLifeMatters will not be provided in connectionwith or preparation for any action against Guardian, IBH, or your employer.

28

WillPrep Services

Special bonus for participants in voluntary life plan

Your employer has worked with Guardian to make WillPrep Services available to eligible members with Voluntary Lifeplans. Keeping an up-to-date will is essential to ensuring that your assets are distributed as you intended, no matter thesize of your estate. You may be avoiding creating a will because you believe you can’t afford the time or legal expense.Now you can with WillPrep Services.

WillPrep Services offer support and guidance to help you properly prepare the documents necessary to preserve yourfamily’s financial security. WillPrep has a range of services including online planning documents, a resource library andaccess to professionals* to help with issues related to:

Advanced Health CareDirectives

Financial Power of Attorney Wills and Living Wills

Estate Taxes Guardianship andConservatorship

Resource Library

Executors & Probate Healthcare Power of Attorney Trusts

For more information about WillPrep Services, go to www.ibhwillprep.com; User name: WillPrep; Password: GLIC09or call 1-877-433-6789

*The Option of an attorney prepared will is available for a small fee.WillPrep Services are provided by Integrated Behavioral Health, Inc., and its contractors. The Guardian Life Insurance Company of America(Guardian) does not provide any part of WillPrep Services. Guardian is not responsible or liable for care or advice given by any provider or resourceunder the program. This information is for illustrative purposes only. It is not a contract. Only the Administration Agreement can provide the actualterms, services, limitations and exclusions. Guardian and IBH reserve the right to discontinue the WillPrep Services at any time without notice. Legalservices will not be provided in connection with or preparation for any action against Guardian, IBH, or your employer.

29

2018 WELLNESS PROGRAM

LIVE BETTER TODAYThe Wellness Revolution will reward you for making healthy choices. Get the motivation you need to improve your health, and the education and support to make wellness a lifestyle.

This is your chance to reach personal health goals and learn what improvements you can make to avoid future health problems. This document explains how you can take control of your health today. Have fun!

Who can participate in the program?Beginning 1/1/18, all health plan‐covered employees are eligible to log on to www.PRMCWellness.com to start the program.

Is my health information confidential?All programs are confidential and in compliance with the Health Insurance Portability and Accountability Act (HIPAA). Any information shared with the Viverae® team will not be disclosed, except in accordance with HIPAA laws. Your Protected Health Information (PHI) will not be shared with your employer.

HOW TO REGISTERStep 1

» Visit www.PRMCWellness.com

» Click New User Registration

» Enter your last name and date of birth (DOB)

» Enter your identifier: SNN

» Enter the registration code: petersonrmc

Step 2

» Create a user name (5 – 25 characters)

» Create a password (8 – 12 characters) using letters (upperand/or lowercase), numerals and/or special characters (such as@$%&#)

» Select a security question and answer, then click Save

TEXT MESSAGE REMINDERSwww.PRMCWellness.com can text you healthy reminders:

» Complete Member Health Assessment (MHA) and BiometricScreening

» Screening appointment date and time

» Important challenge sign‐up dates and Targeted Programdeadlines

Note: Opt‐in on www.PRMCWellness.com to receive text message reminders. Standard text messaging

rates apply.

GETTING STARTED

www.PRMCWellness.com

Start at this site to learn where your health stands. Take action on health risks to develop a healthy lifestyle.

Member Health Assessment (MHA)The MHA consists of questions about specific lifestyle habits. Your MHA responses are analyzed to show your risk level and generate a Health Index. You can complete your MHA at www.PRMCWellness.com

Biometric ScreeningBiometric screenings provide vital information about your overall health, including cholesterol (total, LDL, and HDL), triglycerides, cardiac risk, glucose, blood pressure, height, weight, Body Mass Index (BMI), and waist measurement. If you are unable to attend a Biometric Screening event, you may fulfill the screening requirement by visiting your physician.

Contact the Viverae Health Center at 888‐VIVERAE (848‐3723) with any questions or concerns about the Viverae.

Preventive CareSelf‐report completion of 3 preventive care exams at www.PRMCWellness.com. Exams must be dated between 11/19/17 – 11/17/18.

DOWNLOAD THE VIVERAE APP

Get ready to experience wellness on the go with the new Viverae wellness mobile app! Now, you can take the wellness experience with you no matter the time or place.

Download the Viverae mobile app in the Apple Store (iOS 9 and higher) or in the Google play Store (4.4 or higher).

30

EARNING POINTS

Earn points for completing program activities in the Wellness Revolution and earn rewards. Manage all your program activities and log points at www.PRMCWellness.com.

Complete your MHA, biometric screening, preventive care and earn a total of 300 points by 11/17/18 to earn your cash reward.

ADDITIONAL ACTIVITIES

For more points or support in your wellness program, you have plenty of available resources. Participating in Wellness Revolution allows you to do the following:

» Register for quarterly Employer Challenges PRMC is hosting

» Take an Online Course or join a Targeted Program to addressspecific lifestyle concerns

» Connect your health app or device and track your progress

» Participate in or start a Peer Challenge

CHALLENGES

Challenges let you earn extra points in the program while managing risk factors or lifestyle changes.

Sign up for Employer and Peer Challenges. Log activity and view your status. View challenge details (past and present) and sign up for new challenges from the Challenges section.

FREQUENTLY ASKED QUESTIONS

What is the Viverae Health Center?

The Viverae Health Center is a health and wellness resource that is available for Viverae members. It is staffed by a variety of highly trained customer care representatives and health professionals, including clinicians, exercise specialists, and registered nurses and dietitians.

How do I contact the Viverae Health Center?

There are two ways to contact the Health Center: via secure email message or by phone.

» You can send a secure message to your coach by selecting theInbox link at the top of the screen

» To call toll‐free, please dial 888‐VIVERAE (848‐3723)

The Viverae Health Center hours are as follows:

» Monday – Thursday: 7 a.m. – 7:30 p.m. CT

» Friday: 7 a.m. – 6 p.m. CT

» Saturday – Sunday: Closed

» Closed holidays

2018 WELLNESS REVOLUTIONASSESSMENTS (REQUIRED) POINT VALUE

Member Health Assessment (MHA) 25

Biometric Screening 25

PREVENTIVE CARE COMPLIANCE (REQUIRED) POINT VALUE

Preventive Care Compliance (Complete 3) 25

TOBACCO POINT VALUE

TobaccoTobacco‐Free: Negative Online Attestation 25 each / 25

maxTargeted Program – Breaking Free from Tobacco

HEALTH METRICS / TARGETED ACTIONS POINT VALUE

Body Mass

Index /

Waist

Measurement

BMI: Less than 25.0

50

OR Waist Measurement:

Less than 35 inches (Females)

Less than 40 inches (Males)

OR Any Improvement (from 2016 Biometrics)

Action: Targeted Program – Reaching Your

Healthy Weight

Total

Cholesterol

Less than 200 mg/dL

50OR Any Improvement (from 2016 Biometrics)

Action: Online Course – Lipids: Managing Your

Risk

Blood Pressure

Systolic: Less than 120 mmHG AND

Diastolic: Less than 80 mmHG

50OR Any Improvement (from 2016 Biometrics)

Action: Targeted Program – Tackling Your

Stress

Glucose

Fasting: Less than 100 mg/dL

50

OR Non‐Fasting or Unknown: Less than 140

mg/dL

OR Any Improvement (from 2016 Biometrics)

Action: Online Course – Healthy Eating: Mindful

& Portion Control

ACTIVITIES – Q1 (1/1/18 – 3/31/18) (Complete 2 of the 3) POINT VALUE

(Option 1) Employer Challenge: (Weight Management) WEIGH 2

WIN

(Option 2) 250,000 Steps (Apps & Devices)


25 each / 50

max


(Option 1) Employer Challenge – (Nutrition Challenge) HYDR8TE



25 each / 50

max


(Option 1) Employer Challenge: (Nutrition Challenge) 5‐ A –DAY



25 each / 50

max


(Option 1) Employer Challenge: (Stress Management Challenge)

TAKE 5



25 each / 50

max

PROGRAM GOAL 300 POINTS

31

Sid Peterson Memorial Hospital 401(k) Savings and Profit Sharing Plan

J O I N I N G T H E P L A N

Who is eligible to join the plan?

The following employees may join the plan - Non-Union to make any employee contributions except: Employees covered by a collective bargaining agreement Non-resident aliens with no U.S. earned income Leased employees Peterson Med. excluded from Match & ERYou need to be age 18 and work for at least 90 day(s) to elect any employee contributions.

The following employees may join the plan - Non-Union to receive any employer contributions except: Employees covered by a collective bargaining agreement Non-resident aliens with no U.S. earned income Leased employees Peterson Med. excluded from Match & ERYou need to be age 18 and work for at least 12 month(s) to receive any employer contributions.

When will I join the plan?

Your participation in the plan will begin when you reach the service levels required by the plan. Your payrolldeductions will start as soon as possible after your entry date.

M A K I N G C O N T R I B U T I O N S

What is my “pay” under the plan?

Your plan contains a definition of “pay” for calculating contribution amounts. Your plan may use differentdefinitions of “pay” for other purposes. To learn more about what types of compensation are used by the plan,read your Summary Plan Description.

These are the highlights of your plan. For additional information, read your Summary Plan Description or ask to see the plan document. If any information here conflicts with the terms of your plan, the plan language governs.

32

PLAN HIGHLIGHTS

How much may I contribute to the plan?

The contribution(s) that you may make to the plan are displayed below:

DEFERRED SALARY CONTRIBUTIONS

Through payroll deduction you will make Deferred Salary contributions of 2.00% of your pay. You may changethis percentage and make Deferred Salary contributions up to the maximum amount allowed by law. Thesecontributions consist of pre-tax dollars and earnings on these contributions grow tax-deferred. If you do not wantto make Deferred Salary contributions, you may decline enrollment by completing a Participation form.

You may increase or decrease the amount of your contributions quarterly. You may stop your contributions anytime.

The Internal Revenue Service (IRS) limits the total amount of pre-tax contributions you may make each calendaryear. For 2017, this limit is $18,000. However, if you reach age 50 anytime during the calendar year or are over50, you may make additional pre-tax contributions above and beyond normal plan and legal limits. For 2017, youcan make up to $6,000 in additional contributions.

ROLLOVER CONTRIBUTIONS

You may be able to roll over your existing retirement savings into this plan. Consolidating your retirementsavings can help you continue benefiting from tax-deferred growth - despite any disruptions that may occurduring your working life. Maintaining one retirement account also makes it easy for you to track your retirementsavings. To learn more about making Rollover contributions to this plan, call 1-888-526-6905 and a RetirementSpecialist will assist you.

Will the company contribute?

The company contribution(s) that you may receive are displayed below:

COMPANY MATCH CONTRIBUTIONS

Each year, your company may make Company Match contributions. These contributions will grow tax-deferred.Read your Summary Plan Description for more details.

PROFIT SHARING CONTRIBUTIONS

Each year, your company decides whether to make a Profit Sharing contribution. Your share of the contribution isbased on your pay compared to the pay of all plan participants. These contributions grow tax-deferred.

Your Profit Sharing contributions will be calculated based on your pay for the entire plan year. You receiveProfit Sharing contributions if you work over 1,000 hours in a plan year and are employed on the last day of the

33

PLAN HIGHLIGHTS

plan year. Participants who retire, die or become disabled during the plan year also receive Profit Sharingcontributions.

M A N A G I N G Y O U R A C C O U N T

How will I know how much is in my account?

You will receive a personal statement periodically. You may also use your Personal Identification Number (PIN)to access your account by calling 1-800-74FLASHSM (35274) or accessing The JourneySM atwww.retiresmart.com, 24 hours a day, 365 days a year. You can check your account balance, secure investmentperformance information, obtain loan information and apply for a loan, make investment changes, or requestadditional information about the plan.

How are my contributions invested?

You give investment directions for all of your account, choosing from the investment options your plan provides.

Until you make an investment selection, all of your contributions will be invested into a retirement date basedinvestment option determined by your date of birth and a projected retirement age of 65. You may giveinvestment directions for your account, choosing from the investment options your plan provides. You maychange your investment choices daily. You may transfer your existing balance to other investment options dailysubject to certain restrictions.

To make choosing your investment options easier, your contributions are placed in one or more groups as follows:

Employee Source Group – Deferred Salary

Employer Source Group – Company Match, Profit Sharing

If you call 1-800-74FLASHSM (35274) or access The JourneySM at www.retiresmart.com, these group names arereferenced.

Sid Peterson Memorial Hospital 401(k) Savings and Profit Sharing Plan is intended to constitute an ERISA§404(c) plan. This means that you "exercise control" over the investments in your account. From the investmentoptions available under your plan, you can choose which investments to put your money in now and you canswitch into different investments as your needs change. Complying with ERISA §404(c) may relieve planfiduciaries of liability for any investment losses to your account that are the result of your investment choices.

As a plan participant, you are entitled to request certain information about your plan’s investments, including: theannual operating expenses of each investment; financial statements, reports, or other materials relating to theplan’s investments; a list of assets contained in each investment portfolio; the value of those assets and fund unitsor shares; and the past and current performance of each investment.

34

PLAN HIGHLIGHTS

How does vesting (ownership) apply to my account?

Plans set a “vesting schedule” to determine what percentage of ownership you can apply to your account at specificpoints in time. You are always 100% vested in any Deferred Salary contributions, plus earnings. Your plan’s vestingschedule applies to the following contributions, plus earnings:Company Match, Profit Sharing

Yrs. ofService

VestedPct.

0 0%2 20%3 40%4 80%5 100%

Your years of service for vesting purposes begin on your date of hire.

If you die, become disabled or reach normal retirement age, you will become 100% vested in all contributions your company makes to the plan, plus earnings. T A K I N G A D I S T R I B U T I O N : When may I withdraw money from the plan? The plan is designed to help you save for retirement. So, the IRS has placed restrictions on when you may withdraw money from the plan. You may withdraw money from your account at: Termination

You may receive your vested account balance. Additional requirements may apply.

Normal Retirement

Age 65

Disability Retirement: Disability is determined based on the company’s personnel policy. Death

Your account balance will be paid to your designated beneficiaryYour plan may allow withdrawals of certain contributions and earnings while you are employed. Your Summary Plan Description provides more details about distributions, including important tax information and information on the forms of benefit your plan offers.May I take out loans from the plan?You may borrow money from the plan by taking up to one loan. Your maximum loan balance may not exceed the lesser of: one half of your vested account balance or $50,000.00. You may not initiate a loan for less than $1,000.00. Your loan is secured by your remaining account balance.You must repay all loans within 5 years. The interest rate on your loan will be the prime rate +2.00%. You pay back the principal and interest directly to your account by establishing an Automated Clearing House (“ACH”) Agreement with your bank. The ACH remittance frequency is required monthly, and you may elect to have the debit to your account occur on either the 3rd of the month, or the 15th of the month.If you don’t repay your loan, the IRS considers the unpaid amount to be a taxable payment made to you.

35

Important InformationHIPAA PRIVACY RIGHTS

The Health Insurance Portability and Accountability Act (HIPAA) provides you certain rights to privacy concerning your health information. The regulations designate certain types of information as Protected Health Information (PHI).

Health care providers, medical processionals and health plans, including Peterson health plan representatives, are restricted in their use of PHI to purposes of treatment, payment, and health care operations and as required by national public health activities. Written authorization is required to use or disclose your PHI pertaining to your medical, dental, prescription drug, employee assistance program and health care operations and as required by national public health activities. Written authorization is required to sue or disclose your PHI pertaining to your medical, dental, prescription drug, employee assistance program and health care spending accounts outside of these purposes.

You may receive a form requesting your authorization to use your PHI for another purpose. Should you grant this authorization, your PHI is still protected from use and disclosure by any party other than the one(s) to whom you grant written authorization, and from use and disclosure by authorized parties for any purpose other than the one you specifically authorized.

PROTECTED HEALTH INFORMATION

(PHI)PHI includes information that could be used to identify you as an individual in electronic, printed or spoken forms that relates to (1) past, present or future health, physical or mental condition, (2) provision of health care, or (3) past, present or future payment for the provision of health care.

HIPAA gives you the right to: Receive notice of the health plan’s uses and disclosures of your PHI, your privacy rights and the health plan’s legal duties regarding your PHI; Obtain access to your own PHI; Amend your PHI; Receive an accounting of non-exempt uses and disclosures of your PHI over the past six years upon request; and Received communications by an alternative means or at an alternate location upon request. For information regarding HIPAA privacy rules, refer to your Summary Plan Description.

THE WOMEN’S HEALTH AND CANCER RIGHTS ACT

Do you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy –related services including all stages of reconstruction and surgery to achieve symmetry between the breast, prosthesis, and complications resulting from a mastectomy including lymphedema? Contact the Human Resources Department for more information.

If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient for:

• All stages of reconstructions of the breast on whichthe mastectomy was performed;

• Surgery and reconstruction of the other breast toproduce a symmetrical appearance;

• Prostheses; and• Treatment of physical complications of the

mastectomy, including lymphedema.

These benefits will be provided subject to the same deductibles and co-insurance applicable to other medical and surgical benefits provided under the Peterson Health Plan.

36

Important InformationNEWBORN AND MOTHER’S HEALTH

PROTECTION ACT

Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

PATIENT PROTECTION

Peterson generally allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. For children, you may designate a pediatrician as the primary care provider.

You do not need prior authorization from Peterson or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, maybe required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan or procedures for making referrals.

For information on how to select a primary care provider or for a list of participating primary care providers or health care professionals who specialize in obstetrics or gynecology, contact the Human Resources Department.

HIPAA SPECIAL ENROLLMENT RIGHTS

Loss of Other Coverage – If you are declining enrollment for yourself and/or dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and/or your dependents in this plan if you or your dependents’ in this plan if you or your dependents

lose eligibility for that other coverage or if the employer stops contributing towards your or your dependents’ other coverage. To be eligible for this special enrollment opportunity, you must request enrollment within 30 days after your other coverage ends or after the employer stops contributing towards the other coverage.

New Dependent as a Result of Marriage, Birth, Adoption, or Placement for Adoption – If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll your dependents. To be eligible for this special enrollment opportunity, you must request enrollment within 30 days after the marriage, birth, adoption or placement for adoption. Contact your plan administrator to request a special enrollment.

MAKING ENROLLMENT CHANGES DURING

THE YEAR:

In most cases, your benefit elections will remain in

effect for the entire plan year (January 1st, 2018 - December 31st, 2018) During the annual enrollment period, you have the opportunity to review your benefit elections and make changes for the coming year.

• You may only make changes to your elections duringthe year if you have one of the following statuschanges:

• Marriage, divorce or legal separation (if your staterecognizes legal separation);

• Gain or loss of an eligible dependent for reasonssuch as birth, adoption, court order, disability, death;reaching the dependent child age limit; or

• Significant changes in employment or employer –sponsored benefit coverage that affect you or yourspouse’s benefit eligibility.

• Your benefit change must be consistent with yourchange in family status.

IRS regulations require that for enrollment due to the qualifying events above, change forms must be submitted with in 30 days of that qualifying event. Contact your Human Resources office for information on completing these forms.

37

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible

for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2016. Contact your State for more information on eligibility –

ALABAMA – Medicaid FLORIDA – Medicaid

Website: http://myalhipp.com/ Phone: 1-855-692-5447

Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268

ALASKA – Medicaid GEORGIA – Medicaid

The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: [email protected] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: http://dch.georgia.gov/medicaid - Click on Health Insurance Premium Payment (HIPP)Phone: 404-656-4507

ARKANSAS – Medicaid INDIANA – Medicaid

Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

Healthy Indiana Plan for low-income adults 19-64 Website: http://www.hip.in.gov Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone 1-800-403-0864

COLORADO – Medicaid IOWA – Medicaid

Medicaid Website: http://www.colorado.gov/hcpf Medicaid Customer Contact Center: 1-800-221-3943

Website: http://www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562

KANSAS – Medicaid NEW HAMPSHIRE – Medicaid

Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218

KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP

Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570

Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

LOUISIANA – Medicaid NEW YORK – Medicaid

Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447

Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831

MAINE – Medicaid NORTH CAROLINA – Medicaid

Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711

Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100

MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid

Website: http://www.mass.gov/MassHealth Phone: 1-800-462-1120

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

39

http://www.healthcare.gov/

http://www.insurekidsnow.gov/

http://www.askebsa.dol.gov/

http://myalhipp.com/

http://flmedicaidtplrecovery.com/hipp/

http://myakhipp.com/

mailto:[email protected]

http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

http://dch.georgia.gov/medicaid

http://myarhipp.com/

http://www.hip.in.gov/

http://www.indianamedicaid.com/

http://www.colorado.gov/hcpf

http://www.dhs.state.ia.us/hipp/

http://www.kdheks.gov/hcf/

http://www.dhhs.nh.gov/oii/documents/hippapp.pdf

http://chfs.ky.gov/dms/default.htm

http://www.state.nj.us/humanservices/dmahs/clients/medicaid/

http://www.state.nj.us/humanservices/dmahs/clients/medicaid/

http://www.njfamilycare.org/index.html

http://dhh.louisiana.gov/index.cfm/subhome/1/n/331

http://www.nyhealth.gov/health_care/medicaid/

http://www.maine.gov/dhhs/ofi/public-assistance/index.html

http://www.ncdhhs.gov/dma

http://www.mass.gov/MassHealth

http://www.nd.gov/dhs/services/medicalserv/medicaid/

MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP

Website: http://mn.gov/dhs/ma/ Phone: 1-800-657-3739

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

MISSOURI – Medicaid OREGON – Medicaid

Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

MONTANA – Medicaid PENNSYLVANIA – Medicaid

Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

Website: http://www.dhs.pa.gov/hipp Phone: 1-800-692-7462

NEBRASKA – Medicaid RHODE ISLAND – Medicaid

Website: http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/accessnebraska_index.aspx Phone: 1-855-632-7633

Website: http://www.eohhs.ri.gov/ Phone: 401-462-5300

NEVADA – Medicaid SOUTH CAROLINA – Medicaid

Medicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900

Website: http://www.scdhhs.gov Phone: 1-888-549-0820

SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid

Website: http://dss.sd.gov Phone: 1-888-828-0059

Website: http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-program Phone: 1-800-562-3022 ext. 15473

TEXAS – Medicaid WEST VIRGINIA – Medicaid

Website: http://gethipptexas.com/ Phone: 1-800-440-0493

Website: http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/default.aspx Phone: 1-877-598-5820, HMS Third Party Liability

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP

Website: Medicaid: http://health.utah.gov/medicaid CHIP: http://health.utah.gov/chip Phone: 1-877-543-7669

Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-362-3002

VERMONT– Medicaid WYOMING – Medicaid

Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531

VIRGINIA – Medicaid and CHIP

Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282

To see if any other states have added a premium assistance program since July 31, 2016, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137 (expires 12/31/2019)

40

http://mn.gov/dhs/ma/

http://www.insureoklahoma.org/

http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

http://healthcare.oregon.gov/Pages/index.aspx

http://www.oregonhealthcare.gov/index-es.html

http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP

http://www.dhs.pa.gov/hipp

http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/accessnebraska_index.aspx

http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/accessnebraska_index.aspx

http://www.eohhs.ri.gov/

http://dwss.nv.gov/

http://www.scdhhs.gov/

http://dss.sd.gov/

http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-program

http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-program

http://gethipptexas.com/

http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/default.aspx

http://health.utah.gov/medicaid

http://health.utah.gov/chip

https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf

http://www.greenmountaincare.org/

https://wyequalitycare.acs-inc.com/

http://www.coverva.org/programs_premium_assistance.cfm

http://www.coverva.org/programs_premium_assistance.cfm

http://www.dol.gov/ebsa

http://www.cms.hhs.gov/

mailto:[email protected]

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