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Harmon Electric, Inc. Medical Benefits OverviewEffective 05/01/2017 | 855-280-9638 | www.harmonelectricbenefits.com

Health Benefits Simplified

Effective 05/01/2017 | 855-280-9638 | www.harmonelectricbenefits.com

Welcome!HealthEZ is a national benefit administrator that specializes in helping companies like Harmon Electric, Inc. provide affordable, custom benefit plans. We are here to simplify your healthcare experience.

What you need to do:• Review this benefit overview• Manage your benefits by visiting www.harmonelectricbenefits.com or calling customer service at 855-280-9638.

What’s inside:• Benefit Update • Online Tools• Network of Doctors• Medical Management• Pharmacy• HealthEZpay• HealthEZ Smart ID Cards• Summary of Medical Benefits• Enrollment form

Online Toolswww.harmonelectricbenefi ts.com

Visit your one-stop benefit website for benefit information, forms, account balances, processedclaims, previous statements and much more. An online account allows you to fully manage your benefits. To sign up for online access, follow these steps:

1. Go to www.harmonelectricbenefits.com and click LOGIN.

2. Click “Need to set up your online access?”

3. Enter your Member ID - found on your ID card - your Social Security number, and your date of birth. Pick a Username and Password. Be sure to make your Password at least 8 characters long; any combination of letters or numbers is acceptable. Click Proceed to my Account and you’re registered!


Network of Doctors“Is my doctor in the network?”

Your primary network is Arizona Foundation for Medical Care. To find an in-network physician or facility go towww.harmonelectricbenefits.com and click on “Find a Doctor” or call customer service at 855-280-9638.

Medical Management and NurselineYou have 24/7 access to HealthEZ’s medical management staff. They have extensive experience helping employees navigate the medical maze. These services are available to everyone — whether you have a chronic condition like asthma or diabetes, or a more complex condition such as cancer or heart disease.

If you have questions about what kind of care to seek or where to seek it (do I really need to go to the ER for this?), if you’ve just found out you’re pregnant, or if you have any nagging questions, nurses are there to help you. Just call 855-280-9638, 24/7.

Precertifi cation The medical system is increasingly pushing patients into expensive and unnecessary procedures. To make sure you receive the best treatment possible, we are requiring your doctor to notify us before MRI and CT scans as well as inpatient treatment and surgeries.

PharmacyOptumRx

Your pharmacy benefit manager is OptumRx. OptumRx is one of the nation’s largest pharmacy benefits managers and can offer additional discounts - especially on higher cost drugs. Your pharmacy claims will also appear on your HealthEZ statement. Please see the back of your medical card for information on OptumRx. You can also find more information by going to www.harmonelectricbenefits.com, and clicking on “Prescriptions.”

Saving on Pharmacy CostsHere are a few ways to save on pharmacy costs:

• Ask your doctor to start you on the lowest cost alternative

• Check out the “$4 prescriptions” at places like Wal-Mart

• Price shop your prescriptions at Sam’s Club and Costco; you don’t have to be a member to access their pharmacy


The HealthEZ SmartID CardWith the SmartID card, you and your family will always have your HealthEZ ID card in reach – on your smartphone! Simply login to: www.harmonelectricbenefi ts.com to access your SmartID card.

You can also print a temporary ID card from the website.

Show your new ID card at the pharmacy and your doctor’s office so claims will be submitted to the proper claims processing address - as shown on the back of your ID card.

Pay your medical bills the easy and accurate way. HealthEZpay consolidates your medical bills and allows you

to review online, then simply approve or decline payment for each. You save money and time by securely paying online

using your credit/debit card that you have registered.

The EZ Way to Pay Your Medical Bills

Call 855-280-9638 formore information or go to

www.harmonelectricbenefits.com and click on “My Benefits” then

“HealthEZ Payment Service”

Jane DoeGroup ID: PNA11714321Member ID: 0000012345623

Medical: Employee + dependent(s)OV Copay: $25 PCP & UC/$45 SP


Summary of Medical Benefi tsCalendar Year DeductibleEmployee OnlyFamily

Copay Plan$5,000

$10,000$10,000 $20,000

Out-of-Pocket MaximumsIndividual Out-of-Pocket MaxFamily Out-of-Pocket Max

$6,600 $13,200

$13,200 $26,400

Preventive Care (Routine physical, cancer screenings, eye exams, & prenatal care)

No charge 50%*

Physician ServicesPrimary Care Physician Office VisitSpecialty Office VisitUrgent Care

$30 copay$60 copay$70 copay

50%*50%*50%*

Radiology & LabsLab ServicesX-Ray ServicesMRI, CT, PET Scans

$30 copay$60 copay

0%*

50%*50%*50%*

Hospital Care 0%* 50%*

Emergency Services Emergency Room Ambulance

$250 copay0%*

$250 copay50%*

Mental Health/ Chemical DependencyInpatientOutpatient

0%*$60 copay

50%*50%*

Physical, Occupational, and Speech therapy(60 visit limit, all therapies combined)

0%* 50%*

Chiropractic Services - Therapy & Manipulation $60 copay 50%*

Home Health Care $60 copay 50%*

Hospice 0%* 50%*

Skilled Nursing Care(90 day limit)

0%* 50%*

Durable Medical Equipment 0%* 50%*

Maternity Care (physician & hospital charges) 0%* 50%*

Vision Allowance (contacts, glasses)*Must submit receipts for reimbursement

$150 Per Member Per Year

Prescription Drug CoverageGenericFormularyNon-FormularySpecialty (Mail order available for a 30 day supply)

Retail 30 Day Supply Mail Order 90 Day Supply


30% coinsurance up to $300


Not available

PLEASE NOTE: This only serves as a high level summary of your benefit plan. Please refer to your Summary Plan Description (SPD) for more information on coverage, limitation and exclusion provisions, how benefits are paid, how claims are filed, etc… Members can access their SPD, SBCs and ERISA notices on their custom benefit site, www.harmonelectricbenefits.com.• Deductibles, copays, and coinsurance apply toward out-of-pocket maximums.• Precertification requirements will be outlined in your Summary Plan Document.• Out-of-Network services deemed to be true emergencies by the Plan Administrator will be paid at In-Network Benefit Rate

Weekly Employee Medical ContributionsEmployee $30

Spouse $101.53

Children $86.30

Family $150.69

Bi-Weekly Employee Medical ContributionsEmployee $60

Spouse $203.06

Children $172.60

Family $301.38


Summary of Dental Benefi ts

DeductibleEmployee OnlyEmployee + SpouseEmployee + ChildFamily

Dental Plan$25$50$50$75

Annual MaximumsPer Person, Per Year

$1,000

Preventive and Diagnostic CareRoutine Cleanings (Limit 1 per six months)Routine Oral Exams (Limit 1 per six months)Fluoride Treatments, Up to age 19 (Limit 1 Per 12 months)Bitewing X-Rays (Limit 1 per six months)Panoramic X-rays (Limit 1 per 5 years)Space Maintainers, Up to age 15

No charge

Basic Restorative CareEmergency Palliative Care – office visit, oral exam, consultationsX-Rays – other than intra-oral or bitewingsLab & Other Diagnostic TestsAmalgam, Silicate, Acrylic, Plastic or Composite FillingsEndodontic Treatment- including root canal therapyPeriodontic Treatment or Surgery- Limit 1 scaling, curettage, or surgery per quadrant per 6 monthsOral SurgeryInjection of Antibiotic DrugsGeneral AnestheticsSealants-Up to age 16 Repairs or Re-cementing of Inlays, Bridges, Crowns, and DenturesRelining of Dentures

20%*

Major Restorative CareInlays, Onlays, Crowns, Crown Build-ups, Gold FillingsRepairs or Re-cementing of Inlays, Bridges, Crowns, and DenturesInitial Installation of Partial or Full Removable Dentures (including adjustments of six month period following installation)Initial Installation of Fixed Bridgework to replace one or more natural teeth (including crowns and inlays to form retainers; providing the teeth were lost while covered under the plan)Periodontal AppliancesReplacement of Existing Partial or Full Removable Dentures/ Fixed Bridge- Limit 1 per 5 years

50%*

Note: All charges are subject to Usual and Customary pricing at the 90th percentile.

*After deductible

**Claims should be submitted to HealthEZ electronically at payer ID #41178.

Weekly Employee Dental Contributions

Employee $2.88

Spouse $10.96

Children $8.65

Family $17.88

Bi-Weekly Employee Dental Contributions

Employee $5.76

Spouse $21.92

Children $17.30

Family $35.76

Weekly Employee Medical ContributionsEmployee $30

Spouse $101.53

Children $86.30

Family $150.69

Bi-Weekly Employee Medical ContributionsEmployee $60

Spouse $203.06

Children $172.60

Family $301.38

Weekly Employee Dental Contributions

Employee $2.88

Spouse $10.96

Children $8.65

Family $17.88

Bi-Weekly Employee Dental Contributions

Employee $5.76

Spouse $21.92

Children $17.30

Family $35.76

Benefit Enrollment/Change Form A. Employee Information (all information is required)

First Name: MI: Last Name:

SSN#: Date of Hire:

Date of Birth: Gender: o M or o F Marital Status:

Address: City: State: Zip:

Daytime Phone: ( ) Home phone: ( ) Email:

B. Medical Plan Options (if electing coverage please make a selection in both 1 & 2) 1. Plan applying for o Copay Plan o Dental Plan o Decline Coverage (please complete sections D. & E.) 2. Coverage applying for o Employee only o Employee + Spouse o Employee + Children o Family

C. Dependent/Spouse Information (must be completed for coverage of dependents) Name (Last, First, MI) Relationship Birth date SSN M/F Disabled

(Y/N) Please check below to include on medical plan

o Medical o Dental o Medical o Dental o Medical o Dental o Medical o Dental o Medical o Dental

D. Other Insurance Coverage Information Please check one: o I have other insurance coverage (please provide information below)

o I do not have other insurance coverage o I have other insurance coverage, but intend to cancel that coverage o I have enrolled thru the state or federal

Marketplace (please provide information below) Policyholder’s Name: Policyholder’s Date of Birth: Insurance Co. Name: Policy Number: Group Number: Insurance Co. Address: Names of covered individuals:

E. Enrollment Waiver (check box only if declining coverage) o I understand the benefits provided by the Group Insurance Contract under ERISA regulations include Health and/or Dental coverages. I have reviewed and understand the benefit options and requirements presented herein. I understand that I may not be eligible to enroll myself and dependents if I desire to apply for coverage at a later date, unless I qualify to enroll at a later date in accordance with the special enrollment conditions. o I understand by not enrolling in this plan or a Marketplace health plan as mandated by PPACA, that I may be subject to a tax penalty.

F. Employee Authorization. Employee Authorization I understand I have the option to pay the premiums for my employer-sponsored health plan through a before-tax reduction of my salary. I understand that if this amount increases or decreases during the plan year, my salary reduction will be adjusted to reflect that increase or decrease. I hereby apply for the coverage for which I am now or may be eligible under this group policy. I hereby authorize the deduction from my earnings of the required contribution, if any, toward the cost of such coverage. I authorize payment of medical benefits to all providers, where applicable, for those charges covered by my group insurance benefits. I authorize release to or by HealthEZ of any medical information including copies of medical records or insurance information as necessary for claims adjudication, utilization review, or coordination of benefits. To the best of my knowledge and belief, the information I have provided on this form is complete and correct. I acknowledge that the terms of the Summary Plan Description govern all payments made by the Plans. ____________________________________________________________________________________________ _______________ Employee Signature Date

H. Employer Information (to be completed by the employer or HealthEZ only) Employer: HEZ Group # HEZ Division Code: Effective Date:

To be completed by HealthEZ HEZ Received: HEZ Entered: ID Cards:

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