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Making Important Benefits Choices for 2017

Open Enrollment for 2017 Benefits Is October 17 - November 11, 2016This online guide provides you with the information you need to make the benefit choices that will best meet your needs for the coming year. The information is presented in a simplified format for quick review. You can find more detailed information by clicking on the links in each section or by referring to the Summary Plan Descriptions for your benefit plans. Please review this guide carefully and consider all the options, then make your choices for 2017. The site will open October 17, 2016. Click here for detailed instructions, including print screens of the enrollment process.

Navigating to Open Enrollment

From work: To access the 2017 Open Enrollment system from a WellSpan, Good Samaritan, or Philhaven computer, use your browser to go to INET: HRONLINE and then click on the pumpkins.

From home: Visit www.wellspan.org. At the bottom right of the screen, select Remote Access > HRONLINE and then click on the pumpkins.

Table of Contents

This Benefits Enrollment Guide Is Clickable!Find the information you need in just a few clicks. You can choose a topic from the table of contents navigation across the top, or scroll through the document page by page by clicking on the “Next” link at the bottom of the page. If you want a printed copy, click on the print button to print a specific page or the entire guide.

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What’s New for 2017 Benefits Eligibility 2017 Open Enrollment Choices Cost of Coverage Resources

Enrolling in Your 2017 Benefits..............3 Staff Member, Spouse, and Dependent Eligibility.....................................................10

Highlights...................................................15 Understanding Your Monthly Contribution.............................................63

Contacts...................................................74

Benefit Fairs...............................................5 Making Changes to Your Benefits .........11 Medical ......................................................16 2017 Medical Monthly Contribution...65

What’s New for 2017...............................6 Qualified Work or Family Status Change...12 Spending and Savings Accounts...........38 Financial Assistance...............................69

If You Don’t Make a Benefits Election..8 Dental........................................................48 2017 Dental and Vision Monthly Contribution.............................................71

Vision..........................................................51 2017 Supplemental Life Insurance Contribution.............................................72

Life and Accident.....................................54

Voluntary Benefits...................................57

You may access the Legal Notices by clicking “Legal Notices” at the top of this page or by turning to page 76.

Rev. 10/26/16

https://hr.wellspan.org/documents/2017OENavigationInstructions.pdf

http://www.wellspan.org


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Enrolling in Your 2017 BenefitsThe online Open Enrollment system, new this year, requires that you elect each benefit anew for 2017 once you begin the Open Enrollment process. Here are some important points to remember:

• Using the Open Enrollment system: Once you begin Open Enrollment, you must elect or waive each benefit in order to complete Open Enrollment. The system will guide you through all of your benefit options to change or re-elect for 2017.

• Detailed instructions with screen shots are available on INET, on the Information tab in the lower right corner of HR-Online. Click here to see the instructions. You may wish to print these instructions before starting the Open Enrollment process. (Mercer: External link to INET not available yet)

• Action required for spending or savings accounts: If you want to enroll in a Health Care or Dependent Care Flexible Spending Account (FSA), Limited Purpose Flexible Spending Account (LFSA), and/or Health Savings Account (HSA) for 2017, you must make a 2017 election.

• Finalizing your changes: The “continue” button takes you from screen to screen recording your choices. It also acts as the “final submit” at the end of the process when you see a confirmation of your benefit elections.

• Confirmation: You will receive a message that you have successfully completed Open Enrollment and an email confirmation to your WellSpan email. We suggest you print the confirmation from the system for your records. Please review it and your email confirmation carefully as it shows the plans you have chosen for 2017.

• Remember: If you “exit” at the last screen instead of pressing “continue,” your choices will not go into effect for 2017.

• Changing elections: You may change your elections any time within the Open Enrollment period. Just remember that your most recent elections will be the ones in effect for the next year. Keep a copy of your new confirmation.

• Making no changes: If you do not go online to verify and/or make changes, you will automatically be enrolled in the medical, dental, vision and/or Supplemental Life plan that most resembles your current plan. Some plans will no longer be available. Click here to see how the 2016 plans will be mapped to new 2017 plans.

• Not collecting PCP information: Due to the Open Enrollment program change, we will not be collecting personal physician information for 2017.

https://hr.wellspan.org/documents/2017OENavigationInstructions.pdf


Enrolling in Your 2017 Benefits (continued)Spouse Coverage

• Covering spouse on medical: If you are currently covering your spouse or adding your spouse to a WellSpan medical plan for 2017, you will need to complete the 2017 Spousal Medical Verification Form by December 12, 2016. This is an annual form that must be completed for all covered spouses each year.

Dependent Coverage

• Documentation to add dependents: If you are adding dependents that are not covered in 2016 or for whom you have not previously provided documentation, you will need to submit documentation to show that they are eligible dependents. Click here to see the required documentation.

• This does not apply to Good Samaritan and Philhaven employees at this time.

Guarantee Issue Life Insurance (One Time Only)

• Supplemental Life: For this year’s Open Enrollment only, you may elect Supplemental Life Insurance for January 1, 2017, without submitting an evidence of insurability form.

• Employee, spouse, and children: You may add additional life insurance for yourself, cover your spouse in increments up to $30,000 and/or cover your eligible children in increments up to $10,000. Click here for more information.

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https://hr.wellspan.org/documents/Spousal_Medical_Insurance_Verification_Form_OE_2017.pdf

https://hr.wellspan.org/documents/Spouse_and_Dependent_Verification_for_Open_Enrollment.pdf


Attend a Benefit FairStarting in mid-October, we’ll hold benefit fairs at the locations below. Attend one to learn more about your medical, dental, and vision plans, as well as other benefits, such as life insurance and voluntary benefits.

Review the schedule below and find a benefit fair near you.

Location Date Time Address

Philhaven (Chapel) Monday, October 17 7:00 a.m. – 6:00 p.m. 283 S Butler RoadMt. Gretna, PA 17064

WellSpan Human Resources Center (HRC) (Room 1147)

Tuesday, October 18 11:00 a.m. – 5:00 p.m. 1135 Edgar StYork, PA 17405

Good Samaritan Hospital (Cafeteria) Wednesday, October 19 7:00 a.m. – 5:00 p.m. 4th and Walnut StreetLebanon, PA 17042

Gettysburg Hospital (Community Room A & B) Thursday, October 20 6:00 a.m. – 4:00 p.m. 147 Gettys StreetGettysburg, PA 17325

York Hospital (Cafeteria Function Rooms) Friday, October 21 6:00 a.m. – 4:00 p.m. 1001 S. George StreetYork, PA 17405

Ephrata Hospital (Medical Pavilion) Monday, October 24Monday, October 31

6:00 a.m. – 6:00 p.m.6:00 a.m. – 6:00 p.m.

169 Martin AveEphrata, PA 17522

WellSpan Human Resources Center (HRC) (Room 1147)

Tuesday, November 1 9:00 a.m. – 6:00 p.m. 1135 Edgar StYork, PA 17405

York Hospital (Cafeteria Function Rooms) Wednesday, November 2 6:00 a.m. – 4:00 p.m. 1001 S. George StreetYork, PA 17405

Good Samaritan Hospital (Cafeteria) Thursday, November 3 7:00 a.m. – 5:00 p.m. 4th and Walnut StreetLebanon, PA 17042

Gettysburg Hospital (Community Room A & B) Friday, November 4 6:00 a.m. – 4:00 p.m. 147 Gettys StreetGettysburg, PA 17325

Philhaven (Training Center) Monday, November 7 8:00 a.m. – 4:00 p.m. 283 S Butler RoadMt. Gretna, PA, 17064

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2017 Making Important Benefits Choices

Start with this section to find highlights of what’s new for 2017. Additional information is available throughout this guide.

What’s New for 2017

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What’s New for 2017Here are the highlights of what’s changing beginning January 1, 2017.

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Three Medical Plan Options for 2017You’ll have access to three medical plans. They are WellSpan Plus, WellSpan Standard, and WellSpan High Deductible. Note: All participants will receive new ID cards. Learn more.

New! Health Savings Account (HSA) If you enroll in the WellSpan High Deductible Medical Plan, consider opening and contributing to the tax-advantaged HSA. Learn more.

New! Limited Purpose Flexible Spending Account (FSA) When you enroll in the High Deductible Medical Plan, you can contribute to the new Limited Purpose FSA, and use it for eligible dental and vision expenses. Learn more.

Guarantee Issue Life InsuranceFor this year’s Open Enrollment only, you may elect Supplemental Life Insurance for yourself and/or your spouse and dependents, for January 1, 2017, without submitting an evidence of insurability form. Be sure to review your Supplemental Life options and select the plans you want for 2017. Learn more.

Identity Theft Monitoring—at No Cost to You!Concerned about identity theft? Our new program can help give you and your dependents peace of mind. PayFlex’s complimentary service offers identity theft monitoring, alerts, and ID theft resolution services. You only need a MasterCard to be eligible for this service, and your FSA or HSA MasterCard counts! Once you sign up, you can enter credit cards and bank accounts you’d like to be monitored, as well as your driver license or passport numbers. The program scours the internet, and, if it detects your personal information is being bought or sold online, it will notify you via email. Experts are on hand to help walk you through the otherwise challenging process should your identity be stolen. As they say, it’s better to be safe than sorry, so don’t wait—register today at www.mastercard.us/idtheftalerts.


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If You Don’t Make Your Benefits Election by November 11Open Enrollment is your once-a-year opportunity to choose your benefits. If you are enrolled in a medical, dental, or vision plan for 2016, you’ll automatically be enrolled in the plan that most resembles your current plan in the event that you do not make a benefits election by November 11, 2016. See the charts below to learn more.

Remember to go online to elect, change, or verify your plans, so that you may obtain your coverage of choice.

Medical

Current Medical Plan 2017 Medical Plan

WellSpan Plus or WellSpan Capital Blue Cross WellSpan Plus

Ephrata Blue, Ephrata Silver, or Good Samaritan Medical WellSpan Standard

Philhaven High Deductible WellSpan High Deductible

No coverage No coverage

Dental

Current Dental Plan 2017 Dental Plan

Delta Dental Delta Dental

SCP Dental SCP Dental


Vision

Current Vision Plan 2017 Vision Plan

Vision Benefits of America (VBA) VBA

Davis VBA



During Open Enrollment, review your current dependents and make any necessary changes. Remember to remove any ineligible dependents and be sure to add everyone you want to cover who is eligible. Caution: every year people “forget” to add eligible dependents. Be sure to check your elections online and make any needed changes.

Click on a link below to find more information about:

• Staff Member, Spouse, and Dependent Eligibility• Making Changes to Your Benefits• Qualified Work or Family Status Change

Benefits Eligibility

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Benefits Eligibility

Staff Member, Spouse and Dependent EligibilityAll staff members, with the exception of temporary or contract workers, are eligible to enroll in medical, dental, vision, and some FSAs or the HSA. The amount you pay as your contribution will depend on your employment status and FTE (budgeted hours). You may also cover your eligible dependents. Your cost for coverage depends on your employment status, the hours you work and the dependents you enroll.

Your eligible dependents include:

• Your spouse• Your or your spouse’s children until the end of the month in which they turn age 26. No student requirements.• For a complete definition of eligible dependents, please refer to the Summary Plan Descriptions (SPDs) for your benefit plans. SPDs are available online at

HRONLINE or by contacting the Benefits Service Center Team at 1-717-851-3332.

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Understanding Your Contributions

Learn about how your employment status affects your medical, dental, and vision contributions, as well as your eligibility for FSAs and HSA deductions, here.


Making Changes to Your BenefitsChanges During the Year

Once you enroll in coverage, your elections remain in effect throughout the entire calendar year, as long as you meet each plan’s eligibility requirements. For example, elections you make this enrollment period will be your elections throughout the upcoming plan year (January 1 – December 31, 2017). You can only make changes:

• During Open Enrollment, or• Within 31 days of a qualified work or family status change.

Be sure to provide the necessary spouse and/or dependent verifications when required or coverage will not go into effect for new enrollees and will end on December 31, 2016 for anyone currently enrolled. Coverage lost because of failure to provide verification in a timely manner cannot be reinstated until January 1, 2018, and cannot be continued through COBRA.

Required Documents to Verify Spouse and Dependent Eligibility

If you wish to enroll your spouse or continue their coverage in a WellSpan medical plan for 2017, you must complete the 2017 Spousal Medical Verification Form and submit it to the Benefits Service Center by December 12, 2016. Click here for a copy of the 2017 Spousal Medical Verification Form, and learn more about the process here.

Submitting Spousal and Dependent Documentation

If you are enrolling a spouse or dependent in 2017 and have not previously submitted documentation, you will need to provide copies of all the following documents to verify eligibility for coverage in the WellSpan medical, dental and vision plans:

• Two documents: Copy of your marriage certificate and the first page of your most recent tax return listing your spouse, for coverage of a spouse• Copy of a birth certificate or adoption/legal custody documents for all dependent children; spousal documents required if covering stepchildren

Good Samaritan and Philhaven employees are not required to provide these documents at this time. The 2017 Spousal Medical Verification Form must be completed if you plan to cover your spouse in any WellSpan medical plan during 2017.

Adding a New Dependent

If you gain a new dependent as a result of marriage, birth or adoption, you may be able to enroll yourself and your dependents during the year if you request enrollment (in writing) and submit the required documentation within 31 days of the event.

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https://hr.wellspan.org/documents/Spousal_Medical_Insurance_Verification_Form_OE_2017.pdf

https://hr.wellspan.org/documents/Spouse_and_Dependent_Verification_for_Open_Enrollment.pdf


Qualified Work or Family Status ChangeYou cannot make changes to your benefits during the year unless you experience a qualified work or family status change. All requests for changes must be made in writing by completing the Benefits Enrollment Change Form and must be submitted, along with the required documentation, within 31 days of the qualifying event. Any changes you make to your coverage must be consistent with the change in status.

Qualified events include:

• Your marriage, divorce, legal separation or annulment;• The birth, adoption, placement for adoption or appointment of legal

guardianship of your child;• Your death;• The death of your dependent;• Your dependent losing or gaining employment or employer-provided

coverage;• A change in your (or your dependent’s) employment status due to a

switch between full-time and part-time, or an unpaid leave of absence;• A change in your dependent’s eligibility;• A change in your (or your dependent’s) place of residence or work;• Your requirement to cover your dependent according to a qualified

medical support order or change in legal custody (this does not include coverage you may be required to provide for your divorced spouse; COBRA coverage may be available in that circumstance);

• Your (or your dependent’s) eligibility for COBRA;• Your (or your dependent’s) eligibility for Medicare or Medicaid (you may

change the current election for the eligible person only);• A significant change in the cost of coverage under another group health

plan (does not apply to the Health Care Spending Account);• A significant change in your or your spouse’s medical care coverage

under another plan, that is related to your spouse’s employment;• An open enrollment for your spouse’s benefit plans (all benefit changes

you make must be consistent with the offerings in your spouse’s benefit program);

• A mid-year plan offering through your spouse’s employer (all benefit changes must be consistent with the offerings in your spouse’s benefit program);

• A change in dependent day care fees (applies only to Dependent Day Care Spending Account);

• Your dependent child reaching age 13, and no longer qualifying for dependent day care reimbursement under your Dependent Day Care Spending Account (applies only to Dependent Day Care Spending Account); and

• Any other event that qualifies as a life status change under the Internal Revenue Code (with the approval of the Plan Administrator to be consistent with the status change).

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About Your Benefits Change Effective DateThe effective date of the benefits change will be the first of the month following notification provided the appropriate premium is paid.


Special Enrollment Rights Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA)The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides you with certain special enrollment rights pertaining to your health care coverage.

If you decline enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may be able to enroll yourself or your dependents in this plan in the following circumstances:

• If you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage),

• If you or your dependents lose Medicaid or Children’s Health Insurance Program (“CHIP”) coverage as a result of a loss of eligibility for such other coverage, or

• If you or your dependents become eligible for a premium assistance subsidy under Medicaid or CHIP.

A Note About Requesting EnrollmentYou must request enrollment and submit all required documentation within 31 days after the other coverage ends or within 60 days in the case of changes related to Medicaid or CHIP. Your request must be made in writing by completing the Benefits Enrollment Change Form, and you must also provide evidence of the prior coverage. You must also provide dependent verification documentation (birth certificate or adoption papers).

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You have the opportunity during Open Enrollment to enroll in or make changes to your benefits for the upcoming year. Click on a link below to learn more about your benefit options, and learn more about the new Health Savings Account here.

• 2017 Enrollment Choices Highlights • Medical • Spending and Savings Accounts• Dental• Vision• Life and Accident• Voluntary Benefits*

*You may enroll in Voluntary Benefits any time during the year.

2017 Open Enrollment Choices

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Enrollment Choices HighlightsIf you are currently enrolled in WellSpan benefits and take no action by November 11, you will be automatically enrolled in a medical, dental, or vision plan that may not be your coverage of choice. Find out what coverage you’ll receive. You must re-enroll for the Spending and Savings Accounts each year if you wish to contribute.

Options for Regular Full-Time, Part-Time, PRN 4, and Other PRN Staff Members

Benefit Your Options What You Can Do During Open Enrollment

Medical (including prescription drug and mental health benefits)

• WellSpan Plus (POS/PPO)• WellSpan Standard (POS/PPO)• WellSpan High Deductible (HDHP) • No coverage

• Add, change or drop coverage for yourself• Add, change or drop coverage for your spouse and/or

eligible dependents• Choose no coverage

Dental • Delta Dental (Network Plan)• SCP Dental (Does Not Have a Network)• No coverage

Vision • Vision Benefits of America• No coverage

Spending and Savings Accounts (Only full-time, part-time, and PRN 4/Weekend Option staff members are eligible for FSAs)

• Health Care FSA*• Limited Purpose FSA**• Dependent Day Care FSA• Health Savings Account**• No Spending or Savings Accounts

• Enroll for participation in 2017• Choose no coverage

Please note: Pre-tax deductions for medical, dental, and vision are available for PRN 4 staff members only. All other PRN staff members are required to pay premiums by personal check each month. Payment coupons will be mailed to your home address with payment instructions.

* Not allowed if you participate in the WellSpan High Deductible Medical Plan.** Must participate in the WellSpan High Deductible Medical Plan in order to have a Health Savings Account or Limited Purpose FSA.

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Medical Spending and Savings Accounts Dental Vision Life and Accident Voluntary Benefits

In addition to WellSpan’s core benefits described above, we also encourage you to review our other benefits, including Supplemental Life Insurance, as well as voluntary benefits like pet insurance.


For 2017, you have three options for medical coverage: WellSpan Plus Medical Plan Option, WellSpan Standard Medical Plan Option, and WellSpan High Deductible Medical Plan Option. All three options offer comprehensive medical coverage, as well as prescription drug and behavioral health benefits.

Click on the links below to learn more about each option and decide which one is the right choice for you.

• Your Options• How the Medical Plans Work• Prescription Drug Benefits• Behavioral Health Benefits


Medical

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2017 Open Enrollment Choices: MedicalYour Options

You have the choice of three medical plan options, which are listed below. Click on the plan name to jump to its section.

WellSpan Plus WellSpan Standard WellSpan High Deductible

Type of Plan Point-of-Service/Preferred Provider Organization (POS/PPO) High Deductible Health Plan

Provider Networks Choice of three provider networks for all three plans:• Tier 1: WellSpan Provider Network and Other Select Providers and Facilities• Tier 2: Aetna Signature Administrators Network• Tier 3: Out-of-Network Providers

Find a Provider For Tier 1 providers: Click here to find a provider and click here for a list of Tier 1 providers.For Tier 2 providers: Visit www.aetna.com/asa. For Tier 1 or Tier 2 providers, you can also call SOUTH CENTRAL Preferred at 1-717-851-6800 or 1-800-842-1768.

All three medical plan options are designed to help you stay healthy, and provide the protection you need when you’re not. With each option, you have the flexibility to receive care from three groups of providers:

• WellSpan Provider Network and Other Select Providers and Facilities (Tier 1)• Aetna’s Signature Administrators PPO Network (Tier 2)• Out-of-network (Tier 3)

Your cost for services will be less when you use the Tier 1 or Tier 2 in-network providers. Keep in mind that not all specialists and services are available in the Tier 1 network, and the plan will pay benefits based upon the tier in which the provider participates. All of the plans include 100% covered in-network preventive care. The medical plans also include prescription drug coverage and behavioral health benefits.

Not Sure How to Choose?

When choosing a medical plan option, consider the following things: your needs, the cost of coverage, the cost of services when you receive them, your medical expenses over the past year or two, and the physician or other health care providers you plan to use.

For More Information

For complete information about each of the plans, click on the links below or visit INET: HRONLINE > Benefits Resources > SPDs:

• WellSpan Plus Medical Plan Summary Plan Description (SPD)• WellSpan Standard Medical Plan SPD• WellSpan High Deductible Medical Plan SPD

Remember: it is your responsibility to elect coverage only for eligible dependents and cancel coverage in a timely manner for dependents that are no longer eligible. Covering ineligible dependents could subject you to disciplinary action and require you to repay any ineligible payments.


https://hr.wellspan.org/wpn2017/

https://hr.wellspan.org/documents/2017Tier1ProviderGuide.pdf

http://www.aetna.com/asa

https://hr.wellspan.org/documents/1017WellSpanPlusSPD.pdf

https://hr.wellspan.org/documents/2017WellSpanStandardSPD.pdf

https://hr.wellspan.org/documents/2017WellSpanHighDeductibleSPD.pdf


2017 Open Enrollment Choices: MedicalYour Options

As you consider your medical plan options, keep in mind that you share in the cost of coverage in two ways: through payroll contributions and when you receive care. Generally speaking, when you consider which medical plan is best for you, you will choose to “pay more now” (through payroll contributions) or “pay more later” (if or when you receive care).

WellSpan Plus Medical Plan

This plan has no deductible when care is received from a Tier 1 provider, and a $250 per person deductible for care provided by a Tier 2 provider. Depending upon which Tier provider you use, you may pay nothing or a small copay for care, or share in the cost by paying coinsurance. With the WellSpan Plus Plan, you generally pay more toward the cost of coverage through payroll contributions than the other two options, but will often pay less when receiving medical services. You may elect to contribute to a Health Care FSA to help offset any deductible and to pay for eligible medical, prescription drug, dental, or vision expenses with pre-tax contributions.

PAY NOW

$$$PAY

LATER

$

WellSpan Standard Medical Plan

This plan also has no deductible when care is received from a Tier 1 provider, and a $1,000 individual/$2,000 family deductible for care received from a Tier 2 provider. You pay a percentage of the cost through coinsurance at different amounts depending upon your provider’s Tier classification. You pay more for services than you would under the WellSpan Plus Plan, but payroll contributions toward the cost of coverage are lower. You may elect to contribute to a Health Care FSA to help offset any deductible and pay for eligible medical, prescription drug, dental, or vision expenses with pre-tax contributions.

PAY NOW

$$PAY LATER

$$

WellSpan High Deductible Medical Plan

In a high deductible plan, you must first meet your deductible before any non-preventive services are covered. This plan has a $1,300 individual/$2,600 family in-network deductible for Tier 1 and Tier 2. Depending upon which network you use and the services you obtain, you’ll pay coinsurance (20%, 30%, or 50%) or copays after you meet the annual deductible. With this plan, you pay more at the time of service, but this option has the lowest payroll contributions.

New for 2017: You can elect to make pre-tax contributions to the tax-advantaged HSA to help offset the deductible and pay for eligible medical and prescription drug expenses. You may also elect a Limited Purpose FSA to help offset the cost of eligible dental and vision expenses. The HSA and Limited Purpose FSA are only available when you enroll in the WellSpan High Deductible Medical Plan.

PAY NOW

$PAY LATER

$$$

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WellSpan Plus Plan

FeatureTier 1 Tier 2 Tier 3

WellSpan Provider Network and Other Select Providers and Facilities

Aetna Signature Administrators Network Out-of-Network4

Annual Deductible1 (per person) None $250 $750Out-of-Pocket Maximum2 (Individual/Family)Includes deductible, copays, and coinsurance

$2,500 / $4,500 $10,000 / $20,000

Preventive CareIncludes annual physical and well-child care

100% 100% 50% after deductible

Office Visits• Primary Care• Specialist

$0 copay$20 copay

$20 copay, no deductible$30 copay, no deductible

50% after deductible

Hospital Facility/Physician (Inpatient) 100% $200 copay,then 80% after deductible

$250 copay,then 70% after deductible

Ambulatory, Outpatient, Surgery, MRIs, MRAs, and CT and PET Scans (facility) 100% $200 copay,

then 80% after deductible$250 copay,

then 50% after deductible

Outpatient (Lab/Diagnostic) 100% 80% after deductible 50% after deductible

Massage Therapy 100%, up to a $500 maximum per calendar year5 Not covered Not covered

Urgent Care/Walk-In Clinics/Retail ClinicsPCP: 100%

Specialist: $20 copay100% for other covered services

PCP: $20 copaySpecialist: $30 copay

80% after deductible for other covered services


Emergency Room3 $100 copay (copay waived if admitted) $100 copay (copay waived if admitted) $100 copay (copay waived if admitted)Prescription drug coverage is included with your medical benefits. Click here to see how the plan pays benefits for prescriptions. Behavioral health benefits are also included and are managed by Quest Behavioral Health. See the WellSpan Plus behavioral health benefits page to learn more.

1 Deductibles do not accumulate across Tiers.2 Out-of-pocket maximums accumulate across Tiers 1 and 2 only. They include medical and behavioral health deductibles, coinsurance, and copays.3 For non-emergency use of the Emergency Department, the room charge is not covered and all ancillary and physician services are covered at the applicable deductible and coinsurance rates.4 All out-of-network expenses are subject to usual, customary, and reasonable (UC&R) limits.5 Only covered when services are obtained at a WellSpan Center for Mind Body & Health and at select locations only.

2017 Open Enrollment Choices: MedicalHow the Medical Plans Work



WellSpan Standard Plan




Annual Deductible1 (Individual/Family) None $1,000 / $2,000 $2,000 / $4,000

Out-of-Pocket Maximum2 (Individual/Family)Includes deductible, copays, and coinsurance

$4,000 / $7,500 $6,500 / $12,500




$10 copay$30 copay

$30 copay$40 copay


Hospital Facility/Physician (Inpatient) 80% 70% after deductible 50% after deductible

Ambulatory, Outpatient, Surgery, MRIs, MRAs, and CT and PET Scans (facility) 80% 70% after deductible 50% after deductible

Outpatient (Lab/Diagnostic) 80% 70% after deductible 50% after deductible

Urgent Care/Walk-In Clinics/Retail ClinicsPCP: $10 copay

Specialist: $30 copay80% for other covered services

PCP: $30 copaySpecialist: $40 copay



Emergency Room3 $100 copay (copay waived if admitted)

$100 copay (copay waived if admitted)

$100 copay (copay waived if admitted)

Prescription drug coverage is included with your medical benefits. Click here to see how the plan pays benefits for prescriptions. Behavioral health benefits are also included and are managed by Quest Behavioral Health. See the WellSpan Standard behavioral health benefits page to learn more.

1 Deductibles do not accumulate across Tiers.2 Out-of-pocket maximums accumulate across Tiers 1 and 2 only. They include medical and behavioral health deductibles, coinsurance, and copays.3 For non-emergency use of the Emergency Department, the room charge is not covered and all ancillary and physician services are covered at the applicable deductible and coinsurance rates.4 All out-of-network expenses are subject to usual, customary, and reasonable (UC&R) limits.

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WellSpan High Deductible Plan




Annual Deductible1 (Individual/Family) $1,300 / $2,600 $2,600 / $5,200

Out-of-Pocket Maximum2 (Individual/Family)Includes deductible, copays, and coinsurance

$6,550 / $13,100 $13,100 / $26,200




$10 copay after deductible$30 copay after deductible

$30 copay after deductible$40 copay after deductible


Hospital Facility/Physician (Inpatient) 80% after deductible 70% after deductible 50% after deductible

Ambulatory, Outpatient, Surgery, MRIs, MRAs, and CT and PET Scans (facility) 80% after deductible 70% after deductible 50% after deductible

Outpatient (Lab/Diagnostic) 80% after deductible 70% after deductible 50% after deductible

Urgent Care/Walk-In Clinics/Retail Clinics

PCP: $10 copay after deductibleSpecialist: $30 copay after deductible


PCP: $30 copay after deductibleSpecialist: $40 copay after deductible



Emergency Room3 $100 copay after deductible (copay waived if admitted)

$100 copay after deductible (copay waived if admitted)

$100 copay after deductible(copay waived if admitted)

Prescription drug coverage is included with your medical benefits. Click here to see how the plan pays benefits for prescriptions. Behavioral health benefits are also included and are managed by Quest Behavioral Health. See the WellSpan High Deductible Medical Plan behavioral health benefits page to learn more.

1 Deductibles accumulate across Tiers 1 and 2 only. They include medical, prescription, and behavioral health deductibles.2 Out-of-pocket maximums accumulate across Tiers 1 and 2 only. They include medical, prescription drug, and behavioral health deductibles, coinsurance, and copays.3 For non-emergency use of the Emergency Department, the room charge is not covered and all ancillary and physician services are covered at the applicable deductible and coinsurance rates.4 All out-of-network expenses are subject to usual, customary, and reasonable (UC&R) limits.

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A Closer Look at the High Deductible PlanTo help you understand how the plan works, think of it as a house with a solid foundation (preventive care) and a sturdy roof (an out-of-pocket limit to protect against the high cost of health care).

22

PreventiveCare

(100%)

Deductible

Coinsurance

Roof

2nd

Floo

r1s

t Fl

oor

Foun

dati

on The plan provides preventive care, such as annual physicals, certain prescription drugs, and screenings, at no cost to you when you use an in-network provider.

You pay the full cost of covered services up to the deductible. You can use money in your HSA to satisfy the deductible.

Once you meet the annual deductible, you share in the cost of services by paying coinsurance. You can use the money from your HSA to pay these amounts.

Out-of-Pocket Maximum

Plan Pays

SharedCost

You Pay

Plan Pays

You pay deductibles and coinsurances until you reach the out-of-pocket maximum for the year. Then the plan pays 100% for covered in-network medical expenses. You pay nothing.

HEALTH SAVINGS ACCOUNT (HSA)

A tax-advantaged savings account that you can contribute to and use to meet your deductible and pay for copays and coinsurance, until you reach your out-of-pocket maximum. Or, you can save it for future health expenses.

• You are protected, from the foundation to the roof, for the cost of routine preventive care you need to stay well, and from the high cost of care if you have a serious illness or injury.

• In between is the care you need for most illnesses and injuries. Both you and WellSpan Health share in the cost of this care.

- The “first floor” represents the deductible: the first out-of-pocket expenses you pay, including non-preventive prescription drug expenses. Contributions you make to your HSA can help offset the cost of this deductible.

- The “second floor” is coinsurance, which means youpay a percentage of the total cost of care. If you use in-network providers, the plan pays 80% of eligible charges once you meet the deductible, and you pay the other 20% — up to the out-of-pocket maximum.

• Once your deductible and coinsurance reach the out-of-pocket maximum, the plan pays 100% of any additional eligible expenses for the year — both for medical care and prescription drugs.

Learn more about the Health Savings Account in the Spending and Savings Accounts section.



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Using the Medical PlansEach medical plan allows you to choose a provider at the time of service from either of the two designated networks—WellSpan Provider Network and Other Select Providers and Facilities (Tier 1) and Aetna Signature Administrators PPO Provider Network (Tier 2)—or to obtain care out-of-network (Tier 3). You may see any provider, but how claims are paid will depend on the provider’s network. Note: Claims are paid according to the provider’s network. Not all providers or services are available in the Tier 1 WellSpan Plus Network.

Tier 2 benefits are the standard benefits of the plan. Enhanced benefits are available if you use Tier 1 providers or services.

Finding a Provider

Using in-network care is the first step to using your health care dollars wisely:

• For Tier 1 providers, click here to find a provider and click here for a list of Tier 1 providers..• For Tier 2 providers, visit http://www.aetna.com/asa to find an Aetna provider. Use the Doc Find feature to search for a provider or facility near you.• You can also call SOUTH CENTRAL Preferred at 1-717-851-6800 or 1-800-842-1768 to find a provider.

Know Your Network and Your ProviderWhen you use an in-network provider, you save on care, so become familiar with your Tier 1 and Tier 2 providers. For example, when you visit a WellSpan Laboratory, always ask whether the lab used to process the tests is part of Tier 1. If it isn’t, you’ll pay for care at the tier in which the provider participates. Be mindful of your urgent care clinic’s network and staff, too: When you visit an urgent care clinic that specializes in an area of medicine, such as an orthopedic urgent care, you may pay a specialist fee for the care you obtain.

Using the Tier 1 Network (WellSpan Provider Network and Other Select Providers and Facilities)

When you use the Tier 1 Network, WellSpan passes the savings on to you as higher, enhanced benefits. If you do not or cannot use the Tier 1 network, regardless of the reason, the plan will pay benefits based on the tier in which the provider participates. Please be aware that not all specialists or services are available in the Tier 1 network.

For example, WellSpan Laboratories may use other labs for certain tests. These claims will generally be paid at the Tier in which that laboratory participates. Tier 1 Network providers may need to use providers from other networks to meet your needs. These claims will also be paid at the tier in which the provider participates. If you are having a medical procedure or test, be sure to check with the provider first to find out the tier in which they participate or if other providers will be used.

Continued on the next page


https://hr.wellspan.org/wpn2017/

https://hr.wellspan.org/documents/2017Tier1ProviderGuide.pdf


Using the Medical Plans (continued)Out-of-Pocket Maximums

All WellSpan medical plans include out-of-pocket maximums to help protect you from large claims. Eligible amounts applied to the out-of-pocket maximums will accumulate across Tiers 1 and 2 only. Tier 3 has a separate, higher out-of-pocket maximum.

The out-of-pocket maximum refers to the amount that you will pay toward your health care. Deductibles, copayments, coinsurance, and other payments for qualified medical benefits covered by the plan will count toward the out-of-pocket maximum.

Precertification penalties do not count toward the out-of-pocket maximum and deductible. In addition, the Tier 3 out-of-network providers may charge more than what is Usual, Customary, and Reasonable (UCR), and the amount above the UCR does not count toward the out-of-pocket maximum, so it’s best to try to use in-network providers.

24

Important NoteThe Plan excludes services provided by any Cancer Treatment Center of America. This includes, but is not limited to, the Eastern Regional (Philadelphia area), Midwestern Regional, Southeastern Regional, Southwestern Regional, and Western Regional Facilities. If services are received at any of these facilities, there will be no reimbursement or benefits under the plan, regardless of participation in any network. To receive information about other facilities that provide care for cancer patients, please contact SOUTH CENTRAL Preferred at 1-717-851-6800 or 1-800-842-1768.

Medical Precertifications

When you need medical care that requires precertification, you or your provider will need to notify your medical plan. There are two Medical Management organizations that work together to manage your care: SOUTH CENTRAL Preferred and Active Health. Active Health is the Medical Management organization for Tier 2 Aetna Signature Administrators.

If you live in Pennsylvania and receive care at a WellSpan Provider Network or a WellSpan-owned service location, your provider is responsible for calling SOUTH CENTRAL Preferred with your pre-certification information.Telephone numbers are listed on your member ID card.




Using the Medical Plans (continued)Coordination of Benefits: Medical and Dental

When considering whether to enroll your spouse and/or dependents who may have access to other benefits, it is important to understand how the WellSpan medical and dental plans coordinate with other benefit plans. Coordination of Benefits (COB) is the process that takes into account the total benefits paid for a person who is covered under more than one group health or dental plan. COB ensures that:

• The total benefit payments from both plans do not exceed the total expenses incurred;• The appropriate plan pays expenses first; and• The WellSpan plans pay the appropriate amount.

If you have other insurance as your primary coverage and use, for example, WellSpan Plus or Delta Dental as secondary coverage, a formula is used to determine how much these plans should pay. Generally, your WellSpan coverage pays the difference between the benefit you would have received if you only had WellSpan coverage and what the other plan actually paid. Each claim is reviewed to determine proper payment.

It’s important to understand that all of the WellSpan medical plans and Delta Dental will not pay more for your claim than they would have paid had there been no other group medical or dental plan coverage in place. It’s possible you won’t receive 100% payment of the claim even with two plans.

Example Scenarios

Mary’s husband, Joe, is covered under both her WellSpan Plus plan and his employer’s plan:

Scenario 1 Joe’s plan pays firstClaim $100

Allowable payment $80

The other plan’s payment $50

WellSpan’s plan pays $30

Total payment from both plans $80

Balance due by spouse $20

Scenario 2 Joe’s plan pays first, but it pays more for the claim than Mary’s WellSpan Plus paysClaim $100

The other plan’s payment $90

WellSpan would pay $0

Balance due by spouse $10

In Scenario 2, the payment from the other plan that paid first is greater than what would have been paid by the WellSpan Plus plan, so no further payment would be made by Mary’s plan.

Follow the Rules of Primary Coverage Please note that non-compliance with a patient’s primary medical plan (not following the plan rules) will result in no payment under the WellSpan medical plan as a secondary payer. This includes:

Services provided to an HMO participant by a facility or professional provider who is not participating with that HMO. Please keep this in mind if you are considering an HMO as primary coverage for your spouse or children and a WellSpan medical plan as secondary.

Not following the precertification rules for the primary plan. For example, if you are penalized or a service is not covered by your primary plan because you did not precertify the procedure, the WellSpan plan will not pay for any penalties applied by the primary plan. Please note that medical appropriateness still must be met for consideration under this plan as secondary.

Coordination of benefits can be complicated. If you have questions or need further clarification, call SOUTH CENTRAL Preferred (SCP), at 1-717-851-6800 or 1-800-842-1768, for medical plan questions. For dental coordination of benefits questions, please call Delta Dental at 1-800-932-0783. Please keep in mind that if you are calling before the claim is submitted, it may be difficult to provide an accurate response to your question. SCP or Delta Dental won’t know how another plan is going to pay until the claim has been adjusted by the other plan.

25



2017 Open Enrollment Choices: MedicalPrescription Drug Benefits

You automatically receive prescription drug benefits through Optum Rx if you are enrolled in a WellSpan medical plan option. In addition to using pharmacies at WellSpan Pharmacy locations, you may also purchase prescription drugs from pharmacies in the Optum Rx network. Some drugs may require preauthorization. This will occur at the pharmacy at the time of purchase.

Before you fill your prescription, be sure you know whether your pharmacy is in the OptumRx network. Certain facilities, such as Walgreens and Rite Aid, are not.

Review your prescription drug benefits on each of the plan charts: WellSpan Plus, WellSpan Standard, and WellSpan High Deductible.

Use the Best Pharmacy for Your NeedsFind out more about WellSpan pharmacies and the OptumRx network, and what happens when you use a pharmacy that is out-of-network.

Feature WellSpan Pharmacies OptumRx Network Pharmacies Out-of-Network Pharmacies

Cost for Prescription Drugs Generally less than OptumRx Network Pharmacies

Coinsurance per the medical plan you are enrolled in

Generally higher; you’ll also need to file a claim to receive reimbursement for the negotiated, rather than retail, cost of the prescription drug. This means you may be reimbursed the same, or even less, because the negotiated rate may be less than the retail price.

Maximum Fill Up to 34-day supply, or 100-day supply for maintenance medications (mail order and onsite fills)

Up to 34-day supply Up to 30-day supply

Online Refill Services Yes, complete a refill request form available on HRONLINE under the “Health” tab

Yes N/A

Always keep your medical identification card with you. When you visit a WellSpan Pharmacy or OptumRx Network pharmacy, you’ll need your medical/prescription drug identification card. If you do not provide it, you will need to file a claim for reimbursement.

Note: In 2017, 100-day supplies will only be available through WellSpan Pharmacies, either at their retail locations or via the mail-order program. Remember, a new WellSpan Pharmacy opened in Ephrata as a Tier 1 pharmacy providing 100-day supplies, during 2016.

26 Continued on the next page



27

Use the Best Pharmacy for Your Needs (continued)Choose Better with a WellSpan Pharmacy

In general, when you buy prescriptions through a WellSpan Pharmacy, you pay less because:

• WellSpan Pharmacies provide prescriptions to covered participants at cost plus a small dispensing fee.

• When you purchase your prescriptions at a WellSpan Pharmacy, your share of the cost is based on the pharmacy’s costs, not retail prices.

In addition:

• All WellSpan Pharmacy locations can give you a 100-day supply of your maintenance medication, just like mail order.

• WellSpan Pharmacies also offer online refill services. Refill your prescription online by completing a refill request form, available on HRONLINE under the Health tab.

Note: The WellSpan Standard and WellSpan Plus plans include a separate prescription drug out-of-pocket maximum. Once this maximum is reached, the plan will pay 100% of your qualified prescription drug expenses for the remainder of the plan year. The WellSpan High Deductible Medical Plan has one out-of-pocket maximum that includes medical and prescription drug expenses.

Find a WellSpan Pharmacy

Click here to find WellSpan Pharmacy locations and hours.


Current WellSpan Pharmacies include:

WellSpan Pharmacy - GettysburgAdams Health Center40 V-Twin Dr.Suite 107Gettysburg, PA 17325(717) 339-2600

WellSpan Pharmacy - Ephrata183 N. Reading Rd.Suite 9Ephrata, PA 17522(717) 721-5784

WellSpan Pharmacy - Dallastown755 S. Pleasant Ave.Dallastown, PA 17313(717) 851-1351

WellSpan Pharmacy - YorkApple Hill25 Monument Rd.Suite 265York, PA 17403(717) 741-8150

http://www.wellspan.org/offices-locations/ambulatory-services/pharmacies/


WellSpan Plus Prescription Drug Benefits

Type of Medication

Tier 1 Tier 2 Tier 3Mail Order

(WellSpan Pharmacies Only)100-day Supply

Retail (WellSpan Pharmacy)

Retail* (Optum Rx Pharmacy, Network Pharmacy)

Out of Network Pharmacy**

Generic $10 copay20% coinsurance;

$10 minimum20% coinsurance;

$10 minimum$20 copay

Brand-Name Formulary $25 copay + amount over generic cost

25% coinsurance + amount over generic cost;

$25 minimum


$25 minimum

$50 copay + amount over generic cost

Brand-Name Non-Formulary $50 copay + amount over generic cost


$50 minimum

45% coinsurance + amount over generic cost; $50

minimum


Prescription Out-of-Pocket Maximum (Individual/Family) includes deductible, coinsurance and copays

$2,500 / $4,500* $10,000 / $20,000 Included in the Tier 1 & Tier 2 maximum

* Prescription out-of-pocket maximum for pharmacy is separate from, and in addition to, the medical/behavioral health out-of-pocket maximum.** All out-of-network expenses are subject to usual, customary, and reasonable (UC&R) limits.

Please Note: No benefits are payable for prescriptions filled at Walgreens or Rite Aid.

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WellSpan Standard Prescription Drug Benefits

Type of Medication






Generic $10 copay 30% coinsurance 30% coinsurance $20 copay

Brand-Name Formulary $25 copay + amount over generic cost

35% coinsurance + amount over generic cost



Brand-Name Non-Formulary $50 copay + amount over generic cost





$2,500 / $4,500* None Included in the Tier 1 & Tier 2 maximum

* Prescription out-of-pocket maximum for WellSpan Pharmacy and Optum Rx Pharmacies (Tiers 1 and 2) is separate from and in addition to the medical out-of-pocket maximum. ** All out-of-network expenses are subject to usual, customary, and reasonable (UC&R) limits.


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WellSpan High Deductible Prescription Drug BenefitsPreventive Drugs

Preventive drugs are covered at 100% (no copay, coinsurance or deductible) in the High Deductible Medical Plan option when using in-network pharmacies (WellSpan Pharmacy - Tier 1 or Optum Rx - Tier 2 networks). Click here for a list of Preventive drugs, as determined by Optum Rx.

Non-Preventive Drugs

Type of Medication






Generic $20 copay after deductible 30% coinsurance after deductible

30% coinsurance after deductible $40 copay after deductible

Brand-Name Formulary $35 copay after deductible + amount over generic cost

35% coinsurance after deductible + amount over

generic cost


generic cost

$70 copay after deductible + amount over generic cost

Brand-Name Non-Formulary $60 copay after deductible + amount over generic cost


generic cost


generic cost

$120 copay after deductible + amount over generic cost


$6,550 / $13,100* $13,100 / $26,200 Included in the Tier 1 & Tier 2 maximum

* Out-of-pocket maximums accumulate across Tiers 1 and 2 only. They include medical, prescription, and behavioral health deductibles, coinsurance, and copays.** All out-of-network expenses are subject to usual, customary, and reasonable (UC&R) limits.


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https://hr.wellspan.org/documents/Preventive_drug_list_for_high_deductible_plan.pdf


Mail OrderMail order prescriptions, which provide you with up to a 100-day supply of a maintenance drug, are filled at the WellSpan Pharmacy location in Fairfield, PA and mailed to your home. After establishing your mail order prescription with WellSpan Pharmacy, refills will be processed automatically and mailed to you upon your confirmation that you are ready for the shipment. Mail order forms are available on the INET at HRONLINE.

Remember: You can obtain a 100-day supply of maintenance drugs through WellSpan Pharmacies Mail Order Service. All medications obtained through the prescription drug plan, including injectable drugs and oral oncology drugs, will be subject to the copay tiers as shown in each plan’s benefits chart (WellSpan Plus, WellSpan Standard, WellSpan High Deductible).

Injectable Medications Certain injectable medications require precertification. Click here to see the current list. This list will be updated throughout the year, so please be sure to check the list before filling a new prescription. A deductible will apply to injectable medications covered through the Medical Plan. This deductible does not apply to covered preventive immunizations covered through the medical plan.

Important Details About Prescription DrugsFormularies

WellSpan’s drug program uses formularies, or lists of preferred drugs. While you are not required to have a prescription filled with a drug on the formularies, you will pay more for brand-name drugs that are not on the formulary. Note: If you purchase a brand name drug when a generic alternative is available, you will pay the brand copay plus the difference between the cost of the brand and generic drug. The drug program substitutes generic drugs when they are available. Click here to review the current formulary list.

Specialty Drugs

Specialty drugs, as defined by the Pharmacy Benefit Manager (PBM), are limited to one 30-day supply per fill. Specialty drugs are a group of medications used for serious conditions, such as multiple sclerosis, rheumatoid arthritis, and cancer. These medications often require close monitoring, frequent drug and dosage changes, as well as discontinuation of use which may result in wasted prescriptions. Review the list of specialty drugs to find out if yours is covered.

Step Therapy

Certain medications are subject to Step Therapy Management. This is a medication management process which requires members to begin therapy with the most proven, safest, and cost effective medications prior to stepping up to newer, possibly more expensive medications that often don’t have a proven record of effectiveness. If the initial drugs used are not successful, members will then have access to different drugs which may be more expensive and may cost the member more. Dosage or other convenience reasons alone do not mean you should step up to another drug. The step therapy process allows members to get the best value for their money, without compromising on safety or effectiveness.

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https://hr.wellspan.org/documents/WellSpanRxMailOrderForm.pdf

https://hr.wellspan.org/documents/2016Optum_Catamaran_formulary.pdf


32

Drugs that Require Precertification

Abatacept (Orencia)Abraxane (Nanoparticle Albumin-Bound Paclitaxel)Actemra (Tocilizumab)Adcetris (Brentuximab) Agalsidase Beta (Fabrazyme)Alpha-1-Proteinase Inhibitor (Aralast, Prolastin, Zemaira)Antithymocyte Globulin (Atgam, Thymoglobulin)Aralast (Alpha-1-Proteinase Inhibitor)Arcalyst (Rilonacept) Atgam (Antithymocyte Globulin)Arzerra (Ofatumumab)Avastin (Bevacizumab)Belimumab (Benlysta)Benlysta (Belimumab)Bevacizumab (Avastin)Boniva (Ibandronate) Bortezomib (Velcade) Botox (Botulinum Toxin A)Botulinum Toxin A or B (Botox, Myobloc)Brentuximab (Adcetris) Cabazitaxel (Jevtana)Carfilzomib (Kyprolis) Carimune NF (Immune Globulin)Cetuximab (Erbitux)Docetaxel (Taxotere)Denosumab (Prolia, Xgeva)Dornase Alfa (Pulmozyme)Entyvio (Vedolizumab)Epoprostenol (Flolan)

Erbitux (Cetuximab)Eribulin (Halaven)Euflexxa (Hyaluronic Acid)Fabrazyme (Agalsidase Beta)Flebogamma (Immune Globulin)Flolan (Epoprostenol)Forteo (Teriparatide)Gamastan (Immune Globulin)Gammagard (Immune Globulin)Gamunex (Immune Globulin)Gefitinib (Iressa) Gemcitabine (Gemzar)Gemzar (Gemcitabine)Genotropin (Somatropin)Halaven (Eribulin)Healon (Sodium Hyaluronate)Hemophilia productsHizentra (Immune Globulin)Human Growth Hormone (all available products)Humate-P (Von Willebrand Factor)Humatrope (Somatropin)Hyalgan (Sodium Hyaluronate)Hyaluronate (all available products)Hyaluronic Acid (all available products)Hylan G-F (Sinvisc or Synvisc-One)Hyperrab S/D (Rabies Immune Globulin)Ibandronate (Boniva)Iloprost (Ventavis)Immune Globulin (all available products)

Imogam Rabies HT (Rabies Immune Globulin)Infliximab (Remicade)Ipilimumab (Yervoy)Iressa (Gefitinib)Jevtana (Cabazitaxel)Kyprolis (Carfilzomib) Marqibo (Vincristine Liposomal) Myobloc (Botulinum Toxin B)Nanoparticle Albumin-Bound Paclitaxel (Abraxane)Natalizumab (Tysabri)Norditropin (Somatropin)Nplate (Romiplostim)Nutropin (Somatropin)Octagam (Immune Globulin)Ofatumumab (Arzerra)Omnitrope (Somatropin)Orencia (Abatacept)Orthovisc (Hyaluronate)Perjeta (Pertuzumab) Pertuzumab (Perjeta) Polygam S/D (Immune Globulin)Prolastin (Alpha-1-Proteinase Inhibitor)Prolia (Denosumab)Provenge (Sipuleucel-T)Provisc (Sodium Hyaluronate)Privigen (Immune Globulin)Pulmozyme (Dornase Alfa)Rabies Immune Globulin (Hyperrab S/D, Imogam Rabies HT)Reclast (Zoledronic Acid) Remicade (Infliximab)

Remodulin (Treprostinil)Rilonacept (Arcalyst) Rituxan (Rituximab)Romiplostim (NplateSaizen (Somatropin)Serostim (Somatropin)Sipuleucel-T (Provenge)Sodium Hyaluronate (all available products)Somatropin (all available products)Supartz (Sodium Hyaluronate)Synvisc or Synvisc-One (Hylan G-F)Taxotere (Docetaxel)Teriparatide (Forteo)Testosterone productsTev-Tropin (Somatropin)Thymoglobulin (Antithymocyte Globulin)Tocilizumab (Actemra)Treprostinil (Remodulin)Tysabri (natalizumab)Vedolizumab (Entyvio)Velcade (Bortezomib)Ventavis (Iloprost)Vincristine Liposomal (Marqibo) Vivaglobin (Immune Globulin)Von Willebrand Factor (Humate-P)Xgeva (Denosumab)Yervoy (Ipilimumab)Zaltrap (Ziv-Aflibercept) Zemaira (Alpha-1-Proteinase Inhibitor)Ziv-Aflibercept (Zaltrap) Zoledronic Acid (Reclast, Zometa)Zometa (Zoledronic Acid)Zorbtive (Somatropin)


This list is subject to change throughout the year, and will be updated online if changes take place.


Specialty DrugsThe following drugs and their generics MAY ONLY BE FILLED at a WellSpan Pharmacy:

Actemra (tocilizumab)Adcirca (tadalafil)Alprolix (Factor IX)Aranesp (darbepoetin alfa)Arixtra (fondaparinux)Avonex (Inteferon Beta-1a)BeneFIX (Factor IX)Betaseron (Interferon Beta-1b)Botox (onabotulinumtoxin A)Cimzia (certolizumab pegol)Copaxone (glatiramer)Eligard (leuprolide)Enbrel (etanercept)Epogen (epoetin alfa)Extavia (Interferon Beta-1b)Forteo (teriparatide)Fragmin (dalteparin)

Genotropin (somatropin)Gilenya (fingolimod)Glatopa (glatiramer)Gleevec (imatinib)Granix (tbo-filgrastim)Hemophilia productsHumatrope (somatropin)Humira (adalimumab)Ilaris (canakinumab)Intron A (Interferon Alfa-2b)Kineret (anakinra)KogenateLupron (leuprolide)Lupron Depot (leuprolide depot)Lovenox (enoxaparin)Neulasta (pegfilgrastim)Neupogen (filgrastim)

Norditropin (somatropin)Omnitrope (somatropin)Orencia 125mg (abatacept)Pegasys (peginterferon Alfa-2a)Plegridy (peginterferon Beta-1a)Praluent (alirocumab)Procrit (epoetin alfa)Prolia (denosumab)Pulmozyme (dornase alfa)Rebif (Interferon Beta-1a)Remicade (infliximab)Repatha (evolocumab)Revatio (sildenafil)RibavirinRilutek (riluzole)

Saizen (somatropin) Sandostatin LAR (octreotide)Simponi (golimumab)Sprycel (dasatinib) Stelara (ustekinumab)Tarceva (erlotinib)Tasigna (nilotinib)Temodar (temozolomide)Thalomid (thalidomide)Tykerb (lapatinib)Xeloda (capecitabine)Xgeva (denosumab)Xolair (omalizumab)Zarxio (filgrastim)Zomacton (somatropin)Zytiga (abiraterone)

This list is subject to change throughout the year, and will be updated online if changes take place.

WellSpan Pharmacies will fill these prescriptions through its WellSpan Pharmacy in Fairfield, PA. The requirement to fill these drugs at a WellSpan Pharmacy does not apply to medications supplied or administered by your physician at his/her office. A one-time emergency fill of these medications is allowed at a non-WellSpan pharmacy for emergency situations where dispensing by a WellSpan Pharmacy is not possible.

If your current specialty medication is being supplied by a non-WellSpan Pharmacy, call WellSpan Pharmacy at 1-855-339-2305 to transfer your prescription to the WellSpan Pharmacy. For other specialty drugs, keep WellSpan Pharmacies in mind as a possible source to help you get the drugs you need.

If a WellSpan Pharmacy can’t get what you need, try OptumRx’s specialty drug provider, Briora Rx. Both WellSpan Pharmacies and Briora Rx may be able to get these very costly drugs at lower prices and can help coordinate delivery issues. All specialty drugs are limited to no more than a 30-day fill.

33



2017 Open Enrollment Choices: MedicalMental Health & Substance Abuse Treatment

Quest Behavioral Health administers the mental health and substance abuse treatment benefits for all of WellSpan’s medical plans. Quest offers an affordably priced network of state-licensed mental health providers and certified addiction counselors to help you with your specific needs. Quest Behavioral Health specialists are available 24 hours a day, seven days a week through a toll-free number.

To see how each plan covers mental health and substance abuse treatment benefits, refer to the plan charts on the following pages.

How the Benefit WorksTo receive the best benefits for mental health or substance abuse, call the Quest toll-free number at 1-800-364-6352. The Quest staff will assist you in finding the most appropriate service and direct you to a network provider to set up an appointment. Quest will follow up with your provider to ensure that you are receiving quality care.

Precertification and CertificationPrecertification is required for out-of-network non-emergency inpatient hospital care. Emergency care should be certified with Quest Behavioral Health within 48 hours of hospital admission. Other services are also subject to precertification requirements. If you use a network provider, the provider will be responsible for precertification. If you use an out-of-network provider, you will be responsible for precertification of all non-emergency inpatient hospitalization, partial hospitalization, intensive outpatient or electroconvulsive therapy. Based on your medical plan election, certain services that require precertification will carry a penalty if precertification is not received. For assistance, call Quest or consult your medical plan Summary Plan Description (SPD).

Out-of-Network CareIf you use out-of-network providers, you pay substantially more of the cost for your care. You should coordinate directly with Quest for mental health and substance abuse services, even when using out-of-network providers, and submit claims for these services directly to Quest. They may be able to negotiate a better rate for you even though the services would still be considered out-of-network.

Partial Hospitalization and Outpatient Services

To provide more flexibility in your care, Partial Hospitalization and Intensive Outpatient Services are available through Quest. Please call 1-800-364-6352 to discuss your options concerning these higher levels of care.

34

To receive the best benefits for mental health or substance abuse treatment, call Quest Behavioral Health at 1-800-364-6352. You must also call Quest to precertify any non-emergency out-of-network inpatient hospitalization, intensive outpatient, or electroconvulsive therapy.



WellSpan Plus: Behavioral Health Benefits


WellSpan Provider Network and Other Select Providers and Facilities Quest Network Out-of-Network3

Deductible1 None $250 per person $750 per person

Out-of-Pocket Maximum2 (Individual/Family) $2,500 / $4,500 $10,000 / $20,000

Inpatient

Hospitalization, Partial Hospitalization, and Intensive Outpatient Services 100% 80% after $200 copay 70% after $250 copay and after

deductible

Professional Fees (Inpatient) 100% 80% after deductible 50% after deductible

Outpatient

Outpatient Visits 100%, no copay $20 copay, with no deductible 50% after deductible

Psychological Testing (Outpatient diagnostic) 100% 80% after deductible 50% after deductible

Emergency

Emergency Department/Crisis Evaluation $100 copay then 100%(copay waived if admitted)

$100 copay then 100%(copay waived if admitted)

$100 copay then 100%; Non-emergency is 50% after

deductible

Electroconvulsive Therapy 100% 90% with no deductible after $20 copay 50% after deductible

1 Deductibles do not accumulate across Tiers.2 Out-of-pocket maximums accumulate across Tier 1 and Tier 2.3 All out-of-network claims are subject to adjustments for usual, customary, and reasonable (UCR) charges. The plan does not pay benefits for amounts above UCR.

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WellSpan Standard: Behavioral Health Benefits



Deductible1 None $1,000 / $2,000 $2,000 / $4,000


Inpatient

Hospitalization, Partial Hospitalization, and Intensive Outpatient Services 80% 70% after deductible 50% after deductible

Professional Fees (Inpatient) 80% 70% after deductible 50% after deductible

Outpatient

Outpatient Visits $10 copay then 80% $30 copay then 70%, no deductible 50% after deductible

Psychological Testing (Outpatient diagnostic) 80% 70% after deductible 50% after deductible

Emergency

Emergency Department/Crisis Evaluation $100 copay then 100%(copay waived if admitted)

$100 copay then 100%(copay waived if admitted)

$100 copay then 100%; Non-emergency is 50% after

deductible

Electroconvulsive Therapy 80% 70% no deductible 50% after deductible

1 Deductibles do not accumulate across Tiers.2 Out-of-pocket maximums accumulate across Tier 1 and Tier 2.3 All out-of-network claims are subject to adjustments for usual, customary, and reasonable (UCR) charges. The plan does not pay benefits for amounts above UCR.

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WellSpan High Deductible: Behavioral Health Benefits



Deductible1 $1,300 / $2,600 $2,600 / $5,200


Inpatient

Hospitalization, Partial Hospitalization, and Intensive Outpatient Services 80% after deductible 70% after deductible 50% after deductible

Professional Fees (Inpatient) 80% after deductible 70% after deductible 50% after deductible

Outpatient

Outpatient Visits $10 copay, 80% after deductible $30 copay, 70% after deductible 50% after deductible

Psychological Testing (Outpatient diagnostic) 80% after deductible 70% after deductible 50% after deductible

Emergency

Emergency Department/Crisis Evaluation $100 copay, 100% after deductible (copay waived if admitted)

$100 copay, 100% after deductible (copay waived if admitted)

$100 copay, 100% after deductible (copay waived if admitted)

Non-emergencies: 50% after deductible

Electroconvulsive Therapy 80% after deductible 70% after deductible 50% after deductible

1 Deductibles accumulate across Tier 1 and Tier 2 only. They include medical, prescription drug, and behavioral health.2 Out-of-pocket maximums accumulate across Tier 1 and Tier 2. They do not include precertification penalties.3 All out-of-network claims are subject to adjustments for usual, customary, and reasonable (UCR) charges. The plan does not pay benefits for amounts above UCR.

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In this section, you can find information about how you can use the spending and savings accounts to help pay for out-of-pocket health care and dependent day care expenses while also lowering your taxable income. You must enroll each year if you wish to participate in a Flexible Spending Account or Health Savings Account. Click on a link below to learn more.

• How Flexible Spending Accounts (FSAs) Work• Health Care Flexible Spending Account (FSA)• Limited Purpose Flexible Spending Account (FSA)• Dependent Day Care Flexible Spending Account (FSA)• Health Savings Account (HSA)• How to Use the HSA


Spending and Savings Accounts

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2017 Open Enrollment Choices: Spending and Savings AccountsDuring Open Enrollment, you must elect benefits for Spending and Savings Accounts if you want to participate in 2017. Your current year’s election will endon December 31, 2016. Only full-time, Part-time 1, and PRN 4 staff members are eligible to enroll in Spending or Savings Accounts.

For questions about Spending or Savings Accounts, call 1-844-PAYFLEX (729-3539).

How Flexible Spending Accounts (FSAs) WorkRegardless of which medical, dental or vision plan option you choose, some portion of your expenses may not be covered by the plan. For example, you are responsible for deductibles, copays and coinsurance amounts. And, if you have young children or dependents for whom you use day care services, you may be paying for their care with after-tax dollars.

With an FSA, you can pay for certain medical and dependent day care expenses with pre-tax dollars—money deducted from each paycheck before most taxes are withheld—by setting aside money in a:

• Health Care FSA• Limited Purpose FSA• Dependent Day Care FSA

FSAs allow you to save money because you pay for these expenses with money taken out of your paycheck before most taxes are deducted. You then pay taxes on a reduced salary amount.

Important Note: if you currently contribute to a Health Care FSA and or plan to enroll in the WellSpan High Deductible Medical Plan and contribute to the HSA, your Health Care FSA should be $0 by December 31, 2016 because you cannot roll over any FSA funds into a 2017 Health Care FSA. Refer to this page for additional information.

Limited Carryover—Use It or Lose It!Estimate carefully. If you do not use all of the money in your Health Care FSA for expenses incurred during 2017, you will only be able to carry over up to $500 into the new year. You will lose the remaining unused balance above $500, per IRS regulations. You cannot carry over any unused funds in your Dependent Cay Care FSA. You have 90 days after the plan year ends to request reimbursement of services incurred during the plan year.

How Much Should You Contribute

First, estimate your non-reimbursed health care expenses and/or your dependent day care expenses from January 1 through December 31, 2017. Next, divide these expenses by 12 to determine how much you want withheld from your paycheck every month. FSAs are meant to be “spent” each year, so plan ahead so you don’t forfeit any of your money.

For dependent day care expenses, take into account the times when you may not need dependent day care, such as vacation, or if your child is expected to change to partial or full-day school during the year.

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Submitting ClaimsDepending upon which FSA you use, you may submit claims in a different manner. Download the PayFlex reimbursement form from INET: HRONLINE > Benefits Resources > FSA.

Dependent Day Care FSA Claims

Dependent Day Care FSA claims may be submitted as follows:

• Download the appropriate claim form.• Submit your receipts or other evidence of payment, and the completed claim form online or through the PayFlex app on your mobile device.• Claims are processed and reimbursements are sent weekly or directly deposited into your bank account.

Health Care FSA or Limited Purpose FSA Claims

If you contribute to the Health Care FSA, you will receive a debit card which may be used at participating providers to pay for eligible health care expenses only. Please go to the PayFlex website for more information on using your debit card. While the debit card eliminates the need to file a claim form, it does not eliminate the need to keep your receipts. Debit card transactions may be subject to IRS review. It is up to you to keep all supporting documentation for these transactions. In the case of prescriptions, be sure to keep the detailed receipt, not just the cash register receipt, so you can show proof of purchase if needed. You may also pay the health care expenses, save the receipts, and submit claims for reimbursement as noted on the claim form.

Important Note About Dental Services

Dental offices often give you an estimate for what you will be charged at time of service. You cannot submit these estimated payments to PayFlex. You must wait to use your debit card until you receive your final bill or Explanation of Benefits showing your costs after you submit the claim to your dental insurance carrier.

Real Time Access with PayFlex’s Mobile AppStay connected to your FSA through PayFlex’s mobile app. You have real-time access to your Health Care and Dependent Day Care FSA information and account alerts. The app is secure so no one can access your personal information. Also, you can submit claims right from your phone by using your phone’s camera to photograph it and then upload to PayFlex. It’s as simple as that! The free app is available for all smartphones and can be downloaded from your phone’s app store.


https://WWW.PAYFLEX.COM/


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Health Care FSAWhat You Can Contribute

You may set aside up to $2,500 per year in a Health Care FSA annually. You can use the Health Care FSA for you and your dependents to pay for most out-of-pocket health care expenses.

Minimum Contribution Maximum Contribution

$10 Monthly $120 Annually $208.33 Monthly $2,500 Annually

Eligible Expenses

Here’s a sample list of eligible expenses that are covered under the Health Care FSA.

Expenses that ARE Reimbursable Expenses that ARE NOT Reimbursable

• Medical, dental and vision deductibles and co-pays;• Out-of-pocket costs for hospital or physician care; • Non-reimbursed prescriptions and co-pays; • Over-the-counter medicines and drugs (such as pain relievers, antacids and

allergy and cold medicines) if you have a prescription or letter of medical necessity from a health care provider;

• Insulin;• Dental care, including orthodontia; • Vision care, including exams, eyeglasses and contact lenses; • Hearing aids; and• Other expenses considered eligible by the IRS.

• Health insurance contributions;• Over-the-counter medicines and drugs that are not prescribed by a doctor;• Health insurance premiums under your spouse’s plan;• Most cosmetic surgery procedures; and• Dietary supplements/vitamins, cosmetics, toiletries and sundry items.

The IRS website has a full list of eligible expenses. Select “Forms and Publications” to view or print IRS Publication 502, Medical and Dental Expenses.

Remember, you will receive a debit card to use for eligible health care expenses. Be sure to save your detailed receipts in case you are asked to substantiate an expense. If you already have a debit card and continue to participate in a Health Care FSA, your new election will be loaded on to the same card. You will not receive a new debit card for the new plan year.


www.irs.gov


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Limited Purpose FSA: For High Deductible Medical Plan Participants Only NEW! A Spending Account for WellSpan High Deductible Medical Plan Participants

When you enroll in the WellSpan High Deductible Medical Plan, you are not eligible to contribute to a Health Care FSA but may use your Health Savings Account (HSA) to pay for eligible health care expenses. However, you are eligible to contribute to a Limited Purpose FSA for dental and vision expenses.

What You Can Contribute

You may set aside up to $2,500 per year in a Limited Purpose FSA. You can also carry over up to $500 in unused Health Care FSA funds, if you had an account in the previous year.

Eligible Expenses

The Limited Purpose Spending Account may only be used for eligible dental, orthodontia, and vision expenses. You cannot use the Limited Purpose Spending Account for medical expenses.

Remember, you will receive a debit card to use for eligible dental, orthodontia, and vision expenses. Be sure to save your detailed receipts in case you are asked to substantiate an expense. When you elect an HSA and a Limited Purpose FSA, you will receive one debit card for both accounts.

Your 2016 Health Care FSA Funds If you enroll in the WellSpan High Deductible Medical Plan and the Health Savings Account (HSA), your 2016 Health Care FSA funds will automatically roll over up to $500, into a Limited Purpose FSA.



Dependent Day Care FSA(For your dependent’s day care expenses, not medical expenses)

What You Can Contribute

You may contribute up to $5,000 per calendar year, unless your spouse contributes to a dependent care account. If your spouse contributes, together your contributions cannot exceed $5,000. When planning your monthly contributions, estimate carefully. You cannot carry over any unused balance in the Dependent Day Care FSA.

You may use your Dependent Day Care Spending Account for most day care expenses if you work and your spouse works or attends school full-time.

Minimum Contribution Maximum Contribution

$10 Monthly $120 Annually $416.66 Monthly $5,000 Annually

Eligible Expenses

Eligible expenses include:

• Day care inside or outside your home for children under age 13, or any age if disabled;• Tuition for pre-school, day camp or before- and after-school programs for children under age 13; and• Day care for a dependent or disabled parent who lives with you at least eight hours a day.

The IRS has a full list of eligible expenses. Go to www.payflex.com for a list, or to the IRS website and select “Forms and Publications” to view or print IRS Publication 503, Dependent Day Care Expenses.

The IRS also allows you to take a tax credit on your income tax return for day care expenses. If you contribute to the Dependent Day Care Spending Account, the amount of the tax credit will be reduced. Talk to a tax advisor to determine which option is best for you.

Remember, you can only file a claim for reimbursement after you have incurred an eligible dependent day care expense.

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http://www.payflex.com

www.irs.gov


Dependent Day Care FSA (continued)IRS Clarification for Dependent Day Care Spending Accounts

Here are some IRS clarifications regarding Dependent Day Care FSA eligible expenses:

• An eligible dependent care expense must be necessary to enable you and/or your spouse to work, seek work or attend school full-time. Work can be full or part-time, but volunteer work does not qualify.

• If you are away from work for less than a week, such as for vacation or a minor illness, expenses may still be reimbursable from the account.• If you are away from work for longer than a week, even if you are still paid during your absence, dependent care expenses may not be reimbursed from the

account. So if you are on a leave of absence, expenses for day care while you are not working may not be reimbursable. Contact Human Resources within 31 days before or after your leave and you may be eligible to change the amount of your Dependent Day Care FSA election.

• Pre-school and nursery school fees are generally considered eligible expenses, but kindergarten programs are not; the IRS treats kindergarten as an educational program, not child care.

• Specialized and other day camps are generally considered eligible expenses, but overnight camps are not.

Finally, please remember that it may be necessary to adjust highly paid staff members’ contributions to these accounts. WellSpan will let you know if youare affected.

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A Note About Dependent Day Care ExpensesFor dependent day care expenses, take into account the times when you may not need dependent care, such as vacation, or if your child is expected to change to partial or full-day school during the year. You have 90 days after the plan year ends to request reimbursement of services incurred during the plan year.



The Health Savings Account (HSA)When you enroll in the WellSpan High Deductible Medical Plan, you are eligible to contribute to a tax-free HSA that helps offset higher out-of-pocket expenses, including the deductible. The HSA is available only to individuals who enroll in the WellSpan High Deductible Medical Plan, and offers these advantages:

Your ContributionsYou may contribute to the HSA through both payroll deductions

and lump-sum contributions.

Tax AdvantagesYour contributions are tax-free and earn interest. You don’t pay taxes when you withdraw funds to pay

for eligible expenses.

RolloversUnused funds roll over from year to

year, so you can choose to spend the funds in your HSA or save them

for future medical expenses.

OwnershipThe account is always yours,

even if you leave or retire from WellSpan Health.

A Note About Your Contributions

In 2017, you may contribute up to $3,400 for single coverage and $6,750 for family coverage. If you are 55 or older, you may contribute up to an additional $1,000 in catch-up contributions.

Important Information for Medicare-Eligible Staff Members

If you enroll in Medicare, you can no longer make contributions to your HSA beginning with the first month you are covered by Medicare, even if you are automatically enrolled in Medicare Part A. You may continue to use any remaining balance in your HSA for eligible health care expenses while enrolled in Medicare. Once you turn 65, you may also use your HSA funds for your Medicare premiums and your spouse’s premiums, if he or she is enrolled in Medicare. However, you can’t use your HSA funds for a Medicare supplemental policy.

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Review the Spotlight on Medical Plan Options to learn more about the HSA.



https://hr.wellspan.org/documents/Spotlight.pdf

https://hr.wellspan.org/documents/Spotlight.pdf


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How to Use the HSAOpening an HSA

Once you enroll in the WellSpan High Deductible Medical Plan, you may open an HSA with PayFlex. You must actively open your HSA in order to add your own money. Find out more about opening an HSA here.


Eligible Expenses

Once you enroll in your HSA and begin saving money, you’ll be able to use it to pay for eligible health care expenses for you, your spouse and your tax dependents. Common eligible expenses may include:

• Deductibles, copays and coinsurance• Eligible prescriptions• Vision care, including LASIK laser eye surgery• Dental care, including orthodontia

Paying with Your HSA

Once funds are available in your HSA, you can pay for expenses in three ways:

• Use the PayFlex Card®, your account debit card: When you use the PayFlex debit card, you’ll pay for the expense automatically from your account.• Pay yourself back: Pay for eligible expenses with cash, check, or your personal credit card. Then, withdraw funds from your HSA to pay yourself back. You

can even have your payment deposited directly into your checking or savings account.• Pay your provider: Use PayFlex’s online feature to pay your provider directly from your account.

Find out all the ways you can manage your HSA online here.

Make an Investment with Your HSA

Did you know you can invest your HSA funds? Learn more about your investment options.

Please note: If you contributed to a Health Care FSA in 2016, it is recommended that your account balance be zero by December 31, 2016, because you cannot roll over any funds into a 2017 Health Care FSA. You may, however, roll over up to $500 into a Limited Purpose FSA, which you may use for dental and vision expenses only.


https://hr.wellspan.org/documents/Information_needed_to_open_HSA.pdf

https://hr.wellspan.org/documents/Managing_your_PayFlex_HSA_Online.pdf

https://hr.wellspan.org/documents/PayFlex_HSA_Investment_Guide.pdf


How to Use the HSA (continued)Important Information to Keep in Mind

• View the Internal Revenue Service (IRS) contribution limits and a list of common eligible expense items on the PayFlex member website.• Annual contribution limits apply to all monies that you deposit into your HSA account.• The HSA is like a bank account. You can only withdraw funds that are available in your account, regardless of how much you intend to contribute

throughout the year.• You can make a one-time, tax-free transfer from an Individual Retirement Account (IRA). This amount counts toward your HSA annual contribution limit.• If you’re age 55 or older by the end of 2017, you can contribute up to an additional $1,000 annually.• If you use your HSA for ineligible expenses, you’ll need to pay income taxes and a 20% penalty tax on that amount. Note: If you’re age 65 or older or

disabled at the time of this withdrawal, you won’t have to pay the penalty tax. However, you’re still responsible for paying income taxes.• Save your itemized statements, detailed receipts and any Explanation of Benefits (EOB) statements for your expense records.

Questions About Your HSA?

Visit payflex.com, or call PayFlex at 1-844-PAYFLEX (1-844-729-3539), Monday – Friday, 8 a.m. - 8 p.m. ET, and Saturday, 10 a.m. - 3 p.m. ET. For even more detailed information about the HSAs administered by PayFlex, please click here for a detailed summary of HSA information.

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PayFlex Perks: Take Advantage of what Payflex Has to Offer!

PayFlex Coach

Receive helpful HSA on your mobile phone. Text “PAYFLEXHSA” to 57320 and reply “YES” to participate.

PayFlex Mobile® App

Download the PayFlex Mobile® app and simply tap to:

• Deductibles, copays and coinsurance• Check your balance and view alerts• Make payments, withdrawals, and deposits• View PayFlex debit card transactions• View common eligible expense items, and more

Learn more about the PayFlex mobile app here.


https://www.payflex.com/


https://hr.wellspan.org/documents/HSA_An_Overview_2017.pdf

https://www.payflex.com/

https://hr.wellspan.org/documents/PayFlex_Mobile_App_Guide.pdf


In this section, you’ll find information about WellSpan’s dental benefits. Click on a link below to learn more about your Dental Plan choices.

• How the Plan Works• What the Dental Plan Covers


Dental

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2017 Open Enrollment Choices: Dental

Dental CoverageDuring Open Enrollment, you may:

• Enroll, change or drop coverage for yourself• Enroll, change or drop coverage for eligible dependents• Choose no coverage

Your Dental Plan OptionsDelta Dental Plan

If you select the Delta Dental Plan, you may go to any dentist for treatment. You may choose to see a dentist who participates in the Delta Dental program or one who does not. However, all participating network dentists have agreed to accept payment from Delta Dental as payment in full for covered services, subject to coinsurance and any maximums. So you will pay less when you receive care from a Delta Dental network provider. To find a participating dentist, click here.

SCP Dental Plan

If you select the SCP Dental Plan, you may receive care from any dentist you wish. Your level of benefits will not depend on which provider you choose. You may also be responsible for amounts that exceed the SCP Dental Plan allowance.

Out-of-Network Dentists

If your dentist does not participate in the Delta Dental network, you will have to pay for services at the time you receive them and then submit a claim for reimbursement. You may also be responsible for charges that exceed the Delta Dental plan allowance.

Identification Cards

Delta Dental participants who want an identification card may print a card directly from the Delta Dental website.

Remember: If you do not make any changes to your dental coverage, you will be automatically enrolled in a plan that may not be your coverage of choice. Click here for automatic dental enrollment. Go online to elect, change, or verify your dental benefits for 2017.

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Your Delta Dental Group Number: 4262Your SCP Dental Plan Group Number: W028


www.deltadentalins.com

https://www.deltadental.com/Public/index.jsp


What the Dental Plan Covers

Covered Services Delta Dental SCP Dental

Annual DeductibleNone

$50 per person; $150 family$50 maximum per covered individual

Annual Maximum $1,500 per calendar year for each covered individual $1,500 per calendar year for each covered individual

Diagnostic and Preventive(oral exams, cleanings, fluoride treatments for children under age 19, dental x-rays, sealants and space maintainers for children under age 14)

100% of reasonable and customary charges.Certain procedures do not count toward annual maximum.

100% of reasonable and customary charges. (no deductible applies)

Restorative (e.g., fillings, extractions and oral surgery, root canals, periodontics)

85% of reasonable and customary charges75% of reasonable and customary charges

(deductible applies)

Major Resporative (e.g., crowns and bridges)

50% of reasonable and customary charges 50% of reasonable and customary charges (deductible applies)

Implants 50% of reasonable and customary charges ($1,500 annual maximum) Not covered

Orthodontics for Adults and Children 50% of reasonable and customary charges 50% of reasonable and customary charges (deductible applies)

Orthodontic Lifetime Maximum $1,500 for each covered individual $1,500 for each covered individual

See the Summary Plan Descriptions (SPDs) for Delta Dental and SCP Dental for more information on benefit coverage, maximums, and exclusions.

Plan Maximums

A plan maximum is the limit on the amount of dental benefits you may receive for each calendar year. The Plans will not pay more than $1,500 in benefits for each covered individual. Certain preventive services do not count toward the plan maximum.

In addition, there is a $1,500 lifetime maximum on orthodontia benefits. Any dental costs that exceed these maximum amounts are your responsibility.

You may wish to consider enrolling in a Health Care FSA, Limited Purpose FSA, or Health Savings Account to pay for additional costs on a tax-free basis.

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https://hr.wellspan.org/documents/2016SPD_DeltaDental.pdf

https://hr.wellspan.org/documents/2016WSHSCPdentalSPD.pdf


In this section, you’ll find information about WellSpan’s Vision benefits program, administered through Vision Benefits of America. Click on a link below to learn more about the Vision Plan.

• How the Plan Works• What the Vision Plan Covers


Vision

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2017 Open Enrollment Choices: Vision

Vision CoverageDuring Open Enrollment, you may:

• Enroll in, change or drop coverage for yourself• Enroll in, change or drop coverage for your spouse and eligible dependents• Choose no coverage

How the Vision Plan Works

The vision plan helps you pay for routine expenses like eye exams, eyeglass lenses and frames and contact lenses. Vision Benefits of America (VBA) administers your vision plan.

You may choose to see either a VBA network doctor, or an optometrist, ophthalmologist or dispensing optician who is not a member of the VBA network. You will receive a higher level of benefits if you see a VBA network provider.

Review the Vision Chart to see what the Vision Plan covers.

Using Your Benefits: Filing Claims

Select a VBA participating provider in your area. When scheduling an appointment, notify the provider that your vision coverage is administered by VBA. The provider will contact VBA directly to verify your eligibility and will then process your claim electronically once services are received. No claim form is required if you use a VBA provider.

If you use an out-of-network provider, you are required to pay for services in full and then submit a claim, along with a detailed receipt, to VBA for reimbursement.

See the Summary Plan Description (SPD), for more information on benefit coverage, maximums, and exclusions.

Remember: If you do not make any changes to your vision coverage, you will be automatically enrolled in a plan that may not be your coverage of choice. Click here for automatic vision enrollment. Go online to elect, change, or verify your vision benefits for 2017.


www.visionbenefits.com

https://hr.wellspan.org/documents/SPD_VBA2016.pdf


What the Vision Plan Covers

Covered Service and FrequencyPlan Pays

In-Network Out-of-Network

Eye Exam (every 12 months) 100% after $10 copay for exam $35

Eyeglass Frames (every 24 months) Subject to program limits

100% after $10 copay for materials (one copay for total cost of frames and lenses when

obtained together)1

$40

Eyeglass Lenses (every 12 months)• Single Vision• Bifocal• Trifocal• Lenticular

100% after $10 copay for materials (one copay for total cost of frames and lenses when

obtained together)2

$30$40$60$80

Contact Lenses (every 12 months)Includes exam

• Medically necessary3

• Cosmetic (single version)4UCR cost

$150$250$150

1 Within the plan’s $60 wholesale allowance (approximately $150 to $180 retail value).2 Includes solid and gradient tints, UV and scratch resistant protective coatings and polycarbonate lens material for children under age 19.3 Most contact lenses are considered cosmetic, and therefore the benefit will be $150 per 12-month period for lenses obtained in- or out-of-network. Medically necessary contact

lenses are typically used as part of cataract surgery and represent less than 1% of the contacts provided through most vision plans.4 The cosmetic allowance is applied to all services/materials associated with contact lenses. This includes, but is not limited to, contact exam, fitting and dispensing of lenses.

There is no guarantee that the allowance will cover the entire cost of contacts (material and services).

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WellSpan’s Life and Accident insurance benefits offer financial protection for you and your family in the event of an illness, accident or death. Click on the link below to learn more about how WellSpan benefits can protect both you and your family members.

• Life & Accident Coverage: Company-paid• Supplemental Life Insurance: Employee-paid


Life and Accident

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2017 Open Enrollment Choices: Life and Accident

Life and Accident Coverage: Company-PaidYour Life and Accident benefits offer security if something should happen to you or a family member. If you are an eligible employee of WellSpan Health, you automatically receive the following benefits at no cost to you:

Benefit Coverage

Basic Life Insurance* Pays a benefit to your beneficiary if you die from any cause

Basic Accidental Death & Dismemberment Insurance Pays a benefit if you die or are injured in an accident

Business Travel Accident Insurance Pays a benefit if you die or are injured in an accident while traveling on WellSpan business

Recreational Activities Accident Insurance Pays a benefit if you or your dependent are injured while participating in a WellSpan-sponsored recreational activity

* If your Basic Life Insurance equals more than $50,000, the cost of the amount over $50,000 will be taxable. To avoid the additional tax liability, you may waive coverage of your benefit over $50,000. The taxable amount is shown on your pay stub as “wages” under Group Term Life. The appropriate tax is then deducted for this “wage” amount.

The amount of your benefit depends on your benefit classification and the type of covered loss. See your Summary Plan Description (SPD) for more details.

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Remember: only full-time and part-time employees are eligible for Basic Life and Accident Insurance.

Beneficiary changes may be made at any time. Click here for the Life beneficiary form for company-paid insurance and voluntary Life insurance.


https://hr.wellspan.org/documents/LifeSPD.pdf

https://hr.wellspan.org/documents/Life_Insurance_BeneficiaryForm.pdf


Supplemental Life Insurance: Employee-PaidEmployee Life Insurance For Open Enrollment 2017 only, there will be a one-time guarantee issue for Supplemental Life Insurance. This means that you will not need to submit an evidence of insurability (EOI) form in order to obtain this benefit, if you enroll during Open Enrollment. As a full-time or part-time staff member, you are eligible to increase your life insurance coverage by purchasing Supplemental Life Insurance of an additional one, two or three times your annual salary.The maximum benefit for Supplemental Life Insurance is $500,000. If you select Supplemental Life Insurance, you pay the full cost of coverage.

Dependent Life InsuranceYou also have the option of purchasing Dependent Life Insurance for your spouse and eligible children. If you elect Dependent Life Insurance, you pay the full cost of coverage. You have seven coverage options from which to choose:

For Your Spouse For Each Dependent Child*

$5,000 of coverage $10,000 of coverage $20,000 of coverage $30,000 of coverage

$2,500 of coverage $5,000 of coverage $10,000 of coverage

* Age 14 days to 19 years old, full-time students up to age 25 years old

Please note that your cost is not affected by the number of dependent children you cover. If your spouse or eligible dependent is employed by WellSpan, they cannot also be covered under the spouse or dependent insurance options. Neither you nor your spouse can be covered as both an employee and a dependent of an employee. Supplemental Life Insurance costs will change based on any salary changes during the year and/or your transition into a higher age bracket. Remember to check the age(s) and student status of your children to be sure you are only purchasing coverage for eligible dependents.

How to Enroll

1. Decide whether you wish to have Supplemental Life and/or Dependent Life Insurance coverage.2. For 2017, Open Enrollment, there is a one-time guarantee issue for January 1, 2017 only. Enroll online during Open Enrollment.3. If you enroll after Open Enrollment, you will need to provide EOI and be approved for coverage by the insurance carrier.

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Note: If you go online to elect or change any of your benefits, you must click “Change” and re-elect your current Supplemental Life benefits.


WellSpan offers employees several Voluntary Insurance options, many of which are available at discounted group rates. You may enroll in these plans during Open Enrollment or any other time throughout the year. Voluntary Insurance options include:

• Colonial Supplemental Insurance• Auto and Home Insurance• Veterinary Pet Insurance• Other Benefits


Voluntary Benefits

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2017 Open Enrollment Choices: Voluntary Benefits

Supplemental InsuranceColonial Supplemental Insurance

Colonial offers several insurance policies you can purchase to supplement your existing WellSpan Health benefits. Coverage is available to full-time and part-time employees. Representatives will be present at all Open Enrollment Benefit Fairs to answer questions and accept applications. You may apply for coverage at any time during the year.

Short Term Disability Insurance

In addition to the Short Term Disability benefits provided by WellSpan, you may purchase additional short term disability coverage. This additional benefit will supplement the pay you receive as part of the Short Term Disability Plan. You select the level of coverage that is right for you (combined short term disability benefit cannot exceed 100% of pay).

Universal Life & Level Term Insurance

This life insurance plan is portable. That means you may continue the policy if you retire or leave WellSpan. Coverage is also available for your spouse and/or dependents.

Critical Illness Insurance

In the event of a serious illness such as a heart attack, stroke, renal failure or organ transplant, the plan pays you cash. Benefits are paid directly to you regardless of other insurance coverage.

For more information about Colonial products, service questions, or help with a claim, please call the Colonial Service Center at 1-800-325-4368 or visit www.coloniallife.com.

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Important Note for Good Samaritan Staff Members

Payroll deduction will no longer be available for Aflac products beginning with the first pay period in 2017, which starts on December 25, 2016. If you would like to continue your Aflac policies, please be sure to contact Aflac to make arrangements for direct billing by calling John Capozzi, the Aflac representative, at 1-410-490-8646.

Important Note for Ephrata Staff Members

The Symetra voluntary short-term disability policies will end as of December 31, 2016. Participants may want to see the Colonial representatives if additional coverage is desired.



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Auto and Home InsuranceMetLife Auto & Home is a voluntary group benefit program that provides you with access to insurance coverage for your personal insurance needs. Policies available include: auto, landlord’s rental dwelling, condo, mobile/motor home, renters, recreational vehicle, boat and personal excess liability (“umbrella”) policies.

How Auto and Home Insurance Work

The program gives you access to special group rates* and policy discounts*. The MetLife Auto & Home Program features:

• 24-hour claim reporting;• Extended customer service hours, including weekday evenings and Saturdays;• Coverage you can take with you should you retire or leave the company for another reason; and• Enhanced product coverages that are built into every auto policy**.

Call 1-800-GET-MET8 for more information about the program, request a free insurance quote or make changes to your current policy.

Payment Options

You can choose to have your premiums automatically deducted from your paycheck/checking account. With these options, insurance premiums are spread throughout the policy term with no down payments, interest charges or service fees (a down payment is required in some instances). Other payment options are available including mortgage billing for home insurance.

Quotes and Application Processing

Representatives may be available at most of the Benefit Fairs, but you can apply for group auto and home insurance at any time by calling 1-800-GET-MET8 (1-800-438-6388). You may also enroll online at www.metlife.com/mybenefits. An Insurance Consultant will provide you with free, no-obligation premium quotes. If you choose to switch, a consultant can help you apply for insurance while you’re on the phone. Please have your current insurance policy with you when you call.* Available in most states to those who qualify.** Subject to state availability. See your policy for exact details. A deductible may apply.

Coverage, underwritten by MetLife Auto & Home, is available in most states to those who qualify. In Texas, real property policies are provided by Metropolitan Lloyds Insurance Company of Texas ,Irving, TX. In Texas, auto policies are written by either Metropolitan Direct Property and Casualty Insurance Company, Metropolitan Property and Casualty Insurance Company, Metropolitan Casualty Insurance Company, Metropolitan General Insurance Company, all of Warwick, RI, or GAINSCO County Mutual Insurance Company, Fort Worth, TX, through an arrangement with Metropolitan Property and Casualty Insurance Company. In some instances, special arrangements for coverage have been made with other carriers. MetLife Auto & Home is a brand of Metropolitan Property and Casualty Insurance Company and its Affiliates, Warwick, RI.

L0208NCC0(exp0706)MPC-LD



Pet InsuranceWhen your pet needs medical care, the last thing you want to be concerned about is how to pay for it. Fortunately, Nationwide can help you handle the ever-increasing costs of caring for your pets when they are ill or injured.

How the Benefit Works

A Nationwide policy covers thousands of medical problems and conditions related to accidental injuries, emergencies, poisonings and illnesses, and even cancer. You may also add optional Vaccination & Routine Care Coverage that helps pay for vaccinations, annual physical exams, heartworm protection, choice of spay/neuter, teeth cleaning or comprehensive health screening, prescription flea control and more. The coverage includes:

• A $50 deductible applied to each different accident or illness per policy term.• After you meet the deductible, the policy pays 90% of the first $180 and 100% in excess of $180 of the

plan’s Benefit Schedule Allowance, per incident, during each policy term. • You may submit multiple claims for the same accident or illness (e.g., pet is hit by car and requires follow-up

visits) and only one deductible applies because it is related to the same incident.

Like most insurance policies, there are some exclusions to keep your premiums low, including:

• Elective procedures• Pet foods• Grooming

Vaccinations, routine teeth cleaning and other annual routine care expenses are not covered under the primary plans, but are available through optional Vaccination & Routine Care Coverage. A pre-existing condition before the policy effective date may be covered during the policy term if the condition has been previously cured. Additional information can be found on the Nationwide pet insurance website at www.petinsurance.com.

Payment Options

Nationwide offers convenient payment options: payroll deduction (for active employees only) and credit card or checking account automatic deduction. A Nationwide representative can confirm which payment options are available to you.

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How to EnrollRepresentatives will attend most of the Benefit Fairs. At any time during the year, you may also call 1-888-899-4874 to speak with a Nationwide representative who can answer questions, give personalized premium quotes and enroll you in the program over the phone. Nationwide representatives are available Monday through Saturday and weekday evenings.

• Behavioral problems• Congenital or hereditary defects• Medical conditions that are present prior to the policy effective date


http://www.petinsurance.com/?item=%2fcoverage%2fbenefitschedule&user=extranet%5cAnonymous&site=website

www.petinsurance.com


Other Year-Round BenefitsAs a WellSpan employee, you may be entitled to a number of benefit offerings beyond the core benefits at no cost to you, depending on your employment status. Below is a list of additional benefits that may be available to you year-round and do not require enrolling during Open Enrollment:

• Short Term and Long Term Disability Coverage• Employee Assistance Plan• Child Care Services and Child Care Referral Services• Holidays• Paid Time Off (PTO)• Leave of Absence Programs (bereavement, military, personal and family and medical leave)• Educational Assistance• Credit Unions: First Capital, Members 1st and Belco Credit Unions are available to WellSpan Employees

For more information, contact the Benefits Service Center at 1-717-851-3332.

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Wellness Matters

Wellness Matters is a comprehensive online wellness program for WellSpan employees. If enrolled in a WellSpan medical plan, you can earn a wellness incentive by enrolling in Wellness Matters, completing a health risk assessment and getting the required biometric screening completed within 31 days of your hire date and by September 30 in the following years. Learn more about the program and other available incentives at www.wellspanwellness.org.


For each of the benefits provided through WellSpan, you will be responsible for sharing in the cost by paying a monthly contribution. Click on the links below to view the monthly contributions.

• Medical• Dental and Vision• Supplemental Life Insurance

Contributions will generally be deducted from your paycheck on a pre-tax basis for all full-time, part-time 1, and PRN 4 staff members.

Part-time 2 and other PRN staff members must pay their contributions by personal check.

Cost of Coverage

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Understanding Your Monthly ContributionsHow much you pay for benefits is dependent on your employment and your full-time equivalent status (your FTE). Your FTE reflects the number of hours you are budgeted to work and not the number of hours you actually may work in a pay period. WellSpan will consider you to be “full time” if you work at least 70 hours in a pay period or have an FTE of .875 or above.

Your Medical Rates

The Affordable Care Act (ACA) requires employers to offer full-time medical benefits to staff members whose average hours for a defined measurement period are 30 hours or more per week. The measurement period for WellSpan staff members is October 2015 to October 2016. Hours worked and any time you are on certain absences, such as PTO, FMLA, or low census, may be included in the average hours determination.

WellSpan also considers you to be full time for employee premium purposes if your employment status is full time as of December 25, 2016. Finally, it is possible to lower your cost for medical benefits by participating in the WellSpan Wellness Matters program. The lower 2017 wellness rates apply to staff members who complete the Bronze Level of the Wellness Matters program by September 30, 2016.

In summary, your medical monthly premium rates are based on:• Whether your hourly salary is $13.00 per hour or less, or $13.01 and above as of the first payroll for the new plan year. For this year, that date is

December 25, 2016;• Your full-time employment status as of December 25, 2016 or, if you are not full time on that date, your average hours for a defined measurement period

as of October 2016; and• Whether you have completed the Wellness Matters program requirements by September 30, 2016 to receive a lower medical premium.

The employee premium charts are divided in sections based on your employment status, your FTE, and completion of the Wellness Matters program as shown below:

For Medical Premiums Only

Full-time rate: 60 or more average hours per paycheck as per ACA regulations

Part-time 1 & PRN 4 rate: FTE at least .40 but less than .75 (32 - 59 budgeted hours per paycheck)

Part-time 2 & all other PRN rate: FTE less than .40 (fewer than 32 budgeted hours per paycheck)

Cost of Coverage

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Your Dental and Vision Rates

Monthly premium rates for dental and vision are based on your employment status and your FTE as shown below.

Full-time rate: FTE .875 – 1.0 (70 or more budgeted hours per paycheck)

Part-time 1 & PRN 4 rate: FTE at least .40 but less than .875 (at least 32 but less than 70 budgeted hours per paycheck)

Part-time 2 & all other PRN rate: FTE less than .40 (fewer than 32 budgeted hours per paycheck)

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2017 Medical Monthly ContributionIf you completed the Health Risk Assessment and the biometric screening through the Wellness Matters program by September 30th, you can receive a $30 wellness incentive per month on your medical premiums. Review your 2017 medical plan contributions with and without the wellness incentive.Note: Rates are shown as monthly contributions. Deductions occur 24 times per year (with no deduction occurring on the third pay of the month).

Employees with $13.00 and Under Hourly Pay Rate (With $30 Per Month Wellness Incentive)


Monthly Cost for Full-Time Staff Members*

Employee Only $42 $25 $18

Employee and children $172 $130 $70

Employee and spouse $202 $156 $130

Family $224 $172 $160

Monthly Cost for Part-Time Staff Members 1 and PRN 4 Staff Members**




Family $525 $414 $370

Monthly Cost for Part-Time Staff Members 2 and All Other PRN Staff Members***



Employee and spouse $1,084 $860 $740

Family $1,166 $924 $800

* All WellSpan Medical Plans: 60 or more hours per paycheck as per ACA regulations** All WellSpan Medical Plans: FTE at least .40 but less than .75 (32 - 59 budgeted hours per paycheck)*** All WellSpan Medical Plans: FTE less than .40 (fewer than 32 budgeted hours per paycheck)


2017 Medical Monthly Contribution (continued)Employees with $13.00 and Under Hourly Pay Rate (Without $30 Per Month Wellness Incentive)






Family $254 $202 $190





Family $555 $444 $400




Employee and spouse $1,114 $890 $770

Family $1,196 $954 $830


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2017 Medical Monthly Contribution (continued)Employees with $13.01 and Over Hourly Pay Rate (With $30 Per Month Wellness Incentive)






Family $254 $198 $170





Family $622 $490 $420



Employee and children $1,188 $946 $670

Employee and spouse $1.354 $1,078 $790

Family $1,456 $1,160 $850


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2017 Medical Monthly Contribution (continued)Employees with $13.01 and Over Hourly Pay Rate (Without $30 Per Month Wellness Incentive)






Family $284 $228 $200





Family $652 $520 $450



Employee and children $1,218 $976 $700

Employee and spouse $1,384 $1,108 $820

Family $1,486 $1,190 $880


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Financial Assistance As part of our charitable mission, WellSpan Health is committed to providing exceptional care for all our patients which includes our staff members and their families. We recognize that sometimes staff members may need financial assistance to help with the costs of health care. WellSpan offers two ways to obtain assistance for medical costs to qualified staff members.

Premium Assistance Program: WellSpan Plus

The Premium Assistance Program helps eligible full-time staff members pay for medical insurance premiums for the WellSpan Plus plan. Staff members who qualify for the program receive medical coverage for themselves and their covered dependents for the upcoming calendar year without making contributions. Participating staff members are still responsible for paying applicable out-of-pocket costs (copays, coinsurance and deductible amounts) for services.

Eligibility Requirements

Staff members must:

• Be full-time at the time of the application and remain full-time throughout the 2017 calendar year• Have at least one year of service by January 1, 2017• Meet the earnings criteria within the WellSpan Health Financial Assistance Policy and provide proof of income• Apply for assistance each year during Open Enrollment (staff members who experience a financial need during the year will only be considered for the

program if they also experience a qualifying change in status)• Click here to review the application on INET

Application Process (Staff Members will be required to reapply annually)

1. Download an application from HRONLINE and submit it via interoffice mail to Premium Assistance, PCC - Suite B5, Attn: Patient Financial Rep. Supervisor, Confidential, by Friday, November 11, 2016. Be sure to write “Open Enrollment” on the envelope. (Personal financial records will remain confidential and will not be shared outside of the Healthy Community Network.) If you prefer, you may also scan and email the application to [email protected].

2. Patient Financial Representatives will determine if the applicant qualifies for the program.3. If approved, the Patient Financial Representative will notify the individual in writing or by phone.

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https://hr.wellspan.org/documents/PremiumAssist2017.pdf

https://hr.wellspan.org/documents/PremiumAssist2017.pdf


Financial Assistance for Medical Costs

The WellSpan Financial Assistance policy was recently updated and is available to help staff members and their families with medical costs. The Financial Assistance policy has been expanded and improved and can provide free or discounted care depending on need.

In order to qualify for assistance, staff members must be enrolled in a medical plan either through WellSpan, a spouse’s employer, the plans available on the Exchanges (Affordable Care Act) or through Pennsylvania’s Medical Assistance (Medicaid) program. Claims must be submitted to your medical coverage first before you may be considered for financial assistance.

To apply, you must complete an application and provide the necessary documentation. Qualification for assistance is based on income and household size, relative to Federal Poverty Level guidelines.

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Please Note: The new Financial Assistance policy, available now, at www.wellspan.org/financialassistance provides a consistent approach to financial assistance throughout WellSpan. It replaces the various courtesy allowance policies that have been administered throughout WellSpan including those that may have been available at WellSpan legacy, Ephrata, Good Samaritan and Philhaven. These courtesy allowance policies will no longer be in effect as of January 1, 2017. The new Financial Assistance policy can help medical costs including amounts owed due to copay and coinsurance medical plan requirements and amounts owed because the deductible for your plan has not yet been met. Applications are available through customer service at the following numbers, or online at www.WellSpan.org/FinancialAssistance.

York/Adams: 1-717-851-2102Lancaster: 1-717-738-6261Lebanon: 1-717-270-4881Philhaven: 1-717-675-1111

http://www.wellspan.org/financialassistance

http://www.WellSpan.org/FinancialAssistance


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2017 Dental and Vision Monthly ContributionNote: Rates are shown as monthly contributions. Deductions occur 24 times per year (with no deduction occurring on the third pay of the month).

Delta Dental SCP Dental Vision


Employee Only $6.65 $8.30 $2.36

Family $20.12 $25.33 $5.58


Employee Only $16.58 $24.89 $3.72

Family $41.63 $43.15 $8.68


Employee Only $31.33 $48.50 $6.20

Family $79.83 $102.06 $14.86

* Delta Dental, SCP Dental and VBA: FTE .875 – 1.0 (70 or more budgeted hours per paycheck)** Delta Dental, SCP Dental and VBA: FTE at least .40 but less than .875 (At least 32 but less than 70 budgeted hours per paycheck) *** Delta Dental, SCP Dental and VBA: FTE less than .40 (Fewer than 32 budgeted hours per paycheck)


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2017 Supplemental Life Insurance ContributionSupplemental Life Insurance

Your Age Monthly Contribution Per $1,000 of Coverage

under age 25 $.05

ages 25 - 29 $.06

ages 30 - 34 $.08

ages 35 - 39 $.09

ages 40 - 44 $.10

ages 45 - 49 $.15

ages 50 - 54 $.23

ages 55 - 59 $.43

ages 60 - 64 $.66

ages 65 - 69 $1.27

age 70 and over $2.06

Dependent Life Insurance

Coverage Monthly Contribution

Spouse Life

$5,000 for spouse $1.40/month




Dependent Child(ren) Life

$2,500 for each child $.40/month

$5,000 for each child $.80/month

$10,000 for each child $1.60/month

When you enroll for life insurance coverages, you should indicate a beneficiary (someone to whom benefits would be paid should you die while covered by the plan). Don’t forget to review your beneficiary designations from time to time, especially if you get married or divorced. If you designate a minor as your beneficiary, the minor would not be paid the benefit until he or she is age 18.Enroll in Supplemental and/or Dependent Life insurances online during Open Enrollment.

Beneficiary Information

Click here for the beneficiary form. Return completed form by faxing to 1-717-851-3100 or by emailing it to [email protected]. Keep a copy your beneficiary information in a safe place for your records.

https://hr.wellspan.org/documents/Life_Insurance_BeneficiaryForm.pdf


In this section, you’ll find contact information for the programs and resources available to you through WellSpan.

Resources

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Resources


Resources

Resource Phone Number Web Use it to...

Online Open Enrollment N/A http://hr.wellspan.org

Once you’re at HRONLINE, click on the pumpkins.

Enroll, change, drop or elect no benefit coverage during Open Enrollment

Employee Benefits Service Center 1-717-851-3332 Email: [email protected] Connect with WellSpan Benefits staff who can answer your benefit questions M - F 8:00 a.m. to 4:30 p.m.

WellSpan Medical Plans Network Search Site

N/A http://hr.wellspan.org/wellspanplus Determine which tier your provider belongs to and, as a result, how much you can expect to pay for service

South Central Preferred 1-800-842-17681-717-851-6800

www.scphealth.com Access provider directories, general health information, online newsletters and links to customer service and other health-related websites

Aetna Signature Administrators PPO Network

N/A www.aetna.com/asa Access provider directories for the Tier 2 Aetna Signature Administrators PPO Network.

WellSpan Pharmacy 1-717-851-5980 or1-877-448-8809

www.wellspan.org/offices-locations/ambulatory-services/pharmacies/

Order refills online

WellSpan Pharmacy Mail Order 1-855-339-2305 www.wellspan.org/offices-locations/ambulatory-services/pharmacies/

Get information on mail order or specialty drugs.

Quest Behavioral Health 1-800-364-6352 www.questbh.com Access provider directories, forms and benefit information; connect with clinical staff who can answer behavioral heath questions 24 hours a day 7 days a week


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http://hr.wellspan.org

mailto:benefits%40wellspan.org?subject=

http://hr.wellspan.org/wellspanplus

http://www.scphealth.com

http://www.aetna.com/asa





http://www.questbh.com

Resources


Resources (continued)

Resource Phone Number Web Use it to...

Delta Dental 1-800-932-0783 www.deltadentalins.com Get a list of participating dentists, claim forms and useful dental health tips

SCP Dental 1-800-842-17681-717-851-6800

N/A Get claim forms and benefits information

Vision Benefits of America 1-800-432-4966 www.visionbenefits.com Download claim forms and access a network provider directory

PayFlex 1-844-PAYFLEX (729-3539)

www.payflex.com Get information and services for employees with the Health Savings Account and Health Care, Limited Purpose, and/or Dependent Day Care FSAs (such as claims submission, account balance infomation and eligible expenses)

MetLife 1-800-438-6388 www.metlife.com/mybenefits Learn more about the voluntary benefits program, including auto, home and veterinary pet insurance

Wellness Matters 1-717-851-4336 www.wellspanwellness.org Participate in a comprehensive online wellness program and earn cash rewards

Colonial 1-800-325-4368 www.coloniallife.com Get information on supplemental disability plans and critical illness insurance

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http://www.deltadentalins.com

http://www.visionbenefits.com


http://www.metlife.com/mybenefits

http://www.wellspanwellness.org

www.coloniallife.com


The following legal notices are included in this guide to inform you of your rights under federal law. All legal notices, including the new wellness notice, can be found at the links below or on INET: HRONLINE > Benefits Resources > Legal.

if you have any questions about the legal notices in this guide, call the Human Resources Benefits Service Center at 1-717-851-3332.

Legal Notices

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Resources


Legal Notices

Legal Notice This Notice Describes…

Health Insurance Marketplace Coverage Options and Your Health Coverage

Information about the public health exchanges and your health coverage offered by WellSpan Health.

COBRA Coverage Information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the WellSpan Health medical, dental and vision plans, as well as Health Care FSA and Employee Assistance Program.

Employees Eligible for Medicare

(All plans are creditable)

Information about your current prescription drug coverage with WellSpan Health and prescription drug coverage if you are enrolled in or eligible for Medicare. It also explains the options you have under Medicare prescription drug coverage and can help you decide whether or not you want to enroll.

HIPAA Notice of Privacy Practices Your rights under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requiring health plans to protect the confidentiality of your private health information.

Maternity and Newborn Length of Stay Your rights to benefits connected with your length of hospital stay after the delivery of a child.

Mastectomy Services Your rights to receive coverage for breast reconstruction and related services.

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

Offer Free Or Low-Cost Health Coverage To Children And Families

If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have premium assistance programs that can help pay for coverage.

Click here to access this entire group of Legal Notices.

Additional Legal Notices

Legal Notice This Notice Describes…

WellSpan Health Cafeteria Plan Summary Annual Report

Summary of the annual report which has been filed with the Employee Benefits Security Administration, as required under the Employee Retirement Income Security Act of 1974 (ERISA).

Additional Legal Notices have been placed on INET: HR ONLINE > Benefits Resources > Legal.

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https://hr.wellspan.org/documents/2017_Benefits_Legal_Notices.pdf

https://hr.wellspan.org/documents/CafeteriaPlanSAR.pdf

https://hr.wellspan.org/documents/CafeteriaPlanSAR.pdf


Health Insurance Marketplace Coverage Options and Your Health CoveragePART A: General Information As part of the Affordable Care Act, there is another way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace.

What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers “one-stop shopping” to find and compare private health insurance options. You may also be eligible for a tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2016 for coverage starting as early as January 1, 2017.

Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn’t meet certain standards. The savings on your premium that you’re eligible for depends on your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer’s health plan. However, you may be eligible for a tax credit that lowers your monthly premium or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the “minimum value” standard set by the Affordable Care Act, you may be eligible for a tax credit.1 Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution –as well as your employee contribution to employer-offered coverage –is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis.

How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact WellSpan Health Benefits Department.The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area. 1 An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs.

Legal Notices

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https://www.healthcare.gov


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Health Insurance Marketplace Coverage Options and Your Health Coverage (continued)Inrmation About Health Coverage Offered by Your EmployerThis section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application.

3. Employer name WellSpan Health

4. Employer Identification Number (EIN) 22-2517863

5. Employer address 1135 Edgar Street PO Box 15198

6. Employer phone number 1-717-851-3332

7. City York

8. State PA

9. ZIP code 17405

10. Who can we contact about employee health coverage at this job? Benefits Department

11. Phone number (if different from above) 12. Email Address [email protected]

Here is some basic information about health coverage offered by this employer:

• As your employer, we offer a health plan coverage to:

All employees.

X Some employees. Eligible employees are:

All full-time, part-time and PRN staff members

• With respect to dependents:X We do offer coverage. Eligible dependents are:

• Spouse;• Your child(ren) or those of your spouse up to age 26

We do not offer coverage.

X If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages. Please see below: WellSpan Plus – Employee Coverage Cost The WellSpan Plus plan exceeds the minimum value standard. The insurance plan is intended to be affordable for all full-time employees. If your employee status is not full-time, the insurance plan may be affordable depending on pay rate and hours scheduled to work.

** Even though your employer intends for your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount.

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here’s the employer information you’ll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums.

https://www.healthcare.gov/

https://www.healthcare.gov/


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COBRA CoverageCONTINUATION COVERAGE RIGHTS UNDER COBRA (Medical, Dental, Vision, EAP and Health Care Spending Account Benefits)

IntroductionThis notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the WellSpan Health medical, dental, vision, Employee Assistance Program and health care spending account plans (the Plans). The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and to other members of your family who are covered under the Plans when you would otherwise lose your group health coverage. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. This notice gives only a summary of your COBRA continuation coverage rights. For more information about your rights and obligations under the Plan and under federal law, you should review the Plans’ Summary Plan Descriptions.

COBRA Continuation CoverageCOBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.” Specific qualifying events are listed later in this notice. COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event. Depending on the type of qualifying event, employees, spouses of employees, and dependent children of employees may be qualified beneficiaries. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you are an employee, you will become a qualified beneficiary if you will lose your coverage under the Plan because one of the following qualifying events happens:

• Your hours of employment are reduced; or• Your employment ends for any reason other than your gross misconduct.• If you are the spouse of an employee, you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following qualifying events happens:• Your spouse dies• Your spouse’s hours of employment are reduced;• Your spouse’s employment ends for any reason other than his or her gross misconduct;• Your spouse becomes enrolled in Medicare (Part A, Part B or both); or• You become divorced or legally separated from your spouse; in a state that recognizes legal separation.• Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens:• The parent-employee dies;• The parent-employee’s hours of employment are reduced;• The parent-employee’s employment ends for any reason other than his or her gross misconduct;• The parent-employee becomes enrolled in Medicare (Part A, Part B or both);• The parents become divorced or legally separated; in a state that recognizes legal separation; or• The child stops being eligible for coverage under the Plan as a “dependent child.”

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee or enrollment of the employee in Medicare (Part A, Part B or both), the employer must notify the Plan Administrator of the qualifying event within 31 days of any of these events.

For the other qualifying events (divorce or legal separation of the employee and spouse, or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator. The Plan requires you to notify the Plan Administrator within 60 days after the qualifying event occurs. Failure to provide timely notice will result in loss of COBRA rights. Written notice must be given to Employee Benefits, Human Resources. Notice may be provided by e-mail ([email protected]), letter (certified mail, return receipt requested) or delivered in person to the Human Resources Office, 1135 Edgar Street, Suite 103, P.O. Box 15198, York, PA 17405.


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COBRA Coverage (continued)When coverage is lost due to the reasons set forth below, you must provide documentation as shown beside each reason:

• Death of the employee – death certificate;• Legal separation or divorce – copy of legal separation papers or divorce decree (PA does not recognize legal separation); or• Enrollment of the employee in Medicare – Medicare Card.

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses and parents may elect COBRA continuation coverage on behalf of children. COBRA continuation coverage will begin on the date that Plan coverage would otherwise have been lost. COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, enrollment of the employee in Medicare (Part A, Part B or both), your divorce or legal separation, dissolution of a domestic partner relationship or a dependent child losing eligibility as a dependent child, COBRA continuation coverage lasts for up to 36 months. When the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage lasts for up to 18 months. There are two ways in which this 18-month period of COBRA continuation coverage can be extended.

Disability Extension of 18-Month Period of Continuation CoverageIf you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled at any time during the first 60 days of COBRA continuation coverage and you notify the Plan Administrator in a timely fashion, you and your entire family may receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. You must make sure that the Plan Administrator is notified in writing of the Social Security Administration’s determination within 60 days of the date of determination and before the end of the original 18-month period of COBRA continuation coverage. This notice should be sent to: Human Resources Department – Employee Benefits, WellSpan Health, 1135 Edgar Street, P. O. Box 15198, York, PA 17405

Second Qualifying Event Extension of 18-Month Period of Continuation CoverageIf your family experiences another qualifying event while receiving COBRA continuation coverage, the spouse, and dependent children in your family can get additional months of COBRA continuation coverage, up to a maximum of 36 months. This extension is available to the spouse, and dependent children if the former employee dies, gets divorced or legally separated. The extension is also available to a dependent child when that child stops being eligible under the Plan as a dependent child. In all of these cases, you must make sure that the Plan Administrator is notified in writing of the second qualifying event within 60 days of the second qualifying event. This notice must be sent to: Human Resources Department – Employee Benefits, WellSpan Health, 1135 Edgar Street, P.O. Box 15198, York, PA 17405. When the qualifying event is due to the reasons set forth below, you must provide documentation as shown beside each reason:

• Death of the employee – death certificate; or• Legal separation or divorce – copy of legal separation papers or divorce decree (PA does not recognize legal separation);

If You Fail to Elect COBRAIf you do not choose COBRA continuation coverage within the time allowed or if you do not respond to requests for additional information about your qualifying event within a reasonable period of time, your group health coverage and your participation in the Health Care Spending Account will end at the end of the month in which the qualifying event occurs, e.g., after the date of divorce.

The Cost of Continuation CoverageEach individual who elects to continue coverage under COBRA must pay the full cost of coverage, plus 2% for administrative expenses. You pay for COBRA continuation coverage in monthly premiums which are due on the first day of each month. Payments not received within 31 days after your premium is due will result in loss of coverage retroactive to the day before your premium was due. Your first payment must be made within 45 days after you elect COBRA continuation coverage, and is retroactive to the date you lost coverage. An administrative fee equal to 50% of the full cost of coverage may be charged for COBRA continuation for qualified disabled individuals beginning with the 19th month and continuing until COBRA coverage terminates. That means, for the first 18 months of COBRA coverage, you would pay 102% monthly, and for the remaining coverage period you would pay 150% monthly. This includes a second qualifying event which would allow you up to a maximum of 36 months of continuation coverage that occurs after the end of the end of the original 18-month period. However, if the second qualifying event occurs within the original 18-month period of coverage, you cannot be charged more than 102% at any time during the 36-month period.


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COBRA Coverage (continued)When coverage is lost due to the reasons set forth below, you must provide documentation as shown beside each reason:

• Death of the employee – death certificate;• Legal separation or divorce – copy of legal separation papers or divorce decree (PA does not recognize legal separation); or• Enrollment of the employee in Medicare – Medicare Card.

Loss of Continuation CoverageThere are certain circumstances which will cut short the period during which you, your spouse, and/or children can have coverage continued under COBRA. These circumstances are:

• You fail to pay the monthly premium for the coverage within 31 days of its due date (or within 45 days, if it is the first monthly payment);• You, your spouse, or child become covered under any other group health plan which has no exclusions or limitations regarding that person’s own pre-existing conditions (if any);• You, your spouse, or child become covered by Medicare (Part A, Part B or both);• WellSpan Health ceases to provide any group health plan to its employees; or• You extended coverage for up to 29 months due to your disability, and there has been a determination that you are no longer disabled.

Continuation coverage may also be terminated for any reason the Plan would terminate coverage of a participant or beneficiary not receiving continuation coverage (such as fraud).

Proof of Insurability Not Required for COBRAYou do not have to show that you are insurable to choose continuation coverage. The law also says that at the end of the 18-month or 36-month continuation coverage period, you must be allowed to enroll in any individual conversion health plan then provided under WellSpan Health’s health plans for employees, if available.

If You Have QuestionsThe Plan Administrator is WellSpan Health Human Resources Department, 1135 Edgar Street, P. O. Box 15198, York, PA 17405, 1-717-851-3332. The Plan Administrator is responsible for administering COBRA continuation coverage. If you have questions about your COBRA continuation coverage, you should contact the Human Resources Department – Employee Benefits, WellSpan Health, or you may contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA). Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website at www.dol.gov/ebsa.

Keep Your Plan Informed of Address ChangesIn order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy for your records of any notices you send to the Plan Administrator.


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Employees Eligible for MedicareImportant Notice from WellSpan Health About Your Prescription Drug Coverage and MedicareThis is a required annual mailing. It provides you with information should you want to consider enrollment in a Medicare Part D prescription plan.

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with WellSpan Health and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. WellSpan Health has determined that the prescription drug coverage offered by the WellSpan Medical Plan (WellSpan Plus, WellSpan Standard, and WellSpan High Deductible) is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you may keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

When Can You Join a Medicare Drug Plan?You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?If you are an active employee who is eligible for Medicare Part D and you enroll in a plan, you will lose your entire medical coverage with WellSpan at the end of the month in which you enroll in a Part D plan.

If you do decide to join a Medicare drug plan and drop your current WellSpan Medical Plan coverage, you will be able to enroll again during Open Enrollment. If you no longer carry WellSpan medical coverage, you will not receive an Open Enrollment notice. Please be aware that Open Enrollment begins on October 17 and ends November 11.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?You should also know that if you drop or lose your current coverage with WellSpan and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage, contact the WellSpan Health Benefits Department at 1-717-851-3332.

You will receive this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through WellSpan changes. You may also request a copy of this notice at any time.


Employees Eligible for Medicare (continued)Where Can You Find More Information About Your Options Under Medicare Prescription Drug Coverage?More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage:• Visit www.medicare.gov• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help.• Call 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

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HIPAA Notice of Privacy PracticesWellSpan Health Employee Benefit Plans Effective Date: April 14, 2003This Notice Describes How Medical Information About You May Be Used And Disclosed And How You May Get Access To Your Medical Information. Please Review It Carefully.

This Notice describes the WellSpan Health Employee Health Plans’ practices in connection with the use and disclosure of your medical information, your rights and certain obligations we have regarding the use and disclosure of your medical information. This notice and the privacy practices described in it apply to your medical information regardless of where the information is maintained or collected by the Plans.

We are required by law to maintain the privacy of your medical information and to provide you with this Notice describing our privacy practices. We are required to abide by the terms of this Notice, as it is modified from time to time. We understand that medical information about you and your health is personal.

If you have any questions about this notice, please contact the Plans’ Privacy Officer, Shirley Dwyer, Senior Director of HR Operations, 1135 Edgar Street, Suite 103, P. O. Box 15198, York, PA 17405-7198.

WE MAY MAKE CHANGES TO THIS NOTICE IN THE FUTURE, AND ANY OF THE TERMS OF THIS NOTICE THAT ARE CHANGED WILL APPLY TO ALL OF YOUR MEDICAL INFORMATION. IF WE CHANGE OUR NOTICE, YOU MAY OBTAIN A COPY OF THE REVISED NOTICE BY REQUESTING IT IN PERSON AT THE HUMAN RESOURCES OFFICE OR BY SENDING A WRITTEN REQUEST FOR A COPY TO THE PRIVACY OFFICER AT THE ADDRESS LISTED ABOVE. YOU MAY ALSO REVIEW OUR NOTICE ON THE HRONLINE PAGE OF THE COMPANY INTRANET SITE, “THE INET.”

How We May Use or Disclose Your Medical InformationWe are permitted or required to use your medical information for various purposes. We cannot describe every possible use or disclosure of your medical information in this Notice. However, uses or disclosures that we are permitted or required to make will generally fall within one of the following categories.

For Treatment — We may use and disclose medical information about you in order to ensure that you receive proper medical treatment. We may disclose medical information about you to doctors, nurses, technicians, medical students or other personnel who are involved in taking care of you. For example, if you are treated in the emergency room, information regarding your visit may be disclosed to your family doctor so that he or she can be kept up to date regarding your health. If you are referred to a specialist, information regarding your healthcare may be shared with the specialist in order to assist him or her in evaluating your healthcare needs. If you are in a facility, different departments of that facility may share medical information about you in order to coordinate the different aspects of your care, such as prescription of medications, lab work and x-rays. We may also disclose your medical information to another health care provider who is involved in your care.

For Payment — We may use and disclose medical information about you so that the treatment and services provided to you may be billed to and payment may be collected from you, an insurance company or the Plan, to determine eligibility for Plan benefits, or to coordinate Plan coverage. For example, we may need to give your health care provider information about your medical history to determine whether a particular treatment is experimental, investigational or medically necessary or to determine whether the Plan will cover the treatment. We may also share medical information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments. We may also disclose your medical information to another entity that is covered by the privacy regulations or a health care provider for that entity’s payment.

For Health Care Operations — We may use and disclose medical information about you for other Plan operations. Plan operations are activities that are necessary to run the Plans such as conducting quality assessment and improvement activities; underwriting, premium rating, disease management, plan design and other activities relating to Plan coverage; submitting claims for stop-loss (or excess loss) coverage; conducting or arranging for medical review, legal services, audit services and fraud and abuse detection programs; business planning and development such as cost management; and business management and general Plan administrative activities.

Individuals Involved in Your Care or Payment for Your Care — We may release medical information about you to a family member, domestic partner, common law partner, personal representative or close personal friend who is involved in your medical care or payment for that care. The medical information will be relevant to that person’s involvement in your care or payment related to your care.

As Required by Law — We will disclose medical information about you when required to do so by federal, state or local law.


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HIPAA Notice of Privacy Practices (continued)To Avert a Serious Threat to Health or Safety — We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threatened harm.

Other Special Situations• Organ and Tissue Donation — information may be disclosed to organ procurement organizations;• Military and Veterans — information may be disclosed to military command authorities;• Worker’s Compensation — information may be disclosed on work-related injuries• Public Health Risks — information may be disclosed to public agencies to prevent or control disease, report births and deaths, abuse or neglect and product problem/recall issues. • Health Oversight Activities — information may be disclosed to a health oversight agency for activities authorized by law including to organizations designated by the Medicare

program to review medical services provided to Medicare beneficiaries.• Lawsuits and Disputes — information may be disclosed in response to a court or administrative order, subpoena, discovery request or other lawful process.• Law Enforcement — information may be disclosed to law enforcement officials (1) in response to a court order, subpoena, warrant, summons or similar process; (2) to identify or locate

a suspect, fugitive, material witness or missing person; (3) about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct at a WellSpan facility; and (6) in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

• Coroners, Medical Examiners and Funeral Directors — information may be disclosed to identify a deceased person, determine cause of death or for burial purposes.• Government Purposes — information may be disclosed to (1) authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law, (2)

authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations. If you are an inmate of a correctional institution or under the custody of a law enforcement official, information may be disclosed to (1) allow the institution to provide you with health care, (2) protect your health and safety or the health and safety of others, or (3) for the safety and security of the correctional institution.

• Incidental Uses and Disclosures — information may be disclosed if it is a by-product of any of the uses or disclosures described above and it could not be reasonable prevented.

Your Health Information RightsYou have the following rights regarding the medical information we maintain about you:

Right to Inspect and Copy — You have the right to inspect and copy your medical information that is in our possession. You may not, however, have access to psychotherapy notes or information that is gathered for use in a civil, criminal or administrative proceeding. We may deny your request to inspect or copy your health information in certain very limited circumstances. Your request may be denied to the extent that the information is protected by the Privacy Act or was provided to your healthcare providers by someone else under a promise of confidentiality.

Right to Amend — If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend that information. Your request must be in writing and sent to the Plans’ Privacy Officer at the address listed above and must explain why you believe that the medical information is incorrect or incomplete.

We may deny your request for amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that (1) was not created by us, unless the person or entity that created the information is no longer available to make the amendment, (2) is not part of the medical information kept by us, (3) is not part of the information which you would be permitted to inspect and copy or (4) is accurate and complete.

Right to Inspect and Copy — You have the right to inspect and copy your medical information that is in our possession. You may not, however, have access to psychotherapy notes or information that is gathered for use in a civil, criminal or administrative proceeding. We may deny your request to inspect or copy your health information in certain very limited circumstances. Your request may be denied to the extent that the information is protected by the Privacy Act or was provided to your healthcare providers by someone else under a promise of confidentiality.


HIPAA Notice of Privacy Practices (continued)Your Health Information Rights (continued)Right to Amend — If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend that information. Your request must be in writing and sent to the Plans’ Privacy Officer at the address listed above and must explain why you believe that the medical information is incorrect or incomplete.

We may deny your request for amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that (1) was not created by us, unless the person or entity that created the information is no longer available to make the amendment, (2) is not part of the medical information kept by us, (3) is not part of the information which you would be permitted to inspect and copy or (4) is accurate and complete.

Right to Accounting of Disclosures — You have the right to request a listing of our disclosures of your medical information. However, we are not required to include on that list any of the following: (1) disclosures to carry out your treatment, payment for your care and our health care operations, (2) disclosures to you, (3) disclosures for national security or law enforcement purposes, (4) if you are an inmate, disclosures to correctional institutions or law enforcement officials, (5) disclosures that occurred prior to April 14, 2003 or (6) disclosures that were made pursuant to your authorization. To request this accounting of disclosures, you must submit your request in writing to the Plans’ Privacy Officer listed above. Your request must state a time period covered by your request, which can be no longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the costs involved and you may choose to withdraw or modify your request before any costs are incurred.

Right to Request Restrictions — You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. However, we are not required to agree to your request. If we do agree, we will comply with the request unless the information is needed to provide you emergency treatment, and we may terminate the restriction at any time by notifying you of that termination. To request restrictions, you must make your request in writing to the Plans’ Privacy Officer at the address listed above. Your request must list what information you want to limit, whether you want to limit our use, disclosure or both and to whom you want the limits to apply (for example — disclosures to your spouse).

Right to Request Confidential Communications — You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the Plans’ Privacy Officer at the address listed above. We will attempt to accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of this Notice — You may obtain a copy of this Notice at our intranet site “HRONLINE”. You may also request a paper copy of this Notice in person or by sending a written request for a copy to the Plans’ Privacy Officer at the address listed above.

For More Information or to Report a ProblemIf you have questions and would like additional information, you may contact the WellSpan Health Employee Health Plans Privacy Officer at 1-717-851-2400 or at the address listed above. If you believe your privacy rights have been violated, you can file a complaint with the WellSpan Health Plans Privacy Officer or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

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Maternity and Newborn Length of StayUnder federal law, group health plans and health coverage issuers offering group coverage generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to:

• Fewer than 48 hours following a normal vaginal delivery; or• Fewer than 96 hours following a cesarean section.

They may also not require that a provider obtain authorization from the Plan or coverage issuer for prescribing a length of stay not in excess of those periods. The law generally does not prohibit an attending provider of the mother or newborn (in consultation with the mother) from discharging the mother or newborn earlier than 48 hours or 96 hours, as applicable.

Covered maternity services include services and supplies due to pregnancy, childbirth and related conditions incurred by a female employee or covered dependent. Covered newborn services include circumcision of a newborn child by a licensed physician.

Mastectomy Services Federal law requires a group health plan to provide coverage for the following services to an individual receiving plan benefits in connection with a mastectomy:

• Reconstruction of the breast on which the mastectomy has been performed;• Surgery and reconstruction of the other breast to produce a symmetrical appearance; and• Prostheses and physical complications for all stages of a mastectomy, including lymphedemas (swelling associated with the removal of lymph nodes).

The group health plan must determine the manner of coverage in consultation with the attending physician and patient. Coverage for breast reconstruction and related services will be subject to deductibles and coinsurance amounts that are consistent with those that apply to other benefits under the plan. If you would like more information on these benefits, call your plan administrator.

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).

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

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ALABAMA - Medicaid ALASKA - Medicaid ARKANSAS - Medicaid

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

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

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

COLORADO - Medicaid FLORIDA - Medicaid GEORGIA - Medicaid

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

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

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

INDIANA - Medicaid IOWA - Medicaid KANSAS - Medicaid

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

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

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

KENTUCKY - Medicaid LOUISIANA - Medicaid MAINE - Medicaid

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

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

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

MASSACHUSETTS - Medicaid and CHIP MINNESOTA - Medicaid MISSOURI - Medicaid

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

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

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

MONTANA - Medicaid NEBRASKA - Medicaid NEVADA - Medicaid

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

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

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

NEW HAMPSHIRE - Medicaid NEW JERSEY - Medicaid and CHIP NEW YORK - Medicaid

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

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

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


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

NORTH CAROLINA - Medicaid NORTH DAKOTA - Medicaid OKLAHOMA - Medicaid and CHIP

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

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

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

OREGON - Medicaid PENNSYLVANIA - Medicaid RHODE ISLAND - Medicaid

Website: http://www.oregonhealthykids.gov; http://www.hijossaludablesoregon.govPhone: 1-800-699-9075

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

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

SOUTH CAROLINA - Medicaid SOUTH DAKOTA - Medicaid TEXAS - Medicaid

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

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

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

UTAH - Medicaid and CHIP VERMONT - Medicaid VIRGINIA - Medicaid and CHIP

Website: Medicaid: http://health.utah.gov/medicaidCHIP: http://health.utah.gov/chipPhone: 1-877-543-7669

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

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

WASHINGTON - Medicaid WEST VIRGINIA - Medicaid WISCONSIN - Medicaid and CHIP

Website: http://www.hca.wa.gov/medicaid/premiumpymt/pages/index.aspxPhone: 1-800-562-3022 ext. 15473

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

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

WYOMING - Medicaid

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

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 LaborEmployee Benefits Security Administrationwww.dol.gov/ebs1-866-444-EBSA (3272)

OMB Control Number 1210-0137 (expires 10/31/2016)

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U.S. Department of Health and Human ServicesCenters for Medicare & Medicaid Serviceswww.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565