plan year: 1-1-2019 through 12-31-2019 · web viewemployee benefits enrollment guide plan year:...

Employee Benefits Enrollment GuidePlan Year: 1-1-2019 through 12-31-2019

Daybreak Family Services

2019 Benefit SummaryWe are proud to offer you and your eligible family members a comprehensive benefit package. We strongly

encourage you take time and review the following pages to educate yourself about the different plan options available.

Who is Eligible?

If you are a full-time employee (working 30 or more hours per week) you are eligible to enroll in the benefits described in this guide. You may cover your legal spouse and dependent children up to age 26, unless otherwise stated by the plan. Coverage begins the first day of the month following 60 days.

How to Enroll?

First, gather social security numbers and date of birth for any dependents you wish to cover. Next, go to the open enrollment website and enroll in benefits. If you make changes outside of open enrollment make sure to notify HR immediately. Once you have made your elections, you will not be able to change them until the next open enrollment period, unless you have a qualified change in status. Qualified changes in status include: marriage, divorce, birth or adoption of a child, death, loss of coverage, or change in employment status.

How to Make Changes?

You cannot make changes to the benefits you elect until the next open enrollment period, unless you have a qualified change in status. You have 30 days from the date of your event to notify HR and complete an enrollment/change form. You must also attach your documentation to the completed form.

What are the costs?

Each year your employer tries to select plans with the best overall value based on a number of different considerations. Prices will be presented in this guide and are based on PER PAY PERIOD costs.

Medical – United HealthcarePLAN United Healthcare United Healthcare United HealthcareOPTIONS GOLD BI-72 SILVER BI-8D BRONZE BI-7INetwork UHC Choice Plus UHC Choice Plus UHC Choice PlusDeductible (Ind / Fam) $3,000 / $9,000 $5,500 / $11,000 $5,250 / $10,500Coinsurance 100% 80% 100%Out of Pocket Maximum

(Ind / Fam) $6,500 / $13,000 $7,350 / $14,700 $6,650 / $13,300Office Visit Copay

(PCP / Specialist) $30 / $60 $40 / $80 Ded. & Coins.Wellness Benefits Yes Yes YesEmergency Room 300 $400 + Coins. Ded. & Coins.Inpatient / Outpatient Surgery Ded. & Coins. $250 + Ded. & Coins. Ded. & Coins.

Prescription Drug Benefit$15 / $40 / $70 / $100 /

$300$15 / $40 / $70 / $100 /

$300 $10* / $40* / $80* / $200*

HSA Compatible No No YesBENEFIT

HIGHLIGHTSFollowing are some of the unique aspects of these benefit programs.

$40 Lab/X-Ray .. $400 Major Diagnostic (MRI, CT, etc.) .. $50 Urgent Care ..$10 Virtual Visits

$400 Major Diagnostic (MRI, CT, etc.) .. $50Urgent Care .. $10 Virtual Visits

Copays apply after medical deductible has been met

Rates Per Pay PeriodEmployee Only $71 $51 $31Employee and Spouse $163 $125 $100Employee and Children $200 $140 $100Employee and Family $400 $300 $200

Please Note: These comparisons and benefit descriptions are meant for illustrative purposes only and should not be considered a legally binding offer or a comprehensive explanation of benefits. The purpose of this document is to give our clients a side-by-side comparison of select benefits to help target the most comprehensive benefits at the best price to fit their specific needs. See Summary of Benefits and Coverage for additional details related to these plans. Look up Doctors or Hospitals by visiting: www.myuhc.com and selecting link to “find a provider”.

Dental – Delta Dental of OklahomaDENTAL INSURANCE

Carrier Delta Dental of OklahomaPPO Network PPO Plus PremierWebsite www.deltadentalok.orgPlan Name Select For Small GroupDeductible SINGLE $50Deductible FAMILY $50 Per PersonClass I - Preventive 100% (100%)Class II - Basic 80% (80%)Class III - Major 50% (50%)Calendar Year Maximum (Class I, II, III Combined) $1,500Orthodontics 50% After Deductible (Child Only)Orthodontics LIFETIME Maximum $1,500 (Children Only)Rates Per Pay Period

EmployeeDaybreak pays 100% of Employee

OnlyEmployee + Spouse $18.36Employee + Child(ren) $31.62Family $55.08

See Summary of Benefits and Coverage for additional details related to these plans.Look up a Dentist by visiting: www.ddpok.org and selecting link to “find a dentist” and selecting “Delta PPO Plus”

Vision – AmeritasVISION INSURANCE

Carrier AmeritasPPO Network VSP Choice PlusCopay - Exam $10Copay - Materials $25Frequency - Exam Once Every 12 MonthsFrequency - Lenses Once Every 12 MonthsFrequency - Materials (Frames) Once Every 24 MonthsExam Allowance Covered in FullLenses Allowance Covered in Full

Material Allowance (Frames)$50 Wholesale (Approximately

$130 Retail)Rates Per Pay PeriodEmployee $4.32Employee + 1 $9.32Employee + Children $7.54Family $12.54See Summary of Benefits and Coverage for additional details related to these plans.Look up Doctors by visiting: www.ameritas.com and selecting link to “find a doctor” and selecting “Vision: VSP”All benefits quoted assume use of in-network providers and facilities. This summary is for illustration purposes only and is not a legal document.

Basic Term Life– Dearborn NationalYour Employer provides employee life insurance and accidental death and dismemberment (AD & D) insurance through Dearborn National. The benefits for the life insurance are as follows: $50,000 Life & AD&D

Voluntary Life & Ad & D– Dearborn NationalThe Voluntary Group Life Insurance Plan is offered through Dearborn National. You may add coverage for yourself, your spouse and your dependent children. Elections over the Guaranteed Issue Amount will require completion of an Evidence of Insurability (EOI) form. Coverage added during open enrollment will require completion the EOI form. Voluntary term life is an after tax deduction, prices are based on age and tobacco usage. Please see following rate charts.

MONTHLY Rates

Age Rate Per Thousand Age Rate Per Thousand<20 $0.052 45-49 $0.15620-24 $0.052 50-54 $0.23925-29 $0.062 55-59 $0.44630-34 $0.083 60-64 $0.68535-39 $0.093 65-69 $1.31740-44 $0.104 70+ $2.137

These rates are:- Unisex- Shown as a monthly rate per $1,000 of Life Insurance Coverage- Adjusted once each year on the program anniversary date

Accidental Death & Dismemberment coverage is $0.018 per $1,000 per month and is included in the rates shown above.

Dependent Children coverage is $1.80 per month for $10,000, regardless of the number of children.

Individually Underwritten Products (Life/Critical Illness, etc.)– NFPNFP Corp. is happy to run quotes to compare with your individual Life Insurance or Critical Illness policies, ask us about a quote today!

How to contact your insurance carriers:

United Healthcare AmeritasWebsite: www.myuhc.com Website: www.amertias.comCustomer Service: 888-842-4571 Customer Service: 800-487-5553

Delta Dental NFP Corp.Website: ddpok.org Website: www.nfp.comCustomer Service: 800-522-0188 Customer Service: 800-564-8422

Dearborn NationalWebsite: www.dearbornnational.comCustomer Service: 800-348-4512

The information in this Benefit Summary is presented for illustrative purposes only. The information contained in this Summary was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of discrepancy between the Benefits Snapshot and the actual plan documents, the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any questions about this summary, contact NFP Corp. at 800-564-8422.

Daybreak Family ServicesHRA Plan Parameters for HRA Plan Renewal Effective January 1, 2019

IMPORTANT: only employees enrolling in either plan: BI-8D or BI-72 will be eligible to enroll in the H.R.A. (employees enrolling in the High Deductible Health Plan that is eligible for a Health Savings Account; BI- 7I, WILL NOT be able to enroll in the H.R.A.)

Employer will provide $1,500 to all employees with individual coverage and $3,000 for employees that carry employee + dependent coverage [EE/Spouse, EE/Child(ren) and Full Family] for use in reimbursing them for the now higher deductible costs, etc. NOTE: There is a $1,500 payout limit per coveredindividual. Once an employee submits their EOB’s (Explanation of Benefits) from United Healthcare/UHC showing they have met $500 in expenses, the Daybreak Family Services’ HRA will reimburse the employee $1,500 or $3,000 as noted above. This will be inclusive of deductibles, coinsurance and any other health expenses that may be excluded or limited from the health insurance plan with United Healthcare/UHC.

****The plan will NOT reimburse employees for items that are of a cosmetic/beautification nature, any Over the Counter items or any Prescription expenses.****

All reimbursements will be made by the following HRA Administration company that we have hired on your behalf:

Keystone Flex Administrators, LLCP.O. Box 5502

Edmond, OK 73083Phone #405-285-1144/Toll Free Phone #1-866-680-8308

Manage your Healthcare Finances in a Whole New Way….

We're introducing a different way to manage your healthcare finances!

1. Make payments with ease- WEX Benefits Card!All it takes is a swipe of your benefits debit card to pay for a healthcare expense. Payments are automatically withdrawn from your reimbursement account, so there are no out-of-pocket costs. And because the majority of your purchases are verified (or substantiated) at the point of purchase, you will need to submit fewer receipts manually*. You can also have reimbursements direct deposited to the account of your choice!

2. Access your accounts anytime, anywhere w/ our MOBILE APP!With our convenient Mobile App, you can get to the healthcare account information you need—fast. Wondering whether you have enough money to pay a bill or make a purchase? The Keystone Mobile App puts the answers at your fingertips!

Quickly check available balances and account details for medical and dependent care FSA reimbursement plans

View charts summarizing account information Set account alerts and get notifications via text message View claims requiring receipts Link to an external web page to obtain helpful information such

as a list of eligible expenses Retrieve a lost username or password Use your device of choice – including iPhone®, iPad®, iPod

touch® and Android™ smartphones and tablet devices

* Receipts may be required upon request in accordance to plan rules.

3. Get up and going quickly w/ EMPLOYEE PORTAL ACCESS!Even if this is the first time using benefits software, you'll find the experience is intuitive and easy-to-use; most importantly, you'll have 24/7 access to your benefit accounts.- When you log in to your portal, you can:

See your balances in real- time File claims Upload receipts Visualize spending with charts and graphs

You'll find everything you need to manage your healthcare finances simply!

4. FSA STORE!FSA Store is great tool to search eligibility of items you have questions on, and also to purchase FSA eligible items online and have them show up directly to your front door!

To access, just visit: www.keystoneflex.com and click SHOP NOW!

As you can see, managing your healthcare and taking control of your decisions has never been more convenient and fast, so you can spend more time doing the things you love without the hassle or worry. If you have any questions, please contact Keystone Flex Adminstrators at 1(866)680-8308!

©2018 ALL RIGHTS RESERVED WEX Inc. 0818

MANAGE YOUR BENEFITS ONLINE!

An easy-to-use Consumer (Employee) Portal will allow secure, 24/7 access to your accounts:

To gain access visit the link below:

https://keystoneflex.lh1ondemand.com

LOGIN ID: First initial of first name, last name,

and last four numbers of their SSN.PASSWORD:

SAME as Login ID - (Ex. Jdoe1601)

You will be prompted to answer security questions, and reset your password.

Available features : Check your up-to-minute plan balances! View all plan, claims and payment detail File claims and submit receipts online View upcoming reimbursements Sign up for direct deposit And much more!

For any questions or concerns contact Keystone Flex Administrators toll free at : 1 (866) 680-8308

PLAN COMPARISON CHARTA comparison of HSA, HRA and FSAs

Healthcare accounts are not all created equal. To help you understand the differences between HSAs, HRAs and FSAs, take a look at the comparison chart below.NOTE: This publication is for informational purposes only. The IRS releases limits and maximums throughout each year. Therefore, be sure to check IRS.gov for updates by the IRS after the date of this publication.

HSA HRA FSAHealth Savings

Account (HSA)

Health Reimbursement Arrangement (HRA)

Flexible Spending Account (FSA)

Definition An HSA is a tax-advantaged savings account that is used in combination with a high deductible health plan (HDHP). Consumers use the HSA funds to cover qualifiedmedical expenses.

An HRA is an employer- funded plan that may be used to reimburse employees for qualified medical expenses.

An employer-established, tax- advantaged account funded by the employee and/or the employer to pay for qualified medical expenses with pre-tax dollars.

Who “owns” account? Individual\Employee Employer Employer

Who can contribute to the account?

Individual\Employee, Employer

Employer only Employee and Employer

Where are funds held? In HSA Deposit Account – Qualified Financial Institution and Mutual Funds

By employer By employer

Pre-tax payroll deductions allowed?

Yes No Yes

Annual maximum limit on contributions[www.irs.gov]

Yes1 No2 Yes3

Entire election available for reimbursement atstart of plan year

No Depends on plan design. Yes

What distributions are allowed?

Debit Card4

Request for distribution or bill-payOnline/Paper

Debit Card“Claim” – Request for reimbursement or bill pay Online/Mobile/Paper

Debit Card“Claim” – Request for reimbursement or bill pay Online/Mobile/Paper

1 IRS-imposed HSA limits for 2019: The 2019 annual HSA contribution limit for individuals with self-only HDHP coverage is $3,500 (a $50 increase from 2018), and the limit for individuals with family HDHP coverage is $7,000 (a $100 increase from 2018). Annual catch-up contributions for those 55 and over: $1,000 (unchanged from 2017).

2 IRS does not impose HRA limits; limits are set by employer.3 Employee contribution limits for 2019 for FSAs will be announced by the IRS; for 2018, the limit for an FSA cannot exceed $2,650 per IRS Rules. Employer

contributions may not discriminate in favor of highly compensated individuals. Healthcare reform limits employer contributions to $500 per year or an

arrangement in which employer contributions will not exceed the employee’s contributions, such as a one-to-one match, up to $2,650.4 HSA, HRA and FSA debit cards are automatically restricted for use with medical service providers and for items purchased at retail that are identified as

qualified medical expenses based on electronic inventory control codes.

© 2018 ALL RIGHTS RESERVED WEX 08

HSA

HRA FSA

Health Savings Account (HSA)

Health Reimbursement

Arrangement (HRA)

Flexible Savings Account (FSA)

Substantiation Not required for payment5 Required Required

Must have Health Plan? Yes, Qualified HDHP whether through employer or not

Beginning in 2014, employees had to be enrolled in employer-sponsored group coverage unless the HRA is limited to vision or dental expenses6

No. But employer must offer qualified health coverage.

Can have other (non HDHP) Health Plan?

No, except for certain permissible coverage such as dental or other limited purpose plan(s)7

Yes Yes

Tax Benefit Contributions are tax free, interest and investment gains are tax free and withdrawals are tax free when used for qualified medical expenses

Employer deposits and claim payments are tax free

Employer/Payroll deposits and claim payments are tax free

Interest earning? Interest can be accrued on a tax-deferred basis in qualified HSAs. And if the account balance reaches the minimum balance requirement, the funds can be invested in mutual funds and those gains are also tax free.

No No

Access to funds after termination

Individual account not tied to employment status

Employee must be offered COBRA

Employees must be offered COBRA (usually until the end of the year)

Employees carry over unused amounts

Yes. The individual owns the account and any contributions made to it, regardless of the source or timing of the contribution.

Employer discretion Limited to up to $500 carryover to the immediately following plan year OR a grace period8

5 HSA distributions subject to IRS audit to prove they do not exceed out-of-pocket qualified medical expenses since HSA opened.6 PHS Act sec 2711, per DOL FAQ re: PPACA Part XI Q1, Q3 http://www.dol.gov/ebsa/faqs/faq-aca11.html HRA Enrollees must be

enrolled in group health plan.7 Dental, vision, accident, disability, long-term care, workers’ compensation, specified disease or illness and fixed dollar hospitalization,

certain deductible plans.8 Employers may elect to have (i) a “grace” period for employees to use leftover funds from a previous plan year to pay for expenses

incurred in the period up to 2 months and 15 days into the new plan year; or (ii) a carryover of up to $500 to the new plan year for payment of medical expenses during the entire year in which it is carried over.

© 2018 ALL RIGHTS RESERVED WEX 08

HSA HRA FSAHealth Savings Account

(HSA)Health

ReimbursementArrangement

(HRA)

Flexible Savings Account (FSA)

What is the tax treatment for employer contributions?

Employer contributions may qualify as a deductible business expense and are exempt from FICA and other employment taxes.



What is the tax treatment for employee contributions?

Employee contributions may be made through a cafeteria plan and are tax free. If made outside of a cafeteria plan, they are treated as an “above the line” deduction.

Employees are not permitted to contribute to an HRA.

Employee contributions to an FSA are made on a pre-tax basis, and therefore reduce annual taxable income.

What expenses qualify for distribution?

Medical expenses under § 213(d) of the Internal Revenue Code (over the counter drugs are not an eligible medical expense unless prescribed by a health care provider). HSAs may not be used to pay insurance premiums except for (1) COBRA, (2) qualified long-term care insurance (3) health care coverage while the individual is receiving unemployment compensation; and (4) premiums for Medicare Part A or B, Medicare HMO, and (5) after age 65, the employee’s share of employer-sponsored retiree health care

Employers configure the account to reimburse all or a subset of any otherwise unreimbursed expenses that are qualified under §213(d) of IRC (over the counter drugs are not an eligible medical expense unless prescribed by a health care provider). This can include health insurance premiums (other than premiums that are paid through an employer’s cafeteria plan) and long-term care insurance premiums.However, long-term care services are not reimbursable.

Any otherwise unreimbursed medical expenses that are defined under §213(d) of IRC (over the counter drugs are not an eligible medical expense unless prescribed by a health care provider).Health insurance premiums and long-term care services are not reimbursable.

This Plan Comparison Chart is a summary of differences between plan types, and it does not describe all of the rules and limitations that apply to these arrangements. It is not legal or tax advice. See IRS Publication 969, Health Savings Accounts and Other Tax-Favored Health Plans, for more information on HSAs, HRAs and FSAs.

Address: StreetCityStateZip_( ) ( ) Home PhoneEmployer NameWork Phone

Check box if this is a new address.

XXX-XX-Social Security Nbr (Last 4 Digits Only)M.I.First NameLast Name

Health Reimbursement Arrangement Reimbursement Request Form

PLEASE PRINT

A copy of the Explanation of Benefits (EOB) OR a letter received from your health insurance plan MUST accompany this completed form in order to process your HRA reimbursement request and show proof of deductible met.

Date of Expense or EOB

Name of Covered Participant

Relationship to Employee

(Self, Spouse, Child)

Type of ExpenseTotal

Expense

$

$

$

$

$

Reimbursement Total $

By my signature below I certify that I and/or my spouse and/or dependent child incurred expenses detailed above and are eligible for reimbursement under the above employer’s Health Reimbursement Arrangement. I have attached a true and accurate Explanation of Benefits or other acceptable documentation. I also certify that expenses detailed above have not been and will not be reimbursed by any health insurance or reimbursement plan. I am not applying these expenses toward any federal or state income tax deduction or credit. I assume all responsibility for any taxes or penalties arising out of any disallowed deductions.

Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, administrator, or plan service provider, files a statement of claim containing false, incomplete or misleading information may be guilty of a criminal act punishable under law.

Your Signature Date

Keystone Flex Administrators, L.L.C.P.O. Box 5502 Edmond, OK 73083

#405-285-1144/Toll Free #866-680-8308 FAX #405-285-1763/Toll Free #855-259-1779

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2

3

Health & WellnessMotion

Your Apple Watch®:Pay it off by walking it off.As you participate in the UnitedHealthcare Motion® program and meet your daily walking goals, our Walk-It-Off payment option1 puts your earned rewards toward the cost of your Apple Watch.

Getting started is easy:Download the Motion app.

Start walking.

Pay off your watch.

Track your activity. Pay down your balance. Hit your stride.Just a few reasons why Walk-It-Off can be a step in the right

direction. For more information on Motion, visit

unitedhealthcaremotion.com.

For information and assistance, please call:1-855-256-8669 (TTY 711) or [email protected].

Apple Watch is a registered trademark of Apple, Inc. The FIT logo is a trademark of Qualcomm Life, Inc. and is used with permission.1Terms and conditions apply. The Walk-It-Off payment option currently applies to the Apple Watch only. You cannot have any existing outstanding tracking device balances with Motion. You can only purchase one Apple Watch, under the Walk-It-Off payment option, at a time. Your total price = device price + administrative fee + taxes and shipping and handling. As you achieve your daily Frequency, Intensity, Tenacity (FIT) goals, your accrued monthly rewards will be applied toward the outstanding balance for your Apple Watch. The initial payment due at checkout will include administrative fee, taxes and shipping and handling. Any outstanding balance after6.5 months will be billed to your stored credit card on file. Your credit card information is stored to facilitate automated billing. You can make changes to or update your credit card information at any time by visiting your profile page at UnitedHealthcareMotion.com. At that time, the Walk-It-Off option will be complete. At the 90-day mark, you must meet a weekly average of 3 FIT goal completions (any FIT goal combination); otherwise the outstanding device balance will be applied to the stored credit card on file. At that time, the Walk-It-Off option will be complete. Device returns can only be made within 14 days from the purchase date. Specific return criteria applies. If your Apple Watch is deemed to be defective, please contact Motion Member Services for additional details 1-855-256-8669. Device balances left unpaid will be secured from future FIT earnings until balances are paid in full.

UnitedHealthcare Motion is a voluntary program. The information provided under this program is for general informational purposes only and is not intended to be nor should be construed as medical advice. You should consult an appropriate health care professional before beginning any exercise program and/or to determine what may be right for you. Receiving an activity tracker and/or certain credits may have tax implications. You should consult an appropriate tax professional to determine if you have any tax obligations from receiving an activity tracker and/or certain credits under this program, as applicable. If any fraudulent activity is detected (e.g., misrepresented physical activity), you may be suspended and/or terminated from the program. If you are unable to meet a standard related to health factor to receive a reward under this program, you might qualify for an opportunity to receive the reward by different means. Contact us and we will work with you (and, if necessary, your doctor) to find another way for you to earn the same reward. Rewards may be limited due to incentive limits under applicable law.Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates.

Facebook.com/UnitedHealthcare Twitter.com/UHC Instagram.com/UnitedHealthcare YouTube.com/UnitedHealthcare

MT-1178300.1 10/18 ©2018 United HealthCare Services, Inc. 18- 10074

BI 1

S mmary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesChoice Plus BI72 /DT

Coverage Period: Based on group plan year Coverage for: Employee/Family | Plan Type: POS

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit or by calling 1-800-782-3158. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at or

Important Questions Answers Why This Matters:What is the overall deductible?

Designated Network and Network: $3,000 Individual / $9,000 Familyout-of-Network: $5,000 Individual / $15,000 FamilyPer calendar year.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.Are there services covered before you meet your deductible?

Yes. Preventive care and categories with a copay are covered before you meet your deductible.This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services atwww.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

No. You don’t have to meet deductibles for specific services.

What is theout-of-pocket limit for this plan?

Designated Network and Network: $6,500 Individual / $13,000 Familyout-of-Network: $10,000 Individual / $30,000Family

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their ownout-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?

Premiums, balance-billing charges, health care this plan doesn’t cover and penalties for failure toobtain preauthorization for services.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Will you pay less if you use a network provider?

Yes. See www.welcometouhc.com or call1-800-782-3158 for a list of network providers.

You pay the least if you use a provider in the Designated Network. You pay more if you use a provider in the Network. You will pay the most if you use anout-of-Network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing) . Be aware, your Network provider might use an out-of-Network provider for someservices (such as lab work). Check with your provider before you get services.

BI 2

Do you need a referral to see a specialist?

No. You can see the specialist you choose without a referral.

2

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other Important Information

Designated Network Provider (You will pay the

least)Network Provider

Out-of-Network Provider (You will pay the most)

If you visit a health care

Primary carevisit to treat an

$30 copay per visit,deductible does not


30% coinsurance

If you receive services in addition to office visit,additional copays, deductibles, or coinsurance may

provider’s office or clinic

injury orillness

apply apply apply e.g. surgery.Virtual visits (Telehealth) - $10 copay per visit by aDesignated Virtual Network Provider, deductible doesnot apply.Children under age 19: No Charge.

Specialist visit

$30 copay per visit, deductible does notapply


30% coinsurance

If you receive services in addition to office visit, additional copays, deductibles, or coinsurance mayapply e.g. surgery.

Preventive care/screening /immunizatio-

No Charge No Charge * 30%coinsurance

Includes preventive health services specified in the health care reform law. You may have to pay forservices that aren’t preventive. Ask your provider if the

n services needed are preventive. Then check what yourplan will pay for.*Deductible/coinsurance may not apply to certainservices.

If you have a test

Diagnostic test (x-ray, bloodwork)

$40 copay per service, deductible does notapply

$40 copay per service, deductible does notapply

30% coinsurance

Preauthorization required for out-of-Network for certain services or benefit reduces to 50% of allowed.

Imaging (CT/PETscans, MRIs)

$400 copay per service, deductibledoes not apply


30% coinsurance

Preauthorization required for out-of-Network or benefit reduces to 50% of allowed.

3



What You Will Pay


Designated Network

Provider (You will pay the

least)

Network Provider


If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at www. welcometouhc.com.

Tier 1 - Your Lowest-Cost Option

Deductible does not apply. Retail:$15 copayMail-Order:$37.50 copay Specialty Drugs** : $15 copay


Deductible does not apply. Retail:$15 copaySpecialty Drugs:$15 copay

Provider means pharmacy for purposes of this section. Retail: Up to a 31 day supply. Mail-Order*: Up to a 90 day supply or *Preferred 90 Day Retail Network Pharmacy. If you use an out-of-Network pharmacy (including a mail order pharmacy), you may be responsible for any amount over the allowed amount.**Your cost shown is for a Preferred Specialty Network Pharmacy. Non-Preferred Specialty Network Pharmacy: Copay is 2 times the Preferred Specialty Network Pharmacy Copay or the coinsurance (up to 50% of the Prescription Drug Charge) based on the applicable Tier.Copay is per prescription order up to the day supply limit listed above.You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by us.Certain drugs may have a preauthorization requirement or may result in a higher cost. See the website listed for information on drugs covered by your plan. Not all drugs are covered. You may be required to use alower-cost drug(s) prior to benefits under your policy being available for certain prescribed drugs. Certain preventive medications and Tier 1 contraceptives are covered at No Charge.If a dispensed drug has a chemically equivalent drug, the cost difference between drugs in addition to any applicable copay and/or coinsurance may be applied.

Tier 2 - Your Midrange-Cost Option

Deductible does not apply. Retail:$40 copayMail-Order: $100 copaySpecialty Drugs** : $100 copay







Tier 4 - Additional High-Cost Options

Not Applicable

Not Applicable

Not Applicable

If you have outpatient surgery

Facility fee (e.g., ambulatory surgerycenter)

0% coinsurance

0% coinsurance

30% coinsurance

Preauthorization required for certain services forout-of-Network or benefit reduces to 50% of allowed.

4



What You Will Pay


Designated Network


least)

Network Provider


Physician/surgeonfees

0% coinsurance

0% coinsurance

30% coinsurance

None

If you need immediate medical attention

Emergency room care $300 copay per visit, deductibledoes not apply

$300 copay per visit, deductibledoes not apply


None

Emergency medicaltransportation

0% coinsurance

0% coinsurance

0% coinsurance

None

Urgent care $50 copay per visit, deductibledoes not apply


30% coinsurance

If you receive services in addition to urgent care visit, additional copays, deductibles, or coinsurance mayapply e.g. surgery.

If you have a hospital stay

Facility fee (e.g.,hospital room)

0% coinsurance

0% coinsurance

30% coinsurance

Preauthorization required for out-of-Network orbenefit reduces to 50% of allowed.


0% coinsurance

0% coinsurance

30% coinsurance

None

If you need mental health, behavioral health, or substance abuse services

Outpatient services

$30 copay per visit, deductible does not apply


0% coinsurance

Network partial hospitalization /intensive outpatient treatment: 0% coinsurancePreauthorization required for certain services forout-of-Network or benefit reduces to 50% of allowed.

Inpatient services

0% coinsurance

0% coinsurance

30% coinsurance


If you are pregnant Office visits No Charge No Charge 30% coinsurance

Cost sharing does not apply for preventive services . Depending on the type of services, a copayment,deductibles, or coinsurance may apply.

Childbirth/delivery professional0% coinsurance

0% coinsurance

30% coinsurance

Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)

5

services

6



What You Will Pay


Designated Network


least)

Network Provider


Childbirth/delivery facility services

0% coinsurance

0% coinsurance

30% coinsurance

Inpatient preauthorization apply for out-of-Network if stay exceeds 48 hours (C-Section: 96 hours) or benefitreduces to 50% of allowed.

If you need help recovering or have other special health needs

Home health care

0% coinsurance

0% coinsurance

30% coinsurance

Limited to 60 visits per calendar year. Preauthorization required for out-of-Network or benefit reduces to 50% of allowed.

Rehabilitation services$30 copay per outpatient visit, deductible doesnot apply

$30 copay per outpatient visit, deductible doesnot apply

30% coinsurance

Limits per calendar year: Physical, Speech, Occupational: 25 visits (combined). Pulmonary: unlimited; Cardiac 36 visits.

Habilitation services



30% coinsurance

Limits per calendar year: Physical, Speech, Occupational: 25 visits (combined).Preauthorization required for out-of-Network inpatientservices or benefit to 50% of allowed.

Skilled nursing care

0% coinsurance

0% coinsurance

30% coinsurance

Skilled nursing is limited to 30 days per calendar year. (Inpatient Rehabilitation and Habilitation limited to 30 days each).Preauthorization required for out-of-Network orbenefit reduces to 50% of allowed.

Durable medicalequipment

0% coinsurance

0% coinsurance

30% coinsurance

Preauthorization required for out-of-Network Durablemedical equipment over $1,000 or no coverage.

Hospice services 0% coinsurance

0% coinsurance

30% coinsurance

Preauthorization required for out-of-Network before admission for an Inpatient Stay in a hospice facility orbenefit reduces to 50% of allowed.

If your child needs dental or eye care

Children’s eye exam



30% coinsurance

One exam every 12 months.

Children’s glasses

$25 copay per frame, deductible $25 copay per frame, deductible

30% coinsurance

One pair every 12 months.Costs may increase depending on the frames selected. You may choose

7

doesnot apply

doesnot apply

contact lenses instead of eyeglasses.The benefit does not cover both.

Children’s dentalcheck-up

0% coinsurance

0% coinsurance

0% coinsurance

Cleanings covered 2 times per 12 months.

Private Duty Nursing - 85 visits/calendar yearHearing Aids - 1 every 4 yearsChiropractic careOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

8

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

Acupuncture Long-Term Care

Bariatric SurgeryNon-emergency care whentraveling outside the U.S.

Cosmetic Surgery Routine Eye Care (Adult)

Dental Care (Adult) Routine Foot Care

Infertility Treatment Weight Loss Programs

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: 1-866-444-3272 or www.dol.gov/ebsa/healthreform for the U.S. Department of Labor, Employee Benefits Security Administration. You may also contact us at 1-800-782-3158 . Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: 1-800-782-3158 ; or the Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform or the Oklahoma Insurance Department at 1-800-522-0071 or www.ok.gov/oid.Does this plan provide Minimum Essential Coverage? Yes.If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.Does this plan meet Minimum Value Standards? Yes.If your plan doesn’t meet the Minimum Value Standards , you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.Language Access Services:Spanish (Espa ol): Para obtener asistencia en Espa ol, llame al 1-800-782-3158 .Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-782-3158 . Chinese 1-800-782-3158 .Navajo (Dine): Dinek ehgo shika at ohwol ninisingo, kwiijigo holne 1-800-782-3158 .

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

Ab t these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

9

The plan’s overall deductible $ 3,000 Specialist copayment $60 Hospital (facility) coinsurance 0% Other coinsurance 0%

This EXAMPLE event includes services like:Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

In this example, Peg would pay:


This EXAMPLE event includes services like:Primary care physician office visits (including disease education)Diagnostic tests (blood work)Prescription drugsDurable medical equipment (glucose meter)

In this example, Joe would pay:


This EXAMPLE event includes services like:Emergency room care (including medical supplies)Diagnostic test (x-ray)Durable medical equipment (crutches)Rehabilitation services (physical therapy)

Total Example Cost $1,900

In this example, Mia would pay:

Cost SharingDeductibles $100Copayments $1,600Coinsurance $0

What isn’t coveredLimits or exclusions $30The total Joe would pay is $1,730

The plan would be responsible for the other costs of these EXAMPLE covered services


Total Example Cost $7,40Cost Sharing

Deductibles $700Copayments $400Coinsurance $0

What isn’t coveredLimits or exclusions $0The total Mia would pay is $1,100

Cost SharingDeductibles $3,000Copayments $300Coinsurance $0

What isn’t coveredLimits or exclusions $60The total Peg would pay is $3,360

Peg is Having a Baby

(9 months of in-network pre-natal care and a Managing Joe’s type 2

Diabetes(a year of routine in-network care of a well-

Mia’s Simple Fracture

(in-network emergency room visit and follow up

Notice of Non-DiscriminationWe do not treat members differently because of sex, age, race, color, disability or national origin.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator.Online: [email protected]: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free number listed within this Summary of Benefits and Coverage (SBC), TTY 711, Monday through Friday, 8 a.m. to 8 p.m.

You can also file a complaint with the U.S. Dept. of Health and Human Services.Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsfComplaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD)Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the number contained within this Summary of Benefits and Coverage (SBC), TTY 711, Monday through Friday, 8 a.m. to 8 p.m.

ATENCION: Si habla espafiol (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposici6n. Llame al numero gratuito que aparece en este Resumen de Beneficios y Cobertura (Summary of Benefits and Coverage, SBC).

ft :n:m1 mig:ix (Chinese) , fr, Ji f m:f mf i=i ffiWJ IUlo mHJ!s::mifU:¥Uffd Hl(Summary of Benefits and Coverage, SBC) pgpfr9tlErn 1'.i" -MHlo

XIN LUU Y: N u quy vi n6i ti ng Vi t (Vietnamese), quy vise dm;:rc cung cdp dich v1,1 trq giup vS ngon ngu: mi n phf. Vui long gqi sf> di n thoi;ti mi n phi ghi trong ban Tom hrqc vS quySn lqi va dai thq bao hiSm (Summary of Benefits and Coverage, SBC) nay.

<el: E! - 01( Korean ) Ar§orAI: : 13-9- <2:101 Al't:! kf tfj. A .!:i='-E.£ Ol§or* £ gL.ICr.o [lfilj ';!J :g .RQ.J= A-i(Summary of Benefits and Coverage, SBC)01[ 7IAH.!a .!:i='-.si. £r .£.£

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PAUNAWA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng serbisyo ng tulong sa wika. Pakitawagan ang toll-free na numerong nakalista sa Buod na ito ng Mga Benepisyo at Saklaw (Summary of Benefits and Coverage o SBC).

BHHMAHHE: 6ecrmaTHbre ycnym rrepeBo.[(a .[(OCTYIIHbI ,1:i;1rn mo.[(eii, 1.1eii po.[(Hoii 513bIIC 5.IBJUieTca pycc1 0M (Russian). ITo3BOHMTe no 6ecrnrnTHOMY HOMepy TenecpoHa, yKa3aHHOMY B .!(aHHOM «Ofoope JibroT H rrOI<pbITIUD> (Summary of Benefits and Coverage, SBC).

e;:_i.i...11 l+JI u.1"'4-11 Y. JL..dl':/1 ts=?-J . :t.:.,l:i,, l+JI I o..\cl..:.JI wL. u!-s '(Arabic) ¼ I a i.::.i.iS l J =.111. (Summary of Benefits and Coverage, SBC) I_, ylj,,11 u-afu J:;..l.l!

ATANSYON: Si w pale Kreyol ayisyen (Haitian Creole), ou kapab benefisye sevis ki gratis pou ede w nan lang pa w. Tanpri rele nimewo gratis ki nan Rezime avantaj ak pwoteksyon sa a (Summary of Benefits and Coverage, SBC).

ATTENTION: Si vous parlez fran ais (French), des services d'aide linguistique vous sont proposes gratuitement. Veuillez appeler le numero sans frais figurant dans ce Sommaire des prestations et de la couverture (Summary of Benefits and Coverage, SBC).

UWAGA: Jezeli m6wisz po polsku (Polish), udostypnilismy darmowe uslugi thtmacza. Prosimy zadzwonic pod bezplatny numer podany w niniejszym Zestawieniu swiadczen i refundacji (Summary of Benefits and Coverage, SBC).

ATEN<;AO: Se voce fala portugues (Portuguese), contate o servi90 de assistencia de idiomas gratuito. Ligue para o nu.mere gratuito listado neste Resumo de Beneficios e Cobertura (Summary of Benefits and Coverage - SBC).

ATTENZIONE: in caso la lingua parlata sia l'italiano (Italian), sono disponibili servizi di assistenza linguistica gratuiti. Chiamate il numero verde indicato alfinterno di questo Sommario dei Benefit e della Copertura (Summary of Benefits and Coverage, SBC).

vi, C::: ""' -,-a N

ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfugung. Bitte rufen Sie die in dieser Zusammenfassung der Leistungen und Kostenubernahmen (Summary of Benefits and Coverage, SBC) angegebene gebiihrenfreie Rufnummer an.

t± *:r.& : B:ifi:! (Japanese) ;J1,.:S -% 1!W S}O) i§ x -if--1:::•· :a:- .:::· iJffl 1,, \ t;:ti ft'iTo

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CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau tus xov tooj hu dawb teev muaj nyob ntawm Tsab Ntawv Nthuav Qhia Cov Txiaj Ntsim Zoo thiab Kev Kam Them Nqi (Summary of Benefits and Coverage, SBC) no.

cirunuHin::::Hl.Jl: 1uNsHASt.1J1t11.f'ilMt21 (Khmer) 1n1nclswn1M1f:::flruf'ln Ald Fit::nswm..JHA9 B§fti:f'J tsiuuef'\AtGf11lf;i r rut::nsAAtsiQtl tNG n11 uH TI,Jtt.1J1t::is st:1ri11ilu.t2utl (Summary of Benefits and Coverage, SBC) is:'I

PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Maidawat nga awagan ti awan bayad na nu tawagan nga numero nga nakalista iti uneg na daytoy nga Dagup dagiti Benipisyo ken Pannakasakup (Summary of Benefits and Coverage, SBC).

Dif BAA1Al<.ONINIZIN: Dine (Navajo) bizaad bee yanilti 1go, saad bee aka1anida'awo'igfi, t1aa jiik'eh, bee na1ah66t1i1

• T1aa shc;,c;,df Naaltsoos Bee 'Aa'ahayanf d66 Bee 1Ak1e1asti' Bee Baa Hane'f (Summary ofBenefits and Coverage, SBC) biyi' t'aajiik'ehgo beesh bee hane1i bika1ig ff bee hodfilnih.

OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac lambarka bilaashka ah ee ku yaalla Soo-koobitaanka Dheefaha iyo Caymiska (Summary of Benefits and Coverage, SBC).

BI 1

S mmary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesChoice Plus BI8D /DT




Designated Network and Network: $5,500 Individual / $11,000 Familyout-of-Network: $10,000 Individual / $30,000 FamilyPer calendar year.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.Are there services covered before you meet your deductible?

Yes. Preventive care and categories with a copay are covered before you meet your deductible.This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services atwww.healthcare.gov/coverage/preventive-care-benefits/.




Designated Network and Network: $7,350 Individual / $14,700 Familyout-of-Network: $30,000 Individual / $60,000Family







You pay the least if you use a provider in the Designated Network. You pay more if you use a provider in the Network. You will pay the most if you use anout-of-Network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing) . Be aware, your Network provider might use an out-of-Network provider for someservices (such as lab work). Check with your provider before you get services.

BI 2



2




What You Will Pay


Designated Network Provider (You will pay the

least)Network Provider


If you visit a health care

Primary carevisit to treat an



30% coinsurance

If you receive services in addition to office visit,additional copays, deductibles, or coinsurance may

provider’s office or clinic

injury orillness

apply apply apply e.g. surgery.Virtual visits (Telehealth) - $10 copay per visit by aDesignated Virtual Network Provider, deductible doesnot apply.Children under age 19: No Charge.

Specialist visit



30% coinsurance

If you receive services in addition to office visit, additional copays, deductibles, or coinsurance mayapply e.g. surgery.

Preventive care/screening /immunizatio-

No Charge No Charge * 30%coinsurance

Includes preventive health services specified in the health care reform law. You may have to pay forservices that aren’t preventive. Ask your provider if the

n services needed are preventive. Then check what yourplan will pay for.*Deductible/coinsurance may not apply to certainservices.

If you have a test

Diagnostic test (x-ray, bloodwork)

20% coinsurance 20% coinsurance 50% coinsurance

Preauthorization required for out-of-Network for certain services or benefit reduces to 50% of allowed.Imaging (CT/PETscans, MRIs)



50% coinsurance

Preauthorization required for out-of-Network or benefit reduces to 50% of allowed.

3



What You Will Pay


Designated Network


least)

Network Provider




Tier 1 - Your Lowest-Cost Option




Provider means pharmacy for purposes of this section. Retail: Up to a 31 day supply. Mail-Order*: Up to a 90 day supply or *Preferred 90 Day Retail Network Pharmacy. If you use an out-of-Network pharmacy (including a mail order pharmacy), you may be responsible for any amount over the allowed amount.**Your cost shown is for a Preferred Specialty Network Pharmacy. Non-Preferred Specialty Network Pharmacy: Copay is 2 times the Preferred Specialty Network Pharmacy Copay or the coinsurance (up to 50% of the Prescription Drug Charge) based on the applicable Tier.Copay is per prescription order up to the day supply limit listed above.You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by us.Certain drugs may have a preauthorization requirement or may result in a higher cost. See the website listed for information on drugs covered by your plan. Not all drugs are covered. You may be required to use alower-cost drug(s) prior to benefits under your policy being available for certain prescribed drugs. Certain preventive medications and Tier 1 contraceptives are covered at No Charge.If a dispensed drug has a chemically equivalent drug, the cost difference between drugs in addition to any applicable copay and/or coinsurance may be applied.










Not Applicable

Not Applicable

Not Applicable


Facility fee (e.g., ambulatory surgery center)

20% coinsurance

20% coinsurance

50% coinsurance

Preauthorization required for certain services forout-of-Network or benefit reduces to 50% of allowed.$250 outpatient surgery per occurrence deductibleapplies prior to the overall deductible.

5



What You Will Pay


Designated Network


least)

Network Provider



20% coinsurance

20% coinsurance

50% coinsurance

None


Emergency room care $400 copay per visit. After copay, 20%coinsurance, deductible doesnot apply

$400 copay per visit. After copay, 20%coinsurance, deductible doesnot apply

$400 copay per visit. After copay, 20%coinsurance, deductible doesnot apply

None


20% coinsurance

20% coinsurance

20% coinsurance

None

Urgent care $50 copay per visit, deductibledoes not apply


50% coinsurance

If you receive services in addition to urgent care visit, additional copays, deductibles, or coinsurance mayapply e.g. surgery.


Facility fee (e.g., hospital room)

20% coinsurance

20% coinsurance

50% coinsurance

Preauthorization required for out-of-Network or benefit reduces to 50% of allowed.$250 Inpatient Stay per occurrence deductible appliesprior to the overall deductible.


20% coinsurance

20% coinsurance

50% coinsurance

None


Outpatient services



0% coinsurance


Inpatient services

20% coinsurance

20% coinsurance

50% coinsurance


If you are pregnant Office visits No Charge No Charge 30% Cost sharing does not apply for preventive services . Depending on

6

coinsurance the type of services, a copayment,deductibles, or coinsurance may apply.

Childbirth/delivery professionalservices

20% coinsurance

20% coinsurance

50% coinsurance

Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)

7



What You Will Pay


Designated Network


least)

Network Provider


Childbirth/delivery facility services

20% coinsurance

20% coinsurance

50% coinsurance

Inpatient preauthorization apply for out-of-Network if stay exceeds 48 hours (C-Section: 96 hours) or benefit reduces to 50% of allowed.$250 Inpatient Stay per occurrence deductible appliesprior to the overall deductible.


Home health care

20% coinsurance

20% coinsurance

50% coinsurance

Limited to 60 visits per calendar year. Preauthorization required for out-of-Network or benefit reduces to 50% of allowed.

Rehabilitation services$40 copay per outpatient visit, deductible doesnot apply


50% coinsurance

Limits per calendar year: Physical, Speech, Occupational: 25 visits (combined). Pulmonary: unlimited; Cardiac 36 visits.

Habilitation services



50% coinsurance

Limits per calendar year: Physical, Speech, Occupational: 25 visits (combined).Preauthorization required for out-of-Network inpatientservices or benefit to 50% of allowed.

Skilled nursing care

20% coinsurance

20% coinsurance

50% coinsurance

Skilled nursing is limited to 30 days per calendar year. (Inpatient Rehabilitation and Habilitation limited to 30 days each).Preauthorization required for out-of-Network orbenefit reduces to 50% of allowed.

Durable medicalequipment

20% coinsurance

20% coinsurance

50% coinsurance

Preauthorization required for out-of-Network Durablemedical equipment over $1,000 or no coverage.


20% coinsurance

50% coinsurance

Preauthorization required for out-of-Network before admission for an Inpatient Stay in a hospice facility orbenefit reduces to 50% of allowed.


Children’s eye exam



50% coinsurance


8

Children’s glasses

$25 copay per frame, deductible doesnot apply

$25 copay per frame, deductible doesnot apply

50% coinsurance

One pair every 12 months.Costs may increase depending on the frames selected. You may choose contact lenses instead of eyeglasses.The benefit does not cover both.


9



What You Will Pay


Designated Network


least)

Network Provider


Children’s dentalcheck-up

0% coinsurance

0% coinsurance

0% coinsurance









Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: 1-866-444-3272 or www.dol.gov/ebsa/healthreform for the U.S. Department of Labor, Employee Benefits Security Administration. You may also contact us at 1-800-782-3158 . Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: 1-800-782-3158 ; or the Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform or the Oklahoma Insurance Department at 1-800-522-0071 or www.ok.gov/oid.Does this plan provide Minimum Essential Coverage? Yes.If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.Does this plan meet Minimum Value Standards? Yes.If your plan doesn’t meet the Minimum Value Standards , you may be eligible for a premium tax credit to help you pay for a

10

plan through the Marketplace.

11

Language Access Services:Spanish (Espa ol): Para obtener asistencia en Espa ol, llame al 1-800-782-3158 .Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-782-3158 . Chinese 1-800-782-3158 .Navajo (Dine): Dinek ehgo shika at ohwol ninisingo, kwiijigo holne 1-800-782-3158 .



12











Cost SharingDeductibles $300Copayments $1,500Coinsurance $0





Deductibles $800Copayments $200Coinsurance $100


Cost SharingDeductibles $5,500Copayments $30Coinsurance $1,100











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BI 1

S mmary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesChoice Plus BI7I /700




Network: $5,250 Individual / $10,500 Family out-of-Network: $10,000 Individual / $20,000 FamilyPer calendar year.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall familydeductible.

Are there services covered before you meet your deductible?

Yes. Preventive care is covered before you meet your deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services atwww.healthcare.gov/coverage/preventive-care-benefits/.




Network: $6,650 Individual / $13,300 Family out-of-Network: $20,000 Individual / $40,000Family







This plan uses a provider Network. You will pay less if you use a provider in the plan’s Network. You will pay the most if you use an out-of-Network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your Network provider might use an out-of-Network provider for some services (such as lab work). Checkwith your provider before you get services.



2


Common Medical Event Services You May Need

What You Will Pay


Network Provider (You

will pay the least)

Out-of-Network Provider (You

will pay the most)

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness0% coinsurance

30% coinsurance

Virtual visits (Telehealth) - 0% coinsurance by a Designated Virtual Network Provider.

Specialist visit 0% coinsurance

30% coinsurance

None

Preventive care/screening/immunizati- on

No Charge * 30%coinsurance

Includes preventive health services specified in the health care reform law. You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.*Deductible/coinsurance may not apply to certain services.

If you have a test Diagnostic test (x-ray, bloodwork)

0% coinsurance

30% coinsurance

Preauthorization required for out-of-Network for certainservices or benefit reduces to 50% of allowed.

Imaging (CT/PET scans,MRIs)

0% coinsurance

30% coinsurance

Preauthorization required for out-of-Network or benefitreduces to 50% of allowed.

3


What You Will Pay



will pay the least)


will pay the most)



Tier 1 - Your Lowest-Cost Option Retail: $10 copay Mail-Order: $25 copay

Retail: $10 copay

Provider means pharmacy for purposes of this section.Retail: Up to a 31 day supply. Mail-Order*: Up to a 90 day supply or *Preferred 90 Day Retail Network pharmacy. If you use an out-of-Network pharmacy (including a mail order pharmacy), you may be responsible for any amount over the allowed amount.Copay is per prescription order up to the day supply limit listed above.You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by us.Certain drugs may have a preauthorization requirement or may result in a higher cost. You may be required to use a lower-cost drug(s) prior to benefits under your policy being available for certain prescribed drugs.See the website listed for information on drugs covered by your plan. Not all drugs are covered.If a dispensed drug has a chemically equivalent drug, the cost difference between drugs in addition to any applicable copay and/or coinsurance may be applied. Certain preventive medications and Tier 1 contraceptives are covered at No Charge.

Tier 2 - Your Midrange-Cost Option Retail: $40 copay Mail-Order: $100 copay

Retail: $40 copay

Tier 3 - Your Midrange-Cost Option Retail: $80 copay Mail-Order: $200 copay

Retail: $80 copay


Retail: $200 copay Mail-Order: $500 copay

Retail: $200 copay


Facility fee (e.g., ambulatorysurgery center)

0% coinsurance

30% coinsurance

Preauthorization required for certain services forout-of-Network or benefit reduces to 50% of allowed.

Physician/surgeon fees

0% coinsurance

30% coinsurance

None


Emergency room care 0% coinsurance

0% coinsurance

None


0% coinsurance

0% coinsurance

None

Urgent care 0% coinsurance

30% coinsurance

None


Facility fee (e.g., hospital

0% 30% Preauthorization required for out-of-Network or benefit

4

room) coinsurance coinsurance reduces to 50% of allowed.

5


What You Will Pay



will pay the least)


will pay the most)

Physician/surgeon fees

0% coinsurance

30% coinsurance

None


Outpatient services 0% coinsurance

0% coinsurance


Inpatient services 0% coinsurance

30% coinsurance

Preauthorization required for out-of-Network or benefitreduces to 50% of allowed.

If you are pregnant

Office visits No Charge 30% coinsurance

Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, deductibles, orcoinsurance may apply.

Childbirth/deliveryprofessional services

0% coinsurance

30% coinsurance

Maternity care may include tests and services describedelsewhere in the SBC (i.e. ultrasound.)

Childbirth/delivery facility services 0% coinsurance

30% coinsurance

Inpatient preauthorization apply for out-of-Network if stay exceeds 48 hours (C-Section: 96 hours) or benefit reduces to50% of allowed.


Home health care 0% coinsurance

30% coinsurance

Limited to 60 visits per calendar year.Preauthorization required for out-of-Network or benefit reduces to 50% of allowed.

Rehabilitation services 0% coinsurance

30% coinsurance

Limits per calendar year: Physical, Speech, Occupational: 25visits (combined); Pulmonary: unlimited; Cardiac 36 visits.

Habilitation services 0% coinsurance

30% coinsurance

Limits per calendar year: Physical, Speech, Occupational: 25 visits (combined).Preauthorization required for out-of-Network inpatient servicesor benefit to 50% of allowed.

Skilled nursing care 0% coinsurance

30% coinsurance

Skilled nursing is limited to 30 days per calendar year. (Inpatient Rehabilitation and Habilitation limited to 30 days each).Preauthorization required for out-of-Network or

6

benefitreduces to 50% of allowed.

Durable medical equipment

0% coinsurance

30% coinsurance

Preauthorization required for out-of-Network Durable medicalequipment over $1,000 or no coverage.


7


What You Will Pay



will pay the least)


will pay the most)


30% coinsurance

Preauthorization required for out-of-Network before admission for an Inpatient Stay in a hospice facility or benefit reduces to50% of allowed.


Children’s eye exam No Charge 30% coinsurance


Children’s glasses 0% coinsurance

30% coinsurance

One pair every 12 months.

Children’s dental check-up

0% coinsurance

0% coinsurance









Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: 1-866-444-3272 or www.dol.gov/ebsa/healthreform for the U.S. Department of Labor, Employee Benefits Security Administration. You may also contact us at 1-866-673-6293 . Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: 1-866-673-6293 ; or the Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform or the Oklahoma Insurance Department at 1-800-522-

8

0071 or www.ok.gov/oid.

9

Does this plan provide Minimum Essential Coverage? Yes.If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.Does this plan meet Minimum Value Standards? Yes.If your plan doesn’t meet the Minimum Value Standards , you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.Language Access Services:Spanish (Espa ol): Para obtener asistencia en Espa ol, llame al 1-866-673-6293 .Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-673-6293 . Chinese 1-866-673-6293 .Navajo (Dine): Dinek ehgo shika at ohwol ninisingo, kwiijigo holne 1-866-673-6293 .



10

The plan’s overall deductible $ 5,250 Specialist coinsurance 0% Hospital (facility) coinsurance 0% Other coinsurance 0%















Deductibles $1,900Copayments $0Coinsurance $0













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UW-01, Revised: Nov CONFIDENTI

Delta Dental Program Highlights

Delta Dental of Oklahoma – Select PPO – Plus Premier

Your Program Highlights provides a brief description of the most important features of your group’s dental benefits program. If you have more specific questions regarding your benefits, please contact Delta Dental of Oklahoma’s Customer Service Department at 405-607-2100 (OKC Metro) or 800-522-0188 (Toll Free).

Dental benefits for participants and covered dependents are payable for eligible dental treatment not otherwise limited or excluded, and shall be paid in accordance with the benefit provisions of your plan, as follows:

Percent Payable for Covered and Allowable Dental ServicesClass I:Diagnostic and Preventive Services 100%

Class II:Basic Services such as amalgam and composite fillings 80%

Class III:Major Services such as crowns, dentures and implants 50%

Class IV:Orthodontic Services are available to dependent children under age 26 50%

Deductible and Maximum AmountsAnnual Maximum Benefit and Deductible Accumulation Period January 1 - December 31Annual Deductible Per Person – applies to Classes II and III $50Annual Maximum Benefit Per Person – applies to Classes I, II and III combined $1,500*Lifetime Maximum Benefit Payment Per Child – applies to Class IV only $1,500

*Benefits paid by the plan for covered oral evaluations and routine prophylaxis (cleanings) will not reduce your Annual Maximum Benefit Per Person for Classes I, II and III combined services.

Endodontics, Periodontics and Oral Surgery are covered benefits under Class II

Services. Eligible dependent children can be covered to age twenty-six (26).

The information contained herein is not intended as a Summary Plan Description nor is it designed to serve as Evidence of Coverage for this program. Some benefits are subject to limitations such as age of patient, frequency of procedure, exclusions, etc.

UW-01, Revised: Nov CONFIDENTI

Your dental benefits program allows payment for eligible services performed by any properly licensed dentist. However, maximum savings and lower out-of-pocket expenses are achieved when treatment is provided by a Delta Dental participating dentist. Below is an illustration of a typical 100/80/50/50 plan, assuming annual deductible has been satisfied.

Delta Dental PPO participating dentist Delta Dental Premier participating dentist Out-of-Network dentistDentist Charge $100 Dentist Charge $100 Dentist Charge $100PPO Maximum Allowable $70 Premier Maximum Allowable $85 Prevailing Fee $75Plan pays80% of PPO Allowable $56 Plan pays

80% of Premier Allowable $68 Plan pays80% of Prevailing Fee $60

You pay20% of PPO Allowable $14 You pay

20% of Premier Allowable $17 You payBalance of the dentist charge $40

How to use your dental program:Call the dental office of your choice and make an appointment. During your first appointment be sure to provide your dentist with the following information:

Your Group name Your Group number The employee’s social security or member ID number

Your dental program allows you to: Change dentists and visit a specialist of your choice at any time without preapproval Select a different dentist for each member of your family Receive dental care anywhere in the world

Find a Delta Dental participating dentist:Two-thirds of the nation’s practicing dentists are Delta Dental participating dentists. To find a participating dentist, refer to our National Dentist Directory at www.DeltaDentalOK.org or call Delta Dental’s Customer Service Department at405-607-2100 (OKC Metro) or 800-522-0188 (Toll Free).

Benefit Payment ProcedureDelta Dental pays participating dentists directly. You are responsible for any co-insurance percentages, deductible amounts, charges for non-covered services and amounts in excess of your annual maximum benefit. A Delta Dental participating dentist cannot charge you for amounts payable by Delta Dental. If you obtain treatment from a nonparticipating dentist, you may have to pay the entire bill in advance. Delta Dental will directly reimburse you, or any other participant or beneficiary, if required by law, up to your plan’s maximum allowable amount.

The advantage of predeterminationIf you are scheduled for dental treatment that will cost more than $250, your dentist can request a predetermination of benefits by Delta Dental to determine if the proposed treatment is covered under your program, approximately how much the service will cost and your estimated share of the cost.

Filing your claimA Delta Dental participating dentist will file your claim at no charge. If necessary, a printable claim form may be obtained on our website at www.DeltaDentalOK.org. Completed claim forms should be submitted to the address below:

Delta Dental of Oklahoma - Claims Processing CenterP.O. Box 548809

Oklahoma City, OK 73154-

GR 7074 09-

Focus® features VSP network savings

Vision Benefits You ExpectConvenient, affordable vision plans for 3 or more enrolled employees

Help your Oklahoma employees and their families meet their vision needs with the right plan, featuring the VSP Choice Plus Affiliates Network

Benefit Summary

In Network Out of Network

Annual Deductible $10 exam, $25 materials

Benefit Frequencies Exam-Lens-Frame frequencies are 12-12-24 months. Choose eyeglass lenses or contacts every 12 months.

Annual Eye Exam 100% $45

Single Vision Lenses 100% $30

Bifocal Lenses 100% $50

Trifocal Lenses 100% $65

Progressive Lenses Up to $130 allowance, plus 20% discount

Frame $130 $70

Contact Lenses $130 $105

• In network contact lens exam, member fit & follow up cost capped at $60.

• Retinal imaging $39 for members in network, vs. dilation with drops.

• Polycarbonate lenses for dependent children 100% covered in network.

• Prescription safety glasses may be selected in lieu of eyeglasses.

VSP Choice Network offers over 78,000 access points, including 37,000 doctors and 5,000 retail locations nationwide.

Network savings with VSP:

• 20% off remaining frame balance

• 20% off additional noncovered complete prescription glasses

• 20-25% off noncovered lens options such as UV coating and polycarbonate lenses

• Average of 15% off usual and customary price, or 5% off promotional price, for LASIK or PRK through VSP and a contracted laser surgery center

Based on applicable laws, reduced costs may vary by doctor location.

GR 7074 09-

3 + Enrolled

Employee $8.64

Employee & Spouse $18.64

Employee & Children $15.08

Employee, Spouse & Children $25.08

Plan Requirements for All Plans• Rates/benefits quoted are based on a minimum of 3

enrolled employees. All rates and benefits quoted are not valid if the final enrollment is below the minimum threshold.

• Employer funding not required. If no employer money is involved, it is required that the vision plan will be sold in conjunction with a bona fide cafeteria plan regulated by Section 125 of the Internal Revenue Service code and it must meet all Section 125 requirements.

• No benefits are payable for a service which is not listed under the Schedule of Eye Care Services found in the certificate. Members pay costs exceeding plan benefits.

• Benefits available for all full-time, active employees working at least 30 hours per week who have completed the designated waiting period.

• Prescription medication savings through many pharmacies across the nation requires an Rx savings ID card available through the Ameritas secure member portal. This non- insurance discount is available at no additional cost.

• Through AXA Assistance, Ameritas offers vision plan members access to emergency vision provider referrals when traveling outside the U.S.

All rates are effective through 2/1/2020, and are guaranteed for four years (or may be set to align with the Section 125 plan year for voluntary plans).

This brochure highlights the vision coverage available through Ameritas Life Insurance Corp. Please refer to the Certificate of Insurance for a complete list of covered procedures. Options listed available in most states. Check with your Ameritas sales representative for product approval and availability.

LimitationsPlease refer to the Certificate of Insurance for a complete list of covered procedures. Check for availability in your state. Covered expenses will not include and no benefits will be payable for:

• Vision examinations, lenses and frames more than the frequency as indicated on the plan summary page.

• Services and/or materials not specifically included in the schedule as covered plan benefits.

• Plano lenses (lenses with refractive correction of less than plus or minus .50 diopter) except as specifically allowed in the frames benefit section of the Plan Benefits.

• Services or materials that are cosmetic, including plano contact lenses to change eye color and artistically painted contact lenses.

• Two pairs of glasses in lieu of bifocals.

• Replacement of spectacle lenses, frames, and/or contact lenses furnished under this plan that are lost or damaged, except at the normal intervals when services are otherwise available.

• Orthoptics or vision training and any associated supplemental testing.

• Medical or surgical treatment of the eyes.

• Contact lens modification, polishing or cleaning.

• The refitting of contact lenses after the initial 90-day filing period.

• Contact lens insurance policies or service contracts.

• Additional office visits associated with contact lens pathology.

• Local, state and/or federal taxes, except where law requires us to pay.

• Covered persons may be required to purchase a membership at certain retail locations before accessing plan benefits.

This information is provided by Ameritas Life Insurance Corp. (Ameritas Life). Group dental, vision and hearing care products (9000 Rev. 03-16, dates may vary by state) and individual dental and vision products (indiv. 9000 Rev. 07-16, dates may vary by state) are issued by Ameritas Life. Some plan designs are not available in all areas. In Texas, our dental network and plans are referred to as the Ameritas Dental Network. Some states require that producers be appointed with Ameritas Life before soliciting its products. To become appointed with Ameritas Life, please call 800-659-2223.

Ameritas, the bison design, “fulfilling life” and product names designated with SM or ® are service marks or registered service marks of Ameritas Life, affiliate Ameritas Holding Company or Ameritas Mutual Holding Company. All other brands are property of their respective owners. © 2017 Ameritas Mutual Holding Company.

800-776-9446 ameritas.com

GROUP BENEFIT PROGRAM SUMMARY For DAYBREAK FAMILY SERVICES - #F020233

The death of a family provider can mean that a family will not only find itself facing the loss of a loved one, but also the loss of financial security. With our Group Term Life plan, an employee can achieve peace of mind by giving their family the security they can depend on.

GROUP TERM LIFE

Eligibility All Eligible Active Full Time Employees

Group Term Life/AD&D Benefit: $50,000

Guarantee Issue Amount – Employee $50,000

Age Reduction Schedule Life and AD&D benefits reduce by 35% of the original amount at age 70 and further reduce by 50% of the original amount at age 75.

Waiver of Premium If an employee is unable to engage in any occupation as a result of injury or sickness for a minimum of 9 months, prior to age 60, premium will be waived for the employee’s life insurance benefit until the employee is no longer disabled or reaches age 65,whichever occurs first.

Definition of Disability Diagnosed by a doctor to be completely unable, because of sickness or injury to engage in any occupation for wage or profit or any occupation for which they become qualified by education,training or experience.

Accelerated Death Benefit (ADB) Upon the employee’s request, this benefit pays a lump sum up to 75% of the employee’s Life insurance, if diagnosed with a terminal illness and has a life expectancy of 12 months or less. Minimum:$7,500. Maximum: $250,000. The amount of group term lifeinsurance otherwise payable upon the employee’s death will be reduced by the ADB.

Conversion Privilege Included.

Travel Resource Services Helps travelers deal with the unexpected that may take place while traveling. Services include emergency medical assistance, financial, legal and communication assistance, and access to othercritical services and resources available via the internet.

This information is only a product highlight. Life benefits may be subject to medical underwriting. Coverage for a medically underwritten benefit is not effective until the date the insurer has approved the employee’s application. The policy has exclusions, limitations, and reduction of benefits and/or terms under which the policy may be continued or discontinued. The policy may be cancelled by the insurer at any time. The insurer reserves the right to change premium rates, but not more than once in a 12-month period.

Products and services marketed under the Dearborn National® brand and the star logo are underwritten and/or provided by Dearborn National® Life Insurance Company, (Downers Grove, IL) in all states (excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico. Product features and availability vary by state and company, and are solely the responsibility of each affiliate. Refer to your certificate for complete details and limitations of coverage. (For internal use only: Policy number FDL1-504-707)

For employee distribution

.

GROUP ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) PROGRAM SUMMARY

Group AD&D is an additional death benefit that pays in the event a covered employee dies or is dismembered in a covered accident. AD&D benefit is 24-hour coverage.

AD&D Schedule of Loss* Principal SumLoss of Life 100%Loss of Both Hands or Both Feet 100%Loss of One Hand and One Foot 100%Loss of Speech and Hearing 100%Loss of Sight of Both Eyes 100%Loss of One Hand and the Sight of One Eye 100%Loss of One Foot and the Sight of One Eye 100%Quadriplegia 100%Paraplegia 75%Hemiplegia 50%Loss of Sight of One Eye 50%Loss of One Hand or One Foot 50%Loss of Speech or Hearing 50%Loss of Thumb and Index Finger of Same Hand 25%Uniplegia 25%

* Loss must occur within 365 days of the accident.

AD&D Product Features Included: Seatbelt and Airbag Benefits Felonious Assault Benefit Repatriation Benefit Spouse Training Benefit Education Benefit Day Care Benefit

Exclusions – Unless specifically covered in the policy, or required by state law, we will not pay any AD&D benefit for any loss that, directly or indirectly, results in any way from or is contributed to by:1. disease of the mind or body, or any treatment thereof;2. infections, except those from an accidental cut or wound;3. suicide or attempted suicide;4. intentionally self-inflicted injury;5. war or act of war;6. travel or flight in any aircraft while a member of the crew;7. commission of, or participation in a felony;8. under the influence of certain drugs, narcotics, or hallucinogen unless properly used as prescribed by a physician; or9. intoxication as defined in the jurisdiction where the accident occurred;10. participation in a riot.




SUPPLEMENTAL GROUP TERM LIFE/AD&D

Eligibility All Eligible Active Full Time Employees

Group Term Life/AD&D Benefit: Employee Incremental selection from a minimum of $10,000 to a maximum of the lesser of $500,000 or 7.0 times annual earnings in increments of$10,000.

Guarantee Issue Amount* – Employee $100,000* NEW EMPLOYEES ONLY

Group Term Life/AD&D Benefit: Spouse(Includes Domestic Partners)

$5,000 - $150,000, in increments of $5,000, not to exceed 50% of the employee benefit amount.

Guarantee Issue* Amount – Spouse $20,000 (*New Employees’ Spouse)

Group Term Life/AD&D Benefit: Child(ren) Birth to 14 days: $0Age 15 days to 6 months: $100Age 6 months to 21 years (21 years and over if full-time student):$2,000 - $10,000, in $2,000 increments.

Age Reduction Schedule Life and AD&D benefits reduce by 35% of the original amount at age 70 and further reduce by 50% of the original amount at age 75.

Employee Contribution 100%

Waiver of Premium If an employee is unable to engage in any occupation as a result of injury or sickness for a minimum of 9 months, prior to age 60, premium will bewaived for the employee’s life insurance benefit until the employee is no longer disabled or reaches age 65, whichever occurs first.

Accelerated Death Benefit (ADB) Upon the employee’s request, this benefit pays a lump sum up to 75% of the employee’s Life insurance, if diagnosed with a terminal illness and has a life expectancy of 12 months or less. Minimum: $7,500. Maximum: $250,000. The amount of group term life insurance otherwisepayable upon the employee’s death will be reduced by the ADB.

Portability Feature (Life coverage) Included. (Employee)

Conversion Privilege (Life coverage) Included.

Exclusions One-year suicide exclusion applies to Supplemental Group Term Life coverage. AD&D exclusions are the same as Basic AD&D exclusions.




Policy Provisions may vary by state. Refer to a certificate or enrollment brochure for details about coverage features and For internal use only: Policy number FDL1-504- Slife/blend-w/

Products and services marketed under the Dearborn National® brand and the star logo are underwritten and/or provided by Dearborn National® Life Insurance Company® (Downers Grove, IL) (formerly known as Fort Dearborn Life Insurance Company®) in all states (excluding New York),

Employee Supplemental Life Monthly rates per $1,000AgeRates

Under 20$0.05220-24$0.05225-29$0.06230-34$0.08335-39$0.09340-44$0.10445-49$0.15650-54$0.23955-59$0.44660-64$0.68565-69$1.31770+$2.137

Supplemental AD&DMonthly rates per $1,000 Employee$0.018

Dependent Life (Children)Monthly Premium per Family LifeAD&D$2,000$0.22$0.02$4,000$0.43$0.04$6,000$0.65$0.06$8,000$0.86$0.08$10,000$1.08$0.10

SUPPLEMENTAL GROUP LIFE AND AD&DPREMIUM RATE GRID

DAYBREAK FAMILY SERVICES - #F020233 EligibilityYou are eligible to enroll if you work the minimum number of hours per week by your employer, and you have satisfied any waiting period.You must be covered under the basic life plan sponsored by your employer in SD and VT.

Supplemental Life/AD&D InsuranceEmployee Benefit: $10,000 to $500,000, in increments of $10,000 or 7 times annual

earnings, whichever is less.

Spouse Benefit: $5,000 to $150,000, in increments of $5,000(not to exceed 50% of the employee benefit)

Note: Spouse may not have coverage unless the employee has coverage.The amount of spouse life insurance is limited to 50% of the employee benefit in FL, KS, NE and PR.

The spouse benefit may not exceed the employee benefit amount in AZ, CA, IL, MD, NJ, RI, VT, VA and WA.

The Spouse amount may not exceed the amount for which the employee is eligible in TX and NY.

Guarantee Issue*Employee $100,000Spouse $20,000* NEW EMPLOYEES ONLY

Child CoverageBirth to 14 days: $015 days to 6 months: $1006 months to age 21 $2,000 to $10,000 in $2,000 increments(or 21 years and over if fulltime Student)

Life and AD&D benefits reduce by 35% of the original amount at age 70 and further reduce by 50% of the original amount at age 75.

Supplemental Life/AD&D InsuranceMonthly Premium Cost (Based on 12 payroll deductions per year)

ATTAINED AGEBenefit Amount

EEAD&D <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74

$10,000 $0.18 $0.52 $0.52 $0.62 $0.83 $0.93 $1.04 $1.56 $2.39 $4.46 $6.85 $13.17 $21.37$20,000 $0.36 $1.04 $1.04 $1.24 $1.66 $1.86 $2.08 $3.12 $4.78 $8.92 $13.70 $26.34 $42.74$30,000 $0.54 $1.56 $1.56 $1.86 $2.49 $2.79 $3.12 $4.68 $7.17 $13.38 $20.55 $39.51 $64.11$40,000 $0.72 $2.08 $2.08 $2.48 $3.32 $3.72 $4.16 $6.24 $9.56 $17.84 $27.40 $52.68 $85.48$50,000 $0.90 $2.60 $2.60 $3.10 $4.15 $4.65 $5.20 $7.80 $11.95 $22.30 $34.25 $65.85 $106.85$60,000 $1.08 $3.12 $3.12 $3.72 $4.98 $5.58 $6.24 $9.36 $14.34 $26.76 $41.10 $79.02 $128.22$70,000 $1.26 $3.64 $3.64 $4.34 $5.81 $6.51 $7.28 $10.92 $16.73 $31.22 $47.95 $92.19 $149.59$80,000 $1.44 $4.16 $4.16 $4.96 $6.64 $7.44 $8.32 $12.48 $19.12 $35.68 $54.80 $105.36 $170.96$90,000 $1.62 $4.68 $4.68 $5.58 $7.47 $8.37 $9.36 $14.04 $21.51 $40.14 $61.65 $118.53 $192.33

$100,000 $1.80 $5.20 $5.20 $6.20 $8.30 $9.30 $10.40 $15.60 $23.90 $44.60 $68.50 $131.70 $213.70$110,000 $1.98 $5.72 $5.72 $6.82 $9.13 $10.23 $11.44 $17.16 $26.29 $49.06 $75.35 $144.87 $235.07$120,000 $2.16 $6.24 $6.24 $7.44 $9.96 $11.16 $12.48 $18.72 $28.68 $53.52 $82.20 $158.04 $256.44$130,000 $2.34 $6.76 $6.76 $8.06 $10.79 $12.09 $13.52 $20.28 $31.07 $57.98 $89.05 $171.21 $277.81$140,000 $2.52 $7.28 $7.28 $8.68 $11.62 $13.02 $14.56 $21.84 $33.46 $62.44 $95.90 $184.38 $299.18$150,000 $2.70 $7.80 $7.80 $9.30 $12.45 $13.95 $15.60 $23.40 $35.85 $66.90 $102.75 $197.55 $320.55$200,000 $3.60 $10.40 $10.40 $12.40 $16.60 $18.60 $20.80 $31.20 $47.80 $89.20 $137.00 $263.40 $427.40$250,000 $4.50 $13.00 $13.00 $15.50 $20.75 $23.25 $26.00 $39.00 $59.75 $111.50 $171.25 $329.25 $534.25$300,000 $5.40 $15.60 $15.60 $18.60 $24.90 $27.90 $31.20 $46.80 $71.70 $133.80 $205.50 $395.10 $641.10$350,000 $6.30 $18.20 $18.20 $21.70 $29.05 $32.55 $36.40 $54.60 $83.65 $156.10 $239.75 $460.95 $747.95$400,000 $7.20 $20.80 $20.80 $24.80 $33.20 $37.20 $41.60 $62.40 $95.60 $178.40 $274.00 $526.80 $854.80$450,000 $8.10 $23.40 $23.40 $27.90 $37.35 $41.85 $46.80 $70.20 $107.55 $200.70 $308.25 $592.65 $961.65$500,000 $9.00 $26.00 $26.00 $31.00 $41.50 $46.50 $52.00 $78.00 $119.50 $223.00 $342.50 $658.50 $1,068.50

Spouse Supplemental LifeMonthly rates per $1,000AgeRates

Policy Provisions may vary by state. Refer to a certificate or enrollment brochure for details about coverage features and For internal use only: Policy number FDL1-504- Slife/blend-w/

Products and services marketed under the Dearborn National® brand and the star logo are underwritten and/or provided by Dearborn National® Life Insurance Company® (Downers Grove, IL) (formerly known as Fort Dearborn Life Insurance Company®) in all states (excluding New York),

SUPPLEMENTAL GROUP LIFE AND AD&DPREMIUM RATE GRID

DAYBREAK FAMILY SERVICES - #F020233 EligibilityYou are eligible to enroll if you work the minimum number of hours per week by your employer, and you have satisfied any waiting period.You must be covered under the basic life plan sponsored by your employer in SD and VT.

Supplemental Life/AD&D InsuranceEmployee Benefit: $10,000 to $500,000, in increments of $10,000 or 7 times annual Under 20 $0.052

earnings, whichever is less. 20-24 $0.05225-29 $0.062

Spouse Benefit: $5,000 to $150,000, in increments of $5,000 30-34 $0.083(not to exceed 50% of the employee benefit) 35-39 $0.093

Note: Spouse may not have coverage unless the employee has coverage. 40-44 $0.104The amount of spouse life insurance is limited to 50% of the employee benefit in FL, KS, NE and PR. 45-49 $0.156The spouse benefit may not exceed the employee benefit amount in AZ, CA, IL, MD, NJ, RI, VT, VA and WA. 50-54 $0.239The Spouse amount may not exceed the amount for which the employee is eligible in TX and NY. 55-59 $0.446

60-64 $0.685Guarantee Issue* 65-69 $1.317Employee $100,000 70+ $2.137Spouse $20,000* NEW EMPLOYEES ONLY

Child CoverageBirth to 14 days: $015 days to 6 months: $1006 months to age 21 $2,000 to $10,000 in $2,000 increments(or 21 years and over if fulltime Student)

Supplemental AD&DMonthly rates per $1,000

Spouse $0.020

Dependent Life (Children)Monthly Premium per Family

Life AD&DLife and AD&D benefits reduce by 35% of the original amount at age 70 and further reduce $2,000 $0.22 $0.02by 50% of the original amount at age 75. $4,000 $0.43 $0.04

$6,000 $0.65 $0.06$8,000 $0.86 $0.08

Supplemental Life/AD&D Insurance $10,000 $1.08 $0.10Monthly Premium Cost (Based on 12 payroll deductions per year)

Benefit Amount

SP AD&D <20 20-24 25-29 30-34 35-39

ATTAINED AGE

40-44 45-49 50-54 55-59 60-64 65-69 70-74$5,000 $0.10 $0.26 $0.26 $0.31 $0.42 $0.47 $0.52 $0.78 $1.20 $2.23 $3.43 $6.59 $10.69

$10,000 $0.20 $0.52 $0.52 $0.62 $0.83 $0.93 $1.04 $1.56 $2.39 $4.46 $6.85 $13.17 $21.37

$15,000 $0.30 $0.78 $0.78 $0.93 $1.25 $1.40 $1.56 $2.34 $3.59 $6.69 $10.28 $19.76 $32.06$20,000 $0.40 $1.04 $1.04 $1.24 $1.66 $1.86 $2.08 $3.12 $4.78 $8.92 $13.70 $26.34 $42.74

$25,000 $0.50 $1.30 $1.30 $1.55 $2.08 $2.33 $2.60 $3.90 $5.98 $11.15 $17.13 $32.93 $53.43$30,000 $0.60 $1.56 $1.56 $1.86 $2.49 $2.79 $3.12 $4.68 $7.17 $13.38 $20.55 $39.51 $64.11

$35,000 $0.70 $1.82 $1.82 $2.17 $2.91 $3.26 $3.64 $5.46 $8.37 $15.61 $23.98 $46.10 $74.80$40,000 $0.80 $2.08 $2.08 $2.48 $3.32 $3.72 $4.16 $6.24 $9.56 $17.84 $27.40 $52.68 $85.48

$45,000 $0.90 $2.34 $2.34 $2.79 $3.74 $4.19 $4.68 $7.02 $10.76 $20.07 $30.83 $59.27 $96.17$50,000 $1.00 $2.60 $2.60 $3.10 $4.15 $4.65 $5.20 $7.80 $11.95 $22.30 $34.25 $65.85 $106.85

$55,000 $1.10 $2.86 $2.86 $3.41 $4.57 $5.12 $5.72 $8.58 $13.15 $24.53 $37.68 $72.44 $117.54$60,000 $1.20 $3.12 $3.12 $3.72 $4.98 $5.58 $6.24 $9.36 $14.34 $26.76 $41.10 $79.02 $128.22

$65,000 $1.30 $3.38 $3.38 $4.03 $5.40 $6.05 $6.76 $10.14 $15.54 $28.99 $44.53 $85.61 $138.91$70,000 $1.40 $3.64 $3.64 $4.34 $5.81 $6.51 $7.28 $10.92 $16.73 $31.22 $47.95 $92.19 $149.59

$75,000 $1.50 $3.90 $3.90 $4.65 $6.23 $6.98 $7.80 $11.70 $17.93 $33.45 $51.38 $98.78 $160.28$80,000 $1.60 $4.16 $4.16 $4.96 $6.64 $7.44 $8.32 $12.48 $19.12 $35.68 $54.80 $105.36 $170.96

$85,000 $1.70 $4.42 $4.42 $5.27 $7.06 $7.91 $8.84 $13.26 $20.32 $37.91 $58.23 $111.95 $181.65$90,000 $1.80 $4.68 $4.68 $5.58 $7.47 $8.37 $9.36 $14.04 $21.51 $40.14 $61.65 $118.53 $192.33

$95,000 $1.90 $4.94 $4.94 $5.89 $7.89 $8.84 $9.88 $14.82 $22.71 $42.37 $65.08 $125.12 $203.02$100,000 $2.00 $5.20 $5.20 $6.20 $8.30 $9.30 $10.40 $15.60 $23.90 $44.60 $68.50 $131.70 $213.70

$120,000 $2.40 $6.24 $6.24 $7.44 $9.96 $11.16 $12.48 $18.72 $28.68 $53.52 $82.20 $158.04 $256.44$150,000 $3.00 $7.80 $7.80 $9.30 $12.45 $13.95 $15.60 $23.40 $35.85 $66.90 $102.75 $197.55 $320.55

plan year: 1-1-2019 through 12-31-2019 · web viewemployee benefits enrollment guide plan year:...

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