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2018 RETIREE BENEFITS REFERENCE GUIDE

Over 65 and Medicare Eligible

2www.JacksonBenefits.org 3 www.JacksonBenefits.org

What’s New Benefits Providers Directory

FBMC Benefits Management, Inc.Retiree and Direct Bill DepartmentP.O. Box 10789Tallahassee, FL 32302-2789

FBMC Service Center 855-56JHS4U (855-565-4748)www.myFBMC.com

ON-SITE FBMC SERVICE CENTER1611 N.W. 12th AvenuePark Plaza West L-109BMiami, FL 33136-1096 305-585-6512

MEDICAL PROVIDER AvMed Health Plan844-439-5378www.avmed.org/jhs DENTAL PROVIDER Delta Dental1-888-335-8227P.O. Box 997330Sacramento, CA 95899-7330www.deltadentalins.comPPO Group Number – 19083DHMO Group Number – 78933

VISION PROVIDER Davis Vision Vision Care Processing Unit P.O. Box 1525 Latham, NY 12110 Member Service: 877-393-7363www.davisvision.com

TAX SHELTER ANNUITY PROVIDERS Nationwide Retirement Solutions457 P.O. Box 182797Columbus, OH 43218-2797877-677-3678www.nrsforu.com

VOYA Life Insurance & Annuity Company 403(b) and 4573201 West Commercial BoulevardSuite 211Ft. Lauderdale, FL 33309954-486-2236www.voya.com

Fidelity Investments Tax Exempt Services Co. 403(b)P.O. Box 770002Cincinnati, OH 45277-0089800-343-0860www.fidelity.com/workplace

Lincoln National Life Insurance Co. (403(b) and 457)P.O. Box 2340Fort Wayne, IN 46801800-454-6265 (403(b))800-341-0441 (457)www.lfg.com

AIG/VALIC 403(b) / 457(b)Miami District Office701 Brickell Avenue, Suite 1950Miami, FL 33131Office Phone: 305-817-2250Office Fax: 786-777-7626VALIC Client Care Center: 800-448-2542www.valic.com

OTHER PROVIDERS PET DISCOUNT PLANPet Assure and PETplus Rx415 Cedar Bridge Avenue Lakewood, NJ 08701 888-789-7387www.petassure.com

LEGAL PLANARAG 400 Locust StreetSuite 480Des Moines, IA 50309800-247-4184ARAGLegalCenter.com, Access Code 17845ret

IDENTITY THEFT ID CommanderMembership Services1-855-592-7941Mon - Fri, 9 a.m. - 6 p.m. ET.www.idcommander.com

CREDIT MONITORING ConstantCreditMembership Services1-888-384-7935Mon – Fri, 9 a.m. - 6 p.m. ET.www.constantcredit.com

Important Enrollment Information• In addition to this 2018 Retiree Reference Guide

enclosed in this mailing, you will find an enrollment form.

• You must enroll if you wish to make changes, cancel or decrease coverage during the Open Enrollment period. You may not add coverage, add dependent coverage or increase coverage to medical or dental coverages.

You must fax/ mail completed forms to: FBMC Benefits Management, Inc. Retiree and Direct Bill Department PO Box 10789 Tallahassee, FL 32302-2789 Fax to: 1-866-836-9943

Mailed forms must be postmarked by December 6, 2017, which is the last day of the enrollment.

Please direct all questions or comments to Customer Service at 855-56JHS4U (855-565-4748), Monday–Friday, 7 a.m. – 7 p.m. ET.

Important Dates to RememberYour plan year dates are:

January 1, 2018 through December 31, 2018

Your open enrollment dates are: November 22, 2017 through December 6, 2017

Benefits Providers Directory 3

Key Things To Know 4

Medical Plans 5

Dental Plans 14

Vision Plans 18

ARAG® Legal Insurance 21

Pet Assure and PETplus Rx 23

ConstantCredit 24

ID Commander 24

Notices 25

Online Resources 27


Key Things To Know

Enrollment at a GlanceBenefits Open Enrollment for the 2018 plan year will take place November 22 through December 6, 2017.

You must enroll if you wish to make changes, or cancel and/or decrease coverage. Otherwise, you do not need to complete an enrollment form and your current benefits will automatically roll over to the corresponding 2018 plan year. Please note that you are not allowed to add new dependents or increase coverage.

An Over 65 Retiree Benefits Guide, enrollment form and FBMC return envelope are included with this mailing. To make your benefits selections, please complete the enrollment form and a deduction authorization form and return it by mail, postmarked by December 6, 2017, which is the last day of the enrollment. You are only required to complete and submit a new deduction authorization form if electing a new benefit that you did not have for 2017 plan year. The ACH, FRS, or PHT deduction authorization forms are all available online at www.JacksonBenefits.org.

You must fax/ mail completed forms to: FBMC Benefits Management, Inc. Retiree and Direct Bill Department P.O. Box 10789 Tallahassee, FL 32302-2789

Fax to: 1-866-836-9943

Retirees must fax/mail a completed authorization form for all new deductions (or restarted deductions).

Listed below are the changes for the 2018 plan year:

• Medical Rates: We are pleased to announce that the AvMed High Option with Rx and High Option without Rx rates will remain the same for the 2018 Plan Year.

• Medical Plan Changes for Dependents Under 65 and/or Not Medicare Eligible Dependents: Jackson will phase out the Jackson Standard HMO option, which is costly and largely similar to our

more affordable Jackson Select HMO. The Jackson Standard plan will be offered for the last time during our upcoming open enrollment, allowing dependents who are not Medicare eligible to continue using it during the 2018 plan year with a rate increase.

• Dental Provider Change: Effective January 1, 2018, Jackson will bring back Delta Dental with four different plan options (DHMO & PPO). The plan designs will mirror the plan from previous years.

• Davis Vision: The vision benefit will continue to be administered by Davis Vision with enhanced benefits and a choice of two plans (base and premium). Retirees will have the option to enroll in the Davis Vision plan if not currently enrolled.

For questions or more information about Open Enrollment, please contact the On-site FBMC Service Center at (305) 585-6512.

Core Benefits AvailableMedical Plans• AvMed High Plan• AvMed High w/No Rx Plan

Dental Plans• Delta Dental PPO Standard or Enriched• DeltaCare DHMO Standard or Enriched

Vision Plans• Base Plan• Premier Plan

Medical Plans

The medical chart pages are intended to highlight the plans available and do not constitute a contract. Precise benefits will be governed by the contracts and not by these charts. Please review details of any modification in benefits in the plan literature, or seek clarification through the health plan.

Health Plans are on an ongoing basis renegotiating contracts with affiliated providers (doctors, hospitals etc.). As a result, providers may be added to or deleted from the participating provider listing of the various plans during the plan year. We highly recommend verifying if the provider of your preference still participates in the program prior to seeking use of their services.

† Option also applies to Adult Children (AC) between 26 through 30 years of age, children of DP and/or eligible dependents.

AvMed Retiree, Spouse/DP & DependentsMonthly Rates

AVMED HIGH PLAN

AVMEDHIGH W/NO RX

PLAN

Retiree 65 and Over Only $561.46 $244.04Retiree 65 and Over & Spouse/DP 65 and Over $1,101.90 $478.97Retiree 65 and Over & Spouse/DP 65 & Over plus Child(ren)† on AvMed POS Plan

$2,147.27 N/A

Retiree 65 and Over & Spouse/DP 65 & Over plus Child(ren)† on AvMed Standard HMO $1,785.48 N/A

Retiree 65 and Over & Child(ren)† on AvMed POS Plan $1,606.83 $1,289.41

Retiree 65 and Over & Child(ren)† on AvMed Standard HMO $1,245.04 $927.62

Retiree 65 and Over & Spouse/DP Under 65 on AvMed POS Plan

$2,245.84 N/A

Retiree 65 and Over & Spouse/DP Under 65 on AvMed Standard HMO

$1,714.45 $1,397.03

Retiree 65 and Over & Spouse under 65 on POS $1,783.75 $1,466.33Retiree 65 and Over & Spouse/DP under 65 on AvMed Standard HMO $1,118.04 $800.62

AvMed Dependent Coverage Monthly Rates Retiree 65 and Over w/Non-JHS Medicare Plan

JACKSON FIRST HMO PLAN

JACKSONSELECT

HMO PLAN

JACKSON STANDARD HMO PLAN

JACKSONPOS

PLAN

Spouse/DP Under 65† $387.42 $419.23 $556.58 $1,222.29

Child(ren)† $423.59 $453.62 $683.58 $1,045.37Spouse/DP Under 65 and Child(ren)† $811.01 $872.85 $1,152.99 $2,267.66


Benefit Summary MEDICARE ELIGIBLE RETIREE HIGH OPTION WITH PRESCRIPTION DRUG COVERAGE

SF-JHS RETIREE HIGH W/RX-15 SF-3579 (01/15)

JACKSON HEALTH SYSTEM SCHEDULE OF BENEFITS LIFETIME MAXIMUM Unlimited DEDUCTIBLE AMOUNT PER CALENDAR YEAR Per Individual

$147 for Private Duty Nursing $250 for Foreign Travel Emergency Care

CHOICE OF HOSPITALS Unlimited MEDICARE PART B DEDUCTIBLE: $147 PER CALENDAR YEAR Not Covered

INPATIENT HOSPITAL FACILITYCovered by Medicare Part A. Medicare covers: Days 1—60: All but $1,260Days 61—90: All but $315 per day Days 91—150: All but $630 per day

*Days 91—150 are the 60 Lifetime Reserve Days. Medicare will cease until a new Benefit Period begins. A new Benefit Period begins after you have been out of the hospital or facility for at least 60 days. In a new Benefit Period, all Medicare Part A will renew except for the Lifetime Reserve Days.

100% up to $1,260 100% up to $315 per day 100% up to $630 per day

*365 additional lifetime days after Medicare Lifetime Reserve Days are exhausted

Covered at 100% of Medicare eligible expense

Must be medically necessary Limiting semi-private room (unless medically necessary) & board amount

HOSPITAL OUTPATIENT/PHYSICIAN Covered by Medicare Part B Remainder 20% of Medicare approved amount

SKILLED NURSING FACILITIES Days 1—20: Covered by Medicare Part A Days 21—100: Covered all but $157.50 per day

Days 1—20: Not Covered Days 21—100: 100% up to $157.50 per day Days 101 & beyond: Not Covered

PHYSICIAN VISITS/ILLNESS Covered by Medicare Part B Remainder 20% of Medicare approved amount

EMERGENCY AND URGENT CARE SERVICES Covered by Medicare Part B Remainder 20% of Medicare approved amount

PHYSICIAN’S OFFICE VISIT Covered by Medicare Part B Remainder 20% of Medicare approved amount

SPECIALIST’S OFFICE VISIT Covered by Medicare Part B Remainder 20% of Medicare approved amount

SURGICAL PROCEDURES Covered by Medicare Part B Remainder 20% of Medicare approved amount

PREVENTIVE CARE Covered by Medicare Part B

Includes, but is not limited to: Annual Screening Mammogram Pap Smear & Pelvic Exam Bone Mass Measurement Prostate Cancer Screening Physical Exam (Yearly “Wellness” Exam) Colorectal Screening Subject to Preventive Care guidelines outlined in the “2015 Medicare & You” publication from Centers for Medicare & Medicaid Services (CMS)

No Charge

ALLERGY INJECTIONS Covered by Medicare Part B Remainder 20% of Medicare approved amount

Visit our website at www.avmed.org/go/mdphtAvMed Health Plans HIGH OPTION with Rx



JACKSON HEALTH SYSTEM SCHEDULE OF BENEFITS DURABLE MEDICAL EQUIPMENT Covered by Medicare Part B Remainder 20% of Medicare approved amount

IMMUNIZATIONS Covered by Medicare Part B Remainder 20% of Medicare approved amount

X-RAYS Covered by Medicare Part B Remainder 20% of Medicare approved amount

ADVANCED RADIOLOGICAL IMAGING (I.E. MRIs, MRAs, CAT Scans and PET Scans) Covered by Medicare Part B

Remainder 20% of Medicare approved amount

PHYSICAL THERAPY SERVICES Covered by Medicare Part B Remainder 20% of Medicare approved amount

TMJCovered by Medicare Part B Surgical and Non-Surgical


OTHER LAB/RADIOLOGY SERVICES Covered by Medicare Part B Remainder 20% of Medicare approved amount

SHORT-TERM REHABILITATION Covered by Medicare Part B

Includes:Cardiac Rehab Speech Therapy Occupational Therapy Pulmonary Rehab Cognitive Therapy Chiropractic Therapy (includes Chiropractors)


Limited to$1,940 per calendar year for Physical Therapy (PT) and Speech Therapy Language Pathology (SLP) services combined

Limited to$1,940 per calendar year for Occupational Therapy (OT) services

AMBULANCE Covered by Medicare Part B Remainder 20% of Medicare approved amount

HOME HEALTH CARE When covered by Medicare

When not covered by Medicare

No Charge

Plan will pay up to $40 per visit limited to $1,600 per calendar year.

FOREIGN TRAVEL/EMERGENCY CARE Not covered by Medicare

80% of Medicare approved amount after $250 calendar year deductible, up to a lifetime maximum of $50,000

PRIVATE DUTY NURSING Covered by Medicare Part B (While Inpatient In a Hospital or Other Health Care Facility Only)

80% of the Reasonable & Customary charges after $147 calendar year deductible



JACKSON HEALTH SYSTEM SCHEDULE OF BENEFITS DURABLE MEDICAL EQUIPMENT Covered by Medicare Part B Remainder 20% of Medicare approved amount






TMJCovered by Medicare Part B Surgical and Non-Surgical






Limited to$1,940 per calendar year for Physical Therapy (PT) and Speech Therapy Language Pathology (SLP) services combined

Limited to$1,940 per calendar year for Occupational Therapy (OT) services




No Charge











JACKSON HEALTH SYSTEM SCHEDULE OF BENEFITS MATERNITY SERVICES Covered by Medicare Part B

Initial Visit to confirm pregnancy

All subsequent prenatal and postnatal visits

Covered by Medicare Part A Delivery, (Inpatient Hospital or Birthing Center)



Days 1 to 60: 100% up to $1,260 Days 61 to 90: 100% up to $315 per day Days 91 -150: 100% up to $630 per day

ABORTION-NON-ELECTIVE Covered by Medicare Part A Inpatient

Payable as Inpatient

OUTPATIENT SURGICAL FACILITY\ Covered by Medicare Part B Surgical sterilization procedures for Vasectomy/Tubal Ligations


BLOODFirst three pints of blood not covered by Medicare

First three pints of blood covered at 100% of the Reasonable & Customary charges

OUTPATIENT FACILITY Covered by Medicare Part B Services in Operating and Recovery Room, Procedures Room and Treatment


HOSPICEInpatient Services

Outpatient Services (same coinsurance level as Home Health Care)

Plan pays 100% of amount approved but not paid by Medicare, when Medicare certification and election requirements are met.

INFERTILITY - OFFICE VISIT FOR DIAGNOSIS Covered by Medicare Part B Remainder 20% of Medicare approved amount

ORGAN TRANSPLANT Covered by Medicare Part A Payable as Inpatient Hospital

EXTERNAL PROSTHESES Covered by Medicare Part B Remainder 20% of Medicare approved amount



JACKSON HEALTH SYSTEM SCHEDULE OF BENEFITS MATERNITY SERVICES Covered by Medicare Part B

Initial Visit to confirm pregnancy








OUTPATIENT SURGICAL FACILITY\ Covered by Medicare Part B Surgical sterilization procedures for Vasectomy/Tubal Ligations






HOSPICEInpatient Services

Outpatient Services (same coinsurance level as Home Health Care)

Plan pays 100% of amount approved but not paid by Medicare, when Medicare certification and election requirements are met.




Visit our website at www.avmed.org/go/mdphtAvMed Health Plans HIGH OPTION with Rx Benefit Summary

MEDICARE ELIGIBLE RETIREE HIGH OPTION WITH PRESCRIPTION DRUG COVERAGE


JACKSON HEALTH SYSTEM SCHEDULE OF BENEFITS MENTAL HEALTH /SUBSTANCE ABUSE INPATIENT Covered by Medicare Part A

Mental Health Acute: based on ratio of 1:1

Partial: based on a ratio of 2:1

Substance Abuse Acute detoxification: requires 24 hour nursing; based on a ratio of 1:1

Acute Inpatient Rehab: requires 24 hour nursing; based on a ratio of 1:1


Residential: based on a ratio of 2:1

Plan pays 100% of amount approved but not paid by Medicare; if charges not approved by Medicare, there is no coverage

MENTAL HEALTH/SUBSTANCE ABUSE OUTPATIENT HOSPITAL/FACILITY Covered by Medicare Part B

Coverage assumes enrollment in Medicare Part B; Plan pays remainder of charges approved but not paid by Medicare Part B and member has $0 responsibility

EYEGLASSES Covered by Medicare Part B Not Covered

PRESCRIPTION DRUG COVERAGE

Retail (30-day supply)

Specialty (30-day supply at Participating Specialty Pharmacy)

Mail Order (90-day supply at Participating Pharmacy)

Mail Order at Non-Participating Pharmacy

80% after $200 calendar year deductible

$100 co-payment per prescription for Specialty drugs

100% after $10 co-payment for Generic 100% after $20 co-payment for Preferred Brand 100% after $30 co-payment for Non-Preferred Brand

Not Covered

FOR ADDITIONAL INFORMATION, PLEASE CALL: 1-844-439-5378

For specific information on benefits, exclusions and limitations please see your Summary Plan Description (SPD).














PRESCRIPTION DRUG COVERAGE

Retail (30-day supply)

Specialty (30-day supply at Participating Specialty Pharmacy)

Mail Order (90-day supply at Participating Pharmacy)

Mail Order at Non-Participating Pharmacy

80% after $200 calendar year deductible

$100 co-payment per prescription for Specialty drugs

100% after $10 co-payment for Generic 100% after $20 co-payment for Preferred Brand 100% after $30 co-payment for Non-Preferred Brand

Not Covered




Visit our website at www.avmed.org/go/mdphtAvMed Health Plans HIGH OPTION without Rx

Benefit Summary MEDICARE ELIGIBLE RETIREE HIGH OPTION WITHOUT PRESCRIPTION DRUG

COVERAGE

SF-JHS RETIREE HIGH W/O RX-15 SF-3577 (01/15)

JACKSON HEALTH SYSTEM SCHEDULE OF BENEFITS LIFETIME MAXIMUM Unlimited DEDUCTIBLE AMOUNT PER CALENDAR YEAR Per Individual

$147 for Private Duty Nursing $250 for Foreign Travel Emergency Care

CHOICE OF HOSPITALS Unlimited MEDICARE PART B DEDUCTIBLE: $147 PER CALENDAR YEAR Not Covered

INPATIENT HOSPITAL FACILITYCovered by Medicare Part A. Medicare covers:Days 1—60: All but $1,260Days 61—90: All but $315 per day Days 91—150: All but $630 per day

*Days 91—150 are the 60 Lifetime Reserve Days. Medicare will cease until a new Benefit Period begins. A new Benefit Period begins after you have been out of the hospital or facility for at least 60 days. In a new Benefit Period, all Medicare Part A will renew except for the Lifetime Reserve Days.

100% up to $1,260 100% up to $315 per day 100% up to $630 per day

*365 additional lifetime days after Medicare Lifetime Reserve Days are exhausted

Covered at 100% of Medicare eligible expense

Must be medically necessary

Limiting semi-private room (unless medically necessary) & board amount

HOSPITAL OUTPATIENT/PHYSICIAN Covered by Medicare Part B Remainder 20% of Medicare approved amount

SKILLED NURSING FACILITIES Days 1—20: Covered by Medicare Part A Days 21—100: Covered all but $157.50 per day

Days 1—20: Not Covered Days 21—100: 100% up to $157.50 per day Days 101 & beyond: Not Covered

PHYSICIAN VISITS/ILLNESS Covered by Medicare Part B Remainder 20% of Medicare approved amount

EMERGENCY AND URGENT CARE SERVICES Covered by Medicare Part B Remainder 20% of Medicare approved amount

PHYSICIAN’S OFFICE VISIT Covered by Medicare Part B Remainder 20% of Medicare approved amount

SPECIALIST’S OFFICE VISIT Covered by Medicare Part B Remainder 20% of Medicare approved amount

SURGICAL PROCEDURES Covered by Medicare Part B Remainder 20% of Medicare approved amount

PREVENTIVE CARE Covered by Medicare Part B

Includes, but is not limited to: Annual Screening Mammogram Pap Smear & Pelvic Exam Bone Mass Measurement Prostate Cancer Screening Physical Exam (Yearly “Wellness” Exam) Colorectal Screening Subject to Preventive Care guidelines outlined in the “2015 Medicare & You” publication from Centers for Medicare & Medicaid Services (CMS)

No Charge



COVERAGE


JACKSON HEALTH SYSTEM SCHEDULE OF BENEFITS ALLERGY INJECTIONS Covered by Medicare Part B Remainder 20% of Medicare approved amount

DURABLE MEDICAL EQUIPMENT Covered by Medicare Part B Remainder 20% of Medicare approved amount






TMJ Surgical and Non-Surgical Covered by Medicare Part B Remainder 20% of Medicare approved amount





Limited to $1,940 for Physical Therapy (PT) and Speech Therapy Language Pathology (SLP) services combined

Limited to $1,940 for Occupational Therapy (OT) services




No Charge







COVERAGE


JACKSON HEALTH SYSTEM SCHEDULE OF BENEFITS ALLERGY INJECTIONS Covered by Medicare Part B Remainder 20% of Medicare approved amount

DURABLE MEDICAL EQUIPMENT Covered by Medicare Part B Remainder 20% of Medicare approved amount






TMJ Surgical and Non-Surgical Covered by Medicare Part B Remainder 20% of Medicare approved amount





Limited to $1,940 for Physical Therapy (PT) and Speech Therapy Language Pathology (SLP) services combined

Limited to $1,940 for Occupational Therapy (OT) services




No Charge









COVERAGE


JACKSON HEALTH SYSTEM SCHEDULE OF BENEFITS MATERNITY SERVICES Covered by Medicare Part B Initial Visit to confirm pregnancy








OUTPATIENT SURGICAL FACILITY Covered by Medicare Part B Surgical sterilization procedures for Vasectomy/Tubal Ligations






HOSPICEInpatient Services Outpatient Services (same coinsurance level as Home Health Care)

Plan pays 100% of amount approved but not paid by Medicare, when Medicare certification and election requirements are met





COVERAGE


JACKSON HEALTH SYSTEM SCHEDULE OF BENEFITS MATERNITY SERVICES Covered by Medicare Part B Initial Visit to confirm pregnancy








OUTPATIENT SURGICAL FACILITY Covered by Medicare Part B Surgical sterilization procedures for Vasectomy/Tubal Ligations






HOSPICEInpatient Services Outpatient Services (same coinsurance level as Home Health Care)

Plan pays 100% of amount approved but not paid by Medicare, when Medicare certification and election requirements are met






COVERAGE













PRESCRIPTION DRUG COVERAGE Not Covered




COVERAGE













PRESCRIPTION DRUG COVERAGE Not Covered




STANDARD ENRICHED

Monthly Dental Rates

DELTACAREDHMO*

DELTA DENTALPPO

DELTACARE DHMO*

DELTA DENTAL PPO

Retiree Only $8.00 $31.22 $14.57 $40.87

Retiree &One Dependent† $13.24 $61.76 $24.15 $80.81

Retiree & Dependents† $20.22 $99.55 $38.39 $130.30

Dental Rates

+ Option also applies to Domestic Partners and/or Children of Domestic Partners and eligible dependents.* DeltaCare DHMO plans are not available outside of Florida.Non-Delta Dental dentists are reimbursed based on the PPO Fee Schedule instead of the maximum program allowance. As a result members visiting a non-Delta Dental dentist may see a change in out-of-pocket costs.

Dental PlansDental Plans

You may choose from the following dental plans:• Delta PPO

• DeltaCare DHMO

Employees can select coverage in a PPO or a prepaid dental program. Choices include standard or enriched dental PPO plans offered by Delta Dental, and standard or enriched prepaid dental plans offered by Delta. Employees with dental PPO coverage may also choose a dentist not participating in their program and will receive applicable benefits.

Prepaid dental plans provide preventive, diagnostic, and many other services free of charge to members. Other services, including major procedures such as crowns, have fixed copayments established by the plan. Claim forms are not required. Members must use one of the plan’s participating dentists to receive benefits. There is no annual dollar maximum under the prepaid dental programs.

With Delta PPO you can select between two plan options: the Standard or Enriched dental plans.

When you’re covered under either of the Delta plans, you and your family members:• Can visit any licensed dentist, including the dental

specialist of your choice.

• Can visit different dentists.

• May change dentists any time without notifying Delta Dental.

• Can receive dental care anywhere in the world (out-of-network benefits apply outside the U.S.).

• Will never have to pay more than the patient’s share at the time of treatment or file claims forms when you visit a Delta PPO network dentist.

Under either of the Delta Dental Plans (Standard or Enriched), you have access to the Delta PPO network

The Delta network provides access to the largest network of its kind nationwide. Delta PPO network dentists agree to accept the Delta PPO contracted fees as full payment when treating PPO patients. This

means your out-of-pocket costs are usually lower than when you visit a non-Delta Dental dentist.

Benefits are payable at various coinsurance levels, depending on the type of services being performed. A dental deductible is applied for services other than preventive and diagnostic. The standard plan has an annual dollar maximum of $1,000. The enriched plan includes an orthodontia benefit not provided under the standard plan. The annual dollar maximum is $1,500 under the enriched plan, and $1,000 lifetime max for orthodontia.

Note: Non-Delta Dental dentists will be reimbursed based on the 90th percentile of usual and customary. As a result members visiting a non-Delta Dental dentist may see a change in out-of-pocket costs.

When you enroll in the DeltaCare DHMO, you and your covered family members can access the dental care you need through DeltaCare’s network of quality dentists.

Each covered family member can choose their own general dentist from the network. You will need a referral from your general dentist to see any specialist, such as an endodontist, oral surgeon, pediatric dentist or orthodontist.

DHMO Features and Benefits• No deductible. No dollar maximums. No claim

forms to file. No waiting periods for coverage.• Reduced rates on all covered services.• Coverage for most preventive services at no

charge.• The first two cleanings are in any 12 month period

are at no charge. Each additional cleaning will incur a charge.

• Discounts on complex procedures.• Specialty care provided at the same fee as general

care with an approved referral.• Orthodontic benefits for adults and children.• Teeth whitening covered. See copay schedule for

details.


Delta PPO Chart

STANDARD ENRICHEDCHOICE OF DENTIST You’ll likely save more when you choose a Delta PPO in-network dentist rather than an out-of-network

dentist. Services provided by out-of-network providers will be reimbursed at the 90th percentile of usual and customary charges. Percentages below are based on Delta’s applicable allowances and not necessarily

the dentist’s actual charge.MAXIMUM BENEFIT/DEDUCTIBLE $1,000 per year per person, $50 deductible per

year per person; $150 family maximum$1,500 per year per person, $50 deductible per

year per person; $150 family maximum

TYPE I 0150 Comprehensive Oral Evaluation - New or Established 0120 Periodic Oral ExamX-RAYS 1110/20 Prophylaxis 1203 Fluoride Treatment (Children Up To The Age 19) 1351 Sealant- Per Tooth 1510 Space Maintainers

STANDARD ENRICHED

Plan Pays (No deductible) - 100%100%100%

100% (Twice per calendar year)100%, 2x per year

100% to age 16100% to age 19

Plan Pays (No deductible) - 100%100%100%

100% (Twice per calendar year)100%, 2x per year

100% to age 16100% to age 19

TYPE IIFillings: (Silver And White) 2330 One Surface 2331 Two Surfaces 2332 Three Surfaces 2334 Four Or More SurfacesRestorative Services: 2930 Prefabricated Stainless Steel Primary ToothRoot Canals: 3310 Anterior 3320 Bicuspid 3330 Molar 3410 ApicoectomyExtractions: 7111 Single Tooth 7140 Extraction, Erupted Tooth Or Exposed Tooth 7210 Surgical Extraction Of Erupted ToothPeriodontics: (Gum Treatment) 4341 Periodontal Scaling & Root Planing- Per Quadrant 4210 Gingivectomy/Gingivoplasty - Per Quadrant 4910 Periodontal Maintenance Procedures

STANDARD ENRICHED

100% (In PPO Network) / 75% (Out of PPO Network)100% (In PPO Network) / 75% (Out of PPO Network)100% (In PPO Network) / 75% (Out of PPO Network)100% (In PPO Network) / 75% (Out of PPO Network)

75% for children to age 16

75%75%75%75%

75%75%75%

75%75%75%

100% (In PPO Network) / 75% (Out of PPO Network)100% (In PPO Network) / 75% (Out of PPO Network)100% (In PPO Network) / 75% (Out of PPO Network)100% (In PPO Network) / 75% (Out of PPO Network)

75% for children to age 16

75%75%75%75%

75%75%75%

75%75%75%

TYPE IIICrown & Bridge: 2791 Crown Full Cast Predominately Base Metal 2751 Crown Porcelain Fused To Base MetalPontics: 6210 Full Cast 6240 Porcelain Fused To MetalProsthodontics (Dentures): 5110 Complete Upper 5120 Complete Lower 5213/14 Partial Upper Or Lower - Cast Metal Base

STANDARD ENRICHED

50%50%

50%50%

50%50%50%

50%50%

50%50%

50%50%50%

ORTHODONTIAConsultationEvaluationRecordsChildren-Normal Class IIAdult - Normal Class II 8750 Retention

Not CoveredNot CoveredNot CoveredNot CoveredNot CoveredNot Covered

Adult & Child covered at 50% after a one time deductible of $50 per person.

$1,000 lifetime maximum benefit

VISION ExaminationSINGLE VISION LENSES Bifocal Lenses Trifocal Lenses Contact Lenses - Non-Elective Contact Lenses - Elective Frames

Not Covered

Not CoveredNot CoveredNot CoveredNot CoveredNot Covered

Not Covered

Not CoveredNot CoveredNot CoveredNot CoveredNot Covered

*All Type II and III charges subject to annual deductible.

Delta PPO Dental Plan

DeltaCare DHMO Dental Chart

DeltaCare DHMO Dental PlanSTANDARD ENRICHED

CHOICE OF DENTIST Limited to Participating Dentists in Private Practice

MAXIMUM BENEFIT/DEDUCTIBLE No Maximum, No Deductible

TYPE I1110/20 Prophylaxis0120 Periodic Oral Exam0150 Comprehensive Oral Evaluation - New Or Established1203 Fluoride Treatment (Children Up To The Age 19)1351 Sealant - Per Tooth1510 Space Maintainers

STANDARD - YOU PAY ENRICHED - YOU PAY

No ChargeNo ChargeNo Charge

No Charge

$5.00$30.00



TYPE IIFillings: (Silver) 2140 One Surface 2150 Two Surfaces 2160 Three Surfaces 2161 Four Or More SurfacesRoot Canals 3310 Anterior 3320 Bicuspid 3330 Molar 3410 ApicoectomyExtractions: 7111 Single Tooth 7140 Extraction, Erupted Tooth Or Exposed Tooth 7210 Surgical Extraction Of Erupted ToothPeriodontics: (Gum Treatment) 4210 Gingivectomy/Gingivoplasty - Per Quadrant 4341 Periodontal Scaling & Root Planing- Per Quadrant 4910 Periodontal Maintenance Procedures Two Additional Every 12 Months

STANDARD ENRICHED

$5.00$5.00

$10.00$13.00

$75.00$85.00

$150.00$100.00

$10.00$10.00$30.00

$75.00$30.00

$15.00 each (Twice every 12 months) $60.00 each

No ChargeNo ChargeNo ChargeNo charge

$70.00$80.00

$140.00$90.00

$10.00$10.00$35.00

$60.00$25.00

$15 each (Twice every 12 months)$60.00 each

TYPE IIICrown & Bridge: 2751 Crown Porcelain Fused To Base Metal 2791 Crown Full Cast Predominately Base Metal 2930 Prefabricated Stainless SteelProsthodontics (Dentures): 5110 Complete Upper 5120 Complete Lower 5213/14 Partial Upper Or Lower - Cast Metal Base

STANDARD ENRICHED

$180.00$180.00$15.00

$190.00$190.00$220.00

$95.00$95.00$10.00

$110.00$110.00$130.00

ORTHODONTIAConsultationEvaluationRecordsChildren-Normal Class IIAdult - Normal Class II8680 Retention

This plan covers orthodontia as follows: Comprehensive for dependent children

under age 19: $1,500. Adults: $2,800

This plan covers orthodontia as follows: Comprehensive for dependent children

under age 19: $1,500. Adults: $2,800


Vision Plan Vision Plan

Davis Vision Plan The plan offers a network of providers that service your eyecare needs with only a modest member copayment shown in the Schedule of Benefits. The out-of-network-benefit allows you to select any out-of-network provider and reimburses a fixed dollar amount based on the schedule shown for the out-of-network services. The following chart indicates the benefits the plan pays for the services you receive. For more information, see the Davis plan literature.

Monthly Rates

BASE PLAN

Retiree Only $4.14

Retiree + One $8.30

Retiree + 2 or more $15.23

PREMIER PLAN

Retiree Only $9.95

Retiree + One† $21.39

Retiree + 2 or more† $41.29

Vision Plan Rates

COVERED SERVICES

BASE PLAN COPAY

PREMIER PLANCOPAY

FREQUENCYExamLenses & Lens UpgradesFrameContacts Evaluation & Fitting

Once Every Calendar YearOnce Every Calendar Year

Once Every Other Calendar YearOnce Every Calendar Year

Once Every Calendar YearOnce Every Calendar YearOnce Every Calendar YearOnce Every Calendar Year

EXAMS & SERVICESEye ExamCONTACTS EVALUATION, FITTING:Standard Lens & Specialty Lens

$25

15% Discount1

$10

15% Discount1

GLASSESFRAMESOther LocationsVisionworks4

Any OveragesTHE EXCLUSIVE COLLECTION: Fashion/Designer/Premier

$100$150

Additional 20% off any overage1

Covered in Full/$15/$40

$160Covered In Full

Additional 20% off any overage1 Covered In Full

LENSES $25 $0

COPAYS FOR OPTIONS & UPGRADES LENS OPTIONSClear Plastic Single-Vision, Bifocal, Trifocal or Lenticular Lenses (any Rx)Oversized LensesPlastic LensesPolycarbonate Lenses (Children/Adults)High-Index LensesPolarized LensesProgressive Lenses (Standard/Premium/Ultra)Anti-Reflective (AR) Coating (Standard/Premium/Ultra)Ultraviolet CoatingTinting of Plastic Lenses (Solid / Gradient)Plastic Photochromic Lenses (Transitions® Signature™)Scratch-Resistant CoatingScratch-Protection Plan (Single-Vision | Multifocal)ADDITIONAL SAVINGS

Retinal Imaging (Member charge) Additional Pairs of Eyeglasses

$0$0$0

$0/$35$60$75

$65 / $105 / $140$40 / $55 / $69

$15$15$70$0

$20 | $40

$3930% discount1

$0$0$0

$0/$30$55$75

$0 / $90 / $140$35 / $48 / $60

$12$0

$65$0

$20 | $40

$3930% discount1

CONTACTS2 IN LIEU OF GLASSES

Contact AllowanceAny OveragesTHE EXCLUSIVE COLLECTION OF CONTACT LENSES: 3

$100Additional 15% off any overage1

N/A

$120Additional 15% off any overage1

Covered In Full

Covered Vision Services

Chart continued on next page.


COVERED SERVICES

BASE PLAN COPAY

PREMIER PLANCOPAY

OUT-OF-NETWORK BENEFITSYou may receive services from an out-of-network provider, although you will receive the greatest value and maximize your benefit dollars if you select a provider who participates in the network.

OUT-OF-NETWORK REIMBURSEMENT SCHEDULE (UP TO)Eye ExaminationFrameSingle-Vision LensesBifocal / Progressive Lenses Trifocal LensesLenticular Lenses Elective Contact LensesVisually Required Contacts

$40$50$40$60$80

$116$100$210

$40$50$40 $60$80

$116 $120$210

1. Some limitations apply to additional discounts; discounts not applicable at all in-network providers.

2. Contact lens coverage varies by product selection. Visually Required contacts are covered in full with prior approval.

3. The Davis Vision Exclusive Collection of Contact Lenses is available at participating independent providers. Evaluation, fitting and follow-up care for Collection contacts are covered in full.

4. Excludes Maui Jim® eyewear. Davis Vision has done its best to accurately reflect plan coverage herein. If differences exist between this document and the plan contract, the contract will prevail.

Vision Plan

Covered Vision Services

ARAG® Legal Insurance

The Freedom and Control to Embrace Life’s OpportunitiesAt Jackson Health System, we want you to embrace life’s opportunities with fewer worries. That’s why we’re excited to provide you with legal insurance from ARAG. It’s affordable and reliable legal counsel for everyday life matters – like a dispute with a contractor, buying or selling a home or the need for estate planning. The plan provides you with the peace of mind knowing that attorney fees for most covered legal matters are 100% paid in full when you work with a Network Attorney. That means you’ll avoid paying high-cost attorney fees, which currently average $347 an hour.1

Resolve Your Legal Issues with a Network Attorney by Your SideWhen a life event turns into a legal issue, ARAG will be there for you, backed by a nationwide network of more than 12,000 credentialed attorneys. They can review or prepare documents, make follow-up calls or write letters on your behalf, provide legal advice and consultation, and represent you in court. Rely on legal help and protection with a wide range of covered services. For additional details regarding your plan’s specifically-covered services, visit ARAGLegalCenter.com and enter Access Code 17845ret to learn more about what these plans offer, research specific legal topics and more.

Preexisting And Personal Legal Matters Not Listed Above For any legal matters not covered and not excluded, you can still receive at least 25% off the Network Attorney’s normal hourly rates.

Call for Questions or Legal AssistanceYou can also get assistance form trusted professionals and an award-winning Customer Care Center, with dedicated representatives who will help you navigate your legal issues. Call 800- 247-4184 to speak with an ARAG Customer Care Specialist.

Monthly Price UltimateAdvisor® UltimateAdvisor

PlusTM

Retiree $13.33 $17.30

Family $17.60 $22.82

Visit www.ARAGLegalCenter.com and enter Access Code 17845ret to learn

more about your UltimateAdvisor® and Ultimate Advisor® Plus Plans! See the plan options on the following page.

http://ARAGLegalCenter.com


ARAG® Legal Insurance

Limitations and exclusions apply. Insurance products are underwritten by ARAG Insurance Company of Des Moines, Iowa, GuideOne® Mutual Insurance Company of West Des Moines, Iowa or GuideOne Specialty Mutual Insurance Company of West Des Moines, Iowa. Service products are provided by ARAG Services, LLC. This material is for illustrative purposes only and is not a contract. For terms, benefits or exclusions, call our toll-free number.1Average attorney rates in the United States of $347 per hour for attorneys with 11 to 15 years of ex-perience, Survey of Law Firm Economics, The National Law Journal and ALM Legal Intelligence, July 2015. 2Attorney fees are 100% paid in full when using an ARAG Network Attorney for a covered legal matter. 3Attorney costs calculated by multiplying the 2015 ARAG Claims Data by the average attorney rate in the United States of $347 per hour for attorneys with 11-15 years of experience.

© 2016 ARAG North America, Inc.

Legal Insurance from ARAG®

Count on a wide range of coverage and services, like the examples shown below, that address the legal matters you encounter in life:

*Eligibility, coverage, limitations and exclusions are governed by a separate coverage document. Please see the identity theft plan summary for details.

You’ll also receive a minimum 25% reduced fee on a Network Attorney’s normal rate for any other non-covered, non-excluded issues.

Plan OptionsUltimate Advisor®

Ultimate Advisor Plus™Plan Options

Ultimate Advisor®

Ultimate Advisor Plus™Plan Options

Ultimate Advisor®

Ultimate Advisor Plus™

501333

800-247-4184ARAGLegalCenter.com, Access Code 17845ret

For your organization’s complete list of covered matters and coverage levels, visit ARAGLegalCenter.com, Access Code 17845ret.

Consumer ProtectionAuto Repairs, Buy/Sell a Car, Consumer Fraud, Contractors

and More

Estate PlanningWills and Powers of Attorney

Revocable Living Trusts

Irrevocable Living Trusts

Estate Administration & Closing (9 Hours)

Protection of Inheritance Rights (6 Hours)

FamilyAdoption

Contested Divorce (15 Hours)

Contested Divorce (10 Hours)

Uncontested Divorce

Child Support Enforcement (8 Hours)

Post Decree Enforcement (8 Hours)

Post Decree Defense (8 Hours)

Guardianship/Conservatorship

Uncontested Guardianship/Conservatorship

Name Change

Prenuptial Agreements

Postnuptial Agreements

Domestic Violence Protection

Mental Incompetency or Infirmity

School Administrative Hearings

CaregivingAnnual Checkup, Advice and Services

Real EstateBuy/Sell - Primary Residence

Buy/Sell - Secondary Residence

Refinance - Primary Residence

Real Estate Disputes - Primary Residence

Real Estate Disputes - Secondary Residence

Neighbor Disputes - Primary Residence

Neighbor Disputes - Secondary Residence

Easement

Zoning and Variances

Building Codes

Disputes with a Landlord - Contracts, Lease, Eviction, Deposits

Traffic and VehicleMinor Traffic - 1 Use Per Year (Excluding DWI)

Minor Traffic - Unlimited (Excluding DWI)

Driving Privilege Restoration (Excluding DWI)

Driving Privilege Protection (Excluding DWI)

Financial ServicesFinancial Education and Counseling Services

ImmigrationImmigration Services

BenefitsSocial Security/Veterans/Medicare

Identity TheftIdentity Theft Services

Full Service Identity Restoration

$1 Million Identity Theft Insurance*

Single-Bureau Credit Monitoring

Internet Surveillance

Child Monitoring

Lost Wallet Services

Credit Record Correction

TaxesTax Services

IRS Audit Protection

IRS Collection Defense

Property Tax

DebtBankruptcy

Defense of Debt Collection

Foreclosure

Defense of Garnishment

CriminalCriminal Misdemeanor Defense

Habeas Corpus

Parental Responsibilities

Juvenile Court

Civil Damage DefenseLibel/Slander, Pet-Related Matters and More

General CoveragesSmall Claims Court

General In-Office Services (4 Hours)

Document Preparation and Review

Personal Property Protection

Pet Assure and PETplus Rx

Pet AssurePet Assure is a post-tax employee benefit program that enables members to receive discounts on all medical services provided by network veterinarians.

You will save hundreds on your pets’ medical care for only $7 month. Pet Assure is the nation’s oldest and largest veterinary discount plan and has been saving pet caretakers money on pet expenses since 1995.

Here’s what your membership includes:• 25% off all in-house medical services each and

every time you visit a network veterinarian. With Pet Assure, you’ll receive your discount right at the vet’s office. This plan is not insurance so there are no hassles, no claim forms and no deductibles. Savings are instant! (See details below.)

• Any type of pet, with absolutely no exclusions, can receive the discounts. There are no exclusions based on type, breed, age, past medical history, or pre-existing conditions. Do you have one dog, five cats, a lazy iguana and a donkey? One Pet Assure membership covers them all.

• You will also save 15% on all orders from PetCareRx.com: including prescriptions, preventatives, supplies, food and more. Unlimited use.

• 24/7 Pet Assure Locator Service (PALS). Don’t worry about your pet getting lost anymore! Every pet that joins can register in the Pet Assure’s 24/7 Lost Pet Recovery Service.

There are dozens of network providers in Miami and the surrounding areas. For a complete list of participating veterinary practices and merchants, visit Pet Assure online at www.petassure.com.

If you have any questions, please call Pet Assure at: 800-891-2565.

Monthly Pet Assure & PETplus RatesPet Assure $7.00

PETplus Single Pet Plan $4.50

PETplus Multiple Pet Plan $8.50

Pet Assure + PETplus Single Pet $11.50

Pet Assure + PETplus Multiple Pet $15.50

PETplus RxWith PETplus, members get wholesale pricing on prescriptions, preventatives and other products which are almost never covered by insurance. It’s instant savings without any paperwork, and no exclusions based on pre-existing conditions. All dogs and cats are covered!YOU WILL GET WHOLESALE PRICING ON:• Flea and Tick Preventatives• Heartworm Preventatives• Rx Medications• Vitamins and Supplements• Dietary FoodBENEFITS:Free shipping on all mail orders

• Rx pickup at over 50,000 CareMark pharmacies nationwide, including CVS and Walmart

• PETplus will get a prescription for you, no need to ask your vet

• 24/7 Ask-A-Vet Helpline, using phone, email or chat with a licensed Veterinarian (valued at $150/year)

Join today to start saving!

http://PetCareRx.com

www.petassure.com


Notices

CREDITABLE COVERAGE NOTICEImportant Notice from Jackson Health System About Your Prescription Drug Coverage and MedicarePlease read this notice carefully and keep it where you can find it.

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

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

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

2. Jackson Health System has determined that the prescription drug coverage offered by the AvMed High Option with Rx plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and are therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

3. When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? Your current coverage pays for other health expenses, in addition to prescription drugs, and you will still be eligible to receive all of you current health and prescription drug benefits if you choose to enroll in a Medicare prescription drug plan.

If you do decide to join a Medicare drug plan and drop your current Jackson Health System coverage, be aware that you and your dependents will not be able to get this coverage back.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Jackson Health System and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of

the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For More Information About This Notice Or Your Current Prescription Drug Coverage…Refer to your certificate of coverage issued by your medical insurance plan or visit www.avmed.org/jhs. Contact AvMed at 844-439-5378.

You will receive this notice annually and at other times in the future such as before the next period you can enroll in Medicare prescription drug coverage, and if this coverage changes. You also may request a copy.

For More Information About Your Options Under Medicare Prescription Drug Coverage…More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage:

• Visit www.medicare.gov

• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help

• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).REMEMBER: KEEP THIS CREDITABLE COVERAGE NOTICE. IF YOU DECIDE TO JOIN ONE OF THE MEDICARE DRUG PLANS, YOU MAY BE REQUIRED TO PROVIDE A COPY OF THIS NOTICE WHEN YOU JOIN TO SHOW WHETHER OR NOT YOU HAVE MAINTAINED CREDITABLE COVERAGE AND, THEREFORE, WHETHER OR NOT YOU ARE REQUIRED TO PAY A HIGHER PREMIUM (A PENALTY).

Last Updated: October 27, 2017Name of Entity: Jackson Health SystemContact-Position/Office: Human ResourcesHealth and Wellness DepartmentAddress: 1500 NW 12 Ave, Suite 106 W., Miami, FL 33136Phone Number: 786-466-8378

ConstantCredit

It’s YOUR credit. Keep it that way with ConstantCredit.

ConstantCredit monitors your credit report for any changes that may indicate suspicious activity or possible fraud. With ConstantCredit, you can be more aware of your credit health by receiving alerts when changes are reported. You will also receive information on your credit score, and access to tools that allow you to keep track of how your current and future activities may affect your credit score.

Features and Benefits:Level 3 (L3) VerificationYou will first verify your identity before monitoring begins. This ensures you are the only person to have access to your personal information through ConstantCredit.Full Access to Credit ReportsWith ConstantCredit, you have access to your full credit report at any time, regardless of what level of plan you have.

Credit MonitoringConstantCredit monitors bureau activity and alerts you to any reported changes on your credit report. The sooner you find out if someone is acting on your

behalf, the sooner you can act to mitigate the damage.

Score TrackerScore Tracker is a monthly report based on four credit factors, showing you graphically how your credit score changes over time.

Score SimulatorScore simulator is a tool that helps you determine how certain actions will affect your credit, such as opening a new line of credit or paying off a loan.

Resource CenterAt the Resource Center, you can find recent news and articles on issues related to financial health and other information to educate you on the importance of a healthy credit record.

Have Questions? Need Help? Call ConstantCredit at 855-592-7940.

Identity theft is the fastest growing crime in America, with an identity stolen once every four seconds. ID Commander, a leader in proactive identity theft protection, uses a variety of industry-leading tools to help protect you from the growing crime of identity theft:• Advanced Identity Monitoring and Alerts• $1 Million Identity Theft Insurance Policy, with $0

deductible• Full-service Identity Restoration• 24/7 Lost Wallet Assistance• Award-winning Computer Protection Software

ID Commander’s comprehensive identity theft protection plans are available to both individuals and families, with complete access to benefits the moment membership begins. The ID Commander Family Protection Plan provides a truly managed household program and empowers individual

family members with the tools and data they need to proactively manage the health and well-being of their identities.

If the worst happens, and you become the victim of identity theft while covered by ID Commander, we will restore your identity and any related credit accounts to pre-theft status. No limits, no fine print, no “service guarantee.” In addition, if you suffer any covered out-of-pocket expenses as a result of a breach, you’re covered by a real insurance policy that will put money in your hands for qualified losses.

Take command of your future with ID Commander – sign up today!

ID Commander

ConstantCredit RatesRetiree $11.50Retiree + Spouse $23.00

ID Commander Rates UltimateRetiree $10.50Family $22.50


DISCLAIMER – HEALTH INSURANCE BENEFITS PROVIDED UNDER HEALTH INSURANCE PLAN(S)Health Insurance benefits will be provided not by your Employer’s Flexible Benefits Plan, but by the Health Insurance Plan(s). The types and amounts of health insurance benefits available under the Health Insurance Plan(s), the requirements for participating in the Health Insurance Plan(s) and the other terms and conditions of coverage and benefits of the Health Insurance Plan(s) are set forth from time to time in the Health Insurance Plan(s). All claims to receive benefits under the Health Insurance Plan(s) shall be subject to and governed by the terms and conditions of the Health Insurance Plan(s) and the rules, regulations, policies and procedures from time to time adopted.

INSURANCE COVERAGE AFTER RETIREMENTUnder section 112.0801, Florida Statutes, your FRS employer is required to offer you or your eligible dependents the option of continued participation in any employer-sponsored group insurance plans in which you were participating at your retirement or at your DROP termination date.

As a retiree, your premium cost for health and hospitalization insurance coverage may not exceed the total retiree and employer premium cost applicable to active Retirees. You may lose your eligibility to participate if you choose not to continue participating in your employer’s group plan at retirement, initially choose to continue but subsequently stop participating, defer your retirement to a future date, or otherwise do not meet your employer’s group plan requirements. Before you terminate employment, contact your FRS employer about continuing your employer-sponsored group insurance coverage. The division has no authority over or responsibility for employer group health and hospitalization plans.

INCOME TAXES ON YOUR RETIREMENT BENEFITEach year at the end of January, the division provides you an IRS Form 1099-R. Your annual taxable income is shown in the taxable amount box (Box 2a). You should use this form when you file your income tax return.

NOTICE OF FBMC’S CAPACITYFBMC Benefits Management, Inc. (FBMC) has been authorized by your employer to provide certain administrative services for some the insurance plans offered within your employer’s benefit program. Importantly, FBMC is not the policyholder or an insurance company. The policyholder is the entity to whom the insurance policy has been issued; the employer is the policyholder for group insurance products and the retiree is the policyholder for individual products. The policyholder is identified on either the face page or schedule page of the policy or certificate. The insurance companies noted in this guide have been selected by your employer and are liable for the funds to pay your insurance claims.

HIPAA PRIVACYThe Plan complies with the privacy requirements of the Health Insurance Portability and Accountability Act of (HIPAA). These requirements are described in a Notice of Privacy that was previously given to you. A copy of this notice is available upon request.

COBRA Q & AWhat is continuation coverage? The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because

of a life event, also called a “qualifying event.” After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay (note: this depends on the café plan) for COBRA continuation coverage. If you’re an retiree, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:• Your hours of employment are reduced; or Your employment ends

for any reason other than your gross misconduct.

If you’re the spouse of an retiree, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:• Your spouse dies; Your spouse’s hours of employment are reduced;

Your spouse’s employment ends for any reason other than his or her gross misconduct; Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events:• The parent-retiree dies; The parent-retiree’s hours of employment

are reduced; The parent-retiree’s employment ends for any reason other than his or her gross misconduct; The parent-retiree becomes entitled to Medicare benefits (Part A, Part B, or both); The parents become divorced or legally separated; or The child stops being eligible for coverage under the Plan as a “dependent child.”

When is COBRA available?The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events:· The end of employment or reduction of hours of employment;· Death of the retiree; or· The retiree’s becoming entitled to Medicare benefits (under Part A,

Part B, or both).

For all other qualifying events (divorce or legal separation of the retiree and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days (Note: this depends on the café plan) after the qualifying event occurs. You must provide this notice to: Jackson Health Systems.

Options Besides COBRAInstead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.

More InformationThis COBRA Q & A section does not fully describe continuation coverage or other rights under the Plan. More information about continuation coverage and your rights under the Plan is available from your employer.

Keep Address UpdatedTo protect your family’s rights, let your Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.

Notices Online Resources

ONLINE RESOURCES:View important information and more!

JHS Benefits Website: www.JacksonBenefits.org

2018 Retiree Over 65 Form

2018 Retiree Over 65 Benefits Reference Guide

Retiree FAQs

Deduction Authorization Forms:FRS l PHT l Direct Debit (ACH)

DOWNLOAD AN FRS,PHT OR ACH FORM AT JACKSONBENEFITS.ORGAND MAIL TO:FBMC Benefits Management, Inc.Retiree and Direct Bill DepartmentPO Box 10789Tallahassee, FL 32302-2789

Rev. 8/13

INS DOC

FLORIDA RETIREMENT SYSTEM PENSION PLAN

Insurance Payroll Deduction Authorization Form

FBMC Benefits Management

Approved Deduction Name

FBMC-Direct Bill

Retiree Contact Person

(855) 565-4748

Retiree Contact Person’s Telephone No.

I hereby authorize the Division of Retirement to deduct my insurance premium from my monthly Florida

Retirement System (FRS) benefit check and make any subsequent premium changes as directed by my

insurance provider. I understand that my insurance provider is responsible for notifying me of premium

changes as they occur and for any refunds (if applicable.) If I am changing insurance companies I will

notify the existing company of the cancellation or changes.

Payee’s signature:

Signature required if no premium deduction (for above deduction code) from previous month’s pension payment.

Address:

Date:

Telephone No:

Date of Birth: Date Member Retired:

Retirees must fax or mail a completed authorization form for all new deductions (or restarted deductions) to: FBMC Benefits

Management, Retiree and Direct Bill Department, PO Box 10789, Tallahassee, FL 32302-2789; FAX 866-836-9943

The payee must authorize new insurance deductions OR the restart of a previously closed

deduction. The payee is the person receiving the FRS pension payment.

PAYEE SSN: DEDUCTION CODE: 408 (Health)

PAYEE NAME: DEDUCTION CODE: 409 (Life)

Insurance office use only. The Division of Retirement will not use this information.

408 $ __________

409 $ __________

FRS deductions added/updated _______________________ Date: ________________

#135 Jackson Health System

FBMC/PHTFORM/1016

PHT Pension Plan Insurance Payroll Authorization Form FBMC Benefits Management Retiree and Direct Bill Department • PO Box 10789 • Tallahassee, FL 32302-2789

Service Center: 855-56JHS4U (855-565-4748) Fax: 1-866-836-9943

The payee must authorize new insurance deductions selected OR the restart of a previously closed deduction.

The payee is the person receiving the PHT Pension Plan.

Payee SSN: ______________________________________Payee Name: ______________________________________

I hereby authorize FBMC to have my insurance premiums deducted from my monthly pension check and to

make any subsequent premium changes as directed by the insurance provider. I understand that the provider is

responsible for notifying me of those changes as they occur and for any refunds. If I am changing insurance

companies, I will notify the existing company of the insurance cancellation or changes.

Payee’s Signature: _________________________________________________________________________________

Address: _________________________________________________________________________________________

Date: _________________________________ Telephone Number: __________________________________________

Date of Birth: ________________________________ Date Member Retired: __________________________________ EMPLOYER SECTION

Medical Deduction: _________________ Dental Deduction: __________________ Vision Deduction: ______________

Life Insurance Deduction: _____________ Legal Deduction: ___________________ Pet Deduction: ________________

Ocenture Deduction: _____________________

EFFECTIVE DATE ____/____/____

http://jacksonbenefits.org

http://jhs.fbmcbenefitscommunications.com/18jhs_pdfs/retiree/jhs retireeover65 form_18.pdf

http://jhs.fbmcbenefitscommunications.com/18jhs_pdfs/retiree/18 JHS_Over 65 book.pdf

http://jhs.fbmcbenefitscommunications.com/18jhs_pdfs/retiree/retiree faq_18.pdf

http://jhs.fbmcbenefitscommunications.com/18jhs_pdfs/retiree/jhs frs form_18.pdf

http://jhs.fbmcbenefitscommunications.com/18jhs_pdfs/retiree/jhs pht form_18.pdf

http://jhs.fbmcbenefitscommunications.com/18jhs_pdfs/retiree/jhs ach form_18.pdf

http://jacksonbenefits.org

© FBMC 2017 FBMC/JHS_RETOV65/1117

On-site FBMC Service CenterJackson Memorial Hospital1611 N.W. 12th AvenuePark Plaza West L-109BMiami, FL 33136-1096305-585-6512

Retirement DepartmentJackson Memorial Hospital1500 N.W. 12th Avenue, Suite 106WMiami, FL 33136786-466-8355

Office Hours: 7:30 a.m. - 4:30 p.m., Monday - Friday ET

Information contained herein does not constitute an insurance certificate or policy.Certificates or policies will be provided to participants following the start of the plan year, if applicable.

Contract Administrator FBMC Benefits Management, Inc.P.O. Box 1878 • Tallahassee, Florida 32302-1878FBMC Service Center 855-56JHS4U (855-565-4748)www.myFBMC.com

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