wilco welcome booklet 8.13 - askallegiance.com

Welcome to Your

Health Plan

Allegiance Benefit Plan Management, Inc.P.O. Box 3018

Missoula, MT 59806-30181-855-333-1009

www.askallegiance.com/wilco

Please note: This booklet is not a plan document or summary plan description (SPD) as those terms are definedby federal law but rather just key highlights of your plan. The outline of benefits contained in this booklet are

subject to change by the Plan Administrator. Please refer to your actual SPD for the terms and conditionsregarding the payment of a claim. If there is any difference between this booklet and the SPD, the SPD will control.

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Important Contact Information

Allegiance Dedicated Customer Service: 1-855-333-1009

Allegiance Online Services: www.askallegiance.com/wilco

Claims Submission Address:CIGNA

1000 Great West DriveKennett, MO 63857-3749

24-hour Faxback Verification of Coverage:1-800-877-1122 or 1-406-523-3199

CVS CareMark Prescription Customer Service:1-866-475-0056

Connection Dental1-877-277-6872

StarPoint Utilization Management / Pre-Certification1-800-342-6510

StarPoint Case Management:1-877-792-7827

www.starpointmedical.com

24/7 Nurse Line1-888-546-8463

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Dear Plan Member,

Welcome to your Health Plan administered by Allegiance Benefit Plan Management(Allegiance.) We offer the highest quality service in claims administration andmanagement.

You will be receiving a new identification card(s) (ID cards) for your Health Plan in themail in October. You will receive an ID card for yourself and one for each dependentover the age of 18. These important cards contain your group number and provideclaims filing information. It is your responsibility to present your Allegiance ID cardeach time you visit a provider in order to assure claims are filed using your benefitplan.

Important Features on Your ID Card:

1 Group ID Number 20010252 Your employee ID number: A randomly generated 12 digit number assigned to

you personally. Please show your providers your new ID card and they will submitthis ID number on claims, rather than your social security number.

3 You will see Cigna Logos indicating your Network providers are contracted withthe Cigna Open Access Network.

Please keep in mind that the phone lines will not be open untilcloser to or after your November 1, 2012 effective date.

Welcome to your Health Plan

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Please present your new ID card to your health care providersand pharmacy to prevent any claims disruption .

Front of ID Card

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4 The address for claims submission is on the back of the ID card: CIGNA 1000 Great WestDrive Kennett, MO 63857-3749. Most providers will bill Allegiance directly on your behalf;however, if you need to submit a claim, please mail that to the address on the card.

5 24-hour verification of coverage at 1-406-523-3199.is available through our Interactive Voice Response (IVR) faxback system

6 The Allegiance toll-free Customer Service number is 1-855-333—1009.

7 Pre-Certification is required before admission for inpatient hospital stays. Pre-Notification mayalso be required prior to receiving certain outpatient services. Refer to your Summary PlanDescription booklet for complete pre-notification information. Contact StarPoint HealthcareGroup, your healthcare management organization, at 1-800-342-6510 to pre-certify inpatientadmissions and Customer Service at 1-855-333-1009 to notify of scheduled outpatientprocedures.

8 For pharmacy coverage, you will see a CVS CareMark logo on back of your card. The BIN/PCNnumbers, employee’s ID number and patient’s date of birth, is all the pharmacy will need toprocess your prescription claims. The prescription help line is 1-866-475-0056.

9 Information regarding your Connection Dental Network will be listed.

10 Your website is www.askallegiance.com/wilco The website can provide you withthe status of health claims, a summary of recent online activity, and direct linksto a Network Provider websites for lists of participating providers and theirlocations.

If you have any questions regarding your new ID card, please call Customer Service at1-855-333-1009.

Identification Card

Your card may not be identical to the sample card.Certain aspects, such as logos, vary for different locations.

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Back of ID Card

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What is a network provider?Your plan will access In-network services through the CIGNA Open Access Network. Thisnational network includes local physicians and health care professionals in your area.Network providers agree to file claim forms on behalf of enrollees and accept thecontracted maximum allowable fees as payment in full with no balance billing. You will beresponsible for any remaining balance over what the plan has paid, but only up to thecontracted maximum allowable expense that the provider has agreed upon. You may alsobe responsible for paying a deductible and any applicable copayments.

Advantages of Using the Network:As a plan participant of the Core or Deductible Plan options, you are free to go to anyprovider you choose for services covered by the plan. However, by utilizing networkproviders you can save on out of pocket expenses. The amount of money you may save byusing the network will vary depending on the provider, the service provided, and thedetails of your plan benefits. You are not required to use a preferred provider but if youobtain service from an out of network provider you may be responsible for those amountswhich are in excess of the “usual, customary and reasonable” charges in the area wherethe service was provided.

As a plan participant of the EPO Plan option, you must see a Network provider tohave your claims considered for payment by the plan. (Exceptions apply. see yourSummary Plan Description for more information on exceptions in emergency situationsand when a network provider is not available in the area)

Using a network provider from the Open Access Network may not always ensure adiscount, but your claim will be processed at the higher benefit level.

How to Access the Network:You can access information regarding contracted providers in your area by calling thecustomer service line and request the names of providers in your area.You can also perform a provider search on the internet:

1. Log on to www.askallegiance.com/wilco2. Click on the “Find a Provider” link3. Select the way you would like to search a provider4. Under “Select a Network” click “Open Access Plus/Open Access”5. Fill out the search fields and click Submit6. A list of provider according to your criteria will pull up

Please note that the network listing of PPO or Network Providers is subject to changewithout notice. Before receiving services, please verify with the provider that he/she isstill a participating provider.

Network Providers

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General Questions

Claims ProcedureIn most instances all you will need to do is present your new ID card to your physician,hospital, or other health care provider. Most providers will take the claims informationfrom your new card and bill Allegiance directly.

Service QuestionsIf you have a benefit question you may call our Customer Service Department at1-855-333-1009. The Customer Service Department is available from 7:00 am to7:00 pm Central time.

Our staff will be available to assist you with any questions or problems you may have. Ifyour question is whether or not a claim has been received and what the status is,there are two other options to access that information 24 hours a day, seven days aweek. Voice Response (IVR) system.

1. You may call 1-855-333-1009 to reach an auto-attendant2. Choose option 2 to access the IVR system3. Follow the voice prompts to check on your claim.

You will need the 12 digit identification number of the employee and the dateof service for the claim to complete the inquiry.

The other option is to sign up for Internet access to your claims data. That processis described in detail on the next page.

COBRAPlease refer to the section in your Summary Plan Description (SPD) booklet onContinuation of Coverage (COBRA) for your rights and responsibilities for continuedhealth plan coverage upon loss of coverage. These COBRA rights may apply to you andyour covered dependents and may vary depending on the number of employees inyour company and the state where you live. Please consult your Summary PlanDescription for complete COBRA information.

The Allegiance Toll-free Customer Service number is:

1-855-333-1009

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Online Services

At Allegiance, our number one priority is taking care of our members. We offer broadaccess while maintaining security on Allegiance’s state-of-the-art website, puttingbenefits and claims information at your fingertips.

Our website offers personalized services at the click of a mouse. By registering, youwill have 24-hour a day access to information regarding your health plan. You cancheck the status of a claim, review coverage and benefits, and verify who is coveredunder your plan. You can even view your plan document and review the mostfrequently asked questions.

Follow these steps to register. Please note that you cannot create a login until after youare effective on the plan.

1. Log onto www.askallegiance.com/wilco.2. Select “Employee / Employer Login”.3. If you have never logged into the site, you will need to click Register New User on

the Login page.4. This will prompt you to create a Username of 1-20 case sensitive characters. You

will also need to enter your email address and mark what type of user you are. ClickNext.

5. The next screen will ask you to validate some information. If your informationentered does not match the Allegiance database or you previously created a login,you will receive an error stating a login could not be created. Please double checkthe information you entered. If everything was entered correctly, contact Allegiancefor assistance at 1-855-333-1009 option 4. Mon-Fri 7am-7pm Central Time.

6. Once you have successfully matched your personal information to the system, youwill be prompted to create a Password (also case sensitive) as well as a passwordhint.

7. Once this step is completed, you will be logged into your personal benefit site.

The Allegiance Web Address is:

www.askallegiance.com/wilco

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StarPoint Healthcare Group

As part of your health benefit plan, you are enrolled in a managed care program calledStarPoint Healthcare Group which contracts your health plan to review services formedical necessity determinations, according to the terms of your plan. A certificationfrom StarPoint; however, is not a guarantee of payment. Check your plan booklet fornotification information. You are encouraged to call StarPoint once an admission datehas been scheduled. The StarPoint nurse reviewer will initiate the certification processand will answer your questions. After your hospital discharge, a StarPoint casemanagement nurse will assist with any questions or follow-up health care needs youmay have.

Pre-Notification: Pre-notification is required for all inpatient hospital admissions sothat medical necessity can be established before services are rendered.

Emergency Notification: Notification is required within 72 hours for emergencyadmissions and for observation stays when the stay exceeds 23 hours.

Continued Stay Review: StarPoint will contact the hospital on your anticipatedrelease date to confirm discharge. If you require continued hospitalization, aStarPoint nurse will work with the hospital to identify medical necessity and extenddays as appropriate.

StarPoint’s Utilization ManagementToll-free Number is:

1-800-342-6510

24/7 Nurse LineA Nurse line is available 24 hours a day to provide health advice and informationconcerning your family. Call the nurse line to speak to a registered nurse at no cost toyou. For questions on health conditions like asthma, diabetes or hypertension. When you need help deciding if you should see a doctor or go to the Emergency

Room. If you want more information on a medical test or procedure. For answers to health questions any time of day even on weekends and holidays!

Nurse Line Toll-Free Number:

1-888-546-8463

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Case Management

StarPoint is committed to providing you with case management that will best meetyour needs. The Case Manager may assist you with a variety of services, some ofwhich are listed below: Provide education on your medical condition Work with you, your family, and health care providers to support your physician’s

plan of care Provide coordination and access to appropriate health care treatment and

community resources Assist in the assessment process to help ensure that you receive the most

appropriate treatment and least restrictive level of care

Your case manager will be in regular contact with you by phone and will provide writteninformation upon your request. To learn more about case management services, callthe toll-free number below.

StarPoint’s Case ManagementToll-free Number is:

1-877-792-7827

StarBaby is your health plan’s maternity management program. This program

offers pregnancy-related information and support from a personal Registered Nurse(RN) that is available to talk with you throughout your pregnancy and after birth.

The program is FREE TO YOU and will provide you with: Important pregnancy-related information Support and assistance from a Registered Nurse A post pregnancy assessment A pregnancy-related book or $25 gift card

For more information or to register for the program, please call the toll-free numberbelow or go online to www.starpointmedical.com and click the “Get Secure EmailAccess” link.

StarBabyToll-free Number is:

1-877-792-7827Or register online at www.starpointmedical.com

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Diabetes Care Plan

Just for peoplewith diabetes or pre-diabetes

If you have diabetes or pre-diabetes, managing your health is a top priority.With the Diabetes Care Plan (DCP), you can save money and receiveresources to help you stay on track.

BenefitsWith the Diabetes Care Plan, you’ll receive: No copays for three diabetes related visits as well as annual preventive care per

Plan Year No copays for select diabetes related medications and supplies Wellness information to help you manage your condition Access to and outreach from a Case Manager to assist you with information on the

Health Action requirements of the DCP

Health ActionsManaging an ongoing health condition can be challenging. Your Health Actions willguide your way to better health. To stay in the DCP you will need to follow HealthActions outlined in the DCP. These may include: Lab Evaluations: Cholesterol, A1c, Kidney Function tests Professional Services: Two regular Primary Care visits, Retinal Exam from an

Ophthalmologist Cancer Screenings: Mammogram/ Colonoscopy

EnrollmentIf you were enrolled in the DCP during 2011-2012 Plan Year, you will be automaticallyenrolled for the 2012-2013 Plan Year. If you have been recently diagnosed with pre-diabetes or diabetes, you will need to contact HR for more information about enrollingin the DCP.

If you are eligible, please look for future communication in the mail, and on yourdedicated website at www.askallegiance.com/wilco. An Allegiance StarPoint CaseManager will reach out to you to discuss the plan benefits and the requirements youmust meet to continue receiving the enhanced benefits of the DCP.

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Sample Explanation of Benefits

A larger print-ready version of this form is available on our website at:www.askallegiance.com/wilco

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Bi-Weekly Medical Plan Premiums

Core Plan Bi-Weekly PremiumOne Premium

Discount Applied*Two Premium

Discounts Applied**

Employee $99.65 $67.34 $35.03

Employee + Spouse $225.18 $160.57 $95.95

Employee + Child(ren) $145.85 $113.54 $81.23

Employee + Family $261.23 $196.62 $132.00

Deductible Plan Bi-Weekly PremiumOne Premium


Discounts Applied**

Employee $67.15 $34.85 $2.54

Employee + Spouse $162.23 $97.62 $33.00


Employee + Family $183.55 $118.94 $54.32

EPO Plan Bi-Weekly PremiumOne Premium


Discounts Applied**

Employee $153.83 $121.52 $89.22

Employee + Spouse $328.25 $263.63 $199.02


Employee + Family $384.09 $319.48 $254.86

Bi-Weekly Medical Plan Premiums for Active Employees

*One Premium Discount Applied (Non-Tobacco / Reasonable Alternative OR Prevention Plan Participation)

**Two Premium Discounts Applied (Non-Tobacco / Reasonable Alternative AND Prevention Plan Participation)

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Monthly Medical Plan Premiums

Core Plan Monthly PremiumOne Premium


Discounts Applied**

Employee $215.90 $145.90 $75.90

Employee + Spouse $487.90 $347.90 $207.90


Employee + Family $566.00 $426.00 $286.00

Deductible Plan Monthly PremiumOne Premium


Discounts Applied**

Employee $145.50 $75.50 $5.50

Employee + Spouse $351.50 $211.50 $71.50


Employee + Family $397.70 $257.70 $117.70

EPO Plan Monthly PremiumOne Premium


Discounts Applied**

Employee $333.60 $263.60 $193.60

Employee + Spouse $711.20 $571.20 $431.20


Employee + Family $832.20 $692.20 $552.20

Monthly Medical Plan Premiums for Retirees currently enrolled in medical OR Active Employees who retirewith a TCDRS monthly annuity by January 31, 2013 and elect to continue their medical coverage.



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Core Plan Monthly PremiumOne Premium Discount

Applied*Two Premium

Discounts Applied**

Employee $816.66 $745.26 $673.86

Employee + Spouse $1,529.90 $1,387.10 $1,244.30

Employee + Child(ren) $1,193.91 $1,122.51 $1,051.11

Employee + Family $1,785.51 $1,642.71 $1,499.91

Deductible Plan Monthly PremiumOne Premium Discount

Applied*Two Premium

Discounts Applied**

Employee $744.86 $673.46 $602.06

Employee + Spouse $1,390.77 $1,247.97 $1,105.17

Employee + Child(ren) $1,076.10 $1,004.70 $933.30

Employee + Family $1,613.84 $1,471.04 $1,328.24

EPO Plan Monthly PremiumOne Premium Discount

Applied*Two Premium

Discounts Applied**

Employee $936.72 $865.32 $793.92

Employee + Spouse $1,757.66 $1,614.86 $1,472.06

Employee + Child(ren) $1,383.12 $1,311.72 $1,240.32

Employee + Family $2,057.03 $1,914.23 $1,771.43

Monthly Medical Plan Premiums for Active Employees who retire after February 1, 2013TCDRS monthly annuity and elect to continue their medical coverage.



< 8 years of Williamson County Service:

8—15 years of Williamson County Service:


Applied*Two Premium

Discounts Applied**

Employee $479.74 $408.34 $336.94

Employee + Spouse $907.75 $764.95 $622.15


Employee + Family $1,035.56 $892.76 $749.96


Applied*Two Premium

Discounts Applied**

Employee $443.83 $372.43 $301.03

Employee + Spouse $838.19 $695.39 $552.59


Employee + Family $949.72 $806.92 $664.12


Applied*Two Premium

Discounts Applied**

Employee $539.76 $468.36 $396.96

Employee + Spouse $1,021.63 $878.83 $736.03


Employee + Family $1,171.32 $1,028.52 $885.72

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Applied*Two Premium

Discounts Applied**

Employee $344.96 $273.56 $202.16

Employee + Spouse $658.89 $516.09 $373.29


Employee + Family $735.57 $592.77 $449.97


Applied*Two Premium

Discounts Applied**

Employee $323.42 $252.02 $180.62

Employee + Spouse $617.15 $474.35 $331.55


Employee + Family $684.07 $541.27 $398.47


Applied*Two Premium

Discounts Applied**

Employee $380.98 $309.58 $238.18

Employee + Spouse $727.22 $584.42 $441.62


Employee + Family $817.03 $674.23 $552.20

Monthly Medical Plan Premiums for Active Employees who retire after February 1, 2013TCDRS monthly annuity and elect to continue their medical coverage.



16—25 years of Williamson County Service:

> 25 years of Williamson County Service:


Applied*Two Premium

Discounts Applied**

Employee $243.88 $172.48 $101.08

Employee + Spouse $487.90 $347.90 $207.90


Employee + Family $566.00 $426.00 $286.00


Applied*Two Premium

Discounts Applied**

Employee $233.11 $161.71 $90.31

Employee + Spouse $451.38 $308.58 $165.78


Employee + Family $484.84 $342.04 $199.24


Applied*Two Premium

Discounts Applied**

Employee $333.30 $263.30 $193.30

Employee + Spouse $711.20 $571.20 $431.20


Employee + Family $832.20 $692.20 $552.20

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Medical and Pharmacy Plan Design

This Benefit Summary is intended only to highlight your benefits and should not be relied upon to fullydetermine coverage. This document does not cover all provisions, limitations and exclusions. This

benefit plan may not cover all of your health care expenses. More complete descriptions of benefits andthe terms under which they are provided are contained in the Summary Plan Description.

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(1) In Network benefits percentage paid is based on eligible expenses and the health care providers contractual agreement

(2) Out of Pocket Maximum does not include the Deductible and Out of Network charges will not apply to the Out of Pocket Maximum

(3) The $1,250 Prescription Out of Pocket Maximum does not include the Deductible and is separate from Medical Out of Pocket Maximum

(4) There is a $100 maximum per prescription filled for one-month supply through a retail pharmacy

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CVS CareMark Pharmacy

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To view a formulary, a complete list of TexasPharmacies and other pharmacy relatedresources, please visit your website atwww.askallegiance.com/wilco

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Mail Order Form

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Mail Order Form

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Prior Authorization

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Prior Authorization

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Specialty Pharmacy Drug List

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Bi-Weekly Dental and Vision Plan Premiums

Dental Low Plan Bi-Weekly Premium

Employee $14.77

Employee + Spouse $27.23

Employee + Child(ren) $30.46

Employee + Family $33.69

Bi-Weekly Dental and Vision Plan Premiums for Active Employees

Dental High Plan Bi-Weekly Premium

Employee $20.31




Vision Plan Bi-Weekly Premium

Employee $6.46




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Monthly Dental and Vision Plan Premiums

Dental Low Plan Monthly Premium

Employee $32.00




Monthly Dental and Vision Plan Premiums for Retirees currently enrolled in dental, Active Employeeswho retire with a TCDRS monthly annuity by January 31, 2013 and elect to continue their dental

coverage and for Active Employees who retire after February 1, 2013 TCDRS monthly annuity andelect to continue their medical coverage.

Dental High Plan Monthly Premium

Employee $44.00




Vision Plan Monthly Premium

Employee $14.00




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Dental and Vision Plan Design

This Benefit Summary is intendedonly to highlight your benefits andshould not be relied upon to fully

determine coverage. Thisdocument does not cover allprovisions, limitations and

exclusions. This benefit plan maynot cover all of your health care

expenses. More completedescriptions of benefits and the

terms under which they areprovided are contained in theSummary Plan Description.

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Dental and Vision Discounts

Connection Dental and Connection Vision Network

As a participant of either Dental Plans or the Vision Plan, you are free to go to anyprovider you choose for services covered by the plan. However, by utilizing networkproviders through the PPO USA / Connection Dental and Connection Vision EyeMedNetwork, you may receive discounts on services which would allow your plan benefitsto go even farther.

Locating a Connection Dental or Vision ProviderYou can locate a provider who may offer discounts through Connection Dental orConnection Vision two ways:

1. Call 877-277-6872

2. Perform an online search at: http://ppousa.com/Under the “Info for Patients” area, select

“Find a CONNECTION Dental Dentist.” or

“Find a CONNECTION Vision Provider.” (select Insight provider network)

Some providers listed on the directory may not participate in the Connection Network at all locationin which they practice. Before receiving services, it is the members responsibility to verify that the

provider is a participating provider at the location the member receives services.

Documentation Needed to Obtain Discounts

Information to obtain discounts from ConnectionDental Providers is located on the back of yourIdentification Card.

In order to take advantage of the discounts offered byVision providers, you must visit your dedicated websiteat www.askallegiance.com/wilco, select the icon forVision, then print off a copy of the “Connection VisionEyeMed ID Card” to present to your provider.

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Flexible Spending Account

Flex is a great way to instantly get tax dollars back in your paycheck andincrease your spendable income

Health Flexible Spending AccountBefore the start of each Flex Plan year, you may elect to use “before-tax” dollars to payfor your out of pocket medical, dental and vision expenses including deductibles, co-pays, and prescriptions. Eligible health FSA expenses include those defined by IRSCode Section 213(d). For a list of examples go to www.allegianceflexadvantage.com.Your health FSA election will reimburse you for eligible expenses that you, your spouse,and your dependants incur during the plan year. The entire annual amount you electcan be used at any time during the plan year.

The minimum you can elect each plan year is $120.00

The maximum you can elect each plan year is $5,000.00

Dependent Care Flexible Spending AccountIf both you and your spouse work or you are a single parent, you may have dependentcare expenses. A Dependant Care FSA would let you use “before-tax” dollars to paycare expenses for children age 12 and under, or individuals unable to care forthemselves. The care may be provided through live-in care, baby sitters, and licensedday care centers. Schooling expenses at the kindergarten level and above are notreimbursable, and you may not use these funds to pay your spouse or one of yourchildren under 19 for providing care.

The maximum you can elect each plan year is equal to the smallest of the following:

$5,000 per couple if married and filing federal taxes jointly, or for a singleparent;

$2,500 if married and filling a separate federal tax return Your spouses earned income

Unlike Health FSA. Dependent Care FSA may only reimburse expenses up to theamount you have already contributed at any time during the year.

Customer ServiceRepresentatives are available to answer questions each business day between 8:00am and 7:00 pm Central Time. After hours and on weekends, you can find access toyour account information online or through the toll free automated voice-responsesystem.

Please call us toll free at 1-877-424-3570

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FSA Online Services/ Debit Card

Online ResourcesVisit us online for useful tools such as a tax savings calculator, secure uploader, and tolearn more about what qualifies as an eligible expense. Once you have registeredonline, you can track your contribution history and review payments.

Please visit www.allegianceflexadvantage.com

Flex Debit CardWilliamson County will offer a debit card for you to access Health Flex contributions.This will provide you with access to funds at the point-of-purchase for eligibleexpenses. Please watch for your card in the mail at the end of October, it will come inan unmarked white envelope.

In most ways, your card works just like any debit card, but there are threeimportant differences:

Its use is limited to specific merchants and to expenses deemed eligible byyour Benefits Plan

You cannot use it at an ATM, or to obtain “cash back” when making apurchase

You are not given a PIN with this card. When given the option between debitand credit at the terminal, choose “CREDIT”

Flex eligible items will be automatically approved for debit card payment, and noadditional paperwork or substantiation would be necessary for eligible purchasesmade at Grocery / Box Store Pharmacies with an Inventory Information ApprovalSystem. (IIAS)

Additionally doctor, dental, and optical office visits and hospital services with astandard co-pay will be automaticallyapproved. Other amounts may requiredocumentation and a letter would besent in the mail requestingsubstantiation.

Please remember to save all ofyour itemized receipts and fax,mail, or securely upload thempromptly if requested!

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NOTICE TO ENROLLES IN A SELF-FUNDED NON-FEDERAL GOVERNMENTAL GROUP HEALTH PLANGroup health plans sponsored by State and local governmental employers must generally comply with Federal law

requirements in title XXVII of the Public Health Service Act. However, these employers are permitted to elect to exempta plan from the requirements listed below for any part of the plan that is "self-funded" by the employer, rather thanprovided through a health insurance policy. The Williamson County Benefits Committee has elected to exempt The

Williamson County Employee Benefits Plan from all of the following requirements:

1.) Protection against limiting hospital stays in connection with the birth of a child to less than 48 hours for a vaginaldelivery, and 96 hours for a cesarean section.

2.) Protections against having benefits for mental health and substance use disorders be subject to more restrictionsthan apply to medical and surgical benefits covered by the plan.

3.) Certain requirements to provide benefits for breast reconstruction after a mastectomy.

4.) Continued coverage for up to one year for a dependent child who is covered as a dependent under the plan solelybased on student status, who takes a medically necessary leave of absence from a postsecondary educational

institution.

The exemption from these Federal requirements will be in effect for the plan year beginning November 1, 2012 andending October 31, 2013. The election may be renewed for subsequent plan years.

HIPAA also requires the Plan to provide covered employees and dependents with a “certificate of creditable coverage”when they cease to be covered under the Plan. There is no exemption from this requirement. The certificate providesevidence that you were covered under this Plan, because if you can establish your prior coverage, you may be entitledto certain rights to reduce or eliminate a preexisting condition exclusion if you join another employer’s health plan, or if

you wish to purchase an individual health insurance policy.In compliance with the Newborns and Mothers Health Protection Act (NMHPA), benefits for any hospital length of stayin connection with childbirth for the mother or newborn child will not be restricted to less than 48 hours following an

uncomplicated vaginal delivery or less than 96 hours following an uncomplicated caesarean section delivery. Providerauthorization from the Plan for prescribing a length of stay not in excess of the above periods is not required. Newborn

children are covered at birth if the Covered Employee enrolls the child within thirty (31) days from the date of birth.

Women’s Health & Cancer Rights Act Notice

In compliance with the Women’s Health and Cancer Rights Act of 1998, Williamson County Employee Benefits Plancovers mastectomy-related services including reconstruction and surgery to achieve symmetry between the breasts,

prostheses, and complications resulting from a mastectomy (including lymphedema).If you should have any questions concerning these notices, please contact the Williamson County Human Resources

Department at (512) 943-1604 or [email protected].

NOTICE OF PRIVACY PRACTICESThe Notice of Privacy Practices describes how protected health information may be used or disclosed by yourGroup Health Plan to carry out payment, health care operations, and for other purposes that are permitted or

required by law. The Notice also sets out our legal obligations concerning your protected health information, anddescribes your rights to access and control your protected health information.

Protected health information (or "PHI") is individually identifiable health information, including demographicinformation, collected from you or created or received by a health care provider, a health plan, your employer

(when functioning on behalf of the group health plan), or a health care clearinghouse and that relates to: (1) yourpast, present, or future physical or mental health or condition; (2) the provision of health care to you; or (3) the

past, present, or future payment for the provision of health care to you.

This Notice of Privacy Practices has been drafted to be consistent with what is known as the "HIPAA PrivacyRule," and any of the terms not defined in this Notice should have the same meaning as they have in the HIPAA

Privacy Rule.If you have any questions or want additional information about the Notice or the policies and procedures

described in the Notice, please contact: Health Plans Administrator, Williamson County, 710 S. Main, Suite 304,Georgetown, TX 78626, (512) 943-1604.

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Summary of Williamson County Rx

Deductible $50 per person, per benefit plan year

Core PPO Plan Retail 30% Co-Benefit ($100 maximum per Rx) Generic/BrandMail Order $20 Generic / $70 Brand

Deductible PPO Plan Retail 30% Co-Benefit ($100 maximum per Rx) Generic/BrandMail Order $20 Generic / $70 Brand

EPO/ HMO Plan Retail 30% Co-Benefit ($100 maximum per Rx) Generic/BrandMail Order $20 Generic / $70 Brand

Important Notice from Williamson County About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drugcoverage with Williamson County and about your options under Medicare’s prescription drug coverage. This information can help youdecide 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 inyour 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 aMedicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. AllMedicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a highermonthly premium.2. Williamson County has determined that the prescription drug coverage offered by the Williamson County Benefits Plan is, on averagefor all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore consideredCreditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (apenalty) if you later decide to join a Medicare drug plan.

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

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?If you decide to join a Medicare drug plan, your current Williamson County coverage will not be affected. You may keep your WilliamsonCounty coverage as long as you remain an active employee even if you elect Part D. This plan will coordinate with Part D coverage. If youdo decide to join a Medicare drug plan and drop your current Williamson County coverage, be aware that you and your dependents may notbe 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 Williamson County and don’t join a Medicare drug plan within 63continuous 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% ofthe Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteenmonths 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 haveto wait until the following October to join.

For More Information About This Notice Or Your Current Prescription Drug Coverage…For further information or call 512-943-1604. NOTE: You’ll get this notice each year. You will also get it before the next period you can joina Medicare drug plan, and if this coverage through Williamson County changes. You also may request a copy of this notice at any time.

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 acopy 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 theirtelephone 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 thisextra 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 acopy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are

required to pay a higher premium (a penalty).

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