Table of Contents. Benefits. BCBSNC PPO Health Plan BCBSNC HSA Health Plan Ameritas Dental High and Low Plan... 14

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1 Table of Contents Benefits BCBSNC PPO Health Plan BCBSNC HSA Health Plan Ameritas Dental High and Low Plan Reliance Standard Short-Term Disability Reliance Standard Term Life For Your Reference Contact Information for Questions and Claims Plan Arranged By: y

2 * * * * * * * * NOTICE * * * * * * * * The products described in this booklet are part of a Cafeteria Benefi ts Plan arranged by Mark III Brokerage for eligible City of Sanford employees. The Cafeteria Benefi ts Plan allows you to pay for certain insurance premiums before taxes are taken out of your paycheck. Paying for benefi ts in this method reduces your taxes and increases your take home pay. The Plan Year is July 1, 2012 through June 30, Health and dental products described in this booklet are deducted on a pre-tax basis. Reliance Standard short term disability and term life are employer paid benefi ts. If you wish to add or make changes to your insurance coverage(s), please consult a Benefi ts Representative during your scheduled enrollment period. You will not be able to make any changes once the enrollment period is over unless you experience a qualifi ed event outlined by the IRS (i.e., marriage, divorce, birth of a child, etc.) If you should experience a qualifi ed event, you have 30 days from the date of the event to make any changes. All information in this booklet is a brief description of your coverage and is not a contract. Please refer to your policy or certifi cate for each product for the exact terms and conditions.

3 BlueCross BlueShield Of NC PPO Health Plan Blue OptionsSM Benefit Highlights (PPO) Physician Office Services In-network (See Outpatient Clinic Services for outpatient clinic or hospital-based services.) Out-of-network1 Office Visit Includes Office Surgery, Consultation, X-ray and Lab, and benefi t period maximum of 4 offi ce visits for the assessment of obesity in and out of network. See Inpatient and Outpatient Services. Primary Care Provider $20 copayment 70% after deductible Specialist $40 copayment 70% after deductible Preventive Care (Preventive Diagnosis Only) Routine Examinations, Well-Child Care, Immunizations, Gynecological exams, cervical cancer screening, ovarian cancer screening, screening mammograms, colorectal screening, bone mass measurement, newborn hearing screening and prostate specific antigen tests (PSAs). Primary Care Provider 100%, no deductible Not Available* Specialist 100%, no deductible Not Available* Outpatient Clinic 100%, no deductible Not Available* *Gynecological exams, cervical cancer screening, ovarian cancer screening, screening mammograms, colorectal screening, bone mass measurement, newborn hearing screening and prostate specific antigen tests (PSAs) are covered Out-of-network. Therapies Short-term Rehabilitative Therapies (Maximums apply to Home, Office and Outpatient Settings): Physical/Occupational: 30 per Benefit Period; Speech Therapy: 30 per Benefi t Period Primary Care $20 copayment 70% after deductible Specialist $40 copayment 70% after deductible Urgent Care Centers and Emergency Room Urgent Care Centers $40 copayment $40 copayment Emergency Room Visit (Inpatient Hospital benefits apply if admitted. If held for observation, outpatient benefi ts apply. See Inpatient and Outpatient Hospital Services.) $250 copayment $250 copayment Ambulatory Surgical Center 80% after deductible 70% after deductible Inpatient and Outpatient Hospital Services Hospital and Hospital Based Services 80% after deductible 70% after deductible Outpatient Clinic Services (other than preventive services above) 80% after deductible 70% after deductible Professional Services 80% after deductible 70% after deductible Page 3

4 Hospital and Professional Outpatient Labs and Mammograms with surgery or other services Outpatient Labs and Mammograms without surgery or other services Outpatient X-rays, ultrasounds, and other diagnostic tests, such as EEG s and EKG s CT scans, MRI s, MRA s and PET scans in any location, including physician s office Other Services Skilled Nursing Facility (60 days per Benefit Period) Home Health Care, Ambulance, Durable Medical Equipment and Hospice 80% after deductible 70% after deductible 100% 70% after deductible 80% after deductible 70% after deductible 80% after deductible 70% after deductible 80% after deductible 70% after deductible 80% after deductible 70% after deductible Maternity Maternity Delivery includes Prenatal and Post-delivery care Hospital Services (Delivery) 80% after deductible 70% after deductible Professional Services (Delivery) 80% after deductible 70% after deductible Transplants Hospital Services 80% after deductible 70% after deductible Professional Services 80% after deductible 70% after deductible Infertility Services Up to $5,000 Lifetime max Primary Care Provider $20 copayment 70% after deductible Specialist $40 copayment 70% after deductible Hospital Services 80% after deductible 70% after deductible Inpatient and Outpatient Professional Services 80% after deductible 70% after deductible Vision Care Comprehensive Eye Exam 100%, no deductible Benefi ts not available Page 4

5 Lifetime Maximum, Deductibles & Coinsurance Maximums In-network Out-of-network1 The following Deductibles and Coinsurance Maximums apply to the services on the previous page [and Mental Health and Substance Abuse services below]: Lifetime Benefit Maximum Unlimited Unlimited Deductibles Individual (per Benefi t Period) $750 $1,500 Family (per Benefi t Period) $1,500 $3,000 Coinsurance Maximum Individual (per Benefi t Period) $2,000 $4,000 Family (per Benefi t Period) $4,000 $8,000 Mental Health and Substance Abuse Services Mental Health Services Office $40 copayment 70% after deductible Inpatient/Outpatient 80% after deductible 70% after deductible Substance Abuse Services Office Visit $40 copayment 70% after deductible Inpatient/Outpatient 80% after deductible 70% after deductible Prescription Drugs Up to 30 day supply day supply is two copayments and day supply is three copayments. Mail order 2x copayment up to 90 day supply. Infertility Drugs up to $5,000 Lifetime Maximum. MAC B Pricing, Brand Penalty Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Brand) $4 copayment $35 copayment $50 copayment Copayment + charge over In-network allowed amount Copayment + charge over In-network allowed amount Copayment + charge over In-network allowed amount Tier 4 (Specialty Brand) 75% coinsurance Coinsurance + charge over In-network allowed amount There is a $50 per Drug Minimum and a $100 per Drug Maximum for each 30-day supply of Tier 4 Specialty Brand drugs. 1 NOTICE: Your actual expenses for covered services may exceed the stated coinsurance percentage or co-payment amount because actual provider charges may not be used to determine the payment obligations for BCBSNC and its members. Page 5

6 ADDITIONAL INFORMATION ABOUT BLUE OPTIONS FROM BCBSNC Benefit Period The period of time, usually 12 months as stated in the group contract, during which charges for covered services provided to a member must be incurred in order to be eligible for payment by BCBSNC. A charge shall be considered incurred on the date the service or supply was provided to a member. Allowed Amount The maximum amount BCBSNC determines is to be paid for covered services provided to a member. Coinsurance Maximum The dollar amount of coinsurance a member must pay prior to BCBSNC paying 100% for certain services. NOTE: In some plans, there is no coinsurance maximum; members are responsible for coinsurance once the deductible has been met. Day and Visit Maximums All day and visit maximums are on a combined In- and Out-of Network basis. Utilization Management To make sure you have access to high quality, cost-effective health care, we manage utilization through a variety of programs including certifi cation, transplant management, concurrent and retrospective review and care management. If you have a concern regarding the fi nal determination of your care, you have the right to appeal the decision. If you would like a copy of a benefi t booklet providing more information about our Utilization Management programs, call the toll free number listed in your information packet. Certification Certifi cation is a program designed to make sure that your care is given in a cost effective setting and effi cient manner. If you need to be hospitalized, you must obtain certifi cation. Non-emergency and non-maternity hospital admissions must be certifi ed prior to the hospitalization. If the admission is not certifi ed, a penalty will be applied. For maternity admissions, your provider is not required to obtain certifi cation from BCBSNC for prescribing a length of stay up to 48 hours for a normal vaginal delivery, or up to 96 hours for delivery by cesarean section. You or your provider must request certifi cation for coverage for additional days, which will be given by BCBSNC, if medically necessary. All inpatient and certain outpatient Mental Health and Substance Abuse services must be certifi ed in advance by Magellan Behavioral Health. Call Magellan Behavioral Health at Offi ce visits do not require certifi cation. In-network providers are responsible for obtaining certifi cations. The member will bear no fi nancial penalties if the in-network provider fails to obtain the appropriate Page 6

7 authorization. The member is responsible for obtaining certifi cation for services rendered by an out-of-network provider. Health and Wellness Program Because we want to help you stay healthy, we offer a variety of wellness benefi ts and services. You can take advantage of HealthLine Blue, our 24-hour health information service, a health topics library, asthma and diabetes management and a prenatal program. You will also receive Active Blue, our health magazine and have access to online health and wellness information at With our program you can get health advice anytime you need it, so you can learn how to take charge of your health. What Is Not Covered? The following are summaries of some of the coverage restrictions. A full explanation and listing of restrictions will be found in your benefi t booklet. Your health benefi t plan does not cover services, supplies, drugs or charges that are: Not medically necessary For injury or illness resulting from an act of war For personal hygiene and convenience items For inpatient admissions that are primarily for diagnostic studies For palliative or cosmetic foot care For investigative or experimental purposes For hearing aids or tinnitus maskers For cosmetic services or cosmetic surgery For custodial care, domiciliary care or rest cures For treatment of obesity, except for surgical treatment of morbid obesity, or as specifically covered by your health benefit plan For reversal of sterilization For treatment of sexual dysfunction not related to organic disease For conception by artifi cial means For self-injectable drugs in the provider's office A waiting period for coverage of pre-existing conditions may apply to your coverage. Pre-existing conditions are those conditions for which medical advice, diagnosis, care or treatment was received or recommended within 6 months of the date that your BCBSNC coverage begins. You may receive credit toward the 12-month waiting period if your enrollment date is within 63 days of the termination of your previous health coverage. The benefi t highlights is a summary of Blue Options benefi ts. This is meant only to be a summary. Final interpretation and a complete listing of benefi ts and what is not covered are found in and governed by the group contract and benefi t booklet. You may preview the benefi t booklet by requesting a copy of the Blue Options benefi t booklet from BCBSNC Customer Services., SMRegistration and Service marks of the Blue Cross and Blue Shield Association. An Independent Licensee of the Blue Cross and Blue Shield Association Page 7

8 BCBS PPO Monthly Subsidy Rates Employee Only $0.00 Employee & Spouse $ Employee & Child(ren) $ Employee & Family $ BCBS PPO Monthly Without Subsidy Rates Employee Only $0.00 Employee & Spouse $ Employee & Child(ren) $ Employee & Family $ For Customer Service needs and questions, please call BCBSNC at Page 8

9 BlueCross BlueShield Of NC HSA Plan Lifetime Maximum, Deductibles & Total Out of Pocket Maximums 1 In-network Out-of-network 2 The following Deductibles and Total Out of Pocket Maximums apply to all services unless otherwise indicated: Lifetime Benefit Maximum Unlimited Unlimited Deductibles (per benefit period) Employee Only $1,500 $3,000 Family Coverage - Aggregate (Entire $3,000 $6,000 family contributes to the Deductible) Total Out of Pocket (OOP) Maximum (per Benefit Period) Employee Only $3,500 $7,000 Family Coverage - Aggregate $5,000 $10,000 (Entire family contributes to the Total OOP Maximum) Physician Office Services Office Visit Includes Office Surgery, Consultation, X-rays, Lab and benefi t period maximum of 4 offi ce visits for the evaluation and treatment of obesity in and out of network. Primary Care Provider or Specialist 80% after deductible 50% after deductible Preventive Care (Preventive Diagnosis Only) Well-Child Care (Age 3 and under), Immunizations,annual routine examinations, gynecological exams, cervical cancer screening, ovarian cancer screening, screening mammograms, colorectal screening, bone mass measurements, newborn hearing screening, routine eye exam and prostate specifi c antigen tests (PSAs). Primary Care Provider or Specialist 100%, no deductible 70% after deductible Outpatient Clinic 100%, no deductible 70% after deductible Other Preventive Care Primary Care Provider or Specialist 100%, no deductible 70% after deductible Therapies Short-Term Rehabilitative Therapies (Maximums apply to Home, Offi ce and Outpatient Settings): Physical/Occupational: 30 visits per Benefit Period, Speech Therapy: 30 visits per Benefi t Period Primary Care Provider or Specialist 80% after deductible 50% after deductible Urgent Care Centers and Emergency Room Urgent Care Centers 80% after deductible 80% after deductible Emergency Room Visit 80% after deductible 80% after deductible Ambulatory Surgical Center 80% after deductible 50% after deductible Page 9

10 Outpatient Hospital Services (Includes physician services, hospital and hospital-based services, outpatient clinic services, outpatient diagnostic services and therapy services including short-term rehabilitative therapies and other therapies.) Inpatient Hospital Services (Includes physician services, hospital and hospital-based services, and maternity delivery, prenatal and postdelivery care.) Other Services Skilled Nursing Facility (60 days per Benefi t Period) Home Health Care, Ambulance, Durable Medical Equipment and Hospice 80% after deductible 50% after deductible 80% after deductible 50% after deductible 80% after deductible 50% after deductible 80% after deductible 50% after deductible Maternity Maternity Delivery includes Prenatal and Post-delivery care Hospital Services (Delivery) 80% after deductible 50% after deductible Professional Services (Delivery) 80% after deductible 50% after deductible Transplants Hospital Services 80% after deductible 50% after deductible Professional Services 80% after deductible 50% after deductible Infertility Services Up to $5,000 per Lifetime Primary Care Provider or Specialist 80% after deductible 50% after deductible Hospital Services 80% after deductible 50% after deductible Inpatient and Outpatient Professional 80% after deductible 50% after deductible Services Infertility Drugs 80% after deductible 80% after deductible Vision Care Routine Eye Exam 100%, no deductible 70% after deductible Prescription Drugs Mac C Pricing. Open Formulary. Enhanced Preventitive Drugs Generic Drugs from the Enhanced Preventive Drug List prescribed for a preventive reason 80% after deductible 100% 80% after deductible + charge over in-network allowed amount 80% after deductible + charge over innetwork allowed amount Page 10

11 Mental Health and Substance Abuse Services Mental Health Services Office 80% after deductible 50% after deductible Inpatient/Outpatient 80% after deductible 50% after deductible Substance Abuse Services Office Visit 80% after deductible 50% after deductible Inpatient/Outpatient 80% after deductible 50% after deductible 1 NOTICE: If you selected Employee Coverage, the Employee Coverage deductible and total out of pocket maximum will apply; if you selected Family Coverage the Family Coverage deductible and total out of pocket will apply. 2 NOTICE: Your actual expenses for covered services may exceed the stated coinsurance percentage or copayment amount because actual provider charges may not be used to determine the payment obligations for BCBSNC and its members. ADDITIONAL INFORMATION ABOUT BLUE OPTIONS HSA FROM BCBSNC Benefit Period The period of time, usually 12 months as stated in the group contract, during which charges for covered services provided to a member must be incurred in order to be eligible for payment by BCBSNC. A charge shall be considered incurred on the date the service or supply was provided to a member. Allowed Amount The maximum amount BCBSNC determines is to be paid for covered services provided to a member. Total Out of Pocket Maximum The dollar amount of total out of pocket expenses a member must pay prior to BCBSNC paying 100% for certain services; it includes the deductible and coinsurance. Day and Visit Maximums All day and visit maximums are on a combined In- and Out-of Network basis. Utilization Management To make sure you have access to high quality, cost-effective health care, we manage utilization through a variety of programs including certification, transplant management, concurrent and retrospective review and care management. If you have a concern regarding the final determination of your care, you have the right to appeal the decision. If you would like a copy of a benefit booklet providing more information about our Utilization Management programs, call the toll free number listed in your information packet. Certification Certifi cation is a program designed to make sure that your care is given in a cost effective setting and efficient manner. Page 11

12 If you need to be hospitalized, you must obtain certification. Non-emergency and non-maternity hospital admissions must be certified prior to the hospitalization. If the admission is not certified, a penalty will be applied. For maternity admissions, your provider is not required to obtain certifi cation from BCBSNC for prescribing a length of stay up to 48 hours for a normal vaginal delivery, or up to 96 hours for delivery by cesarean section. You or your provider must request certification for coverage for additional days, which will be given by BCBSNC, if medically necessary. All inpatient and certain outpatient Mental Health and Substance Abuse services must be certified in advance by Magellan Behavioral Health. Call Magellan Behavioral Health at Office visits do not require certification. Innetwork providers are responsible for obtaining certifications. The member will bear no financial penalties if the in-network provider fails to obtain the appropriate authorization. The member is responsible for obtaining certifi cation for services rendered by an out-of-network provider. Obtaining certification for Mental Health and Substance Abuse services is the member s responsibility. Health and Wellness Program Because we want to help you stay healthy, we offer a variety of wellness benefits and services. You can take advantage of HealthLine Blue, our 24-hour health information service, a health topics library, asthma and diabetes management and a prenatal program. You will also receive Active Blue, our health magazine and have access to online health and wellness information at With our program you can get health advice anytime you need it, so you can learn how to take charge of your health. What Is Not Covered? The following are summaries of some of the coverage restrictions. A full explanation and listing of restrictions will be found in your benefit booklet. Your health benefit plan does not cover services, supplies, drugs or charges that are: Not medically necessary For injury or illness resulting from an act of war For personal hygiene and convenience items For inpatient admissions that are primarily for diagnostic studies For palliative or cosmetic foot care For investigative or experimental purposes For hearing aids or tinnitus maskers For cosmetic services or cosmetic surgery For custodial care, domiciliary care or rest cures For treatment of obesity, except for surgical treatment of morbid obesity, or as specifically covered by your health benefit plan For reversal of sterilization For treatment of sexual dysfunction not related to organic disease For conception by artifi cial means For self-injectable drugs in the provider s office A waiting period for coverage of pre-existing conditions may apply to your Page 12

13 coverage. Pre-existing conditions are those conditions for which medical advice, diagnosis, care or treatment was received or recommended within 6 months of the date that your BCBSNC coverage begins. You may receive credit toward the 12-month waiting period if your enrollment date is within 63 days of the termination of your previous health coverage. Health Savings Account Blue Options HSA is not a Health Savings Account (HSA), but it instead is a health insurance plan intended to be paired with an HSA. The HSA is provided to you directly by a separate HSA Administrator. An HSA is a savings vehicle for medical care expenses. It helps to pay the expenses that insurance does not pay. Individuals and employers can contribute money into an HSA on a tax-deductible or pre-tax basis for individuals. If used to pay for qualified health care expenses, your HSA account s growth and use is tax-free. In addition, HSAs roll over from year to year and are fully portable if an individual changes jobs. HSAs can only be opened by and contributed to on behalf of individuals who are covered under a qualifi ed High Deductible Health Plan (HDHP). For more information on your HSA eligibility if you have other, additional health coverage, consult your tax advisor., SMRegistration and Service marks of the Blue Cross and Blue Shield Association. An Independent Licensee of the Blue Cross and Blue Shield Association BCBS HSA Monthly Subsidy Rates Employee Only $0.00 Employee & Spouse $ Employee & Child(ren) $ Employee & Family $ BCBS HSA Monthly Without Subsidy Rates Employee Only $0.00 Employee & Spouse $ Employee & Child(ren) $ Employee & Family $ For Customer Service needs and questions, please call BCBSNC at Page 13

14 Ameritas Dental High and Low Plan Low Plan Dental Plan Summary Coinsurance Type 1 - Preventive 100% Type 2 - Basic 80% Deductible $50/Calendar Year Type 2 Waived Type 1 Maximum (per person) Allowance Waiting Period 3 Family Maximum $1,000 per calendar year 90th U&C None Low Plan Sample Procedure Listing (Current Dental Terminology American Dental Association.) Type 1 - Preventive Type 2 - Basic Routine Exam (2 per benefit period) Bitewing X-rays (1 per benefit period) Full Mouth/Panoramic X-rays (1 in 5 years) Periapical X-rays Cleaning (2 per benefit period) Fluoride for Children 18 and under (2 per benefit period) Sealants (age 16 and under) Space Maintainers High Plan Dental Plan Summary Restorative Amalgams Restorative Composites (anterior teeth only) Endodontics (nonsurgical & surgical) Periodontics (nonsurgical & surgical) Simple Extractions Complex Extractions Anesthesia Coinsurance Type 1 - Preventive 100% Type 2 - Basic 80% Type 3 - Major 50% Deductible $50/Calendar Year Type 2 & 3, Waived Type 1, 3 Family Maximum Maximum (per person) $1,000 per calendar year Allowance 90th U&C Waiting Period None High Plan Sample Procedure Listing (Current Dental Terminology American Dental Association.) Type 1 - Preventive Type 2 - Basic Type 3 - Major Routine Exam (2 per benefit period) Bitewing X-rays (1 per benefit period) Full Mouth/Panoramic X-rays (1 in 5 years) Periapical X-rays Cleaning (2 per benefit period) Fluoride for Children 18 and under (2 per benefit period) Sealants (age 16 and under) Space Maintainers Restorative Amalgams Restorative Composites (anterior teeth only) Periodontics (nonsurgical & surgical) Denture Repair Simple Extractions Anesthesia Onlays Crowns (1 in 5 years per tooth) Crown Repair Complex Extractions Endodontics (nonsurgical & surgical) Implants Prosthodontics (fixed bridge; removable complete/partial dentures) (1 in 5 years) Page 14

15 Dental Rewards This dental plan includes a valuable feature that allows qualifying plan members to carryover part of their unused annual maximum. A member earns dental rewards by submitting at least one claim for dental expenses incurred during the benefit year, while staying at or under the threshold amount for benefits received for that year. Employees and their covered dependents may accumulate rewards up to the stated maximum carryover amount, and then use those rewards for any covered dental procedures subject to applicable coinsurance and plan provisions. If a plan member doesn't submit a dental claim during a benefit year, all accumulated rewards are lost. But he or she can begin earning rewards again the very next year. Benefit Threshold $500 Dental benefits received for the year cannot exceed this amount Annual Carryover Amount $250 Dental Rewards amount is added to the following year's maximum Maximum Carryover $1,000 Maximum possible accumulation for Dental Rewards Open Enrollment If a member does not elect to participate when initially eligible, the member may elect to participate at the policyholder's next enrollment period. This enrollment period will be held each year and those who elect to participate in this policy at that time will have their insurance become effective on July 1. Rx Savings Our valued plan members and their covered dependents (even their pets) can save on prescription medications through any Walmart or Sam's Club pharmacy across the nation. This Rx discount is offered at no additional cost, and it is not insurance. To receive the Walmart Rx discount, Ameritas plan members just need to show their original Ameritas ID card. The identifier is the Ameritas logo. It's that easy. Or members can visit us at ameritasgroup.com and sign into (or create) a secure member account where they can print off an onlineonly Rx discount savings ID card. Eligible Employee You are eligible for insurance if you are a regular full-time employee working at least 40 hours per week. Eligible Dependents Eligible Dependents include your spouse and children. A dependent is eligible up to age 26 regardless of student status. Pre-Determination of Benefits A pre-treatment plan may be filed if a proposed course of treatment will exceed $ With this information, Ameritas can determine the benefits payable under this policy prior to the work actually being done. It will give the insured the amount payable, along with an idea of the out of pocket expense. Coordination of Benefits If you or any of your covered dependents incur charges which are covered by any other group plan, the benefits of this plan will be coordinated with the benefits of the other plan so that the total benefits received are not greater than the charges incurred. Page 15

16 Limitations/Exclusions (not a complete list) For any treatment which is for cosmetic purposes. Facings on crowns or pontics behind the 2 nd bicuspid are considered cosmetic. Charges incurred prior to the date the individual became insured under this plan, or following the date of termination of coverage. Orthdontic treatment. Services which are not recommended by a dentist or which are not required for necessary care and treatment. Expenses incurred to replace lost or stolen appliances. Expenses incurred by an insured because of a sickness for which he/she is eligible for benefits under Worker s Compensation Act or similar. Section 125 This policy is provided as part of the Policyholder s Section 125 Plan. Each member has the option under the Section 125 Plan of participating or not participating in the benefit offered. A member may change their election only during an annual election period, except for a change in a family status. Examples of such events would be marriage, divorce, birth of a child, death of a spouse or child or termination of employment. Please see your plan administrator for details. Passive PPO City of Sanford proudly offers employees a dental program, administered by Ameritas Life Insurance Corp., providing excellent coverage for you and your eligible dependents. Please refer to the plan highlight for more details. As an added bonus, the plan includes access to Ameritas Participating Provider Organization (PPO). With a Passive PPO, the coinsurance, deductible and maximum are the same for the member when utilizing a network provider or non-network provider. The difference in these options is the claim allowance. There is an incentive for the member to see an in-network dentist; however, there is no penalty for seeing an out-ofnetwork provider. The member has the liberty to choose any licensed dental provider. However, they will usually save out-of-pocket costs by utilizing an in-network dentist. Do I have to use an Ameritas PPO provider? Employees and their covered dependents may utilize any licensed dental provider that they choose. Please note, there is no difference in the coinsurance, deductible, and maximums on either plan whether a PPO provider is utilized or not. Why would I use an Ameritas PPO provider? A Participating Provider is a dentist who has entered into an agreement to provide services to insured members of Ameritas plans for at a specific fee. Any insured member who chooses to go to a PPO provider will receive this discounted fee for procedures performed by that provider. As part of their contractual agreement with Ameritas, the PPO provider cannot back-bill the patient for the difference between the dentists normal charges and the discounted fees that the dentist agreed to charge as an Ameritas PPO provider. PPO providers are required to file the claim for the patient. PPO providers are required to wait for reimbursement from Ameritas before billing the patient for any balances owed for deductibles, coinsurance, any amounts exceeding the annual maximum benefits, etc. PPO panels are available in many areas; please visit the Ameritas website at to search for a provider in your area. Page 16

17 What happens if I don t use an Ameritas PPO provider? The City of Sanford wants employees to have options regarding their choice of providers. In addition, we want to ensure that employees that utilize non-panel providers receive exceptional benefits that reimburse claims for non-panel providers in the most optimal way. Non-panel providers can charge their standard fees for any service. However, the amount Ameritas allows for each procedure for non-panel provider utilizes 90 th percentile of U&C which is considered to be one of the highest reimbursement levels in the industry. This means that 9 out of 10 dentist s charges will fall within the amount that Ameritas allows for each procedure. In doing so, employees can feel comfortable that very little back billing will occur due to the amounts allowed by the plan. Non-panel providers have no specific requirements regarding filing of claims. However, we have found that many dentists will assist the patient with the paperwork needed to file the claim. If a dentist is not willing to file the claim on the patient s behalf, the patient can simply attach the dentist s bill to a claim form that includes the patient s name and identification number, and fax or mail the claim to Ameritas for processing. Ameritas will process the claim, typically within 7-10 working days. Claim payment can be made to the patient or directly to the dentist if noted on the claim form. The patient can use Ameritas claim forms which are available in the Benefit s Department, on the Ameritas web site (or our employee Intranet site), OR the patient can use any generic claim forms that the dental office may have available. Filing claims is fast and easy with Ameritas! Low Plan Monthly Rates Employee Only $25.40 Employee & 1 Dependent $51.94 Employee & 2 or More $81.00 Dependents High Plan Monthly Rates Employee Only $40.42 Employee & 1 Dependent $81.58 Employee & 2 or More $ Dependents Ameritas Information This plan was designed specifically for the associates of City of Sanford. At Ameritas Group, we do more than provide coverage - we make sure there's always a friendly voice to explain your benefits, listen to your concerns, and answer your questions. Our customer relations associates will be pleased to assist you 7 a.m. to midnight (Central Time) Monday through Thursday, and 7 a.m. to 6:30 p.m. on Friday. You can speak to them by calling toll-free: For plan information any time, access our automated voice response system or go online to ameritasgroup.com/member. Page 17

18 Reliance Standard Short-Term Disability Effective Date: July 1, 2012 Employer Paid Benefit - no cost to you Coverage outside normal working hours (ie covered during weekends and holidays) Benefit payments are paid directly to the insured Benefit payments may not be considered taxable by IRS Sickness includes normal pregnancy, and certain complications of pregnancy Injury & Sickness Coverage Benefits may be payable due to total or partial disability due to a sickness or injury. There is an elimination period of 7 days or the end of any accumulated sick leave or vacation leave paid for sicknesses and injuries. The benefi t is 60% of covered weekly earnings, up to a maximum weekly benefit of $ Maximum benefi t duration is 26 weeks. Eligibility Regular full-time actively at work employees working 40 hours or more per week are eligible. The disability coverage is offered to eligible employees only. Exclusions: Weekly Income Benefits are not paid for any period of disability caused by: (a) an intentionally self-inflicted injury; or (b) an act of war, declared or undeclared; or (c) the Insured committing a felony; or (d) sickness which is covered by a Workers Compensation Act, or other worker s disability law; or (e) injury which occurs in the course of work for wage or for profit. Proof of Loss: The initial claim form or proof of disability must be signed by a physician and sent to Reliance Standard within 30 days following the elimination period. If it is not possible to give proof within these limits, it must be given as soon as reasonably possible. Proof of claim may not be given later than one year after the time proof is otherwise required. Reliance Standard also will periodically send the person additional claim forms. These subsequent claim forms must be returned to Reliance Standard within 30 days after they are received by the person. The contract has exclusions, limitations, reduction of benefits, and terms under which the contract may be continued in force or discontinued. The contract may contain a waiting or elimination period between the effective date of the contract and the effective date of coverage, and between the date a loss occurs and the date benefits begin to be payable for the loss. For a comprehensive list of exclusions and limitations, please refer to the Certifi cate of Insurance. The Certificate also provides all requirements necessary to be eligible for coverage and benefi ts. This Plan Highlight is a brief description of the key features of the RSL insurance plan. It is not a certificate of insurance or evidence of coverage. Page 18

19 Reliance Standard Group Term Life Plan Effective Date: July 1, 2012 Basic Employee Life/Accidental Death Insurance (paid by your employer) Two times annual earnings, rounded to the next higher $1,000, subject to a maximum of $200,000. Dependent Life Insurance Provides coverage on: (a) an Insured s legal spouse who is not legally separated or divorced from that Insured; and (b) an Insured s unmarried child(ren), from live birth to 20 years, who is fi nancially dependent upon the Insured for support. Adoptive, foster and step-children are considered dependents if they are in the custody of the Insured; and (c) an Insured s unmarried child(ren), attending a college or other school on a full-time basis, who is fi nancially dependent upon the Insured for support, up to age 26. Eligibility You will be eligible for this program if you are a full-time employee working 40 hours or more per week. Enrollment Enrollment is simple - just fi ll out the election card provided by your employer. You have 31 days to enroll yourself and dependents without evidence of insurability; if you are a new hire or due to a qualifying event. Beneficiary You have the right to designate the benefi ciary of your choice. The benefi ciary elected on your life enrollment form designates your benefi ciary for basic coverage. You are automatically the benefi ciary under dependent life. It is the responsibility of the insured to update one s benefi ciary designation as necessary. When Your Insurance Starts Within 31 days of hire or date of eligibility for a life event situation. Reductions At Age 70 & Over If you remain in active service beyond age 70 your amount of Basic Life Insurance will reduce as follows: Attained Age Percent of Original Amount 70 50% (The above age reduction also applies to dependent spouse.) Termination of Coverage All insurance under this plan will terminate upon the earlier of the date you retire or the date your employment terminates. Nevertheless, if you or a covered dependent should die within 31 days thereafter, the life insurance will still be paid to the benefi ciary. Page 19

20 Conversion If your employment terminates while you are covered under the plan, you may purchase without medical evidence of insurability, any individual insurance, except a term policy. If you wish to continue with a term policy, please refer to the section below on Portability. The amount of the individual contract may not be more than the amount of your life coverage in effect on your date of termination. You must apply for this policy within 31 days after the date your employment terminates. This privilege applies to Basic Employee Life Insurance, Dependent Spouse Life Insurance, and Dependent Child Life Insurance. Portability Reliance Standard has included a Portability provision as part of your group life benefi ts. You may be eligible to port your coverage upon termination. Please see certifi cate for more details. Accelerated Death Benefit Reliance Standard has included an Accelerated Benefi t Option as part of your group life benefi ts. Under this option, if you are diagnosed as having a terminal illness, you may be eligible to receive a portion of your group life benefi ts at such a diffi cult time. Please refer to your Group Certifi cate for details. Claims Procedure Claim forms needed to fi le for benefi ts under the group insurance program can be obtained from Human Resources who will also be ready to answer questions about the insurance benefi ts and to assist in fi ling claims. The instructions on the claim form should be followed carefully. This will expedite the processing of the claim. Be sure all questions are answered fully. If there is any question about a claim payment, an explanation can be requested from your Human Resources department, who is usually able to provide the necessary information. SCHEDULE OF BENEFITS Basic Employee Life Insurance Two times annual earnings, rounded to the next higher $1,000, subject to a maximum of $200,000. Dependent Life Insurance Spouse Amount: $2,000 Children Amount: Live birth to 6 months: $200 6 months and over: $2,000 For a comprehensive list of exclusions and limitations, please refer to the Certifi cate of Insurance. The Certificate also provides all requirements necessary to be eligible for coverage and benefi ts. This Plan Highlight is a brief description of the key features of the RSL insurance plan. It is not a certificate of insurance or evidence of coverage. Page 20

21 Contact Information for Questions and Claims Blue Cross and Blue Shield of North Carolina Customer Service Ameritas Dental Customer Service Reliance Standard Short-Term Disability and Term Life To check the status of your claim please call Mark III Brokerage 211 Greenwich Rd Charlotte, NC ext Page 21