Medicare Part D Notice: The benefits in this summary are effective:

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2 Medicare Part D Notice: If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, a federal law gives you more choices about your prescription drug coverage. Please see the Annual Notices for more details. The benefits in this summary are effective: January 1, December 31, 2019

3 Table of Contents For Assistance... 3 Who Can You Cover... 4 Making The Most of Your Benefits Program... 5 Medical Benefits... 6 Pharmacy Benefits... 7 Dental Benefits Vision Benefits Basic Life/AD&D Disability Flexible Spending Accounts Carrum Health Key Terms Required Federal Notices Revised: September 4, 2018

4 Plan Type Provider Phone Number Website Policy/Group # City of Merced s Insurance Department Rosa Winzer Phone (209) winzerr@cityofmerced.org Maggie Fuentes Phone (209) fuentesm@cityofmerced.org

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6 Start a conversation now. livehealthonline.com

7 Core Benefits Buy-Up Option In-Network In-Network Annual Deductible Annual Out-of-Pocket Max Lifetime Max Office Visit Primary Provider Specialist Preventive Services Chiropractic Care Lab & X-Ray Inpatient Hospitalization Outpatient Surgery Speech/ Physical Therapy/ Occupational Therapy Emergency Room

8 Core Benefits Buy-Up Option In-Network Only In-Network Prescription Drug Deductible Annual Out-of- Pocket Limit Pharmacy Mail Order

9 Retail fill allowance: Get the Facts on Your Maintenance Medication Pharmacy Network Smart90 There are Two Ways to Save on Your Maintenance Prescriptions Saving with generics If you re taking a brand-name drug, talk to your doctor and ask whether a less expensive generic drug could treat your condition. If your doctor agrees, ask your doctor to write a new prescription for the generic that you can fill under your plan. FDA-approved generics are as safe and effective as their brand-name counterparts. Saving with mail Express Scripts member services Once enrolled

10 three purchases your co-payment may increase. * However, if you order your long-term prescriptions by mail from Express Scripts Pharmacy or transfer your maintenance medication to a nearby CVS or Walgreens for a 90 day supply, you ll pay your mail-order copayment. For short-term medication short-term To learn more about how to use Home Delivery Services from Express Scripts Pharmacy Go to Call the number on the back of your prescription drug ID card 24 hours a day, 7 days a week

11 Save money with a Delta Dental PPO dentist. Delta Dental (Core Benefit) Delta Dental (Buy-Up Option) Calendar Year Deductible Maximum Annual Benefit (per member) In-Network Out-of-Network In-Network Out-of-Network $25 Individual $25 Individual $25 Individual $25 Individual $75 Family $75 Family $75 Family $75 Family $1,000 $1,000 $1,500 $1,500 Preventative Services (deductible waived) Oral Exam(s) Cleaning (2x per year) 100% 100% 100% 100% Sealants of a PPO dentist fees of UCR of a PPO dentist fees of UCR Fluoride treatment Basic Services Amalgam Fillings Most Extractions 100% 100% 100% 100% Oral Surgery of a PPO dentist fees of UCR of a PPO dentist fees of UCR Endodontics Periodontics Major Services 100% 100% 100% 100% Bridgework Dentures of a PPO dentist fees of UCR of a PPO dentist fees of UCR Crowns Orthodontia Covered for Adults & Child(ren) 100% of a PPO dentist fees $1,000 Lifetime Maximum 100% of UCR 100% of a PPO dentist fees $1,000 Lifetime $1,500 Lifetime Maximum Maximum 100% of UCR $1,500 Lifetime Maximum

12 VSP provides participants with access to a large network of vision care providers. To locate a network provider visit If you decide not to see a VSP doctor, the plan co-pay still applies. This choice is yours either way, your VSP benefits are a tremendous part of your overall benefits package. There are no ID cards necessary for this plan VSP-Choice Network (Core Benefits) VSP-Choice Networks (Buy-Up Option) In-Network Out-of-Network In-Network Out-of-Network Examination $25 Copay Up to $45 $25 Copay Up to $45 Benefit Frequency Every 12 Months Every 12 Months Every 12 Months Every 12 Months Eyeglass Lenses Single Vision Lens $25 Copay Up to $30 Combined with Exam Up to $30 Bifocal Lens $25 Copay Up to $50 Combined with Exam Up to $50 Trifocal Lens $25 Copay Up to $65 Combined with Exam Up to $65 Benefit Frequency Every 24 Months Every 24 Months Every 12 Months Every 12 Months Frames (amounts reimbursed, less deductible) $120 Allowance + 20% Off the Amount Over the Allowance Up to $70 $120 Allowance + 20% Off the Amount Over the Allowance Up to $70 Benefit Frequency Every 24 Months Once every 24 Months, In Lieu of Eyeglasses Once every 12 Months, In Lieu of Eyeglasses Once every 12 Months, In Lieu of Eyeglasses Contacts $120 Allowance Up to $105 $120 Allowance Up to $105 (Elective) Benefit Frequency Once every 24 Months, In Lieu of Eyeglasses Once every 24 Months, In Lieu of Eyeglasses Once every 12 Months, In Lieu of Eyeglasses Once every 12 Months, In Lieu of Eyeglasses

13 Basic Life Amount Basic AD&D Amount Guarantee Issue Amount Beneficiary Reminder: Employee Benefit: Buy-Up Life Amount Election Options Guarantee Issue Amount Employees over Age 70 Spouse Benefit: Buy-Up Life Amount Election Options Guarantee Issue Amount Dependent Child(ren) Benefit: Birth to 14 Days 14 Days to 6 Months 6 Months to 26 Years Guarantee Issue Amount

14 Short-Term Disability Long-Term Disability Long-Term Disability STD Plan: Core Benefit Buy-Up Option Weekly Benefit Amount Maximum Weekly Benefit $600/ week $1,650/ week Benefits Begin After: Maximum Payment Period* Plan: Core Benefit Buy-Up Option Monthly Benefit Amount Maximum Monthly Benefit $2,500 $7,000 Benefits Begin After: Accident Sickness Maximum Payment Period* To Age 65 or SSNRA To Age 65 or SSNRA If you are interested in purchasing the Buy-Up Disability benefits, please see Support Services.

15 Short-Term Disability Long-Term Disability Long-Term Disability STD Eligibility: STD Plan: Core Benefit Buy-Up Option Weekly Benefit Amount Maximum Weekly Benefit $600/ week $1,650/ week Benefits Begin After: Accident Sickness Maximum Payment Period* 18 Weeks (All Other Employees) 18 Weeks (All Other Employees) Plan: Core Benefit Buy-Up Option Monthly Benefit Amount Maximum Monthly Benefit $2,500 $7,000 Benefits Begin After: Accident Sickness Maximum Payment Period* To Age 65 or SSNRA To Age 65 or SSNRA If you are interested in purchasing the Buy-Up Disability benefits, please see Support Services.

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17 Your Flexible Spending Account with BCC Fast and Easy Claim Processing Online Account Access Convenience at your Fingertips Direct Deposit FSA Benefits Debit Card Convenience - Customer Service (800) Supplies & More Information

18 The City of Merced has partnered with Carrum Health to provide eligible health plan members access to an enhanced surgery benefit program with top-quality hospitals and surgeons. Carrum Health is a special surgery benefit that provides exclusive access to Scripps Hospital, Stanford Health Care, Providence Saint John s Health Center (Santa Monica), and The Hoag Orthopedic Institute s Outpatient Center (Orange County). Eligible members include active employees, dependents, and early retirees who are enrolled in the Anthem Health Plans. Eligible procedures include: hip and knee replacement, spinal fusion surgery, orthopedic procedures (shoulder, elbow, wrist, hand, hip, knee, ankle, foot and spine), multiple spine procedures, coronary bypass (CABG), bariatric (weight loss) surgery. Please contact Carrum Health to learn if your desired procedure is available. Use of this benefit is optional. This benefit is separate from and in addition to the benefits already provided under Anthem. This benefit is not administered by Anthem. This benefit must be accessed through Carrum Health. Under the Carrum Health surgery benefit program, your personally assigned Carrum Care Concierge will: Help complete forms Gather and transfer medical records Assist in the selection of a surgeon Schedule the surgery Make travel arrangements (if necessary) Coordinate post-discharge recovery care You will have special access to Centers of Excellence which are hospitals and surgeons that have been vetted for providing top-quality care and achieving better outcome! There are no medical bills! Co-insurance and deductibles will be waived! Travel expenses (if applicable) will be covered for the patient and an adult companion! To learn more or get started with the program, contact Carrum Health Toll Free: Online: carrum.me/eiahealth

19 MEDICAL/GENERAL TERMS Allowable Charge Balance Billing Coinsurance Copay Explanation of Benefits (EOB) Family Deductible Individual Deductible In-Network Out-of-Network Out-of-Pocket Maximum Preventive Care PRESCRIPTION DRUG TERMS Brand Prescription Drug Dispense as Written (DAW) Maintenance Medications Non-Preferred Brand Drug Preferred Brand Drug

20 Specialty Pharmacy Step Therapy DENTAL TERMS Basic Services Diagnostic and Preventive Services Endodontics Implants Major Services Orthodontia Periodontics Pre-Treatment Estimate

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24 Premium Assistance under Medicaid and the Children s Health Insurance Program (CHIP) healthcare.gov If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, Contact your State for more information on eligibility

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