Your Benefits Quick Start Guide

Transcription

1 Your Benefits Quick Strt Guide Enroll in the Aetn insurnce plns offered through Michels tody Unexpected stuff hppens to ll of us. Tht s why you need to be redy with insurnce options from Aetn Voluntry Plns. This is your opportunity to sign up for benefits. So tke few minutes to find out bout your options now! Plese note, these plns provide supplementl benefits nd re not substitute for comprehensive medicl insurnce. You hve limited time to enroll. If you were just hired, you hve 60 dys from the dte you re hired to enroll. Aetn Vision Pln Reimburses you for n exm, frmes, lenses or contct lenses up to n nnul limit. Aetn Dentl Pln Covers portion of your bill for common dentl procedures. Aetn Term Life Insurnce Pys your beneficiry if you die, to help with funerl or other expenses. Dentl AETNA VOLUNTARY PLANS [COMPANY NAME] MICHAELS STORES, INC. GROUP NUMBER: [000000] GROUP NUMBER: YOUR NAME: FOR MEMBER SERVICES CALL Cut out your temporry member identifiction long the dotted line. These plns do not count s minimum essentil coverge under the ffordble cre ct. These re supplement to helth insurnce nd re not substitute for mjor medicl coverge. Lck of mjor medicl coverge (or other minimum essentil coverge) my result in n dditionl pyment with your txes SGE B (05/16) C (11/15)

2 Strt your benefits! How do I enroll? Upon eligibility, go to michelsbenefits.vpenroll.com to view your benefits. Complete your enrollment vi Orcle HR t or by clling Michels Tem Member Services t MIKE (6453). Am I eligible to enroll? All Michels U.S. Prt Time tem members my enroll in the benefits progrm. If you re n eligible tem member, you cn lso enroll your eligible dependents. Your eligible dependents re your lwful spouse or domestic prtner nd your children from birth until ge 26, through ny ge if hndicpped nd unble to ern living, or until they cn no longer be leglly declred s dependents. Dependent ge nd sttus requirements my vry by stte. How do I py? Pyment is simple. Premium costs will be deducted from your pycheck. If you miss pyment, you cn py directly nd keep your coverge ctive. There is form in this kit to use when sending in missed premium pyments. When does coverge begin? Coverge is effective on the first dy following the pycheck dte in which deduction occurs. Signing up is esy! First, red your enrollment informtion. To enroll, go to Orcle HR t or by clling Michels Tem Member Services t MIKE (6453). For dditionl questions, Tem Members my lso cll Aetn t , between 8.m. nd 6 p.m., Mondy through Fridy. If you require lnguge ssistnce, plese cll Member Services t nd n Aetn representtive will connect you with n interpreter. If you re def or hrd of hering, use your TTY nd dil 711 for the Telecommunictions Rely Service. Once connected, plese enter or provide the Aetn telephone number you re clling. Si usted necesit sistenci lingüístic, por fvor llme l Servicios l Miembro , y un representnte de Aetn le conectrá con un intérprete. Si usted es sordo o tiene problems de udición, use su TTY y mrcr 711 pr el Servicio de Retrnsmisión de Telecomunicciones (TRS). Un vez conectdo, por fvor entrr o proporcionr el número de teléfono de Aetn que está llmndo. If you choose Dentl coverge, plese use this temporry member ID until you get your plstic member ID crd. INSURED: The person listed on the crd hs been enrolled in Limited Dentl pln sponsored by the employer. Avilble benefits re subject to exclusions nd limittions. This crd does not gurntee coverge. For verifiction of coverge, filing clim or for questions other thn the discount progrms, contct us t the number printed on the front of this crd or mil us t the ddress below. EMERGENCY: Cll 911 or go to the nerest emergency fcility. Aetn Voluntry Plns P.O. Box Lexington, KY Insurnce plns re underwritten by Aetn Life Insurnce Compny (Aetn). This mteril is for informtion only. Providers re independent contrctors nd re not gents of Aetn. Provider prticiption my chnge without notice. Aetn does not provide cre or gurntee ccess to helth services. Insurnce plns contin exclusions nd limittions. Informtion is believed to be ccurte s of the production dte; however, it is subject to chnge. See the limittions nd exclusions document included in this kit for the Aetn insurnce plns offered by your employer. Policy forms issued include: GR-9N, GR-29N Aetn Inc SGE B (05/16) C (11/15)

3 Aetn Voluntry Plns Aetn Life Insurnce Compny Missed Premium Pyment Coupon Compny nme Group number Tody s dte (mm/dd/yyyy) Michels Stores, Inc Member nme (lst, first, middle initil) Member dytime telephone number lst four of Socil Security Number Pyment will be pplied to the oldest gp in coverge within the lst 45 dys from the postmrk on your miled pyment. To find out wht gps in coverge you my hve, plese cll us toll free t X $ = $ Number of py periods missed Amount of deduction per py period Full premium pyment due Instructions: Mke copy of this pge. Complete the pyment coupon. Cut long the dotted line. Mil coupon with your full mount, mde pyble to Aetn Life Insurnce Compny, to: Missed Premiums P.O. Box Atlnt, GA Wht if I miss pyroll deduction? Your coverge will not begin until you hve your first pyroll deduction. Ech pyroll deduction pys for coverge for one pyroll period. If you miss pyroll deduction fter your coverge begins, you will not hve coverge during the time tht pyroll deduction would cover, unless you py the full missed premium directly to Aetn Voluntry. Will my insurnce be cnceled if I don t mke up missed premium? Once your coverge hs begun, it will not be cnceled becuse you do not mke up missed premium. However, no clims will be pid for losses or covered expenses tht occur during the period for which premium is unpid. How do I py my missed premium? To py by personl check, cshier s check, or money order, mke pyble to Aetn Life Insurnce Compny nd send with completed copy of the coupon bove to: Missed Premiums, P.O. Box , Atlnt, GA You cn get dditionl pyment coupons by clling Cn I pick which missed premiums I wish to py? No. Your missed premium pyment will lwys be pplied to the oldest gp in coverge within the lst 45 dys (from the postmrk on your miled pyment). You cnnot choose to cover lter gp in coverge if you hve n erlier gp within the pst 45 dys from the dte your pyment is postmrked. To find out wht gps in coverge you my hve, plese cll toll free , Mondy through Fridy, 8.m. to 6 p.m. How long do I hve to py missed premium? You my py for gp in coverge tht is up to 45 dys old, from the dte your pyment is postmrked. Plese note, if you hve gp in coverge of more thn 30 dys, your 3 to12 month witing period for dentl services will reset. Cn I py just prt of missed premium? No. You must py the full premium deduction tht ws missed in your pycheck, for ll coverge you hve. We cnnot ccept prtil pyments. If I become ineligible or my employment ends, cn I continue coverge with missed premium pyments? No. If your coverge termintes, you my not continue coverge by pying missed premiums. Insurnce plns re underwritten by Aetn Life Insurnce Compny (Aetn). Informtion is believed to be ccurte s of the production dte; however, it is subject to chnge Aetn Inc D (03/15)

4 Qulity helth plns & benefits Helthier living Finncil well-being Intelligent solutions Tke better cre of your eyesight Aetn Vision Pln Tke good cre of your eyesight For most of us, vision is mong the most precious of our senses. Regulr eye exms not only detect chnges in your vision they cn lso help detect medicl problems erly, including high blood pressure nd dibetes. The Aetn Vision insurnce pln cn provide you nd your loved ones with: Benefits to help py for vision services, from routine eye exm to eyeglsses, frmes, lenses, or contct lenses Access to discounts through brod ntionwide network of vision cre providers Affordble group rtes Esy pyroll deduction (03/15)

5 Locte locl Vision provider by visiting: Exclusions nd limittions Reimbursements for vision cre services other thn eye exms, frmes or lenses re not included in this pln. Red your enrollment informtion for the reimbursement mount of your pln. Benefit period is 12 consecutive months beginning on the lter of your effective dte or your most recent eye exm covered under this pln. This limited helth pln does not meet Msschusetts Minimum Creditble Coverge stndrds. This pln does not cover ll helth cre expenses nd hs exclusions nd limittions. Members should refer to their booklet certificte to determine which helth cre services re covered nd to wht extent. The following is prtil list of services nd supplies tht re generlly not covered. However, your pln my contin exceptions to this list bsed on stte mndtes or the pln design purchsed. Orthoptic vision trining (eye exercises to improve vision), subnorml vision ids (tools such s mgnifying devices, tlking books, etc. used for those with low vision or prtil sight), ny ssocited supplementl testing Medicl nd/or surgicl tretment of the eyes or supporting structure Any eye or vision exmintion, or ny corrective eyewer, required by n employer s condition of employment In cse of emergency, cll 911 or your locl emergency hotline; or go directly to n emergency cre fcility. 80% of ll visul impirment cn be prevented or corrected. 1 Enroll Tody. Follow the instructions provided in your enrollment mterils. 1 Vision Disbility: Types, News & Informtion. Avilble t Accessed Mrch Vision insurnce plns re underwritten by Aetn Life Insurnce Compny (Aetn). Certin network dministrtion services re provided through EyeMed Vision Cre ( EyeMed ), LLC. Providers prticipting in the Aetn Vision network re contrcted through EyeMed Vision Cre, LLC. EyeMed nd Aetn re independent contrctors nd not employees or gents of ech other. Prticipting vision providers re credentiled by nd subject to the credentiling requirements of EyeMed. Aetn does not provide medicl/vision cre or tretment nd is not responsible for outcomes. Aetn does not gurntee ccess to vision cre services or ccess to specific vision cre providers nd provider network composition is subject to chnge without notice. Vision insurnce plns contin exclusions nd limittions. Policy forms issued include: GR-9N, GR-29N Aetn Inc (03/15)

6 Qulity helth plns & benefits Helthier living Finncil well-being Intelligent solutions Be prepred with dentl cre Aetn Dentl Pln Protect your smile tody nd tomorrow If you hd cvity, would you hve the money vilble to tke cre of it? Now you cn be redy with n Aetn Dentl pln. The dentl insurnce pln is ffordble nd gret wy to help you nd your loved ones keep your smiles helthy. The pln provides: Benefits to help you py for checkups, clenings nd common dentl services The flexibility to see ny dentist you like Access to discounted rtes through Aetn s brod network of dentists Group rtes which re typiclly lower thn those you cn find on your own Esy pyroll deduction How the pln works Once the nnul deductible is met, the pln helps py for mny of the most common dentl services up to its stted nnul limit. These include: Preventive services like checkups nd clenings Bsic services like fillings nd orl surgery Mjor services like crowns, bridges, dentures nd root cnls (benefits vry by pln) Witing periods my pply to some services. See your enrollment informtion for detils (03/15)

7 Locte locl preferred Dentl provider by visiting: Exclusions nd limittions The dentl preferred provider orgniztion (PPO) network is not vilble in Albm, Arknss, Idho, Hwii, Louisin, Mississippi, New Mexico or Puerto Rico. To locte preferred provider, cll toll-free Aetn will py benefits only for expenses incurred while this coverge is in force, nd only for the necessry tretment of injury or disese. A service or supply is necessry if it is determined by Aetn to be pproprite for the dignosis, cre or tretment of the disese or injury involved. The pln requires tht deductible is met before benefit is pid except for preventive services. In cse of emergency, cll 911 or your locl emergency hotline; or go directly to n emergency cre fcility. Did you know there s link between dentl helth nd overll helth? Reserch hs shown tht diseses of the teeth nd gums re risk fctors for dibetes, kidney disese, hert disese nd even cncer. So going to the dentist twice yer is bout more thn hving nice smile. 1 Enroll Tody. Follow the instructions provided in your enrollment mterils. A deductible is the mount you must py for eligible expenses before the pln begins to py benefits. This pln does not cover ll helth cre expenses nd hs exclusions nd limittions. Your pln my contin exceptions to this list bsed on stte mndtes or the pln design purchsed. The following is prtil list of services nd supplies tht re generlly not covered. However, your pln my contin exceptions to this list bsed on stte mndtes or the pln design purchsed. The following chrges re not covered under the dentl pln, nd they will not be recognized towrd stisfction of ny deductible mount: Cosmetic procedures unless needed s result of injury Any procedure, service or supply tht is included s covered medicl expenses under nother group medicl expense benefit pln Prescribed drugs, premediction, nlgesi or generl nesthesi Services provided for ny type of temporomndibulr (TMJ) or relted structures, or myofscil pin Chrges in excess of the Recognized Chrge 1 Everydy Helth. Dentl Helth nd Overll Helth. Helthy mouth, helthy body: The link between them my surprise you. Avilble t: Accessed June, Dentl insurnce plns re underwritten nd dministered by Aetn Life Insurnce Compny (Aetn). This mteril is for informtion only. Providers re independent contrctors nd re not gents of Aetn. Provider prticiption my chnge without notice. Aetn does not provide cre or gurntee ccess to dentl services. Dentl insurnce plns contin exclusions nd limittions. Informtion is believed to be ccurte s of the production dte; however, it is subject to chnge. Policy forms issued include: GR-9N, GR-29N Aetn Inc (03/15)

8 Qulity helth plns & benefits Helthier living Finncil well-being Intelligent solutions Protect the finncil future of those you love Aetn Term Life Insurnce Pln Protection for those who depend on you Could your loved ones fford to py for funerl? Could they py everydy living expenses or py off debts upon your deth? Life insurnce provides your loved ones with money they cn use to help do things like: Py off debts nd funerl costs Py the monthly rent or mortgge Crete svings fund for eduction or retirement Now you cn be redy with ffordble term life insurnce tht includes these gret benefits: Flexible options to cover just you or your entire fmily. No helth questions. Esy pyroll deduction. Additionl benefit pys if your deth is the result of n covered ccident. (This pplies to you, but not to covered dependents.) Even young, single dults my need life insurnce to help fmily members del with expenses. Are you nd your fmily redy? (03/15)

9 How the pln works: The beneficiry you choose will receive lump sum pyment upon your deth. If you die in n covered ccident, your beneficiry will receive n dditionl pyment, depending on the pln you select. Exclusions nd limittions This pln hs exclusions nd limittions. Members should refer to their booklet-certificte to determine which services re covered nd to wht extent. The following is prtil list of services nd supplies tht re generlly not covered. However, your pln my contin exceptions to this list bsed on stte mndtes or the pln design purchsed. Term Life exclusions: Suicide or ttempted suicide (while sne or insne) Protect those who depend on you Did you know tht some cskets my sell for $10,000 or more? 1 Enroll Tody. Follow the instructions provided in your enrollment mterils. Plese note tht benefits re reduced by 50 percent when you rech ge Federl Trde Commission: Shopping for Funerl Services. Avilble t: Accessed Februry Life insurnce policies re offered nd underwritten by Aetn Life Insurnce Compny (Aetn). This mteril is for informtion only. Insurnce plns contin exclusions nd limittions. Informtion is believed to be ccurte s of the production dte; however, it is subject to chnge. For more informtion bout Aetn plns, refer to Policy forms issued include: GR-9N, GR-29N Aetn Inc (03/15)

10 Michels Stores, Inc LA BENEFITS SUMMARY Aetn Voluntry Plns Pln design nd benefits insured nd dministered by Aetn Life Insurnce Compny (Aetn). Unless otherwise indicted, ll benefits nd limittions re per covered person. Inside this Benefits Summry: Vision Cre Dentl Term Life nd Accidentl Deth Insurnce Vision Cre Eye Exms Vision Cre Exclusions: Reimbursements of up to $100 every 12 months for n exm, frmes, lenses, or contct lenses. Fees for other services must be pid by you. Benefit period is 12 consecutive months beginning on the lter of your effective dte or your most recent eye exm covered under this pln. This pln does not cover ll helth cre expenses nd hs exclusions nd limittions. Members should refer to their booklet certificte to determine which helth cre services re covered nd to wht extent. The following is prtil list of services nd supplies tht re generlly not covered. However, your pln my contin exceptions to this list bsed on stte mndtes or the pln design purchsed. Orthoptic vision trining, subnorml vision ids, ny ssocited supplementl testing. Medicl nd/or surgicl tretment of the eyes or supporting structure. Any eye or vision exmintion, or ny corrective eyewer, required by n employer s condition of employment. 05/25/2016 Benefits Summry Pge 1

11 Michels Stores, Inc LA Dentl Mximum benefit per coverge yer Deductible per coverge yer Preventive services (includes checkups nd clenings) Bsic services (includes fillings, orl surgery, nd denture, crown nd bridge repir) Mjor services (includes Perio nd Endodontics, crowns, bridges, nd dentures) $500 $50 You re responsible for pying up to 20% of the Recognized Chrges. These services hve no witing period. You re responsible for pying up to 40% of the Recognized Chrges. You must be covered under the dentl pln without interruption for 3 months before the pln begins to py for these services. You re responsible for pying up to 50% of the Recognized Chrges. You must be covered under the dentl pln without interruption for 12 months before the pln begins to py for these services. The percentge of the cost tht you re responsible for pying preferred provider is bsed on Negotited Chrge. A Negotited Chrge is the mximum mount tht preferred provider hs greed to chrge for covered visit, service, or supply. After your pln limits hve been reched, the provider my require tht you py the full chrge rther thn the Negotited Chrge. The percentge of the cost tht you re responsible for pying non-preferred provider is bsed on Recognized Chrge. A Recognized Chrge is the mount tht Aetn recognizes s pyble by the pln for visit, service, or supply. For nonpreferred providers (except inptient nd outptient fcilities nd phrmcies), the Recognized Chrge generlly equls the 80th percentile of wht providers in tht geogrphic re chrge for tht service, bsed on the FAIR Helth RV Benchmrks dtbse from FAIR Helth, Inc. This mens tht 80% of the chrges in the dtbse for geogrphic re re tht mount or less nd 20% re more for tht service or supply. For preferred providers, the Recognized Chrge equls the Negotited Chrge. A non-preferred provider my require tht you py more thn the Recognized Chrge, nd this dditionl mount would be your responsibility. The dentl PPO network is not vilble in Idho, Hwii, Montn, New Mexico or Puerto Rico. To locte preferred provider, cll toll-free or visit In Texs, the Preferred Provider Orgniztion (PPO) network is known s the Prticipting Dentl Network (PDN). Dentl Exclusions: This pln does not cover ll helth cre expenses nd hs exclusions nd limittions. Members should refer to their booklet certificte to determine which helth cre services re covered nd to wht extent. The following is prtil list of services nd supplies tht re generlly not covered. However, your pln my contin exceptions to this list bsed on stte mndtes or the pln design purchsed. The following chrges re not covered under the dentl pln, nd they will not be recognized towrd stisfction of ny deductible mount. Cosmetic procedures unless needed s result of injury. Any procedure, service or supplies tht re included s covered medicl expenses under nother group medicl expense benefit pln. Prescribed drugs, pre-mediction, nlgesi or generl nesthesi. Services provided for ny type of temporomndibulr (TMJ) or relted structures, or myofscil pin. Chrges in excess of the Recognized Chrge, bsed on the 80th percentile of the FAIR Helth RV Benchmrks. 05/25/2016 Benefits Summry Pge 2

12 Michels Stores, Inc LA Term Life nd Accidentl Deth Insurnce Tem member term life benefit Tem member ccidentl deth benefit Optionl dependents coverge $20,000 $20,000 $2,500 in term life for dependents over 6 months of ge. $500 for children from birth through 6 months of ge. Benefits pid to the beneficiry of your choice; benefits reduced by 50% when you rech ge 70. Term Life nd Accidentl Deth Exclusions: This pln does not cover ll circumstnces nd hs exclusions nd limittions. Members should refer to their booklet certificte to determine which circumstnces re covered nd to wht extent. The following is prtil list of circumstnces tht re generlly not covered. However, your pln my contin exceptions to this list bsed on stte mndtes or the pln design purchsed. Term Life Exclusions: Suicide or ttempted suicide (while sne or insne). Accidentl Deth Benefit Exclusions: Use of lcohol, intoxicnts, or drugs, except s prescribed by physicin. Suicide or ttempted suicide (while sne or insne). An intentionlly self-inflicted injury. A disese, ptomine or bcteril infection except for tht which results directly from n injury. Medicl or surgicl tretment except for tht which results directly from n injury. Voluntrily inhltion of poisonous gses. Commission of or ttempt to commit criminl ct. 05/25/2016 Benefits Summry Pge 3

13 Michels Stores, Inc LA Questions nd nswers Wht should I do in cse of n emergency? In cse of emergency, cll 911 or your locl emergency hotline, or go directly to n emergency cre fcility. Wht if I don t understnd something I ve red here, or hve more questions? Plese cll us. We wnt you to understnd these benefits before you decide to enroll. You my rech one of our Customer Service representtives Mondy through Fridy, 8.m. to 6 p.m., by clling toll free We re here to nswer questions before nd fter you enroll. Importnt informtion bout your benefits Serch our network for doctors, hospitls nd other helth cre providers Here s how you cn find out if your helth cre provider is in our network. Log in to nd follow the pth to find doctor, or cll us t the toll-free number on your Aetn ID crd. If you would like printed list of doctors, contct Member Services t the toll-free number on your Aetn ID crd. Our online directory is more thn just list of doctors nmes nd ddresses. It lso includes informtion bout where the physicin ttended medicl school, bord certifiction sttus, lnguge spoken nd gender. You cn even get driving directions to the office. If you don t hve Internet ccess, cll Member Services to sk bout this informtion. Complints nd ppels Plese tell us if you re not stisfied with response you received from us or with how we do business. Cll Member Services to file verbl complint or to sk for the ddress to mil written complint. You cn lso e-mil Member Services through the secure member website. If you re not stisfied fter tlking to Member Services representtive, you cn sk us to send your issue to the pproprite deprtment. If you don t gree with denied clim, you cn file n ppel. To file n ppel, follow the directions in the letter or explntion of benefits sttement tht explins tht your clim ws denied. The letter lso tells you wht we need from you nd how soon we will respond. We protect your privcy We consider personl informtion to be privte. Our policies protect your personl informtion from unlwful use. By personl informtion, we men informtion tht cn identify you s person, s well s your finncil nd helth informtion. Personl informtion does not include wht is vilble to the public. For exmple, nyone cn ccess informtion bout wht the pln covers. It lso does not include reports tht do not identify you. When necessry for your cre or tretment, the opertion of our helth plns or other relted ctivities, we use personl informtion within our compny, shre it with our ffilites nd my disclose it to: your doctors, dentists, phrmcies, hospitls nd other cregivers, other insurers, vendors, government deprtments nd third-prty dministrtors (TPAs). We obtin informtion from mny different sources prticulrly you, your employer or benefits pln sponsor if pplicble, other insurers, helth mintennce orgniztions or TPAs, nd helth cre providers. These prties re required to keep your informtion privte s required by lw. Some of the wys in which we my use your informtion include: Pying clims, mking decisions bout wht the pln covers, coordintion of pyments with other insurers, qulity ssessment, ctivities to improve our plns nd udits. We consider these ctivities key for the opertion of our plns. When llowed by lw, we use nd disclose your personl informtion in the wys explined bove without your permission. Our privcy notice includes complete explntion of the wys we use nd disclose your informtion. It lso explins when we need your permission to use or disclose your informtion. We re required to give you ccess to your informtion. If you think there is something wrong or missing in your personl informtion, you cn sk tht it be chnged. We must complete your request within resonble mount of time. If we don t gree with the chnge, you cn file n ppel. If you d like copy of our privcy notice, cll or visit us t 05/25/2016 Benefits Summry Pge 4

14 Michels Stores, Inc LA If you require lnguge ssistnce, plese cll Member Services t nd n Aetn representtive will connect you with n interpreter. If you re def or hrd of hering, use your TTY nd dil 711 for the Telecommunictions Rely Service. Once connected, plese enter or provide the Aetn telephone number you re clling. Si usted necesit sistenci lingüístic, por fvor llme l Servicios l Miembro , y un representnte de Aetn le conectrá con un intérprete. Si usted es sordo o tiene problems de udición, use su TTY y mrcr 711 pr el Servicio de Retrnsmisión de Telecomunicciones (TRS). Un vez conectdo, por fvor entrr o proporcionr el número de teléfono de Aetn que está llmndo. This mteril is for informtion only nd is not n offer or invittion to contrct. Insurnce plns contin exclusions nd limittions. Providers re independent contrctors nd re not gents of Aetn. Provider prticiption my chnge without notice. Aetn does not provide cre or gurntee ccess to helth services. Not ll helth services re covered. See pln documents for complete description of benefits, exclusions, limittions nd conditions of coverge. Pln fetures nd vilbility my vry by loction. Informtion is believed to be ccurte s of the production dte; however, it is subject to chnge. Finncil Snctions Exclusions Cluse If coverge provided by this policy violtes or will violte ny US economic or trde snctions, the coverge is immeditely considered invlid. For exmple, Aetn compnies cnnot mke pyments or reimburse for helth cre or other clims or services if it violtes finncil snction regultion. This includes snctions relted to blocked person or entity, or country under snction by the United Sttes, unless permitted under vlid written Office of Foreign Assets Control (OFAC) license. For more informtion on OFAC, visit Policy forms issued include GR-9N, GR-29N. 05/25/2016 Benefits Summry Pge 5

15 Aetn Voluntry Plns Enrollment/Chnge Request Insurnce plns re underwritten nd dministered by Aetn Life Insurnce Compny (Aetn). Michels Stores, Inc Instructions: Red nd fill out the Enrollment/Chnge Request (ll pges). Mke copy for yourself. Give the originl to your employer. IF YOU ARE NOT CHANGING YOUR EXISTING COVERAGE, YOU DO NOT NEED TO COMPLETE THIS ENROLLMENT/CHANGE REQUEST. INFORMATION ABOUT YOU Complete ll informtion. Print your nme (first, middle initil, lst) Socil Security Number Dte of birth (MM/DD/YYYY) Home ddress Aprtment number City Stte Zip code Home phone Work phone ( ) ( ) ACTION YOU WANT TO TAKE I m not currently enrolled nd I wnt to I m currently enrolled nd I wnt to Emil ddress Sex Mle Femle Check the box next to the ction you wnt to tke. Enroll in the coverge choices selected below. Decline this opportunity to prticipte. Primry lnguge spoken (Idiom principl) Mke chnges to my current coverge choices (dd, increse, drop, decrese) s selected below. All of my other coverge choices will remin the sme s previously elected. (If outside of n open enrollment, see Mking Chnges Outside of n Open Enrollment. ) Updte my personl nd/or my dependent nd/or beneficiry informtion. Drop ll of my current coverge choices. Your pyroll deductions will be tken before txes re tken. (Term Life deduction will be tken fter txes.) YOUR COVERAGE CHOICES Check( ) the box for the level of coverge you wnt. Coverge type Coverge level Weekly Biweekly cost cost Vision, Dentl nd Term Life Insurnce Plese nme your beneficiry. No Vision, Dentl nd Term Life Yourself only... $ $ Yourself plus one... $ $ Yourself nd fmily... $ $ Beneficiry Reltionship: Socil Security Number AFBP LA This Enrollment/Chnge Request is not proof of coverge / MichelsSt DE - 03/25/2016

16 INFORMATION ABOUT YOU Repet your nme nd Socil Security number here. Print your nme (first, middle initil, lst) Socil Security Number INFORMATION ABOUT YOUR DEPENDENTS List the dependents for whom you re dding/chnging/removing coverge. If you hve more dependents, write down their informtion on seprte sheet nd ttch it to this Enrollment/Chnge Request. Add Chnge Print dependent s nme (first, middle initil, lst) Socil Security Number Remove Sex Reltionship Dte of birth Enrolled in: Vision / Dentl / Term Life Mle Femle Address (if different thn yours) City Stte Zip code Dependent ccidentl deth nd/or term life coverge does not pply to Sponsored Dependents. Add Chnge Remove Add Chnge Remove Print dependent s nme (first, middle initil, lst) Socil Security Number Sex Mle Reltionship Dte of birth Enrolled in: Vision / Dentl / Term Life Femle Address (if different thn yours) City Stte Zip code Dependent ccidentl deth nd/or term life coverge does not pply to Sponsored Dependents. Print dependent s nme (first, middle initil, lst) Socil Security Number Sex Mle Reltionship Dte of birth Enrolled in: Vision / Dentl / Term Life Femle Address (if different thn yours) City Stte Zip code Dependent ccidentl deth nd/or term life coverge does not pply to Sponsored Dependents. MAKING CHANGES OUTSIDE OF AN OPEN ENROLLMENT Plese red below to see if you re ble to mke chnges to your coverge. If your deductions re tken before txes re tken out of your py, you cn chnge your coverge during Loss of Other Coverge (LOC): the pln yer only if you hve Qulifying Life Event (QLE). QLEs fll under one of these two Divorce, legl seprtion or deth ctegories: Termintion of employment of dependent Loss of Other Coverge (LOC): If you previously declined helth coverge becuse you or your Reduction of dependent s hours dependents were lredy covered under nother helth pln nd you or your dependents hve lost tht Termintion of your or your dependents COBRA rights other coverge, you my be ble to enroll yourself nd your dependents. If you hd recent LOC, go to Loss of employer s contribution to spouse s or the list on the right nd check the box next to your LOC nd supply the dte of the LOC. domestic prtner's coverge Fmily Sttus Chnge (FSC): Whether you re currently enrolled or previously declined coverge, you Dependent child losing eligibility s dependent my be ble to dd or increse, drop or decrese coverge when you experience certin FSC events. If Other loss of coverge you hd recent FSC, go to the list on the right nd check the box next to your FSC nd supply the dte Fmily Sttus Chnge (FSC): of the FSC. Divorce, legl seprtion or deth Next, complete the rest of this Enrollment/Chnge Request. When finished, mke copy nd submit it to Mrrige your employer with your documenttion ttched. You must submit this Enrollment/Chnge Request, Birth or doption of dependent together with documenttion, to your employer within 31 dys of the LOC/FSC. Other Dte of LOC or FSC (mm/dd/yyyy) YOUR AUTHORIZATION You must sign nd dte this Enrollment/Chnge Request for ll new enrollments or coverge chnges. I represent tht ll informtion supplied in this Enrollment/Chnge Request is true nd complete to the best of my knowledge nd/or belief. I hve red nd gree to the Conditions of Enrollment on the lst pge of this Enrollment/Chnge Request. Your signture Tody s dte (MM/DD/YYYY) AFBP LA This Enrollment/Chnge Request is not proof of coverge / MichelsSt DE - 03/25/2016

17 CONDITIONS OF ENROLLMENT Applicnt cknowledgments nd greements On behlf of myself nd the dependents listed on this Enrollment/Chnge Request, I gree to or with the following: 1. I cknowledge tht by enrolling in n Aetn pln coverge is underwritten nd dministered by Aetn Life Insurnce Compny (Aetn) 151 Frmington Avenue, Hrtford, CT I uthorize deductions from my ernings for ny contributions required for coverge nd I gree to mke ny necessry pyments s required for coverge. 3. For life coverge: I understnd tht the effective dte of insurnce for myself or for ny of my dependents, if pplicble, is subject to my being ctively t work on tht dte nd tht the effective dte of insurnce for ny of my dependents is lso subject to the dependent helth condition requirements of the benefit pln. I understnd tht, in the event I fil to sign this form within 30 dys of the effective dte of eligibility or tht for ny reson Aetn does not receive notice of the Enrollment/Chnge Request within resonble time following the dte I ws eligible to enroll or chnge my coverge, my nd my dependents' eligibility, if pplicble, my be ffected. Further, I understnd tht ny insurnce subject to evidence of good helth or medicl informtion will not become effective until Aetn gives its written consent. 4. I understnd nd gree tht this Enrollment/Chnge Request my be trnsmitted to Aetn or its gent by my employer or its gent. I uthorize ny physicin, other helthcre professionl, hospitl or ny other helthcre orgniztion ("Providers") to give Aetn or its gent informtion concerning the medicl history, services or tretment provided to nyone listed on this Enrollment/Chnge Request, including those involving mentl helth, substnce buse nd HIV/AIDS. I further uthorize Aetn to use such informtion nd to disclose such informtion to ffilites, providers, pyors, other insurers, third prty dministrtors, vendors, consultnts nd governmentl uthorities with jurisdiction when necessry for my cre or tretment, pyment for services, the opertion of my helth pln, or to conduct relted ctivities. I hve discussed the terms of this uthoriztion with my spouse nd competent dult dependents nd I hve obtined their consent to those terms. I understnd tht this uthoriztion is provided under stte lw nd tht it is not n "uthoriztion" within the mening of the federl Helth Insurnce Portbility nd Accountbility Act. This uthoriztion will remin vlid for the term of the coverge nd so long therefter s llowed by lw. I understnd tht I m entitled to receive copy of this uthoriztion upon request nd tht photocopy is s vlid s the originl. 5. NOTICE: Aetn does not request informtion for genetic testing nd does not subject insureds to genetic testing. 6. The pln documents will determine the rights nd responsibilities of member(s) nd will govern in the event they conflict with ny benefits comprison, summry or other description of the pln. 7. I understnd nd gree tht ll prticipting providers nd vendors re independent contrctors nd re neither gents nor employees of Aetn. Aetn Rx Home Delivery, LLC nd Aetn Specilty Phrmcy, LLC, wholly owned subsidiries of Aetn Inc., re prticipting providers nd independent contrctors of Aetn, nd re neither gents nor employees of Aetn. The vilbility of ny prticulr provider cnnot be gurnteed nd provider network composition is subject to chnge. Notice of the chnge shll be provided in ccordnce with pplicble stte lw. Aetn does not provide helth or dentl cre services nd, therefore, cnnot gurntee ny results or outcome. Some benefits re subject to limittions or mximums. 8. Misrepresenttion: Any person who knowingly presents flse or frudulent clim for pyment of loss or benefit or knowingly presents flse informtion in n ppliction for insurnce is guilty of crime nd my be subject to fines nd confinement in prison. AFBP LA This Enrollment/Chnge Request is not proof of coverge / MichelsSt DE - 03/25/2016