Plant Site Logistics, Inc.

Transcription

1 Plant Site Logistics, Inc. Employee Benefits 6/1/2018 to 5/31/ Fax: Alexander Spring Road Suite 4 Carlisle, PA

2 Plant Site Logistics, Inc. Employee Benefit Overview Open Enrollment The Open Enrollment period is your once a year opportunity to review the various benefits that are offered and to change your benefit selections for the upcoming year. During this annual open enrollment period, you can make changes to your benefit plan without restriction. You may enroll or disenroll from the benefit plan, you may also add or remove eligible dependents from the plan. Changes after open enrollment can only be made if you have a qualified life event (QLE). You must request a special enrollment period within 30 days of a QLE. Examples of a QLE: Marriage or Divorce Birth or adoption of a child Gain or loss of insurance Death of a spouse or dependent Please Note: You are unable to enroll in your employer s insurance plan until the New Hire Waiting Period has been met. Please find below new employee benefit information. Benefit grids outlining the coverages are attached. Medical Effective 6/1/2018 5/31/2019 Group # Option One Highmark PPO $500 Plan (Copy of Benefit Grid is Attached) o $500/$1,000 deductible (ind./family), 80% is covered after deductible o Office Visit copay $20 o Specialist Visit copay $40 o Emergency Room copay $250, waived if admitted o Urgent Care copay $60 o Hospitalization, 80% after deductible RX (Copy of Benefit Grid is Attached) o Retail Prescription copays up to 34 day supply $5 Generic $35 Formulary brand $75 Non-Formulary brand o Mail Order Prescription copays up to 90 day supply $10 Generic $70 Formulary brand $150 Non-Formulary brand

3 Plant Site Logistics, Inc. Employee Benefit Overview Option Two Highmark HSA $1500 Plan (Copy of Benefit Grid is Attached) o $1,500/$3,000 deductible (ind./family), 100% covered after deductible o Office Visit copay $20 after deductible o Specialist Visit copay $40 after deductible o Emergency Room copay $250 after deductible, waived if admitted o Urgent Care copay $60 after deductible o Hospitalization, 100% after deductible RX - integrated with medical deductible (Copy of Benefit Grid is Attached) o Retail Prescription copays up to 34 day supply $5 Generic, after deductible $35 Formulary brand, after deductible $75 Non-Formulary brand, after deductible o Mail Order Prescription copays up to 90 day supply $10 Generic, after deductible $70 Formulary brand, after deductible $150 Non-Formulary brand, after deductible Carrier Access o - for 24 hour access to: Deductible balances Provider Directory View claims and authorizations View prescription history View and print forms, i.e. prescription mail order, etc. o Customer Service Department Toll Free , Monday through Friday, 8 am to 6 pm EST

4 Plant Site Logistics, Inc. Employee Benefit Overview Dental Effective 6/1/2018 5/31/2019 Group # United Concordia Advantage Plus (Copy of Benefit Grid is Attached) o Class I Services covered at 100% o Class II Services covered at 100%, o Class III Services Not covered o Orthodontics Not covered o Deductible (Ind/Family) - $0 o Calendar Year Maximum - $1,000 per member Carrier Access o - for 24 hour access to: Provider Directory Review of coverage ID Cards Claim History and Explanation of Benefits Online Payments o Customer Service Department Toll Free for additional information. Vision VOLUNTARY- Effective 6/1/2018 5/31/2019 Group # NVA Voluntary - Option 4 (Copy of Benefit Grid is Attached) o Single/Employee only rate is $6.42 per month o Employee/Child, Employee/Children, Employee/Spouse, and Family rate is $16.06 per month o Eye examination every 12 months, 100% after $10 copay o Frames every 12 months, up to $130, see grid for details o Eyeglass Lenses every 12 months, 100% after $20 copay o Contact Lenses every 12 months, 100%, up to $130 retail, see grid for details Carrier Access o Log on to: or contact National Vision Administration Member Services Department at for additional information.

5 Plant Site Logistics, Inc. Employee Benefit Overview Life & Disability Insurance - Effective 10/1/17-9/30/19 Group # UNUM Life/AD&D (Copy of Benefit Highlight is Attached) o Provided to all full-time employees working 40 hours or more, dependents are not covered o Life Insurance benefit of 1.5 times basic annual earnings up to a maximum of $75,000 o Accidental Death & Dismemberment benefit is equal to the amount of Life Insurance in effect at the time of loss o Benefits will reduce to 65% of original amount at age 65 and to 50% of original amount at age 70 o Benefits terminate at retirement UNUM Long Term Disability o 60% of monthly salary up to a maximum monthly benefit of $7,000 o Benefits begin after a 90-day absence due to accident or illness UNUM OPTIONAL Life / AD&D o Employee Benefit Amounts starting at $10,000 Maximum benefit is the lesser of $500,000 or 5 times annual salary Benefits will reduce to 65% of original amount at age 65 and to 50% of original amount at age 70 o Spouse Benefit amounts starting at $10,000 Maximum benefit is the lesser of $500,000 or 100% of employee insured amount Benefits will reduce to 65% of original amount at age 65 and to 50% of original amount at age 70 o Child Benefit amounts up to $10,000 in increments of $1,000 Carrier Access o for 24-hour access to additional information o Customer Service Department o Toll Free: :00 a.m. - 8:00 p.m. ET, Monday Friday

6 Plant Site Logistics, Inc. Employee Benefit Overview VSP This is a vision discount program provided by Plant Site Logistics at no cost to you! See your Benefits Administrator to enroll in this program. Information necessary to use this discount is attached. Your employer, Plant Site Logistics, understands your needs and concerns regarding your benefits. If you should have any questions regarding this Employee Benefit Overview, please see your Benefits Administrator. Thank you!

7 Plant Site Logistics - PPO 500 Plan On the chart below, you'll see what your plan pays for specific services. You may be responsible for a facility fee, clinic charge or similar fee or charge (in addition to any professional fees) if your office visit or service is provided at a location that qualifies as a hospital department or a satellite building of a hospital. Benefit In Network Out of Network General Provisions Benefit Period(1) Contract Year Deductible (per benefit period) Individual Family $500 $1,000 $1,000 $2,000 Plan Pays payment based on the plan allowance 80% after deductible 60% after deductible Out-of-Pocket Limit ( Once met, plan pays 100% coinsurance for the rest of the benefit period) Individual $500 $1,000 Total Maximum Out-of-Pocket (Includes deductible, coinsurance, copays, prescription drug cost sharing and other qualified medical expenses, Network only) (2) Once met, the plan pays 100% of covered services for the rest of the benefit period. Individual Family $6,600 $13,200 not applicable not applicable Office/Clinic/Urgent Care Visits (one copay/provider/date of service) Retail Clinic Visits & Virtual Visits 100% after $20 copay 60% after deductible Primary Care Provider Office Visits & Virtual Visits 100% after $20 copay 60% after deductible Specialist Office Visits & Virtual Visits 100% after $40 copay 60% after deductible Virtual Visit Originating Site Fee 80% after deductible 60% after deductible Urgent Care Center Visits 100% after $60 copay 60% after deductible Telemedicine Services (3) 100% after $20 copay not covered Preventive Care (4) Routine Adult Physical Exams 100% (deductible does not apply) 60% after deductible Adult Immunizations 100% (deductible does not apply) 60% after deductible Colorectal Cancer Screening 100% (deductible does not apply) 60% after deductible Routine Gynecological Exams, including a Pap Test 100% (deductible does not apply) 60% (deductible does not apply) Mammograms, Annual Routine 100% (deductible does not apply) 60% after deductible Mammograms, Medically Necessary 100% (deductible does not apply) 60% after deductible Diagnostic Services and Procedures 100% (deductible does not apply) 60% after deductible Routine Pediatric Physical Exams 100% (deductible does not apply) 60% after deductible Pediatric Immunizations 100% (deductible does not apply) 60% (deductible does not apply) Diagnostic Services and Procedures 100% (deductible does not apply) 60% after deductible Emergency Services Emergency Room Services 100% after $250 copay (waived if admitted) Ambulance Emergency 80% after deductible 60% after deductible Ambulance - Non-Emergency 80% after deductible 60% after deductible Hospital and Medical / Surgical Expenses (including maternity) Hospital Inpatient 80% after deductible 60% after deductible Hospital Outpatient 80% after deductible 60% after deductible Maternity (non-preventive facility & professional services) including dependent daughter 80% after deductible 60% after deductible Medical Care (including inpatient visits and consultations)/surgical Expenses Excludes Neonatal Circumcision and Reversal Procedures 80% after deductible 60% after deductible Therapy and Rehabilitation Services (one copay/provider/date of service) Physical Medicine 100% after $40 copay 60% after deductible limit: 20 visits/benefit period Respiratory Therapy 80% after deductible 60% after deductible Speech Therapy 100% after $40 copay 60% after deductible limit: 12 visits/benefit period Occupational Therapy 100% after $40 copay 60% after deductible limit: 12 visits/benefit period Spinal Manipulations 100% after $40 copay 60% after deductible limit: 10 visits/benefit period

8 Benefit In Network Out of Network Other Therapy Services (Cardiac Rehab, Infusion Therapy, Chemotherapy, Radiation Therapy and Dialysis) 80% after deductible 60% after deductible Mental Health / Substance Abuse Inpatient Mental Health Services 80% after deductible 60% after deductible Inpatient Detoxification / Rehabilitation 80% after deductible 60% after deductible Outpatient Mental Health Services (includes virtual behavioral health visits) Hypnotherapy Not Covered 80% after deductible 60% after deductible Outpatient Substance Abuse Services Hypnotherapy Not Covered 80% after deductible 60% after deductible Other Services Allergy Extracts and Injections 80% after deductible 60% after deductible Autism Spectrum Disorder Including Applied Behavior Analysis (5) 80% after deductible 60% after deductible Assisted Fertilization Procedures not covered not covered Dental Services Related to Accidental Injury 80% after deductible 60% after deductible Diagnostic Services Advanced Imaging (MRI, CAT, PET scan, etc.) 80% after deductible 60% after deductible Basic Diagnostic Services (standard imaging, diagnostic medical, lab/pathology, allergy testing) 80% after deductible 60% after deductible Durable Medical Equipment, Orthotics and Prosthetics 80% after deductible 60% after deductible Home Health Care 80% after deductible 60% after deductible limit: 90 visits/benefit period Hospice 80% after deductible 60% after deductible Infertility Counseling, Testing and Treatment (6) not covered not covered Private Duty Nursing 80% after deductible 60% after deductible limit: 240 hours/benefit period Skilled Nursing Facility Care 80% after deductible 60% after deductible limit: 100 days/benefit period Transplant Services 80% after deductible 60% after deductible Precertification Requirements (7) Yes Yes Prescription Drugs Prescription Drug Deductible Individual Family Prescription Drug Program (8) Soft Mandatory Generic Defined by the National Plus Pharmacy Network - Not Physician Network. Prescriptions filled at a non-network pharmacy are not covered. Your plan uses the Comprehensive Formulary with an Incentive Benefit Design none none Retail Drugs (34-day Supply) $5 generic copay $35 formulary brand copay $75 non-formulary brand copay Maintenance Drugs through Mail Order (90-day Supply) $10 generic copay $70 formulary brand copay $150 non-formulary brand copay This is not a contract. This benefits summary presents plan highlights only. Please refer to the policy/ plan documents, as limitations and exclusions apply. The policy/ plan documents control in the event of a conflict with this benefits summary. (1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's effective date. Contact your employer to determine the effective date applicable to your program. (2) The Network Total Maximum Out-of-Pocket (TMOOP) is mandated by the federal government. TMOOP must include deductible, coinsurance, copays, prescription drug cost share and any qualified medical expense. (3) Services are provided for acute care for minor illnesses. Services must be performed by a Highmark approved telemedicine provider. Virtual Behavioral Health visits provided by a Highmark approved telemedicine provider are eligible under the Outpatient Mental Health benefit. (4) Services are limited to those listed on the Highmark Preventive Schedule (Women's Health Preventive Schedule may apply). (5) Coverage for eligible members to age 21. Services will be paid according to the benefit category (e.g. speech therapy). Treatment for autism spectrum disorders does not reduce visit/day limits. (6) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered depending on your group's prescription drug program. (7) Highmark Medical Management & Policy (MM&P) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related inpatient admission. Be sure to verify that your provider is contacting MM&P for precertification. If this does not occur and it is later determined that all or part of the inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered. (8) The Highmark formulary is an extensive list of Food and Drug Administration (FDA) approved prescription drugs selected for their quality, safety and effectiveness. The formulary was developed by Highmark Pharmacy Services and approved by the Highmark Pharmacy and Therapeutics Committee made up of clinical pharmacists and physicians. All plan formularies include products in every major therapeutic category. Plan formularies vary by the number of different drugs they cover and in the cost-sharing requirements. Your program includes coverage for both formulary and non-formulary drugs at the copayment or coinsurance amounts listed above. Under the soft mandatory generic provision, when you purchase a brand drug that has a generic equivalent, you will be responsible for the brand-drug copayment plus the difference in cost between the brand and generic drugs, unless your doctor requests that the brand drug be dispensed.

9 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 06/01/ /31/2019 Plant Site Logistics: PPO Blue 500 Coverage for: Individual/Family Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, please visit or call For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at or call to request a copy. Important Questions Answers Why this Matters: What is the overall deductible? Are there services covered before you meet your deductible? $500 individual/$1,000 family network. $1,000 individual/$2,000 family out-ofnetwork. Network deductible does not apply to office visits, preventive care services, emergency room care, urgent care, rehabilitation services, and prescription drug benefits. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at Are there other deductibles for specific services? What is the out-of-pocket limit for this plan? Copayments and coinsurance amounts don't count toward the network deductible. No. $500 individual/$0 family network out-ofpocket limit, up to a total maximum outof-pocket of $6,600 individual/$13,200 family. $1,000 individual/$0 family out-ofnetwork. You don t have to meet deductibles for specific services. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. An example of a benefit book can be found at 1 of , 75, 76 GE_ _ _SBC

10 What is not included in the out of pocket limit? Will you pay less if you use a network provider? Do I need a referral to see a specialist? Network: Premiums, balance-billed charges, and health care this plan doesn't cover do not apply to your total maximum out-of-pocket. Out-of-network: Copayments, deductibles, premiums, balance-billed charges, prescription drug expenses, and health care this plan doesn't cover. Yes. For a list of network providers, see or call. No. Even though you pay these expenses, they don't count toward the out-of-pocket limit. This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your overall deductible has been met, if a deductible applies. Common Medical Event If you visit a health care provider s office or clinic Services You May Need Network Provider (You will pay the least) What You Will Pay Out-of-Network Provider (You will pay the most) Limitations, Exceptions, and Other Important Information Primary care visit to treat an injury or illness Specialist visit Preventive care/screening/immunization $20 copay/visit $40 copay/visit 40% coinsurance 40% coinsurance You may have to pay for services that aren t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. No charge for preventive care services 40% coinsurance for preventive care services Please refer to your preventive schedule for additional information. If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance Precertification may be required. Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance Precertification may be required. 2 of 10

11 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at. If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Generic drugs Formulary Brand drugs Services You May Need Non-Formulary Brand drugs Network Provider (You will pay the least) $5 copay (retail) $10 copay (mail order) $35 copay (retail) $70 copay (mail order) $75 copay (retail) $150 copay (mail order) What You Will Pay Out-of-Network Provider (You will pay the most) Not covered Not covered Not covered Limitations, Exceptions, and Other Important Information Up to 34-day supply retail pharmacy. Up to 90-day supply maintenance prescription drugs through mail order. Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance Precertification may be required. Physician/surgeon fees 20% coinsurance 40% coinsurance Precertification may be required. Emergency room care $250 copay/visit $250 copay/visit Out-of-network: Not subject to deductible. Copay waived if admitted as an inpatient. Emergency medical transportation 20% coinsurance 40% coinsurance none Urgent care $60 copay/visit 40% coinsurance none Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance Precertification may be required. Physician/surgeon fee 20% coinsurance 40% coinsurance Precertification may be required. 3 of 10

12 Common Medical Event If you have mental health, behavioral health, or substance abuse needs Services You May Need Network Provider (You will pay the least) What You Will Pay Out-of-Network Provider (You will pay the most) Limitations, Exceptions, and Other Important Information Outpatient services 20% coinsurance 40% coinsurance Precertification may be required. Inpatient services 20% coinsurance 40% coinsurance Precertification may be required. If you are pregnant Office visits 20% coinsurance 40% coinsurance Cost sharing does not apply for Childbirth/delivery professional services 20% coinsurance 40% coinsurance preventive services. Childbirth/delivery facility services 20% coinsurance 40% coinsurance Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.) Network: The first visit to determine pregnancy is covered at no charge. Please refer to the Women s Health Preventive Schedule for additional information. Precertification may be required. 4 of 10

13 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Network Provider (You will pay the least) What You Will Pay Out-of-Network Provider (You will pay the most) Limitations, Exceptions, and Other Important Information Home health care 20% coinsurance 40% coinsurance Combined network and out-of-network: 90 visits per benefit period. Precertification may be required. Rehabilitation services $40 copay/visit 40% coinsurance Combined network and out-of-network: 20 physical medicine visits, 12 speech therapy visits, and 12 occupational therapy visits per benefit period. Precertification may be required. Habilitation services Not covered Not covered none Skilled nursing care 20% coinsurance 40% coinsurance Combined network and out-of-network: 100 days per benefit period. Precertification may be required. Durable medical equipment 20% coinsurance 40% coinsurance Precertification may be required. Hospice service 20% coinsurance 40% coinsurance Precertification may be required. Children s Eye exam Not covered Not covered none Children s Glasses Not covered Not covered none Children s Dental check-up Not covered Not covered none 5 of 10

14 Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Hearing aids Routine eye care (Adult) Cosmetic surgery Infertility treatment Routine foot care Dental care (Adult) Long-term care Weight loss programs Habilitation services Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Bariatric surgery Coverage provided outside the United States. See Chiropractic care Non-emergency care when traveling outside the U.S. Private-duty nursing Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor s Employee Benefits Security Administration at EBSA (3272) or or the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at x61565 or The Pennsylvania Department of Consumer Services at Other options to continue coverage are available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim appeal or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Your plan administrator/employer. The Department of Labor s Employee Benefits Security Administration at EBSA (3272) or Does this plan provide Minimum Essential Coverage? Yes If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? Yes If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 10

15 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition) Mia s Simple Fracture (in-network emergency room visit and follow up care) The plan s overall deductible Specialist copayment Hospital (facility) coinsurance Other coinsurance $500 $40 20% 20% The plan s overall deductible Specialist copayment Hospital (facility) coinsurance Other coinsurance $500 $40 20% 20% The plan s overall deductible Specialist copayment Hospital (facility) coinsurance Other coinsurance $500 $40 20% 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $500 Deductibles $500 Deductibles $500 Copayments $30 Copayments $800 Copayments $400 Coinsurance $500 Coinsurance $400 Coinsurance $80 What isn t covered What isn t covered What isn t covered Limits or exclusions $0 Limits or exclusions $0 Limits or exclusions $0 The total Peg would pay is $1,030 The total Joe would pay is $1,700 The total Mia would pay is $980 Note: These numbers assume the patient does not participate in the plan s wellness program. If you participate in the plan s wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact:. The plan would be responsible for the other costs of these EXAMPLE covered services. 7 of 10

16 Insurance or benefit administration may be provided by Highmark Blue Shield which is an independent licensee of the Blue Cross and Blue Shield Association. Health care plans are subject to terms of the benefit agreement. To find more information about Highmark s benefits and operating procedures, such as accessing the drug formulary or using network providers, please go to DiscoverHighmark.com/QualityAssurance; or for a paper copy, call

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19 Plant Site Logistics - QHDHP 1,500 Plan This program is a qualified high deductible plan as defined by the Internal Revenue Service. It is designed for use with a Health Savings Account (HSA). On the chart below, you'll see what your plan pays for specific services. You may be responsible for a facility fee, clinic charge or similar fee or charge (in addition to any professional fees) if your office visit or service is provided at a location that qualifies as a hospital department or a satellite building of a hospital. Benefit In Network Out of Network General Provisions Benefit Period(1) Contract Year Deductible (per benefit period) Individual Family $1,500 $3,000 $3,000 $6,000 Plan Pays payment based on the plan allowance 100% after deductible 80% after deductible Out-of-Pocket Limit (Includes prescription drug expenses, coinsurance and copays. Once met, plan pays 100% coinsurance for the rest of the benefit period) Individual Family $4,950 $9,900 $5,000 $10,000 Total Maximum Out-of-Pocket (Includes deductible, coinsurance, copays, prescription drug cost sharing and other qualified medical expenses, Network only) (2) Once met, the plan pays 100% of covered services for the rest of the benefit period. Individual Family $6,450 $12,900 not applicable not applicable Office/Clinic/Urgent Care Visits (one copay/provider/date of service) Retail Clinic Visits & Virtual Visits $20 copay after deductible 80% after deductible Primary Care Provider Office Visits & Virtual Visits $20 copay after deductible 80% after deductible Specialist Office Visits & Virtual Visits $40 copay after deductible 80% after deductible Virtual Visit Originating Site Fee 100% after deductible 80% after deductible Urgent Care Center Visits $60 copay after deductible 80% after deductible Telemedicine Services (3) 100% after deductible not covered Preventive Care (4) Routine Adult Physical Exams 100% (deductible does not apply) 80% (deductible does not apply) Adult Immunizations 100% (deductible does not apply) 80% (deductible does not apply) Colorectal Cancer Screening 100% (deductible does not apply) 80% (deductible does not apply) Routine Gynecological Exams, including a Pap Test 100% (deductible does not apply) 80% (deductible does not apply) Mammograms, Annual Routine 100% (deductible does not apply) 80% (deductible does not apply) Mammograms, Medically Necessary 100% after deductible 80% after deductible Diagnostic Services and Procedures 100% (deductible does not apply) 80% (deductible does not apply) Routine Pediatric Physical Exams 100% (deductible does not apply) 80% (deductible does not apply) Pediatric Immunizations 100% (deductible does not apply) 80% (deductible does not apply) Diagnostic Services and Procedures 100% (deductible does not apply) 80% (deductible does not apply) Emergency Services Emergency Room Services $250 copay after network deductible (copay waived if admitted) Ambulance Emergency 100% after network deductible Ambulance - Emergency and Non-Emergency 100% after deductible 80% after deductible Hospital and Medical / Surgical Expenses (including maternity) Hospital Inpatient 100% after deductible 80% after deductible Hospital Outpatient 100% after deductible 80% after deductible Maternity (non-preventive facility & professional services) including dependent daughter 100% after deductible 80% after deductible Medical Care (including inpatient visits and consultations)/surgical Expenses Excludes Neonatal Circumcision, Sterilization Reversal Procedures 100% after deductible 80% after deductible Therapy and Rehabilitation Services (one copay/provider/date of service) Physical Medicine $40 copay after deductible 80% after deductible limit: 20 visits/benefit period Respiratory Therapy 100% after deductible 80% after deductible Speech Therapy $40 copay after deductible 80% after deductible limit: 12 visits/benefit period Occupational Therapy $40 copay after deductible 80% after deductible limit: 12 visits/benefit period

20 Benefit In Network Out of Network Spinal Manipulations $40 copay after deductible 80% after deductible limit: 10 visits/benefit period Other Therapy Services (Cardiac Rehab, Infusion Therapy, Chemotherapy, Radiation Therapy and Dialysis) 100% after deductible 80% after deductible Mental Health / Substance Abuse Inpatient Mental Health Services 100% after deductible 80% after deductible Inpatient Detoxification / Rehabilitation 100% after deductible 80% after deductible Outpatient Mental Health Services (includes virtual behavioral health visits) Hypnotherapy Not Covered 100% after deductible 80% after deductible Outpatient Substance Abuse Services - Hypnotherapy Not Covered 100% after deductible 80% after deductible Other Services Allergy Extracts and Injections 100% after deductible 80% after deductible Autism Spectrum Disorder Including Applied Behavior Analysis (5) 100% after deductible 80% after deductible Assisted Fertilization Procedures not covered not covered Dental Services Related to Accidental Injury 100% after deductible 80% after deductible Diagnostic Services Advanced Imaging (MRI, CAT, PET scan, etc.) 100% after deductible 80% after deductible Basic Diagnostic Services (standard imaging, diagnostic medical, lab/pathology, allergy testing) 100% after deductible 80% after deductible Durable Medical Equipment, Orthotics and Prosthetics 100% after deductible 80% after deductible Home Health Care 100% after deductible 80% after deductible limit: 90 visits/benefit period Hospice 100% after deductible 80% after deductible Infertility Counseling, Testing and Treatment (6) not covered not covered Private Duty Nursing 100% after deductible 80% after deductible limit: 240 hours/benefit period Skilled Nursing Facility Care 100% after deductible 80% after deductible limit: 100 days/benefit period Transplant Services 100% after deductible 80% after deductible Precertification Requirements (7) Yes Yes Prescription Drugs Prescription Drug Deductible Individual Family Prescription Drug Program (8) Soft Mandatory Generic Defined by the National Plus Pharmacy Network - Not Physician Network. Prescriptions filled at a non-network pharmacy are not covered. Your plan uses the Comprehensive Formulary with an Incentive Benefit Design Integrated with medical deductible Integrated with medical deductible Retail Drugs (34-day Supply) $5 generic copayment after deductible $35 formulary brand copayment after deductible $75 non-formulary brand copayment after deductible Maintenance Drugs through Mail Order (90-day Supply) $10 generic copayment after deductible $70 formulary brand copayment after deductible $150 non-formulary brand copayment after deductible This is not a contract. This benefits summary presents plan highlights only. Please refer to the policy/ plan documents, as limitations and exclusions apply. The policy/ plan documents control in the event of a conflict with this benefits summary. (1) Your group's benefit period is based on a Contract Year. The Contract Year is a consecutive 12-month period beginning on your employer's effective date. Contact your employer to determine the effective date applicable to your program. (2) The Network Total Maximum Out-of-Pocket (TMOOP) is mandated by the federal government. TMOOP must include deductible, coinsurance, copays, prescription drug cost share and any qualified medical expense. If you are enrolled in a "Family" plan, with your non-embedded deductible, the entire family deductible must be satisfied before claims reimbursement begins. In addition, with your embedded out-of-pocket limit, once an individual family member s out-of-pocket limit is satisfied, additional claims reimbursement begins for that person. Finally, with your embedded TMOOP, once any eligible family member satisfies his/her individual TMOOP, claims will pay at 100% of the plan allowance for covered expenses for the family, for the rest of the plan year. (3) Services are provided for acute care for minor illnesses. Services must be performed by a Highmark approved telemedicine provider. Virtual Behavioral Health visits provided by a Highmark approved telemedicine provider are eligible under the Outpatient Mental Health. (4) Services are limited to those listed on the Highmark Preventive Schedule (Women's Health Preventive Schedule may apply). (5) Coverage for eligible members to age 21. Services will be paid according to the benefit category (e.g. speech therapy). Treatment for autism spectrum disorders does not reduce visit/day limits. (6) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be covered depending on your group's prescription drug program. (7) Highmark Medical Management & Policy (MM&P) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or maternity-related inpatient admission. Be sure to verify that your provider is contacting MM&P for precertification. If this does not occur and it is later determined that all or part of the inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered. (8) At a retail or mail-order pharmacy, if your deductible has not been met, you pay the entire cost for your prescription drug at the discounted rate Highmark has negotiated. The amount you paid for your prescription will be applied to your deductible. If your deductible has been met, you will only pay any member responsibility based on the benefit level indicated above. You will pay this amount at the pharmacy when you have your prescription filled. The Highmark formulary is an extensive list of Food and Drug Administration (FDA) approved prescription drugs selected for their quality, safety and effectiveness. The formulary was developed by Highmark Pharmacy Services and approved by the Highmark Pharmacy and Therapeutics Committee made up of clinical pharmacists and physicians. All plan formularies include products in every major therapeutic category. Plan formularies vary by the number of different drugs they cover and in the cost-sharing requirements. Your program includes coverage for both formulary and non-formulary drugs at the copayment or coinsurance amounts listed above. Under the soft mandatory generic provision, when you purchase a brand drug that has a generic equivalent, you will be responsible for the brand-drug copayment plus the difference in cost between the brand and generic drugs, unless your doctor requests that the brand drug be dispensed.

21 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 06/01/ /31/2019 Plant Site Logistics: PPO Blue QHDHP Coverage for: Individual/Family Plan Type: HDHP The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, please visit or call For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at or call to request a copy. Important Questions Answers Why this Matters: What is the overall deductible? Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this plan? What is not included in the out of pocket limit? $1,500 individual/$3,000 family network. $3,000 individual/$6,000 family out-ofnetwork. Network deductible does not apply to preventive care services. Copayments and coinsurance amounts don't count toward the network deductible. No. $4,950 individual/$9,900 family network out-of-pocket limit, up to a total maximum out-of-pocket of $6,450 individual/$12,900 family. $5,000 individual/$10,000 family out-ofnetwork. Network: Premiums, balance-billed charges, and health care this plan doesn't cover do not apply to your total maximum out-of-pocket. Out-of-network: Deductibles, premiums, balance-billed charges, and health care this plan doesn't cover. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the policy, the overall family deductible must be met before the plan begins to pay. This plan covers some items and services even if you haven t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at You don t have to meet deductibles for specific services. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Even though you pay these expenses, they don't count toward the out-of-pocket limit. An example of a benefit book can be found at 1 of , 05, 06 GE_ _ _SBC

22 Will you pay less if you use a network provider? Do I need a referral to see a specialist? Yes. For a list of network providers, see or call. No. This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your overall deductible has been met, if a deductible applies. Common Medical Event If you visit a health care provider s office or clinic Services You May Need Network Provider (You will pay the least) What You Will Pay Out-of-Network Provider (You will pay the most) Limitations, Exceptions, and Other Important Information Primary care visit to treat an injury or illness Specialist visit Preventive care/screening/immunization $20 copay/visit $40 copay/visit 20% coinsurance 20% coinsurance You may have to pay for services that aren t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. No charge for preventive care services 20% coinsurance for preventive care services Out-of-network: Screenings and immunizations are not subject to the deductible. Please refer to your preventive schedule for additional information. If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Precertification may be required. Imaging (CT/PET scans, MRIs) No charge 20% coinsurance Precertification may be required. 2 of 10

23 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at. If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Generic drugs Formulary Brand drugs Services You May Need Non-Formulary Brand drugs Network Provider (You will pay the least) $5 copay (retail) $10 copay (mail order) $35 copay (retail) $70 copay (mail order) $75 copay (retail) $150 copay (mail order) What You Will Pay Out-of-Network Provider (You will pay the most) Not covered Not covered Not covered Limitations, Exceptions, and Other Important Information Up to 34-day supply retail pharmacy. Up to 90-day supply maintenance prescription drugs through mail order. Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Precertification may be required. Physician/surgeon fees No charge 20% coinsurance Precertification may be required. Emergency room care $250 copay/visit $250 copay/visit Out-of-network: Subject to network deductible. Copay waived if admitted as an inpatient. Emergency medical transportation No charge No charge Out-of-network: Subject to network deductible. Urgent care $60 copay/visit 20% coinsurance none Facility fee (e.g., hospital room) No charge 20% coinsurance Precertification may be required. Physician/surgeon fee No charge 20% coinsurance Precertification may be required. 3 of 10

24 Common Medical Event If you have mental health, behavioral health, or substance abuse needs Services You May Need Network Provider (You will pay the least) What You Will Pay Out-of-Network Provider (You will pay the most) Limitations, Exceptions, and Other Important Information Outpatient services No charge 20% coinsurance Precertification may be required. Inpatient services No charge 20% coinsurance Precertification may be required. If you are pregnant Office visits No charge 20% coinsurance Cost sharing does not apply for Childbirth/delivery professional services No charge 20% coinsurance preventive services. Childbirth/delivery facility services No charge 20% coinsurance Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.) Network: The first visit to determine pregnancy is covered at no charge. Please refer to the Women s Health Preventive Schedule for additional information. Precertification may be required. 4 of 10

25 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Network Provider (You will pay the least) What You Will Pay Out-of-Network Provider (You will pay the most) Limitations, Exceptions, and Other Important Information Home health care No charge 20% coinsurance Combined network and out-of-network: 90 visits per benefit period. Precertification may be required. Rehabilitation services $40 copay/visit 20% coinsurance Combined network and out-of-network: 20 physical medicine visits, 12 speech therapy visits, and 12 occupational therapy visits per benefit period. Precertification may be required. Habilitation services Not covered Not covered none Skilled nursing care No charge 20% coinsurance Combined network and out-of-network: 100 days per benefit period. Precertification may be required. Durable medical equipment No charge 20% coinsurance Precertification may be required. Hospice service No charge 20% coinsurance Precertification may be required. Children s Eye exam Not covered Not covered none Children s Glasses Not covered Not covered none Children s Dental check-up Not covered Not covered none 5 of 10

26 Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Hearing aids Routine eye care (Adult) Cosmetic surgery Infertility treatment Routine foot care Dental care (Adult) Long-term care Weight loss programs Habilitation services Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Bariatric surgery Coverage provided outside the United States. See Chiropractic care Non-emergency care when traveling outside the U.S. Private-duty nursing Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor s Employee Benefits Security Administration at EBSA (3272) or or the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at x61565 or The Pennsylvania Department of Consumer Services at Other options to continue coverage are available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim appeal or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Your plan administrator/employer. The Department of Labor s Employee Benefits Security Administration at EBSA (3272) or Does this plan provide Minimum Essential Coverage? Yes If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? Yes If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 10

27 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition) Mia s Simple Fracture (in-network emergency room visit and follow up care) The plan s overall deductible Specialist copayment Hospital (facility) coinsurance Other coinsurance $1,500 $40 0% 0% The plan s overall deductible Specialist copayment Hospital (facility) coinsurance Other coinsurance $1,500 $40 0% 0% The plan s overall deductible Specialist copayment Hospital (facility) coinsurance Other coinsurance $1,500 $40 0% 0% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $1,500 Deductibles $1,500 Deductibles $900 Copayments $30 Copayments $200 Copayments $400 Coinsurance $0 Coinsurance $0 Coinsurance $0 What isn t covered What isn t covered What isn t covered Limits or exclusions $0 Limits or exclusions $0 Limits or exclusions $0 The total Peg would pay is $1,530 The total Joe would pay is $1,700 The total Mia would pay is $1,300 Note: These numbers assume the patient does not participate in the plan s wellness program. If you participate in the plan s wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact:. The plan would be responsible for the other costs of these EXAMPLE covered services. 7 of 10

28 Insurance or benefit administration may be provided by Highmark Blue Shield which is an independent licensee of the Blue Cross and Blue Shield Association. Health care plans are subject to terms of the benefit agreement. To find more information about Highmark s benefits and operating procedures, such as accessing the drug formulary or using network providers, please go to DiscoverHighmark.com/QualityAssurance; or for a paper copy, call

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31 Health Savings Accounts Frequently Asked Questions What is a Health Savings Account ("HSA")? An HSA is a tax-favored medical savings account designed to pay for current and future medical, dental, vision and preventative expenses with tax-free money. See reverse side for list of eligible expenses. HSAs are owned by the individual and the funds roll over and accumulate year to year if they are not spent. Who is eligible for an HSA? In order to make deposits into an HSA, you must be covered by a Qualified High Deductible Health Plan (QHDHP). In addition to being covered under an HSA-eligible QHDHP, you must not be covered by any other health insurance that is not an QHDHP. You also cannot be on Medicare, be a dependent on someone else's tax return or have received VA medical benefits at any time over the past three months. How do I make deposits? Deposits to an HSA may be made by the enrollee of an HSA-eligible QHDHP through payroll deductions or by the employer. If these options are not available, contributions may be made on a post-tax basis and then used to decrease gross taxable income on the following year s Form Deposits may only be made for persons covered under an HSA-eligible QHDHP. A catch-up provision also applies for enrollees who are age 55 or over, allowing the IRS limit to be increased. What are the contribution limits? Taxpayers can generally make contributions to their HSA for a given tax year until the deadline for filing the individual s income tax returns for that year, which is typically April 15 th. All contributions to an HSA from both the employer and the employee count toward the annual maximum. ITEM Annual Contribution Limit Individual * $3,400 $3,450 Annual Contribution Limit Family * $6,750 $6,900 Annual Catch-Up Contribution Limit (Age 55 to 65) $1,000 $1,000 How do I make withdrawals? There are several ways that funds can be withdrawn from an HSA. Some accounts include a debit card or checks. Funds can be withdrawn for any reason, but withdrawals that are not documented qualified medical expenses are subject to income taxes plus a 20% penalty. Exceptions: The tax penalty does not apply if the withdrawal is made after you have turned age 65,or have become permanently disabled. HSA account holders are required to retain documentation of their qualified medical expenses. See reverse side for a list of eligible expenses. *Partial year enrollment in an HSA eligible plan may change the allowable annual contribution limits. Please discuss with your tax professional for more information.

32 HSA Eligible Expenses Acupuncture Alcoholism treatment Ambulance services Annual physical examination Artificial limb or prosthesis Birth control pills (by prescription) Chiropractor Childbirth/delivery Convalescent home (for medical treatment only) Crutches Doctor s fees Dental treatments (including x-rays, braces, dentures, fillings, oral surgery) Dermatologist Diagnostic services Disabled dependent care Drug addiction therapy Fertility enhancement (including in-vitro fertilization) Guide dog (or other service animal) Gynecologist Hearing aids and batteries Hospital bills Insurance premiums** Laboratory fees Lactation expenses Lodging (away from home for outpatient care) Pregnancy test kit Obstetrician Osteopath Oxygen Nursing home Nursing services Podiatrist Prescription drugs and medicines (over-thecounter drugs are not IRS-qualified medical expenses unless prescribed by a doctor) Prenatal care & postnatal treatments Psychiatrist Psychologist Smoking cessation programs Special education tutoring Surgery Telephone or TV equipment to assist the hearing or vision impaired Therapy or counseling Medical transportation expenses Transplants Vaccines Vasectomy Vision care (including eyeglasses, contact lenses, lasik surgery) Weight loss programs (for a specific disease diagnosed by a physician such as obesity, hypertension, or heart disease) Wheelchairs X-rays This list is not comprehensive. For more detailed information, please refer to IRS Publication 502 titled, Medical and Dental Expenses. Insurance premiums only qualify as an IRS-qualified medical expense for HSAs under the following circumstances: while continuing coverage under COBRA; for qualified long-term care coverage; coverage while receiving unemployment compensation; for any healthcare coverage for those over age 65 including Medicare (except Medicare supplemental coverage).if tax advice is required, you should seek the services of a professional Fax: Alexander Spring Road Suite 4 Carlisle, PA

33 Glossary of Health Coverage and Medical Terms This glossary has many commonly used terms, but isn t a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs. (See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan document.) Bold blue text indicates a term defined in this Glossary. See page 4 for an example showing how deductibles, co-insurance and out-of-pocket limits work together in a real life situation. Allowed Amount Maximum amount on which payment is based for covered health care services. This may be called eligible expense, payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.) Appeal A request for your health insurer or plan to review a decision or a grievance again. Balance Billing When a provider bills you for the difference between the provider s charge and the allowed amount. For example, if the provider s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services. Co-insurance Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. Jane pays Her plan pays You pay co-insurance 20% 80% plus any deductibles (See page 4 for a detailed example.) you owe. For example, if the health insurance or plan s allowed amount for an office visit is $100 and you ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount. Co-payment A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service. Deductible The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins Jane pays Her plan pays to pay. For example, if 100% 0% your deductible is $1000, your plan won t pay (See page 4 for a detailed example.) anything until you ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services. Durable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics. Emergency Medical Condition An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm. Emergency Medical Transportation Ambulance services for an emergency medical condition. Complications of Pregnancy Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a nonemergency caesarean section aren t complications of pregnancy. Emergency Room Care Emergency services you get in an emergency room. Emergency Services Evaluation of an emergency medical condition and treatment to keep the condition from getting worse. OMB Control Numbers , , and Glossary of Health Coverage and Medical Terms Page 1 of 4

34 Excluded Services Health care services that your health insurance or plan doesn t pay for or cover. Grievance A complaint that you communicate to your health insurer or plan. Habilitation Services Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Health Insurance A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium. Home Health Care Health care services a person receives at home. Hospice Services Services to provide comfort and support for persons in the last stages of a terminal illness and their families. Hospitalization Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care. Hospital Outpatient Care Care in a hospital that usually doesn t require an overnight stay. In-network Co-insurance The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance. In-network Co-payment A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments. Medically Necessary Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine. Network The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services. Non-Preferred Provider A provider who doesn t have a contract with your health insurer or plan to provide services to you. You ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a tiered network and you must pay extra to see some providers. Out-of-network Co-insurance The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Outof-network co-insurance usually costs you more than innetwork co-insurance. Out-of-network Co-payment A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network co-payments. Out-of-Pocket Limit The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, Jane pays Her plan pays 0% 100% balance-billed charges or (See page 4 for a detailed example.) health care your health insurance or plan doesn t cover. Some health insurance or plans don t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit. Physician Services Health care services a licensed medical physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine) provides or coordinates. Glossary of Health Coverage and Medical Terms Page 2 of 4

35 Plan A benefit your employer, union or other group sponsor provides to you to pay for your health care services. Preauthorization A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn t a promise your health insurance or plan will cover the cost. Preferred Provider A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a tiered network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also participating providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more. Premium The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly. Prescription Drug Coverage Health insurance or plan that helps pay for prescription drugs and medications. Prescription Drugs Drugs and medications that by law require a prescription. Primary Care Physician A physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient. Provider A physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law. Reconstructive Surgery Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions. Rehabilitation Services Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings. Skilled Nursing Care Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home. Specialist A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care. UCR (Usual, Customary and Reasonable) The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount. Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. Primary Care Provider A physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services. Glossary of Health Coverage and Medical Terms Page 3 of 4

36 How You and Your Insurer Share Costs - Example Jane s Plan Deductible: $1,500 Co-insurance: 20% Out-of-Pocket Limit: $5,000 January 1 st Beginning of Coverage Period December 31 st End of Coverage Period Jane pays 100% Her plan pays 0% more costs Jane pays 20% Her plan pays 80% more costs Jane pays 0% Her plan pays 100% Jane hasn t reached her $1,500 deductible yet Her plan doesn t pay any of the costs. Office visit costs: $125 Jane pays: $125 Her plan pays: $0 Jane reaches her $1,500 deductible, co-insurance begins Jane has seen a doctor several times and paid $1,500 in total. Her plan pays some of the costs for her next visit. Office visit costs: $75 Jane pays: 20% of $75 = $15 Her plan pays: 80% of $75 = $60 Jane reaches her $5,000 out-of-pocket limit Jane has seen the doctor often and paid $5,000 in total. Her plan pays the full cost of her covered health care services for the rest of the year. Office visit costs: $200 Jane pays: $0 Her plan pays: $200 Glossary of Health Coverage and Medical Terms Page 4 of 4

37 Dental Benefits Summary for Plant Site Logistics, Inc. Network: Advantage Plus Benefit Category 1 CONCORDIA FLEX PLAN In-Network 2 Non-Network 2 Class I Diagnostic/Preventive Services Exams Bitewing X-rays All Other X-rays Cleanings & Fluoride Treatments Space Maintainers Palliative Treatment Class II Basic Services Basic Restorative (Includes Posterior Resin Fillings) 100% 100% Simple Extractions Endodontics Complex Oral Surgery General Anesthesia Class III Major Services Inlays, Onlays, Crowns 100% 100% Repairs of Crowns, Inlays, Onlays, Bridges & Dentures Prosthetics (Bridges, Dentures) Nonsurgical Periodontics Surgical Periodontics Orthodontics Diagnostic, Active, Retention Treatment Not Covered Not Covered Not Covered Not Covered Maximums & Deductibles (applies to the combination of services received from network and non-network dentists) Calendar Year Program Deductible (per person/per family) $0 Calendar Year Program Maximum (per person) $1,000 Reimbursement Advantage Plus 90 th Percentile Representative listing of covered services certificate of coverage provides a detailed description of benefits. 1. Dependent children covered to age Reimbursement is based on our schedule of maximum allowable charges (MACs). Network dentists agree to accept our allowances as payment in full for covered services. Non-network dentists may bill the member for any difference between our allowance and their fee (also known as balance billing). United Concordia Dental s standard exclusions and limitations apply. EEM UnitedConcordia.com

38 Service/Frequency Examination Once Every Plan Year Lenses Once Every Plan Year Single Vision Bifocal Trifocal Lenticular Polycarbonates (under age 19) Frame Once Every Plan Year Contact Lenses Once Every Plan Year Elective Contact Lenses Medically Necessary*** Schedule of Vision Benefits Participating Provider Covered 100% after $10 copay Standard Glass or Plastic Covered 100% after $20 copay Retail Allowance Up to $130 (20% discount off balance)* Up to $130 Retail (15% discount (Conventional) or 10% discount (Disposable) off balance)** Covered 100% *Does not apply to Wal-Mart / Sam s Club locations **Does not apply to Wal-Mart / Sam s Club or Contact Fill locations ***Pre-approval from NVA required Non- Participating Provider Reimbursed Amount Up to $30 Up to $36 Up to $48 Up to $58 Up to $90 N/A Up to $72 Up to $75 Up to $210 Low Vision Aids*** Once Every Two Plan Years Up to $999 N/A Additional professional services related to contact lenses (also known as fitting fees) would be included in the contact lens allowance shown above. Lens options purchased from a participating NVA provider will be provided to the member at the amounts listed in the fixed option pricing list below: $10 Solid Tint $50 Progressive Lenses Standard $12 Fashion / Gradient Tint $65 Transitions Single Vision Standard $10 Standard Scratch-Resistant Coating $70 Transitions Multi-Focal Standard $12 Ultraviolet Coating $25 Polycarbonate (Single Vision)19 & over $40 Standard Anti-Reflective $30 Polycarbonate (Multi-Focal)19 & over $20 Glass Photogrey (Single Vision) $30 Blended Bifocal (Segment) $30 Glass Photogrey (Multi-Focal) $55 High Index $75 Polarized $100 Progressive Lenses Premium Options not listed will be priced by NVA providers at their reasonable & customary retail price less 20%. Wal-Mart / Sam s Club Stores: Due to their everyday low prices Wal-Mart / Sam s Club will not provide the lens options at the fees listed in the fixed option pricing list. Wal-Mart / Sam s Club stores accept NVA for materials. Doctors affiliated with Wal-Mart / Sam s Club are not Wal-Mart / Sam s Club employees; therefore, participation for exams varies. National Vision Administrators, L.L.C. Plant Site Logistics, Inc. Summary of Vision Care Benefits National Vision Administrators, L.L.C. (NVA) has been contracted by your group to offer a comprehensive vision care plan to you and your eligible family members. Founded in January of 1979, NVA manages vision benefit services for approximately seven million lives nationwide. Group effective 06/01/2012. Revised 06/01/2016. How Your Vision Care Program Works For your convenience, at the start of the program, you will receive two identification cards with participating providers in your zip code area listed on the back. When scheduling your appointment, please notify the NVA participating provider of your choice that your vision coverage is administered by NVA. The provider will contact NVA to verify eligibility. At the time of your appointment, simply present your NVA identification card to the provider or indicate clearly that your benefit is administered by NVA. A vision claim form is not required at an NVA participating provider. The provider will inform you of your eligibility status prior to rendering services. Be sure to inform the provider of your medical history and any prescription or over-the-counter medications you may be taking. To verify your benefit eligibility prior to calling or visiting your eye care provider, please visit our website at or contact NVA s Customer Service Department toll-free at Eligibility: Eligible members and dependents are entitled to receive a vision examination and one (1) pair of lenses and a frame and contact lenses once every plan year. Customer Service: To verify eligibility, locate a participating provider and receive answers to all your vision care related inquiries, please call NVA s Customer Service Department toll-free at (TDD: ). NVA s Interactive Voice Response (IVR) system is available twenty-four (24) hours per day, seven (7) days per week. The IVR allows you to locate a participating provider in your area, check eligibility as well as the status of your claim(s). An NVA Customer Service Representative can be contacted twenty-four (24) hours per day, seven (7) days per week. National Vision Administrators, L.L.C. PO Box 2187 Clifton, NJ Web: Toll-Free: NVA is a registered mark of National Vision Administrators, L.L.C This document has been printed on recycled paper. Iwf607

39 Benefits at Participating Providers: Highlights of your vision care benefit: The option of receiving services in- or out-of-network Extensive national provider network Enhanced in-network benefits: 100% covered Vision examination, after copay 100% covered standard spectacle lenses, after copay Frame allowance covers countless fashionable frames in full Allowance towards the cost of contact lenses and fitting fees No claim forms; providers will submit claims directly to NVA. Examinations: The comprehensive exam includes case history, examination for pathology or anomalies, visual acuity (clearness of vision), refraction, tonometry (glaucoma test) and dilation. Comprehensive eye examinations can aid in the early detection of ocular diseases and other serious medical conditions, diabetes and cardiovascular disease for example. Lenses: NVA provides coverage in full for standard glass or plastic eyeglass lenses. Frames: Select any frame from the participating provider s inventory. Any amount in excess of your plan allowance is the member s responsibility. Frame choices vary from office to office. Contact Lenses: The contact lens benefit includes all types of contact lenses such as hard, soft, gas permeable and disposable lenses. Medically necessary contact lenses may be covered with prior authorization when prescribed for: post cataract surgery, correction of extreme visual acuity problems that cannot be corrected to 20/70 with spectacle lenses, Anisometropia or Keratoconus. Discounts: In addition to your funded benefit you are eligible to access the EyeEssential SM Plan discount on additional purchases during the plan period. Non-Participating Providers: You will be responsible for one hundred percent (100%) of the cost at the time of service at a non-participating provider. To obtain direct reimbursement according to your plan design, you can print a claim form from Please complete this form and submit along with an original or copy of the itemized receipt. If you cannot print the claim form you may submit receipts along with a letter containing the member s full name, patient s full name, address, ID# and sponsoring organization to NVA s Clifton, NJ office. Remember, obtaining vision care services from a non-participating provider will result in greater out-ofpocket expense. Exclusions / Limitations: No payment is made for medical or surgical treatments / Rx drugs or OTC medications / non-prescription lenses / two pair of glasses in lieu of bifocals / vision examination or materials required for employment / replacement of lost, stolen, broken or damaged lenses/ contact lenses or frames except at normal intervals when service would otherwise be available / services or materials provided by federal, state, local government or Worker's Compensation / examination, procedures training or materials not listed as a covered service / industrial safety lenses and safety frames with or without side shields / parts or repair of frame / sunglasses. Participating providers are not contractually obligated to offer sale prices in addition to outlined coverage. Regardless of medical or optical necessity, vision benefits are not available more frequently than specified in your policy. Valuable Member Discounts Laser Eye Surgery: NVA has chosen The National LASIK Network to serve their members. This network was developed by LCA Vision in 1999 and is one of the largest panels of LASIK surgeons in the U.S. Members are entitled to significant discounts and a free initial consultation with all innetwork providers. All providers are contracted to extend members discounts on standard prices or promotional prices, ensuring the member will pay less than the public. 15% off standard prices - or - 5% off promotional pricing All-Inclusive Discount All in network providers extend the discount on the entire cost of the procedure, maximizing member savings. Additional Member Value Members are entitled to these additional benefits available exclusively at select providers (over 70 locations nationwide). Special set prices ranging from $695 to $1,895 per eye on select technologies. Free initial consultation and comprehensive LASIK exam Advanced laser technologies including Wavefront and IntraLase (All-Laser LASIK) Attractive financing options available The process is simple: Find a provider (Call or visit Schedule a pre-operative exam to determine if laser vision correction is right for you Schedule a treatment Pay discounted member price directly to the provider Contact Fill: NVA provides you with the convenience and savings of Contact Fill, our mail order contact lens replacement service. You may access Contact Fill s services online at or by calling them toll-free at Contact Fill provides contact lens wearers with significant savings packaged with the convenience of home delivery. Plan discounts applicable at participating retail locations do not apply to purchases made through Contact Fill due to the already low prices. Plan Specific Details Online: The NVA website is easy to use and provides the most up to date information for program participants: Locate a nearby participating provider by name, zip code, or City/State Verify eligibility for you or a dependent View benefit program and specific details Review claims Print ID cards Nominate a non-participating provider to join the NVA network If you are not a registered subscriber, you can still search our providers online by selecting the Find a Provider link on our home page. Enter group number or the group number on the identification card you will be receiving prior to your effective date and enter in your search parameters. It s that easy! Iwf607

40 Plant Site Logistics Summary of Employer-Paid Benefits Policy # Group Term Life/AD&D Group Term Life and Accidental Death and Dismemberment (AD&D) Insurance is an affordable and sensible way to provide your family with the additional financial protection they may need if an untimely death should occur. Benefit Amount: 1.5x annual salary to a maximum benefit of $75,000 for Life and AD&D Accelerated Benefit Amount: 50% to $750,000 Life Benefit Reduction Formula: Life Benefit reduces to 65% of original amount at age 65 and to 50% of the original amount at age 70. Group Life / AD&D Standard Plan Features Include: Portability and Conversion Life Planning Financial and Legal Resources AD&D Education Benefit (6% or $6,000) AD&D Repatriation Benefit AD&D Seat Belt and Airbag Benefit AD&D Exposure and Disappearance Benefit Disability Insurance Coverage Disability Insurance, sometimes called income protection or paycheck insurance, can help replace a substantial portion of your gross salary if you are unable to work for a few weeks or months due to covered accident or illness. It can help you cover your expenses and protect your finances at a time when you re not getting a paycheck and have extra medical bills. Long Term Disability Insurance Benefit Amount: 60% of monthly earnings to a maximum of $7,000 per month Elimination Period: 90 Days Definition of Earnings: current salary Benefit Duration: Benefits will be payable until Social Security Normal Retirement Age. Mental Nervous Limitation: 24 months Pre-Existing Condition Limitation: 3 months prior/12 months after effective date Group LTD Standard Plan Features Include: Rehabilitation and Return to Work Assistance Program: provides a rehabilitation and return to work assistance benefit for disabled employees who are receiving LTD payments, and who are medically able to participate. Unum will determine eligibility for this program. Work-life Balance Employee Assistance Program: a comprehensive resource providing access to professional assistance for a wide range of personal and work-related issues. Plan includes 24-hour access to a variety of resources online or by phone. Worldwide Emergency Travel Assistance: Emergency medical assistance when traveling 100 miles or more from home. With one phone call anytime of the day or night, you, your spouse and dependent children can get immediate assistance anywhere in the world. This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. For complete details of coverage and availability, please refer to your policy. Underwritten by Unum Life Insurance Company of America, Portland, Maine 2015 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.