May 1, Benefits Eligible Employees. From: Archdiocese Benefits Office

Transcription

1 May 1, 2017 To: Benefits Eligible Employees From: Archdiocese Benefits Office Welcome to Open Enrollment for Health Benefits for the Archdiocese of Portland, Plan Year This program gives you the freedom to mix and match your health care, life insurance, disability, and other benefits. The materials enclosed in this packet are intended to provide you with detailed information on each benefit plan and guide you through the steps of enrollment. The effective date for all coverage is July 1, The first deduction will begin June 30, Benefits will remain in effect until June 30, Please review the Benefits Information Packet. If you have any questions, contact Customer Service at , Monday Friday 5:30am to 5:00pm PST. This year will be an Active Enrollment, meaning all benefit eligible employees must make an affirmative election to enroll online. Failure to complete online enrollment during Open Enrollment period will result in default coverage. Default coverage is employee only UHC Medical, Reta Delta Dental, and VSP Vision. Healthcare FSA will not continue; you must go through the enrollment process if you want to renew your Healthcare FSA. The contents of this packet are: 1. The formal Open Enrollment Announcement. This document is an overview of the Reta Benefits Center and includes information regarding the online Open Enrollment process. You will find the website is very interactive and user friendly. It will direct you to the "Open Enrollment Wizard" to complete your enrollment process. 2. A Health Benefits Cost Sheet that shows the new monthly employee rates. You may want to use it to track your selections before entering this information electronically. This cost sheet is NOT an enrollment form. 3. Frequently Asked Questions 4. A Table of Contents listing all materials in this package: Benefits Plan Summaries, a Contact List, and a table of approved dependent validation documents. We provided hard copies of the plan summaries to assist you through the transition to electronic enrollment. As you access the Reta Benefits Center, which is a state of the art website, you will find all plan summaries and selections. Please refer to the Contact List to identify experts who are ready to support you.

2 Open Enrollment For Health Benefits LAY EMPLOYEES 2017

3 Welcome to your Annual Open Enrollment for the Reta Trust The Open Enrollment period for the Archdiocese of Portland in Oregon employees is: May 11 th through May 25 th, 2017 RetaEnroll The Open Enrollment period is your annual opportunity to make changes to your benefit elections and coverage level. The elections you make during Open Enrollment will be effective July 1, You will NOT be permitted to make any changes to your benefit elections until the next annual Open Enrollment, unless you experience a Qualified Life Event Change as defined by the IRS Section 125 Guidelines. Reta Benefits Center Before making any benefits decisions, be sure to visit the newly enhanced Reta Benefits Center, where information is customized with the specific benefits available to you. Also new is a tool to help you decide which medical plan best fits your personal healthcare needs. You can log in to see the personalized lobby that works like an online virtual benefit fair. Professional representatives from Reta s benefits partners provide information and answers to your questions. Visit anytime beginning May 11, 2017 (the start of 2017 Open Enrollment) and select Reta Benefits Center. We encourage you to consider any recent or forthcoming changes in your personal or family s medical needs, so you can select the coverage best suited to your needs. This year will be an Active Enrollment, meaning all benefit eligible employees must make an affirmative election to enroll online. Failure to complete online enrollment during the Open Enrollment period will result in default coverage. Default coverage is employee only UHC Medical, Reta Delta Dental, and VSP Vision. Healthcare FSA will not continue; you must go through the enrollment process if you want to renew your Healthcare FSA. With RetaEnroll you will be able to view your insurance benefits and update your information, including: Personal Data (home address, birth date, etc.) Dependents (names, birth dates, Social Security Numbers, student status, etc.) Benefit Elections (medical, dental, life, disability, etc.) Beneficiaries (life insurance beneficiaries) Page 1 of 5

4 Accessing your Open Enrollment Online DO YOU KNOW YOUR USER ID AND PASSWORD? Log in to and review your current benefits. If you have forgotten or misplaced your user ID and password, follow the instructions below. Obtaining a User ID and Password To get started, a user ID and Password are required to access the site. You may obtain your unique User ID and Password for the first time, or have it re-sent to you if you are a returning user, by going to the Reta Trust home page ( and clicking on the help button on the right. Enter your address; provided that your address has been previously entered into the RetaEnroll system and validated. Otherwise, to view your User ID and Password onscreen, select Option 3: View User ID & Password on Your Screen and you will be prompted to enter: Last Name Date of Birth 5-digit Zip Code Last 4-Digits of your Social Security Number RetaEnroll will immediately verify your information and ask you to enter an address, if available. If you do not have an address, select the option button indicating such, and then click on Continue. For additional security, you will be asked to verify at least two pieces of identification (last four of SSN and zip code). Your User ID and Password will be displayed onscreen for 45 seconds. The password issued by RetaEnroll will be good for 12 hours. If you do not log on and create your own password within 12 hours, you will need to request another password. Please save your confidential User ID and Password in a secure place. Neither your HR department nor BAS can provide you with your User ID or Password. You must use the self-service Help link at to obtain this information. Making your Online Elections The enrollment site is available 24 hours a day, 7 days a week during the Open Enrollment period. When you re ready to make your elections, follow these five steps: 1. Go to and enter your User ID and Password in the upper right hand corner. 2. Choose your destination RetaEnroll. 3. Follow the easy enrollment steps in the Open Enrollment Wizard. 4. Review and confirm your elections, making changes as necessary. 5. Print your benefits statement. You may go back and make changes as many times as you like during the Open Enrollment period - May 11 through May 25, No changes may be made after the close of Open Enrollment for the 2017 plan year. Page 2 of 5

5 Dependent Validation Process For new dependents, the request for validation will be part of the electronic enrollment process. Employees will be required to provide documentation of dependent eligibility in order for all newly added dependent s coverage to be approved. (Spouse Marriage certificate, Child Birth certificate, Adoption/Legal Guardianship - Court documents) Reta Trust Dependent Validation Approved Documents Dependent Type Spouse Child to age 26 Stepchild Disabled Dependent Adoption/placed for adoption Legal Guardianship/Foster Child Approved Documents Requirement Marriage certificate plus one piece of documentation dated within the past 60 days to establish a common residence or financial interdependence Examples of secondary documentation: Jointly filed Form 1040 Separately filed Form 1040 with the same address Financial documents in both parties name Utility bill in both parties name Birth certificate listing the employee's name Hospital Birth Record (newborns only) Birth certificate naming spouse as the child s biological parent and Marriage Certificate and Jointly filed 1040* Separately filed 1040 with same address* Financial document in both names Utility bill in both names Birth certificate and a copy of the employee's recent Form 1040 claiming the individual as a dependent OR the dependent's Form 1040 filed from the employee's address OR SSDI documentation Appropriate court document Court document establishing employee or the employee's spouse is the legal guardian *Not required of marriage less than 90 days Page 3 of 5

6 What s New for ? We are now using a Basic Rate format (see chart below); we will no longer be using a Flex Credit format. Rate increased 11% Two new United HealthCare (UHC) plans have been added. Employees can no longer select the UHC- 250 plan. One new Kaiser plan has been added in addition to the existing Kaiser plan. Dental plans remain the same. They are bundled with VSP vision. Employees can now elect any Dental/Vision, regardless of their Medical selection. Willamette Dental reduced the copay for posterior (molar and bicuspid) resin-based composite fillings on two or more surfaces from $52 to $0, which is equal to the copay for amalgam fillings. This is a great enhancement! VSP benefit for frame and lenses will increase to every 12 months from every 24 months. Unum Basic Life Insurance core benefit will increase from $10, to $25, DCRP Open Enrollment will now run on the same Open Enrollment schedule as all other health benefit elections. Employee Assistance Program (EAP) now offers full intake assistance for all eligible services. Health Benefit Rate Changes Benefit Selection Employee Employee and Spouse Employee and Child(ren) Employee and Family Kaiser DEPO st-CO NEW Kaiser EPO UHC PPO NEW UHC PPO current UHC PPO (replaces UHC 250) NEW Dental / Vision required Reta Delta Dental Willamette Dental Kaiser Permanente Dental Vision - RETA VSP included included included included Unum Basic Life Core benefit is now $25, Optional Plans Unum Short Term Disability STD STD STD Unum Long Term Disability Buy Up LTD - core 7.15 LTD - 60% 6.62 LTD /3% 9.75 Unum Supplemental Life Rate - See Life Rate Chart in packet. Page 4 of 5

7 If You Need More Detailed Information or Assistance Detailed information about your benefits plan is available in the Reta Benefits Center at the RetaTrust.org website. The Benefits Center will be in a Blackout until Open Enrollment begins. For assistance with accessing your account, call the Reta Enroll Client Services Department at from 5:30 AM to 5:00 PM PST, Monday through Friday, or via to Service@RetaEnroll.org. The Reta Client Services team will either directly assist you or connect you with the best resource for help. If you need further assistance regarding your individual benefit plan options, see the Benefit Plan Comparison Sheet included in this packet. Additional information can be obtained by contacting plan providers on the Health Benefits Contact Sheet. Don t forget Open Enrollment for 2017 will begin on May 11th and will end on May 25th. Do not wait until the last minute to begin your enrollment. For your convenience, we have included benefit summaries for each of your benefit choices with this package. This information will also be available in the Reta Benefits Center on May 11 th, where we encourage you to go for information regarding your benefits plan. This comprehensive information resource center has a live representative available to help you with any questions or needs. The Reta Trust services over 35,000 members across the United States, including over 50 Roman Catholic Dioceses, Archdioceses, and Religious Communities. What s Next? Open House for Health Benefits Archdiocese of Portland, May 16, :00-5:00pm St. Pius X, Beaverton, May 17, :00-5:00pm Come join us on either of these dates to ask any questions about the plans you may have! Enrollment Deadline: May 25, 2017 Open Enrollment ends at Midnight PST Page 5 of 5

8 HEALTH BENEFITS COST PER EMPLOYEE Use this sheet to complete your benefits selections. Go to and input all information. Basic monthly benefits. Rates are net. Basic Monthly Benefit Rate for Employees per month Medical Plans required unless you have other current medical coverage Employee Only Employee + spouse Employee + children Employee + family Kaiser DEPO st-CO NEW No cost $ $ $ Kaiser EPO $27.00 $ $ $ UHC PPO NEW No cost $ $ $ UHC PPO current $31.00 $ $ $ UHC PPO (replace UHC 250) NEW $68.00 $ $ $ Dental/Vision - Required Reta Delta Dental No cost $40.00 $22.00 $58.00 Willamette Dental -$25.00 $2.00 -$10.00 $20.00 Kaiser Permanente Dental -$6.00 $37.00 $20.00 $55.00 Vision RETA VSP Included Included Included Included Healthcare Flexible Spending Account FSA - Optional If you elect this coverage, a pro rata portion of your annual election will be deducted from each of 12 remaining pay periods in the plan year 2017 Maximum election is $2, per year. Write in the amount of your monthly election. Pre-tax costs Medical, Dental/Vision, and Healthcare FSA Add medical, dental/vision, and FSA and enter total here Dependent Care Reimbursement Plan DCRP - Optional If you elect this coverage, a pro rata portion of your annual election will be deducted from each of 12 remaining pay periods in the plan year 2017 Maximum election is $5, per year. Write in the amount of your monthly election

9 Optional Post-tax benefits Additional Life/AD&D - Optional To enroll family members, you must select coverage for yourself. See rate sheet for premiums and the schedule of age-based premium increases. Employee coverage amount $ (cannot exceed lesser of $500,000 or 5x annual wages. Do not include your basic Life/AD&D amount here). After tax enter cost here Spouse coverage amount (cannot exceed 100% of employee coverage). Child(ren) coverage amount (cannot exceed 100% of employee coverage) $ $1.80 ($6,000) $2.40 ($8,000) After tax enter cost here $3.00 After tax ($10,000) enter cost here Short-Term Disability - Optional OPT OUT No cost $ day elimination $ day elimination $ day elimination After tax enter cost here Buy-up Long-Term Disability - Optional $6.62 LTD - 60% of wages $9.75 LTD 66 2/3% of wages After tax enter cost here Total Post-tax costs Add amounts in shaded boxes above and enter here

10 FREQUENTLY ASKED QUESTIONS FOR EMPLOYEES Here are questions that you may have regarding Open Enrollment and benefit plan changes. Please contact BAS Customer Service at , Monday through Friday between 5:30 AM and 5:00 PM PST, with any other questions or concerns you may have. 1. I m happy with my plan. Do I need to re-enroll during Open Enrollment? Yes, because this year is an Active Enrollment, you must make an affirmative action to complete your enrollment. Failure to complete the online enrollment process will result in default coverage. Default coverage is employee only UHC Medical, Reta Delta Dental, and VSP Vision. 2. Am I required to be enrolled in a medical insurance plan? Yes, with very few exceptions, all legal US residents are required to have minimum essential coverage or face a tax penalty. If you are not currently covered under a medical plan elsewhere, and you do not enroll in a Reta plan, you may choose to purchase coverage through the private marketplace. Note: the Reta medical plan will include a premium contribution from your employer. The Archdiocese requires all benefit eligible employees to be enrolled in a Dental/Vision plan. If you waive medical, you are required to elect a Dental/Vision plan. 3. Do I need to re-enroll for the Healthcare Flexible Spending Accounts? Yes, Healthcare Flexible Spending Accounts (FSA) do NOT renew automatically each year. If you wish to participate in the Healthcare FSA for the coming plan year, you must enroll during Open Enrollment. 4. Where do I go to see my current benefits? To see your current benefits, log on to and click on the RetaEnroll link and then click on Coverage to see your current benefits. If you don t have a User ID or Password, or have forgotten see #5 below. 5. How do I obtain my forgotten or lost User ID and Password to access the Reta Benefits Center and RetaEnroll? You may request your forgotten User ID and Password, by going to the Reta Trust home page ( Click on the help button in the upper right. Next, select Option 3: View User ID & Password, then on the next screen select Option 2, View User ID & Password. You will be prompted to enter personal verification information. For a step-by-step process, please refer to the sheet Accessing Your Open Enrollment Online, or call BAS Customer Service (see above). 6. How do I know if I have all of the information I need to enroll? Your location s business administrator or business manager can provide assistance.

11 FREQUENTLY ASKED QUESTIONS 7. Will the Unum Evidence of Insurability (EOI) form open in the enrollment window for completion? Yes. There will be 2 options to complete an EOI Form with Unum. The first option allows you to download the document and send the form to Unum. The second option allows you to submit the EOI form online. Employees will have the ability to choose either of these options within the enrollment module. 8. Do I need to re-enroll in Supplemental Life AD&D and STD /LTD? No, current elections for supplemental Life AD&D and optional STD/LTD will roll over to , unless you choose to make changes during Open Enrollment. 9. Do I need to validate existing covered dependents during Open Enrollment? No, you do not. 10. What happens if I miss the Open Enrollment deadline or do not enroll? Because this year is an Active Enrollment, failure to complete the online enrollment process during Open Enrollment will result in default coverage. Default coverage is employee only UHC Medical, Reta Delta Dental, and VSP Vision. 11. Can I change my benefit elections at any time throughout the year? The decisions you make during Open Enrollment are locked in for the Plan Year. The only exception is if you have a Qualifying Life Event Change, which includes events such as: marriage, divorce, birth or adoption of a child, reduction in work hours, loss of dependent status, or a change in your spouse s employment status as defined by Section 125 of the Internal Revenue Code. 12. Where can I check to see if my medical care provider is in-network with United Healthcare? Go to Select Find a Physician. On the next page, enter your location information above the search bar. You can search by provider name or by provider specialty. Within the site you can also review providers and their quality rating information. 13. Do I have a paper option for my enrollment? No, you must enroll online. All enrollment will be completed electronically through the RetaEnroll system. 14. How many times can I log out of the enrollment system and come back to my enrollment? As many times as you need, between Thursday May 11 and midnight, Thursday May 25. However, you will need to save each enrollment step. The enrollment will not be complete until you save all of your elections and submit your electronic signature.

12 FREQUENTLY ASKED QUESTIONS 15. What do I need to know regarding Dependent Validation? a. Why is it necessary? To ensure that only eligible dependents are enrolled on the plan. The plan is not responsible to cover claims for those individuals who do not meet eligibility guidelines. b. When will I receive the Request for Validation? For newly added dependents, the request for validation, including instructions, will be a part of the electronic enrollment process. Coverage for newly added dependents will be pended until documentation is submitted. c. What is the deadline? For new dependents, you will be asked at the time of enrollment to submit documentation within 60 days. The effective date of coverage will be retroactively assigned once documentation is received and validated or approved. 16. After the Open Enrollment period is over, how can I add dependents to my plan? If you have a qualifying event, you will need to submit requested changes by using a Life Event Change form. All changes will be pended until requested documentation has been received and approved. 17. Who do I call if I need provider assistance? See the attached Health Benefits Contact sheet. 18. Who do I contact if I need assistance, cannot access the online enrollment system, or my enrollment is rejected? You can call RetaEnroll Customer Service at between 5:30 AM and 5:00 PM PST or Service@RetaEnroll.org. 19. Is there a glossary of acronyms? A glossary of acronyms for general healthcare terms is available at:

13 Open Enrollment LAY EMPLOYEES Health Benefits Plan Information

14 For Lay Employees Benefit Items included in this packet of material are listed here in order of content. These items are included as a convenience. We would like you to log into for comprehensive detailed benefit information and enrollment. 1. HEALTH BENEFITS PLAN OVERVIEW 2. RETA TRUST UNITED HEALTH CARE COMPARISON OF 500-1, 500-2, AND PPO 3. ENVISION PRESCRIPTION RX PLAN OVERVIEW 4. RETA TRUST KAISER EPO AND DEPO PLAN COMPARISON 5. DELTA DENTAL PPO PLAN SUMMARY 6. KAISER PERMANENTE DENTAL PLAN SUMMARY 7. WILLAMETTE DENTAL GROUP PLAN SUMMARY 8. RETA TRUST VSP VISION CARE SUMMARY 9. MHN EAP BENEFIT PLAN SUMMARY 10. UNUM LIFE AD & D PLAN HIGHLIGHTS 11. UNUM LTD PLAN HIGHLIGHTS 12. UNUM STD PLAN HIGHLIGHTS 13. MONTHLY LIFE RATE SHEET 14. HEALTH CARE FSA OVERVIEW 15. DEPENDENT CARE FSA OVERVIEW 16. HEALTH BENEFIT CONTACT SHEET 17. DEPENDENT VALIDATION APPROVED DOCUMENTS

15 BENEFITS PLAN OVERVIEW Health Plans Kaiser EPO Kaiser DEPO UHC PPO C PPO 500- UHC PPO C PPO 500- UHC PPO C PPO 500- You may select any dental plan regardless of the medical plan you choose. Waive Medical C PPO 500- Reta Delta Dental Willamette Dental Kaiser Dental VSP Vision Basic Life Insurance, AD&D, LTD are provided CORE BENEFITS VOLUNTARY OPTIONS DENTAL - Reta Delta, Willamette, and Kaiser VISION - VSP Basic Life Insurance, AD&D Long-term disability (LTD) Employee Assistance Program (EAP) Additional Life Insurance, AD&D Short-term Disability (STD) Long-term Disability (LTD) buy-up Flexible Spending Account (FSA) Healthcare Flexible Spending (HFSA) Dependent Care Reimbursement Plan (DCRP) The Delta Dental PPO plan makes it easy to find a dentist, visit the dentist of your choice, and save money with a Delta Dental PPO dentist. Willamette and Kaiser Dental plans cover only dental services received from their dentists at their dental clinics. VSP provides routine vision care benefits for all eligible employees and dependents. While vision benefits are automatic with your dental coverage, VSP is entirely separate from your dental plan. For Basic Life Insurance and AD&D, employer pays 100% of the premium at no cost to employee on all Health Plan packages. Employee coverage is $25,000. (Reduces at age 65 & 70) LTD is intended to help replace some of your income for an extended period when you cannot work because of a disability. Elimination period is 90 days. Monthly benefit of 50% of monthly salary up to $4,000 per month. EAP is provided to all benefit eligible employees and their family even if they don t enroll family members in any other coverage. EAP is provided to help employees overcome emotional, family, and other personal problems; offer guidance on financial and legal issues; improve your health and wellness, and much more. There is no charge to you for covered services. Voluntary Life and AD&D is an employee-paid plan available to all benefits eligible employees during open enrollment period. Coverage available to eligible employee and dependents. The available options are listed on the monthly rate sheet in the enrollment packet. STD shortens the waiting period for the LTD from core benefit of 90 days to your choice of 44, 30, or 14 days. You will automatically receive 44-day option unless you choose a shorter waiting period or opt out of STD. You may elect the buy-up LTD option of 60% or 66 2/3 %. If you decline, you will be covered by the basic LTD equal to 50% of monthly wages. Participating in the FSA can help save you money on taxes. The money you set aside in FSA is not subject to federal income or Social Security tax. This allows you to benefit from more of the money you earn. HFSA allows you to set aside a portion of your salary, before-tax, to reimburse certain amounts expended for medical care. Contribution may not exceed $2,600. DCRP FSA allows you to set aside a portion of your salary, before-tax, to reimburse certain amounts spent for eligible dependent care expenses. Under federal tax law, maximum annual contribution may be up to $5,000 ($2,500 maximum if you are married, filing separate income tax returns.)

16 PLAN COMPARISON VISIT FOR DETAILED PLAN SUMMARY Reta United Healthcare (UHC) UHC PPO UHC PPO UHC PPO Plan Designs Out of Out of In-network In-network network network In-network Out of network Annual Out-of-pocket maximum (Includes deductible, copays, and coinsurance) For any one Member in the same $4,000 $8,000 $2,500 $5,000 $2,000 $4,000 Family Unit For an entire Family Unit of two or more Members $8,000 $16,000 $5,000 $10,000 $4,000 $8,000 Calendar Year Deductible $750 Individual/$1,500 Family $500 Individual/$1,000 Family $500 Individual/$1,000 Family Professional Services Office Visit Copayments Well Child Care (birth to age 7) Adult routine exams and preventive services (mammograms, pap smears, & prostate cancer screenings) Chiropractic Care (up to 24 visits in calendar year) Outpatient Services $25 copay, deductible waived No charge, deductible waived No charge, deductible waived $40 copay, deductible waived 40% 40% 40% 40% $25 copay, deductible waived No charge, deductible waived No charge, deductible waived $40 copay, deductible waived 40% 40% 40% 40% $20 copay, deductible waived No charge, deductible waived No charge, deductible waived $35 copay, deductible waived Outpatient surgery 20% 40% 20% 40% 10% 30% X-rays and lab tests 20% 40% 20% 40% 10% 30% MRI, CT, and PET 20% 40% 20% 40% 10% 30% Inpatient Services Room and board, surgery, anesthesia, x-rays, lab tests, and drugs 20% 40% 20% 40% 10% 30% Emergency Health Coverage Emergency Room visits (copay waived if admitted) $200 copay, then 20% $200 copay, then 20% Subject to UCR* $200 copay, then 20% $200 copay, then 20% Subject to UCR* $100 copay, then 10% 30% 30% 30% 30% $100 copay, then 10% Subject to UCR* Urgent Care $50 copay $50 copay $50 copay Prescription Drug (RX provided through EnvisionRx**) Generic/Formulary/Non- Formulary Generic/Formulary/Non- Formulary Generic/Formulary/Non- Formulary Retail (up to 30-day supply) $10/$25/$40 $10/$20/$30 $10/$20/$30 Mail order (up to 90-day supply) $20/$50/$80 $20/$40/$60 $20/$40/$60 *Usual and customary expenses **Subject to market based pricing

17 PLAN COMPARISON VISIT FOR DETAILED PLAN SUMMARY Kaiser Permanente Plan Designs Kaiser EPO Legacy Kaiser DEPO-500 In-network Out of network In-network Out of network Annual Out-of-pocket maximum (Includes deductible, copays, and coinsurance) For any one Member in the same Family Unit $1,500 No coverage $3,000 No coverage For an entire Family Unit of two or more Members $3,000 No coverage $6,000 No coverage Calendar Year Deductible None No coverage None No coverage Professional Services Office Visit Co-payments $15 copay No coverage $20 copay No coverage Well Child Care (birth to age 7) No charge No coverage No charge No coverage Adult routine exams and preventive services (mammograms, pap No charge No coverage No charge No coverage smears, & prostate cancer screenings) Chiropractic Care No coverage No coverage $15 copay, up to 24 visits in calendar No coverage year Outpatient Services Outpatient surgery 10% after $15 copay No coverage deductible No coverage X-rays and lab tests No charge No coverage $10 copay No coverage MRI, CT, and PET No charge No coverage $10 copay No coverage Inpatient Services Room and board, surgery, anesthesia, x-rays, lab tests, and drugs Emergency Health Coverage Emergency Room visits (copay waived if admitted) $250 per admission $100 copay No coverage Copay waived if admitted Prescription Drug (RX provided through Kaiser) Retail (up to 30-day supply) Mail order (up to 90-day supply) Generic/Formulary 10% after deductible 10% after deductible Generic/Formulary $10/$20 $10/$30 $20/$40 $20/$60 No coverage

18 Member Service Information For your EnvisionRx pharmacy benefit & prescription mail order option Support for your pharmacy benefit Register to manage your benefit online To manage your benefits conveniently online, register at envisionrx.com and see your: Secure login Rx coverage and Preferred Drug List Important information in a single dashboard Recent prescriptions Best ways to save Nearest pharmacy Drug information and pricing ID card online (and how to print) Download the EnvisionRx member app Our free app gives you a secure way to help manage your prescription benefit on your mobile device. Features include: Digital ID card Locate in-network pharmacy Medicine Cabinet for access to prescription claims information, including days until next refill Benefit and cost information Plan-specific cost savings opportunities Refill reminders Secure connection Contact our Member Services Help Desk Your pharmacy benefit includes 24/7/365 support for any questions you may have Phone: customerservice@envisionrx.com Receive prescriptions through the mail Your plan offers mail order services through EnvisionMail pharmacy that lets you order prescriptions from the convenience of your home. Mail order is an excellent way to receive prescriptions you will be taking on an ongoing basis, without having to worry about availability at your local pharmacy. Dependent on plan design, members often save money by getting reduced copays for using mail order to receive longer (90-day) fills! To start getting prescriptions through the mail, you need to register using one of these easy, secure options: Online recommended visit envisionpharmacies.com and select Not registered? Click here to register. Your account will activate within 24 hours. By registering online, you can also track the progress of your orders. Phone: (TTY 711), Monday-Friday 8 a.m. 10 p.m. (EST) and Saturday 8:30 a.m. 4:30 p.m. (EST) envisionrx.com

19 The Reta Trust EnvisionRx Prescription Drug Plan Pharmacy Schedule of Benefits Summary of Benefits Retail Pharmacy Copayment (per Prescription Unit or up to 30 days) Mail-Service Pharmacy Copayment (up to 3 Prescription Units or up to 90 days) Specialty Pharmacy Copayment (up to 30 days) Reta Value Options (RVO) Market Priced Drugs Generic Brand Formulary Brand Non Formulary $10 $25 $40 $20 $50 $80 $40 $40 $40 See below description What is my Schedule of Benefits? This Schedule of Benefits provides a summary of your Prescription Drug Benefit, as well as its exclusions and limitations. How do I use my Prescription Drug Benefit? Your Prescription Drug Benefit helps to cover the cost for some of the medications prescribed by a licensed Physician. Using your benefit is simple. Present your doctor s prescription and EnvisionRx ID card at any EnvisionRx Participating Pharmacy. Pay the Copayment for a Prescription Unit or its retail cost, whichever is less. Receive your medication. What do I pay when I fill a prescription? You will pay a Copayment when filling a prescription at an EnvisionRx Participating Pharmacy. You will pay a Copayment every time a prescription is filled until you reach your medical plan annual out-of-pocket maximum. Your benefits are as follows: When you fill or refill a prescription for a generic medication, your Copayment is $10 for a 30-day supply (excluding maintenance medications). When you fill or refill a prescription for a Formulary brand-name medication, your Copayment is $25 for a 30- day supply (excluding maintenance medications). When you fill or refill a prescription for a Non-Formulary brand-name medication, your Copayment is $40 for a 30-day supply (excluding maintenance medications). MAINTENANCE MEDICATIONS: For all Maintenance Medications you are allowed 3 fills for a 30 day supply at a retail pharmacy for your standard copay. At the 4 th fill you will have two options: Option 1: To continue to fill at retail pharmacy for a 30 day supply but for double the standard copay. Option 2: To switch to EnvisionMail for a 90 day supply for the mail order copay. If you choose to switch to mail order, please contact EnvisionMail at to set up your account. You also must REGISTER your member information with EnvisionMail Pharmacy. You may use any of the following 3 easy registration options: 1. Online: (Recommended method) Visit and select Not registered? Click here to register. Your account will activate within 24 hours. By registering online, you can also track the progress of their orders. 2. Phone: Call EnvisionMail Pharmaceutical Services Customer Service at to speak with a representative. 3. Mail: Complete the Registration and Prescription Order Form enclosed in this packet. 3 Tier Revised 4/24/2017 1

20 Once registered, you may mail the original 90 day supply prescription(s) with the enclosed brochure or your physician can fax your prescription(s) to EnvisionMail at Please be sure that your prescriber includes your date of birth and contact information on the fax. Only faxes sent from a physician s office will be valid. Reta Value Options (RVO) Many brand-name medications have generics, brands, or over-the-counter (OTC) equivalents available that cost less and are FDA-approved drugs with similar effectives. RVO drugs are: The most cost-effective FDA-approved drugs (generics, brands or OTC equivalents) that provide a therapeutically equivalent result, based on available medical evidence. Designated as the formulary drug for each therapeutic category (a therapeutic category is a group of drugs that treat a given diagnosis, such as statins used to treat high cholesterol). If you are taking a drug in an RVO therapeutic category that is not the formulary RVO medication, you will be contacted by EnvisionRx after your 1 set prescription is filled with more information about the RVO program and your options. How Reta Value Options Works Under Reta Value Options pricing, you can choose to continue to use a drug that has a lower-priced, formulary drug equivalent, but Reta will pay only the amount it would have paid for the therapeutically similar drug that costs less (the RVO drug). You will pay the difference between the full market price of your prescription and the full market price of the lowest cost RVO therapeutic alternative plus the copay for the lowest cost therapeutic alternative. The Plan s contribution for all therapeutic alternatives is based on what the Plan currently contributes to the lowest cost alternative. The Plan does not provide a greater subsidy or benefit for more expensive, therapeutically similar, medications. if you use a Non-Preferred Drug, you will pay more for it when you fill the prescription. You may avoid the cost increase by taking action and talking with your doctor about Preferred Drugs as alternatives to Non- Preferred Drugs. Log in to your member profile at to find out how much your current prescription drugs cost and research Preferred Drugs. Using this information, you ll be able to work more effectively with your doctor to make informed decisions about medications. All the drug options have been approved by the Food and Drug Administration (FDA) for safety. When I fill a prescription, how much medication do I receive? For a single retail Copayment, Members receive either one Prescription Unit or up to a 30-day supply of a drug. When you use the EnvisionMail Service Pharmacy program, you will receive three Prescription Units or up to a 90- day supply of maintenance medications. What if the Preferred Drug doesn t work for me? Your physician can file for a Physician Exception Request Form, by calling EnvisionRx at , to have you continue using a Non-Preferred Drug. Typically, exceptions are requested for reasons like the following: You ve tried the Preferred Drug and it doesn t work as well as the Non-Preferred Drug. The Preferred Drug won t work with other medications you take. Your Physician feels your condition would be better treated with a Non-Preferred Drug. If the request is approved, you pay the applicable generic or brand copayment for the drug. How can I request a Physician exception form? You can call EnvisionRx at , and ask them to fax a Physician exception form to your Physician. Please note: your physician must complete and submit the form to using the fax number on the form. EnvisionRx will perform a detailed clinical review and then notify you and your physician of the decision. If you disagree with the decision, you have the right to file an appeal with EnvisionRx 3 Tier Revised 4/24/2017 2

21 What else do I need to know? You should become familiar with EnvisionRx prescription drug Formulary. Any medication not on the Formulary you will pay the higher non-formulary copayment. For more information on the Formulary, please visit It is possible to buy a brand-name drug in place of a generic equivalent, even though the generic drug is the only one listed on our Formulary. Your cost, however, will be higher (Non-Formulary copayment). For more information, please continue to Medications Covered by Your Benefit and read the description for Generic Drugs. ADDITIONAL INFORMATION Medications Covered by Your Benefit The following medications are included in the EnvisionRx managed Formulary and are available to your Physician. Federal Legend Drugs: Any medicinal substance which bears the legend: Caution: Federal law prohibits dispensing without a prescription. State Restricted Drugs: Any medicinal substance that may be dispensed by prescription only according to state law. Generic Drugs: Comparable generic drugs may be substituted for brand-name drugs. For the purposes of determining coverage, the following items are considered prescription drug benefits: glucagon, insulin, insulin syringes, blood glucose test strips, lancets, inhaler extender devices, urine test strips and anaphylaxis prevention kits (including, but not limited to, EpiPen, Ana-Kits and Ana-Guard ). Injectable drugs (except as listed under Exclusions and Limitations ). Exclusions and Limitations While the Prescription Drug Benefit covers most medications, there are some that are not covered: Drugs or medicines purchased and received prior to the Member s effective date or subsequent to the Member s termination. Therapeutic devices or appliances, including hypodermic needles, syringes (except insulin syringes), support garments and other nonmedicinal substances. All nonprescription (over-the-counter) contraceptive jellies, ointments, foams or devices. Contraceptives prescribed for birth control Medications to be taken or administered to the eligible Member while a patient in a hospital, rest home, nursing home, sanitarium, etc. Drugs or medicines delivered or administered to the Member by the prescriber or the prescriber s staff. Dietary supplements, including vitamins and fluoride supplements (except prenatal), health or beauty aids, herbal supplements and/or Alternative Medicine. Bulk Chemicals used in compounded medications. Medication for which the cost is recoverable under any workers compensation or occupational disease law or any state or government agency, or medication furnished by any other drug or medical service for which no charge is made to the patient. Medication prescribed for Experimental or Investigational therapies, unless required by an external independent review panel pursuant to California Health and Safety Code Section For non-food-and-drug- Administration-approved indications, see the following exclusion. Off-Label Drug Use: Off-Label Drug Use means that the Provider has prescribed a drug approved by the Food and Drug Administration (FDA) for a use that is different than that for which the FDA approved the drug. EnvisionRx excludes coverage for Off-Label Drug Use, including off-label self-injectable drugs, except as described in the Subscriber Agreement and any applicable Attachments. If a drug is prescribed for Off-Label Drug Use, the drug and its administration will be covered only if it satisfies the following criteria: o The drug is approved by the FDA. o The drug is prescribed by a licensed health care professional for the treatment of a life-threatening condition or for a chronic and seriously debilitating condition. o The drug is Medically Necessary to treat the condition. o The drug has been recognized for treatment of the life-threatening or chronic and seriously debilitating condition by one of the following: The American Medical Association Drug Evaluations; The American Hospital Formulary Service Drug Information; the United States Pharmacopeia Dispensing Information; or in two articles from major peer-reviewed medical journals that present data supporting the proposed 3 Tier Revised 4/24/2017 3

22 o Off-Label Drug Use or Uses as generally safe and effective. The drug is administered as part of a core medical benefit as determined by EnvisionRx. Nothing in this section shall prohibit EnvisionRx from use of a Formulary, Copayment, technology assessment panel or similar mechanism as a means for appropriately controlling the utilization of a drug that is prescribed for a use that is different from the use for which that drug has been approved for marketing by the FDA. Denial of a drug as investigational or experimental will allow the Member to use the Independent Medical Review System as defined in the medical Combined Evidence of Coverage and Disclosure Form. Medications available without a prescription (over-the-counter) or for which there is a nonprescription equivalent available, even if ordered by a Physician. Elective or voluntary enhancement procedures, services, supplies and medications, including, but not limited to, weight loss, hair growth, athletic performance, cosmetic purposes, anti-aging and mental performance. Examples of these drugs include, but are not limited to, Penlac, Retin-A, Renova, Vaniqa, Propecia, Lustra, Xenical or Meridia. Drugs used for diagnostic purposes. Saline and irrigation solutions. Replacement of lost, stolen or destroyed medications. EnvisionRx reserves the right to expand the prior authorization requirement for any drug product to assure adherence to FDA-approved indications and national practice standards. The Appeals Process EnvisionRx contracts with a leading independent review organization (IRO) for the administration and determination of appeals. Your appeal will be reviewed and you will be notified in writing of the determination within 30 calendar days of EnvisionRx receipt of the appeal. If your appeal is denied, your written response will include the specific reason for the decision, describe the criteria or guidelines or benefit provision on which the denial decision was based, and notification that upon request the Member may obtain a copy of the actual benefit provision, guideline protocol or other similar criterion on which the denial is based. For determinations delaying, denying or modifying health care services based on a finding that the services are not Covered Services, the response will specify the provisions in the pharmacy plan documents that exclude that coverage. If you are not satisfied with the outcome of the first appeal, you may request a second appeal within four months of the initial appeal. Expedited Review Appeals Process Appeals involving an imminent and serious threat to your health including, but not limited to, severe pain or the potential loss of life, limb or major bodily function will be immediately referred to the IRO s clinical review personnel. Expedited appeals will be reviewed and you will be notified of the determination within 72 hours from EnvisionRx receipt of the appeal. If your case does not meet the criteria for an expedited review, it will be reviewed under the standard appeal process. Specialty Pharmacy (Injectable Medications) Envision Specialty Pharmacy will conveniently deliver your Injectable medications to your home or physician s office, or other location of choice. And there is no charge for shipping! Your prescription drug benefit allows one grace fill at any retail pharmacy, for up to a 30-day supply each, to ensure you continue receiving your specialty medication(s) as scheduled. After that, you are required to utilize Envision Specialty Pharmacy for your specialty medications. Because specialty medications can be more difficult to manage, Envision Specialty Pharmacy offers the following patient support services at no charge: Personalized support to help you achieve the best results from your prescribed therapy Convenient delivery to your home or prescriber s office Easy access to a Care Team who can answer medication questions, provide educational materials about your condition, help you manage any potential medication side effects, and provide confidential support all with one toll-free phone call. If you have any questions, or to begin taking advantage of these complimentary patient support services, please call Envision Specialty Pharmacy at Who should I call with questions? Call EnvisionRx at for direct access to their customer service line. 3 Tier Revised 4/24/2017 4

23 The Reta Trust EnvisionRx Prescription Drug Plan Pharmacy Schedule of Benefits Summary of Benefits Retail Pharmacy Copayment (per Prescription Unit or up to 30 days) Mail-Service Pharmacy Copayment (up to 3 Prescription Units or up to 90 days) Specialty Pharmacy Copayment (up to 30 days) Reta Value Options (RVO) Market Priced Drugs Generic Brand Formulary Brand Non Formulary $10 $20 $30 $20 $40 $60 $30 $30 $30 See below description What is my Schedule of Benefits? This Schedule of Benefits provides specific details about your Prescription Drug Benefit, as well as its exclusions and limitations. How do I use my Prescription Drug Benefit? Your Prescription Drug Benefit helps to cover the cost for some of the medications prescribed by a licensed Physician. Using your benefit is simple. Present your doctor s prescription and EnvisionRx ID card at any EnvisionRx Participating Pharmacy. Pay the Copayment for a Prescription Unit or its retail cost, whichever is less. Receive your medication. What do I pay when I fill a prescription? You will pay a Copayment when filling a prescription at an EnvisionRx Participating Pharmacy. You will pay a Copayment every time a prescription is filled until you reach your medical plan annual out-of-pocket maximum. Your benefits are as follows: When you fill or refill a prescription for a generic medication, your Copayment is $10 for a 30-day supply (excluding maintenance medications). When you fill or refill a prescription for a Formulary brand-name medication, your Copayment is $20 for a 30- day supply (excluding maintenance medications). When you fill or refill a prescription for a Non-Formulary brand-name medication, your Copayment is $30 for a 30-day supply (excluding maintenance medications). MAINTENANCE MEDICATIONS: For all Maintenance Medications you are allowed 3 fills for a 30 day supply at a retail pharmacy for your standard copay. At the 4 th fill you will have two options: Option 1: To continue to fill at retail pharmacy for a 30 day supply but for double the standard copay. Option 2: To switch to EnvisionMail for a 90 day supply for the mail order copay. If you choose to switch to mail order, please contact EnvisionMail at to set up your account. You also must REGISTER your member information with EnvisionMail Pharmacy. You may use any of the following 3 easy registration options: 1. Online: (Recommended method) Visit and select Not registered? Click here to register. Your account will activate within 24 hours. By registering online, you can also track the progress of their orders. 2. Phone: Call EnvisionMail Pharmaceutical Services Customer Service at to speak with a representative. 3. Mail: Complete the Registration and Prescription Order Form enclosed in this packet. 3 Tier Revised 4/24/2017 1

24 Once registered, you may mail the original 90 day supply prescription(s) with the enclosed brochure or your physician can fax your prescription(s) to EnvisionMail at Please be sure that your prescriber includes your date of birth and contact information on the fax. Only faxes sent from a physician s office will be valid. Reta Value Options (RVO) Many brand-name medications have generics, brands, or over-the-counter (OTC) equivalents available that cost less and are FDA-approved drugs with similar effectives. RVO drugs are: The most cost-effective FDA-approved drugs (generics, brands or OTC equivalents) that provide a therapeutically equivalent result, based on available medical evidence. Designated as the formulary drug for each therapeutic category (a therapeutic category is a group of drugs that treat a given diagnosis, such as statins used to treat high cholesterol). If you are taking a drug in an RVO therapeutic category that is not the formulary RVO medication, you will be contacted by EnvisionRx after your 1 set prescription is filled with more information about the RVO program and your options. How Reta Value Options Works Under Reta Value Options pricing, you can choose to continue to use a drug that has a lower-priced, formulary drug equivalent, but Reta will pay only the amount it would have paid for the therapeutically similar drug that costs less (the RVO drug). You will pay the difference between the full market price of your prescription and the full market price of the lowest cost RVO therapeutic alternative plus the copay for the lowest cost therapeutic alternative. The Plan s contribution for all therapeutic alternatives is based on what the Plan currently contributes to the lowest cost alternative. The Plan does not provide a greater subsidy or benefit for more expensive, therapeutically similar, medications. if you use a Non-Preferred Drug, you will pay more for it when you fill the prescription. You may avoid the cost increase by taking action and talking with your doctor about Preferred Drugs as alternatives to Non- Preferred Drugs. Log in to your member profile at to find out how much your current prescription drugs cost and research Preferred Drugs. Using this information, you ll be able to work more effectively with your doctor to make informed decisions about medications. All the drug options have been approved by the Food and Drug Administration (FDA) for safety. When I fill a prescription, how much medication do I receive? For a single retail Copayment, Members receive either one Prescription Unit or up to a 30-day supply of a drug. When you use the EnvisionMail Service Pharmacy program, you will receive three Prescription Units or up to a 90- day supply of maintenance medications. What if the Preferred Drug doesn t work for me? Your physician can file for a RVO Exception Request Form, by calling EnvisionRx at , to have you continue using a Non-Preferred Drug. Typically, exceptions are requested for reasons like the following: You ve tried the Preferred Drug and it doesn t work as well as the Non-Preferred Drug. The Preferred Drug won t work with other medications you take. Your Physician feels your condition would be better treated with a Non-Preferred Drug. If the request is approved, you pay the applicable generic or brand copayment for the drug. How can I request a Physician exception form? You can call EnvisionRx at , and ask them to fax a Physician exception form to your Physician. Please note: your physician must complete and submit the form to using the fax number on the form. EnvisionRx will perform a detailed clinical review and then notify you and your physician of the decision. If you disagree with the decision, you have the right to file an appeal with EnvisionRx. 3 Tier Revised 4/24/2017 2

25 What else do I need to know? You should become familiar with EnvisionRx prescription drug Formulary. Any medication not on the Formulary you will pay the higher non-formulary copayment. For more information on the Formulary, please visit It is possible to buy a brand-name drug in place of a generic equivalent, even though the generic drug is the only one listed on our Formulary. Your cost, however, will be higher (Non-Formulary copayment). For more information, please continue to Medications Covered by Your Benefit and read the description for Generic Drugs. ADDITIONAL INFORMATION Medications Covered by Your Benefit The following medications are included in the EnvisionRx managed Formulary and are available to your Physician. Federal Legend Drugs: Any medicinal substance which bears the legend: Caution: Federal law prohibits dispensing without a prescription. State Restricted Drugs: Any medicinal substance that may be dispensed by prescription only according to state law. Generic Drugs: Comparable generic drugs may be substituted for brand-name drugs. For the purposes of determining coverage, the following items are considered prescription drug benefits: glucagon, insulin, insulin syringes, blood glucose test strips, lancets, inhaler extender devices, urine test strips and anaphylaxis prevention kits (including, but not limited to, EpiPen, Ana-Kits and Ana-Guard ). Injectable drugs (except as listed under Exclusions and Limitations ). Exclusions and Limitations While the Prescription Drug Benefit covers most medications, there are some that are not covered: Drugs or medicines purchased and received prior to the Member s effective date or subsequent to the Member s termination. Therapeutic devices or appliances, including hypodermic needles, syringes (except insulin syringes), support garments and other nonmedicinal substances. All nonprescription (over-the-counter) contraceptive jellies, ointments, foams or devices. Contraceptives prescribed for birth control Medications to be taken or administered to the eligible Member while a patient in a hospital, rest home, nursing home, sanitarium, etc. Drugs or medicines delivered or administered to the Member by the prescriber or the prescriber s staff. Dietary supplements, including vitamins and fluoride supplements (except prenatal), health or beauty aids, herbal supplements and/or Alternative Medicine. Bulk Chemicals used in compounded medications. Medication for which the cost is recoverable under any workers compensation or occupational disease law or any state or government agency, or medication furnished by any other drug or medical service for which no charge is made to the patient. Medication prescribed for Experimental or Investigational therapies, unless required by an external independent review panel pursuant to California Health and Safety Code Section For non-food-and-drug- Administration-approved indications, see the following exclusion. Off-Label Drug Use: Off-Label Drug Use means that the Provider has prescribed a drug approved by the Food and Drug Administration (FDA) for a use that is different than that for which the FDA approved the drug. EnvisionRx excludes coverage for Off-Label Drug Use, including off-label self-injectable drugs, except as described in the Subscriber Agreement and any applicable Attachments. If a drug is prescribed for Off-Label Drug Use, the drug and its administration will be covered only if it satisfies the following criteria: o The drug is approved by the FDA. o The drug is prescribed by a licensed health care professional for the treatment of a life-threatening condition or for a chronic and seriously debilitating condition. o The drug is Medically Necessary to treat the condition. o The drug has been recognized for treatment of the life-threatening or chronic and seriously debilitating condition by one of the following: The American Medical Association Drug Evaluations; The American Hospital Formulary Service Drug Information; the United States Pharmacopeia Dispensing Information; or in two articles from major peer-reviewed medical journals that present data supporting the proposed 3 Tier Revised 4/24/2017 3

26 o Off-Label Drug Use or Uses as generally safe and effective. The drug is administered as part of a core medical benefit as determined by EnvisionRx. Nothing in this section shall prohibit EnvisionRx from use of a Formulary, Copayment, technology assessment panel or similar mechanism as a means for appropriately controlling the utilization of a drug that is prescribed for a use that is different from the use for which that drug has been approved for marketing by the FDA. Denial of a drug as investigational or experimental will allow the Member to use the Independent Medical Review System as defined in the medical Combined Evidence of Coverage and Disclosure Form. Medications available without a prescription (over-the-counter) or for which there is a nonprescription equivalent available, even if ordered by a Physician. Elective or voluntary enhancement procedures, services, supplies and medications, including, but not limited to, weight loss, hair growth, athletic performance, cosmetic purposes, anti-aging and mental performance. Examples of these drugs include, but are not limited to, Penlac, Retin-A, Renova, Vaniqa, Propecia, Lustra, Xenical or Meridia. Drugs used for diagnostic purposes. Saline and irrigation solutions. Replacement of lost, stolen or destroyed medications. EnvisionRx reserves the right to expand the prior authorization requirement for any drug product to assure adherence to FDA-approved indications and national practice standards. The Appeals Process EnvisionRx contracts with a leading independent review organization (IRO) for the administration and determination of appeals. Your appeal will be reviewed and you will be notified in writing of the determination within 30 calendar days of EnvisionRx receipt of the appeal. If your appeal is denied, your written response will include the specific reason for the decision, describe the criteria or guidelines or benefit provision on which the denial decision was based, and notification that upon request the Member may obtain a copy of the actual benefit provision, guideline protocol or other similar criterion on which the denial is based. For determinations delaying, denying or modifying health care services based on a finding that the services are not Covered Services, the response will specify the provisions in the pharmacy plan documents that exclude that coverage. If you are not satisfied with the outcome of the first appeal, you may request a second appeal within four months of the initial appeal. Expedited Review Appeals Process Appeals involving an imminent and serious threat to your health including, but not limited to, severe pain or the potential loss of life, limb or major bodily function will be immediately referred to the IRO s clinical review personnel. Expedited appeals will be reviewed and you will be notified of the determination within 72 hours from EnvisionRx receipt of the appeal. If your case does not meet the criteria for an expedited review, it will be reviewed under the standard appeal process. Specialty Pharmacy (Injectable Medications) Envision Specialty Pharmacy will conveniently deliver your Injectable medications to your home or physician s office, or other location of choice. And there is no charge for shipping! Your prescription drug benefit allows one grace fill at any retail pharmacy, for up to a 30-day supply each, to ensure you continue receiving your specialty medication(s) as scheduled. After that, you are required to utilize Envision Specialty Pharmacy for your specialty medications. Because specialty medications can be more difficult to manage, Envision Specialty Pharmacy offers the following patient support services at no charge: Personalized support to help you achieve the best results from your prescribed therapy Convenient delivery to your home or prescriber s office Easy access to a Care Team who can answer medication questions, provide educational materials about your condition, help you manage any potential medication side effects, and provide confidential support all with one toll-free phone call. If you have any questions, or to begin taking advantage of these complimentary patient support services, please call Envision Specialty Pharmacy at Who should I call with questions? Call EnvisionRx at for direct access to their customer service line. 3 Tier Revised 4/24/2017 4

27 Plan Benefit Highlights for: Effective Date: 1/1/2017 Reta Trust - Plan 3A Eligibility Deductibles Deductibles waived for Diagnostic & Preventive (D & P) and Orthodontics? Maximums Waiting Period(s) Primary enrollee, spouse and eligible dependent children to the end of the month dependent turns age 26 Delta Dental PPO dentists: $50 per person / $150 per family each calendar year Non-Delta Dental PPO dentists: $75 per person / $225 per family each calendar year Yes $2,000 per person each calendar year Basic Benefits None Major Benefits None Prosthodontics None Orthodontics None Benefits and Covered Services* Delta Dental PPO dentists** Non-Delta Dental PPO dentists** Diagnostic & Preventive Services (D & P) 100 % 100 % Exam, cleanings, x-rays and sealants Basic Services Fillings, simple tooth extractions 90 % 80 % Endodontics (root canals) Covered Under Basic Services 90 % 80 % Periodontics (gum treatment) Covered Under Basic Services 90 % 80 % Oral Surgery Covered Under Basic Services 90 % 80 % Major Services Crowns, inlays, onlays and cast 60 % 50 % restorations Prosthodontics Bridges, dentures and implants 60 % 50 % Orthodontic Benefits Adults and dependent children 50 % 50 % Orthodontic Maximums $ 1,500 Lifetime $ 1,500 Lifetime * Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist s submitted fees. ** Reimbursement is based on PPO contracted fees for PPO dentists, Delta Dental Premier contracted fees for Premier dentists and the program allowance for non-delta Dental dentists. Delta Dental of California 100 First St. San Francisco, CA Customer Service deltadentalins.com Claims Address P.O. Box Sacramento, CA This benefit information is not intended or designed to replace or serve as the plan s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company s benefits representative.

28 Summary of Dental Benefits All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest. 500 NE Multnomah St., Suite 100, Portland, OR Membership Services: Oregon LHCJ 7/1/2017-6/30/2018 Archdiocese of Portland In Oregon Group Number: , 106 Benefit Maximum per Member, per Calendar Year None You pay Dental Office Visit Charge Applies to all visits $5 Deductible (Per Calendar Year For one Member $0 For an entire Family $0 Preventive and Diagnostic Services Oral exam No additional charge X-rays No additional charge Teeth cleaning No additional charge Fluoride No additional charge Basic Restoration Services Routine fillings No additional charge Plastic and steel crowns No additional charge Simple extractions No additional charge Oral Surgery Services Surgical tooth extractions 20% Coinsurance Periodontics Treatment of gum disease 20% Coinsurance Scaling and root planing 20% Coinsurance Endodontics Root canal therapy 20% Coinsurance Major Restoration Services Gold or porcelain crowns 20% Coinsurance Bridges 20% Coinsurance Removable Prosthetic Services Full and partial dentures 20% Coinsurance Relines 20% Coinsurance Rebases 20% Coinsurance Nitrous oxide (Not counted toward the Benefit Maximum) Adults and children age 13 years and older $25 Children age 12 years and younger $0 Orthodontics Not a covered benefit SSOB ORLGTRADdental 0117_ MMC-14/7-14

29 Plan is subject to exclusions and limitations. A complete list of the exclusions and limitations is included in the Evidence of Coverage (EOC). Sample EOCs are available upon request. Questions? Call Member Services (M-F, 8 am-6 pm) or visit kp.org Portland area: All other areas: TTY.711. Language Interpretation Services, all areas This is not a contract. This benefit summary does not fully describe your benefit coverage with Kaiser Foundation Health Plan of the Northwest. For more details on benefit coverage, claims review, and adjudication procedures, please see your EOC or call Member Services. In the case of a conflict between this summary and the EOC, the EOC will prevail. SSOB ORLGTRADdental 0117_ MMC-14/7-14

30 Group Number: OR10 Effective Date: July 1 st, 2017 Archdiocese of Portland in Oregon BENEFITS COPAYS Annual Maximum No Annual Maximum Deductible No Deductible General & Orthodontic Office Visit You pay a $4 Copay per Visit DIAGNOSTIC AND PREVENTIVE SERVICES Routine and Emergency Exams Covered with the Office Visit Copay X-rays Covered with the Office Visit Copay Teeth Cleaning Covered with the Office Visit Copay Fluoride Treatment Covered with the Office Visit Copay Sealants (per Tooth) Covered with the Office Visit Copay Head and Neck Cancer Screening Covered with the Office Visit Copay Oral Hygiene Instruction Covered with the Office Visit Copay Periodontal Charting Covered with the Office Visit Copay Periodontal Evaluation Covered with the Office Visit Copay RESTORATIVE DENTISTRY Fillings Covered with the Office Visit Copay Porcelain-Metal Crown You pay a $110 Copay PROSTHODONTICS Complete Upper or Lower Denture You pay a $110 Copay Bridge (per Tooth) You pay a $110 Copay ENDODONTICS AND PERIODONTICS Root Canal Therapy Anterior You pay a $45 Copay Root Canal Therapy Bicuspid You pay a $75 Copay Root Canal Therapy Molar You pay a $95 Copay Osseous Surgery (per Quadrant) You pay a $110 Copay Root Planing (per Quadrant) You pay a $40 Copay ORAL SURGERY Routine Extraction (Single Tooth) Covered with the Office Visit Copay Surgical Extraction You pay a $70 Copay ORTHODONTIA TREATMENT Pre-Orthodontia Treatment You pay a $150 Copay* Comprehensive Orthodontia Treatment You pay a $1,700 Copay MISCELLANEOUS Local Anesthesia Covered with the Office Visit Copay Dental Lab Fees Covered with the Office Visit Copay Nitrous Oxide You pay a $20 Copay Specialty Office Visit You pay a $30 Copay per Visit Out of Area Emergency Care Reimbursement You pay charges in excess of $100 *Copay credited towards the Comprehensive Orthodontia Treatment copay if patient accepts treatment plan. Underwritten by Willamette Dental Insurance, Inc. This plan provides extensive coverage of services and supplies to prevent, diagnose, and treat diseases or conditions of the teeth and supporting tissues. Presented are just some of the most common procedures covered in your plan. Please see the Certificate of Coverage for a complete plan description, limitations, and exclusions. Form No. 028-OR(1/17) Contract No. 001-OR(2/14)

31 Exclusions Bridges, crowns, dentures or any prosthetic devices requiring multiple treatment dates or fittings if the prosthetic item is installed or delivered more than 60 days after termination of coverage. The completion or delivery of treatments, services, or supplies initiated prior to the effective date of coverage. Dental implants, including attachment devices, maintenance, and dental implant-related services. Endodontic services, prosthetic services, and implants that were provided prior to the effective date of coverage. Endodontic therapy completed more than 60 days after termination of coverage. Exams or consultations needed solely in connection with a service not listed as covered. Experimental or investigational services or supplies and related exams or consultations. Full mouth reconstruction, including the extensive restoration of the mouth with crowns, bridges, or implants; and occlusal rehabilitation, including crowns, bridges, or implants used for the purpose of splinting, altering vertical dimension, restoring occlusions or correcting attrition, abrasion, or erosion. General anesthesia, moderate sedation and deep sedation. Hospitalization care outside of a dental office for dental procedures, physician services, or facility fees. Nightguards. Orthognathic surgery. Personalized restorations. Plastic, reconstructive, or cosmetic surgery and other services or supplies, which are primarily intended to improve, alter, or enhance appearance. Prescription and over-the-counter drugs and premedications. Provider charges for a missed appointment or appointment cancelled without 24 hours prior notice. Replacement of lost, missing, or stolen dental appliances; Replacement of dental appliances that are damaged due to abuse, misuse, or neglect. Replacement of sound restorations. Services and related exams or consultations that are not within the prescribed treatment plan and/or are not recommended and approved by a Willamette Dental Group dentist. Services and related exams or consultations to the extent they are not necessary for the diagnosis, care, or treatment of the condition involved. Services by any person other than a licensed dentist, denturist, hygienist, or dental assistant. Services for the diagnosis or treatment of temporomandibular joint disorders. Services for the treatment of an injury or disease that is covered under workers compensation or that are an employer s responsibility. Services for treatment of injuries sustained while practicing for or competing in a professional athletic contest. Services for treatment of intentionally self-inflicted injuries. Services for which coverage is available under any federal, state, or other governmental program, unless required by law. Services not listed as covered in the contract. Services where there is no evidence of pathology, dysfunction, or disease other than covered preventive services. Limitations If alternative services can be used to treat a condition, the service recommended by the Willamette Dental Group dentist is covered. Services listed in the contract, which are provided to correct congenital or developmental malformations which impair functions of the teeth and supporting structures will be covered if primarily for the purpose of controlling or eliminating infection, controlling or eliminating pain, or restoring function. Crowns, casts, or other indirect fabricated restorations are covered only if dentally necessary and if recommended by the Willamette Dental Group dentist. When initial root canal therapy was performed by a Willamette Dental Group dentist, the retreatment of such root canal therapy will be covered as part of the initial treatment for the first 24 months. When the initial root canal therapy was performed by a non-participating provider, the retreatment of such root canal therapy by a Willamette Dental Group dentist will be subject to the applicable copayments. The services provided by a dentist in a hospital setting are covered if medically necessary; pre-authorized by a Willamette Dental Group dentist; the services provided are the same services that would be provided in a dental office; and applicable copayments are paid. The replacement of an existing denture, crown, inlay, onlay, or other prosthetic appliance is covered if the appliance is more than 5 years old and replacement is dentally necessary. Form No. 028-OR(1/17) Contract No. 001-OR(2/14)

32 Your Vision Benefits Summary Get the best in eye care and eyewear with RETA TRUST- Plan 2 and VSP Vision Care. Using your VSP benefit is easy. Create an account at vsp.com. Once your plan is effective, review your benefit information. Find an eye care provider who s right for you. The decision is yours to make choose a VSP doctor, a participating retail chain, or any out-of-network provider. To find a VSP provider, visit vsp.com or call At your appointment, tell them you have VSP. There s no ID card necessary. If you d like a card as a reference, you can print one on vsp.com. That s it! We ll handle the rest there are no claim forms to complete when you see a VSP provider. Best Eye Care You ll get the highest level of care, including a WellVision Exam the most comprehensive exam designed to detect eye and health conditions. Plus, when you see a VSP provider, you'll get the most out of your benefit, have lower out-of-pocket costs, and your satisfaction is guaranteed. Choice in Eyewear From classic styles to the latest designer frames, you ll find hundreds of options. Choose from featured frame brands like bebe, Calvin Klein, Cole Haan, Flexon, Lacoste, Nike, Nine West, and more 1. Visit vsp.com to find a Premier Program location that carries these brands. Prefer to shop online? Check out all of the brands at Eyeconic.com, VSP's online eyewear store. Plan Information VSP Provider Network: VSP Choice RETA TRUST- Plan 2 and VSP provide you with an affordable eyecare plan. Visit vsp.com or call for more details on your vision coverage and exclusive savings and promotions for VSP members. 1 Brands/Promotion subject to change Vision Service Plan. All rights reserved. VSP, VSP Vision care for life, and WellVision Exam are registered trademarks of Vision Service Plan. Flexon is a registered trademark of Marchon Eyewear, Inc. All other company names and brands are trademarks or registered trademarks of their respective owners. Benefit WellVision Exam Prescription Glasses Frame Lenses Lens Enhancements Contacts (instead of glasses) Diabetic Eyecare Plus Program Extra Savings Description Your Coverage with a VSP Provider Focuses on your eyes and overall wellness Every 12 months $150 allowance for a wide selection of frames $170 allowance for featured frame brands 20% savings on the amount over your allowance $80 Costco frame allowance Every 24 months Single vision, lined bifocal, and lined trifocal lenses Polycarbonate lenses for dependent children Every 12 months Standard progressive lenses Premium progressive lenses Custom progressive lenses Anti-reflective coating Average savings of 20-25% on other lens enhancements Every 12 months $150 allowance for contacts; copay does not apply Contact lens exam (fitting and evaluation) Every 12 months Services related to diabetic eye disease, glaucoma and age-related macular degeneration (AMD). Retinal screening for eligible members with diabetes. Limitations and coordination with medical coverage may apply. Ask your VSP doctor for details. As needed Copay $10 $25 Included in Prescription Glasses Included in Prescription Glasses $40 $40 $40 $20 Up to $60 $20 Glasses and Sunglasses Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details. 20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your last WellVision Exam. Retinal Screening No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam Laser Vision Correction Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities Your Coverage with Out-of-Network Providers Visit vsp.com for details, if you plan to see a provider other than a VSP network provider. Exam...up to $45 Lined Trifocal Lenses...up to $65 Frame...up to $70 Progressive Lenses...up to $50 Single Vision Lenses...up to $30 Contacts...up to $105 Lined Bifocal Lenses...up to $50 Tints...up to $5 Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details. Coverage information is subject to change. In the event of a conflict between this information and your organization s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location.

33 Save Up to 60% on Brand-name Hearing Aids Like vision loss, hearing loss can have a huge impact on your quality of life. However, the cost of a pair of quality hearing aids usually costs more than $5,000, and few people have hearing aid insurance coverage. TruHearing makes hearing aids affordable by providing exclusive savings to all VSP Vision Care members. You can save up to 60% on a pair of hearing aids with TruHearing. What s more, your dependents and even extended family members are eligible, too. In addition to great pricing, TruHearing provides you with: Three provider visits for fitting and adjustments 45-day trial Three-year manufacturer warranty for repairs and one-time loss and damage replacement 48 free batteries per hearing aid Plus, with TruHearing you ll get: Access to a national network of more than 3,800 hearing healthcare providers Straightforward, nationally-fixed pricing on a wide selection of the latest brand-name hearing aids Deep discounts on batteries shipped directly to your door Best of all, if you already have a hearing aid benefit from your health plan or employer, you can combine it with TruHearing prices to reduce your out-of-pocket expense even more! Here s how it works: Contact TruHearing. Call You and your family members must mention VSP. Schedule exam. TruHearing will answer your questions and schedule a hearing exam with a local provider. Attend appointment. The provider will perform a hearing exam, make a recommendation, order the hearing aids through TruHearing, and fit them for you. Learn more about this VSP Exclusive Member Extra at truhearing.com/vsp or, call with questions. The relationship between VSP and TruHearing is that of independent contractors. VSP makes no endorsement, representations or warranties regarding any products or services offered by TruHearing, a third-party vendor. TruHearing is solely responsible for the products or services offered by them. Savings based on a survey of national average retail hearing aid prices compared to average TruHearing pricing. Actual customer savings will vary. Three follow-up visits must be used within one year after the date of initial purchase. Forty-five-day trial and hearing aid returns, repairs, and replacements subject to provider and manufacturer fees. For questions regarding fees, contact TruHearing customer service. Not available in the state of Washington Vision Service Plan. All rights reserved. VSP is a registered trademark of Vision Service Plan. All other brands or marks are the property of their respective owners. JOB# VCXA 6/17

34 Enhancements to the EAP Member speaks with a Master Level clinician ( Case Manager) not a customer service representative A quick assessment will happen to better define the issue affecting you MHN will find the provider make sure they are available and match to your medical if able to MHN will call or member back with provider information member then calls provider to set appointment First appointment within 5 days of initial call! Case Manager will reach out to both provider and member after first appointment to ensure match is appropriate and meets the members needs New Ways to Connect with MHN Finally there is an app for your smart phone! o Call Text to reach a Clinical Case Manager New website o Later in 2017 will add Live Connect that will allow text and directly to a work/life consultant Enhanced Work/Life Benefits In My Hands Computerized Cognitive Behavioral Therapy (CCBT) o Online with guidance from Case Manager Geriatric Care and Care Coach for elder care issues Nursing Mother Now 60 minutes free consultation (telephonic or in person) with attorney and then 30% reduction in hourly fee

35 Archdiocese of Portland in Oregon Account Number 5125 Benefit Summary Clinical Counseling 5 face-to-face sessions or telephonic or web-video consultations per individual, per issue, per year Telephonic Work-life Services Child and Elder Care Referrals (confirmed provider openings) Legal Consultations Financial Consultations Identity Theft Prevention and Recovery Assistance Daily Living Services Wellness Coaching Program: o Weight management o Smoking cessation o Fitness and exercise o Stress management o Overall lifestyle improvement o Lifestyle support for chronic conditions Member Website - members.mhn.com Company Code: aportland Assessments: depression, alcoholism, insomnia and stress, and more Self-help programs, articles and resources Wellness Portal - Health Assessment Online Smoking Cessation, Weight Loss and Nutrition Programs Downloadable legal forms and online Estate Planning Self-paced e-learning training workshops Client Services: Job Performance Referrals Critical Incident Response (20 hours free onsite time per event) Management Consultations

36 Archdiocese of Portland in Oregon Account Number 5125 Benefit Summary Training Services Training Workshops: 10 hours (4 of which may be used for Organizational Development) per year with option to buy additional hours on a Fee For Service basis Health Fairs & Orientations As requested in person and telephonic Employee Orientations about Employee EAP benefits per year As requested in person and telephonic Supervisor Orientations about Supervisor EAP benefits per year As requested Health Fair attendance per year

37 The Archdiocese of Portland in Oregon a Corporation Sole Life/AD&D Employer Paid Plan Highlights LIFE/AD&D INSURANCE Unum Policy # Eligibility Group 1 Lay employee or permanent deacon employed by Archdiocese, an affiliated parish or school, or participating employer, in active employment, in the United States with the Employer, scheduled to work: a. at least 20 hours a week, 52 weeks a year, or b. at least 26 hours a week, 39 weeks a year, or c. an average of at least 20 hours a week over 12 months Note: Employees scheduled to work 6 months or less during 12 consecutive months are not eligible employees Benefit Amount $25,000 Accelerated Death Benefit 75% to $500,000 Group 2 A seminarian, diocesan priest, or member of a religious order under the care of and for whom the Employer has financial responsibility and who is not classified as a retiree in active employment in the United States with the Employer Group 3 Licensed or waivered elementary or secondary classroom teachers who are scheduled to work at least 20 hours a week with an employment agreement for longer than six months in active employment in the United States with the Employer Survivor Support Portability Life Planning Financial And Legal Resources Included If you retire, reduce your hours or leave your Employer, you can take this coverage with you according to the terms of the contract. Included Life Benefit Reduction 65% at age 65 and 45% at age 70 Premium Employer Paid This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Details may differ from state to state. Please refer to your certificate booklet for your complete plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern.

38 Term Life Insurance and AD&D Coverage Highlights Your Plan Eligibility The Archdiocese of Portland in Oregon Policy # Please read carefully the following description of your Unum Term Life and AD&D insurance plan. All employees working working in the following groups in the U.S. with the employer, and their eligible spouses and children (up to age 26). *Note: Disabled children over the maximum child age may be eligible for benefits, please see your plan administer for more details. Group 1 Lay employee or permanent deacon employed by the Archdiocese, an affiliated parish or school, or participating employer, in active employment in the United States with the Employer, scheduled to work: a. at least 20 hours a week, 52 weeks a year, or b. at least 26 hours a week, 39 weeks a year, or c. an average of at least 20 hours a week over 12 months Note: Employees scheduled to work 6 months or less during 12 consecutive months are not eligible employees Group 2 Diocesan priests under the care of and for whom the Employer has financial responsibility and who are not classified as retirees in active employment in the United States with the Employer Coverage Amounts Group 3 Licensed or waivered elementary or secondary teachers who are scheduled to work at least 20 hours a week with an employment agreement for longer than 6 months in active employment in the United States with the Employer Note: Employees scheduled to work 6 months or less during 12 consecutive months are not eligible employees Your Term Life coverage options are: Employee: Up to 5 times salary in increments of $10,000. Not to exceed $500,000. Spouse: Up to 100% of employee amount in increments of $5,000. Not to exceed $500,000. Benefits will be paid to the employee. Child: Option A: $6,000 Option B: $8,000 Option C: $10,000 The maximum death benefit for a child between the ages of live birth and 6 months is $1,000. Benefits will be paid to the employee. In order to purchase Life coverage for your spouse and/or child, you must purchase Life coverage for yourself. ADR

39 Your AD&D coverage options are: Term Life Insurance and AD&D Coverage Highlights (Continued) Employee: Up to 5 times salary in increments of $10,000. Not to exceed $500,000. You may purchase AD&D coverage for yourself regardless of whether you purchase Life coverage. Spouse: Up to 100% of employee amount in increments of $5,000. Not to exceed $500,000. Benefits will be paid to the employee. Child: $8,000 The maximum death benefit for a child between the ages of live birth and 6 months is $1,000. Benefits will be paid to the employee. In order to purchase AD&D coverage for your spouse and/or child, you must purchase AD&D coverage for yourself. Guarantee Issue AD&D Benefit Schedule: The full benefit amount is paid for loss of: Life Both hands or both feet or sight of both eyes One hand and one foot One hand and the sight of one eye One foot and the sight of one eye Speech and hearing Other losses may be covered as well. Please see your Plan Administrator. Coverage amount(s) will reduce according to the following schedule: Age: Insurance Amount Reduces to: 65 65% of original amount 70 45% of original amount Coverage may not be increased after a reduction. If you enroll within 31 days of your eligibility date, you may apply for any amount of Life insurance coverage up to $150,000 for yourself and any amount of coverage up to $25,000 for your spouse. Any Life insurance coverage over the Guarantee Issue amount(s) will be subject to evidence of insurability. If you and your eligible dependents do not enroll within 31 days of your eligibility date, you can apply for coverage only during an annual enrollment period and will be required to furnish evidence of insurability for the entire amount of coverage. If you and your eligible dependents enroll within 31 days of your eligibility date, and later, wish to increase your coverage, you may increase your coverage, with evidence of insurability, at anytime during the year. However, you may wait until the next annual enrollment and only coverage over the Guarantee Issue amount(s) will be subject to evidence of insurability. AD&D coverage does not require evidence of insurability. Please see your Plan Administrator for your eligibility date.

40 Term Life Insurance and AD&D Coverage Highlights (Continued) Term Life Coverage Rates Age Band Rates shown are your Monthly deduction: Employee per $10,000 Spouse per $5,000 Child per $2, $.660 $.660 $.80 $.970 $1.580 $2.800 $4.770 $7.800 $ $ $ $ $.440 $.440 $.500 $.610 $.960 $1.670 $2.770 $4.350 $6.810 $ $ $ NOTE: Your rate will increase as you age and move to the next age band. AD&D Coverage Rates AD&D Cost Per: Monthly Rate Employee: $10,000 $.300 Spouse: $ 5,000 $.160 Child: $ 2,000 $.100 Insurance Age $.500 NOTE: The premium paid for child coverage is based on the cost of coverage for one child, regardless of how many children you have. Your rate is based on your insurance age. To calculate your insurance age, subtract your year of birth from the year your coverage becomes effective. To calculate your cost, complete the following by selecting your coverage amount and rate (based on your insurance age). Term Life Calculation Worksheet Coverage Amount Increment Rate Monthly Cost Employee $ $10,000 x $ = $ Spouse $ $ 5,000 x $ = $ Children $ $ 2,000 x $ = $ Total Monthly Cost = $ AD&D Calculation Worksheet Coverage Amount Increment Rate Monthly Cost Employee $ $10,000 x $ = $ Spouse $ $ 5,000 x $ = $ Children $ $ 2,000 x $ = $ Total Monthly Cost = $ Additional Benefits Life Planning Financial & Legal Resources This personalized financial counseling service provides expert, objective financial counseling to survivors and terminally ill employees at no cost to you. This service is also extended to you upon the death or terminal illness of your covered spouse. The financial consultants are master level consultants. They will help develop strategies needed to protect resources, preserve current lifestyles, and build future security. At no time will the consultants offer or sell any product or service.

41 Term Life Insurance and AD&D Coverage Highlights (Continued) Portability/Conversion Accelerated Benefit Waiver of Premium Retained Asset Account Additional AD&D Benefits If you retire, reduce your hours or leave your employer, you can take this coverage with you according to the terms outlined in the contract. However, if you have a medical condition which has a material effect on life expectancy, you will be ineligible to port your coverage. You may also have the option to convert your Term life coverage to an individual life insurance policy. If you become terminally ill and are not expected to live beyond a certain time period as stated in your certificate booklet, you may request up to 75% of your life insurance amount up to $500,000, without fees or present value adjustments. A doctor must certify your condition in order to qualify for this benefit. Upon your death, the remaining benefit will be paid to your designated beneficiary(ies). This feature also applies to your covered dependents. If you become disabled (as defined by your plan) and are no longer able to work, your premium payments will be waived during the period of disability. Benefits of $10,000 or more are paid through the Unum Retained Asset Account. This interest bearing account will be established in the beneficiary's name. He or she can then write a check for the full amount or for $250 or more, as needed. Education Benefit: If you or your insured spouse die within 365 days of an accident, an additional benefit is paid to your dependent child(ren). Your child(ren) must be a full-time student beyond grade 12. (Not available in Illinois or New York.) Seat Belt/Air Bag Benefit: If you or your insured dependent(s) die in a car accident and are wearing a properly fastened seat belt and/or are in a seat with an air bag, an amount will be paid in addition to the AD&D benefit. Limitations/Exclusions/ Termination of Coverage Suicide Exclusion AD&D Benefit Exclusions Life benefits will not be paid for deaths caused by suicide in the first twenty-four months after your effective date of coverage. No increased or additional benefits will be payable for deaths caused by suicide occurring within 24 months after the day such increased or additional insurance is effective. AD&D benefits will not be paid for losses caused by, contributed to by, or resulting from: Disease of the body or diagnostic, medical or surgical treatment or mental disorder as set forth in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders; Suicide, self-destruction while sane, intentionally self-inflicted injury while sane, or self-inflicted injury while insane; War, declared or undeclared, or any act of war; Active participation in a riot; Attempt to commit or commission of a crime; The voluntary use of any prescription or non-prescription drug, poison, fume, or other chemical substance unless used according to the prescription or direction of your or your dependent s doctor. This exclusion does not apply to you or your dependent if the chemical substance is ethanol;

42 Term Life Insurance and AD&D Coverage Highlights (Continued) Termination of Coverage Next Steps How to Apply Effective Date of Coverage Delayed Effective Date of Coverage Changes to Coverage Intoxication. ( Intoxicated means that the individual s blood alcohol level equals or exceeds the legal limit for operating a motor vehicle in the state or jurisdiction where the accident occurred.) Your coverage and your dependents coverage under the Summary of Benefits ends on the earliest of: The date the policy or plan is cancelled; The date you no longer are in an eligible group; The date your eligible group is no longer covered; The last day of the period for which you made any required contributions; The last day you are in active employment unless continued due to a covered layoff or leave of absence or due to an injury or sickness, as described in the certificate of coverage; For dependent s coverage, the date of your death. In addition, coverage for any one dependent will end on the earliest of: The date your coverage under a plan ends; The date your dependent ceases to be an eligible dependent; For a spouse, the date of divorce or annulment. Unum will provide coverage for a payable claim which occurs while you and your dependents are covered under the policy or plan. To apply for coverage, complete your enrollment form within 31 days of your eligibility date. All employees: If you apply for coverage after your effective date, or if you choose coverage over the guarantee issue amount, you will need to complete a medical questionnaire which you can get from your Plan Administrator. You may also be required to take certain medical tests at Unum s expense. Please see your Plan Administrator for your effective date. Employee: Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective. Dependent: Insurance coverage will be delayed if that dependent is totally disabled on the date that insurance would otherwise be effective. Exception: infants are insured from live birth. Totally disabled means that, as a result of an injury, a sickness or a disorder, your dependent is confined in a hospital or similar institution; is unable to perform two or more activities of daily living (ADLs) because of a physical or mental incapacity resulting from an injury or a sickness; is cognitively impaired; is receiving or is entitled to receive any disability income from any source due to any sickness or injury; is receiving chemotherapy radiation therapy or dialysis treatment; or has a life threatening condition. Each year you and your spouse will be given the opportunity to change your Life coverage and AD&D coverage. You and your spouse may purchase additional Life

43 Term Life Insurance and AD&D Coverage Highlights (Continued) Questions coverage up to the Guarantee Issue amounts without evidence of insurability if you are already enrolled in the plan. Life coverage over the Guarantee Issue amounts will be medically underwritten and will require evidence of insurability and approval by Unum s Medical Underwriters. The suicide exclusion will apply to any increase in coverage. AD&D coverage does not require evidence of insurability for increase amounts. If you should have any questions about your coverage or how to enroll, please contact your Plan Administrator. This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Some provisions may vary or not be available in all states. Please refer to your certificate booklet for your complete plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern. For complete details of coverage, please refer to policy form number C.FP-1, et al. Life Planning is provided by Ceridian Incorporated. The services are subject to availability and may be withdrawn by Unum without prior notice. Underwritten by: Unum Life Insurance Company of America, 2211 Congress Street, Portland, Maine 04122, Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries Unum Group. All rights reserved.

44 The Archdiocese of Portland in Oregon LTD Employer Paid Plan Highlights LONG TERM DISABILITY Unum Policy # Eligibility Benefit Amount Definition of Disability: Elimination Period Duration All Diocesean Clergy in the United States working: a. at least 20 hours a week, 52 weeks a year, or b. at least 26 hours a week, 39 weeks a year, or c. an average of at least 20 hours a week over 12 months 50% of your monthly earnings, to max of $4,000 per month. During the first 24 months, Unum will define disability as follows: you are limited from performing the material and substantial duties of your regular occupation due to sickness or injury; and you have a 20% or more loss of indexed monthly earnings due to the same sickness or injury.. 90 days The duration of your benefit payments is based on your age when your disability occurs. Your LTD benefits are payable for the period during which you continue to meet the definition of disability. If your disability occurs before age 60, your benefits could be payable until you reach age 65. If your disability occurs at or after age 60, benefits could be paid according to a benefit duration schedule. Pre-existing Condition 3/12 Travel Assistance Program Premium Included Employer Paid This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Details may differ from state to state. Please refer to your certificate booklet for your complete plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern.

45 Long Term Disability Income Protection Insurance Plan Highlights The Archdiocese of Portland in Oregon Policy # Please read carefully the following description of your Unum Long Term Disability Income Protection insurance plan. Your Plan Eligibility Group 1 As a lay employee or permanent deacon employed by the Archdiocese, an affiliated parish or school, or other participating employer in active employment, you're eligible for benefits if you meet any of these criteria: a. at least 20 hours a week, 52 weeks a year, or b. at least 26 hours a week, 39 weeks a year, or c. an average of at least 20 hours a week over 12 months Employees scheduled to work 6 months or less during 12 consecutive months are not eligible employees Group 2 Licensed or waivered elementary or secondary classroom teachers who are scheduled to work at least 20 hours a week with an employment agreement for longer than six months in active employment. Benefit Amount Base LTD Benefit: 50% of your monthly earnings To a maximum of $4000 Buy up LTD Benefit: Buy up LTD Benefit: 60% of your monthly earnings. To a maximum of $6, /3% of your monthly earnings. To a maximum of $6,000 Definition of Disability You would be considered disabled and eligible for benefits because of sickness or injury if: you are limited from performing the material and substantial duties of your regular occupation; and you have a 20% or more loss in indexed monthly earnings due to the same sickness or injury. You will continue to receive benefits if: after benefits have been paid for 24 months, you are working in any occupation and continue to have a 20% or more loss in indexed monthly earnings due to your sickness or injury; or you are not working and, due to the same sickness or injury, are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience. ADR

46 Elimination Period The Elimination Period is the length of time of continuous disability which must be satisfied before you are eligible to receive benefits. LTD benefits would begin after 90 days of disability, as described in the definition above. Benefit Duration Gainful Occupation Federal Income Taxation Your duration of benefits is based on your age when the disability occurs. Your LTD benefits are payable for the period during which you continue to meet the definition of disability. If your disability occurs before age 60, benefits will be payable until age 65. If your disability occurs at or after age 60, benefits would be paid according to a benefit duration schedule. Gainful occupation means an occupation that is or can be expected to provide you with an income at least equal to your gross disability payment within 12 months of your return to work. You may wonder if your disability benefit amount will be taxed. It depends on how your premium the price of your coverage is paid. If your premium is paid with: Both Pre-Tax and Post-Tax Dollars, a portion of your benefit amount will be taxed The disability benefit amounts you receive will be reported annually on a W-2. It will show any taxable and non-taxable portions separately. *Pre-Tax Dollars are dollars paid by your employer toward premium that are not reported as earnings on your annual W-2. They are also dollars you pay toward premium through a cafeteria plan. **Post-Tax Dollars are dollars paid through payroll deductions after taxes and withholdings have been subtracted from your earnings. They are also dollars paid by your employer toward premium that are reported as earnings on your annual W-2 and taxed accordingly. Additional Benefits Rehabilitation and Return to Work Assistance Waiver of Premium Worldwide Emergency Travel Assistance Services Unum has a vocational rehabilitation program available to assist you to return to work. This program is offered as a service, and is voluntary on your part and on Unum s part. Unum may elect to offer you a return-towork program including, but not limited to, the following services: coordination with your Employer to assist you to return to work; evaluation of adaptive equipment to allow you to work; vocational evaluation to determine how your disability may impact your employment options; job placement services; resume preparation; job seeking skills training; or retraining for a new occupation. You will not be required to pay LTD premiums as long as you are receiving LTD benefits. Whether your travel is for business or pleasure, our worldwide emergency travel assistance program is there to help you when an unexpected emergency occurs. With one phone call anytime of the day or night, you, your spouse and dependent children can get

47 Survivor Benefit Limitations/Exclusions/ Termination of Coverage Pre-existing Condition Exclusion Instances When Benefits Would Not Be Paid Mental and Nervous immediate assistance anywhere in the world. Emergency travel assistance is available to you when you travel to any foreign country, including neighboring Canada or Mexico. It is also available anywhere in the United States for those traveling more than 100 miles from home. Your spouse and dependent children do not have to be traveling with you to be eligible. However, spouses traveling on business for their employer are not covered by this program. Unum will pay your eligible survivor a lump sum benefit equal to 3 months of your gross disability payment. This benefit will be paid if, on the date of your death, your disability had continued for 180 or more consecutive days, and you were receiving or were entitled to receive payments under the plan. If you have no eligible survivors, payment will be made to your estate, unless there is none. In this case, no payment will be made. However, we will first apply the survivor benefit to any overpayment which may exist on your claim. You have a pre-existing condition if: you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; and the disability begins in the first 12 months after your effective date of coverage. Benefits would not be paid for disabilities caused by, contributed to by, or resulting from: intentionally self-inflicted injuries; active participation in a riot; war, declared or undeclared, or any act of war; conviction of a crime under state or federal law; loss of professional license, occupational license or certification; pre-existing conditions (see definition). Unum will not pay a benefit for any period of disability during which you are incarcerated. LTD benefits would be paid for 24 months per lifetime for disabilities caused by mental illness that meet the definition of disability. Mental and nervous benefits would continue beyond 24 months only if you are institutionalized or hospitalized as a result of the disability.

48 Termination of Coverage Next Steps How to Apply Effective Date of Coverage Delayed Effective Date of Coverage Changes to Coverage Questions Your coverage under the policy ends on the earliest of the following: The date the policy or plan is cancelled; The date you no longer are in an eligible group; The date your eligible group is no longer covered; The last day of the period for which you made any required contributions; The last day you are in active employment except as provided under the covered layoff or leave of absence provision. Unum will provide coverage for a payable claim which occurs while you are covered under the policy or plan. To apply for coverage, complete your enrollment form within 31 days of your eligibility date. Please see your Plan Administrator for your effective date. Insurance will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective. Each year, or when you have a change in status, you will have the opportunity to change your long term disability coverage by one level. Any increase in coverage will be subject to the pre-existing condition exclusion. If you should have any questions about your coverage or how to enroll, please contact your Plan Administrator. This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Some provisions may vary or not be available in all states. Please refer to your certificate booklet for your complete plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern. For complete details of coverage, please refer to policy form number C.FP-1, et al. All worldwide emergency travel assistance must be arranged by Assist America, which pays for all services it provides. Medical expenses such as prescriptions or physician, lab or medical facility fees are paid by the employee or the employee s health insurance. Underwritten by: Unum Life Insurance Company of America 2211 Congress Street, Portland, Maine 04122, Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

49 Short Term Disability Income Protection Insurance Plan Highlights The Archdiocese of Portland in Oregon Policy # Please read carefully the following description of your Short Term Disability Income Protection insurance plan, underwritten by Unum Life Insurance Company of America. Your Plan Eligibility Group 1 As a lay employee or permanent deacon employed by the Archdiocese, an affiliated parish or school, or other participating employer in active employment, you're eligible for benefits if you meet any of these criteria: a. at least 20 hours a week, 52 weeks a year, or b. at least 26 hours a week, 39 weeks a year, or c. an average of at least 20 hours a week over 12 months Employees scheduled to work 6 months or less during 12 consecutive months are not eligible employees Group 2 Licensed or waivered elementary or secondary classroom teachers who are scheduled to work at least 20 hours a week with an employment agreement for longer than six months in active employment. Weekly Benefit Amount 60% of your basic weekly earnings to a maximum of $500 Your disability benefit may be reduced by deductible sources of income and any earnings you have while disabled. Deductible sources of income may include such items as disability income or other amounts you receive or are entitled to receive under: workers compensation or similar occupational benefit laws; state compulsory benefit laws; automobile liability and no fault insurance; legal judgments and settlements; certain retirement plans; salary continuation or sick leave plans; other group or association disability programs or insurance; and amounts you or your family receive or are entitled to receive from Social Security or similar governmental programs. Definition of Disability You are disabled when Unum determines that: you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and you have a 20% or more loss in weekly earnings due to the same sickness or injury. ADR

50 Elimination Period and Benefit Duration Federal Income Taxation The Elimination Period is the length of time of continuous disability which must be satisfied before you are eligible to receive benefits. Option A: No Coverage Option B: If your disability is the result of an injury that occurs while you are covered under the plan, your Elimination Period is 44 days. If your disability is due to a sickness, your Elimination Period is 44 days. If you meet the definition of disability you may receive a benefit for 7 weeks. Option C: If your disability is the result of an injury that occurs while you are covered under the plan, your Elimination Period is 30 days. If your disability is due to a sickness, your Elimination Period is 30 days. If you meet the definition of disability you may receive a benefit for 9 weeks. Option D: If your disability is the result of an injury that occurs while you are covered under the plan, your Elimination Period is 14 days. If your disability is due to a sickness, your Elimination Period is 14 days. If you meet the definition of disability you may receive a benefit for 11 weeks. You may wonder if your disability benefit amount will be taxed. It depends on how your premium the price of your coverage is paid. If your premium is paid with: Pre-Tax Dollars,* your benefit amount will be taxed Post-Tax Dollars,** your benefit amount will not be taxed Both Pre-Tax and Post-Tax Dollars, a portion of your benefit amount will be taxed The disability benefit amounts you receive will be reported annually on a W-2. It will show any taxable and non-taxable portions separately. *Pre-Tax Dollars are dollars paid by your employer toward premium that are not reported as earnings on your annual W-2. They are also dollars you pay toward premium through a cafeteria plan. **Post-Tax Dollars are dollars paid through payroll deductions after taxes and withholdings have been subtracted from your earnings. They are also dollars paid by your employer toward premium that are reported as earnings on your annual W-2 and taxed accordingly. Additional Benefits Rehabilitation and Return to Work Assistance Unum has a vocational Rehabilitation and Return to Work Assistance program available to assist you in returning to work. We will make the final determination of your eligibility for participation in the program, and will provide you with a written Rehabilitation and Return to Work Assistance plan developed specifically for you. This program may include, but is not limited to the following benefits: coordination with your Employer to assist your return to work; adaptive equipment or job accommodations to allow you to work; vocational evaluation to determine how your disability may impact your employment options; job placement services; resume preparation; job seeking skills training; or education and retraining expenses for a new occupation. ADR

51 If you are participating in a Rehabilitation and Return to Work Assistance program, we will also pay an additional disability benefit of 10% of your gross disability payment to a maximum of $250 per week. In addition, we will make weekly payments to you for 3 weeks following the date your disability ends, if we determine you are no longer disabled while: you are participating in a Rehabilitation and Return to Work Assistance program; and you are not able to find employment. Limitations/Exclusions/ Termination of Coverage Pre-existing Condition Exclusion Instances When Benefits Would Not Be Paid Termination of Coverage This exclusion applies only to amounts greater than the basic coverage. You have a pre-existing condition if: you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; and the disability begins in the 12 months after your effective date of coverage. Benefits would not be paid for loss resulting from: war, declared or undeclared, or any act of war; active participation in a riot; intentionally self-inflicted injuries; loss of a professional license, occupational license or certification; commission of a crime for which you have been convicted under state or federal law; any period of disability during which you are incarcerated; an occupational injury or sickness,(this will not apply to a partner or sole proprietor who cannot be covered by law under Workers' Compensation or any similar law); pre-existing condition. This applies only to amounts greater than the basic coverage. Your coverage under the policy ends on the earliest of the following: The date the policy or plan is cancelled; The date you no longer are in an eligible group; The date your eligible group is no longer covered; The last day of the period for which you made any required contributions; The last day you are in active employment except as provided under the covered layoff or leave of absence provision. Please see your Plan Administrator for further information on these provisions. Unum will provide coverage for a payable claim which occurs while you are covered ADR

52 under the policy or plan. Next Steps How to Apply Effective Date of Coverage Delayed Effective Date of Coverage Changes to Coverage Questions To apply for coverage, complete your enrollment form within 31 days of your eligibility date. Please see your Plan Administrator for your effective date. Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective. Each year, or when you have a change in status, you will have the opportunity to change your short term disability coverage. Any increase in coverage will be subject to the pre-existing condition exclusion. If you should have any questions about your coverage or how to enroll, please contact your Plan Administrator. This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Some provisions may vary or not be available in all states. Please refer to your certificate booklet for your complete plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern. For complete details of coverage, please refer to policy form number C.FP-1, et al. Underwritten by: Unum Life Insurance Company of America 2211 Congress Street, Portland, Maine 04122, Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. ADR

53 UNUM Monthly Rates Additional Life/Accidental Death and Dismemberment Insurance Employee Additional Life/AD&D Age of Employee on December 31 of current year Monthly rate for each $10,000 in coverage Under 30 $ $ $ $ $ $ $ $ $ or over $39.69 Employee coverage cannot exceed the lesser of $500,000 or 5 times the employee s annual wages. Spouse Additional Life/AD&D Age of Spouse on December 31 of current year Monthly rate for each $5,000 in coverage Under 30 $ $ $ $ $ $ $ $ $ $ or over $45.54 Spouse coverage cannot exceed 100% of the employee s coverage. If you and your spouse are both eligible employees for the Benefits Program, you cannot be covered both as a spouse and an employee. Also, only one of you can cover your dependent children (see the enrollment form for children s rates). Your premium for additional Life/AD&D is based on your age as of December 31 of the current year. For example, if your coverage starts July 2016, and you will turn age 30 on November 10, 2016, effective with July coverage you will pay the monthly premium for a person age until Effective with your January 2021 coverage, your monthly premium will increase to the age rate, since your age on December 31, 2021 will be 35.

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56 DEPENDENT CARE REIMBURSEMENT PLAN (DCRP) This plan has been restructured to coincide with our Health Benefit Open Enrollment period. As a result you can now elect your DCRP payroll deduction amount during the upcoming Open Enrollment period of May 11- May 25, Your election will be for the 12 months of July 2017 through June If you elect the maximum, your payroll deduction will be $ from July 2017 to June The amount is the same, but there will not be an Open Enrollment in November as in past years. If you have any questions, please contact Customer Service at from 5:30am-5:00pm PST.

57 DEPENDENT DAY CARE FLEXIBLE SPEN DIN G ACCO UN T PayingforUnreimbursedDependentDayCareExpensesWithPre-TaxPayrolDeductions DFSABasics TheDependentDayCareFlexibleSpending Account(DFSA)alowsyoutosetasidea portionofyoursalary,before-tax,to reimbursecertainamountsspentforeligible dependentdaycareexpensesthatare necessaryinorderforyou,andifyouare married,yourspouse,toworkorlookfor work. ParticipatingintheDFSAcanhelpsaveyou moneyontaxessincethemoneyyouset asideisnotsubjecttofederalincomeor SocialSecuritytax.Thisalowsyoutobenefit from moreofthemoneyyouearn. Yourmaximum annualdfsacontribution underfederaltaxlaw maybeupto$5,000 ($2,500maximum ifyouaremarried,filing separateincometaxreturns).thetermsof youremployer splanmaysetlower contributionlimits.inanycase,your contributionmaynotexceedyourearned incomeoryourspouse searnedincome, whicheverisless,unlessyourspouseis disabledoraful-timestudent,inwhichcase certainincome-atributionrulesapply. WhatareEligibleDFSA Expenses? Expensesforthefolowingservicesmaybe reimbursedfrom adfsa,providedtheyare necessaryfortheprotectionandcareofyour dependentwhileyouworkorlookforwork: Iftheserviceisprovidedbyadaycare centerthatofferscareforatleastsix people(otherthanresidents),thecenter mustcomplywithallocalandstatelaws andlicensingrequirements.important Note:Youmustreportyourdependent careprovider staxpayeridentification number(orsocialsecuritynumber),name andaddressonthedfsaclaim form,in orderforyoureligibleexpensestobe reimbursedfrom yourdfsa. WhoseExpensesareEligiblefor Reimbursement? Aneligibledependentisanydependent whois: Achildunderage13whoisyour dependentunderfederaltaxrules. Achild,spouseorparentwhois physicalyormentalyincapableof caringforhimselforherselfandhas yoursameplaceofresidenceformore thanhalfoftheyear. Adependentgeneralyhastospendat least8hoursadayinyourhouseholdfor thedependent sexpensestobe reimbursable. WithoutDFSAPlan AfterTax How DoestheDFSAWork? TheDFSAalowsyoutosetasidebefore-tax dolarsfrom yourpaychecktopayforyour out-of-pocketdependentdaycareexpenses. ToparticipateintheDFSA,youmust designatethetotalamountyouwouldliketo contributeeachplanyear.aportionofyour totalcontributionwilbedeductedfrom each paycheckyoureceiveduringtheplanyear. Whenyouincuraneligibledependentday careexpense,simplysubmitaclaim andyou wilbereimbursedtax-freefrom theaccount, totheextentoftheamountyouhavealready contributedtotheaccountfortheyear.an expenseisconsideredincurredwhenthe serviceisprovided,notwhenitisbiledor paid. Whenmakingyourcalculation,itisimportant toconservativelyestimatetheexpensesthat youwilincurwithintheplanyear,andany graceperiod,ifpermitedbythetermsof yourplan.accordingtoirsregulations,any moneyremaininginyouraccountattheend oftheplanyear(andgraceperiod,ifany)wil beforfeited.theplanmaysetatimelimit (generaly3months)forclaimingexpenses aftertheendoftheplanyear.ifyoudonot useamountsduringtheyearorthe subsequentgraceperiod,andtimelysubmit yourclaimsforreimbursement,youwillose it. WithDFSAPlan BeforeTax Childdaycarecenters AnnualGrossPay $30, $30, Babysiters Preschool/NurserySchool Before-taxDependentDay CareExpense , Non-educationalbeforeorafterschool careprograms TaxableGrossPay $30, $26, Adultdaycarecenters Familydaycarecenters Summerdaycamp(non-educational) FederalIncomeTax(25%) FICATax(7.65%)* -7, , , , Youmayclaim expensesforservicesgiven insideoroutsideyourhome.however, paymentsarenotreimbursableiftheyare madetocertainrelatedindividuals,including yourchildunderage19,yourspouse,the child sparent,orcertainotherrelatives. After-taxDependentDay CareExpense NetTake-homePay -4, $16, TOTALANNUALSAVINGS:$1, $17, *Note TheFICAtaxratemaydifferfrom 7.65%.Consultyourtaxadvisor. BenefitAlocationSystems PO Box62407,KingofPrussia,PA solutions@basusa.com BenefitAlocationSystems,Inc.AlRightsReserved.

58 ExamplesofChange instatusevents Changeinlegalmaritalstatus Changeinnumberofdependents Changeinemploymentstatusof employee,spouseordependent thataffectseligibility Reductionorincreaseinhoursof employmentofemployee,spouse orthataffectseligibility Dependentsatisfies(orceasesto satisfy)eligibilityrequirements Ifyoudonotusethemoneyyou depositinthedfsaforexpensesyou incurduringtheplanyear(andgrace period,ifany),anyremainingamount cannotbereturnedtoyouattheend oftheplanyear. RulestoRemember Becauseofthespecialtaxadvantagesthat thedfsaprovides,theirsplacescertain restrictionsoncontributionstoand distributionsfrom thedfsa. OnceyouauthorizedepositstotheDFSA fortheplanyear,federalrulesprohibityou from stoppingorchangingyourelection untilthenextplanyear,unlessyou experiencea ChangeofStatusEvent recognizedbyyourplan. Ifyoudonotusethemoneyyoudepositin thedfsaforexpensesyouincurduringthe planyear(andgraceperiod,ifany), remainingamountscannotbereturnedto youattheendoftheplanyear.ifyoudo notuseit,youloseit. WhichtoUse:DependentDay CareSpendingAccountorthe TaxCredit? Ifyouhavepaiddependentdaycare expensesinthepast,youmaybefamiliar withthefederaltaxcreditalowedfor theseexpenseswhenyoufileyourfederal incometaxreturn.thedfsaisan alternativetothetaxcredit.youmaynot usethesameexpensesforboththetax creditandthedfsa.thechartbelow providesacomparativeoverview ofthese twoalternatives. Thetaxcreditiscalculatedasfolows: Eligibleexpenses(upto$3,000ifyouhave oneeligibledependent,or$6,000ifyou havetwoormoreeligibledependents theseratesmaybesubjecttochange)are multipliedbythepercentageonthetax credittablecorrespondingtoyourfamily s householdincome.theresultingamountis subtractedfrom theamountoftaxyou owe. Examplesof IneligibleExpenses TheIRSdecideswhatisandisnotan eligibledfsaexpense.forexample, thefolowingexpensesarenoteligible tobereimbursedfrom yourdfsa: Non-employmentrelatedcare (i.e.,eveningbaby-siting); 24-hournursinghomeexpenses; Overnightcampexpenses; Educationexpensesforachildin kindergarten,firstgradeor higher; Educationcamps; Childcareexpensesthatenable yourspousetoperform volunteer work. Aldependentdaycareexpensesmust beproperlysubstantiated,consistent withirsguidelines,tobereimbursed from yourdfsa. ComparingtheTaxCredittoDependentDayCareSpendingAccount* HouseholdIncome Upto$15,000 $15,001-$17,000 $17,001-$19,000 $19,001-$21,000 $21,001-$23,000 $23,001-$25,000 $25,001-$27,000 $27,001-$29,000 $29,001-$31,000 $31,001-$33,000 $33,001-$35,000 $35,001-$37,000 $37,001-$39,000 $39,001-$41,000 $41,001-$43,000 $43,001 nolimit TaxCredit 35% 34% 33% 32% 31% 30% 29% 28% 27% 26% 25% 24% 23% 22% 21% 20% *Note-Theseratesmaybesubjecttochange. DFSA TC DFSA TC DFSA TC DFSA TC Maximum contributionis $5,000($2,500ifmarried andfilingseparately). Maximum expense applicabletowardstax Creditis$3,000perchild ($6,000maximum per family). Contributionsaremade before-tax. Percentageofexpenses isappliedascredit againsttaxes. Contributionsarefreeof FICATaxes. Creditdoesnotreduce FICATaxes. Mustdecideonamount ofcontributionbefore expensesareincurred andforfeitunused amounts. Noriskof forfeitures; creditisdeterminedat endofyearafteral expensesareincurred. BenefitAlocationSystems PO Box62407,KingofPrussia,PA solutions@basusa.com BenefitAlocationSystems,Inc.AlRightsReserved.