WELCOME TO THE 2017 SUMMARY PLAN DESCRIPTION FOR ACTIVE EMPLOYEES

Transcription

1 SUMMARY PLAN DESCRIPTION FOR HEALTH AND WELFARE BENEFITS OF ACTIVE EMPLOYEES EFFECTIVE JANUARY 1, 2017

2 Table of contents WELCOME TO THE 2017 SUMMARY PLAN DESCRIPTION FOR ACTIVE EMPLOYEES MUFG Union Bank, N.A. (the company ) remains committed to providing a comprehensive health and welfare benefits package that meets your personal needs and continues to be extremely competitive among the world s leading financial institutions. This Summary Plan Description (SPD) provides an overview of our 2017 health and welfare benefits program. You can find more information about the specific benefits in the appendix to this document. The table of contents will help you navigate the SPD and explain your rights under the laws that govern the group health and welfare employee benefits programs sponsored by the company. Overview and Plan contact information 3 Health and Welfare benefits 8 Eligibility 9 Enrollment procedures 14 Benefit descriptions 15 Medical and Prescription Drug Coverage 17 Dental 32 Vision 33 Basic life / supplemental life and Accidental Death and Dismemberment 34 Short-Term Disability (STD) and Salary Continuation 36 Long Term Disability Basic Plan and Buy up 38 Section 125 Plan Flexible Spending Accounts (FSAs) 39 Health Savings Account (HSA) 41 Business Travel Accident (BTA) 42 Employee Assistance Program (EAP) 43 Wellness Program 44 Voluntary Legal Assistance Plan 44 Your costs 45 Rights under the plans 46 Appendix 67 Plan documentation 69 2

3 Overview and Plan contact information This document, together with the appendix and applicable certificates of insurance, booklets, summaries of benefits and coverage, and contracts referenced herein that describe the benefits provided, constitutes an SPD, which summarizes the important provisions of the MUFG Union Bank, N.A., health and welfare benefits plans (each a Plan ; collectively, the Plans ), as restated and amended, effective as of January 1, Complete details of each Plan are found in the certificates of insurance, booklets, summaries of benefits and coverage, and contracts for the benefit options offered under such Plan. This SPD, the certificates of insurance, the booklets, the summaries of benefits and coverage, the contracts, and any written administrative procedures pertaining to each Plan may be reviewed by employees and their legal representatives upon request and without charge during regular business hours or by appointment at a mutually convenient time with the Total Rewards department. If there is a conflict between this SPD and any such Plan document, the Plan document will govern. Also, without limiting the foregoing, with respect to benefits provided by an insurance company, if there is a conflict between the applicable certificates of insurance, summaries of benefits and coverage, booklets, or contracts and this SPD, the provisions of the relevant certificates of insurance, summaries of benefits and coverage, booklets, or contracts will govern. Copies of the certificates of insurance, summaries of benefits and coverage, booklets, and contracts are available to employees upon request and without charge. None of the Plans are a contract of employment or guarantee continued employment. The benefits under the Plans are provided at the sole discretion of the Plan Sponsor and its designated affiliates. Neither the Plan Sponsor nor any of its affiliates makes any promises to continue any Plan or benefits thereunder in the future, and rights to future benefits will never vest. It is recommended that you read this SPD carefully so you can understand each Plan s operation and benefits. If you have any questions after reading this SPD or would like additional information, please contact the Plan Administrator at the address specified in the Plan Information section. For more information or questions related to Health and Welfare benefits, you may contact the Benefits Service Center at or visit our website at mufgamericas.com/mybenefits. If you would like a printed copy of this SPD, you may request one at no charge from the Benefits Service Center. 3

4 PLAN INFORMATION The SPD portion of this booklet relates only to certain health and welfare benefits offered under the following Plans: MUFG Union Bank, N.A., Health Benefit Plan Plan Number: 541 Plan Sponsor: EIN: Plan Administrator: Employers: Benefits Covered: Type of Administration: MUFG Americas Holdings Corporation 1251 Avenue of the Americas, 15th Floor New York, NY Benefit Plans Administrative Committee MUFG Union Bank, N.A. Total Rewards 400 California Street, 10th Floor San Francisco, CA , option 1 MUFG Union Bank, N.A., and its U.S. subsidiaries MUFG Securities Americas Inc. BTMU Capital Corporation BTMU Leasing & Finance, Inc. BTMU Capital Leasing and Finance, Inc. MUFG Americas Holdings Corporation Mitsubishi UFJ Financial Group, Inc. BTMU Securities, Inc. The Bank of Tokyo-Mitsubishi UFJ, Ltd., Global Financial Crimes Intelligence Division Other employers as designated by the Benefit Plans Administrative Committee Medical Dental Vision Wellness Program The fully insured benefits are administered by insurance companies, and the other benefits are administered by third-party administrators. Plan Year: January 1 December 31 Agent for Service of Legal Process: Funding and Contributions: Plan Administrator The fully insured benefits are funded by the insurance carriers. The other benefits are funded by a voluntary employees beneficiary association (VEBA) trust or company assets. Contributions to the benefits are made by the employers, employees, retirees, and COBRA beneficiaries. 4

5 MUFG Union Bank, N.A., Employee Insurance Plan Plan Number: 542 Plan Sponsor: EIN: Plan Administrator: Employers: Benefits Covered: Type of Administration: Plan Year: Service of Legal Process: MUFG Union Bank, N.A. 400 California Street, 10th Floor San Francisco, CA Benefit Plans Administrative Committee MUFG Union Bank, N.A. Total Rewards 400 California Street, 10th Floor San Francisco, CA , option 1 MUFG Union Bank, N.A., and its U.S. subsidiaries MUFG Securities Americas Inc. BTMU Capital Corporation BTMU Leasing & Finance, Inc. BTMU Capital Leasing and Finance, Inc. MUFG Americas Holdings Corporation Mitsubishi UFJ Financial Group, Inc. BTMU Securities, Inc. The Bank of Tokyo-Mitsubishi UFJ, Ltd., Global Financial Crimes Intelligence Division Other employers as designated by the Benefit Plans Administrative Committee Accidental Death and Dismemberment Insurance Business Travel Accident Insurance Term Life Insurance Employee Assistance Program Life Insurance for BTMU retirees retiring before January 1, 2015 Healthcare and Limited Scope Healthcare FSA portions of the Section 125 Plan Group Legal Benefits Most of the benefits are fully insured and administered by the insurance carriers. However, the FSAs are selffunded and administered by a third-party administrator. January 1 December 31 Agent for Plan Administrator Funding and Contributions: The benefits are funded by the insurance carriers, except for the FSAs, which are self-funded benefits. Contributions to benefits are made by the employers, employees, and retirees. 5

6 MUFG Union Bank, N.A., Section 125 Plan (only the Healthcare FSA and Limited Scope Healthcare FSA portions of the Section 125 Plan are subject to ERISA) Plan Number: N/A Plan Sponsor: MUFG Union Bank, N.A. 400 California Street, 10th Floor San Francisco, CA EIN: Plan Administrator: Employers: Benefit Plans Administrative Committee MUFG Union Bank, N.A. Total Rewards 400 California Street, 10th Floor San Francisco, CA , option 1 MUFG Union Bank, N.A., and its U.S. subsidiaries MUFG Securities Americas Inc. BTMU Capital Corporation BTMU Leasing & Finance, Inc. BTMU Capital Leasing and Finance, Inc. MUFG Americas Holdings Corporation Mitsubishi UFJ Financial Group, Inc. BTMU Securities, Inc. The Bank of Tokyo-Mitsubishi UFJ, Ltd., Global Financial Crimes Intelligence Division Other employers as designated by the Benefit Plans Administrative Committee Benefits Covered: Healthcare FSA Limited Scope Healthcare FSA Dependent Care FSA (not subject to ERISA) Premium conversion, including HSA contributions by employees and employers (not subject to ERISA) Type of Administration: Plan Year: Benefits under the Plan are administered by third-party administrators pursuant to administrative services agreements between the administrators and the Plan Sponsor. January 1 December 31 Agent for Service of Legal Process: Plan Administrator Funding and Contributions: Benefits under the Plan are self-funded. Contributions to the Plan are made by the employees and employers. 6

7 MUFG Union Bank, N.A., Disability Plan Plan Number: 546 Plan Sponsor: EIN: Plan Administrator: MUFG Union Bank, N.A. 400 California Street, 10th Floor San Francisco, CA Benefit Plans Administrative Committee MUFG Union Bank, N.A. Total Rewards 400 California Street, 10th Floor San Francisco, CA , option 1 Employers: MUFG Union Bank, N.A., and its U.S. subsidiaries Benefits Covered: MUFG Union Bank, N.A. MUFG Securities Americas Inc. BTMU Capital Corporation BTMU Leasing & Finance, Inc. BTMU Capital Leasing and Finance, Inc. MUFG Americas Holdings Corporation Mitsubishi UFJ Financial Group, Inc. BTMU Securities, Inc. The Bank of Tokyo-Mitsubishi UFJ, Ltd., Global Financial Crimes Intelligence Division Other employers as designated by the Benefit Plans Administrative Committee Long-Term Disability Plan Year: January 1 December 31 California Voluntary Disability Plan Type of Administration: The Long-Term Disability benefit effective for claims incurred after 2014 is administered by an insurance company. The Long-Term Disability benefit effective for claims incurred before 2015 and the California Voluntary Disability benefit are administered by third-party administrators. Agent for Service of Legal Process: Funding and Contributions: Plan Administrator The fully insured Long-Term Disability benefit is funded by the insurance carrier. The other benefits are funded by a voluntary employee beneficiary association (VEBA) trust and employer general assets. Contributions to the benefits are made by the employers and employees. 1 All references to the Medical plan or Medical benefits in this guide include prescription coverage. 7

8 Health and Welfare Benefits Program Medical and Prescription Drug Coverages 1 Dental Vision Basic Life Supplemental Life (Employee, Spouse and Child) Accidental Death and Dismemberment (Employee and Family) Short-Term Disability Salary Continuation Long-Term Disability Base Plan Long Term Disability Buy Up Section 125- Flexible Spending Accounts (FSAs) (Healthcare, Dependent care, Limited Purpose) Health Savings Account (HSA) Business Travel Accident (BTA) Employee Assistance Program (EAP) Wellness Program Legal Assistance Plan 8

9 Eligibility When are you eligible? If you are regularly scheduled to work 17.5 hours per week and on the U.S Payroll of a Participating Employer that has been designated by the Administrative Committee to participate in the Plan, you and your dependents are eligible to join the company s health and welfare benefits plans. However, the following individuals are not eligible for benefits: employees who are classified as flexible non-benefits-eligible employees, rotational employees, leased employees, seasonal employees, interns, and temporary employees, whether or not they work more than 17.5 hours per week. All benefits eligible employees and their eligible dependents can participate in the Employee Assistance Program (EAP) and Healthy Guidance Wellness Program. All benefits-eligible employees are automatically enrolled in the following company paid benefits: Business travel accident insurance Basic Life Insurance State statutory Short Term Disability applicable to CA, NJ and NY employees only Salary Continuation (You qualify for Salary Continuation after you have been employed for 90 days) Long Term Disability Insurance Base Plan When do benefits become effective? Your Medical, Dental, Vision, Supplemental life, AD&D, Buy Up LTD and FSA s coverages become effective on the first of the day of the month following your date of hire upon for completion of your online enrollment. Company paid benefits are effective the first day of the month following your date of hire (except for the Salary Continuation Program, which takes effect after 90 days of employment). Note: You must complete your enrollment within 30 days of employment to obtain coverage. If you do not enroll timely, you will not have coverage for the current year unless you experience a qualifying life event such as marriage, loss/gain of spousal employment, birth/adoption). Life events require proof of change within 30 days of the event (see Enrollment Procedures ). If you do not experience a life event, your next opportunity to enroll will be during the next Annual Enrollment Period. Any contributions you are required to make will be deducted from your paychecks accordingly. However, retroactive contributions may be required when, for example, you complete your online enrollment after the first day of the month following your date of hire. 9

10 The company offers you the opportunity to enroll in the following plans: Medical Dental Vision Supplemental Life and AD&D Insurance Long-Term Disability Buy Up Section 125- Flexible Spending Accounts (FSAs) (Healthcare, Dependent care, Limited Purpose) Health Savings Account (HSA) Legal Assistance Plan Your prior service with a related employer will be credited to you for purposes of the Plans waiting period only if the break in service between your periods of employment is less than 31 days. In such case, Plan coverage due to employment with the second affiliate will start on the later of your first day of employment with the second affiliate or the first day after coverage would normally end due to termination of employment with the prior affiliate, so long as you elect coverage with the second affiliate no later than 30 days after your start date with the second affiliate. If your break in service between periods of employment is more than 30 days your prior service will not count towards the Plans waiting period. If an existing employee of a participating employer transfers from a benefits-ineligible class of employees to a benefits-eligible class of employees (e.g., from less than 17 1/2 hours per week to at least 17 1/2 hours per week or from a non-us Payroll position to a US-Payroll position) and elects coverage no later than 30 days after his or her transfer date, Plan coverage will begin on his or her transfer date. To be covered under the Health and Welfare plans, you must complete your enrollment within your enrollment window. Who is an eligible dependent? 2 The company defines your eligible dependent as: Your legal spouse unless the person is an employee of the bank and has elected independent coverage under the same Plan. Your domestic partner who is a qualifying domestic partner or a registered domestic partner / civil union partner. A qualifying domestic partner must be 18 years of age or older and live with you in a long-term committed relationship with all of the following: You must live together in the same residence, have an exclusive mutual commitment similar to marriage, and be financially responsible for each other and your debts; neither person can be married or have another domestic partner; you cannot be related by blood in a way that would prevent you from being married to each other according to applicable state law; and both persons must be capable of consenting to the domestic partnership. A registered domestic partner / civil union partner is an individual who has entered into a valid domestic partnership or a civil union with you pursuant to the laws of any state. Only those dependents that are defined by the company as an eligible dependent can participate under the Health and Welfare plans described in this SPD. 2 For information on dependent eligibility, please contact the MUFG Benefits Service Center. 10

11 Your dependent children until the end of the month they attain age 26. This includes natural children and stepchildren as well as legally adopted children from the date you assume legal responsibility, foster children who live with you, and children for whom you assume legal guardianship. Also included are your children (or children of your spouse or domestic partner) for whom you have legal responsibility resulting from a valid court decree. Children who are mentally or physically disabled and dependent on you for support, regardless of age including incapacitated children age 26 or older. To be eligible for coverage as an incapacitated dependent, the dependent must have been covered under the Plan and disabled prior to reaching age 26, must legally reside with you for at least half of the year and must receive at least 50% of his or her financial support from you. Certification of the disability is required within 30 days of attainment of age 26. A certification form is available from the Benefits Service Center or from the claims administrator and may be required periodically. Life Insurance (for your dependents) Your spouse or domestic partner. For information on spousal eligibility, please contact the Benefits Service Center. Your children under the age of 26. Children age 26 or over who are permanently disabled at any time during the year as a result of a disabling illness or injury that commenced prior to attainment of age 26. Children under the age of 26 for whom you or your spouse or domestic partner have been assigned legal guardianship. Section 125 Plan Healthcare Flexible Spending Account (FSA) and Limited Scope Healthcare FSA Your spouse. Your dependent children up to age 26 and any dependent children over age 26, who are permanently disabled, legally reside with you for more than half the year and receive at least 50% of their financial support from you. Any other dependent who is considered a qualifying dependent under IRS rules. Section 125 Plan Dependent Care FSA A child who has not reached the age of 13 and A dependent (i.e., a qualifying child or qualifying relative) who is physically or mentally incapable of self-care and who has the same principal place of abode as the taxpayer for at least eight hours per day. Disability There are no dependent benefits available under Short-Term or Long-Term Disability benefits. Business Travel Accident Your spouse or domestic partner. Your children from the moment of birth, including a natural child, stepchild, or adopted child from the date of placement. The children must be unmarried, under age 19 or under age 26 if enrolled as a full-time student at an institution of higher learning, or considered to be an incapacitated dependent child. 11

12 When do my benefits end? Generally, your health and welfare benefits end either on your date of termination or on the last day of the month that your employment terminates for any reason including death or, if earlier, when you cease to be an eligible employee. Coverage may also cease if you fail to make required contributions. You may be able to continue some coverage, however, if you qualify as a retiree or disabled individual. Generally, coverage you have elected for your eligible dependents under any benefit ceases when your coverage ceases or, if earlier, when such individual ceases to be your eligible dependent. If you are required to make contributions for certain coverage that you have elected for yourself and your eligible dependent, then such coverage will cease if you fail to make the required contributions. Further, all health and welfare benefits coverage provided under a Plan will cease on the date the Plan is terminated. Although coverage may otherwise cease, you may elect COBRA continuation coverage for Medical (including the HRA), Dental, Vision, and the Healthcare and Limited Purpose FSAs. You may also be able to convert some of the group life and Accidental Death and Dismemberment (AD&D) insurance coverage to personal coverage. You should consult this document and the applicable certificates of insurance or contract for such conversion rights. It is your responsibility to convert your life or AD&D insurance at the time your group coverage terminates (within 30 days of termination). A conversion notice may also be provided to you from the company and can be requested directly from the insurance carrier. Family Medical Leave Act (FMLA) leaves of absence FMLA- Paid leave If you are an eligible employee who is on an approved federal Family Medical Leave, you will continue to receive all employerpaid and optional benefits during the period of such leave up to a maximum of 12 weeks (26 weeks for FMLA Service Member Caregiver Leave), assuming you pay your share of any required premiums on a timely basis. Certain benefits contributions and coverage, such as employee HSA contributions, Dependent Care FSA, and commuter benefits, will be stopped and you will need to reenroll within 30 days when you return from your leave. FMLA- Unpaid leave While you are on an unpaid FMLA, you may continue certain benefits while on an unpaid leave of absence. Conexis, the bank s direct pay administrator, will bill you for premiums. If you elect not to continue benefits during an unpaid FMLA leave of absence, then upon your return to employment with the company, benefits must be re-elected and will be reinstated on the first day of the month following your return to work. Optional benefits can be continued based on the terms and provisions of each applicable Plan or program. Flexible Spending Accounts (FSA) - Healthcare and Limited Purpose Healthcare during Paid or Unpaid Leave While on a paid leave of absence, your contributions to your healthcare FSA will be paid by the bank (unless you elect to drop coverage at the start of your leave or due to a qualifying life event) and you will be responsible to pay those contributions back upon your return to work from your leave. Pre-tax contributions from your payroll will resume upon returning to active employment status, unless otherwise elected upon returning to work To stop your healthcare FSA contributions, your request must be made in writing while you re on a leave of absence and upon returning from your leave within 30 days you must re-elect by contacting the Total Rewards representative below: Dedra Turner-Nelson Associate, Health and Welfare Analyst MUFG Total Rewards Direct (415) Fax (415) MUFG Union Bank, N.A. 400 California Street, 10th Floor San Francisco, CA dedra.turner@unionbank.com If you have a qualifying life event while on leave, you must report the qualifying event to the Benefits Center within 30 days of the event date. You are required to furnish written proof of a status change event such as a birth certificate, marriage certificate, divorce decree, or a letter from your spouse's employer. You may go online to 12

13 or call the Benefits Service Center at (800) to make changes to your benefits. For invoice / billing questions you may contact Conexis at (866) Coverage and contributions may resume upon your return from your leave of absence. Other leaves of absence Employees may continue some benefits in the event of certain leaves as follows: Type of Leave of Absence Period Coverage Continued Short-Term Disability Duration of leave but not to exceed 52 Personal and Parental Leave weeks Duration of leave but not to exceed four Military Leave months Duration of leave but not to exceed 24 Other Leave months Duration of leave but not to exceed four months Premium payments to continue benefits will follow with the paid or unpaid leave type. Payment of premiums during a leave of absence If you are on paid leave, the premiums for Medical, Dental, Vision, Supplemental and Dependent Life and AD&D, will be deducted from your paycheck. Your per paycheck contributions to the HSAs, Dependent care FSA and commuter benefits will stop. Upon returning from your leave, you must reimburse the employer for payments made on your behalf. If you elected to stop participation, upon returning from your leave, you must re-enroll.. International assignment U.S. employees on international assignment (and their dependents) may only be enrolled in the international Medical Plan option during their period of international assignment. You may, however, continue your other nonmedical benefits and coverage, if any, during the period of international assignment, so long as you remain eligible. Your U.S per pay deductions will continue to be taken for coverage under the U.S. benefits program. International employees inbound to the United States from a related employer are eligible only for the international Medical Plan option during the period of their assignment, but only if the employee is not covered by a medical plan sponsored by his or her home country employer that covers services performed in the United States. In certain cases, statutory coverage or eligibility will be available to those employees working in New Jersey, New York, and California. Eligibility after employment termination Certain disabled individuals and retirees under age 65 remain eligible for Medical, Dental, and Vision coverage after their employment terminates. For more information, refer to the separate Retiree Guide and the Health and Welfare Plans Summary Plan Description for Pre- 65 Retirees and Disabled Individuals. 13

14 Enrollment procedures How to enroll as a new employee Newly hired employees must complete the company s online enrollment within the first 30 days of employment. If you fail to do so, you ll have to wait until the next annual open enrollment (see Annual Open Enrollment ) or when you have a qualifying life event. Using online enrollment system for the first time Go to mufgamericas.com/mybenefits. You will need to create a user name and password. Select Are you a new user? on the home page. When prompted, enter your personal security information. Once the system verifies this information, you ll be prompted to create your own user name and password. Going forward, you ll use these to access your benefits information. Next choose your benefits and submit your choices. You will receive confirmation of your elections and it s your responsibility to review this state and report any changes within your 30 day enrollment period. Future changes can be made to your elections during the next annual enrollment period or in the event of a qualifying change life status Changes are limited to Qualified Change of Life Status Events You are allowed to make changes to your current benefit elections during the Plan Year if you experience a change in status. Some of the status changes include: Marriage Gain or loss of an eligible dependent for reasons such as birth, adoption, court order, disability, death, marriage, or reaching the dependent-child age limit Changes in your dependents employment affecting their benefits eligibility Changes in your dependents benefits coverage with another employer affecting their benefits eligibility Changes in your or your dependents residence affecting benefits eligibility The change to your benefit elections must be consistent with and on account of the change in status. If you have a status change, you must notify the Benefits Service Center within 30 days of the event. Along with your notification, you are required to provide appropriate documentation timely. If you do not notify the Benefits Service Center during the 30 day window or provide the required documentation, you and/ or your dependents must wait until the next annual open enrollment period to make a change to your benefit elections. Your elections will become effective the first of the month following your status change, with the exception of a change due to birth or adoption, which will be retroactive to the date of birth or adoption. In addition, if you experience a HIPAA special enrollment event, you may be able to elect group health coverage for yourself and your dependents midyear. Annual open enrollment Each year during the annual open enrollment period, you are given the opportunity to make changes to your current health and welfare benefits. Annual open enrollment is the only time during the year you can make changes to your benefits unless you experience a qualifying life event. Our annual open enrollment period usually occurs in October or November for a January 1 effective date. 14

15 Benefit Descriptions Medical and Prescription Drug Plans The company offers three national medical plans the Anthem PPO, Anthem HSA and Anthem HRA which include prescription coverage administered by Anthem. These plans offer the same in-network providers and only in-network prescription drug programs after you meet your deductible. All of the plans allow out of network provider access but the reimbursement levels are different as well as your deductibles. Two of the plans are Consumer-Driven Health Plans (CDHPs), the Anthem HSA allows you to open a Health Savings Account to fund anticipated medical expenses. The Health Reimbursement Account (HRA) works differently, you cannot contribute to this account the company contribution is automatically accessed by the insurance carrier to cover your medical expenses. The company contribution to your high-deductible plan (HSA and HRA) is made annually and prorated based on your coverage level and when you enter the plan. These contributions help you meet some of your out of pocket medical expenses. For employees located in certain areas in California, the company offers the Kaiser HMO Plan... The Kaiser plan provides cost effective coverage and provider services only within its network. Dental Through nationally recognized providers, we offer access to either one comprehensive PPO plan (determined by location) or a cost-effective DMO program. All dental plans offer access to benefits for you and any covered eligible dependents members. Vision Vision Service Plan (VSP) is a nationally recognized carrier, providing access to the largest network of vision providers offering preventive and routine vision care. Life and supplemental AD&D The company provides one times your base annual salary of company-paid life insurance for all eligible employees. To further supplement income protection for your family, you can purchase supplemental life insurance and Accidental Death and Dismemberment Insurance. Some levels require evidence of insurability. Short- and Long-Term Disability The company s programs for short-duration and extended disabilities are comprehensive and provide income replacement levels from one week to retirement age if your medical condition warrants such benefits. You can also increase your long-term income protection with our buy-up LTD option. Section 125- Flexible Spending Accounts (FSAs) You can elect to participate in two types of FSAs, a Healthcare FSA and a Dependent Care FSA. There are two types of Healthcare FSAs available to you, depending on the medical option you choose. You can choose to participate in the traditional Healthcare FSA when enrolling in most of our health plans, except for the HSA plan requires enrollment in a Limited Purpose Healthcare FSA, which can only be used for dental and vision expenses, as medical expenses are covered under the HSA. The Dependent Care FSA helps you save for out-of-pocket expenses incurred for your children under age 13 and elder dependents. Health Savings Account (HSA) When you elect coverage under a CDHP with a Health Savings Account option, you can set aside money through payroll deductions on a pretax basis to help cover qualified out-of- pocket medical expenses as well. The HSA also has investment features similar to a retirement account. Funds can be used now or in the future to offset medical related expenses during retirement. The bank provides an annual contribution toward your HSA on a prorated basis. This account is similar to a bank account and the trustee may charge a monthly fee. The funds are yours even after terminating employment. 15

16 Business Travel Accident (BTA) The company provides additional financial protection for you and your family when you travel on approved company business. Employee Assistance Program (EAP) Benefits eligible employees are able to receive services through the EAP. The program provides confidential, professional counseling on a wide range of issues including the following: Family issues, child care, elder care as well as legal/financial issues.. Wellness Program All employees are eligible to participate in the wellness program offered under the Healthy Guidance Program. The program provides free and confidential support from certified health coaches, Tobacco Cessation, sleep and back care coaching, and a host of wellness tools and resources for physical, emotional, financials and social mindfulness. Voluntary Legal Assistance Plan The Hyatt Legal Plan provides up to 15 hours of pre-paid legal services. 16

17 Medical and Prescription Drug Coverage Comprehensive and preventive health coverage is important in protecting you and your family from the financial risks of unexpected illness and injury, which is why the company offers you a variety of options to choose from. All of the Anthem plans offer the same in-network providers and only allow in network prescription drug programs after you meet your deductibles. The Anthem plans cover out of network providers; the reimbursement levels are subject to each plan design. Anthem Health Reimbursement Account (HRA) Plan is a high deductible plan. The. HRA is a company-funded account in the group health plan from which qualified medical expenses up to a fixed dollar amount per year are paid by the employer from the Plan. Unused amounts may be rolled over to be used in subsequent years if you remain a participant in this Plan in the following year. The company funds and owns the account; therefore upon termination, any remaining funds stay with the employer. Anthem Health Savings Account (HSA) Plan is a high deductible plan and if you are covered under this plan, the IRS allows you to open an HSA to fund out of pocket expenses on a pretax basis. The Anthem HSA plan requires that you first meet your deductible before the plan starts paying for your medical/prescription coverage.. You can invest HSA funds, and save for future healthcare expenses. You have ownership of the funds and earnings within your HSA and can take your account with you should you leave the company. Anthem Preferred Provider Organization (PPO) Plan. The PPO plan design allows for In-Network and Out-of-Network providers. Once you ve satisfied your plan deductible under the Plan, you pay a co-payment for In-Network services and coinsurance for Out-of-Network services. The Plan offers convenience and lower deductibles but higher employee perpaycheck contributions. Anthem offers you a national network of doctors, hospitals, and pharmacies. All Anthem medical options cover both In- Network and Out-of-Network care. In-Network care provides cost savings to you as fees are negotiated with the providers and facilities by the carrier.. In addition to the three Anthem plans, you have access to the Kaiser Permanente California Health Maintenance Organization (HMO) Plan if you reside certain parts of California. With a HMO, you ll typically pay a small co-payment if you visit a physician or hospital within the Plan network. HMOs feature a specific system of doctors, hospitals, and other healthcare providers. If you enroll in the HMO, you must select a Primary Care Physician (PCP) to coordinate your care, and you will only receive benefits if you get care within the HMO system unless you have an emergency. 17

18 ANTHEM HRA HDHP/HSA PPO In-Network Out-of- Network In-Network Out-of-Network In-Network Out-of-Network Referral Not Required Referral Not Required Referral Not Required Bank Contribution Toward Your Deductible $750 Employee $1,500 Employee + Family $750 Employee $1,500 Employee + Family None Your Deductible Your Plan has an embedded Deductible which means: If You, the Subscriber, is the only person covered by this Plan, only the Individual amounts apply to You. If You also cover Dependents (other family members) under this Plan, both the Individual and the Family amounts apply. The Family Deductible amounts can be satisfied by any combination of family members but You could satisfy Your own Individual Deductible amount before the Family amount is met. You will never have to satisfy more than Your own Individual Deductible amount. If You meet Your Individual Deductible amount, Your other family member s claims will still accumulate towards their own Individual Deductible and the overall Family amounts. This continues until Your other family members meet their own Individual Deductible or the entire Family Deductible is met $2,500 Individual $5,000 Family In-Network and Out-of- Network deductibles are combined. Satisfying one helps satisfy the other. Embedded deductible $4,000 Individual $8,000 Family In-Network and Out-of-Network deductibles are combined. Satisfying one helps satisfy the other. Embedded deductible $1,500 Individual $3,000 Family In-Network and Out-of- Network deductibles are combined. Satisfying one helps satisfy the other. The individual deductible does not apply if two or more people are covered; the entire family deductible must be met before coinsurance applies for any individual. $3,000 Individual $6,000 Family In-Network and Out-of-Network deductibles are combined. Satisfying one helps satisfy the other. The individual deductible does not apply if two or more people are covered; the entire family deductible must be met before coinsurance applies for any individual. $1,000 Individual $2,000 Family In-Network and Out-of- Network deductibles are combined. Satisfying one helps satisfy the other. Embedded deductible $1,500 Individual $3,000 Family In-Network and Out-of-Network deductibles are combined. Satisfying one helps satisfy the other. Embedded deductible Your Out-of-Pocket Max. (Includes Your Deductible) Lifetime Maximum Primary Care Visit to Treat an Injury or Illness In-Network: $3,500 Individual; $6,850 Family Out-of-Network: $5,250 Individual; $10,500 Family The individual out-of-pocket limit does not apply if two or more people are covered; the entire family out-of-pocket limit must be met in order to satisfy the limit. Unlimited 20% coinsurance 40% coinsurance 10% coinsurance 30% coinsurance $25 co-pay 30% coinsurance Specialist Visit 20% coinsurance 40% coinsurance 10% coinsurance 30% coinsurance $40 co-pay 30% coinsurance Other Practitioner Office Visit (20 Visits per Year) Chiropractor: 20% coinsurance Acupuncturist: 20% coinsurance Chiropractor: 40% coinsurance Acupuncturist: 40% coinsurance Chiropractor: 10% coinsurance Acupuncturist: 10% coinsurance Chiropractor: 30% coinsurance Acupuncturist: 30% coinsurance Chiropractor/ Acupuncturist: $40 co-pay/visit Chiropractor/ Acupuncturist: 30% coinsurance Preventive Care, Screening, Immunization 100%, no deductible 40% Coinsurance 100%, no deductible 30% coinsurance 100%, no deductible 30% coinsurance Diagnostic Test (X-ray, Blood Work) Lab Office: 20% coinsurance Lab Office: 40% coinsurance Lab Office: 10% coinsurance Lab Office: 30% coinsurance Lab Office: 10% coinsurance Lab Office: 30% coinsurance X-ray Office: 20% coinsurance X-ray Office: 40% coinsurance X-ray Office: 10% coinsurance X-ray Office: 30% coinsurance X-ray Office: 10% coinsurance X-ray Office: 30% coinsurance Imaging (CT/PET Scans, MRIs) 20% coinsurance 40% coinsurance 10% coinsurance 30% coinsurance 10% coinsurance 30% coinsurance 18

19 Generic Drugs (Retail: 30-Day Supply; Mail Order: 90-Day Supply) $250 deductible per member, 10% coinsurance after deductible For 30-day Retail supply: min. cost of $5, max. cost of $15 For 90-day Mail- Order supply: min. cost of $10, max. cost of $30 Not covered Deductible is integrated with Medical, 10% coinsurance after deductible For 30-day Retail supply: min. cost of $5, max. cost of $15 For 90-day Mail- Order supply: min. cost of $10, max. cost of $30 You pay the deductible first before the Plan pays for any prescription drugs. Not covered $100 deductible per member applicable to Retail drugs, 10% coinsurance after deductible For 30-day Retail supply: min. cost of $5, max. cost of $15 For 90-day Mail- Order supply: min. cost of $10, max. cost of $30 Not covered ANTHEM (continued) HRA HDHP/HSA PPO In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Referral Not Required Referral Not Required Referral Not Required Brand-Name Formulary Drugs (Retail: 30-Day Supply; Mail Order: 90-Day Supply) $250 deductible per member, 20% coinsurance after deductible For 30-day Retail supply: min. cost of $20, max. cost of $60 For 90-day Mail- Order supply: min. cost of $50, max. cost of $150 Not covered Deductible is integrated with Medical, 20% coinsurance per Rx for Retail For 30-day Retail supply: min. cost of $20, max. cost of $60 For 90-day Mail- Order supply: min. cost of $50, max. cost of $150 You pay the deductible first before the Plan pays for any prescription drugs. Not covered $100 deductible per member applicable to Retail drugs, 20% coinsurance after deductible For 30-day Retail supply: min. cost of $20, max. cost of $60 For 90-day Mail- Order supply: min. cost of $50, max. cost of $150 Not covered Brand-Name Non- Formulary Drugs (Retail: 30-Day Supply; Mail Order: 90- Day Supply) $250 deductible per member, 30% coinsurance after deductible For 30-day Retail supply: min. cost of $30, max. cost of $90 For 90-day Mail- Order supply: min. cost of $75, max. cost of $225 Not covered Deductible is integrated with Medical 30% coinsurance after deductible For 30-day Retail supply: min. cost of $30, max. cost of $90 For 90-day Mail- Order supply: min. cost of $75, max. cost of $225 You pay the deductible first before the Plan pays for any prescription drugs. Not covered $100 deductible per member applicable to Retail drugs, 30% coinsurance after deductible For 30-day Retail supply: min. cost of $30, max. cost of $90 For 90-day Mail- Order supply: min. cost of $75, max. cost of $225 Not covered Outpatient Surgery 20% coinsurance 40% coinsurance 10% coinsurance 30% coinsurance 10% coinsurance 30% coinsurance Physician/Surgeon Fees 20% coinsurance 40% coinsurance 10% coinsurance 30% coinsurance 10% coinsurance 30% coinsurance Emergency Room Services 20% coinsurance 20% coinsurance 10% coinsurance 10% coinsurance $150 co-pay (waived if admitted) Emergency Medical Transportation 20% coinsurance 20% coinsurance 10% coinsurance 10% coinsurance 10% coinsurance 10% coinsurance Urgent Care 20% coinsurance 40% coinsurance 10% coinsurance 30% coinsurance $35 co-pay/visit 30% coinsurance Hospital Stay Facility Fee (e.g., Hospital Room) 20% coinsurance 40% coinsurance 10% coinsurance 30% coinsurance 10% coinsurance 30% coinsurance Hospital Stay Physician/Surgeon Fee 20% coinsurance 40% coinsurance 10% coinsurance 30% coinsurance 10% coinsurance 30% coinsurance 19

20 Mental/Behavioral Outpatient Services Health Mental/Behavioral Health Office Visit: 20% coinsurance Mental/Behavioral Health Office Visit: 40% coinsurance Mental/Behavioral Health Office Visit: 10% coinsurance Mental/Behavioral Health Office Visit: 30% coinsurance Mental/Behavioral Health Office Visit: $25 co-pay/visit Mental/Behavioral Health Office Visit: 30% coinsurance Mental/Behavioral Health Facility Visit Facility Charges: 20% coinsurance Mental/Behavioral Health Facility Visit Facility Charges: 40% coinsurance Mental/Behavioral Health Facility Visit Facility Charges: 10% coinsurance Mental/Behavioral Health Facility Visit Facility Charges: 30% coinsurance Mental/Behavioral Health Facility Visit Facility Charges: 10% coinsurance Mental/Behavioral Health Facility Visit Facility Charges: 30% coinsurance Mental/Behavioral Health Inpatient Services 20% coinsurance 40% coinsurance 10% coinsurance 30% coinsurance 10% coinsurance 30% coinsurance 20

21 ANTHEM (continued) HRA HDHP/HSA PPO In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Referral Not Required Referral Not Required Referral Not Required Substance Use Disorder Outpatient Services Substance Abuse Office Visit: 20% coinsurance Substance Abuse Office Visit: 40% coinsurance Substance Abuse Office Visit: 10% coinsurance Substance Abuse Office Visit: 30% coinsurance Substance Abuse Office Visit: $25 co-pay/visit Substance Abuse Office Visit: 30% coinsurance Substance Abuse Facility Visit Facility Charges: 20% coinsurance Substance Abuse Facility Visit Facility Charges: 40% coinsurance Substance Abuse Facility Visit Facility Charges: 10% coinsurance Substance Abuse Facility Visit Facility Charges: 30% coinsurance Substance Abuse Facility Visit Facility Charges: 10% coinsurance Substance Abuse Facility Visit Facility Charges: 30% coinsurance Substance Use Disorder Inpatient Services Pregnancy Prenatal and Postnatal Care Pregnancy Delivery and All Inpatient Services 20% coinsurance 40% coinsurance 10% coinsurance 30% coinsurance 10% coinsurance 30% coinsurance 20% coinsurance 40% coinsurance 10% coinsurance 30% coinsurance $25 co-pay/visit 30% coinsurance 20% coinsurance 40% coinsurance 10% coinsurance 30% coinsurance 10% coinsurance 30% coinsurance Home Health Care (120 Visits per Year) Rehabilitation Services (20 Visits per Therapy) 20% coinsurance 40% coinsurance 10% coinsurance 30% coinsurance 10% coinsurance 30% coinsurance 20% coinsurance 40% coinsurance 10% coinsurance 30% coinsurance $40 co-pay/visit 30% coinsurance Habilitation Services 20% coinsurance 40% coinsurance 10% coinsurance 30% coinsurance $40 co-pay/visit 30% coinsurance Skilled Nursing Care (120 Visits) Durable Medical Equipment 20% coinsurance 40% coinsurance 10% coinsurance 30% coinsurance 10% coinsurance 30% coinsurance 20% coinsurance 40% coinsurance 10% coinsurance 30% coinsurance 10% coinsurance 30% coinsurance Hospice Service 20% coinsurance 40% coinsurance 10% coinsurance 30% coinsurance 10% coinsurance 30% coinsurance Child Care Eye Exam Child Care Glasses Child Care Dental Checkup Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered Not covered To find a provider in Anthem s network, go to anthem.com, choose Useful Tools on the right, and select find a doctor or hospital or call KAISER PERMANENTE HMO In-Network Only Bank Contribution Toward Your Deductible None Your Deductible Your Out-of-Pocket Max. (Includes Your Deductible) Lifetime Maximum Primary Care Visit to Treat an Injury or Illness None $1,500 Individual $3,000 Family Unlimited $30 per visit Specialist Visit Other Practitioner Office Visit Preventive Care, Screening, Immunization $30 per visit $30 per visit for acupuncture services $30 per visit 21

22 KAISER PERMANENTE (continued) HMO In-Network Only Diagnostic Test (X-ray, Blood Work) X-ray: no charge; lab tests: no charge Imaging (CT/PET Scans, MRIs) No charge Generic Drugs Plan pharmacy: $10 per prescription for 1 to 30 days; Mail Order: usually two times the plan pharmacy cost sharing for up to a 100-day supply Preferred Brand Drugs Plan pharmacy: $30 per prescription for 1 to 30 days; Mail Order: usually two times the plan pharmacy cost sharing for up to a 100- day supply Non-Preferred Brand Drugs Same as preferred brand drugs Specialty Drugs Same as preferred brand drugs Outpatient Surgery $30 per procedure Physician/Surgeon Fees No charge Emergency Room Services $100 per visit (your cost is the same if you use a Non-Plan Provider) Emergency Medical Transportation $50 per trip (your cost is the same if you use a Non-Plan Provider) Urgent Care $30 per visit (your cost is the same if you use a Non-Plan Provider) Hospital Stay Facility Fee (e.g., Hospital Room) $500 per admission Hospital Stay Physician/ Surgeon Fee No charge Mental/Behavioral Health Outpatient Services $30 per individual visit; $15 per group visit Mental/Behavioral Health Inpatient Services $500 per admission Substance Use Disorder Outpatient Services $30 per individual visit; $5 per group visit 22

23 KAISER PERMANENTE (continued) Substance Use Disorder Inpatient Services HMO) In-Network Only $500 per admission Pregnancy Prenatal and Postnatal Care Prenatal care: $15 per visit; postnatal care: $15 per visit Pregnancy Delivery and All Inpatient Services $500 per admission Home Healthcare No charge (100 visits) Rehabilitation Services Inpatient: $500 per admission; outpatient: $30 per visit Habilitation Services $30 per visit Skilled Nursing Care No charge (100 visits) Durable Medical Equipment 20% coinsurance per item Hospice Service No charge Child Care Eye Exam $30 per visit Child Care Glasses Not covered Child Care Dental Checkup Not covered To find a provider in Kaiser Permanente s network, go to kp.org or call

24 Expatriates Expatriates or employees participating in the Global Rotational Training Program are eligible to participate in GeoBlue, an international medical plan, if you are paid under the U.S. payroll. Please contact the Benefits Service Center at for more information. GEOBLUE Inside the U.S. Outside the U.S. Your Deductible $1,000 Individual $2,500 Family In-Network In-Network and Out-of-Network deductibles are combined. Satisfying one helps satisfy the other. Embedded deductible? Referral Not Required $1,500 Individual $3,750 Family Out-of-Network In-Network and Out-of-Network deductibles are combined. Satisfying one helps satisfy the other. Embedded Deductible? $1,000 Individual $2,500 Family Your Out-of-Pocket Max. (Includes Your Deductible) $4,500 Employee $13,500 Family $5,000 Employee $15,000 Family $4,500 Employee $13,500 Family Lifetime Maximum Unlimited Unlimited Unlimited Primary Care Visit to Treat an Injury or Illness $25 co-pay 30% coinsurance 10% coinsurance Specialist Visit $25 co-pay 30% coinsurance 10% coinsurance GEOBLUE (Continued) In-Network Inside the U.S. Out-of-Network Outside the U.S. Referral Not Required Other Practitioner Office Visit (20 Visits per Year) Chiropractor: $25 co-pay Acupuncturist: $25 co-pay Chiropractor: 30% coinsurance Acupuncturist: 30% coinsurance Chiropract or: 10% coinsuranc e Acupunctu Preventive Care, Screening, Immunization 100%, no deductible 30% coinsurance 100%, no deductible Diagnostic Test (X-ray, Blood Work) Lab Office: 10% coinsurance Lab Office: 30% coinsurance Lab Office: X-ray Office: 10% X-ray Office: 30% 10% coinsurance coinsurance coinsuranc e Imaging (CT/PET Scans, MRIs) 10% coinsurance 30% coinsurance 10% coinsurance Generic Drugs $10 co-pay; maximum 180-day supply $10 co-pay; maximum 180-day supply $10 co-pay; maximum 180- day supply Brand-Name Formulary Drugs $25 co-pay; maximum 180-day supply $25 co-pay; maximum 180-day supply $10 co-pay; maximum 180- day supply Brand-Name Non-Formulary Drugs $25 co-pay; maximum 180-day supply $25 co-pay; maximum 180-day supply $10 co-pay; maximum 180- day supply Outpatient Surgery 10% coinsurance 30% coinsurance 10% coinsurance Physician/Surgeon Fees 10% coinsurance 30% coinsurance 10% coinsurance Emergency Room Services 10% coinsurance 30% coinsurance 10% coinsurance Emergency Medical Transportation 10% coinsurance 30% coinsurance 10% coinsurance Urgent Care 10% coinsurance 30% coinsurance 10% coinsurance Hospital Stay Facility Fee (e.g., Hospital Room) Hospital Stay Physician/Surgeon Fee 10% coinsurance 30% coinsurance 10% coinsurance 10% coinsurance 30% coinsurance 10% coinsurance 24