Starmark Healthy Choices SM

Transcription

1 Starmark Healthy Choices SM Referece-Based Pricig Pla Desigs Self-Fuded Health Pla Desigs ad Stop-Loss Isurace for Small to Mid-Size Busiesses

2 Starmark Healthy Choices SM Desiged specifically to address risig healthcare costs for small to mid-size employers, Starmark Healthy Choices is a iovative self-fuded health beefit pla desig that helps cotrol pla costs while eablig employers to offer more freedom of provider choice. Healthy Choices uses referece-based pricig 2, a strategy that has bee leveraged by large employers, to determie reimbursemet rates to providers based o a multiple of Medicare. Combied with the hallmarks of Starmark s leadig self-fuded pla desigs icludig desig flexibility, potetial for refud, ad stop-loss isurace protectio from Trustmark Life Isurace Compay Starmark Healthy Choices represets a uique approach to smaller group self-fuded healthcare beefits. Why Starmark? Starmark s expertise i group healthcare beefits has served employers for more tha 30 years. Ejoy freedom of choice i healthcare providers atiowide. With Healthy Choices, members ca select providers who best suit their eeds, which eables them to maitai curret provider relatioships. Cotrol costs with olie solutio ad claim egotiatio. Healthcare Bluebook TM helps members get better costs ad quality for medical tests ad procedures. Additioally Starmark s desigated vedor works with providers to egotiate claim amouts, strivig to retai savigs o behalf of the member ad pla. Ecourage your employees to get ad stay healthy with telemedicie services via Teladoc, the CareChampio 24/7 health advocacy service, ad Healthy Foudatios health ad welless maagemet suite. Access olie resources via the Starmark website 24/7. Employers ad members ca log i to the Starmark Documet Ceter to access key healthcare beefit documets. Plus, members ca look up claims ad access cost-savigs resources to help educate ad empower them as healthcare cosumers. Experiece cost-effective pharmaceuticals through prescriptio drug maagemet programs providig atiowide access to retail pharmacies as well as home delivery ad mail order pharmacy services. Make erollmet easy with Express Coect, Starmark s paperless employee erollmet process. Offer a complete beefits package by addig Starmark HealthyDetal SM to complemet your self-fuded health pla. Acillary plas, fully isured by Trustmark Life Isurace Compay, are also available. Except i the istace of orga trasplats, where beefits are available whe performed at a desigated trasplat facility, ad specialty drugs, where beefits are available whe provided by the desigated specialty pharmacy as outlied i the pla documet. 2 Refer to the pla documet for more details. More tha great beefits! Experiece Starmark s uparalleled persoal service. Choose from flexible pla desigs to create a pla to meet your eeds ad budget. Employers have trusted Starmark to serve the healthcare beefit eeds of their employees sice 985. Starmark: Persoal. Flexible. Trusted. 2 Starmark is headquartered with the Trustmark Compaies i this prairie-style buildig i Lake Forest, Illiois.

3 Starmark Healthy Choices SM Customize Your Health Pla Desig Starmark self-fuded pla desigs are flexible ad offer a wide rage of choices so you ca customize your pla to meet your eeds ad budget. Refer to the separate isert (MK85) for a compariso of state-madated beefits for fully isured plas to Starmark self-fuded pla desigs. Ask your broker for details. Beefit Period Caledar Year The 2-moth period from Jauary to December 3 durig which covered expeses ca be applied to satisfy the deductible. The accumulatio period resets every Jauary. Pla Year The 2-moth period durig which covered expeses ca be applied to satisfy the deductible. The pla year begis with the group s effective date ad the accumulatio period resets 2 moths later, o the pla s aiversary. Idividual Deductible $ 0 $ 750 $ 2,000 $ 3,500 $5,000 $6,850 $ 250 $,000 $ 2,500 $ 4,000 $6,000 $7,50 $ 500 $,500 $ 3,000 $ 4,500 $6,350 $7,350 Coisurace 00% 2 90% 80% 70% 50% Idividual Out-of-Pocket Limit $,000 $ 2,500 $ 4,000 $5,500 $6,850 $,500 $ 3,000 $ 4,500 $6,000 $7,50 $ 2,000 $ 3,500 $5,000 $6,350 $7,350 The idividual out-of-pocket limit is the amout of covered charges the member must pay each year. The out-of-pocket limit icludes the pla deductible, coisurace, copays, access fees, ad prescriptio deductibles ad copays. Family Deductible ad Out-of-Pocket Limit Multiplier A multiple of the idividual deductible ad out-of-pocket limit. Oe time Two times Lifetime Maximum Beefit Ulimited for essetial health beefits (as defied by federal regulatio) Whe the deductible is equal to the out-of-pocket limit, oly the 00% coisurace ca be selected. For pla desig purposes, the sum of the deductible, emergecy room copay, outpatiet advaced imagig copay, ipatiet admissio ad outpatiet surgery access fees, prescriptio deductible ad o-preferred brad prescriptio retail copay must be less tha the out-of-pocket limit. 2 Whe the 00% coisurace is selected ad the deductible is equal to the out-of-pocket limit, copays for office visits, urget care, emergecy room, ad outpatiet advaced imagig, ad ipatiet admissio ad outpatiet surgery access fees caot be selected. Additioally, the Price Assurace Program outpatiet prescriptio drug beefit must be selected. 3

4 Beefit Optios Select a physicia/specialist office visit copay, urget care copay ad emergecy room copay to persoalize your selffuded pla desig. If desired, a therapy ad/or alterative medicie copay ca be selected, with the amout depedet o the physicia/specialist office visit copay selected. Copays apply toward the out-of-pocket limit, but do ot apply toward the pla deductible. Physicia/Specialist Office Visit $20 copay $25 copay $30 copay $35 copay $40 copay $45 copay $50 copay $60 copay Deductible ad coisurace Therapies (optioal copay) $20 copay $25 copay $30 copay $35 copay $40 copay $45 copay $50 copay $60 copay Deductible ad coisurace Alterative Medicie (optioal copay) $20 copay $25 copay $30 copay $35 copay $40 copay $45 copay $50 copay $60 copay Deductible ad coisurace Urget Care $40 copay $45 copay $50 copay $60 copay $65 copay $75 copay $80 copay $85 copay $00 copay $25 copay Deductible ad coisurace 4 Physicia/Specialist Office Visit Covered charges are paid up to the Reasoable Fee 2 after the physicia/specialist office visit copay. This icludes charges for the visit, professioal fees for allergy ijectios ad certai o-surgical ijectios performed at the same office visit, ad billed by the attedig physicia. Additioally, the copay applies to maipulative therapy ad icludes procedures provided at the office visit. Diagostic x-rays are subject to the outpatiet diagostic x-ray ad lab beefit selected. Refer to the Covered Services sectio of this brochure for more iformatio. The physicia/specialist office visit copay does ot apply to prevetive care services, allergy testig ad allergy serum, or ay surgical procedure. Coverage for prevetive care services is described i the Covered Services sectio of this brochure. Surgical procedures, as well as services whe a copay is ot selected, are subject to the pla deductible ad coisurace. Therapies Alterative Medicie Covered charges are paid up to the Reasoable Fee 2 after the alterative medicie copay. If a copay is ot selected, covered services are subject to the pla deductible ad coisurace. For a list of covered alterative medicie services, refer to the Covered Services sectio of this brochure. Urget Care Covered charges are paid up to the Reasoable Fee 2 after the urget care copay. This icludes charges for x-ray, lab, pathology ad radiology services performed at the same visit ad billed by the urget care ceter. The urget care copay does ot apply to prevetive care services or ay surgical procedure. Coverage for prevetive care services is described i the Covered Services sectio of this brochure. Surgical procedures, as well as services whe a copay is ot selected, are subject to the pla deductible ad coisurace. Emergecy Room Speech, occupatioal ad physical therapy Copay Choices: $250 $500 The therapy copay applies to speech, occupatioal ad physical therapies. Therapies provided at a physicia/ Covered charges are paid up to the Reasoable Fee 2 after the copay. The copay is ot waived if admitted as ipatiet. specialist office visit may also be subject to the separate Charges for o-emergecy treatmet received i the physicia/specialist office visit copay. Therapies received emergecy room, or services received whe a copay at a hospital are subject to the pla deductible ad is ot selected, are subject to the pla deductible ad coisurace, ad cout toward the maximum visit limit. coisurace. Copays apply toward the out-of-pocket limit, If a copay is ot selected, covered services are subject but do ot apply toward the pla deductible. For iformatio to the pla deductible ad coisurace. o emergecy admissios, see page 0. The urget care copay must be equal to or greater tha the physicia/specialist office visit copay. 2 Reasoable Fee is the lesser of the provider s actual charge, or the greater of the cotracted rate or multiple of the Medicare reimbursemet rate (50 or 75 percet depedig o the service) i effect at the time services are provided. May vary by state. Refer to the proposal for details.

5 Outpatiet Diagostic X-Ray ad Lab Choices: 00% up to $250 per perso, per year 00% up to $500 per perso, per year 00% up to $,000 per perso, per year 00% ulimited (o dollar limit per perso, per year) Coisurace oly (deductible waived) Deductible ad coisurace Coverage icludes x-ray, lab, pathology ad radiology services. This beefit does ot apply to outpatiet advaced imagig such as CT, CTA, MRA, MRI, NCI, PET, PET CT ad 3D Rederig, which is subject to the outpatiet advaced imagig beefit selected. Covered charges exceedig the maximum are subject to the pla deductible ad coisurace. Outpatiet Advaced Imagig Choices: $300 copay Deductible ad coisurace Covered charges are paid up to the Reasoable Fee 2 after the outpatiet advaced imagig copay. The copay applies per procedure ad icludes professioal fees associated with the service. Additioally, the copay applies to the out-ofpocket limit; however, it does ot apply to the deductible. Outpatiet advaced imagig performed i the emergecy room or urget care ceter is subject to the emergecy room copay or urget care copay, if selected. Ipatiet Admissio ad Outpatiet Surgery Access Fees Optio Choices: $250 $500 $750 $,000 Whe the optioal ipatiet admissio ad outpatiet surgery access fees are selected, a additioal access fee applies to facility charges for each hospital admissio, ad to facility charges for each outpatiet surgical visit. After these access fees are paid, covered charges are subject to the pla deductible ad coisurace. These access fees apply toward the out-ofpocket limit, but do ot apply toward the pla deductible. For iformatio o emergecy admissios, see page 0. Note: These access fees caot be selected idividually. Supplemetal Accidet Optio Choose supplemetal accidet beefits to help prepare your employees for a uexpected accidet or ijury by providig first-dollar coverage. The first $500 of covered charges per accidet is paid at 00 percet uder your self-fuded pla desig. Additioal covered charges are subject to the pla deductible ad coisurace. Coverage icludes medical charges resultig from accidetal ijury icurred withi 90 days of the accidet. Materity Optio Selectig the materity optio provides your employees with peace of mid whe plaig for pregacy ad delivery. Normal materity ad ursery care covered charges are subject to the pla deductible ad coisurace. CareChampio 24/7 Optio CareChampio 24/7 is a optioal health advocacy service that supports members as they avigate through the healthcare system. Advisors are available aytime, day or ight, ad ca help members fid a doctor or hospital, uderstad healthcare beefits ad claim paymets, idetify cost-savig opportuities, hadle eldercare issues ad more! YourCare Optio Choose the optioal YourCare health ad welless program to help your employees protect their most importat asset their health. YourCare provides members with proactive, timely ad persoalized iformatio, icludig: Welless remiders to ecourage prevetive tests ad screeigs based o age ad geder. Persoalized, detailed remiders to help members stay curret with recommeded guidelies for maagig a chroic coditio. Outreach from registered urses to assist members who have oe or more serious health coditios. Access to olie self-coachig programs to help members create a persoalized pla to meet their health goals. Starmark Provides Uparalleled Persoal Service Starmark calls each ew group to welcome them ad follows up to esure satisfactio cotiues throughout the year. Starmark s website provides iformatio ad resources to help groups maage their pla ad to help members better maage their healthcare. Members have quick access to importat documets ad beefit iformatio at ad ca quickly access claim status usig their telephoe keypad. Represetatives assist to make trasitioig to future cotract years easy. The coisurace oly optio is ot available whe the 00% coisurace is selected. 2 Reasoable Fee is the lesser of the provider s actual charge, or the greater of the cotracted rate or multiple of the Medicare reimbursemet rate (50 or 75 percet depedig o the service) i effect at the time services are provided. May vary by state. Refer to the proposal for details. 5

6 Outpatiet Prescriptio Drug Beefit Choices Offer Flexibility Starmark Healthy Choices SM self-fuded pla desigs offer 2 prescriptio drug beefit optios to meet your group s eeds: a prescriptio drug card or the Price Assurace Program. Prescriptio Drug Card 2 Price Assurace Program Prescriptio Deductible Must be met i full every year by each member before the copay applies. The prescriptio deductible does ot apply to geerics. $0 per perso $00 per perso $250 per perso $500 per perso 30-Day Supply Specialty Retail Copay Drug Copay* Geeric Preferred Nopreferred Specialty Brad Brad Drugs $ 0 $50 $ 80 $200 $0 $35 $ 55 $200 $5 $35 $ 65 $200 $5 $50 $ 80 $200 $20 $65 $ 95 $ Day Supply Mail Service Copay Geeric Preferred Nopreferred $ 0 $20 $30 $30 $40 Brad $25 $ 85 $ 85 $25 $60 Brad $240 $65 $95 $240 $285 $20 $75 $05 $300 $40 $85 $35 The prescriptio drug deductible ad copays accumulate toward the out-of-pocket limit. The prescriptio drug deductible does ot apply to the medical pla deductibles. Credit from prior pla drug card deductibles ad carry-over provisios do ot apply to the prescriptio beefit. Whe members or their provider choose a brad-ame drug whe a geeric is available, members must pay the geeric copay plus the differece i charges betwee the geeric ad brad-ame drug. *Specialty Drugs: Members order specialty drugs ad related supplies by payig a specialty drug copay ad usig a desigated specialty pharmacy. The specialty drug copay applies to geeric, preferred brad ad opreferred brad specialty drugs. Specialty drugs ot obtaied through the desigated specialty pharmacy are ot covered. OR This program provides prescriptio drug savigs at desigated pharmacies atiowide. Covered prescriptio drugs are subject to the pla deductible ad coisurace whe the prescriptio is filled at a desigated pharmacy. Whe members preset their medical ID card at a desigated pharmacy, they receive: The lowest price available i that store, o that day Geeric drug savigs Drug utilizatio review The Price Assurace Program icludes most drugs that, by federal law, require a prescriptio. If a prescriptio drug is excluded from coverage uder your self-fuded pla desig, members may still receive a discout o their prescriptio through this program. Prescriptio Safeguards To ecourage the safe ad appropriate use of prescriptio drugs, Starmark pla desigs utilize quatity limits ad prior authorizatio for certai drug classes covered by the prescriptio beefit. These limits ad prior authorizatios are iteded to esure proper prescriptio utilizatio ad cliically appropriate quatities. Additioally, Specialty Guidelie Maagemet, provided by Starmark s desigated specialty pharmacy, helps to esure members receive the most appropriate specialty medicatio for maagig their complex medical coditios. Refer to the separate brochure, Safety, Savigs ad Coveiece, for more iformatio. To lear more about the prescriptio drug beefit, specialty pharmacy services ad ways to save o prescriptios, refer to the separate brochure, Makig the Most of Your Prescriptio Beefit. Visit a Desigated Pharmacy to Maximize Beefits Desigated pharmacies have cotracted with Starmark s cotracted pharmacy beefit maager to charge a discouted amout for prescriptio drugs. Nodesigated pharmacies may charge a price sigificatly above this amout, which may mea higher prescriptio expeses for members. Whe a odesigated pharmacy is used, the member pays the full price of the prescriptio drug at the time of purchase. 6

7 Cost-Savigs Features Starmark self-fuded pla desigs offer several ways to help reduce healthcare costs. Get Better Prices ad Quality with Healthcare Bluebook TM Healthcare Bluebook helps members cotrol healthcare spedig by providig Fair Price TM trasparecy for medical tests ad procedures, as well as trasparet, comprehesive quality metrics. This olie solutio lets members: See price rages to avoid overpayig for healthcare Compare providers based o quality data Be better shoppers to help them fid the best providers at the best price Optioal Rewards Program By choosig the optioal Go Gree to Get Gree rewards program, employees ad their eligible depedets ca ear up to $00 per eligible procedure by usig a Fair Price Provider. Note: Employers are resposible for fudig all rewards, ad for all applicable payroll taxes ad withholdigs. Cosult your fiacial advisor. Healthcare Bluebook is ot a affiliate of Starmark or Trustmark Life Isurace Compay. Talk to a Doctor Aytime with Teladoc Teladoc gives members 24/7/365 access to U.S. boardcertified doctors via phoe or video cosults for oemergecy medical coditios. The cosult fee is the lesser of $45 or the office visit copay, if selected. It s a affordable alterative to costly urget care ad ER visits whe care is eeded ow. Availability ad services may vary by state. Note: The cosult fee is subject to chage durig the pla year. Teladoc is ot a affiliate of Starmark or Trustmark Life Isurace Compay. Cotact a Nurse Aroud-the-Clock MyNurse 24/7 SM provides aroud-the-clock access to a registered urse, so members get the aswers they eed, whe they eed them most. Members ca reach a registered urse via telephoe or olie chat. MyNurse 24/7 provides members with decisio support based o cliical guidelies ad evidece-based resources, ad could help idetify emergig coditios before they become serious health issues. Ocology Maagemet Program Supports Patiet Care The Ocology Care Itegratio program maages cacer patiets from detectio to trasitioal care ad features expert support provided by a physicia pael, icludig boardcertified ocologists. The program offers cliical, fiacial ad emotioal support for members/families, ad care coordiatio based o their progosis, stage ad goals. Plus, treatmet plas are proactively reviewed usig atioally recogized, evidece-based cliical criteria. Eligible members are cotacted by a ocology urse specialist to eroll them i the program. The Ocology Care Itegratio program is provided by America Health Holdig, Ic., which is ot a affiliate of Starmark or Trustmark Life Isurace Compay. 7

8 Covered Services Whe medically ecessary, eligible charges for the followig services are payable uder your self-fuded pla desig subject to the pla deductible, coisurace, ad Reasoable Fee. Hospital ad Provider Services Semiprivate hospital room, board ad geeral ipatiet ursig care Itesive care uit Miscellaeous services ad supplies provided by a hospital o a ipatiet basis Miscellaeous services ad supplies provided by a hospital or free-stadig surgical ceter ad related to outpatiet surgery or outpatiet treatmet of ijury Aesthetics ad their admiistratio Physicia s fees, except as otherwise oted Emergecy services Telemedicie services provided by Teladoc Prevetive Care Services Covered prevetive care services will be paid uder your self-fuded pla desig at 00 percet. 2 Age ad frequecy schedules apply. Covered prevetive care services iclude, but are ot limited to: Routie physical exam Blood ad other laboratory tests Screeig ECG (electrocardiogram) Immuizatios PSA (prostate-specific atige) Colorectal cacer screeig Screeig for tobacco use Wome s prevetive services Well-woma visits, icludig preatal routie office visits Mammograms: baselie ad aual Screeig for cervical cacer Cotraceptive methods ad couselig Breastfeedig support, supplies ad couselig For a complete list of prevetive care services, visit ad uspstf-a-ad-b-recommedatios. I o evet will beefits for prevetive care services be less tha that which is required by state or federal law, as applicable. Other Services ad Supplies Prescriptio drugs (See page 6 for details o outpatiet prescriptio drug beefits.) Blood ad blood plasma, oxyge ad retal of equipmet for its admiistratio Local licesed ambulace service to or from a hospital X-rays (ot detal x-rays) ad laboratory tests performed for diagosis ad treatmet X-ray, radium, cobalt ad radioactive isotope therapy Artificial limbs ad eyes Casts, splits, trusses, crutches ad odetal braces Retal of a wheelchair, hospital-type bed or other durable medical equipmet Habilitative ad rehabilitative devices Complicatios of pregacy Outpatiet pre-admissios testig Hospice care Maximum of 6 moths while covered uder the pla Home healthcare Maximum of 00 days per year Skilled ursig care Maximum of 8 days per year RN ad LPN fees for private-duty ursig recommeded by a physicia Nodetal treatmet of temporomadibular joit dysfuctio (TMJ) Chroic pai treatmet programs Maximum of 0 visits per year Hair prosthesis for alopecia resultig from cacer treatmet that ivolves chemotherapy or radiatio therapy Maximum of oe hair prosthesis per member, per year; covered charges are ot subject to the deductible ad coisurace Therapies Habilitative ad rehabilitative services, icludig speech, occupatioal ad physical therapist s fees, whe prescribed by a physicia 60-visit limit per therapy, per year Maipulative therapy 20-visit limit per year Alterative Medicie Acupucture, massage therapy ad aturopathic services 2-visit limit per therapy, per year Nutritioal couselig 3-visit limit while covered uder the pla, except for diabetic couselig Reasoable Fee is the lesser of the provider s actual charge, or the greater of the cotracted rate or multiple of the Medicare reimbursemet rate (50 or 75 percet depedig o the service) i effect at the time services are provided. May vary by state. Refer to the proposal for details. 2 Prevetive care beefits are i accordace with guidelies from the U.S. Prevetive Services Task Force, Health Resources ad Services Admiistratio, ad the Advisory Committee o Immuizatio Practices of the Ceters for Disease Cotrol ad Prevetio. 8

9 Metal Illess, Nervous Disorders, Substace Abuse ad Alcohol Abuse Groups with up to 50 employees Outpatiet expeses 40-visit limit per year; 20 visits while covered uder the pla Covered charges are paid at 60 percet Ipatiet expeses 20 days per year; 40 days while covered uder the pla. These limits do ot apply to ipatiet alcohol abuse treatmet. Covered charges are paid accordig to the coisurace selected. Groups with 5 or more employees Outpatiet ad ipatiet expeses Covered charges are paid the same as ay other covered service. Orga Trasplats Services must be provided at a desigated trasplat facility; otherwise, o beefits are provided. Covered charges for approved trasplat services, icludig orga procuremet or acquisitio, are paid at 00 percet. Coverage is provided for trasportatio, lodgig ad meals for a compaio, subject to the followig limits: a. Trasportatio beefit: maximum of $,000 per approved trasplat procedure b. Lodgig ad meals beefit: maximum of $250 per day; $0,000 while covered uder the pla Covered charges may be payable uder the Ehaced Health Beefits Package, if selected. Optioal Health Beefits Packages for Your Pla Desig Offer your employees a more complete beefits package by choosig these optioal health beefits packages. Sice the passage of the Affordable Care Act, employees may expect these beefits i their health pla. Packages may be selected idividually. Ehaced Health Beefits Package Metal illess, ervous disorders, substace abuse ad alcohol abuse Covered charges are paid the same as ay other covered service. Routie adult visio screeig 00% coverage for oe exam per year for adults ages 9 ad older Routie adult hearig screeig 00% coverage for oe exam per year for adults ages 9 ad older Hearig aids Covered charges are paid the same as ay other covered service ad are limited to a sigle purchase, icludig repair ad replacemet, every 24 moths. Ifertility Health Beefits Package Female members are eligible for beefits up to age 40. Covered charges are paid the same as ay other covered service for the followig: Ovulatio iductio limited to 6 cycles while covered uder this pla Itrauterie isemiatio I-vitro fertilizatio (IVF), gamete itra-fallopia trasfer (GIFT), zygote itra-fallopia trasfer (ZIFT) or low tubal ovum trasfer Pre-implatatio geetic testig, whe medically ecessary Exclusios ad limitatios apply. Healthy Foudatios Helps Members Get ad Stay Healthy Healthy Foudatios provides a comprehesive suite of health ad welless maagemet tools to help members get ad stay healthy, which ca help cotrol your pla costs. Healthy Foudatios icludes: MyNurse 24/7 SM, a URAC-accredited urse lie; MateraLik materity welless program; olie support tools ad the Healthy Foudatios welless e-ewsletter. Plus, you ca elect to add the optioal YourCare health ad welless program with persoalized outreach to help employees protect their most importat asset their health. To lear more, visit 9

10 Precertificatio To avoid pealties, precertificatio is required for all hospital, rehabilitatio or skilled ursig admissios, behavioral health residetial treatmet, hospice, home healthcare or trasplat-related services, home ifusio therapy, outpatiet radiatio ad chemotherapy, ad outpatiet advaced imagig icludig, but ot limited to, CT, CTA, MRA, MRI, NCI, PET, PET CT ad 3D Rederig. To precertify, the member must call the toll-free umber listed o the medical idetificatio card. Failure to precertify will result i a $300 pealty per occurrece. This pealty will ot cout toward the pla deductible, or toward the out-of-pocket limit. Precertificatio does ot guaratee self-fuded pla beefits are payable. The perso must be eligible at the time of service. Refer to the pla documet for more details. Emergecy Admissios I the case of a emergecy admissio, the member must call the toll-free umber listed o the medical idetificatio card withi 48 hours after the admissio or o the ext regular busiess day after the start of treatmet, if later. Failure to call will result i a $300 pealty per occurrece. This pealty will ot cout toward the pla deductible, or toward the out-of-pocket limit. Note: If selected, the ipatiet admissio fee also applies. Deductible Credit for New Groups A member cotiuously covered uder a prior idividual or group health pla with a caledar-year deductible will be credited for ay portio of the deductible satisfied uder the prior pla durig the same caledar year. Deductible credit will ot be give if movig to or from a health pla with a pla-year deductible. Credit is ot provided for out-of-pocket amouts (other tha amouts applied to the deductible), prescriptio drug card deductibles or for employees added to a self-fuded pla after the group s iitial effective date. Limited Occupatioal/ 24-Hour Coverage Sickess or ijury which occurs while workig for wage or profit is ot covered, except for a member who is a sole proprietor, parter or executive officer of the compay sposorig a Starmark -admiistered pla who is ot required by law to have Workers Compesatio or similar coverage ad does ot have such coverage. Erollmet Aual Ope Erollmet Period Eligible employees may eroll themselves ad their eligible depedets durig the aual ope erollmet period, which is the moth prior to the start of the ew pla year. Waitig Period The waitig period is the amout of time the employee must wait before he or she is eligible for coverage uder your self-fuded pla. The waitig period caot exceed 90 days. Timely Erollees Timely erollees are eligible employees who complete ad sig a Employee Eligibility Statemet for themselves ad/or their depedets durig the employer s waitig period ad prior to the ed of the iitial erollmet period. The iitial erollmet period is the 3 days followig the waitig period. Special Erollees Special erollees are employees or depedets who previously waived self-fuded coverage, but may ow be eligible because they have ivolutarily lost their other coverage, had a beefit/coverage chage or had a life-chagig evet. The erollmet period for a special erollee is the 3 days followig the special erollmet evet (60 days for special erollees who have lost their Medicaid or State Childre s Health Isurace Program coverage). Special guidelies apply for special erollees. For more details, refer to the Importat Notice (UW05 SF) or ask your broker. Off-Aiversary Termiatios If the stop-loss isurace cotract termiates before the ed of the cotract period, there is o aggregate stop-loss isurace available for the moths the cotract was i force. As a result, the employer is resposible for reimbursig Trustmark Life Isurace Compay for ay advaces, icludig all aggregate advaces. The employer is also resposible for payig all covered claims, below the specific deductible, if applicable, that were icurred ad ot paid while the pla was i force. Additioally, if the /2 Admiistrative Fee Credit Surplus, the 2/3 Admiistrative Fee Credit Surplus or the 2/3 Admiistrative Fee Credit, 2/3 Cash Surplus optio was selected, the employer forfeits the surplus. Hospital Bill Reward Program If a member detects ad resolves a error whe reviewig hospital bills, he or she will be rewarded 50 percet of the savigs, up to $,000, uder your self-fuded pla desig. 0

11 Exclusios ad Limitatios Major Medical No beefits are payable uder your self-fuded pla desig for the followig expeses: Services ad supplies ot prescribed by a physicia or required to treat a covered coditio, or i excess of the Reasoable Fee except for ay egotiated amout, or ot medically ecessary Telemedicie services, uless received through Starmark s cotracted telemedicie services vedor; surgery of the jaw (orthogathic); detal care ad treatmet, icludig pediatric detal care ad treatmet; hearig aids 2, eyeglasses, eyeglass frames ad cotact leses; eye or hearig exams 2,3 ; all other visio care services; some foot treatmet Cosmetic surgery; hair prosthesis, except as specified uder Covered Services; hair trasplats; treatmet for abormal male breast elargemet Charges the member is ot legally required to pay; charges for missed or caceled appoitmets, stad-by charges or after hours; surcharges for weeked oemergecy office visits ad home visits by a physicia; treatmet redered by a member of the member s family; treatmet, services or supplies provided by a medical departmet, treatmet ceter, or cliic operated by or sposored by a member s employer; occupatioal sickess ad ijury, except for members who are ot covered by workers compesatio or similar coverage ad are ot required by law to have such coverage Normal pregacy, elective abortios ad routie ursery care, uless materity beefits are selected; treatmet for ifertility, except for services related to the diagosis of ifertility, uless the Ifertility Health Beefits Package is selected; pregacy ad all associated charges of a perso who is ot a eligible employee or depedet icludig, but ot limited to, a surrogate; reversal of sterilizatio No-prescriptio drugs 3 ; imported drugs; ay prescriptio drug cotaiig bulk chemical powders; weight reductio 3 ; smokig deterret medicatios 3 ; sex trasformatio or its reversal; restoratio or ehacemet of sexual activity Treatmet received outside the Uited States, except emergecies; immuizatios required for travel outside the Uited States; most treatmet for sorig; excessive sweatig; phoophoresis; surface electromyogram; therapeutic cold devices; x-rays or tests ot related to diagosis or treatmet of sickess or ijury, uless otherwise specified Most dietary supplemets 3 ; experimetal/ivestigatioal drugs or treatmet; items for comfort or coveiece; expeses at a health spa; services ad supplies related to homeopathic medicie; family or marriage couselig, aversio therapy, omedical self-care or self-help programs; custodial care Suicide, attempted suicide or itetioal self-iflicted ijury, if ot the result of a medical coditio; ijury resultig from oe s ow illegal use of alcohol, drugs or over-the-couter medicatios, if ot the result of a medical coditio Acts of war; participatio i a riot; commissio of or attempt to commit a feloy; egagig i a illegal occupatio Optioal Ifertility Health Beefits Package No beefits are payable uder your self-fuded pla desig for the followig expeses: Cryopreservatio (freezig) or bakig of eggs, embryos or sperm; medicatios for sexual dysfuctio; recruitmet, selectio ad screeig, ad ay other expeses of doors; pregacy ad all associated charges of a perso who is ot a eligible employee or depedet icludig, but ot limited to, a surrogate; reversal of sterilizatio Reasoable Fee is the lesser of the provider s actual charge, or the greater of the cotracted rate or multiple of the Medicare reimbursemet rate (50 or 75 percet depedig o the service) i effect at the time services are provided. May vary by state. Refer to the proposal for details. 2 If the Ehaced Health Beefits Package is selected, hearig aids ad routie adult hearig ad visio screeigs are covered, subject to pla provisios. 3 No beefits are payable uder your self-fuded pla desig for these expeses, except as required uder federal guidelies for prevetive care. Starmark HRA: Seamless. Iovative. Bottom-lie friedly. Save moey ad help your employees maage healthcare costs. Pair a higher-deductible health pla with the Starmark HRA (health reimbursemet arragemet) for lower health pla costs ad cash-flow cotrol with the added bous of: Seamless claims ad HRA itegratio, which meas o claims to file No prefudig; HRA expeses are fuded oly as icurred Easy fud maagemet for employees

12 Our missio: Helpig people icrease well-beig through better health ad greater fiacial security. Self-fuded plas are admiistered by Starmark, ad stop-loss isurace coverage is provided by Trustmark Life Isurace Compay. Trustmark: A employee beefits compay for more tha 00 years The Trustmark Compaies serve more tha 2 millio covered lives or pla participats. Trustmark Life Isurace Compay is rated A- (Excellet) by A.M. Best. Starmark: Servig the healthcare beefit eeds of employer groups for more tha 30 years Starmark admiisters self-fuded health beefit plas, offerig extesive pla desig choices, exceptioal persoal service ad atiowide provider access. Starmark The leader i self-fudig for small groups. The iformatio cotaied i this product brochure is a geeral descriptio of features, beefits, requiremets ad restrictios of the self-fuded beefit pla desigs. More details are provided i the self-fuded pla documet, which is the prevailig documet ad the basis for beefit paymet. Pla desigs are subject to chage to comply with federal healthcare reform, as ecessary. Pla desig availability ad/or stop-loss coverage may vary by state. Subchapter S corporatios should cosult their tax advisor as beefits from a self-fuded pla may be taxable. MyNurse 24/7 SM is a service mark of Health Fitess Corporatio, a Trustmark Compay. 400 Field Drive Lake Forest, IL Star Marketig ad Admiistratio, Ic. B er (2-7)