2015 INSURANCE ANNUAL/OPEN ENROLLMENT TRANSFER PERIOD

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1 2015 INSURANCE ANNUAL/OPEN ENROLLMENT TRANSFER PERIOD The insurance annual enrollment/transfer period will be held from October 1 through November 1, If you are currently participating and do not want to change your current coverage, you do not have to do anything during the enrollment period. If you are not enrolled or want to make adjustments to your coverage, you may change health options, change health insurance carriers, enroll in health insurance for yourself or your eligible dependents, or cancel health coverage. You may also enroll in, cancel, or transfer between dental and/or vision options and apply for optional special accident insurance. The State of Tennessee is requiring all enrollment, changes, and cancellations in coverage to be made online using employee self-service in Edison. Directions on how to do this can be found at Your User ID and password were recently mailed to your home address. If you did not receive the User ID and Password or are having trouble logging in, please call Benefits Administration at , option 3. Coverage changes will be effective January 1, The deductions for this coverage will begin with the December 2014 payrolls. Monthly premiums for medical, dental, and vision coverage will be deducted on a pre-tax basis. The Partnership PPO Promise requirements, developed by Benefits Administration at the State of Tennessee and administered by Healthways, are different every year. For 2015 coverage, you must meet the following requirements to remain in the Partnership PPO: Members and covered spouses must complete the online Healthways Well-Being Assessment (health questionnaire) by March 15. Members and covered spouses must participate in health coaching and/or case management if identified. Members and covered spouses in health coaching must complete a biometric screening by July 15. Members and covered spouses must keep their address, phone number and address current with the university. Members and covered spouses must be tobacco free or agree to participate in the tobacco cessation program and work toward becoming tobacco free. The Insurance Committee governing the State and Higher Education insurance plan also approved the following benefit changes/enhancements effective with calendar year 2015 coverage. Health insurance premiums will not increase in There is now a single medical maximum out-of-pocket. The medical copay out-of-pocket maximum is combined with the coinsurance out-of-pocket maximum. The maximum out-of-pocket amounts for medical and pharmacy are changing for both PPO plans. Your total innetwork out-of-pocket maximum will be less in Dental premiums will increase by 2.1% and Vision premiums will increase by 2.4%. If you did not elect health insurance coverage during your initial enrollment period you will have an opportunity to enroll during this enrollment period. This time during October will be the only way for you and/or your eligible dependents to join the plans unless you experience a special enrollment qualifying event. 1

2 HEALTH INSURANCE If you are currently participating in a health insurance plan and do not wish to make any changes to your coverage you do not have to do anything. Your current plan will continue through calendar year The two insurance options available to you are the Partnership PPO and the Standard PPO. Both PPO s cover the same services, treatment and products, but employees and covered spouses who enroll in the Partnership PPO must agree to the terms of the Partnership Promise each year. The incentives for participating in the Partnership PPO are lower monthly premiums, a lower annual deductible, lower pharmacy copays and coinsurance for all types of care, and a lower out-of-pocket maximum. If you participated in the Partnership PPO Plan during calendar year 2014 and you were notified that you or your spouse failed to meet the 2014 Partnership Promise, you will automatically be moved to the Standard PPO Plan with the same provider for calendar year 2015 coverage. If you are currently participating in the Standard PPO Plan, you are eligible to change to the Partnership PPO medical plan provided that you agree to the 2015 Partnership PPO promise. You have the option to transfer from one provider to the other (BlueCross BlueShield of Tennessee to CIGNA or CIGNA to BlueCross BlueShield of Tennessee). Please review the provider networks carefully because both providers have made significant changes. For a provider to be considered in network for BlueCross Blue Shield, they must participate in the BlueCross BlueShield Network S. For a provider to be considered in network for CIGNA, they must participate in the Open Access Plus, OA Plus, or Choice Fund OA Plus networks. Depending on where you live, BlueCross BlueShield and Cigna have a variation in premiums because the networks have different costs in each region. If you are in East or Middle Tennessee, the Cigna Plan costs $20 more per month for employee only coverage and $40 more per month for all other premium levels. If you are in West Tennessee, the BlueCross BlueShield plan costs $20 per month more for employee only coverage and $40 per month for all other premium levels. Although for some procedures different medical criteria may apply based on the carrier you select, you probably want to choose your carrier based on whether or not your doctor, hospital or lab/facility participates in their network. As an additional option in Middle Tennessee only, Cigna will offer the LocalPlus network as a part of a twoyear pilot program. o o o o This is a narrower network than the Cigna Open Access Plus network. The network includes primarily HCA-affiliated hospitals and Vanderbilt Medical Center, among others. The St. Thomas Hospitals (Baptist, St. Thomas, Middle Tennessee Medical), Williamson Medical Center, among others are not included. The $20/$40 network carrier surcharge will not apply (It will cost the same as BlueCross in Middle Tennessee). You have the option to cancel your coverage and/or coverage for your covered dependents WITHOUT a qualifying life changing event. This option does not apply to 1) any dependent child that is a covered dependent as a result of a court order, or, 2) if you and your spouse are in the process of a divorce you cannot terminate the spouse s coverage until the divorce is final. You must select a premium tier based on the size of your family and how many dependents you would like to cover. The available tiers are,,, and Employee + Spouse + Child(ren). 2

3 HEALTH INSURANCE BENEFITS AT A GLANCE PARTNERSHIP PPO STANDARD PPO COVERED SERVICES IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK For the following services, you do not need to meet your deductible first. These costs do apply to the annual out-of-pocket maximum, with the exception of in-network pharmacy, which has a separate out-of-pocket maximum. Preventive Care No charge $45 copay No charge $50 copay Well-Baby, Well-Child Visits No charge $45 copay No charge $50 copay Primary Care $25 copay $45 copay $30 copay $50 copay Specialist Care $45 copay $70 copay $50 copay $75 copay Mental Health and Substance Abuse $25 copay $45 copay $30 copay $50 copay Convenience Clinics/Urgent Care $30 copay $35 copay Facilities Emergency Room (waived if admitted) $125 copay $145 copay X-ray, Lab and Diagnostics 100% covered after 100% covered after 100% covered after 100% covered after office office copay office copay up to office copay MAC copay up to MAC Chiropractic (medical necessity criteria may apply) Pharmacy (30-day supply only from pharmacies in the 30-day network) Pharmacy (90-day supply only from special, less costly 90-day network or mail order) Pharmacy (90-day supply for certain medications only from special, less costly 90-day network or mail order) Out-of-Pocket Copay Maximum Visits 1-20: $25 Visits 21 and up: $45 $5 copay generic; $35 copay preferred ; $85 copay nonpreferred $10 copay generic; $65 copay preferred ; $165 copay nonpreferred $5 copay generic; $30 copay preferred ; $160 copay nonpreferred $2,500 employee only; $5,000 all family tiers Visits 1-20: $45 Visits 21 and up: $70 Copay plus any amount exceeding MAC Copay plus any amount exceeding MAC Copay plus any amount exceeding MAC none Visits 1-20: $30 Visits 21 and up: $50 $10 copay generic; $45 copay preferred ; $95 copay nonpreferred $20 copay generic; $85 copay preferred ; $185 copay nonpreferred $10 copay generic; $40 copay preferred ; $160 copay nonpreferred $3,000 employee only; $6,000 all family tiers Visits 1-20: $50 Visits 21 and up: $75 Copay plus any amount exceeding MAC Copay plus any amount exceeding MAC Copay plus any amount exceeding MAC For the following services, you must meet your deductible before the plan will begin to pay benefits. These costs apply to your annual out-of-pocket maximum. Inpatient Care (including mental health 10% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance and substance abuse) Outpatient Surgery 10% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance Ambulance (air and ground) 10% coinsurance 20% coinsurance Advanced X-ray, Scans and Imaging 10% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance OT/PT/Speech Therapy 10% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance Deductible $450 $800 $800 $1,500 $700 $1,250 $1,250 $2,350 $900 $1,600 $1,600 $3,000 + Child(ren) $1,150 $2,050 $2,050 $3,850 Out-of-Pocket Maximum $2,300 $3,500 $2,600 $3,900 $3,200 $4,600 $3,800 $5,900 $3,700 $5,800 $4,500 $7,200 + Child(ren) $4,600 $7,500 $5,200 $9,500 none 3

4 HEALTH INSURANCE PREMIUMS The following premiums reflect no premium increase for calendar year East and Middle Tennessee BlueCross BlueShield CIGNA LocalPlus in Middle TN only CIGNA Open Access Employee Share Employer Share Employee Share Employer Share Partnership PPO $ $ $ $ $ $ Children $ $ Standard PPO $ $ $ $ $ $ Children $ $ West Tennessee BlueCross BlueShield CIGNA Employee Share Employer Share Employee Share Employer Share Partnership PPO $ $ $ $ $ $ Children $ $

5 West Tennessee BlueCross BlueShield CIGNA Employee Share Employer Share Employee Share Employer Share Standard PPO $ $ $ $ $ $ Children $ $ NOTE: The premiums listed above do not include the additional premium for the Basic Term Life Insurance that is included as part of your medical plan. VISION INSURANCE You have the choice of a basic vision plan or an expanded vision plan. Both plans offer the same services, including an annual routine eye exam, frames, eyeglass lenses, contact lenses, and a discount on Lasik/Refractive surgery. With the basic plan, you pay a discounted rate or the plan pays a fixed-dollar allowance for services and materials. The expanded plan provides services with a combination of copays, allowances and discounted rates. The basic and expanded plans are both administered by EyeMed Vision Care. You will receive the maximum benefit when visiting a provider in their Select network. However, out-of-network benefits are also available. You must select a premium tier based on the size of your family and how many dependents you would like to cover. The available tiers are,,, and Employee + Spouse + Child(ren). VISION INSURANCE BENEFITS AT A GLANCE COVERED SERVICES BASIC PLAN EXPANDED PLAN Routine Eye Exam $0 copay $10 copay Frames $50 allowance per frame; plus 20% discount off any amount above the allowance $115 allowance per frame after $15 copay; plus 20% discount off any amount above the allowance Eyeglass Lenses $50 allowance $15 copay (includes glass or plastic, single vision, lined bifocals, lined trifocals and lenticular lenses) Eyeglass Lens Options (upgrades): Progressive/No-line (basic) Anti-reflective (basic) Polycarbonate Photochromics Scratch resistance coating UV coating Tints All other eyeglass lens 20% discount off all options Maximum copayments: $55 copay $45 copay $30 copay; $0 for children 18 and under $70 copay $15 copay $10 copay $25 copay $25 copay 20% discount 5

6 Exam for Contact Lenses (fitting and evaluation) Minimum 15% discount Copay not to exceed $60 Contact Lenses [1] : Elective (conventional or disposable) Medically Necessary Lasik/Refractive Surgery (for select providers) Out-of-Network Benefits All Eye Exams Frames/Eyeglass Lenses o Single Vision o Lined Bifocal Frames/Lenses o Lined Trifocal Frames/Lenses Elective Contacts (conventional or disposable) Medically Necessary Contacts [2] Frequency Eye Exam Eyeglass Lenses and Contacts Frames $50 allowance $150 allowance 15% discount off usual and customary fees $30 allowance $50 allowance $25 allowance $75 allowance Once every 12 months per person Once every 12 months per person Once every 24 months per person $130 allowance covered at 100% 15% discount off usual and customary fees $45 allowance $70 allowance $30 allowance $50 allowance $65 allowance $50 allowance $100 allowance Once every 12 months per person Once every 12 months per person Once every 24 months per person [1] In lieu of eyeglass lenses and/or frames [2] If medically necessary as first contact lenses following cataract surgery or multiple pairs of rigid contact lenses for treatment of keratoconus EyeMed offers some additional discounts which include: 40% off on additional pairs of eyeglasses at any network location, after the vision benefit has been used $60 off any pair of Ray-Ban polarized sunglasses 20% off non-covered items such as lens cleaner, accessories, and non-prescription sunglasses Expanded Plan Only: 25% to 50% savings on premium progressive and anti-reflective lenses VISION INSURANCE PREMIUMS The following premiums represent a 2.4% increase for calendar year Premium Levels Basic Plan Expanded Plan + Children $3.35 $6.69 $6.35 $9.83 $5.86 $11.72 $11.14 $

7 DENTAL INSURANCE The Dental Program allows you to choose between the Prepaid Dental Plan and the Preferred Dental Organization (PDO) Plan. The Prepaid Plan is administered by Assurant Employee Benefits. To receive benefits, you must select a dentist from the Assurant DentiCare network, complete a dentist selection form and return it to Assurant. This plan provides dental services at pre-determined copay amounts. The Preferred Dental Organization Plan is administered by Delta Dental. You can choose any dentist, but you receive maximum benefits when you use a Delta Dental PPO network provider. You pay coinsurance for covered services, which is a percentage of the maximum allowable charge. In addition, a deductible applies for out-of-network dental care, but not for in-network services. No referrals are required with the PDO. Some services require waiting periods and limitations and exclusions apply. Premium Tiers - You must select a premium tier based on the size of your family and how many dependents you would like to cover. The available tiers are,, Employee+ Spouse, and + Child(ren). DENTAL INSURANCE BENEFITS AT A GLANCE ASSURANT PREPAID OPTION DELTA PDO OPTION COVERED SERVICES GENERAL DENTIST SPECIALIST DENTIST IN-NETWORK OUT-OF-NETWORK Annual Deductible None None $100 single; $300 family, per policy year [5] Annual Maximum Benefit None $1,500 per person, per policy year Pre-existing Conditions Covered Some exclusions Office Visit $15 copay [3] No charge 20% of MAC Periodic Oral Evaluation No charge No charge 20% of MAC Routine Cleaning No charge No charge 20% of MAC X-ray Intraoral, Complete Series No charge $5 copay 20% of MAC 40% of MAC Amalgam (silver) Filling 2 Surfaces $8 copay $10 copay 20% of MAC 40% of MAC Permanent Endodontics Root Canal Therapy Molar (excluding final restoration) $250 copay $600 copay 50% of MAC Major Restorations Crowns (porcelain fused to high noble metal) $275 copay, plus lab fees [1] 50% of MAC [4] Extraction of Erupted Tooth (minor oral $15 copay $70 copay 20% of MAC 40% of MAC surgery) Removal of Impacted Tooth Complete Bony (complex oral surgery) $100 copay $120 copay 50% of MAC Dentures Complete Upper $310 copay, plus lab fees [1] 50% of MAC Orthodontics Annual Deductible Lifetime Maximum 25% off participating orthodontist s usual fees None None Waiting Period Age Limit MAC Maximum Allowable Charge None None 50% of MAC None $1,250 (including any benefits received under a prior dental plan) [2] 12 months Up to Age 19 7

8 The benefits listed are a sample of the most frequently utilized dental treatments. Refer to vendor materials for complete information on coverage, limitations, and exclusions. [1] Members are responsible for additional lab fees for these services. [2] If an individual had coverage through another dental plan, they may also have had a lifetime maximum for orthodontia. The orthodontia maximum is a lifetime benefit, which means, if an individual enrolls under the PDO, the benefit amount will not start over again. The benefits for orthodontia under the PDO would be adjusted based on the benefits a member may have received previously through another dental plan. [3] A charge of $20 may apply for a missed appointment when the member does not cancel at least 24 hours prior to the scheduled appointment. [4] A 12-month waiting period applies. [5] Does not apply to diagnostic and preventive benefits such as periodic oral evaluation, cleaning, and x-ray. DENTAL INSURANCE PREMIUMS The following premiums reflect a premium increase of 2.1% for calendar year Premium Levels + Children Assurant Pre-Paid Plan $10.13 $21.03 $17.95 $24.68 Delta Dental PDO Plan $21.51 $49.46 $40.69 $79.62 BASIC TERM LIFE AND ACCIDENTAL DEATH INSURANCE The state provides a basic level of term life insurance ($20,000) and accidental death and dismemberment insurance ($40,000) to all employees. If you are enrolled in health insurance as the head of contract, your coverage increases with your salary to a maximum of $50,000 for basic term life insurance and $100,000 for accidental death insurance Benefits are administered by Minnesota Life. OPTIONAL ACCIDENTAL DEATH INSURANCE If you would like additional accident protection, you may enroll in optional accidental death and dismemberment insurance for you and your dependents. Premiums vary by age and salary. The maximum benefit available for employees is $60,000. Benefits are administered by Minnesota Life. 8

9 OPTIONAL TERM LIFE INSURANCE If you qualify, you can purchase optional term coverage from Minnesota Life for yourself and your dependent spouse and children. You can apply for up to seven times your annual base salary (to a maximum of $500,000) for yourself and up to a maximum of $30,000 for your spouse ($15,000 for ages 55 and older). You can also apply for coverage for your children equal to $5,000 or $10,000. If you are currently enrolled and are eligible for a guaranteed issue increase, information will be mailed to you. If you and/or your dependent spouse are not presently enrolled, you will be required to present evidence of insurability through a health questionnaire. Enroll through the Minnesota Life website at LONG TERM CARE INSURANCE You are eligible to apply for optional long term care coverage at any time. This insurance covers certain services required by individuals who are no longer able to care for themselves without the assistance of others. Services include nursing home care, assisted living, home health care, home care and adult day care. You can enroll in the long term care coverage through the insurance company s (MedAmerica) website. LONG TERM DISABILITY You may enroll, increase or decrease your current benefit level or cancel participation. If you are not currently enrolled, you may apply as a late applicant at this time. To enroll, you will be required to answer health questions and the coverage will not be effective until the long term disability carrier determines your insurability and the effective date of coverage. To enroll or make changes you should contact your campus insurance office or the Benefits and Retirement Services Office to request the enrollment forms. ASSISTANCE For information concerning eligibility and enrollment guidelines, application forms, or to request written documentation of individual plans, you should contact your campus insurance office. You may also visit the insurance web site to review options. Listed below is campus contact information: LOCATION TELEPHONE NUMBER CAMPUS ADDRESS Knoxville P115 Andy Holt Tower Ag Campus P115 Andy Holt Tower Tullahoma B H. Goethert Parkway, MS-11 Chattanooga McCallie Ave Martin Hall Moody Admin. Bldg. Memphis Madison Ave., Ste 727 U T Hospital (Knoxville) Medical Center Way Benefit and Retirement Services Conference Center Bldg 9

10 For further information concerning benefits, please call or visit the appropriate contact on the internet. Listed below are the telephone numbers and web sites: CONTACT INFORMATION PROVIDED TELEPHONE NUMBER/WEB SITE Partners for Health 2015 Medical Plans Web Address: State of Tennessee Benefits Administration Edison Tennessee Department of Finance BlueCross BlueShield Network S Cigna Network Open Access Plus LocalPlus General Benefits Questions Web Address: Self Service Password Reset option 3 Standard PPO Partnership PPO Standard PPO Partnership PPO Web Address: Web Address: CVS Caremark Pharmacy Benefits Web Address: Assurant Prepaid Dental Plan Prepaid Dental Option Web Address: Minnesota Life Optional Term Life Web Address: Delta Dental PDO Dental Plan PDO Dental Option Web Address: EyeMed Vision Care Vision Care Magellan Health Services Employee Assistance Program Web Address: 10