Benefits. Glance. at a. Open Enrollment all of September District Contribution. Calendar of Events. District Contribution Pool

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1 Benefits at a Glance Open Enrollment all of September Open Enrollment is the ONLY time you may make plan changes, except for certain and specific circumstances. For Mid-Year Plan Changes, contact the Benefits Office. Submit forms to the HR Reception Desk no later than 4:30pm on September 30, District Contribution As of September 2016, Washington State contributes $780 per month for full-time employees. The state s contribution is prorated for part-time employees. Additional district contributions toward insurance are outlined in your employee group agreements. State Allocation Left over benefit dollars Additional District Dollars By Bargaining Group District Contribution Calendar of Events Sep 7, 2016 First Day of School Sep 14, 2016 Benefits Fair 11a 7p Sep 15, 2016 Benefits Drop-In Q&A 8a 12p Sep 22, 2016 Benefits Drop-In Q&A 3p 6p Sep 28, 2016 Benefits Drop-In Q&A 3p 6p Sep 30, 2016 Open Enrollment Ends at 4:30 pm Nov 1, 2016 New Benefit Plan Year Begins All meetings are held at the ESC. District Contribution Pool The District Contribution Pool is divided and reallocated to employees by bargaining group.

2 How to Enroll To enroll in one of the WEA Select plans (Premera Medical, Willamette or Delta Dental), you must use the online benefits center [Upoint]. The web address is: resources.hewitt.com/wea. You may also utilize the WEA Benefits Center by calling between the extended hours of 7:30 am and 5:00 pm during September. YOU MUST ADD ANY DEPENDENTS YOU PLAN TO COVER. The WEA Select plans require documentation on all newly added dependents. The Dependent Verification Team will contact you by mail. If you ignore the request, your dependent will be dropped from your plan. For all other plans (Group Health, VSP Buy-Up, all Voluntary plans, Flexible Spending or Health Savings Account), go to the Staff Portal / HR / Benefits to find the appropriate enrollment form. SCREEN SHOT OF ENROLLMENT SCREEN Mandatory Benefits Mandatory benefits are deducted from the District Contribution first for most groups/bargaining units: Dental, Long Term Disability, Basic Life Insurance and Vision. Dental and Vision coverage are Family Plans; every tax-qualified dependent under age 26 may be covered, even if you are not covering them on your Optional Medical Insurance. Please note you must add any dependents you plan to cover! (For VSP Vision plans only dependents may be added at time of service.) WEA Dental Plans To enroll yourself and dependents (if any) in either of the offered dental plans, see How to Enroll, above. Delta Dental of WA Group #0186 Annual None Annual Maximum (per member per benefit year) $1,750 or $2,000 if you utilize a PPO provider Diagnostic & Preventive Covered at 70% to 100% Restorative Covered at 70% to 100% Crowns & Onlays Covered at 70% to 100% Major Covered at 50% Monthly Premium $ Willamette Dental Group #WEA1 Annual None Annual Maximum (per member per benefit year) N/A Diagnostic & Preventive (exams, x-rays, cleaning, fluoride, sealants) Covered at 100% Restorative (fillings and stainless steel crowns) Covered at 100% Porcelain-Metal Crowns $50 copay, then covered at 100% Endodontics and Periodontics (root canals, root planning) Covered at 100% Oral Surgery (routine extraction, surgical extraction) Covered at 100% Monthly Premium $ 78.40

3 Vision Plans Vision Insurance Teamsters Vision Plan (Bus Drivers ONLY)... $15.10 Includes family coverage (Dependent enrollment form: Staff Portal / HR / Benefits / Vision) Vision Service Plan (VSP) Base Vision Plan... $ 2.59 All groups except Bus Drivers and Food Service Includes family coverage (Family members are enrolled at time of service) Exam $15 copay, contact lens services or hardware at 15-20% discount Optional Vision Buy-up Vision Service Plan (VSP) Buy-up Plan (added to Base Plan rate)... $15.50 Available to all groups except Bus Drivers and Food Service. Vision Buy-up available ONLY to those enrolled in VSP Base Vision Plan AND requires 2 year enrollment commitment. $15 copay for hardware: lenses benefit available every 12 months; frames every 24 months; elective contacts benefit available in lieu of glasses. Discounts available for optional lens services (Progressive lenses, Transition, etc.) from VSP providers. Life and Disability Plans Long Term Disability Insurance (automatically enrolled - no form needed) CIGNA - All groups except Food Service... $ Life Insurance (automatically enrolled - beneficiary form needed) CIGNA: EEA: $10,000 Basic Life and AD&D Benefit... $ 0.76 All Classified groups except Food Service and Paraeducators 1X Annual Salary Basic Life and AD&D Benefit.... $ 3.86 Voluntary Benefits Voluntary benefits are deducted from your pay check if you enroll. Life and AD&D Insurance UnumProvident Life - WEA Select - Employee-only coverage, term life and AD&D insurance of $30, age rated CIGNA - Family coverage also available, term life and AD&D from $10,000 to $300, age rated Salary Insurance (Short Term Disability) - WEA Select American Fidelity... amount varies Critical Care, Cancer Insurance or Accident Indemnity Advantage AFLAC - Individual and Family coverage... amount varies

4 Group Health and Premera WEA Medical Plans All categories below are illustrated with the member s cost share this is a guide for choosing plans, not for predicting your health care costs. Benefit categories with a grey background indicate a change from last year. Refer to plan booklet for specific benefits, limitations and Out-of-Network Benefits. To enroll in Group Health Cooperative, please complete GHC form and return to HR. Group Health Group Premera Blue Cross Group # #00260 The WEA plans include an employee-only $12,500 life insurance policy. (Please remember to update your beneficiaries. Forms on Staff Portal / HR / Benefits.) Plan Name Core WEA Plan 2 WEA Plan 3 WEA Plan 5 Network Group Health Core Heritage Network Heritage Network Foundation Network Individual $200 $300 $500 $200 Family $400 $900 $1,500 $600 Out-of-Pocket Max Individual $2,000 $2,000 $3,000 $1,000 Family $4,000 $6,000 $9,000 $3,000 Office Visits $25 copay $25 copay ($35 Specialist) $30 copay ($40 Specialist) $20 copay ($30 Specialist) Preventive Care 0% - waived 0% - waived 0% - waived 0% - waived Mental Health Outpatient $25 copay $25 copay $30 copay $20 copay Lab & X-ray Inpatient: covered under 20% after 20% after 10% after Inpatient Hospital Outpatient: applies Inpatient Hospital $100 copay per day to $300 max per admission, applies $150 copay/day to $450 max/member PCY, then 20% after $300 copay/day to $900 max/member PCY, then 20% after $150 copay/day to $450 max/member PCY, then 10% after Outpatient Surgery Emergency Room Copay (if applicable) waived if admitted Prescription Drugs Retail Pharmacies Prescription Drug Prescription Drug Out-of- Pocket Maximum Generic / Preferred / Non- Preferred Brands $100 copay, applies $150 copay, applies $100 copay, then 20% after $75 copay; then 20% after $150 copay, then 20% after $100 copay; then 20% after 10% after $50 copay; then 10% after Up to 30-day supply Up to 34-day supply Up to 34-day supply Up to 30-day supply n/a n/a n/a n/a n/a $2,000 individual $4,000 family $2,000 individual $4,000 family $2,000 individual $4,000 family $15/$30/Not covered $10/$20/$35 $15/$25/$40 $10/$15/$30 Specialty Pharmacy Varies by medication $50 copay $60 copay $50 copay Out-of-Network Benefits (individual/family) Combined with In-Network Combined with In-Network $350 per person Out-of-Pocket Max No out-of-network $3,400 / $10,200 $5,900 / $17,700 Unlimited (individual/family) benefits Coinsurance 40% 40% 30% Preventive Care 40%, waived 40%, waived Not Covered Prescription Drugs (Retail) 40% after copays 40% after copays 40% after copays Monthly Premiums 1 Employee Only $ $ $ $1, Employee/Spouse 1, , , , Employee/Children 1, , , , Employee/Family 1, , , , Per ESSB 5940, employees are required to pay 1% of the employee only premiums, even if State and/or District Contributions would cover the full amount of the premium. REFER TO BENEFIT PLAN BOOKLETS AND INSURANCE CERTIFICATES FOR MORE DETAILS (OR CONTACT THE BENEFITS OFFICE.) IN CASE OF CONFLICT, THE PLANS OFFICIAL DOCUMENTS AND CONTRACTS WILL GOVERN.

5 Group Health and Premera WEA Medical Plans (cont.) To enroll in one of the Premera Blue Cross plans, see the How to Enroll section on page 2. All stated plan limits are based on the calendar year (PCY). Plan limits do not reset on the renewal date. All plan limits reset on January 1. Plan booklets will be available via the Staff Portal as soon as they are made available. Premera Blue Cross Group # The WEA plans include an employee-only $12,500 life insurance policy. (Please remember to update your beneficiaries. Forms on Staff Portal / HR / Benefits.) Plan Name WEA QHDHP WEA Select Basic Plan WEA EasyChoice Plan EasyChoice A EasyChoice B Network Foundation Network Heritage Prime Network Heritage Network Heritage Prime Network Individual $1,750 $2,100 $1,250 $750 Family $3,500 $4,200 $3,750 $2,250 Out-of-Pocket Max Individual $5,000 $6,600 $4,000 $3,500 Family $10,000 $13,200 $8,000 $7,000 Office Visits 20% after $35 copay ($50 Specialist) $25 copay ($35 Specialist) $30 copay ($40 Specialist) Preventive Care 0% - waived 0% - waived 0% - waived 0% - waived Mental Health Outpatient 20% after $35 copay $25 copay $30 copay Lab & X-ray 20% after 30% after First $250 subject to coinsurance only; then 20% after 25% after Inpatient Hospital 20% after 30% after 20% after 25% after Outpatient Surgery 20% after 30% after 20% after 25% after Emergency Room Copay (if applicable) waived if admitted Prescription Drugs Retail Pharmacies Prescription Drug Prescription Drug Out-of- Pocket Maximum Generic / Preferred / Non- Preferred Brands 20% after $200 copay; then 30% after $100 copay; then 20% after $150 copay; then 25% after Up to 30-day supply Up to 30-day supply Up to 30-day supply Up to 30-day supply Included in Medical n/a 20% after $750 individual/$1,500 family Included in Medical Out-of-Pocket Max $500, waived for Generics $250, waived for Generics $2,500 individual $5,000 family $2,500 individual $5,000 family $15/$30/$50 $10/30% after Rx $5/$30/$45 Specialty Pharmacy 20% after 30% after 30% after 30% after Out-of-Network Benefits (individual/family) $3,000 / $6,000 $2,500 / $5,000 $2,000 / $6,000 $1,500 / $4,500 Out-of-Pocket Max (individual/family) Unlimited Unlimited Unlimited Unlimited Coinsurance 50% 50% 50% 50% Preventive Care Screenings Only Screenings Only Screenings Only Screenings Only Prescription Drugs (Retail) 20% after Not Covered Not Covered Not Covered Monthly Premiums 1 Employee Only $ $ $ Employee/Spouse , Employee/Children Employee/Family 1, , , Per ESSB 5940, employees are required to pay 1% of the employee only premiums, even if State and/or District Contributions would cover the full amount of the premium. REFER TO BENEFIT PLAN BOOKLETS AND INSURANCE CERTIFICATES FOR MORE DETAILS (OR CONTACT THE BENEFITS OFFICE.) IN CASE OF CONFLICT, THE PLANS OFFICIAL DOCUMENTS AND CONTRACTS WILL GOVERN.

6 Statutory Notices Mid-Ye ar Plan Changes Please note: you will be responsible for any retroactive premium owed based on the effective date of all requested qualifying event changes. HIPAA requires health plans to allow enrollment outside the normal open enrollment period for certain Qualifying Events. These Qualifying Events include: Employee is newly married (must enroll within 60 days of marriage); Employee is divorced or widowed (must enroll within 60 days); Employee has a newborn child or adopts a child (must enroll within 60 days of birth or date of adoption); Employee or dependent s Medicaid or CHIP coverage is terminated as a result of loss of eligibility (must enroll within 60 days); Employee or dependent become eligible for a premium assistance subsidy under Medicaid or CHIP (must drop within 60 days); Dependent s insurance terminates due to change in job or job loss (must enroll within 60 days); Employee or dependent has exhausted COBRA coverage under another employer plan (must enroll within 60 days). If you experience a Qualifying Event that necessitates a change to your benefits elections, please notify us immediately. Contact Benefits via at benefits@edmonds.wednet.edu or call the HR Reception Desk for more info at If you miss your eligibility window, you must wait until the next open enrollment period to make coverage changes. Notice of Availability of Notice of Privacy Practices The Edmonds School District #15 maintains a Notice of Privacy Practices that provides information to individuals whose protected health information (PHI) will be used or maintained by the District s health plans. If you would like a copy of the Notice of Privacy Practices, please contact Benefits at or or benefits@edmonds.wednet.edu. Rescission of Coverage Edmonds School District #15 reserves the right to terminate the health care coverage of you/and your dependent(s) prospectively without notice for cause (as determined by the plan administrators), or if you and/or your dependent are otherwise determined to be ineligible for coverage under the plan. In addition, if you or your dependent commits fraud or intentional misrepresentation in an application for health coverage under the plan, in connection with a benefit claim or appeal, or in response to any request for information by the District or its delegates (including Group Health Cooperative and Premera Blue Cross), your coverage may be terminated retroactively upon 30-day notice. Failure to inform any such persons that you or your dependent is covered under another group health plan or knowingly providing false information in order to obtain coverage for an ineligible dependent are examples of actions that constitute fraud under the plan. Women s Health and Cancer Rights Act (WHCRA) If you have had or are going to have a mastectomy, you may be entitled to certain benefits under WHCRA. For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient for: All stages of reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; Prostheses; and Treatment of physical complications of the mastectomy, including lymphedema. THIS BROCHURE PROVIDES ONLY A HIGHLIGHT OF BENEFITS OFFERED BY EDMONDS SCHOOL DISTRICT #15; PLEASE REFER TO YOUR EMPLOYEE

7 Flexible Spending Account (FSA) / Section 125 Plan Edmonds School District sponsors a Flexible Spending Account program to help employees stretch their health and/or dependent care dollars. The program allows you to reduce your income taxes by setting aside before- tax dollars from your earnings (not subject to federal, Social Security, or Medicare taxes) to use on eligible expenses. The plan year for the FSA matches the District s health plans: November 1 through October 31. Annual re-enrollment in this benefit is required. Your elections do not carry over from year to year. Premium Only Plan (POP) This plan allows you to pay your portion of Medical and/or Vision plan premiums with before-tax dollars. You must opt in when initially enrolling; this plan is not automatic. Health Care and Dependent Daycare FSA Dependent Daycare FSA maximum contribution = $5,000.00, or $2,500 if married and filing separately. The Dependent Daycare FSA can be used for day-care, before- and after-school programs, pre-school programs, as well as elder care services, while you and your spouse work or attend school full-time. Health Care FSA maximum contribution = $2, The Health Care FSA is to pay for eligible expenses incurred by you and your dependents. Expenses include copays, s, prescriptions, and hundreds of over-the-counter items with a doctor s prescription. Please refer to the separate FSA informational packet for details and lists of eligible expenses. The enrollment form is available on Staff Portal / HR / Benefits / Flexible Spending Health Savings Account (HSA) Washington State law requires school districts to offer a Qualifying High Health Plan (QHDHP) in conjunction with an HSA. An HSA is a tax-favored account, which you may use to pay eligible medical expenses. Please refer to informational packet (combined with Flexible Spending Plans) from Flex-Plan that includes details and lists of eligible expenses available on Staff Portal / HR / Benefits / Flexible Spending. Who is eligible for an HSA? Anyone who is: Covered by a high- health plan (HDHP); Not covered under another medical plan that is not an HDHP; Not entitled to (eligible for AND enrolled in) Medicare benefits; or Not eligible to be claimed on another person s tax return. What is the difference between an HSA and FSA? An HSA can roll over unused funds from year to year and is portable - if you leave the District, it goes with you. An FSA cannot roll over unused funds from year to year and is not portable. How much can I contribute to an HSA? Per federal law, the annual contribution limits are: 2016: $3,350 for individual coverage and $6,750 for family coverage 2017: $3,400 for individual coverage and $6,750 for family coverage Individuals age 55 or older may be eligible to make an additional catch-up contribution of $1,000. THIS BROCHURE PROVIDES ONLY A HIGHLIGHT OF BENEFITS OFFERED BY EDMONDS SCHOOL DISTRICT #15; PLEASE REFER TO YOUR EMPLOYEE

8 Carrier and Benefit Contacts Online Benefits Center [UPoint] (WEA) Premera, Delta Dental of WA, and/or Willamette Dental Enrollment Medical Carriers Group Health Cooperative (WEA) Premera Blue Cross Dental Carriers (WEA) Delta Dental of WA (WEA) Willamette Dental option 1 (Customer service) option 3 Vision Carriers Vision Service Plan (VSP) Teamsters (Bus Drivers Only) Long Term Disability and Life Insurance CIGNA Salary Insurance (Short Term Disability Insurance) (WEA) American Fidelity Employee Assistance Program Farwest counseling visits per family per year (# of visits based on bargaining group) Flexible Spending Accounts/Section 125 Plan and Health Spending Account (HSA) Plan Navia AFLAC Plans Contact Mike Patrick Worker s Compensation Eberle Vivian, Julie Kelley x 115 Washington State Department of Retirement Systems (DRS) TRS and SERS Retirement Plans Benefits Office Contacts Monica Carlson Benefits Coordinator CarlsonMo@edmonds.wednet.edu Sheila Waite Benefits Assistant WaiteS@edmonds.wednet.edu Tawni Smith Retirement Specialist SmithTa@edmonds.wednet.edu