EMPLOYEE BENEFIT NEWSLETTER

Transcription

1 EMPLOYEE BENEFIT NEWSLETTER BENEFIT INFORMATION Parkway School District s employee benefit plans renew January 1, 2014, which means it is time for the Annual Enrollment period. Our benefit package includes Medical, Dental, Vision, Basic Life/Accidental Death & Dismemberment, and Voluntary Life/Accidental Death and Dismemberment. For 2014, our medical, dental and vision benefits will remain with all our current carriers. Our Life/AD&D and Voluntary Life/ AD&D will move to Reliance Standard. Parkway School District knows your employee benefit package is extremely important to you. We understand your benefits should meet you and your family s needs, as well as be affordable. Again, this year we worked with CBIZ, our insurance consultants, to review the marketplace and obtain the most competitive rates without sacrificing quality. Our medical plan renewal was especially challenging this year. In addition to escalating claims costs we were also impacted by health care reform. As a self insured plan, our medical rates are a direct result of the claims incurred by our membership. Health care reform fees added approximately an additional 5% over and above the annual renewal. We remain committed to comprehensive benefits as well as your active role in your health. We ll continue to partner with you to enable your success. We will continue to offer 3 District Self Funded medical plan options the Plan, the Plan and the Qualified Health Plan (QHDHP) complemented with a Health Savings Account (HSA). There have been no benefit level reductions with the exception of a slight increase to the out-of-pocket maximum on the Plan. Parkway will continue to offer the and QHDHP plans at no cost for employee only coverage. As well, the cost of the QHDHP will decrease in 2014 for dependent coverage! We have made only modest rate increases for dependent coverage on The and The Plans. The QHDHP complemented with a Health Savings Account offers lower premiums, as well as the opportunity to save the premium dollars and place the savings in a personal account for future claims. Effective January 1, 2014, Parkway will increase their HSA contribution to $120 per month! Please review the next few pages of the newsletter thoroughly as they review the benefit plans, which will be in effect on January 1, During Open Enrollment you may change your benefit elections as well as add or delete any dependents or you may opt out of the medical plan. It is also time for your annual election for the Flexible Spending Medical Reimbursement Account and Dependent Care Accounts. Parkway School District is pleased to announce effective January 1, 2014, UnitedHealthcare will remain our medical carrier. To find helpful medical benefit information and tools, log on to where you will have the ability to: Find Doctors and Hospitals Check Claim Status Order New ID Card Print Temporary ID Card View Benefits Member Services: Express Scripts will remain our pharmacy vendor. For pharmacy benefit information, log on to Refill Mail Order Prescriptions Access Express Scripts Drug List Member Services: DELTA DENTAL AND ASSURANT REMAIN OUR DENTAL CARRIERS. VISION BENEFITS OF AMERICA IS OUR VI S ION C AR R I ER. R EL I AN C E STANDARD WILL BE OUR NEW BASIC L I F E I N S U R A N C E / A D & D A N D VOLUNTARY LIFE INSURANCE/AD&D CARRIER. PLEASE REFER TO THE EMPLOYEE KEY CONTACT SHEET FOR SPECIFIC CONTACT INFORMATION. Employee Meetings November 7th at 4:30 South Middle School (Commons) AND November 12th at 4:30 Central Middle School (Theater) January 1, 2014 Page 1

2 UnitedHealthcare - Plan Plan lights Benefit/Service In-Network Non- Network This plan has copays when you visit your physician, emergency room, or urgent care. The employee cost of this plan is covered by the District. You are responsible for a portion of any elected dependent coverage. You cannot enroll in a Health Savings Account if you elect this plan. Prescription Drug Benefit through Express Scripts includes a mail order benefit for additional cost savings. If you utilize a non-network p h a r m a c y, y o u a r e responsible for any difference between what a non-network pharmacy charges and the amount Express Scripts would have paid for the same prescription drug dispensed from a Network Pharmacy. $500 - Individual $1,000 - Family $2,000 - Individual $4,000 - Family Co-Insurance 10% 40% Out-of-Pocket Max. Physician Office Visit Preventive Care: (Includes Office Visit, Lab, and X-Rays, and Tests associated with preventive care) Inpatient Hospital & Outpatient Surgery Diagnostic Lab, X-Ray, and other Tests $1,500- Individual $3,000 - Family $25 Primary Care $40 Specialist 100% Covered Does Not Apply & & $4,000 - Individual $8,000 - Family & & & & Emergency Room $200 Copay $200 Copay Urgent Care Prescription (through Express Scripts) Retail Copay Mail Order 90 Day Retail $75 Copay $12/ $40/$60 2 Times Copay $36/$120/$180 & Not Available Not Available Not Available Employee Contribution Type of Coverage Monthly Cost Employee $0 Employee & Spouse $230 Employee & Spouse + 1 $340 Employee & Spouse + 2 $460 Employee & Child(1) $110 Employee & Children (2+) $230 January 1, 2014 Page 2

3 UnitedHealthcare - Plan Plan lights Benefit changes to the Plan are bolded in the benefit summary table This plan has copays when you visit your physician, emergency room, or urgent care. Effective January 1, 2014 there will be an employee cost share for employee only coverage. You are responsible for a portion of any elected dependent coverage. You cannot enroll in a Health Savings Account if you elect this plan. Prescription Drug Benefit through Express Scripts includes a mail order benefit for additional cost savings. If you utilize a non-network pharmacy, you are responsible for any difference between what a non-network pharmacy charges and the amount Express Scripts would have paid for the same prescription drug dispensed from a Network Pharmacy. Benefit/Service In-Network $300 - Individual $600 - Family Non- Network $500 - Individual $1,000 - Family Co-Insurance 0% 30% Out-of-Pocket Max. Physician Office Visit Preventive Care: (Includes Office Visit, Lab, and X-Rays, and Tests associated with preventive care) Inpatient Hospital & Outpatient Surgery Diagnostic Lab, X-Ray, and other Tests $900 - Individual $1,800- Family $20 Primary Care $30 Specialist 100% Covered Does Not Apply Applies Applies $3,500 - Individual $7,000 - Family & & & & Emergency Room $150 Copay $150 Copay Urgent Care Prescription (through Express Scripts) Retail Copay Mail Order 90 Day Retail $50 Copay $12/ $35/$55 2 Times Copay $36/$105/$165 & Not Available Not Available Not Available Employee Contribution Type of Coverage Monthly Cost Employee $40 Employee & Spouse $340 Employee & Spouse + 1 $520 Employee & Spouse + 2 $660 Employee & Child(1) $220 Employee & Children (2+) $360 January 1, 2014 Page 3

4 UnitedHealthcare Qualified Health Plan with HSA If you elect the Qualified Health Plan (QHDHP) you may also participate in the Health Savings Account (H.S.A.). The District will deposit $120 on a monthly basis into your H.S.A. You may also elect pre-tax deductions from your paycheck to add additional funds into your H.S.A. Plan lights Prescription Drug Benefit through Optum Rx. You cannot be covered elsewhere under a non-qualified plan. The employee cost of this plan is covered by the District. You or your spouse cannot participate in a Medical Flexible Spending Account. You are allowed to participate in a Dependent Care Flexible Spending Account. You may use your Health Savings Account for reimbursement of any eligible health care expenses for family members even if they are not participating in the QHDHP. Save your receipts. The IRS is notified of all distributions. IRS rules dictate the maximum deposit amount allowed into Health Savings Accounts. The maximum amount includes the District s contribution plus any additional deposits you elect to add to your account. You cannot exceed these set maximums for 2014: Individual Accounts: $3,300 Family Accounts: $6,550 Visit the IRS website for more information: Benefit/Service In-Network $2,500 / Individual $5,000 / Family Non- Network $5,000 / Individual $10,000 / Family Co-Insurance 0% 30% Out-of-Pocket Max. Physician Office Visit Preventive Care: (Includes Office Visit, Lab, and X-Rays, and Tests associated with preventive care) Inpatient Hospital & Outpatient Surgery Diagnostic Lab, X-Ray, and other Tests Emergency Room Urgent Care Prescription Retail Mail Order $2,500 / Individual $5,000 / Family Applies Covered 100% Does Not Apply Applies Applies Applies Applies then $0 Copay then $0 Copay Employee Contribution Type of Coverage $8,000 / Individual $16,000 / Family & & & & 100% after Network has been met & then $0 Copay then $0 Copay Monthly Cost Employee $0 Employee & Spouse $130 Employee & Spouse + 1 $245 Employee & Spouse + 2 $360 Employee & Child(1) $70 Employee & Children (2+) $150 January 1, 2014 Page 4

5 Dental Delta Dental & Assurant Our dental benefit carriers are Delta Dental and Assurant. The Delta Dental plan offers three network options for your dental care. If you utilize the PPO Network, you will receive the advantage of contracted fees negotiated between Delta Dental and the dentist. Your second option is the Premier Network. A dentist in the Premier Network accepts fees offered by Delta Dental under a contractual agreement and will not balance bill. If you elect a non-participating dentist benefits are paid based on Delta s maximum allowance. You may experience balance billing and higher out-of-pocket expenses if you utilize a Non-Network dentist. The Assurant Dental plan offers a copay type plan for in network services only. The employee cost of both plans is covered by The District. Delta Dental Assurant Benefits PPO Network Premier Network Non- Network Benefits In Network Individual Family Applies To: $50 $150 Basic & Major $50 $150 Basic & Major $50 $150 Basic & Major Individual Family $0 $0 Preventive Basic Services Major Services 0% 20% 40% 0% 25% 45% 0% 25% 45% Periodontics 20% 25% 25% Endodontics (Root Canal) 20% 25% 25% Oral Surgery 40% 45% 45% Annual Maximum Orthodontia Adult and Child to age 26 Lifetime Maximum $1,000 Per Person Max Advantage is included charges for preventive services do not apply towards the annual maximum 40% 40% 40% $1,000 Per Child Schedule* Preventive Basic Services Major Services *see plan summary for full details Periodontics Endodontics (Root Canal) Oral Surgery Annual Maximum Orthodontia Scheduled Copayment Scheduled Copayment Scheduled Copayment Scheduled Copayment Scheduled Copayment Scheduled Copayment Unlimited Per Person Discounts Available Delta Dental Type of Coverage Employee Contribution Monthly Cost Employee $0 Employee & Spouse $17.12 Employee & Spouse & 1 or more Child(ren) $43.60 Employee & 1+ Child $26.48 Assurant Type of Coverage Monthly Cost Employee $0 Employee & 1 Dependent $4.32 Employee & 2 Dependents $10.42 January 1, 2014 Page 5

6 Vision Vision Benefits of America Benefit/ Service In Network Exam Copay Covered 100% Frequency Exam Lenses Frames Lenses Single Lined Bifocal $20 copay then 100% 100% 100% Every 12 months Every 12 months Every 24 months Non- Network $38 Reimbursement Reimbursement $31 $51 $64 Lined Trifocal Frames 100% $ Retail $45 Contacts Necessary Cosmetic Type of Coverage UCR $150 Employee Contribution Monthly Cost Employee $0 $300 $150 Plan lights Vision benefits are provided by Vision Benefits of America. There are no benefit changes to our vision plan for Non-Network benefits are based on a reimbursement schedule. Lasik Surgery Discount is available at TLC Laser Eye Centers or Qualsight. Hearing Aid Discounts are available at Beltone. Some scratch resistant lens protection and tinting are covered at 100% in network. Dependents are covered until 26 (end of month) Employee + 1 Dependent $1.90 Employee & Family $3.70 Life Insurance Voluntary Life Insurance The Basic Life/Accidental Death & Dismemberment benefit provided by the District will remain the same. This benefit is provided at no cost to eligible employees through Reliance Standard. If you are currently enrolled in the Voluntary Life program you can take advantage of a one time opportunity to increase your current coverage by one increment without submitting an Evidence of Insurability form as long as you do not go over the guarantee issue amount. This applies to employees voluntary life only. You may also increase or apply for voluntary life coverage for yourself. An Evidence of Insurability form stating the current health status of the applicant is required for late entrants or if you are increasing current coverage. The Evidence of Insurability form is located under the Quick Links tab on the Parkway Website. January 1, 2014 Page 6

7 Flexible Spending Account Effective January 1, 2014, the District will be switching the plan administrator from ASIFlex to UnitedHealthcare. With this transition, we are anticipating that much less documentarian of medical services paid using the FSA MasterCard will be necessary. Potentially, only out-of-network claims, dental and vision claims would require paper documentation. Most other medical claims will be automatically adjudicated at the time of payment. Open enrollment is the time for you to enroll in the Section 125 Flexible Spending Account. You may participate in the Medical Reimbursement Plan AND/OR the Dependent Day Care Reimbursement Plan. You may elect up to $2,500 in the Medical Reimbursement Account and up to $5,000 for the Dependent Care Reimbursement Account for the 2014 calendar year. IMPORTANT FACTS TO REMEMBER IF YOU WANT TO ENROLL IN THE FLEXIBLE SPENDING ACCOUNT You cannot elect to participate in the FSA Medical Reimbursement Account if you select the Qualified Plan. This is an IRS requirement because you are required to participate in a Health Savings Account. There are TWO options to make contributions under an FSA: 1. Medical Reimbursement Account - This account is for reimbursement of any medical, dental, or vision expenses not covered under a benefit plan. You do not have to be enrolled in the Parkway School Districts benefit plans to participate in the FSA. 2. Dependent Day Care Account - This account is for the day care expenses for dependents while you (and your spouse, if applicable) are working. You cannot make a claim for medical reimbursement from this account. THIS IS VERY IMPORTANT: IF YOU ELECT DEPENDENT DAY CARE PRE-TAX DEDUCTIONS AND YOU DO NOT HAVE ELIGIBLE DEPENDENTS YOU WILL LOSE ANY AMOUNT DEDUCTED FROM YOUR PAYCHECK FOR THIS BENEFIT. THE DEDUCTION CAN BE STOPPED UPON REQUEST BUT YOU WILL NOT BE ABLE TO RECOUP WHAT WAS DEDUCTED. Summary of Material Modification Parkway School District has amended the Employee Medical Benefit Plan. This contains a summary of the modifications that were made. It should be read in conjunction with the Summary Plan Description that is available to you. If you need a copy of your Summary Plan Description, please refer to the Health Benefits Link on the Parkway Website. Employee Assistance Program (EAP) Parkway now offers an Employee Assistance Program at no cost to our employees. This benefit is through Reliance Standard and offers confidential, short-term counseling for personal and family issues at no cost to you. The EAP provides counseling in dealing with family and relationship issues, substance abuse, stress and anxiety, communication issues, emotional concerns, and more. The EAP also provides several services to help you balance work and home life. Your communications with the EAP are always confidential. Reliance Standard professionals answer calls 24 hours a day, seven days a week. The EAP telephone number is and their website address is January 1, 2014 Page 7

8 Online Open Enrollment ONLINE ENROLLMENT WILL BE HELD NOVEMBER 11, 2013 through NOVEMBER 27, 2013 Enrollment must be done online through the MUNIS Employee Self Service application. All employees must log on to the system and enroll. If you are not making any benefit plan changes, you must re-elect your current plan elections in order for your benefit enrollment to remain unchanged in the system. 1. Click on the Employee Self Service Tab. 2. Click on the Personal Information Tab here you will verify your personal information as well as dependent information. Please make any necessary updates or changes to your dependents. 3. Click the Benefits button here your current benefit elections will be reflected. You will be able to view options and cost. 4. Click on the Open Enrollment button here you will make your elections for the new plan year. You can enroll, terminate, change plans and make dependent election changes. 5. After you complete your elections a summary page will be displayed based on what you selected. Click on the Submit button to confirm your elections. If you do not click submit you will not be enrolled in the 2014 benefits. The confirmation page is available in a printable format if you would like a paper record. Detailed instructions are available on to Parkway School District's website under the Quick Links. THE ONLINE PROCESS ALLOWS YOU TO: Update your beneficiary information for your life insurance. Confirm or change your coverage on your medical, dental, vision, and voluntary life insurance. Elect your Flexible Spending Account payroll deduction amounts. Print forms: Waiver Form or Evidence of Insurability Form for Voluntary Life Insurance. Turn in forms to The Benefits Office. Complete a consent form in order to establish a Health Savings Account through Optum Bank. View Benefit Summaries. YOU MUST GET ONLINE AND CONFIRM YOUR COVERAGE EVEN IF YOU DO NOT WANT TO MAKE ANY CHANGES. About This Bulletin This bulletin is published for employees of Parkway School District and is only a highlight of our benefits. Official plan and insurance documents actually govern your rights and benefits under each plan. If any discrepancy exists between this bulletin and any of the official documents, the official documents will prevail. January 1, 2014 Page 8

9 Health Savings Account (HSA) If you elect the Qualified Health Plan for your insurance coverage, then you are required to open a Health Savings Account. What is an H.S.A.? A savings account set up by either you or your company where you can either direct pre-tax payroll deductions or deposit money to be used by you to pay for current or future medical expenses for you and/or your dependents. Once money goes into the account, it's yours forever - the H.S.A. is in your name, just like a personal checking or savings account. Why would I want an H.S.A.? Because you fund the H.S.A. with pre-tax money, you are using tax-free funds for health care expenses you would normally pay for out-of-pocket using after-tax dollars. Your HSA contributions do NOT count toward your taxable income for federal taxes. What rules must I follow? You must be covered under a Qualified Health Plan (QHDHP) in order to establish a H.S.A. You cannot establish a H.S.A. if you or your spouse also have a medical flexible spending account (FSA). You cannot set up a H.S.A. if you have insurance coverage under another plan, for example your spouse s employer, unless that secondary coverage is also a qualified high deductible health plan. You cannot be eligible for Medicare. You cannot be claimed as a dependent under someone else s tax return. What is the difference between Qualified Health Plan and a traditional PPO Plan? In a QHDHP, all services received, with the exception of preventive care, are applied to the deductible first. This would include office visits that are not preventive, emergency room visits, and prescription drugs. You will, however, still have the opportunity to benefit from the discounts associated with using a network physician or facility. What else do I need to know? The contribution limits for 2014 are $3,300 for Single and $6,550 for Family. You cannot put more than this amount in the account in a calendar year; you can put less. The contributions from your paycheck go in tax-free, grow tax-free, and come out tax-free as long as you utilize the funds for approved services. (medical, dental, vision) Your unused contributions roll over from year to year and can be taken with you if you leave your current job. If you use the money for non-qualified expenses, then the money becomes taxable and subject to a 20% excise tax penalty. Once you turn 65, become disabled and/or qualify for Medicare you can use the account for other purposes without paying the penalty. The District is establishing accounts with Optum Bank so you can take advantage of payroll deductions on a pre-tax basis. A consent form is available through the online enrollment site if you are interested in establishing a Health Savings Account through Optum Bank. Contributions made outside payroll deductions can be claimed on your tax forms. Catch up provision for employees who are over age 55 is $1,000. Retirees cannot participate in the District s H.S.A. You will have to set up an account at a bank of your choice. Retirees cannot participate in an H.S.A. after age 65. January 1, 2014 Page 9

10 Health Savings Account (H.S.A.) More Information about the Health Savings Account (H.S.A.) Another advantage is that your account can grow over time. Since the money always belongs to you, even if you leave the company, and unused funds carry over from year to year, you never have to worry about losing your money. That means if you don t use a lot of health care services now, your H.S.A. funds will be there if you need them in the future even after retirement. Generally, you can put enough in your H.S.A. to cover your entire deductible. The Qualified Health Plan helps you pay for health care AFTER you meet the deductible. The annual contribution limit is based on IRS rules. In general, the total amount that goes in your account each year from both you and your employer can't be more than the IRS annual contribution limit. If you're age 55 or older, you are allowed to make extra contributions each year. You can spend only the money that is actually in your H.S.A. If your health care expenses are more than your H.S.A. balance, you need to pay the remaining cost another way, such as cash or personal check. You can request reimbursement after you have accumulated more money. You can use your H.S.A. for your spouse and dependents even if they are not covered by your Health Plan. You can use H.S.A. funds for IRS-approved items such as... Doctor's office visits Dental services Eye exams, eyeglasses, contact lenses and solution, and laser surgery Hearing aids Orthodontia, dental cleanings, and fillings Prescription drugs Physical therapy, speech therapy, and chiropractic expenses More information about approved items, plus additional details about the H.S.A., is available on the IRS Website at Every time you use your H.S.A., save your receipt in case the IRS asks you to prove your claim was for a qualified expense. If you use H.S.A. funds for a non-qualified expense, you will pay tax and a penalty on the ineligible amount. The bank is required to notify the IRS of all distributions. January 1, 2014 Page 10

11 Total Employee Cost Examples Employee Only - Claims $0 $480 $0 $500 $300 $2,500 $1,000 Copays $1,500 $1,200 TOTAL EMPLOYEE COST $3,000 $1,980 $1,060 Employee Only - Minimal Claims $0 $480 $0 $200 $200 $1,000 Copays $200 $150 TOTAL EMPLOYEE COST $400 $830 $(440) Employee and Spouse - Claims $2,760 $4,080 $1,560 $1,000 $600 $5,000 $2,000 Copays $2,500 $2,000 TOTAL EMPLOYEE COST $8,260 $6,680 $5,120 Employee and Spouse - Minimal Claims $2,760 $4,080 $1,560 $150 $150 $1,000 Copays $150 $100 TOTAL EMPLOYEE COST $3,060 $4,330 $1,120 Employee, Spouse and Child - Claims $4,080 $6,240 $2,940 $1,000 $600 $5,000 $2,000 Copays $2,500 $2,000 TOTAL EMPLOYEE COST $9,580 $8,840 $6,500 Employee Only - Moderate Claims $0 $480 $0 $200 $200 $1,200 Copays $300 $200 TOTAL EMPLOYEE COST $500 $880 $(240) Employee Only Zero Claims $0 $480 $0 $0 $0 $0 Copays $0 $0 TOTAL EMPLOYEE COST $0 $480 $(1,440) Employee and Spouse - Moderate Claims $2,760 $4,080 $1,560 $600 $400 $4,000 $100 Copays $1,200 $900 TOTAL EMPLOYEE COST $4,660 $5,380 $4,120 Employee and Spouse - Zero Claims $2,760 $4,080 $1,560 $0 $0 $0 Copays $0 $0 TOTAL EMPLOYEE COST $2,760 $4,080 $120 Employee, Spouse and Child - Moderate Claims $4,080 $6,240 $2,940 $600 $400 $3,000 $100 Copays $1,200 $900 TOTAL EMPLOYEE COST $5,980 $7,540 $4,500 January 1, 2014 Page 11

12 Total Employee Cost Examples Employee, Spouse and Child - Minimal Claims $4,080 $6,240 $2,940 $200 $200 $1,500 Copays $150 $100 TOTAL EMPLOYEE COST $4,430 $6,540 $3,000 Employee and Family - Claims $5,520 $7,920 $4,320 $1,000 $600 $5,000 $2,000 Copays $3,000 $2,500 TOTAL EMPLOYEE COST $11,520 $11,020 $7,880 Employee and Family - Minimal Claims $5,520 $7,920 $4,320 $200 $200 $1,000 Copays $200 $150 TOTAL EMPLOYEE COST $5,920 $8,270 $3,880 Employee and Child - Claims $1,320 $2,640 $840 $1,000 $600 $5,000 $2,000 Copays $2,500 $2,000 TOTAL EMPLOYEE COST $6,820 $5,240 $4,400 Employee and Child - Minimal Claims $1,320 $2,640 $840 $150 $150 $1,000 Copays $150 $100 TOTAL EMPLOYEE COST $1,620 $2,890 $400 Employee, Spouse and Child - Zero Claims $4,080 $6240 $2,940 $0 $0 $0 Copays $0 $0 TOTAL EMPLOYEE COST $4,080 $6,240 $1,500 Employee and Family - Moderate Claims $5,520 $7,920 $4,320 $1,000 $600 $3,000 Copays $1,500 $1,200 TOTAL EMPLOYEE COST $8,020 $9,720 $5,880 Employee and Family Zero Claims $5,520 $7,920 $4,320 $0 $0 $0 Copays $0 $0 TOTAL EMPLOYEE COST $5,520 $7,920 $2,880 Employee and Child - Moderate Claims $1,320 $2,640 $840 $600 $400 $3,000 $100 Copays $1,200 $900 TOTAL EMPLOYEE COST $3,220 $3,940 $2,400 Employee and Child - Zero Claims $1,320 $2,640 $840 $0 $0 $0 Copays $0 $0 TOTAL EMPLOYEE COST $1,320 $2,640 $(600) January 1, 2014 Page 12

13 Total Employee Cost Examples Employee and Children - Claims $2,760 $4,320 $1,800 $1,000 $600 $5,000 $2,000 Copays $2,500 $2,000 TOTAL EMPLOYEE COST $8,260 $6,920 $5,360 Employee and Children - Minimal Claims $2,760 $4,320 $1,800 $150 $150 $1,000 Copays $150 $100 TOTAL EMPLOYEE COST $3,060 $4,570 $1,360 Employee and Children - Moderate Claims $2,760 $4,320 $1,800 $500 $300 $2,500 $100 Copays $1,000 $800 TOTAL EMPLOYEE COST $4,360 $5,420 $2,860 Employee and Children - Zero Claims $2,760 $4,320 $1,800 $0 $0 $0 Copays $0 $0 TOTAL EMPLOYEE COST $2,760 $4,320 $360 January 1, 2014 Page 13