Baltimore County Public Schools. Benefits Enrollment & Reference Guide. Open Enrollment Period October 10 November 11, 2016

Transcription

1 Baltimore Couty Public Schools Beefits Erollmet & Referece Guide Ope Erollmet Period October 10 November 11, 2016 Effective Jauary 1, 2017 December 31, 2017

2 Table of Cotets Letter from the Superitedet...1 Importat Resources... 2 What s New for This Pla Year... 3 Beefits ad Eligibility Employee Welless Program... 6 Employee Assistace Program (EAP)... 7 Ope Erollmet New Hire Erollmet...10 Chages to Your Beefits Durig the Pla year COBRA...12 Medical, Detal, ad Visio Deductios for Full-Time Employees...13 Medical, Detal, ad Visio Deductios for Part-Time Employees...14 Your Medical Optios Highlights Ciga Prescriptio Drug Coverage Resources ad Programs Available to All Ciga Participats About Kaiser Permaete Medical Optios At-a-Glace Chart Your Detal Optios Highlights Your Detal Optios At-a-Glace Chart...41 Visio Isurace Flexible Spedig Accouts Electio Life Isurace Volutary Whole Life Isurace Volutary Critical Illess Isurace Persoal Accidet Isurace Log-term Disability Isurace Savigs ad Retiremet Beefits Frequetly Asked Questios (FAQs) Erollmet Form The purpose of this Beefits Erollmet ad Referece Guide is to provide iformatio about your beefit optios ad how to eroll for coverage or make chages to existig coverage. This Guide is oly a summary of your choices ad does ot fully describe each beefit optio. Please refer to your Employee Beefit Guide or Certificate of Coverage for iformatio about the plas. Every effort has bee made to esure that the iformatio i this Guide is accurate; however, the provisios of the actual cotracts for each pla will gover i the evet of ay discrepacy. Copies of the Employee Beefit Guides, pla cotracts, ad other pla materials are available upo request from the Office of Beefits, Leaves ad Retiremet at our Web site, or from the isurace carriers.

3 1 October 2016 Our aual Ope Erollmet period for 2017 begis o Moday, October 10, 2016, ad eds o Friday, November 11, 2016, at 4pm. For 2017, the premium costs for those erolled i the Ciga Ope Access Plus-i/out of etwork Pla (OAP) will see a higher percetage icrease i accordace with the Master Agreemets egotiated i If you are participatig i the Ciga OAP pla ad your providers are i etwork, I would ecourage you to cosider erollig i the Ciga Ope Access Plus i etwork pla (OAPIN) for 2017 sice sigificat savigs are possible with the OAPIN pla. We will cotiue to strive to offer a attractive package of beefits to meet your eeds ad to support the visio of Blueprit 2.0. Letter From the Superitedet For 2017, several provisios of the Affordable Care Act will remai i effect. The primary effect of the 2017 requiremets will ivolve temporary ad cotractual employees of BCPS who are curretly ot eligible for beefits. BCPS employees curretly ot eligible for beefits may be able to eroll i the beefits offered through the State of Marylad Health Care Exchage. The Beefits Erollmet Guide provides details o your 2017 pla optios. Takig time to review these materials carefully will help you make iformed choices about your beefits. Just a Few Remiders Employee Self-Service (ESS) will be available this year for viewig your curret beefit choices ad employees will be able to eroll o lie for medical, detal, visio ad Log-term Disability (LTD). Please ote if you do ot wish to make chages to ay of your beefits, o actio from you is required. The oly exceptio is erollmet i Flexible Spedig Accouts (FSA). Re-erollmet i this beefit is required aually for employees who wish to participate. Erollmet chages may also be completed usig the paper erollmet form. There are o chages to the medical plas. Ciga ad Kaiser are beig offered for Plas iclude the Ciga Ope Access Plus i etwork (OAPIN) ad a Preferred Provider Orgaizatio (PPO) type pla - Ope Access Plus i/ out of etwork (OAP) ad the Kaiser Permaete HMO. Please review the details ad costs of these plas. No actio is required if you wish to maitai your medical coverage. There are o chages to our detal plas. CareFirst PPO ad CareFirst Traditioal plas ad the Ciga Detal DHMO are still i effect for No actio is required if you wish to maitai your detal coverage. CareFirst Davis Visio remais our visio provider. No actio is required if you wish to maitai your visio coverage. You must make a NEW electio to participate i the Flexible Spedig Accouts (FSA). Please ote BCPS must follow strict IRS regulatios regardig the admiistratio of this beefit. Please be sure to review the iformatio cotaied i this beefit guide. If you have ay questios, please refer to the cotact listigs i the back of this Erollmet Guide, call the Office of Employee Beefits, Leaves ad Retiremet at (443) , or at beefits@bcps.org. We hope you cotiue to be pleased with these programs as we edeavor to maitai a competitive beefits package for you ad your family. Sicerely, S. Dallas Dace, Superitedet

4 2 Importat Resources Importat Resources Office of Beefits, Leaves ad Retiremet Phoe: Fax: Web site: (Visit our Web site for may of the forms we use) Office Hours: Moday through Friday, 8:30am 4:45pm Medical Optios HMOs Kaiser Permaete Ciga OAPIN & OAP BCPS Service Area Natioal Group Number Iteret Web site my.kp.org/mida/bcps or Member Services (ID cards, verify provider participatio, claims) Hospital Precert/Health Cosult Service Healthy Pregacy Program TDD Lie Behavioral Health Providers Behavioral TDD Lie Mail Order Detal Optios CareFirst CareFirst Ciga-DHMO Maaged Detal Pla Name Regioal Detal PPO Regioal Detal Traditioal DHMO Network Provider Preferred Participatig I-Network Oly Group Number Iteret Web site Provider Listig Member Services (ID cards, claims) Provider Services Other Numbers Flexible Spedig Accouts Beefits Strategies Visio Isurace Carefirst Davis New cards oly EAP Provider Iteral: Jaice Zimmerma Exteral: CIGNA Behavioral Health or (password: Baltimore) Employee Welless Program EmpWelless@bcps.org Log-term Disability Ext. 4 or Life Isurace Prudetial Cacer Isurace Washigto Natioal Is. Co COBRA Admiistratio First Fiacial Credit Uio Sick Bak Erollmet TABCO employees Sick Bak Erollmet All other employees Retiremet Cotacts BCPS Office of Retiremet Fax: Marylad State Retiremet Agecy (SRA) or Baltimore Couty Employees Retiremet System (BCERS)

5 3 What s New For This Pla Year 2017 At-a-Glace All Ope Erollmet iformatio is available from the BCPS web site at by clickig o the Ope Erollmet lik. Here is a Look at What s New for 2017 I order to provide a improved customer service experiece to our employees, our FSA Pla admiistrator has chaged to Beefit Strategies. Employees who wish to participate i a Health Care FSA or a Depedet Care FSA ca eroll directly with Beefit Strategies by visitig avigatorsuite.com or by callig Employees do ot eed to submit FSA erollmet documetatio to the Office of Beefits, Leaves ad Retiremet. For more iformatio about FSAs, please see page 44 or visit our Web site at The BCPS Employee Welless program has bee growig tremedously. We cotiue to ecourage all employees to lear more about the offerigs of the Employee Welless program. For more iformatio please see page 6 or visit our Web site at offices/sss/employee_welless/. A ope erollmet statemet will be set to you i December 2016 cofirmig your electios for Jauary 1, Review this documet carefully ad compare the iformatio to your copy of the erollmet form. If there is a error, please cotact the Office of Employee Beefits, Leaves ad Retiremet immediately at , so that chages ca be made i a timely maer. Importat Remiders Depedets may be covered util the ed of the moth they tur age 26 for most beefit programs. Participatio i a FSA is ot automatic. You must re-eroll aually durig ope erollmet. Moies remaiig i the accout 90 days after the ed of the pla year caot be retured. The last day for filig claims is March 31. Employees erolled i Ciga or Kaiser Health Plas who wish to maitai their curret beefit choices do ot eed to complete a beefit erollmet form. Your selectios will roll over for What s New for This Pla Year

6 4 Beefits ad Eligibility Beefits ad Eligibility 2017 Basic Beefits With the exceptio of the defied beefit pesio plas, the costs for the basic beefits for all regular part-time ad full-time employees are paid i full by Baltimore Couty Public Schools. Basic beefits iclude: Paid Holidays* Paid Vacatio & Compesable No-Duty Work Days* Paid Sick Leave* Paid ad Upaid Leaves of Absece* Tuitio Reimbursemet* Employee Assistace Program Employee Welless Program $15,000 of Basic Term Life Isurace Employee Visio Coverage* First Fiacial Federal Credit Uio membership available Defied Beefit Pesio Pla *Cotact your supervisor or the Departmet of Huma Resources for more iformatio regardig your eligibility for these beefits. Optioal Beefits I geeral, full ad part-time employees may choose to eroll i ay combiatio of the beefits listed below. BCPS cotributes a large portio toward the purchase of health ad welfare beefits. This allows you the flexibility to choose the beefit plas that best meet your eeds. The Flexible Beefits Program for BCPS is a cafeteria pla as defied by Sectio 125 of the Iteral Reveue Code. A cafeteria pla allows you to pay for certai employee beefits with pre-tax deductios from your paycheck. You pay for most beefits o a before-tax basis, which lowers the taxes take out of each paycheck. Your before-tax beefits iclude: Medical Detal Visio (Must be.5 FTE to be eligible) Cacer & Itesive Care Isurace (ot offered to ew hires after 7/1/2007) Optioal Term Life Isurace up to 10x salary, first $35,000 is before tax. Whole Life Isurace with Log-term Care Critical Illess Isurace Your after-tax beefits iclude: Persoal Accidet Isurace Log-term Disability Isurace (Must be.5 FTE to be eligible) Optioal Term Life Isurace up to 10x salary, amout over $35,000 is after tax. Maximum is $1 millio. Whole Life Isurace with Log-term Care Critical Illess Isurace

7 5 Beefits ad Eligibility (cotiued) Eligibility Employees You are eligible to participate i the BCPS Flexible Beefits Program if you are a: Regular full-time employee Part-time employee workig.5 FTE or more Depedet childre are covered through the ed of the moth that they tur 26 years of age. Depedet childre who are married are eligible. For iformatio about coverage optios for a depedet who has tured 26, please see COBRA o page 12. Beefits ad Eligibility Depedet Eligibility Eligible family members iclude your: Legal spouse Domestic parter (please read the Frequetly Asked Questios o page 58 for the defiitio of a domestic parter) Depedet childre, which icludes: Biological childre Stepchildre Legally adopted childre A child for whom you have legal guardiaship, icludig gradchildre Childre of your eligible domestic parter Childre who are the subjects of a Qualified Medical Child Support Order (QMCSO) that creates the right of the child to receive health isurace beefits uder a employee or retiree s coverage.

8 6 Employee Welless Employee Welless Program The BCPS Employee Welless program works to promote a culture of deliberate welless. Welless is persoal. It s a idividual jourey toward balace, ad a healthy lifestyle. Like walkig, we eed to take it oe step at a time, keepig the pathway i frot of us. This ivolves focusig o the positive ad possible, ad workig together. It is ot about judgmet but about support. The Employee Welless Program works to provide a variety of programs ad offerigs that address the various compoets of welless: emotioal, itellectual, physical, social, fiacial, ad spiritual. Withi every BCPS school ad site is at least oe employee who serves as the Welless Champio. Welless Champios are resposible for commuicatig iformatio about the offerigs of the Employee Welless program to all of the staff at their school or site. If you do ot kow who the Welless Champio is at your school or site, or if you are iterested i becomig a Welless Champio, please EmpWelless@bcps.org. Employee Welless Offerigs Iclude: Osite Biometric Screeigs Health Assessmets Flu Vaccie Cliics Eat Well, Work Well Hugry Harvest Fitess Ceter Discouts 10,000 Steps Toward Welless O-site Fitess Classes Fiacial Welless Semiars Healthiest Loser Healthy Wage Weight Watchers Discout Smokig cessatio CPR Traiig Site based activities Health promotio days: October breast cacer awareess, wear pik Tuesday October 16 February America Heart Associatio, wear red Friday February 3 Rock Your Red, February 24 March utritio promotio, wear ad eat gree Friday March 17 5k Welless Day, May 6 for employees ad their families For more details about these offerigs ad the BCPS Employee Welless Program, please visit:

9 7 Employee Assistace Program (EAP) What is EAP? The Employee Assistace Program (EAP) is a o cost, cofidetial employee beefit. EAP provides services ad support to the employee ad their household members (family) to assist with persoal cocers ad/or workrelated cocers that may impact job performace, health, emotioal well-beig, ad the overall quality of life. EAP services iclude but are ot limited to: Couselig: Up to (10) Face-to-Face sessios with a couselor i your area. Cosultatio ad support by phoe: Cosultatios may be related to questios about behavioral health related topics, assistace with problem idetificatio, problem-solvig skills, approaches ad/or resources to address behavioral cocers. Legal assistace: Free, 30-miute cosultatio with a attorey face-to-face or by phoe. Fiacial: Free 30-miute telephoic cosultatio by phoe with a qualified specialist o issues such as debt couselig or plaig for retiremet. Child care: Resources ad referrals for child care providers, before ad after school programs, camps, adoptio orgaizatios ad iformatio o paretig questios ad preatal care. Elder care: Resources ad referrals for home health agecies, assisted livig facilities, social ad recreatioal programs, ad log-distace care givig. Pet care: Resources ad referrals for pet sittig, obediece traiig, veteriarias ad pet stores. Idetity theft: 60-miute free cosultatio with a fraud resolutio specialist. Who provides the EAP services ad supports ad what is their cotact iformatio? The BCPS EAP has both a iteral ad exteral EAP. Iteral EAP: Ca be reached cofidetially by phoe at durig ormal busiess hours. Web site address: Exteral EAP: The BCPS exteral EAP is maaged through Ciga Behavioral Health ad ca be reached 24 hours a day, 365 days a year at Employees ca also go olie to: Employer ID: baltimore. Employee Assistace Program (EAP)

10 8 Ope Erollmet Ope Erollmet Ope Erollmet Ope Erollmet is the aual time period i which beefit eligible employees ca make chages to their beefit electios. This year s Ope Erollmet period is from October 10, 2016 through November 11, How to Eroll Beefit chages ca be made electroically through Employee Self Services. Beefits chages ca also be made by completig the Beefits Erollmet Chage form foud o page 59. Completed forms must be received i the Office of Beefits, Leaves ad Retiremet o later tha November 11, Forms may be set via iteroffice mail, US mail, faxed to , or ed to beefits@ bcps.org. be set via iteroffice mail to the Office of Beefits, Leaves ad Retiremet, Greewood, via fax to , or scaed ad ed to beefits@ bcps.org. Copies are acceptable, please do ot sed origials to our office. Employees who submit false iformatio iteded to provide health care coverage for alleged depedets ot eligible for such coverage may be subject to disciplie up to ad icludig termiatio of employmet. Such employees will also be held fiacially resposible for all claims filed, ad will be required to reimburse the Board for ay paymets made o behalf of or for the beefits of a ieligible perso claimed as a depedet. To eroll i a Health Care FSA ad/or Depedet Care FSA, please visit or call Beefit Strategies at Importat facts to cosider durig Ope Erollmet The beefit electios you make durig Ope Erollmet stay i effect util the ed of the 2017 Pla Year (Jauary 1, 2017 to December 31, 2017). This is a IRS requiremet which allows our Plas to qualify as pre-tax deductios. Employees who experiece a qualifyig life evet will be permitted to make chages to their beefit electios. Chages must be requested withi 30 days of the qualifyig life evet. Please see page 11 for iformatio about qualifyig life evets. Employees may choose which eligible family members they wat to iclude i each beefit electio. For example, you may cover yourself ad your depedets for medical beefits, but oly yourself for detal coverage. If you ad your spouse are both BCPS employees, you ca each eroll i idividual coverage, or oe of you ca elect two perso or family coverage. If you elect coverage separately, you caot cover oe aother as depedets. Similarly, eligible depedet child(re) may oly be covered uder oe of you. Proof of depedet eligibility is required. Documetatio may be copies of a marriage certificate, birth certificate, or adoptio papers. Documetatio must iclude the employee s ame ad last four digits of their social security umber. Failure to provide this idetifyig iformatio could result i a delay of coverage. Documetatio may Pre-Erollmet ad Post-Erollmet Cofirmatio Statemets Beefit eligible employees will receive two persoalized beefit statemets to assist them durig Ope Erollmet. Pre-Erollmet Cofirmatio Statemets will be set i the begiig of October. This form shows your curret beefits electios. Please review the statemet carefully to determie if you wish to make chages to your beefit pla durig the Ope Erollmet Period. If you do ot wish to make ay chages to your beefit pla, o further actio is eeded; uless you wish to elect a Health Care FSA or a Depedet Care FSA (employees must re-eroll i this beefit every year, if they wat to participate). Post-Erollmet Cofirmatio Statemets will be set i mid-december. This form will show what your electios are after Ope Erollmet. Please review the form for accuracy. If ay processig errors have bee made, please otify the Office of Beefits, Leaves ad Retiremet as soo as possible either by callig or by at: beefits@bcps.org.

11 9 Ope Erollmet (cotiued) Iformatioal Sessios Four beefits iformatioal sessios will be offered at locatios throughout Baltimore Couty durig Ope Erollmet. Beefit pla represetatives ad employees from the Office of Beefits, Leaves ad Retiremet will be available durig the iformatioal sessios to aswer questios. Active employees are highly ecouraged to atted oe of these sessios i order to make educated decisios about their beefits electios. Iformatioal sessios will take place at the followig locatios ad times: Ope Erollmet Date/Time Locatio Tuesday October 11, 3-6pm Dudalk Middle School cafeteria Thursday October 20, 3-6pm Milford Mill Academy cafeteria Wedesday October 26, 3-6pm Loch Rave High School cafeteria Thursday November 3, 3-6pm Pulaski Park Suite 213 Webiar Sessios Two webiar sessios will be offered i the begiig of Ope Erollmet. These sessios will offer employees a overview of their BCPS beefit optios i additio to givig employees a opportuity to ask questios. Employees will eed computer ad phoe access to participate i a webiar sessio. To register please beefits@bcps.org Webiar sessios will be held o the followig dates: Date/Time Moday October 17, 12-12:30pm Moday October 24, 4-4:30pm

12 10 New Hire Erollmet New Hire Erollmet Newly Hired Employees As a ewly hired employee you have 60 days from your first day of employmet to eroll i beefits. If you do ot elect beefits durig the 60 day widow, you must wait util the aual Ope Erollmet period to eroll. How to Eroll Newly hired employees must complete the Beefits Erollmet Chage form foud o page 59. Completed forms should be submitted to the Office of Beefits, Leaves ad Retiremet durig the 60 day widow. Forms may be set via iteroffice mail, US mail, faxed to , or ed to beefits@bcps.org. To eroll i a Health Care FSA ad/or Depedet Care FSA, please visit or call Beefit Strategies at Importat facts to cosider as New Hire Beefits for ewly hired employees will take effect the first day of the moth, followig either your employmet date or the date that you submit your forms to the Office of Beefits, Leaves, ad Retiremet, whichever is later. For example, if you submit a form o March 15, your beefit coverage will beig April 1. The beefit electios you make as a ew hire stay i effect util the ed of the 2017 Pla Year (Jauary 1, 2017 to December 31, 2017). This is a IRS requiremet which allows our Plas to qualify as pre-tax deductios. depedet child(re) may oly be covered uder oe of you. Proof of depedet eligibility is required. Documetatio may be copies of a marriage certificate, birth certificate, or adoptio papers. Documetatio must iclude the employee s ame ad last four digits of their social security umber. Failure to provide this idetifyig iformatio could result i a delay of coverage. Documetatio may be set via iteroffice mail to the Office of Beefits, Leaves ad Retiremet, Greewood, via fax to , or scaed ad ed to beefits@bcps.org. Copies are acceptable, please do ot sed origials to our office. Employees who submit false iformatio iteded to provide health care coverage for alleged depedets ot eligible for such coverage may be subject to disciplie up to ad icludig termiatio of employmet. Such employees will also be held fiacially resposible for all claims filed, ad will be required to reimburse the Board for ay paymets made o behalf of or for the beefits of a ieligible perso claimed as a depedet. Verifyig your Beefit Electios As a ewly hired employee you must check your paystub to make sure the proper deductios are beig take. Cotact the Office of Beefits, Leaves, ad Retiremet immediately if you otice a discrepacy. Employees who experiece a qualifyig life evet will be permitted to make chages to their beefit electios. Chages must be requested withi 30 days of the qualifyig life evet. Please see page 11 for iformatio about qualifyig life evets. Employees may choose which eligible family members they wat to iclude i each beefit electio. For example, you may cover yourself ad your depedets for medical beefits, but oly yourself for detal coverage. If you ad your spouse are both BCPS employees, you ca each eroll i idividual coverage, or oe of you ca elect two perso or family coverage. If you elect coverage separately, you caot cover oe aother as depedets. Similarly, eligible

13 11 Chages to Your Beefits Durig the Pla Year beefits program allows you to choose the beefits you eed while providig valuable tax advatages. Your share of the cost for your beefits is paid with pre-tax payroll deductios. This meas that employee payroll deductios for beefits are ot subject to State, Federal, ad O.A.S.D.I. taxes. I order to maitai this favorable tax treatmet, the Iteral Reveue Service (IRS) has established rules that gover our beefit program. Most importatly, the IRS requires that the beefits you elect remai i effect for the etire Pla Year (1/1/ /31/2017) uless you experiece a qualifyig life evet. Qualifyig Life Evets The followig are cosidered qualifyig life evets: How to eroll followig a Qualifyig Life Evet It is the employee s resposibility to otify the Office of Beefits, Leaves ad Retiremet withi 30 days of each qualifyig life evet, if they wish to make a chage to their beefit pla. Employees must provide a completed Beefits Erollmet Chage form foud o page 59, alog with ay required documetatio (i.e. copies of birth certificate, marriage certificate). Documetatio must iclude the employee s ame ad last four digits of their social security umber. Failure to provide this idetifyig iformatio could result i a delay of coverage. Pla selectio caot be chaged due to a qualified life evet. Oly the level of coverage ca be chaged depedig o the life evet. Completed forms ad documetatio should be submitted to the Office of Beefits, Leaves ad Retiremet durig the 60 day widow. Forms may be set via iteroffice mail, US mail, faxed to , or ed to beefits@bcps.org. Notice of HIPAA Special Erollmet Rights If you declie erollmet for yourself or your depedets (icludig your spouse) because of other health isurace coverage, you may i the future be able to eroll yourself or your depedets i this pla. A erollmet request must be made withi 30 days of your other coverage edig. Chages to Your Beefits Durig the Pla Year Marriage, divorce, death of a spouse, or legal separatio Birth or adoptio of a ew child Please ote: Childre must be added to your coverage eve if you already have family coverage. Loss or gai of o-bcps coverage by the employee s spouse or domestic parter Loss or gai of coverage due to a chage i employmet status (i.e. switchig from part-time ad full-time, commecemet or retur from a upaid leave of absece) Loss of depedet child status (i.e. depedet has reached age 26) Eligibility for Medicare or Medicaid A judgmet, decree or order that requires health coverage for a employee s depedet

14 12 COBRA COBRA Cotiuatio Coverage Rights Uder COBRA Oce you become covered uder a group health pla (the Pla) you have COBRA rights. COBRA cotiuatio coverage is a temporary extesio of coverage uder the Pla. The right to COBRA cotiuatio coverage is a federal law that may become available to you or other members of your family who are covered uder the Pla whe you or your covered depedets would otherwise lose group health coverage. COBRA Eligibility If you are a employee you will be become a COBRA qualified beeficiary if you lose your coverage for ay of the followig reasos: Your hours of employmet are reduced Your employmet eds for ay reaso other tha gross miscoduct If you are the spouse or domestic parter of a employee, you will become a COBRA qualified beeficiary if you lose your coverage for ay of the followig reasos: Your spouse/domestic parter dies Your spouse/domestic parter s hours are reduced Your spouse/domestic parter s employmet eds for ay reaso other tha gross miscoduct Your spouse/domestic parter becomes etitled to Medicare beefits You become divorced or legally separated, or termiate your domestic partership Your depedet childre will become COBRA qualified beeficiaries if they lose coverage for ay of the followig reasos: The paret-employee dies The paret-employee s hours are reduced The paret-employee s employmet eds for ay reaso other tha gross miscoduct The paret-employee becomes etitled to Medicare beefits The child o loger qualifies as a Depedet child Importat facts to cosider about COBRA The cost of COBRA cotiuatio coverage is the total cost of the premium (what was previously the employee s cost, plus the Board cotributio) plus a admiistratio charge of 2%. COBRA cotiuatio coverage is temporary. The followig limitatios apply: If COBRA is offered as a result of employee death, divorce/separatio, or a depedet child losig eligibility, cotiuatio coverage ca last for a maximum of 36 moths. If COBRA is offered as a result of employmet termiatig, or a reductio i employee hours, cotiuatio coverage ca last for a maximum of 18 moths. Extesios of COBRA If you or ayoe i your family covered uder the Pla is determied by the Social Security Admiistratio to be disabled ad you otify the Office of Beefits, Leaves ad Retiremet withi 30 days, you ad your family may be etitled to receive up to a additioal 11 moths of COBRA cotiuatio coverage, for a maximum total of 29 moths. The disability would have had to have started before the 60th day of COBRA cotiuatio coverage ad must last at least util the ed of the 18-moth period of cotiuatio coverage. You must provide writte otice to: The Office of Beefits, Leaves ad Retiremet, 6901 Charles Street, Buildig B, Towso, MD If your family experieces a secod COBRA qualifyig evet while receivig 18 moths of COBRA cotiuatio coverage, the spouse ad depedet childre i your family ca get up to 18 additioal moths of COBRA cotiuatio coverage, for a maximum of 36 moths, if otice of the secod evet is give to the Pla. This extesio may be available if: The employee or former employee dies The employee or former employee gets divorced/ legally separated The child o loger qualifies as a Depedet child

15 13 Medical, Detal, ad Visio Deductios for Full-Time Employees Effective 1/1/ /31/2017 MEDICAL INSURANCE ** Total Premium or Equivalet Board Aual Share Your Aual Share Your bi-weekly Deductio * CIGNA OAPIN (I Network) Idividual $7, $6, $1, $57.97 Paret/Child 15, , , Two Adults 18, , , Family 20, , , CIGNA OAP (I/Out Network) Idividual $8, $6, $1, $87.27 Paret/Child 17, , , Two Adults 20, , , Family 23, , , Kaiser Permaete HMO Idividual $8, $7, $1, $64.83 Paret/Child(re) 17, , , Two Adults 20, , , Family 23, , , Medical, Detal ad Visios Deductios: Full-Time DENTAL INSURANCE ** CareFirst Regioal Detal PPO Idividual $ $ $ $5.25 Paret/Child or Two Adults Family CareFirst Regioal Detal Traditioal Idividual $ $ $ $7.25 Paret/Child or Two Adults Family 1, CIGNA Detal DHMO Idividual $ $ $ $15.44 Paret/Child(re) or Two Adults Family 1, VISION INSURANCE CareFirst Davis Visio Idividual (Free if FTE is.5 or greater) $26.28 $26.28 $- $- Family (icludes Paret/Child ad Two Adults) *All employee beefits deductios are based upo 20 pay periods **Domestic Parter beefits may be subject to imputed icome

16 14 Medical, Detal ad Visios Deductios: Part-Time Medical, Detal, ad Visio Deductios for Part-Time Employees Effective 1/1/ /31/2017 Part-Time Employee Bi-Weekly Deductio* MEDICAL INSURANCE ** Your Full-Time Equivalecy (FTE) CIGNA OAPIN (I Network) Idividual $90.82 $ $ $ $ Paret/Child Two Adults Family CIGNA OAP (I/Out Network) Idividual $ $ $ $ $ Paret/Child Two Adults Family Kaiser Permaete HMO Idividual $ $ $ $ $ Paret/Child(re) Two Adults Family DENTAL INSURANCE ** CareFirst Regioal Detal PPO Idividual $6.23 $7.20 $8.18 $9.15 $10.13 Paret/Child or Two Adults Family CareFirst Regioal Detal Traditioal Idividual $8.23 $9.20 $10.18 $11.15 $12.13 Paret/Child or Two Adults Family CIGNA Detal DHMO Idividual $16.42 $17.39 $18.37 $19.34 $20.32 Paret/Child(re) or Two Adults Family VISION INSURANCE CareFirst Davis Visio Idividual (Free if FTE is.5 or greater) $- $- $- $- $- Family (icludes Paret/Child ad Two Adults) Cost of Coverage for Part-Time Employees The cost of medical ad detal coverage varies accordig to your full-time equivalecy (FTE). All employees are assiged a FTE based o the hours worked as a percetage of the umber of hours a full-time employee i that same positio would work. For example, a employee who works 20 hours durig a week i a positio which defies full-time employmet as workig 40 hours each week would have a FTE of.5. * All employee beefits deductios are based upo 20 pay periods ** Domestic Parter beefits may be subject to imputed icome

17 15 Your Medical Optios Highlights BCPS offers eligible employees the choice of the followig medical pla optios: Kaiser Permaete HMO Ciga Ope Access Plus I-Network OAPIN Ciga Ope Access Plus OAP Noe of these plas cotai a pre-existig coditio limitatio. This meas that each pla will ot exclude beefits for illesses you had whe you joied BCPS. About Our Medical Pla Optios The medical plas offered through BCPS flexible beefits program have differet ways of deliverig health care. BCPS gives you the choice of oe Health Maiteace Orgaizatio (HMO) pla, oe Ope Access I-Network pla (OAPIN), ad oe Ope Access i- or out- ofetwork pla (OAP). The differeces betwee the HMO pla ad the Ope Access plas are the levels of coverage ad the selectio of providers. A HMO ad Ope Access Plus I-Network pla (OAPIN) offers oe level of coverage ad you must use the etwork of participatig providers. The Ope Access Plus (OAP) allows for both i- ad out-of etwork providers. The flexibility to seek care outside the etwork traslates ito a higher price tag from your paycheck. You decide which pla works best for you. O the followig pages you will fid a compariso of the beefits provided uder each medical optio. Importat Note: This erollmet guide is either a cotract or a summary descriptio of your health pla choices. If you have specific questios about a particular pla before erollig i it, call the Office of Beefits, Leaves ad Retiremet. Kaiser Permaete HMO The Kaiser Permaete HMO optio requires the selectio of a Primary Care Physicia (PCP) to obtai the highest level of coverage. A PCP is typically a geeral practitioer, a family practitioer, a iterist, or a pediatricia. You ad each covered member of your family must choose a PCP from the pla s provider directory. The most curret provider directory iformatio is available from each pla s Web site, from Member Services, or you may call the Office of Beefits, Leaves ad Retiremet to obtai a paper copy of the directory. The Ope Access Plus I Network (OAPIN) ad the Ope Access Plus (OAP) plas do ot require a PCP but it is recommeded that a PCP be used to coordiate care. Your PCP provides your medical care or refers you to a specialist, as ecessary. Your PCP will get to kow your medical history ad your idividual health care eeds. Primary Care Physicias make sure that you are ot receivig uecessary medical treatmet ad that the medicatios that you are takig are safe ad effective. There are geerally o claim forms to complete or submit. Call the Member Services umber o your medical pla idetificatio card for iformatio o chagig your PCP. The Kaiser Permaete HMO product allows employees ad their depedets to receive excellet coordiatio of care, because all of Kaiser Permaete s providers are closely coected. Participats of this pla experiece the coveiece of havig may of their health services i oe cetral locatio, creatig efficiecy i health care delivery ad savig participats time ad moey. Your Medical Optios Highlights

18 16 Your Medical Optios Highlights Your Medical Optios Highlights (cotiued) Ciga Ope Access Plus I-Network (OAPIN) Ciga s Ope Access Plus I-Network pla allows you to choose the doctors, health professioals ad facilities that work best for you, from a selectio of Ciga I-Network providers. Details about the Ciga OAPIN Pla Primary Care Physicia (PCP) You decide if you wat to choose a PCP as your persoal doctor to help coordiate care ad act as a persoal health advocate. It s recommeded but ot required. I-etwork For your health care to be covered by the pla, you must choose a health care professioal who is part of the Ciga etwork. No-Referral Specialist Care If you eed to see a specialist, you do ot eed a referral to see a doctor who participates i the Ciga etwork just make the appoitmet ad go! Pre-certificatio may be ecessary for hospitalizatios ad some types of outpatiet care, but there is o paperwork for you. Out-of-etwork If you choose to see a doctor who is ot i the etwork, your care will ot be covered except i emergecies. Emergecy ad Urget Care Whe you eed care, you re covered, 24 hours a day, worldwide. Questios ad Aswers What if my doctor is t o your list? That meas your PCP does ot participate i the Ciga etwork. To receive coverage from your health pla, you must select a doctor from the Ciga list of participatig doctors ad other health care professioals. If you decide to cotiue seeig your curret doctor, your care will ot be covered by your pla. Do I eed a referral to see a specialist? Though you may wat your persoal doctor s advice ad assistace i arragig care with a specialist, you do ot eed a referral to see a participatig specialist. If you choose a out-of-etwork specialist, your care will ot be covered by your pla. How does my pla cover my care? Whe you visit a doctor who participates i the Ciga etwork, you receive i-etwork coverage ad will have lower out-of-pocket costs. That s because our participatig health care professioals have agreed to charge lower fees, ad your pla covers a larger share of the charges. If you choose to visit a doctor outside of the etwork, your care will ot be covered by your pla. What if I eed to be admitted to the hospital? I a emergecy, your care is covered. Requests for o- emergecy hospital stays other tha materity stays must be approved i advace or pre-certified. This eables Ciga HealthCare to determie if the services are covered. Pre-certificatio is ot required for materity stays of 48 hours for vagial deliveries or 96 hours for caesarea sectios. Depedig o your pla, you may be eligible for additioal coverage. Ay hospital stay beyod the iitial 48 or 96 hours must be approved. Who is resposible for obtaiig pre-certificatio? Your doctor will help you decide which procedures require hospital care ad which ca be hadled o a outpatiet basis. If your doctor participates i the Ciga etwork, he or she will arrage for pre-certificatio. If you use a out-of-etwork doctor, you are resposible for makig the arragemets ad your care will ot be covered. Your pla materials will idetify which procedures require precertificatio. How do I fid out if my doctor is i the Ciga etwork before I eroll? Our dedicated Erollmet Iformatio Lie is available 24/7 to help you lear about the beefits ad advatages of Ciga. Call today ad a kowledgeable Erollmet Specialist will provide you with assistace i idetifyig participatig physicias ad related service providers. Call us at or go to the olie provider directory foud o What is Case Maagemet? Case maagemet is a program that assists customers with the hardships of a illess. A urse Case Maager will help to coordiate the most appropriate care ad works with you, your family ad your physicias for the best results.

19 17 Your Medical Optios Highlights (cotiued) Ciga Ope Access Plus (OAP) Ciga s Ope Access Plus pla allows you to choose the doctors, health professioals ad facilities that work best for you, with coverage for providers both i ad out of the Ciga etwork. Details about the Ciga OAP Pla: Primary Care Physicia (PCP) You decide if you wat to choose a PCP as your persoal doctor to help coordiate care ad act as a persoal health advocate. It s recommeded but ot required. I-etwork Choose to see doctors or other health professioals who participate i the Ciga etwork to keep your costs lower ad elimiate paperwork. No-referral specialist care If you eed to see a specialist, you do ot eed a referral to see a doctor who participates i the Ciga etwork just make the appoitmet ad go! Pre-certificatio may be ecessary for hospitalizatios ad some types of outpatiet care, but there is o paperwork for you. Out-of-etwork You also have the freedom to visit doctors or use facilities that are ot part of the Ciga etwork, but your costs will be higher ad you may eed to file a claim. Emergecy ad urget care Whe you eed care, you re covered, 24 hours a day, worldwide. Questios ad Aswers What if my doctor is t o your list? That meas your PCP does ot participate i the Ciga etwork. To receive your maximum coverage, you should select a doctor from the Ciga list of participatig doctors ad other health care professioals. You ca cotiue seeig your curret doctor, eve if he or she is ot i Ciga s etwork. However, i that case, you will pay higher out-of-pocket costs, ad your care will be covered at the out-of-etwork coverage level. Do I eed a referral to see a specialist? Though you may wat your persoal doctor s advice ad assistace i arragig care with a specialist i the etwork, you do ot eed a referral to see a participatig specialist. If you choose a out-of-etwork specialist, your care will be covered at the out-of-etwork coverage level. What is the differece betwee i-etwork ad outof-etwork coverage? Each time you seek medical care, you ca choose your doctor either a doctor who participates i the Ciga etwork or someoe who does ot participate. Whe you visit a participatig doctor, you receive i-etwork coverage ad will have lower out-of-pocket costs. That s because our participatig health care professioals have agreed to charge lower fees, ad your pla covers a larger share of the charges. If you choose to visit a doctor outside of the etwork, your out-of-pocket costs will be higher. What if I eed to be admitted to the hospital? I a emergecy, your care is covered. Requests for oemergecy hospital stays other tha materity stays must be approved i advace or pre-certified. This eables Ciga HealthCare to determie if the services are covered. Pre-certificatio is ot required for materity stays of 48 hours for vagial deliveries or 96 hours for cesarea sectios. Depedig o your pla, you may be eligible for additioal coverage. Ay hospital stay beyod the iitial 48 or 96 hours must be approved. Who is resposible for obtaiig pre-certificatio? Your doctor will help you decide which procedures require hospital care ad which ca be hadled o a outpatiet basis. If your doctor participates i the Ciga etwork, he or she will arrage for pre-certificatio. If you use a out-of-etwork doctor, you are resposible for makig the arragemets. Your pla materials will idetify which procedures require pre-certificatio. What if I go to a out-of-etwork physicia who seds me to a etwork hospital? Will I pay i-etwork or out- of-etwork charges for my hospitalizatio? Ciga HealthCare will cover authorized medical services provided by a Ope Access Plus participatig hospital at your i-etwork beefits level whether you were set there by a i- or out-of-etwork doctor. How do I fid out if my doctor is i the Ciga etwork before I eroll? Our dedicated Erollmet Iformatio Lie is available 24/7 to help you lear about the beefits ad advatages of Ciga. Call today ad a kowledgeable Erollmet Specialist will provide you with assistace i idetifyig participatig physicias ad related service providers. Call us at or go to the olie provider directory foud o What is Case Maagemet? Case maagemet is a program that assists customers with the hardships of a illess. A urse Case Maager will help to coordiate the most appropriate care ad works with you, your family ad your physicias for the best results. Your Medical Optios Highlights

20 18 Ciga Prescriptio Drug Coverage Ciga Prescriptio Drug Coverage With Ciga s pharmacy beefit, you ll be able to receive phoe ad olie support. The prescriptio program covers most medicatios which require a prescriptio by either State or Federal law ad are prescribed by a licesed practitioer. Isuli is covered; however, it requires a physicia s prescriptio. Co-paymets 30 day Geeric drug- $10.00 copay. Brad ame drug o the Ciga Pharmacy formulary- $20.00 copay. Brad ame drug that is o-formulary - $35.00 copay. Brad ame drugs that have a FDA geeric equivalet require a $35 copay plus the cost differece betwee the brad ame drug ad its geeric equivalet regardless of physicia s istructios. A brad-ame drug is protected by a 17-year patet that limits productio to oe maufacturer. Whe the patet expires, other compaies may maufacture a geeric versio of the drug. The geeric is just like the brad-ame drug ad follows the same FDA safety rules. The geeric is essetially a chemical copy of the bradame drug. The ame, color or shape may be differet, but the active igrediets are the same. Examples of geeric medicatios are simvastati, the geeric equivalet of Zocor, or omeprazole, the geeric for Prilosec. Acute Medicatios For prescriptio drugs eeded for shorter-term eeds such as atibiotics, the pla allows for a 30-day supply per copay up to a maximum 102-day supply with refills based o your physicia s istructios. Prescriptios filled at a retail Pharmacy require oe copay per mothly supply. Maiteace Medicatios For prescriptio drugs eeded o a o-goig (sometimes daily basis), the pla allows for a 90-day supply of maiteace medicatio with refills based o your physicia s istructios. Prescriptios filled at a retail Pharmacy require oe copay per mothly supply. Mail order prescriptios require two copays for up to 102 day supply. Ciga Home Delivery Pharmacy You ll save whe you switch from retail to Ciga s accurate, fast home delivery. Other beefits iclude: FDA-approved medicatios Free stadard shippig 102-day refills Daily dose remiders through , text or phoe Ciga Specialty Pharmacy Services Are you maagig a complex chroic coditio that requires a specialty medicatio? Ciga Specialty Pharmacy Services ca help you maage your health ad prescriptio eeds i the privacy of your home, with 24/7 access to customer service ad pharmacists, expert coaches traied o your coditio, remider services ad more. To start a ew order, please call us at: You ca maage delivery of your maiteace prescriptios olie at For specialty medicatios, your prescriptio drug pla requires you to fill through Ciga Home Delivery Pharmacy. You re allowed oe fill at a retail pharmacy before you are required to use Ciga Home Delivery Pharmacy. Otherwise, your pla will ot cover the cost of your medicatio. Prior Authorizatio Some prescriptio medicatios require a Prior Authorizatio review i certai situatios before beig covered. Prior Authorizatio verifies that a medicatio is appropriate for the diagosis, dosage, frequecy ad duratio of therapy. To iitiate a request, have your doctor cotact Ciga Pharmacy at Step Therapy Step Therapy is a prior authorized program which meas that certai medicatios eed approval before they are covered. I Step Therapy you ad your doctor follow a series of steps whe choosig your medicatio. Step Therapy ecourages you to try the most cost-effective ad appropriate medicatios available to treat your coditio. Typically, these medicatios are geerics or low cost brads. You eed to try these first before more expesive medicatios are approved.

21 19 Ciga Prescriptio Drug Coverage (cotiued) Whe you fill a prescriptio for a Step Therapy medicatio, we ll sed you ad your doctor a letter explaiig what steps you eed to take before you refill your medicatio. This may iclude tryig a geeric or lower cost alterative, or askig Ciga for authorizatio for coverage of your medicatio. At ay time, if your doctor feels a differet medicatio is t right for you due to medical reasos, he/ she ca request authorizatio for cotiued coverage of a Step Therapy medicatio. Prescriptio Drug List Ciga s Prescriptio Drug List (PDL) is a extesive listig of geeric ad brad ame prescriptio medicatios. Your pharmacy pla covers the cost of medicatios o the PDL all you have to pay is your pla s copays, coisurace ad/ or deductibles. Sometime after Ope Erollmet, you ll be able to access that list o myciga.com. Your PDL splits medicatios ito three categories, or tiers: 1st Tier, Geeric Medicatios: Geerics have similar stregth ad active igrediets as their brad ame couterparts. You will usually pay less for geeric medicatios. 2d Tier, Preferred Brad Medicatios: These medicatios will usually cost more tha a geeric, but may cost less tha a o-preferred brad. 3rd Tier, No-Preferred Brad Medicatios: No-preferred brads geerally have geeric alteratives ad/or oe or more preferred brad optios withi the same drug class. You will usually pay more for o-preferred medicatios. How ca myciga.com help me make the most of my pharmacy pla? You ca: 1. Search our list of over 62,000 retail etwork pharmacies to fid a pharmacy ear you. If you are o the go ad wat to access our list o your smartphoe, it is GPS accessible which meas that we ca help you fid a pharmacy earest to you. 2. See your pharmacy claim history, pla details ad accout balaces. 3. Use the prescriptio drug price quote tool to see ad compare real-time drug prices at local retail pharmacies ad Ciga Home Delivery Pharmacy SM. Pricig is show specifically for your pharmacy pla. The prescriptio drug price quote tool is also desiged to work easily o your smartphoe for use o the go. 4. See a complete list of covered prescriptio drugs ad see the category uder which they are covered. Ciga Prescriptio Drug Coverage

22 20 Resources ad Programs Available to All Ciga Participats Resources ad Programs Available to All Ciga Participats myciga.com Nothig is more importat tha your good health. That s why there s your olie home for assessmet tools, pla maagemet, medical updates ad much more. O you ca: Choose your doctor ad create a persoalized list of earby doctors, hospitals, treatmet facilities ad much more. Prit temporary ID cards. Verify pla details such as coverage, copays ad deductibles. Keep track of medical coditios, medicatios, allergies, surgeries, immuizatios ad emergecy cotacts. Lear about health coditios, treatmets ad medicatios usig a iteractive medical library. Fid iformatio ad estimate costs i your regio for specific medical procedures ad treatmets. Register today. It s this easy: 1. Go to myciga.com ad select Register. 2. Eter your persoal details like ame, address ad date of birth. 3. Cofirm your idetity with secure iformatio like your Ciga ID, social security umber or complete a security questioaire. This will make sure oly you ca access your iformatio. 4. Create a user ID ad password. 5. Review ad submit. Access to myciga Mobile App Life ca be busy ad complicated. So, we created a simple-to-use tool that ca help make your life easier (ad healthier) while you re o the go. The myciga Mobile App helps you persoalize, orgaize ad access your importat pla iformatio o your phoe or tablet. The app has a ew look ad feel ad it s available i Spaish too! Health Matters Cofidetial Health Assessmet At Ciga, your health matters. We re here to make your jourey easier. We offer persoalized support that meets you where you are, so we ca help you get to where you eed to be. Simply logo ito your myciga.com accout to check out the ewest suite of digital tools ad olie activities. Whe you take the health assessmet, you aswer simple questios about your health ad the result is a thorough review of your overall health. It s quick, persoal ad it s cofidetial. Come play. 1. Log i to myciga.com begiig 2. Go to the My Health tab 3. Click o the health assessmet tile Choose your game piece to begi Aswer questios ad complete each step of your assessmet jourey Fiish with iformatio, recommedatios ad coectios to health improvemet opportuities 24 Hour Health Iformatio Lie What do you do whe your child spikes a fever i the middle of the ight? Do t worry, woder or wait wheever there s a questio about health just call to coect with the Health Iformatio Lie ad talk directly with a specialist traied as a urse, 24 hours a day, 7 days a week. Discout Programs Healthy Rewards Save moey whe you purchase health ad welless products ad services through the Ciga Healthy Rewards program. Visit myciga for olie program iformatio or call Programs iclude- Weight ad Nutritio Fitess ad Mid/Body Visio, detal ad hearig care Vitamis, health ad welless products Alterative medicie

23 21 ONE CONNECTION to total health ad well-beig Everyoe has differet eeds whe it comes to improvig their health ad well-beig. Do you always kow all of your optios? Where to get a quick aswer? Or where to go for help with a more serious situatio? You ow have a team of health specialists icludig idividuals traied as urses, coaches, utritioists, cliicias ad couselors who will liste, uderstad your eeds ad help you fid solutios, eve whe you re ot sure where to begi. ay time. compassioate professioals. Parter with a health advocate to take a more active role i your health: health improvemet goals disease, low back pai, arthritis, high blood pressure, high cholesterol ad more. Lear skills at your ow pace olie : reduce stress your utritio. Oe phoe call lets you: optios - so you ad your doctor ca choose what works for you. to meet your eeds ad prefereces. to sped time i the hospital or eed surgery. fidig your way through the health care system. treat your child s high fever. Here is oe umber you eed to kow: for your health eeds or myciga.com Offered by: Ciga Health ad Life Isurace Compay, Coecticut Geeral Life Isurace Compay, or their affiliates. Ciga, the Tree of Life logo ad GO YOU are registered service marks of Ciga Itellectual Property, Ic., licesed for use by Ciga Corporatio ad its operatig subsidiaries. All products ad services are provided by or through such operatig subsidiaries ad ot by Ciga Corporatio. Such operatig subsidiaries iclude Coecticut Geeral Life Isurace Compay, Ciga Health ad Life Isurace Compay, Ciga Health Maagemet, Ic., Ciga Behavioral Health, Ic., vielife Limited, ad HMO or service compay subsidiaries of Ciga Health Corporatio. All models are used for illustrative purposes oly b 10/ Ciga. Some cotet provided uder licese.

24 22 About Kaiser Permaete It s oe eat package At Kaiser Permaete, we combie health plas, facilities, ad practitioers i oe eat package makig your membership coveiet ad easy to use. Our members have relied o this all-i-oe model of health care for more tha 65 years, ad it s somethig we cotiue to perfect. Your health pla made simple Your health pla is the key to the care you eed ad so much more, icludig: u Freedom to your doctor s office, aytime, day or ight. u Olie tools that let you make appoitmets, order most prescriptio refills, ad read most lab test results (ad so much more). u Urget care cliics ope o eveigs ad weekeds to suit your eeds. u Health ad welless programs, both olie ad off, to help you stay well. Where you go for persoalized care Every Kaiser Permaete facility i our area is coected to your electroic health record, which keeps your care team iformed ad ready to give you the right care at the right time. Our medical ceters combie state-of-the-art techology ad expert physicias i coveiet medical ceters. Most iclude pharmacy, lab, ad X-ray services o site so you ca sped more time o thigs you ejoy. A care team focused o you With Kaiser Permaete, you get a choice of persoal physicias for you ad your family. To fid oe that s right for you, just go olie to kp.org/doctor. All of our Kaiser Permaete physicias work closely together to help you get well ad stay well. This teamwork is part of our focus o prevetio ad our commitmet to providig you with persoalized care.

25 23 What s ew i your area With medical ceters close to where you live ad work, health care has ever bee more coveiet. To fid a locatio ear you, visit kp.org/facilities or dowload a free app for your smartphoe or mobile device from the App Store or from Google Play. Marylad 1 Aapolis Medical Ceter 2 Camp Sprigs Medical Ceter 3 City City Plaza Medical Ceter 4 Columbia Gateway Medical Ceter Ceter 5 5 Kaiser Kaiser Permaete Permaete Frederick Frederick Medical Ceter Medical Ceter 6 NEW Gaithersburg 6 Gaithersburg Medical Ceter Medical Ceter 7 Kesigto Medical Ceter 7 Kesigto Medical Ceter 8 8 EXPANDING EXPANDING Largo Largo Medical Medical Ceter Ceter 9 Marlow Heights Medical Ceter Ceter Price George s Medical Ceter Ceter Severa Park Park Medical Ceter Shady Grove Medical Ceter Silver Sprig Medical Ceter COMING South Baltimore SOON South Couty Baltimore Medical Couty Ceter Medical Ope Ceter 24/7/365 Days 15 Summit Behavioral Health Ceter Ceter 16 Towso Medical Ceter 16 Towso Medical Ceter 17 White Marsh Medical Ceter 17 White Marsh Medical Ceter 18 Woodlaw Medical Ceter 18 Woodlaw Medical Ceter Virgiia 19 EXPANDED Ashbur Medical Ashbur Ceter Medical Ceter 20 Burke Medical Ceter 20 Burke Medical Ceter 21 Fair Oaks Medical Ceter 21 Fair Oaks Medical Ceter 22 Falls Church Medical Ceter 22 Falls Church Medical Ceter 23 Kaiser Permaete 23 Kaiser Fredericksburg Permaete Medical Ceter Fredericksburg Medical Ceter 24 Maassas Medical Ceter 24 Maassas Medical Ceter 25 MOVING Pederbrook Medical 25 MOVING Pederbrook Ceter Medical Ceter Resto Resto Medical Medical Ceter Ceter Sprigfield Sprigfield Medical Medical Ceter Ceter NEW Tysos Tysos Corer Corer Medical Ceter 29 Medical Woodbridge Ceter Medical Ceter 29 Woodbridge Medical Ceter Washigto, D.C. 30 Kaiser Permaete Capitol Hill Medical Ceter Northwest NEW Northwest D.C. Medical D.C. Medical Office Office Buildig Buildig For iformatio about the services all our medical ceters provide, visit kp.org/facilities.

26 24

27 25 Medical Optios At-a-Glace

28 26 Medical Optios At-a-Glace Medical Optios At-a-Glace Chart (Summary Pla Documet Prevails; visit for full details) Pla Facts Pla Name Beefit Levels Member Services Ciga OAPIN Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health Group Number Caledar Year Deductible (Ja 1 - Dec 31) - Idividual - Family Idividual $0 Family $0 Coisurace Caledar Year Out-of-Pocket Maximum - Idividual - Family Lifetime Maximum PROFESSIONAL SERVICES Office Visits - PCP - Specialist Physical/Speech/Occupatioal Therapy Office Visit Medical: Idividual $1,100 Family $3,600 Ulimited Primary Care Physicia You pay $15 per visit Specialist You pay $20 per visit You pay $20 per visit 40 days for each therapy per caledar year Prescriptio: Idividual $5,500 Family $9,600 Chiropractic Office Visit Diagostic Laboratory Tests, X-Rays You pay $20 per visit Limited to 40 days per caledar year Physicia s Office Associated PCP or Specialist visit copay may apply. Allergy Shots/Other Covered Ijectios Allergy Serum Allergy Testig

29 Kaiser Permaete Kaiser (Metal Health) Jauary 1, 2017 to December 31, 2017 I-Network Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health Ciga OAP Out-of-Network Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health HMO 27 Medical Optios At-a-Glace Noe Noe Idividual $200 Family $400 Idividual $300 Family $600 N/A You pay 15% Pla pays 85% Idividual $3,500 Family $9,400 Medical: Idividual $1,000 Family $2,000 Prescriptio: Idividual $5,600 Family $11,200 Pla pays 75% Medical Idividual $1,500 Family $3,000 Ulimited Ulimited Ulimited Prescriptio: Idividual $5,600 Family $11, % after $5 copay 100% after $5 copay (referral required) 100% after $5 copay (maximum 30 visits or 90 days per cotract year) Discouts available- o referral Primary Care Physicia You pay $20 per visit Specialist You pay $30 per visit You pay $30 per visit 100 days all therapies combied per caledar year (I-etwork ad Out-of-etwork) You pay $30 per visit Ulimited days per caledar year 100% Physicia s Office Associated PCP or Specialist visit copay may apply. 100% after $5 copay o deductible 100% o deductible 100% after $5 copay You pay 15% Pla pays 85% Pla pays 75% Pla pays 75% 100 days all therapies combied per caledar year (I-etwork ad Out-of-etwork) Pla pays 75% Ulimited days per caledar year Pla pays 75% after deductible is met Pla pays 75% Pla pays 75% Pla pays 75%

30 28 Medical Optios At-a-Glace Medical Optios At-a-Glace Chart (cotiued) (Summary Pla Documet Prevails; visit for full details) Pla Facts Pla Name Beefit Levels Member Services Ciga OAPIN Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health Group Number PREVENTIVE CARE Well Child Visit/Immuizatio Routie Gyecological Exam (o referral required) Routie Pap Smear (o referral required) Routie Mammogram (oce per 12 moths) Routie Adult Physical PSA Testig HOSPITAL SERVICES (Ipatiet & Outpatiet) Semi-Private Room ad Board Lab Tests ad X-Rays (Outpatiet) $100 copay per admissio, the Physicia s Office Associated PCP or Specialist visit copay may apply. Home Health Care Ulimited days per caledar year Skilled Nursig Facility/Rehab Facility Care 100 days per caledar year Physicia/Surgical Services Aesthesia Services

31 Kaiser Permaete Kaiser (Metal Health) Jauary 1, 2017 to December 31, 2017 I-Network Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health Ciga OAP Out-of-Network Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health HMO 29 Medical Optios At-a-Glace 100% o deductible 100% o deductible 100% o deductible 100% o deductible 100% (oce per caledar year) o deductible 100% o deductible Pla pays 75% Pla pays 75% o deductible o deductible Pla pays 75% o deductible 100% You pay 15% Pla pays 85% 100% Physicia s Office Associated PCP or Specialist visit copay may apply. 100% o deductible 130 days per caledar year (I-etwork ad Out-of-etwork) 100% (maximum of 100 days per pla year) You pay 15% Pla pays 85% 120 days per caledar year (I-etwork ad Out-of-etwork) 100% You pay 15% Pla pays 85% 100% You pay 15% Pla pays 85% Pla pays 75% Pla pays 75% after deductible is met Pla pays 75% 130 days per caledar year (I-etwork ad Out-of-etwork) Pla pays 75% 120 days per caledar year (I-etwork ad Out-of-etwork) Pla pays 75% per visit Pla pays 75%

32 30 Medical Optios At-a-Glace Medical Optios At-a-Glace Chart (cotiued) (Summary Pla Documet Prevails; visit for full details) Pla Facts Pla Name Beefit Levels Member Services Ciga OAPIN Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health Group Number HOSPITAL SERVICES (Ipatiet & Outpatiet) (CONT.) Medical Cosultatios Outpatiet - Primary Care Physicia You pay $15 per visit Specialist You pay $20 per visit Ipatiet - ICU/CCU $100 copay per admissio, the Hospice Care Dialysis/Radiatio/Chemotherapy (Ipatiet) Dialysis/Radiatio/Chemotherapy (Outpatiet) Physical/Speech/Occupatioal Therapy (Ipatiet) $100 copay per admissio the $100 copay per admissio the Physical/Speech/Occupatioal Therapy (Outpatiet) You pay $20 per visit, 40 days for each therapy per caledar year Outpatiet Diagostic Services SUPPLIES Durable Medical Equipmet, pla pays 100%,(ulimited maximum) Hearig aids for adult ad childre: Ulimited dollar amout, 2 hearig aids every three years Prosthetic Devices ad Orthopedic Braces Ulimited Maximum per Caledar Year Diabetic Supplies

33 Kaiser Permaete Kaiser (Metal Health) Jauary 1, 2017 to December 31, 2017 I-Network Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health Ciga OAP Out-of-Network Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health HMO 31 Medical Optios At-a-Glace 100% Outpatiet - Primary Care Physicia You pay $20 per visit Specialist You pay $30 per visit Ipatiet - You pay 15% Pla pays 85% 100% You pay 15% Pla pays 85% 100% o deductible 100% You pay 15% Pla pays 85% 100% after $5 copay o deductible 100% You pay 15% Pla pays 85% 100 days per caledar year (I-etwork ad Out-of-etwork) 100% after $5 copay You pay $30 per visit 100 days per caledar year (I-etwork ad Out-of-etwork) 100% Outpatiet ad Ipatiet Pla pays 75% Pla pays 75% o deductible Pla pays 75% Pla pays 75% Pla pays 75% 100 days per caledar year (I-etwork ad Out-of-etwork) Pla pays 75% 100 days per caledar year (I-etwork ad Out-of-etwork) Pla pays 75% 100% of allowed beefit for basic DME; Hearig aids for adults ad childre 1 per ear every 36 moths to $1,000 max per ear for adults; $1,400 max per ear for childre., pla pays 100%,(ulimited maximum) Hearig aids for adult ad childre: Ulimited dollar amout, 2 hearig aids every three years 100% of allowed beefit o deductible Ulimited Maximum per Caledar Year 80% of allowed beefit o deductible, pla pays 100%,(ulimited maximum) Hearig aids for adult ad childre: Ulimited dollar amout, 2 hearig aids every three years Pla pays 75% after deductible is met Ulimited Maximum per Caledar Year Pla pays 75% after deductible is met

34 32 Medical Optios At-a-Glace Medical Optios At-a-Glace Chart (cotiued) (Summary Pla Documet Prevails; visit for full details) Pla Facts Pla Name Beefit Levels Member Services Ciga OAPIN Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health Group Number EMERGENCY SERVICES Emergecy Room if admitted if discharged Urget Care Ambulace (Air Ambulace if medically ecessary) MATERNITY/INFERTILITY SERVICES * Pre- ad Postatal Care ad Delivery Sterilizatio/Reverse Sterilizatio Elective Abortios i Ipatiet ad Outpatiet Facility You pay $50 per visit (copay waived if admitted) Copay waived if admitted, You pay $25 per visit, o deductible Iitial Visit to cofirm pregacy Primary Care Physicia You pay $15 per visit Specialist You pay $20 per visit Global Materity Professioal Fees Ipatiet Facility $100 copay per admissio, the Physicia s Office Primary Care Physicia You pay $15 per visit Specialist You pay $20 per visit Ipatiet Facility $100 copay per admissio, the Outpatiet Facility Excludes reversal of sterilizatio Primary Care Physicia You pay $15 per visit Specialist You pay $20 per visit Ipatiet Facility $100 copay per admissio, the Outpatiet Facility; Physicia s Services * Importat Notice About Materity Coverage ad Newbor Legth of Stay Uder federal law, group health plas ad health isurace issuers offerig group isurace coverage geerally may ot restrict beefits for ay hospital legth of stay i coectio with childbirth for the mother or ewbor child to: Less tha 48 hours followig a ormal vagial delivery or; Less tha 96 hours followig a cesarea sectio.however, the pla or health isurace issuer may pay for a shorter stay if the attedig provider (e.g., your physicia, urse midwife, or physicia assistat), after cosultatio with the mother, discharges the mother or the ewbor earlier.i additio, uder federal law, plas ad issuers may ot set the level of beefits or out-of-pocket

35 Kaiser Permaete Kaiser (Metal Health) Jauary 1, 2017 to December 31, 2017 I-Network Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health Ciga OAP Out-of-Network Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health HMO 33 Medical Optios At-a-Glace 100% 100% after $35 copay 100% if medically ecessary o deductible You pay $70 per visit o deductible (copay waived if admitted) Copay waived if admitted, You pay $30 per visit, o deductible You pay $70 per visit o deductible (copay waived if admitted) Copay waived if admitted, You pay $30 per visit, o deductible o deductible 100% Iitial Visit to cofirm pregacy Primary Care Physicia You pay $20 per visit Specialist You pay $30 per visit Global Materity Professioal Fees You pay 5% Pla pays 95% Ipatiet Facility, Outpatiet Facility You pay 15% Pla pays 85% Applicable cost share based upo place of service. Reverse sterilizatio ot covered. Primary Care Physicia You pay $20 per visit Specialist You pay $30 per visit Ipatiet Facility, Outpatiet Facility, Physicia s services You pay 15% Pla pays 85% Excludes reversal of sterilizatio Pla pays 75% Pla pays 75% Excludes reversal of sterilizatio Applicable cost share based upo place of service Primary Care Physicia You pay $20 per visit Specialist You pay $30 per visit Ipatiet Facility, Outpatiet Facility, Physicia s services You pay 15% Pla pays 85% Pla pays 75% after deductible is met costs so that ay later portio of the 48-hour (or 96-hour) stay is treated i a maer less favorable to the mother or the ewbor tha ay earlier portio of the stay. I additio, a pla or issuer may ot, uder federal law, require that a physicia or other health care provider obtai authorizatio for prescribig a legth of stay up to 48 hours (or 96 hours). However, to use certai providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtai precertificatio. Please cotact your health pla s member services uit.

36 34 Medical Optios At-a-Glace Medical Optios At-a-Glace Chart (cotiued) (Summary Pla Documet Prevails; visit for full details) Pla Facts Pla Name Beefit Levels Member Services Ciga OAPIN Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health Group Number MATERNITY/INFERTILITY SERVICES 2 Artificial Isemiatio (requires pre-authorizatio) IVitro Fertilizatio (requires pre-authorizatio) MENTAL HEALTH AND SUBSTANCE ABUSE Pre-authorizatio Required Metal Health Ipatiet Services Primary Care Physicia You pay $15 per visit Specialist You pay $20 per visit Ipatiet Facility $100 copay per admissio, the Outpatiet Facility; Physicia s Services Ulimited dollar maximum Primary Care Physicia You pay $15 per visit Specialist You pay $20 per visit Ipatiet Facility $100 copay per admissio, the Outpatiet Facility; Physicia s Services Ulimited dollar maximum Max (10) EAP visits with Ciga Behavioral or BCPS Call or Ciga Behavioral Yes $100 copay per admissio, the

37 Kaiser Permaete Kaiser (Metal Health) Jauary 1, 2017 to December 31, 2017 I-Network Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health Ciga OAP Out-of-Network Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health HMO 35 Medical Optios At-a-Glace Applicable cost share based upo place of service Primary Care Physicia You pay $20 per visit Specialist You pay $30 per visit Ipatiet Facility, Outpatiet Facility, Physicia s services You pay 15% Pla pays 85% Ulimited dollar maximum Pla pays 75% after deductible is met $100,000 lifetime maximum 50% of allowed beefit lifetime maximum of $100,000 per member Primary Care Physicia You pay $20 per visit Specialist You pay $30 per visit Ipatiet Facility, Outpatiet Facility, Physicia s services You pay 15% Pla pays 85% Ulimited dollar maximum Pla pays 75% after deductible is met $100,000 lifetime maximum Max (10) EAP visits with Ciga Behavioral or BCPS Call or Ciga Behavioral Max (10) EAP visits with Ciga Behavioral or BCPS Call or Ciga Behavioral Max (10) EAP visits with Ciga Behavioral or BCPS Call or Ciga Behavioral Yes Yes Yes 100% You pay 15% Pla pays 85% Pla pays 75%

38 36 Medical Optios At-a-Glace Medical Optios At-a-Glace Chart (cotiued) (Summary Pla Documet Prevails; visit for full details) Pla Facts Pla Name Beefit Levels MENTAL HEALTH AND SUBSTANCE ABUSE 3 Metal Health Outpatiet Services Member Services Ciga OAPIN Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health Group Number Office Visit You pay $20 per visit Outpatiet Facility Substace Abuse Ipatiet Services Substace Abuse Outpatiet Services $100 copay per admissio, the Office Visit You pay $20 per visit Outpatiet Facility OTHER SERVICES Kidey, Corea, Boe Marrow Trasplats Primary Care Physicia You pay $15 per visit Specialist You pay $20 per visit Ipatiet Facility $100 copay per admissio, the Heart, Heart-Lug, Lug, Pacreas, Liver Trasplats (requires preauthorizatio) Outpatiet Facility; Physicia Services Primary Care Physicia You pay $15 per visit Specialist You pay $20 per visit Ipatiet Facility $100 copay per admissio, the Outpatiet Facility; Professioal Fees

39 Kaiser Permaete Kaiser (Metal Health) Jauary 1, 2017 to December 31, 2017 I-Network Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health Ciga OAP Out-of-Network Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health HMO 37 Medical Optios At-a-Glace 100% after $5 copay for idividual visits; $5 copay for group therapy visits. Office Visit You pay $30 per visit Outpatiet Facility 100% You pay 15% Pla pays 85% 100% after $5 copay for idividual visits; $5 copay for group therapy visits. Office Visit You pay $30 per visit Outpatiet Facility Pla pays 75% Pla pays 75% Pla pays 75% 100% Primary Care Physicia You pay $20 per visit Specialist You pay $30 per visit Pla pays 75% after deductible is met Ipatiet Facility, Outpatiet Facility, Physicia s services You pay 15% Pla pays 85% (covered at 100% at LifeSource Ceter) 100% Primary Care Physicia You pay $20 per visit Specialist You pay $30 per visit Pla pays 75% after deductible is met Ipatiet Facility, Outpatiet Facility, Physicia s services You pay 15% Pla pays 85 % (covered at 100% at LifeSource Ceter)

40 38 Medical Optios At-a-Glace Medical Optios At-a-Glace Chart (cotiued) (Summary Pla Documet Prevails; visit for full details) Pla Facts Pla Name Beefit Levels Member Services Ciga OAPIN Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health Group Number OTHER SERVICES (cotiued) Orga Trasplat Procuremet Orga Trasplat Travel Cardiac Rehabilitatio Ulimited Travel maximum $10,000 per trasplat (oly available if usig Lifesource Facility) You pay $20 per visit 40 days per caledar year PRESCRIPTION DRUG SERVICES Retail Prescriptio services provided through Ciga. Copays are per fill at participatig pharmacies up to a 30-day supply. Patiets may purchase up to 90 day supply at retail, however (3) copays will apply for 90 day supply. Madatory geeric $10 Formulary brad $20 No-formulary brad $35 Mail Order Prescriptio services provided through Ciga. Copays are per fill up to a 90-day supply. Madatory geeric $20 Formulary brad - $40 No-formulary brad - $70 VISION DENTAL COMMENTS Routie visio services ot covered Routie detal services ot covered Chiropractic care, Acupucture & massage therapy discout available. No referral required.

41 Kaiser Permaete Kaiser (Metal Health) Jauary 1, 2017 to December 31, 2017 I-Network Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health Ciga OAP Out-of-Network Ciga (Medical & Pharmacy) Ciga (Metal Health) EAP - CIGNA Behavioral Health HMO 39 Medical Optios At-a-Glace 100% covered if recipiet is the member Ulimited Ulimited Limited beefit Travel maximum $10,000 per trasplat (oly available if usig Lifesource Facility) Not Applicable 100% after $5 copay You pay $30 per visit Ulimited days per caledar year Copays are per fill up to a 60-day supply. Madatory geeric $5 Brad $5 At a participatig commuity pharmacy: Madatory geeric $15 Brad $15 Prescriptio services provided through Ciga. Copays are per fill at participatig pharmacies up to a 30-day supply. Patiets may purchase up to 90 day supply at retail, however (3) copays will apply for 90 day supply. Madatory geeric $10 Formulary brad $20 No-formulary brad $35 Pla pays 75% Ulimited days per caledar year Prescriptio services provided through Ciga. Copays are per fill at participatig pharmacies up to a 30-day supply. Patiets may purchase up to 90 day supply at retail, however (3) copays will apply for 90 day supply. Madatory geeric $10 Formulary brad $20 No-formulary brad $35 Copays are per fill for maiteace prescriptios up to a 90-day supply. Madatory geeric $5 Brad $5 $5 copaymet for routie exam; discout o leses & frames available Noe Chiropractic care, acupucture & massage therapy discout available. No referral required. my.kp.org/mida/bcps or Prescriptio services provided through Ciga. Copays are per fill up to a 90-day supply. Madatory geeric $20 Formulary brad - $40 No-formulary brad - $70 Routie visio services ot covered Routie detal services ot covered Chiropractic care, Acupucture & massage therapy discout available. No referral required. Prescriptio services provided through Ciga. Copays are per fill up to a 90-day supply. Madatory geeric $20 Formulary brad - $40 No-formulary brad - $70 Routie visio services ot covered Routie detal services ot covered Chiropractic care, Acupucture & massage therapy discout available. No referral required.

42 40 Your Detal Optios Highlights Your Detal Optios Highlights BCPS Offers Three Detal Optios: CareFirst BlueCross BlueShield Regioal Detal PPO CareFirst BlueCross BlueShield Regioal Detal Traditioal Ciga Detal Care DHMO Regioal Detal PPO The CareFirst Detal PPO Program offers two levels of beefits i oe pla. Whe you eed detal care, you may see the detist of your choice. Beefit levels ad out of pocket expeses are determied based upo whether you receive detal care from a preferred detist. I-Network Beefits Whe you use a Preferred Provider, you receive the highest level of coverage with the least amout of out-of-pocket expese. I order to choose a preferred detist, please refer to the Preferred Detal Provider directory or cotact Member Services at Out-of-Network Beefits You may choose to use detists outside of the etwork, but your costs may be higher. There are two types of out-ofetwork detists: Participatig detists are ot preferred detists, but they have agreed to bill oly up to the allowed beefit amout by CareFirst BlueCross BlueShield, thus limitig your out-of-pocket expese. No-participatig detists have o agreemet with CareFirst BlueCross BlueShield ad may bill you up to their charges, which may icrease your out-of-pocket expese. Members who receive care from o-participatig detists must pay for their services at the time the services are redered ad must file a claim for reimbursemet directly from CareFirst BlueCross BlueShield. Pla Highlights Each erolled family member receives up to $1,000 i paid beefits per caledar year Flexibility to choose ay detist CareFirst Preferred ad Participatig Providers will file claims for you ad caot balace bill you Prevetive care is available with o out-of-pocket expese if a CareFirst Preferred Provider is used Regioal Detal Traditioal The CareFirst Traditioal Detal Program allows you the freedom to choose ay detist. If you seek care from a CareFirst participatig provider, the detist caot bill you the differece betwee their charge ad the allowed amout. You are oly resposible for deductibles ad coisurace. A o-participatig provider will bill for ay amout over CareFirst s allowed beefit. Pla Highlights Each erolled family member receives up to $750 i paid beefits per caledar year Flexibility to choose ay detist CareFirst s Participatig Providers will file claims for you ad caot balace bill Ciga Detal Care Ciga Detal Care is a detal health maiteace orgaizatio (DHMO). You must select ad seek services from your DHMO facility. No beefits are available if o-participatig detists are used. For the most curret iformatio regardig participatig detists i your area, call You may also visit Ciga s Web site at Both resources are available 24 hours a day. You may chage your primary detist selectio by callig Member Services. I most cases, the chage will take effect o the first day of the followig moth. Pla Highlights There is o deductible There are o aual dollar maximums There are o claim forms for you to file All prevetive care ad some restorative care is available with zero copaymets from you Complex procedures are available for low, pre-set patiet charges that are published i the Patiet Charge Schedule

43 41 Your Detal Beefits At-a-Glace Chart Detal Plas Covered Service Deductible per caledar year** Maximum Beefit per Caledar Year** Prevetive Care Exams, Cleaigs, X-rays, Fluoride Restorative Care Filligs, Crows, Root Caals Periodotic Services CareFirst BlueCross BlueShield Regioal Detal PPO Group# 7 91 I-Network (Preferred) $10 per perso $20 per family Out-of-Network (Participatig or o-participatig*) $25 per perso $50 per family CareFirst BlueCross BlueShield Regioal Detal Traditioal Group# 7 91 $10 per perso $25 per family Participatig or o-participatig* $-0- $1,000 per perso $750 per perso Ulimited PLAN PAYS: 100% 80% 100% whe usig a Participatig Provider (No-Participatig Providers ca balace bill) 80% after deductible 80% for limited services after deductible 60% after deductible 60% for limited services after deductible 100% Ciga Detal DHMO Group# I-Network Oly 80% after deductible* Most filligs ad root caals: o out-of-pocket expese; copaymets for other covered procedures rage from $0 to $220 80% for limited services after deductible Copaymets for covered procedures rage from $15 to $335, o deductible Detal Beefits At-a-Glace Prosthetic Services, Detures, Bridgework Emergecy Care Orthodotia Services 50% after deductible 30% after deductible Paid accordig to covered service. No additioal emergecy provisios are provided. 50% after deductible ($1,500 lifetime maximum) 50% after deductible ($1,000 lifetime maximum) (for depedet childre oly to age of 19 - ed of moth) 50% after deductible Copaymets for covered procedures rage from $15 to $335; o deductible 50% after deductible ($1,000 lifetime maximum) (for depedet childre oly to age of 19 - ed of moth) $0 ($54 after regularly scheduled hours) Copaymets vary from case to case. Maximum beefit of 24 moths. See patiet charge schedule for details. * CareFirst paymets based o allowed beefits. No-participatig providers ca bill ay amout over the CareFirst BlueCross BlueShield allowed beefit. ** Caledar Year meas Jauary 1 through December 31.

44 42 Visio Isurace Visio Isurace Davis Visio, oe of the atio s leadig maaged visio care compaies, will cotiue to provide visio beefits. Davis Visio has a provider etwork cosistig of 22,000 private practitioers, idepedet optometrists ad ophthalmologists, opticias, ad retailers atiowide. Collectio of covered frames If you select a frame from the Davis Visio Tower Collectio, available at idepedet providers, you will ot have a copay. If you select a o-tower frame, you will be give up to $130 towards the retail cost. Expaded etwork May atioal ad regioal retail stores are ow i etwork, icludig Wal-Mart, Target Optical, Sears Optical, Pearle Visio, ad Doctor s Visioworks! To fid a visio provider, please visit ad click o Fid a Doctor or call Davis Visio at Who is eligible All employees who have a full-time equivalecy of.500 or greater are eligible, ad the Board pays 100% of the cost. You have the optio of coverig your depedets. If you ad your spouse are both employees of BCPS, you may ot isure each other ad oly oe of you may provide coverage for your childre. Beefit From Davis Visio Provider From Out-Of-Network Provider* Examiatio (every 12 moths 1 ) Spectacle Leses (every 24 moths 2 ) $20 Copay Covered up to $35 $20 Copay Covered up to $25/sigle visio Covered up to $40/bifocal Covered up to $55/trifocal Covered up to $80/leticular Frames (every 24 moths) Tower Collectio No-Tower Frames Covered i full Covered up to $130 Covered up to $35 Cotact Leses 3 (every 24 moths 2 ) Elective (i lieu of frames & leses) Medically Necessary** Covered up to $130 $20 Copay Covered up to $130 Covered up to $210 Laser Visio Correctio Discouted services Noe 1 Based o your last date of service. 2 Basic sigle visio, lied bifocal or lied trifocal leses. 3 Patiets choosig cotacts use their eligibility for a frame ad leses. Fittig is icluded if Davis Visio Collectio cotact leses are prescribed. You are resposible for all charges after the allowed amout for o-davis Viso Collectio cotact leses. * You are resposible for all charges for services received out-of-etwork ad must file a claim for reimbursemet up to the pla beefit. Claims must be submitted withi twelve moths of the date of service. ** Medically Necessary Cotact leses prescribed for coditios where visual acuity caot be adequately corrected with eyeglasses but ca be corrected by cotact leses. Preapproval required. I-Network Providers All i-etwork or participatig Davis Visio providers will offer the followig services at o additioal cost. Oe year breakage warraty o pla eyeglasses Plastic or glass leses Oversized leses Before selectig your eyewear, ask your doctor what is fully covered by your visio pla through Baltimore Couty Public Schools. To fid a provider ear you, please visit ad click o Fid a Doctor or call CareFirst Davis Visio at

45 43 Visio Isurace Out-of-Network Providers Should you choose to visit a eye care professioal ot i the Davis Visio etwork, you will still receive coverage; however, your out-of-pocket costs will be higher tha if you had visited a etwork provider. Note: Please be aware that o-davis Visio providers will expect the etire paymet up-frot. You may the seek reimbursemet by submittig a claim form to CareFirst Davis Visio. You will be reimbursed up to your allowed amouts. Visio Isurace Discouted Rates o Special Services I additio to your stadard eye glass coverage, you will also be offered discouts or pre-egotiated fees for additioal optios. Laser Visio correctio whe usig a provider i the Davis Visio Laser Visio etwork, you are etitled to a discout of up to 25% off providers usual ad customary charge or a 5% discout from the Laser ceter s advertised special. Les 123 Mail Order Replacemet Cotact Les Program allows sigificat savigs of up to 50% o replacemet cotact leses. Les 123 will guaratee the lowest price. You would simply call LENS123 with a valid prescriptio for replacemet cotacts or additioal boxes. 20% courtesy discout at most Davis Visio participatig offices towards the purchase of items ot covered, such as a secod pair of glasses. Prescriptio Chages If your les prescriptio chages before you are eligible for ew leses ad that prescriptio meets at least oe of the followig criteria, leses ad frames will be replaced at a 12-moth frequecy: a. a ew prescriptio differs from the origial by at least.50 diopter sphere or cylider; b. a axis chage of 15 degrees or more; c. a.5 prism diopter chage i at least oe eye. For More Iformatio Call Davis Visio s dedicated Baltimore Couty Customer Service Departmet at , Mo. Fri., 8am 11pm, Sat. 9 am 4 pm, Su. oo 4 pm, Easter time. To access the Davis Visio Web site, visit com ad click o Fid a Doctor i the Solutio Ceter. The click o Visio uder Search by Provider Type.

46 44 Flexible Spedig Accout (FSA) Highlights Flexible Spedig Accouts (FSA) Highlights Flexible Spedig Accout (FSA) Highlights Who is Eligible? All active employees workig for Baltimore Couty Public Schools are eligible to participate i the Flexible Spedig Accouts (FSA). How Do Flexible Spedig Accouts Work? Flexible Spedig Accouts allow you to set aside dollars from your salary, before payig taxes, to pay for certai out-of-pocket health ad depedet care expeses. Tax savigs result because you do ot have to pay icome or FICA taxes o the amout withheld from your paycheck or the reimbursemet amout. You choose the amout to be deducted from your gross pay by projectig your health care ad depedet care expeses for the Pla Year. The Pla Year starts Jauary 1 ad eds December 31. BCPS has pre-fuded the elected amout for health care spedig accouts, but ot the depedet care accouts. Through automatic payroll deductios, the elected amout for health care ad depedet care accouts is deposited ito your flexible spedig accout. You ca the use your debit card to pay for services or submit a claim to be reimbursed for your expeses. How Do I Eroll? BCPS FSA pla admiistrator is Beefit Strategies. You may eroll by visitig or by callig New erollees will receive their debit cards o or before Jauary 1. Type of FSA Miimum Aual Cotributio Maximum Aual Cotributio Health Care $100 $2,550 Depedet Care $500 $5,000 Health Care Spedig Accout You may set aside $100 to $2550 aually i a Health Care Spedig Accout to pay for qualified medical, prescriptio, over-the-couter (OTC) medical supplies, prescribed over-the-couter (OTC) medicatios, detal ad visio care expeses. The health care expeses may be for you, your spouse, or your depedets (as log as you claim them as depedets o your tax retur). Some examples of eligible medical expeses are: orthodotia, copaymets, deductibles, acupucture, chiropractic care, hearig aids ad batteries, eyeglasses, smokig cessatio expeses, LASIK eye surgery, prescriptio drug copaymets, ad prescribed OTC Medicatios. How Do I Use My Health Care FSA? Employees erolled i the health care FSA will receive a pre-fuded health care beefit card which is similar to a debit card. The card ca be used to pay for health care goods ad services at the time of service or purchase. The card may also be used to pay for your prescriptio ad eligible over-the-couter (OTC) items at participatig pharmacies. You may also choose to submit paper claims o lie to Beefit Strategies for health care FSA reimbursemet. After payig for qualified expeses, you may submit the FSA claim form alog with required documetatio to the pla admiistrator o lie. With each reimbursemet, you ll receive a statemet showig the status of your accout. The pla admiistrator will sed you a check reimbursig you up to the amout of your aual electio. You also have the optio of your FSA reimbursemets beig deposited directly ito your bak accout. For more iformatio o the claim process ad for a list of all eligible expeses, please visit: Depedet Care Spedig Accout The Depedet Care Spedig Accout helps you pay the cost of day care for your depedets so you ad your spouse ca work. Eligible depedets for this accout must be claimed as depedets o your federal tax retur ad are either: Uder age 13 or Metally or physically uable to care for him/ herself regardless of age (this may be a spouse or older relative) If you are sigle or are joitly filig a tax retur, you may cotribute up to $5,000 each caledar year. If you are married ad filig separately, you may cotribute up to $2,550 per year. If you eroll, you must cotribute a miimum of $500 per year. Eligible depedet care expeses iclude: Licesed Day Care Facility (child or adult), Preschool or Nursery School (ot Kidergarte), Before/After-School Programs, Care i Someoe Else s Home, Housekeeper who performs depedet care duties, ad Day Care Provided by a No- Depedet Relative over the age of 19*. * The o-depedet relative must claim this icome o their tax retur.

47 45 Flexible Spedig Accout (FSA) Highlights (cotiued) Importat facts to cosider about Flexible Spedig Accouts IRS regulatios impose a use it or lose it rule that requires you to forfeit ay moey ot used by the ed of the Pla Year. BCPS ca either refud moey, or carry it forward from oe Pla Year to the ext. You must re-eroll i FSAs each Pla Year, eve if the amout of your cotributio remais the same. You may participate i oe or both of the Flexible Spedig Accouts; but Health Care ad Depedet Care Spedig Accouts are treated separately. Moey caot be trasferred from oe accout to the other. Employees who ed employmet with BCPS (i.e. termiatio, resigatio, retiremet) have 90 days from the last day worked to submit claims; however oly claims submitted for costs icurred prior to the employee s separatio date will be paid. The Iteral Reveue Service (IRS) determies which expeses are eligible ad which are ieligible. For a detailed list of examples, cotact our Beefit Strategies visit their Web site at New hires ad erollmet chages due to a qualified life evet, which occur after the begiig of the Pla Year, should determie the umber of payroll deductios that remai. The elected amout will be deducted equally from the remaiig pay periods i the academic year. Payroll deductios are take from 20 pays betwee Jauary 1 ad December 31. No deductios for beefits are made i July ad August. Please remember to save all paperwork ad receipts for FSA card trasactios i case Beefit Strategies would request documetatio to support a expese. Amouts remaiig i your accout at the ed of the Pla Year, that are ot applied to pay expeses submitted o or before the March 31 deadlie, will be forfeited. Claim Substatiatio With each claim submitted or debit card trasactio substatiatio, you may be asked to submit a Explaatio of Beefits (EOB), receipt or statemet with the followig iformatio: Provider/Vedor Name, Date(s) of Service, Descriptio of Service, ad Your Portio of Cost. Please submit requested documetatio withi 30 days of the trasactio. Flexible Spedig Accout (FSA) Highlights FSA Grace Period (Health Care accouts oly) Grace period applies to Health Care accouts oly. Not applicable for Depedet Care accout. Expeses icurred durig the Grace Period (Jauary 1 through March 15), ad approved for reimbursemet, will first be paid from ay remaiig amout from the precedig Pla Year. Ay expeses beyod the precedig Pla Year s balace will be reimbursed from the curret Pla Year s electio. Claims will be paid i the order i which they are approved. All Grace Period expeses must be submitted to Beefit Strategies by March 31. It is importat to keep the extesio i mid whe you determie your ew FSA cotributios.

48 46 Life Isurace Life Isurace Basic Life Isurace BCPS provides $15,000 of basic term life isurace coverage, at o cost, to all permaet full ad part-time employees. Prudetial is the isurer of the program. Optioal Life Isurace All permaet full ad part-time employees may request optioal life isurace to supplemet the basic life isurace coverage. Additioal coverage ca be purchased i icremets of your aual salary, with a miimum of 1 times your salary ad maximum of 10 times your aual salary, ot to exceed $1,000,000. Note: The multiple of your salary that you select for optioal coverage will automatically result i a icrease i isurace coverage wheever your salary icreases. Similarly, the premium that you pay will be adjusted automatically as a result of chages to your salary or age. Requestig Optioal Life Isurace Employees may icrease, decrease, or cacel the amout of life isurace by completig a erollmet applicatio. Employees icreasig isurace must complete a short form health statemet questioaire. Requested icreases are subject to approval by Prudetial. Optioal coverage of $35,000 or less, or the miimum aual salary icremet above $35,000, may oly be cacelled durig ope erollmet sice this coverage is purchased pre-tax. Amouts over $35,000 may be cacelled at aytime. Note: Chage amouts must be a multiple of salary. Requestig Optioal Life Isurace as a New Hire Employees electig optioal life isurace coverage withi 60 days of employmet, may obtai coverage up to 3.0 times their aual base salary ot to exceed $500,000 without providig proof of isurability. Simply select the multiple of salary that you wish to purchase o your Prudetial/BCPS erollmet applicatio. Optioal Life Isurace for Your Spouse & Childre You may purchase coverage for your spouse i $25,000 icremets ot to exceed the total amout of employee coverage to a maximum of $500,000. Eligible childre may be isured for $10,000. Optioal life isurace for a spouse or umarried child(re) may be requested or cacelled at ay time. The beeficiary for this coverage is always the employee. Employees may purchase up to $50,000 of isurace for a spouse withi 60 days of hire without evidece of isurability. Married childre, regardless of age, are ot eligible for optioal term life isurace. If you ad your spouse are both employees of BCPS, you may ot isure each other ad oly oe of you may provide coverage for your childre. See the Prudetial erollmet packet for more iformatio. Employees with depedet childre who are BCPS employees are ot eligible for depedet life isurace. Requestig Additioal Optioal Life Isurace Due to a Chage I Status Employees may request a chage i the amout of life isurace by completig a erollmet applicatio withi 30 days of the evet. Requested icreases are subject to approval by Prudetial. Cacellig or Reducig Optioal Life Isurace The first $35,000, or the lowest multiple that does ot go below $35,000, of optioal life isurace is paid o a pre-tax basis. Therefore, it may oly be cacelled or reduced durig ope erollmet. Amouts over $35,000, or the lowest multiple that does ot go below $35,000, may be cacelled at ay time. Examples: Base Salary Multiple of Salary Elected Total Amout of Optioal Life Isurace Amout (or Multiple) that may be cacelled outside Ope Erollmet $16,000 3x $48,000 May ot be chaged $65,000 3x $195,000 May reduce to 1x salary ($65,000) Effective Date of Life Isurace Basic Life Isurace is effective the first day of the moth after your hire date. Optioal Life Isurace that requires o medical uderwritig is effective the first day of the moth after you eroll. Call the BCPS Office of Beefits, Leaves ad Retiremet at or beefits@bcps.org. Certificates of Isurace are available at

49 Life Isurace Optioal Life Isurace that requires medical uderwritig is effective the first day of the moth after Prudetial has approved the applicatio. Features of the Pla Waiver of Life Isurace Premium Disability Beefit: Prudetial will waive each Life Isurace premium that becomes due for you uder the Group Policy while you are totally disabled uder certai coditios listed. Whe a premium is waived, the amout of Life Isurace equals the amout that would have bee provided if you had ot become totally disabled. That amout will reduce accordig to the Schedule of Beefits i effect o the date total disability begis. Whe a premium is waived it icludes (basic ad optioal) Life Isurace, Accelerated Death Beefit, ad Waiver of Premium. It does ot iclude ay other beefits as elected uder this certificate which were effective at the time of disability. Travel Assistace Services: As part of the Basic Life isurace, Prudetial offers a Travel Assistace Beefit to all permaet full- ad part-time employees. This program, offered through the AXA Travel Assistace Program, is a travel assistace service provided to isureds ad their depedets while travelig iteratioally or domestically over 100 miles from home. The program provides medical, travel, legal ad fiacial assistace, 24 hours a day, 365 days a year, icludig the followig services: Geeral travel iformatio about visa, passport, ioculatio requiremets ad local customs Legal referrals Assistace with pet friedly hotel accommodatios, boardig facilities ad travel home for pets Lost documet ad luggage assistace Emergecy cash/bail assistace 24-hour pre-departure iformatio (weather, currecy, holidays) Urget message trasmissio Political evacuatio The Repatriatio Beefit is described below, but is oly icluded for employees with optioal PAI coverage (Persoal Accidet Isurace): Retur of Remais (Repatriatio) Beefit If loss of life occurs outside a 100 mile radius from your home, the pla pays the lesser of the cost to retur your remais or $5,000. Retur of remais expeses iclude embalmig, crematio, coffi, ad trasportatio of remais. Accelerated Death Beefit: If you become termially ill with less tha 12 moths to live, you may apply to receive up to 80% of your life isurace beefit to a maximum of $600,000. There are o restrictios o how this moey ca be spet, ad o fees will be charged. Portability: If you termiate your employmet, you may be able to port your provided coverage. You must complete a applicatio to port your coverage withi 31 days of the date that your coverage eds through BCPS. Coversio: If you are ieligible for the portability provisio, the you have the optio to covert your term life isurace policy to a idividual whole-life level premium pla without havig to provide evidece of isurability. You must complete a coversio applicatio withi 31 days of the date that your coverage eds through BCPS. Call the BCPS Office of Beefits, Leaves ad Retiremet at or beefits@bcps.org. Certificates of Isurace are available at offices/beefits. 47 Life Isurace

50 48 Life Isurace Life Isurace How Do I Chage My Beeficiary Electio? You may desigate or update your life isurace beeficiary iformatio quickly ad easily at If you have ay questios about Prudetial s Web site, your user profile or eed additioal assistace, cotact Prudetial s Customer Service at , Moday-Friday, 8am-8pm EST. Your basic life isurace beefit plus your optioal beefit (if elected) will be paid to the beeficiary(ies) amed. You may select a perso(s), your estate, or a orgaizatio, such as a charity, as your beeficiary(ies). You must desigate a primary beeficiary ad have the optio of desigatig cotiget beeficiaries. A primary beeficiary is the perso(s) who will receive a beefit upo your death. If you ame more tha oe primary beeficiary, the the beefit will be split equally amog the survivig beeficiaries if o allocatio was made. A cotiget beeficiary is the perso(s) who will receive a beefit i the evet that all of the desigated primary beeficiaries die before you. It is very importat that you update your beeficiary desigatios as your life situatio chages (e.g., marriage, divorce, death, birth of a child, etc.) to esure that your life isurace proceeds are paid to the appropriate perso(s). A chage i your life isurace beeficiary electio does ot chage your pesio beeficiary desigatio; they are separate electios ad must be updated separately. Optioal Life Calculatio Worksheet Step 1: Eter your aual basic salary (ot icludig bous or overtime). Step 2: Eter the ew multiple of salary requested. Step 3: Multiply the result of Step 1 & 2. Step 4: Roud the result i Step 3 up or dow to the earest $1,000. This is your requested amout of optioal isurace. Step 5: Divide by 1,000. Step 6: Look o the table to the right for the rate for your age. Eter the rate. Step 7: Multiply the result of Step 5 by the result i Step 6. This is your bi-weekly deductio. Your Calculatio Example (30 years old) $21, $42,418 $42, $.04 $1.68 Requested icreases are subject to medical uderwritig approval. Complete the Prudetial Short Form Health Statemet Questioaire located i the back of this guide. Prudetial will cotact you directly if additioal medical uderwritig is required. Your payroll deductio ad level of coverage will ot chage util your request is approved by Prudetial. Bi-Weekly Isurace Rates Beefit deductios will be take from 20 pays. Age Rate* Uder *Rate chages o birth dates ad is the rate per thousad dollars of coverage. The same rate table is used for your spouse/parter Child Coverage $10,000 $1.20 bi-weekly

51 49 Volutary Whole Life Isurace Who is Eligible? All regular full-time employees ad part-time employees workig.5 FTE or more are eligible to participate. What is Whole Life Isurace? Whole Life Isurace gives you permaet life isurace with cash value that grows over time. You get tax-deferred cash accumulatio (based o curret tax laws). Beefit paymets are reduced by proportioate amouts of ay outstadig policy loa. About the Pla The volutary Whole Life pla is isured by VOYA. You ca choose to isure yourself, yourself ad your eligible depedet childre, ad your depedet gradchildre. I the Volutary Whole Life Pla you ca: Elect to purchase the greater of $5,000 or the amout that $5 per week will purchase, up to $500,000 for o tobacco users or $250,000 for tobacco users Cover your spouse for the greater of $5,000 or the amout that $5 per week will purchase, up to $500,000 for o tobacco users or $250,000 for tobacco users Cover your childre for either $12,500, $15,000, $20,000 or $25,000 (Rules of depedet eligibility apply) Requestig Whole Life Isurace as a ew hire Employees may oly elect volutary whole life isurace coverage durig the Ope Erollmet period. Employees may obtai coverage up to $50,000 without providig proof of isurability if they are betwee the ages of 15 ad 55. Features of the Pla Several optioal riders are available to ehace coverage: Log-Term Care Coverage Rider with restoratio ad extesio of beefits: Log-term care beefits are paid through a acceleratio of the life isurace death beefit. The duratio ad amout of log-term care beefits will vary based o the type of care required log-term care, assisted livig care, home health care, or adult day care. Each moth a log-term care paymet is made, the life isurace death beefit will be restored. The full isurace amout remais available after the log-term care beefit has bee paid. Waiver of Premium Rider: If you become totally disabled for at least four cosecutive moths, your life isurace coverage ad ay riders will be cotiued without paymet of further premiums while you remai totally disabled. This rider is available to employees who are uder age 56. Accidetal Death Beefit Rider: Coverage equal to the base policy face amout up to a maximum beefit of $150,000 is available for you ad your spouse if betwee the ages of 15 ad 60. Beefits are payable for death due to a covered accidet (death due to certai causes is ot covered). Childre s Term Life Isurace Rider: If you are uder age 61, you ca add coverage from $2,000 to $10,000 i $1,000 icremets for your eligible depedet childre who are uder age 24 for a modest premium amout. Oce you add this rider, ay ewly eligible childre are automatically covered from the age of 15 days, provided they are ot hospitalized. You ca also cover your gradchildre who are fiacially depedet o you ad meet the policy s defiitio of a depedet child. Volutary Whole Life Isurace How to Lear More For iformatio regardig how to eroll i the volutary Whole Life isurace thru the Volutary Beefits Call Ceter, please either call , or volutarybeefits@lwarer.com. Beefit Specialists from The Warer Compaies will be available Moday through Friday from 9 a.m. util 5 p.m. EST to eroll you. Please ote that this umber is oly active durig Ope Erollmet. For questios ad service durig the year, please either call or sed a to volutarybeefits@lwarer. com. Please visit for more iformatio.

52 50 Volutary Critical Illess Isurace Volutary Critical Illess Isurace Who is Eligible? All regular full-time employees ad part-time employees workig.5 FTE or more are eligible to participate. What is Critical Illess Isurace? Critical Illess Isurace ca help relieve the fiacial impact of a sudde, life-threateig evet by helpig to pay the direct ad idirect costs of the illess. The policy provides a lump-sum cash beefit upo the iitial positive diagosis for the first ever occurrece of a covered critical illess after the policy effective date (Covered critical illesses are limited to the specific defiitios foud i the policy.) About the Pla The volutary Critical Illess pla is isured by Trasamerica Life Isurace Compay, Cedar Rapids, Iowa. You ca choose to isure yourself, yourself ad your childre, or your etire family. I the Volutary Critical Illess Pla you ca: Elect to purchase from $5,000 to $50,000 of coverage Cover your spouse for 50% of your beefit amout Cover your childre for 50% of your beefit amout (Rules of depedet eligibility apply) Requestig Volutary Critical Illess Isurace as a New Hire Employees may oly elect volutary critical illess isurace coverage durig the Ope Erollmet period. Employees may obtai coverage up to $20,000 without providig proof of isurability. Schedule of Beefits The volutary Critical Illess pla pays a lump sum beefit equal to the Beefit Electio multiplied by the applicable percetage show i the chart below upo the first diagosis withi each category. If the beefit paymet is less tha 100% of the selected beefit amout. Trasamerica will pay a lump sum beefit amout upo the diagosis of a differet type of critical illess withi the same category. Trasamerica will Covered Illess or Evet pay this % of the beefit amout Category 1 Heart 100% Stroke 100% Heart Trasplat Surgery 100% Coroary Bypass Surgery 25% Agioplasty/Stet 5% Category 2 Major Orga Trasplat 100% Surgery (excludig heart) Ed-Stage Real Failure 100% Paralysis Not due to Stroke all 4 limbs Burs (3rd degree of 50% coverage) 100%; 50% if fewer tha 4 limbs 100% Category 3 Ivasive Cacer 100% Carcioma 25% Prostate Cacer with TNM 25% Classificatio of T1 Ski Cacer 5% Cacer Screeig Beefit $50 per caledar year How to Lear More For iformatio regardig how to eroll i the volutary Critical Illess isurace through the Volutary Beefits Call Ceter, please either call , or volutarybeefits@lwarer.com. Beefit Specialists from The Warer Compaies will be available Moday through Friday from 9am util 5pm EST to eroll you. Please ote that this umber is oly active durig Ope Erollmet. For questios ad service durig the year, please either call or sed a to volutarybeefits@ lwarer.com. Please visit for more iformatio.

53 51 Persoal Accidet Isurace (PAI) Who Is Eligible? All permaet full ad part-time employees are eligible to participate. If you ad your spouse are both employees of BCPS, you may ot isure each other ad oly oe of you may provide coverage for your childre. Employees with depedet childre who are BCPS employees are ot eligible for depedet PAI Isurace. Married childre of BCPS employees are ot eligible for PAI regardless of their age. About the Pla The volutary PAI pla is isured by Prudetial. You ca choose to isure yourself ad your family members agaist the risk of death or dismembermet from accidetal causes. I the PAI Pla You Ca: Elect to purchase from $25,000 to $500,000 of coverage if less tha 10 times your salary Cover your spouse for the same beefit amout that you have elected (up to $500,000) or cover your spouse for half your amout Cover your childre for 10% of your beefit amout (Rules of depedet eligibility apply) Beeficiary Iformatio Whe you elect PAI, you do ot eed to desigate a beeficiary. The policy will pay based o the life isurace beeficiary desigatio o file at Prudetial. Prudetial will pay the full beefit amout for accidetal loss of life occurrig withi 365 days of a covered accidet. To help survivors of severe accidets adjust to ew livig circumstaces, Prudetial will pay beefits for paralysis, dismembermet ad loss of eyesight, speech, or hearig accordig to the chart provided. If withi 365 days of a covered accidet, bodily ijuries result i: Prudetial will pay this % of the beefit amout For you or your spouse: For your childre: Loss of life 100% 100% Quadriplegia; Loss of 100% 200% ay two: had, foot or eyesight; Loss of speech ad hearig i both ears Hemiplegia ad Paraplegia; 50% 100% Loss of oe eye, had or foot; Loss of speech or loss of hearig i both ears Loss of thumb ad idex 25% 50% figer of the same had Coma Beefit 1% of the pricipal sum for up to 11 moths ad full pricipal sum after the 12th moth 1% of the pricipal sum for up to 11 moths ad full pricipal sum after the 12th moth Child Care Beefit 5% to $5,000 per N/A year up to 4 years Spouse Retraiig Beefit Lesser of 5% of the pricipal sum or $5,000 per year. N/A Chagig from the Group Pla to Idividual Coverage If, this group coverage eds for ay reaso except opaymet of premium, you may be able to port your coverage. No medical certificatio is eeded. To cotiue coverage, you must complete a applicatio for portability withi 31 days after your group coverage eds. Call Prudetial at Persoal Accidet Isurace

54 52 Persoal Accidet Isurace Persoal Accidet Isurace (PAI) Cost Per 20 Pay Periods The followig chart illustrates examples of the beefit amout ad related pay period cost for several pla optios. Add the idividual costs together to determie your total bi-weekly cost. Your Beefit Amout Rate Per $1,000 You Pay Period Cost For: Your Spouse at 100% Your Spouse at 50% Your Childre at 10% $500,000* $0.012 $3.60 $3.60 $1.80 $0.36 $400,000* $0.012 $2.88 $2.88 $1.44 $0.29 $300,000* $0.012 $2.16 $2.16 $1.08 $0.22 $200,000 $0.012 $1.44 $1.44 $0.72 $0.14 $100,000 $0.012 $0.72 $0.72 $0.36 $0.07 $75,000 $0.012 $0.54 $0.54 $0.27 $0.05 $50,000 $0.012 $0.36 $0.36 $0.18 $0.04 $25,000 $0.012 $0.18 $0.18 $0.09 $0.02 *Beefit amouts over $250,000 caot be greater tha 10 times your aual earigs. Example: Beefit Amout Cost Yourself $200,000 $1.44 = $1.44 Your Spouse (100%) Your Childre (10%) $200,000 $1.44 = $1.44 $20,000 = $ 0.14 Total Pay Period Cost $3.02

55 53 Persoal Accidet Isurace (PAI) (cotiued) For You ad Your Spouse For Your Childre Seat Belt Beefit 10% to $25,000 Air Bag Beefit 5% to $5,000 Commo Disaster Spouse Beefit: 100% to $600,000 combied with employee beefit Special Educatio Beefit 10% to $10,000 per chid per year up to 4 years; $1,000 if o depedets qualify Persoal Accidet Isurace Spouse Retraiig 5% to $5,000 Icreased Depedet Child Beefit Child Care Beefit Coma Beefit 200% to $60,000; if death occurs withi 90 days, 100% to $30,000 5% to $5,000 per year up to 4 years (age 13 maximum) 1% up to 11 moths, the 100% after 12th moth Mothly Medical Premium Beefit 1% to $200 per moth, o more tha 12 moths while ot workig Feloious Assault Beefit Emergecy Disaster Respose Team Beefit Exposure ad Disappearace 10% to $10,000 for a physical attack cosidered a feloy or misdemeaor 10% to $10,000 if o BCPS s emergecy respose team Disappearace will be cosidered as loss of life after oe year, ad Exposure will be treated as a accidetal ijury Repatriatio Up to $5,000 Travel Assistace Services Icluded

56 54 Log-term Disability Isurace Log-term Disability Isurace (LTD) How Do I Eroll? Make the selectio for LTD o the Flexible Beefits Erollmet/Chage Applicatio Form i the back of this guide. Who Is Eligible? Ay regular employee over age 18, actively at work whose full-time equivalecy equals.5 or more is eligible to joi the Volutary Log-term Disability (LTD) pla isured by Sulife uderwritte by Uio Security Isurace Compay. Employees ca eroll or cacel at ay time. (Your uio may also offer a members-oly LTD Pla. You caot participate i both.) Pre-Existig Coditio Limitatio Proof of good health is ot required. Istead, this pla pays o beefit for ay ijury or sickess, which begis i the first 12 moths of your coverage, if the disability results from a preexistig coditio. A pre-existig coditio is oe for which you have see a medical practitioer or take medicatio i the 3 moths before your coverage effective date, ad for which you did ot go treatmet-free for 3 moths before your disability bega. Pla Highlights LTD provides cotiuig icome ad protectio if you become disabled due to a ijury, accidet, or sickess. If you are qualified as disabled for 180 days, you will be eligible for beefits. The pla pays % of your base mothly salary up to a maximum of $10,000 each moth while you are disabled. This % of your salary is offset by ay icome from Social Security, workers compesatio, or retiremet pla(s) if ay of these beefits are beig received. Pla Features Paymets to You Beefits Start Combied Beefits Duratio of Beefits Pla Coverage % less applicable offset After 180 days of disability or oce sick leave is exhausted, whichever is later Guaratees total Combied Beefits Paymets whe this pla is added to Social Security, Workers Compesatio, ad Sick Leave Beefits Maximum beefit period: Uder 60 the day before retiremet age moths moths moths moths 72 or over 12 moths How Much Will My Coverage Cost? You ca determie how much your coverage will cost by followig the four steps below: Four Steps: Step 1. Eter your gross or pre-tax pay (ot icludig bous or overtime) Step 2. Eter your rate based o your age ad Sick Leave Bak eligibility from the table below Step 3. Multiply Step 1 by Step 2 Step 4. Divide Step 3 by 20 to determie the amout of premium that will be deducted from each paycheck Calculatio Example (30 yr. old No SLB member) $ $35,000 $ $ $51.10 $ $2.55 Rate Chart Rates Chage o Birth Dates If you are betwee For Sick Leave Bak* For No-Sick Leave these ages: Participats: Bak Participats: 18 to to to to to to to to *For iformatio regardig the Sick Leave Bak, TABCO Members cotact TABCO; others cotact the Office of Payroll. Where To Get More Details About This Pla For a full descriptio of the pla beefits, limitatios, ad exclusios please refer to the Log-term Disability Icome Pla Booklet available olie at beefits ad click o Pla Documets. For specific beefit questios, you may also cotact Crawford Advisors, LLC at

57 Savigs ad Retiremet Beefits offers you several ways to begi savig moey through payroll deductios. Defied Beefit Pesio Pla Tax Sheltered Auities ad Custodial Accouts Defied Beefit Pesio Pla Did you kow that the average perso eeds to replace 60% to 80% of his fial icome i order to afford retiremet? Whe it comes to retiremet plaig, it s ever too soo to start. Your retiremet icome will come from more tha oe source. However, the pricipal sources of icome whe you retire are persoal savigs, Social Security, ad your pesio from oe of the systems i which Baltimore Couty Public Schools participates. It is importat to uderstad which retiremet pla you are eligible for ad the beefits your pla will provide at retiremet. Which Retiremet Pla am I Eligible For? Depedig o your job classificatio ad the date you were employed, you may be eligible for oe of the retiremet programs listed below: Eligibility provisio Marylad State Teachers Pesio System (SRA) Automatic membership after 1980 for eligible employees as defied by Code of Marylad Regulatios (COMAR). Baltimore Couty Employees Retiremet System (BCERS) Employees i job classificatios ieligible for the State Teacher s pesio system are eligible for BCERS. Participatio is volutary, subject to the 60 day erollmet widow. 55 Savigs ad Retiremet Beefits

58 56 Savigs ad Retiremet Beefits Savigs ad Retiremet Beefits (cotiued) 403(b), 403(b)(7), ad 457(b) Plas Tax-Deferred Auity Plas ad Custodial Accouts You may save for retiremet ad reduce your curret taxes by participatig i a Tax-Deferred Auity Pla or Custodial Accout ad/or a Deferral Compesatio Pla. Sectios 403(b), 403(b)(7) ad 457(b) of the Iteral Reveue Code authorize a tax-deferred retiremet savigs program for employees of public schools. The accout shelters your moey from taxes i two ways: Pre-tax ivestig Ivestmets are made through payroll deductios before federal ad state taxes are calculated o your icome. FICA tax is also withheld which lowers your curret taxable icome. Tax-deferred compoudig Your cotributios ad ivestmet earigs accumulate tax-free while i your 403(b) accout. You pay taxes oly whe you withdraw the moey. Importat facts to cosider about 403(b) ad 457(b) plas All employees are eligible to participate i the 403(b)/(b)(7) pla ad the 457(b) pla. Employees do ot have to wait util Ope Erollmet to begi savig i a pla. You may eroll or diseroll at ay time. Participatio is 100% volutary. Baltimore Couty Public Schools does ot cotribute to your accout. Deductios are take from 24 paychecks per caledar year for 12-moth employees ad from 20 paychecks per caledar year for 10-moth employees. IRS regulatios permit you to set aside up to $18,000 for caledar year A additioal cotributio ca be made if you are age 50 or older by the ed of the caledar year. Cotact your approved vedor to assist you i determiig your persoal aual maximum. You may obtai the curret listig of authorized providers or other iformatio o the web at: There are curretly five 403(b)/(b)(7) providers. Natiowide is the oly 457(b) provider. Your savigs i these accouts are geerally ot available util age uless you have a fiacial hardship, as defied by the IRS. If you meet the hardship requiremets, you may be able to borrow or withdraw moey from your accout before Distributios from a 457(b) pla are ot subject to the 10% early withdrawal pealty that applies to the 403(b) plas. Retiremet savigs optios such as 403(b) ad 457(b) accouts are iteded to provide fuds after a idividual has reached age Employees who have to take distributios early should cosider cotributig to a savigs accout through our credit uio, FFFCU, to avoid icurrig tax pealties if fuds are eeded urgetly. For more iformatio about 403(b) ad 457(b) plas: If you would like more iformatio about participatig i oe of these plas, please visit our Web site at www. bcps. org/offices/beefits ad click o Cosider the Beefits. Or you may also call the Office of Beefits, Leaves ad Retiremet at to obtai a copy of the booklet etitled Cosider the Beefits!