U.S. Benefits. Type of Coverage Medical. Medical. HRA, HRA Plus, Medical. Program. section below. Hawaii PPO. Prescription Drug Plan

Transcription

1 U.S. Benefits What s new for Plan Year Here s a look at how your benefits are changing. All changes are effective July 1, 2015 and are consistent with the Patient Protection and Affordable Care Act of 2010 (the Affordable Care Act ). Type of Coverage Benefit Plan Option ALL MEDICAL PLANS HRA HRA Plus Hawaii PPO What s New andd What s Changing Affordable Care Act Requirement: Coverage of anti breast cancer prescription drug at $0 member cost when prescribed by a physician as preventive. Coverage of annual lung cancer screening at $0 member cost when prescribed by a physician as preventive. Increase in paycheck contributions from $1 to $8 per month. Infertility Benefits Enhancement o The infertility medical lifetime maximum will increase from $7,500 to $ 15,000. o The infertility prescription drug lifetime maximum benefit will increase from $2,5000 to $7,500. o Too access infertility benefits, members are required too enroll in the Reproductive Resource Services (RRS) Program. o For further details about the changes to infertility benefits, please review the Changes to the HRA, HRA Plus, and Hawaii PPO Plans section below. Adding coverage for Applied Behavioral Analysis (ABA) therapy for coveredd members with a diagnosed Autism Spectrum Disorder. For further details about the addition of ABA therapy benefits, please review Changes to the HRA, HRA Plus, and Hawaii PPOO Plans section below. Prescription Drug Plan Adding an annual Out of Pocket Maximumm amount for the prescriptionn drug plan through Express Scripts. Limiting coverage for compound drugs. For details, please see the Changes to the HRA, HRA Plus, and Hawaii PPOO Plans section below.

2 Dental Vision Life Insurance Health Care Flexible Spending Account (FSA) Benefits Eligibility Rules Kaiser California Kaiser Hawaii MVP (Fishkill, NY) MCS Dental Dental Plus Vision Vision Plus Life Insurance/AD&D Plans No changee to paycheck contributions. Adding an annual Deductible amount. New annual Out of Pocket maximum amounts. The Out of and prescription drugs. Pocket amounts are combined for medical Certain services such as Emergency Care and Hospitalization (including Outpatient Surgery) will change to 20% co section below for details. Increase inn your paycheckk contributions from $59 to $98 per insurance,, subject to the deductible. Please refer to Kaiser California Plan Changes month if you cover dependents. You will have a single out of pocket drugs. maximum for medical and prescription No changee to paycheck contributions. Increase inn copay amounts for office visits, urgent care, and emergencyy care. Separate out of pocket maximums for medical and prescription drugs. Certain services such as Ambulance, Hospital, and Home Health Care will change too 20% co insurance, subject to the deductible. Please refer to MVP Plann Changes section below for details. You will have a single out of pocket drugs. maximum for medical and prescription Dental Plus Changes Only Increase inn paycheck contributions from $2 to $5 per month. Increase too orthodontia lifetime benefit from $1,500 to $2,000. Vision Plus: Slight decrease in paycheck contributions. Vision andd Vision Plus: Basic eye exams will require a $10 copay. Rates are decreasing for Basic Life and Supplemental / Spouse Life plans. Children can be covered for Dependent Child Life Insurance to age 26 without showing proof of full time student status. The maximum annual contribution amount is increasing from $2,500 to $2,550. Benefits eligibility will be based on the federal definition of a full time employee. Employees working an average of 30 hours per week, over a 52 week period are benefits eligible. Please refer to Change too Benefits Eligibility Rules section below for details of this change.

3 Important Note: ABA benefits requiree prior approval for services regardless of whether your provider is in network or out of network. Changes to the HRA, HRA Plus, and Hawaiii PPO Plans Infertility Benefits Enhancement We are increasing the lifetime maximum amounts related to infertilityy benefits for medical from $7,500 to $15,000 and from $2,500 to $7,500 for the prescription drug benefit. To be eligiblee for this benefit, the employee must have one year of service and is required to enroll in the Reproductivee Resource Services (RRS) Program through UnitedHealthcare prior to seeking treatment. Failure to enroll will result in no benefit. Infertility services must be provided at an RRS Center of Excellence (COE) too access benefits. If member does not have access to a Center of Excellence within 30 miles then RRS will direct the member to a non your COE facility. Call , Mon Fri, 8 am to 5 pm CST, to speak with a RRS nurse consultant about infertility benefits. Adding Applied Behavioral Analysis (ABA) Therapy Coverage of ABA therapy will be provided to covered members with a diagnosed Autism Spectrum Disorder. Coverage of specific servicess will be subject to UBH (United Behavioral Health a division of UHC) coveragee determination guidelines. Coverage determination guidelines are available at: You will receive access to a specialized UBH ABA Autism Care Advocate to support both your family and provider with treatment decisions, billing/claims support, and ongoing treatment planning to ensure high quality outcomes. To access benefits: Call , enter your date of birth and ID number as requested. When prompted for the reason you are calling say Benefits and at the next prompt say Mental Health. You will be connected to the Benefits Advocate Team. Tell the Benefits Advocate Team representative you are calling about Gap Inc. s ABA therapy benefit. The Benefits Advocate Team can assist with reviewing Gap Inc. s ABA therapy benefit, effective July 1, If additional benefit information is needed, the Benefits Advocate Team representative willl transfer you to a UBH team representative.

4 Prescription Drug Plan Changes Limited Coverage for Compound Medications If you are prescribed a compound medication and if any ingredient in the prescribed compound is on the list of excluded ingredients managed by Express Scripts, thee compound will not be covered. Compound medications are made when a licensed pharmacist combines, mixes or alters a medication s ingredients to meet a doctor s request. The U.S. Food and Drug Administration (FDA) do not verify the quality, safety and/or effectiveness of compound medications. While they may be used if an FDA that can approved, commercially available drug doesn t work, compound medications have ingredients often cost more but are not necessarily more effective than similar FDA approved medications. A majority of compound medications are creams, ointments, and gels. Separate Out of Pocket Maximums for Prescription Drugs As required by the Affordable Care Act, the Prescription Drug Plan which is administered by Express Scripts will have annual out of pocket maximum amounts. The out of pocket maximum amount is the most you will pay in a plan year for eligible prescription drug expenses. This includes the amounts you pay such as the flat copay amount for generic drugs or the co insurancee amount you pay for brand name drugs. Once the amounts you have paid for your eligible medication reaches the out of pocket of the plan maximum amount, you will not be charged for eligible prescription drugs for the remainder year. The out of pocket maximumm amounts for prescription drugss will apply for the HRA, HRA Plus, and Hawaii PPO Plans. Therefore, for these benefit plan options, keep in mind that youu will have two separate out of for the pocket maximum amounts, one for medical and one for prescription drugs.. The amounts prescription drug plan are as follows: Out of pocket Prescription Drug Maximumm Amounts Employee Only Employee+Spouse/Domestic Partner or Employee+Child(ren) $2,6000 $3,9000 Employee+Family $5,2000 One family member can meet the out of pocket maximum in any of the categories above. The following items will not apply towards your out of pocket maximum: Prescription drugs that are not covered under thee plan. Brand/generic difference penalty. This occurs if you purchase a brand name drug when a generic equivalent is available. You pay the difference between the full cost of the brand name drug and the generic drug, plus the generic copay.

5 Kaiser California Plan Changes The following are important changes to the Kaiser California Plan: Plan Provisions Annual Deductible o EE Only o EE+SP/DP and EE+CH o EE+FAM 2014 / (Current) 2015 / 2016 (Effective 7/1/2015) $500 $1,000 $1,000 Annual Out of Pockeo EE Only Maximum o EE+SP/DP and EE+CH o EE+FAM $1,500 $3,000 $3,000 & Rx combined $3,000 $6,000 $6,000 Member Co insurance 0% 20% Office Visits (Primary Care, Specialist, Urgent Care) Allergy Injections Advanced Imaging Services (MRI, CT, PET scans) Emergency Room Ambulance Inpatient Hospital Outpatient Surgery and Services Skilled Nursing Facility Care $35 copay $3 copay $50 copay $150 copay $100 copay $500 copay $150 copay No charge No change $ 3 copay after deductible $50 copay after deductible $150 copay after deductible Facility: Doctor s Office: Office visit copay Pharmacy Generic $15 copay/ Brand $35 copay No change

6 MVP Plan Changes The following are important changes to the MVP Plan: Plan Provisions Annual Deductible o Individual o Family 2014 / 2015 (Current) 2015 / 2016 (Effective 7/1/2015) $500 $1,250 Annual Out of Pockeo Individual Maximum () o Family Annual Out of Pockeo Individual Maximum (Rx) o Family $6,350 $12,700 (combined with medical) $1,500 $3,750 $2,000 $4,000 Member Co insurance 0% 20% Office Visits (Includes Diagnostic X ray) o Preventive $0 o Primary Care Physician (PCP) $25 copay o Specialist Urgent Care $25 copay Emergency Room $100 copay Ambulance $100 copay Advanced Imaging Services (CT/PET scans, MRIs) o Physician Office or Freestanding Radiology Facility o Outpatient Hospital Services Physical, Occupational, and Speech Therapy o Physician Office o Outpatient Hospital Services Hospital o Inpatient $500 copay + $100 for surgery o Outpatient $75 copay Home Health Care $25 copay Vision Exam Generic: $10 copay Pharmacy Brand Formulary: $30 copay Brand Non Formulary: $50 copay $0 $30 copay $50 copay $30 copay $200 copay $150 copay $50 copay Not Covered* No change *Employees are automatically covered under Gap Inc. s basic Vision plan. Change to Benefits Eligibility Rules

7 U.S. benefits eligibility is changing to support Gap Inc. business objectives to offer a consistent approach to benefits eligibility across brands and functions and comply with the Affordable Care Act. Employees, who work an average of 30 hours per week, over a 52 week period,, will be classified as benefits eligible. Gap Inc.: has established an automated hours counting processs to manage benefits eligibility. uses a 52 week look back measurement period and a 12 month stability period. If you have any questions about these eligibility rules, please contact Employee Services at , ext Important Notices Summary of Benefits and Coverage To help you choose the right medical coverage, review the Summary of Benefitss and Coverage (SBC) documents and compare plan options. SBCs are available on Gapweb or you may request a paper copy, free of charge, by contacting Employee Services. You should share the information provided in the SBC with your family members whoo live with you and are eligible for Gap Inc. medical coverage. If an eligible family member resides at a different address of which the Plan is made aware, he or she will be separately provided with a copy of the SBC. About this Document This document constitutes a Summary of Material Modifications (SMM) for the Summary Plan Description (SPD) of the Gap Inc. Health and Life, Disability and Flexible Spending Account Plans (collectively,, the Gap Inc. Plans ). Unless a different effective date is otherwise noted, this SMM is effective July 1, 2015, for benefits eligible employees. The information described in this document summarizes the official text and contracts concerning the Gap Inc. Plans. Please refer to the Gap Inc. SPD, Certificates of Coverage and Plan Documents for complete details; in all cases these documents govern the Gap Inc. Plans and programs. Employees may request copies of those documents. In case of any conflict between the information in this SMM or the SPD and thatt in the official Plan documents,, the official Plann documents will govern. Gap Inc. reserves the right at any time and for any reason to amend, terminate or modify the Plans,, in whole or in part, with or without prior notice. You can request a paper copy of this SMM document free of charge by calling Employee Services at , x20600.