Folsom Cordova Unified School District

Transcription

1 Folsom Cordova Unified School District Open Enrollment Classified Employees May 1, 2018 to May 24, 2018 All enrollment/change forms are due no later than 4:30 pm on Thursday, May 24, 2018 (You must re enroll in the Medical FSA and/ or Dependent Care FSA in order to par cipate for the upcoming plan year) May 8 2:30pm 6:00pm Open Enrollment Fairs Educa on Services Center, Board Room 1965 Birkmont Drive Rancho Cordova, CA May 16 9:30am 1:00pm 2:30pm 6:00pm (Wellness Fair) May 22 2:30pm 6:00pm High Deduc ble Health Plan (HDHP) / Health Savings Account (HSA) Educa onal Mee ng Educa on Services Center, Computer Lab 1965 Birkmont Drive Rancho Cordova, CA May 15, 2018 Presenta on begins promptly at 5:00pm Edgewood Partners Insurance Center Please arrive on me. CA License 0B29370 I 1

2 Annual Reminders EPIC Benefits Help Line & Employee Benefits Office If you have any ques ons about your benefits, please contact: EPIC Benefits Help Line (877) or Darcie Turner (916) x or Full benefit summaries for all plans and pro rated employee contribu ons can be found on the District s MyBenefits site at: h ps://pcms.plansource.com. Username: FCUSDEmployee Password: benefits Qualifying Events Outside of the District s annual Open Enrollment period, you cannot add, drop, or change your elec on un l the next Open Enrollment period unless you experience a Qualified Status Change or HIPAA Special Enrollment event as defined by the IRS. The following are examples of Qualified Status Changes. Other changes may be permissible. Marriage, domes c partnership, divorce or legal separa on Birth or adop on Death of a dependent Change in eligibility for you and/or your dependents under an employer or state sponsored plan including but not limited to: Termina on of employment for you and/or your dependents Becoming newly eligible for your spouse s employer s plan Your dependent child a aining age 26 If you experience a Qualified Status Change, you have up to 30 days from the date of the event to report the event, request an enrollment change and submit the necessary paperwork. Failure to do so will result in a forfeiture of any COBRA rights for you and/or your dependents if applicable. Any contribu ons taken for dependents who are no longer eligible will also be forfeited. If you do not take ac on within the 30 day window, you may have to wait un l the District s next Open Enrollment period to make a change. Contact the Employee Benefits Department if you experience a Qualified Status Change or if you have any ques ons. Returning Employees You cannot add, drop or change plans when you return for the new school year, even if you incur a contribu on change. Benefits in place or selected during this Open Enrollment period will remain in effect for the en re plan year July 1 to June 30 unless you experience a Qualified Status Change as described above. Make sure you take the me to understand the deduc ons that will be coming out of your paycheck. Online Benefits Informa on This guide in addi on to benefit summaries, contribu on sheets, enrollment forms and more can be found online 24/7. This allows you to review the informa on at home with your family. You can access this informa on by visi ng the District s MyBenefits website (see login informa on at the top of the page). Hard copies of benefit summaries and enrollment forms will be made available at each school site, the Educa on Services Center and at the Open Enrollment Fairs. Eligibility for Benefits All full me and part me employees working at least 20 hours or more per week are eligible for benefits through the District. You may enroll your eligible dependents in the District s medical, dental and vision programs. Eligible dependents include: Your spouse (as defined by state law) or state registered domes c partner Your children up to age 26 (disabled children may be covered beyond age 26 if they meet the health plan s requirements and are approved prior to turning age 26) Important No ce: Read Carefully The District has made every a empt to ensure the accuracy of the informa on described in this enrollment guide. Any discrepancy between this guide and the insurance contracts or other legal documents that govern the plans of benefits described in this enrollment guide will be resolved according to the insurance contracts and legal documents. Nothing in this enrollment guide will amend, modify, increase, expand, enhance or in any other way alter the terms of the underlying benefit plans as set forth in the insurance contracts and other legal documents that govern them. This enrollment guide creates neither an employment agreement of any kind nor a guarantee of con nued employment with the District. 2 I 2018 Edgewood Partners Insurance Center CA License 0B29370

3 Open Enrollment Open Enrollment is the perfect me to evaluate the best benefit op ons for you and your family. Be sure to consider factors like plan costs and what type of services you an cipate needing for the upcoming year. Open Enrollment for the plan year your one me to make changes to your benefits 1 begins May 1 and will end on May 24. The benefits you choose will become effec ve on the first day of the next plan year July 1, You must par cipate in Open Enrollment if you wish to do any or all of the following: Make changes to your medical, dental or vision coverages Par cipate in the Health Care and/or Dependent Care Flexible Spending Accounts (FSA) If you do not make changes during this Open Enrollment period, your current elec ons (including waiving coverage) will remain in place for the upcoming plan year and you will not par cipate in the Health Care or Dependent Care FSA. You must re enroll in the Health Care and/or Dependent Care FSAs each plan year. Please take the me to read and understand this guide so you can choose what is best for you and your family. If a er reading this guide you need more informa on, please contact the Benefits Help Line or the Employee Benefits Office. Contact informa on is listed on page 2 of this guide. All forms are due to the Employee Benefits Office no later than 4:30pm on Thursday, May 24, All forms can be scanned and ed to Darcie Turner, faxed to (916) A n: Benefits Office, hand delivered to the District Office or during one of the Open Enrollment Fairs. Please note that District mail is not a preferred method as ming of delivery cannot be guaranteed. Plan Changes The following plan changes will take effec ve on July 1, No other plan changes were reported by the carriers. Kaiser Hospital Copay HMO NEW! The District is adding a new HMO plan offering that is similar to the Hospital Copay plan through WHA. The plan offers a lower premium than the Kaiser $20 HMO without a deduc ble but includes an Inpa ent Hospitaliza on Copay. For rate and benefit informa on, please see page 5. Kaiser HDHP HMO Calendar Year Deduc ble Change There will be an increase to the deduc bles due to minimum limits set by the IRS. Individual Coverage (Single) $1,350 (currently $1,300) Individual within a family or family $2,700 (currently $2,600) Su er Health Plus (SHP) HDHP HMO NEW! The District is adding a High Deduc ble Health Plan (HSA qualified) to the plan offerings through SHP. Rate and benefit details can be found on page 5. WHA All Plans Network Expansions Canopy Health was added to the WHA network effec ve 1/1/2018. This expands coverage to San Francisco, Alameda, Contra Costa and part of San Mateo coun es. This also provides access to John Muir Health and UCSF. Smart90 with Express Scripts Members can receive a three month of retail maintenance drugs at a Walgreens pharmacy, excluding specialty drugs. Members will need a prescrip on with at least a 3 month refill indicated. Mail order s will apply. $0 for certain high value drugs WHA has made certain non preven ve drugs available to members at no cost either at the pharmacy or through mail order (a er deduc ble, if applicable). To determine which prescrip ons are eligible, please visit WHA s website at WHA HDHP HMO Calendar Year Deduc ble Change There will be an increase to the individual within a family deduc ble due to minimum limits set by the IRS. Individual within a family $2,700 (currently $2,600) General Health Care & Limited Purpose Flexible Spending Accounts (FSAs) The maximum contribu on for these accounts will be increasing to $2,650 per year (currently $2,600). 1 You can change your coverage during the year if you experience a Qualified Status Change including but not limited to marriage, domes c partnership, divorce, birth or adop on of a child or death of a spouse. Please see page 2 for more informa on Edgewood Partners Insurance Center CA License 0B29370 I 3

4 Health Fair May 15 The District will be hos ng a Health Fair during Open Enrollment on May 15 at the Educa on Services Center. In addi on to the District s insurance carriers, other vendors will be par cipa ng. All par cipants will receive a cket to be included in the District s Open Enrollment raffle to win prizes donated by the carriers and vendors. This year s vendors include but are not limited to: Medical Insurance You have the choice of several quality and comprehensive medical plans that include prescrip on drug coverage. When choosing your plan, consider your budget, your preferences, your health and your covered dependent s health. The informa on on the following page is a summary of coverage only. The deduc bles, s and coinsurance percentages listed indicate the amounts for which you are responsible for. For more informa on, please visit the District s MyBenefits website (see page 2 for login informa on) or obtain an enrollment packet from the Educa on Services Center, your site s administra ve assistant or one of the Open Enrollment Fairs. Medical Employee Deduc ons The employee deduc ons listed on the following page are based on full me status (working 8 hours per day) and are reflected as either monthly deduc ons (12 paychecks per year) or tenthly deduc ons (10 paychecks per year). If you work less than full me, the District s contribu on will be pro rated based on the number of hours you work. Part me employee contribu ons are available on the District s MyBenefits site. See page 2 for login informa on. High Deduc ble Health Plans (HDHP) The District now offers three High Deduc ble Health Plans (HDHPs). HDHPs combine a medical plan and a funding method, Health Savings Accounts (HSAs). These plans are designed to change consumers behavior by giving them opportuni es to control their health care costs. A HSA is a special bank account owned by an individual that allows federally pre tax dollars to be set aside in an interest bearing account for current and future medical expenses. There are regula ons and limita ons regarding these plans. If you are interested in enrolling in one of these plans, we highly recommend you a end the HDHP/HSA educa onal mee ng listed on the cover of this booklet. Chiroprac c and Acupuncture Services The medical carriers contract with outside vendors for their chiroprac c and acupuncture benefits. You must receive covered services from a par cipa ng provider. Acupuncture services for the Kaiser HDHP and SHP HDHP plans are only available upon referral from your primary care physician. You can search for par cipa ng providers by u lizing the following list. A brief summary is included on the following page. Addi onal details can be found on the District s MyBenefits website (see page 2 for login informa on) or at one of the Open Enrollment Fairs. Carrier Vendor Phone Number Website Kaiser American Specialty Health (ASH) (800) h ps:// SHP OptumHealth (800) WHA Landmark Healthplan (800) ca.com ALL ENROLLMENT/CHANGE FORMS MUST BE SUBMITTED TO THE DISTRICT OFFICE NO LATER THAN 4:30 pm on THURSDAY, MAY 24, I 2018 Edgewood Partners Insurance Center CA License 0B29370

5 Benefit Summaries Kaiser $20 Copay Plan Kaiser Hospital Copay Plan Kaiser HDHP Plan SHP ML32 Plan SHP HDHP Plan WHA $20 Copay Plan WHA Hospital Copay Plan WHA HDHP Plan Cal. Year Deduc ble Individual Individual within a family Cal. Year Out of Pocket Max Individual Individual within a family Physician/Specialist Office Visits $6,000 $20 $20 Adult Preven ve Care Room & Board Hospital Inpa ent (semi private) Outpa ent Services Emergency Room Services ( waived if admi ed) $20 per procedure $500 per day $250 per procedure $100 $150 Urgent Care Services $20 $20 Ambulance Services $150 $1,350 $2,700 $2,700 *Ded. Included* $6,000 $20 a er (deduc ble waived) $250 per admission a er $150 per procedure a er $100 a er $20 a er $100 a er $750 $750 $10 $2,700 *Ded. Included* $6,000 $2,500 $2,500 $2,500 $4,500 $20 $20 $30 $15 $30 $50 per admit a er Office: $20 ; Facility: $100 $500 per day, days 1 5 Office: $20 ; Facility: $100 $100 $100 $35 $35 $1,800 $2,700 $3,600 *Ded. Included* $3,600 $3,600 $7,200 (deduc ble waived) Prescrip on Drug Copay (Retail) $10 Generic $30 Brand $15 Generic $35 Brand $10 Generic $30 Brand a er $5 Tier 1 $20 Tier 2 $40 Tier 3 up to 30 day a er up to 30 day $10 Tier 1 $30 Tier 2 $50 Tier 3 $10 Tier 1 $30 Tier 2 $50 Tier 3 $0 Tier 1 $30 Tier 2 $50 Tier 3 a er Prescrip on Drug Copay (Mail Order) $20 Generic $60 Brand up to a 100 day $30 Generic $70 Brand up to a 100 day $20 Generic $60 Brand up to a 100 day a er $10 Tier 1 $40 Tier 2 $80 Tier 3 up to a 100 day up to a 100 day $25 Tier 1 $75 Tier 2 $125 Tier 3 up to a 90 day $25 Tier 1 $75 Tier 2 $125 Tier 3 up to a 90 day $0 Tier 1 $75 Tier 2 $125 Tier 3 up to a 90 day a er Specialty Prescrip on Drugs (30 day ) Chiroprac c Care Acupuncture $100 30% up to a $200 max combined with combined with acupuncture acupuncture combined with chiroprac c combined with chiroprac c 20% up to a $150 max a er to 20 visits per a er Available through medical plan only a er 10% up to a $100 max combined with acupuncture combined with chiroprac c a er Not covered Available through medical plan only a er 20% up to a $100 max 20% up to a $100 max a er up to 20 visits per a er up to 20 visits per a er Total Employee Deduc ons (Monthly 12 paychecks per year) Full me Employees (working 8 hours per day)* Single $ $ $99.44 $ $79.84 $ $ $ $ $ $ $ $ Total Employee Deduc ons (Tenthly 10 paychecks per year) Full me Employees (working 8 hours per day)* Single $ $ $ $ $95.81 $1, $1, $ $ $ $1, $ $ The informa on presented in the chart is a summary only. The informa on does not include all of the detailed explana on of benefits, exclusions and limita ons. Plan par cipants should refer to the Evidence of Coverage (EOC) document for coverage details. In the event informa on in this summary differs from the EOC, the EOC will prevail. *Pro rated 2018 Edgewood benefit sheets Partners for part me Insurance employees Center can be found on the District s MyBenefits website (see page 2 for login informa on). CA License 0B29370 I 5

6 Dental Insurance The District offers you and your dependents two dental plans through Delta Dental to choose from DeltaCare DHMO and Delta Dental PPO. Benefit summaries can be found on the District s MyBenefits site. See page 2 for login informa on. DeltaCare DHMO This plan is similar to a medical HMO in that you must select a contrac ng den st or dental group who will provide all of your dental care. This plan has a specific network of providers to choose from. You must ini ate your dental care through your assigned den st or dental group. There are no benefits payable if you do not use your assigned den st or dental group. You can search for an in network den st by visi ng and selec ng the DeltaCare USA network. If you transfer from the Delta Dental PPO plan to this plan and later return to the PPO, your incen ve level will reset at 70%. Delta Dental PPO (Incen ve Plan) New members under this plan begin with a 70% benefit for the majority of services. If a member has one claim in the calendar year, the benefit will increase 10% the following January 1 up to 100%. Each member within a family has their own incen ve level and a member will maintain their benefit level as long as they remain on the PPO plan. This plan allows you to visit any licensed den st; however, you receive advantages such as claims submission by the den st and lower out of pocket expenses when choosing a network den st. You can search for a provider by visi ng While you will receive discounts by seeing a PPO or Premier den st, the discounts are deeper when u lizing PPO den sts. Employee Contribu ons For full me employees (working 8 hours per day), the District pays 100% of the cost for employees and their dependents on the DeltaCare DHMO plan or 100% of the single rate on the Delta Dental PPO. Employees working less than full me receive a pro rated por on of the District contribu on. Part me contribu ons can be found on the District s MyBenefits website. Vision Insurance The District offers you and your dependents vision insurance through Superior Vision. This plan provides an exam, glasses and/or contact lenses on an annual basis. You can seek care through any vision provider; however, you receive discounts for seeking care through a contracted Superior Vision provider. To find an in network provider, please visit A benefit summary can be found on the District s MyBenefits website. See page 2 for login informa on. Employee Contribu ons For full me employees (working 8 hours per day), the District pays 100% of the cost for employees and their dependents. Employees working less than full me receive a pro rated por on of the District contribu on. Part me contribu ons can be found on the District s MyBenefits website. See page 2 for login informa on. Employee Assistance Program (EAP) Full me Employees (working 8 hours per day) Plan Name DeltaCare Delta Dental PPO Superior Vision All benefit eligible employees are automa cally enrolled in the EAP at no cost to you. Through MHN, you may receive a confiden al personal assessment and referral services. The program may help with a wide array of concerns including finding elder care, rela onship and family issues, general stress, personal loss, financial hardship and paren ng. You and your family members are en tled to up to 7 telephonic sessions per incident (unlimited incidents) and 7 face to face clinical consulta ons per member. Call MHN toll free at (800) , 24 hours a day, 7 days a week or you can access services online. MHN Online EAP: Access Code: sia (all lower case). All interac ons with MHN are confiden al. Life Insurance Basic Life/Accidental Death and Dismemberment (AD&D) The District provides you with basic Life and AD&D insurance in the amount of $25,000 at no cost to you. Your dependents, spouse and children (age 6 months to age 26) have a basic Life benefit of $5,000 also at no cost to you. Op onal Life Insurance You have the op on to purchase Op onal (addi onal) Life insurance for yourself in increments of $25,000 not to exceed $150,000 or 3 mes your annual salary. When enrolling in Op onal Life insurance, you pay 100% of the cost of coverage. Any amounts purchased outside of your ini al enrollment period as a new hire are subject to medical underwri ng. For costs and enrollment informa on, please visit the District s MyBenefits website (see page 2 for login informa on) or a end one of the Open Enrollment Fairs. 6 I 2018 Edgewood Partners Insurance Center CA License 0B29370 Tier Single Two Party Single Two Party Single/ 12 Month Deduc ons Employee Cost* $58.87 $ Month Deduc ons Employee Cost* $70.64 $ *Pro rated benefit sheets for part me employees can be found on the District s MyBenefits website (see page 2 for login informa on).

7 Tax Advantaged Accounts The District offers employees several tax advantaged account op ons. All of the below men oned accounts are offered through the District s third party administrator, BASIC pacific. Flexible Spending Accounts (FSAs) You may par cipate in FSAs to help pay for eligible medical and dependent care expenses with pre tax dollars. General Health Care FSA up to $2,650 per year You may use the General Health Care FSA to be reimbursed for eligible medical, dental and vision out of pocket expenses, like deduc bles, s, coinsurance and prescrip on drugs (except insulin, which is covered without a prescrip on) as well as other qualified medical expenses that aren t covered by your health plans. Note: While you re enrolled in a General Health Care FSA, you can t make or receive Health Savings Account (HSA) contribu ons. (For Employees NOT enrolled in a HDHP medical plan) Limited Health Care FSA up to $2,650 per year You can use the Limited Health Care FSA to pay for eligible outof pocket dental and vision expenses only. Note: You can make or receive HSA contribu ons when you re enrolled in a Limited Health Care FSA. (For Employees ENROLLED in a HDHP medical plan) Dependent Care FSA up to $5,000 per year You may use the Dependent Care FSA to be reimbursed for eligible child and elder care expenses (such as day care) so you may work. FSAs work like a savings account. Each pay period, a pre tax payroll deduc on based on your annual elec on is deposited into your FSA(s). Pre tax deduc ons allow you to save on taxes. When deciding how much to contribute to a FSA, es mate your future medical and dependent care expenses to the best of your ability. Keep in mind that any unused balance at the end of the plan year will generally be forfeited. Grace Period: If you have not spent all of your Health Care FSA dollars by the end of the plan year June 30, 2019 you may con nue to incur claims for expenses during the Grace Period. The Grace Period extends un l September 15, 2019, during which me you can con nue to incur claims and use up any remaining amounts. Claims for all of the above accounts must be submi ed no later than September 30, Health Savings Accounts (HSAs) If you re enrolled or are enrolling in one of the High Deduc ble Health Plans (HDHPs), you may also open a tax advantaged Health Savings Account. A HSA is a bank account that can be used for qualified health care expenses. Funds won t expire. Your HSA balance is yours. If you don t spend your balance in a year, it ll roll over into the following year. The account follows you. You own the HSA account. Think of it as a personal checking account for qualified health care expenses. If you switch jobs or re re, you ll take it with you. Note: You must be enrolled in a qualified HDHP in order to make contribu ons to your HSA and cannot be enrolled in any other medical plan. Triple tax advantages. Once you ve opened your HSA, you can contribute pre tax money (federal only), your account will grow tax free and you may pay for eligible health care expenses tax free. Each year the IRS sets limits on how much you can contribute to a HSA. Maximum employee contribu ons for 2018 are: Single coverage $3,450 coverage (two or more enrolled) $6,850 Catch up (for those age 55 or older) Addi onal $1,000 Important: HSAs involve very complex rules, including limita ons on eligibility, contribu on limits and expense reimbursement. Federal and state tax penal es may be assessed upon you if these requirements are not met. For more informa on, please see the District s MyBenefits website (see page 2 for login informa on). We also highly recommend that you a end the educa onal mee ng listed on the cover of this guide. You should also talk to a tax advisor about your personal circumstances with respect to HSA rules. Debit Cards If you enroll in one of the Health Care FSAs or the HSA, you will automa cally receive 2 debit cards to pay for services directly out of your account if you choose. All Dependent Care FSA expenses must be paid by the employee and submi ed for reimbursement. Par cipa on Cost The above accounts have a $4.50 per month administra ve fee that is deducted from your paycheck on a post tax basis. The fee is the same whether you have the HSA in addi on to one or both of the FSAs or on a stand alone basis. Please note the fee may be adjusted based on the number of months you work annually (i.e. 10 months, 11 months) Edgewood Partners Insurance Center CA License 0B29370 I 7

8 Annual Notices Summary of Benefits and Coverage (SBC) As an employee, the health benefits available to you represent a significant component of your compensa on package. They also provide important protec on for you and your family in the case of illness or injury. The District offers a variety of health coverage op ons and choosing a health coverage op on is an important decision. To help you make an informed choice, a Summary of Benefits and Coverage (SBC) is available for your medical plan which summarizes important informa on about your health coverage op ons. The SBC and a Uniform Glossary are available on the District s MyBenefits website (see page 2 for login informa on). A paper copy is also available, free of charge, by ing Darcie Turner in Employee Benefits. Newborns and Mothers Health Protec on Act Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connec on with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean sec on. However, Federal law generally does not prohibit the mother s or newborn s a ending provider, a er consul ng with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authoriza on from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). If you would like more informa on on maternity benefits, contact your health plan. Pa ent Protec on No ce Folsom Cordova Unified School District s WHA HMO and Su er Health Plus (SHP) HMO plans generally require the designa on of a primary care provider. You have the right to designate any primary care provider who par cipates in the network and who is available to accept you or your family members. Un l you make this designa on, the plan designates one for you. For informa on on how to select a primary care provider, and for a list of the par cipa ng primary care providers, contact WHA at (888) or SHP at (888) For children, you may designate a pediatrician as the primary care provider. You do not need prior authoriza on from Kaiser, WHA or SHP or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authoriza on for certain services, following a pre approved treatment plan, or procedures for making referrals. For a list of par cipa ng health care professionals who specialize in obstetrics or gynecology, contact Kaiser at (800) , WHA at (888) or SHP at (855) Special Enrollment No ce If an eligible employee declines enrollment in this group health plan for the employee or the employee s spouse or dependents because of other health insurance or group health plan coverage, the eligible employee may be able to enroll him/herself and eligible dependents in this plan if eligibility is lost from the other coverage (or because the employer stops contribu ng toward this other coverage). However, the eligible employee must request enrollment within 30 days a er the other coverage ends (or a er the employer ceases contribu ons for the coverage). In addi on, if an eligible employee acquires a new dependent as a result of marriage, birth, adop on or placement for adop on, the eligible employee may be able to enroll him/herself and any eligible dependents, provided that the eligible employee requests enrollment within 30 days a er the marriage, birth, adop on, or placement for adop on. If the eligible employee does not take ac on to enroll, he/she may be required to wait un l the group s next open enrollment to do so. The eligible employee also may be subject to addi onal limita ons on the coverage available at that me. Furthermore, eligible employees and their eligible dependents who are eligible for coverage but not enrolled, shall be eligible to enroll for coverage within 60 days a er (a) becoming ineligible for coverage under a Medicaid or Children s Health Insurance Plan (CHIP) plan or (b) being determined to be eligible for financial assistance under a Medicaid, CHIP, or state plan with respect to coverage under the plan. Women s Health and Cancer Rights Act Annual No ce If you have had or are going to have a mastectomy, you may be en tled to certain benefits under the Women s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy related benefits, coverage will be provided in a manner determined in consulta on with the a ending physician and the pa ent, for: All stages of reconstruc on of the breast on which the mastectomy was performed; Surgery and reconstruc on of the other breast to produce a symmetrical appearance; Prostheses; and Treatment of physical complica ons of the mastectomy, including lymphedema. These benefits will be provided subject to the same deduc bles and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like more informa on on WHCRA benefits, call Member Services at the number found on your medical ID card. 8 I 2018 Edgewood Partners Insurance Center CA License 0B29370