FACILITY SPECIFIC BENEFIT INFORMATION FOR Dignity Health Corporate - Arizona This document contains important information about your Medical, Dental, Vision, Life, Accidental Death & Dismemberment and Long-term Disability Plan options. It also describes the Default Plan and Rollover Plan, which are the package of benefits provided to you if you do not enroll by the enrollment deadline. If you have any questions, contact the Dignity Health HR Service Center at 855.475.4747 and press "1". ELIGIBILITY Minimum hours per pay period Waiting Period Eligibility Date 40 30 days 1st of the month following completion of waiting period Newborns are not automatically enrolled; you must elect coverage within 31 days of the birth by logging on to dignityhealthmember.org/totalrewards ELIGIBLE DEPENDENTS Dual coverage is not allowed in any medical, dental or vision plan Eligible dependents include the following: One adult from the following categories: - Spouse - Legally Domiciled Adult (LDA)* - Adult Tax Dependent (ATD)* Dependent Child(ren) * An LDA or ATD with continuous coverage as of December 31, 2015. For eligible dependents definitions, refer to the Dignity Health Summary Plan Description (SPD). MEDICAL PLAN OPTIONS DENTAL PLAN OPTIONS Delta 1200 Delta 2500 VISION PLAN OPTIONS Dignity Health Arizona Preferred Dignity Health Arizona Premier Dignity Health Vision Plan Dignity Health Vision Plan Plus 1 DH Corp Arizona CY 2017 V1-010117
LIFE & AD&D INSURANCE OPTIONS LTD INSURANCE OPTIONS Life and AD&D coverage options include: Employee Life 1 x Pay 2 x Pay 3 x Pay 4 x Pay 5 x Pay $10,000 $50,000 Employee AD&D 1 x Pay 2 x Pay 3 x Pay 4 x Pay $10,000 Dependent Spouse $5,000 $10,000 $25,000 $50,000 Dependent Child $2,000 $5,000 $10,000 Long Term Disability coverage options include: 40% 50% 60% 2 DH Corp Arizona CY 2017 V1-010117
Tier 1 Tier 2 Provider Network Dignity Health Preferred Network United Healthcare Choice Plus Network Calendar Year Deductible² $250 per person / $750 per family $500 per person / $1,500 per family Hospital Deductible $0 $0 Medical Out-of-Pocket Maximum³ Physician Office Visits $4,000 per person / $12,000 per family Combined with Tier 2 Primary Care⁴: $20 Specialist: $30 Behavioral Health: $20 $4,000 per person / $12,000 per family Combined with Tier 1 Primary Care⁴: $30 Specialist: $50 Behavioral Health: $30 Preventive Services 11 100% 100% Hospital Facility Services Medical: 90% after Medical: 60% after Behavioral Health: 90% after Behavioral Health: 90% after Tier 1 Emergency Room $250 ⁵ (waived if admitted) $250 ⁵ (waived if admitted) Urgent Care $30 $75 PRESCRIPTION DRUG PROGRAM BENEFITS Prescription Drug Deductible Prescription Drug Out-of-Pocket Maximum³ FORMULARY Walk-up Dignity Health Arizona Preferred¹ (31-day supply) UMR $0 Included in the Medical Plan Out-of-Pocket Maximum $14 when filled with generic; $50 when filled with brand name when no generic equivalent is available; $50 plus cost difference between brand and generic when generic equivalent is available. Specialty Medications 6 : 25% no less than $25 or more than $50 At the St. Joseph s McAuley Pharmacy: $5 when filled with generic; $20 when filled with brand if no generic available; $20 plus cost difference between brand and generic when filled with brand if generic available. Mail Order These s also apply to specialty medications filled at the St. Joseph s McAuley Pharmacy. Specialty Medications 6 : 25% not less than $25 or more than $50 (90-day supply) $20 when filled with generic; $70 when filled with brand if no generic available; $70 plus cost difference between brand and generic when generic is available. 3 DH Corp Arizona CY 2017 V1-010117
NON-FORMULARY Walk-up Mail Order OTHER MEDICAL SERVICES INPATIENT 7 Dignity Health Arizona Preferred¹ (31-day supply) Tier 1 Tier 2 At the St. Joseph s McAuley Pharmacy: $40 ; $40 plus cost difference between brand and generic when filled with brand if generic available. (90-day supply) Anesthesiologist 90% after 60% after Hospital Facility Services Medical: 90% after Medical: 60% after Behavioral Health: 90% after Behavioral Health: 90% after Tier 1 Physician Visits 90% after 60% after Surgeon, Surgical Assistant Surgeon: 90% after Surgeon: 90%, no Surgical Assistant: 90% after Surgical Assistant: 60% after Diagnostic X-ray/Imaging 90% after 60% after Diagnostic Lab 90%, no 90%, no Acupuncture Medical: 90% after Medical: 60% after Behavioral Health: 90% after Behavioral Health: 90% after Tier 1 Surgeon: 90% after Surgeon: 60% after Surgical Assistant: 90% after $30 (up to 20 annual visits combined with Chiropractic) Visit limit is combined with Tier 2 Allergy Injections and Services (includes 90%, no 90%, no serum) Ambulance 90%, no 90%, no Chemotherapy/Radiation Therapy 90%, no 90%, no Chiropractic 9 $30 (up to 20 annual visits combined with Acupuncture) Visit limit is combined with Tier 2 Durable Medical Equipment 90%, no 90%, no Hospice 90%, no 90%, no Short - Term Therapy 10 (Physical; Occupational; Speech and Respiratory) $90 $140 Note: During the year, your prescription may change between the formulary and non-formulary. Some prescription drugs are subject to monthly quantity limits. OUTPATIENT 8 Hospital Facility Services Surgeon, Surgical Assistant OTHER SERVICES $20 $30 Surgical Assistant: 60% after $50 (up to 20 annual visits combined with Chiropractic) Visit limit is combined with Tier 1 $50 (up to 20 annual visits combined with Acupuncture) Visit limit is combined with Tier 1 4 DH Corp Arizona CY 2017 V1-010117
Dignity Health Arizona Preferred¹ Tier 1 Tier 2 ¹ Subject to limitations and exclusions. A complete list of the limitations and exclusions (applicable to this medical plan) is provided in the Medical Plan Document. ² Deductible is per person. The combined family maximum is three times the illustrated amount. Expenses incurred in the Dignity Health Preferred Network and the United Healthcare Choice Plus Network are credited separately to each limit. ³ The Medical Out-of-Pocket Maximum includes Prescription Drug Out-of-Pocket costs. ⁴ Primary Care visits: Family Practitioner, General Practitioner, Pediatrician, Internist, Physicians Assistant, and OB/GYN visits, including behavioral health/substance abuse. All other professional visits are considered Specialist. ⁵ Non-emergent care not covered. ⁶ Other than the 1 st fill, specialty medications must be received through Plan s Specialty Pharmacy or the St. Joseph s McAuley Pharmacy. 7 Required precertification for all Inpatient Hospital services. 8 Requires precertification. For a detailed list of services that require precertification refer to the Medical Plan Document. 9 Includes spinal manipulation performed by MD, DO or other providers. 10 Limited to 50 sessions per calendar year per therapy type. Must meet medical necessity criteria. 11 All preventive services defined by the Affordable Care Act are covered without having to pay a or co-insurance or meet a. This applies only when services are delivered by a network provider. A complete list of preventive services can be found at www.healthcare.gov/coverage/preventive-carebenefits/. This is a basic summary of the medical plan benefits. If you have questions about coverage or costs under this plan, please contact the plan administrator at the number listed on your ID card or log on to the Total Rewards Portal to access plan resources. From "My Health" you can link to the administrator's website or review the plan's Medical Plan Document (MPD) document. To view the MPD, select "Summary Plan Descriptions" from the "Resource" section under "Quick Links". 5 DH Corp Arizona CY 2017 V1-010117
Tier 1 Tier 2 Tier 3 Provider Network UMR Dignity Health Preferred Network United Healthcare Choice Plus Network Out-of-Network Calendar Year Deducible 2 $0 $0 $1,000 per person/$3,000 per family 2 Hospital Deductible $0 $0 $0 Medical Out-of-Pocket Maximum 3,4 $4,000 per person / $12,000 per family Combined with Tier 2 $4,000 per person / $12,000 per family Combined with Tier 1 $10,000 per person / $30,000 per family Physician Office Visits Primary Care⁵: $20 Specialist: $30 Primary Care⁵: $30 Specialist: $50 Primary Care⁵: 50% of allowable after Specialist: 50% of allowable after Behavioral Health: $20 Behavioral Health: $30 Behavioral Health: 50% of allowable after Preventive Services 11 100% 100% Not covered Hospital Facility Services Medical: 95% after $100 Medical: 70% after $250 Medical: 50% of allowable after Behavioral Health: 95% after $100 Behavioral Health: 95% after $100 Behavioral Health: 50% of allowable after Emergency Room $250 ⁶ (waived if $250 ⁶ (waived if $250 ⁶ (waived if admitted) admitted) admitted) Urgent Care $30 $75 50% of allowable after PRESCRIPTION DRUG PROGRAM BENEFITS Prescription Drug Deductible Prescription Drug Out-of- Pocket Maximum⁴ FORMULARY Walk-up Dignity Health Arizona Premier¹ (31-day supply) $0 Included in the Medical Out-of-Pocket Maximum $14 when filled with generic; $50 when filled with brand name when no generic equivalent is available; $50 plus cost difference between brand and generic when generic equivalent is available. Specialty Medications⁷: 25% no less than $25 or more than $50 At the St. Joseph s McAuley Pharmacy: $5 when filled with generic; $20 when filled with brand if no generic available; $20 plus cost difference between brand and generic when filled with brand if generic available. Mail Order These s also apply to specialty medications filled at the St. Joseph s McAuley Pharmacy. Specialty Medications⁷: 25% not less than $25 or more than $50. (90-day supply) $20 when filled with generic; $70 when filled with brand if no generic available; $70 plus cost difference between brand and generic when generic is available. 6 DH Corp Arizona CY 2017 V1-010117
NON-FORMULARY Walk-up Mail Order Dignity Health Arizona Premier¹ Tier 1 Tier 2 Tier 3 Anesthesiologist 95%, no 70%, no 50% of allowable after Medical: 95% after $100 Behavioral Health: 95% after $100 Medical: 70% after $250 Behavioral Health: 95% after $100 Medical: 50% of allowable after Behavioral Health: 50% of allowable after Physician Visits 95%, no 70%, no 50% of allowable after Surgeon: 95%, no Surgeon: 70%, no Surgeon: 50% of allowable after Surgical Assistant: 95%, no Surgical Assistant: 70%, no Surgical Assistant: 50% of allowable after Diagnostic X-ray/Imaging 95% after $50 70% after $100 50% of allowable after Diagnostic Lab 95%, no 95%, no 50% of allowable after Surgeon, Surgical Assistant Acupuncture (31-day supply) $90 At the St. Joseph s McAuley Pharmacy: $40 ; $40 plus cost difference between brand and generic when filled with brand if generic available. (90-day supply) $140 Note: During the year, your prescription may change between the formulary and non-formulary. Some prescription drugs are subject to monthly quantity limits. OTHER MEDICAL SERVICES INPATIENT 8 Hospital Facility Services Surgeon, Surgical Assistant OUTPATIENT 9 Hospital Facility Services OTHER SERVICES Medical: 95% after $100 Medical: 70% after $250 Medical: 50% of allowable after Behavioral Health: 95% after $100 Behavioral Health: 70% after $250 Behavioral Health: 50% of allowable after Surgeon: 95% no Surgeon: 70% no Surgeon: 50% of allowable after Surgical Assistant: 95% no Surgical Assistant: 70% no Surgical Assistant: 50% of allowable after $30 (up to 20 annual visits combined with Chiropractic) Visit limit is combined with Tier 2 $50 (up to 20 annual visits combined with Chiropractic)Visit limit is combined with Tier 1 Not covered Allergy Injections and Services 95%, no 95%, no 50% of allowable after (includes serum) Ambulance 95%, no 95%, no 95% of allowable, no 7 DH Corp Arizona CY 2017 V1-010117
Chemotherapy/Radiation Therapy Chiropractic¹⁰ Dignity Health Arizona Premier¹ Tier 1 Tier 2 Tier 3 95%, no 95%, no 50% of allowable after $30 (up to 20 annual visits combined with Acupuncture) Visit limit is combined with Tier 2 $50 (up to 20 annual visits combined with Acupuncture) Visit limit is combined with Tier 1 Not covered Durable Medical Equipment 95%, no 95%, no 50% of allowable after Hospice 95% after 95% after 50% of allowable after Short-Term Therapy (Physical, Occupational, Speech and Respiratory) $20 $30 50% of allowable after ¹ Subject to limitations and exclusions. A complete list of the limitation and exclusions (applicable to this medical plan) is provided in the Medical Plan Document. ² Deductible is per person. The combined family maximum is three times the illustrated amount. Expenses incurred In-Network are not credited to the Out-of- Network. ³ Out-of-Pocket Maximum is per person. The combined family maximum is three times the illustrated amount. Expenses incurred In-Network are credited to the In-Network maximum only. Expenses incurred Out-of-Network are credited to the Out-of-Network maximum only. ⁴ The Medical Out-of-Pocket Maximum includes the Prescription Drug Out-of-Pocket costs. ⁵ Primary Care visits: Family Practitioner, General Practitioner, Pediatrician, Internist, Physician Assistant, and OB/GYN visits. All other professional visits are considered Specialists. ⁶ Non-emergent care not covered. ⁷ Other than the 1 st fill, specialty medications must be received through Plan s Specialty Pharmacy or the St. Joseph s McAuley Pharmacy. 8 Requires precertification for all Inpatient Hospital services. 9 Requires precertification. For a detailed list of services that require precertification refer to the Medical Plan Document. 10 Includes spinal manipulation performed by MD, DO or other providers. 11 All preventive services defined by the Affordable Care Act are covered without having to pay a or co-insurance or meet a. This applies only when services are delivered by a network provider. A complete list of preventive services can be found at www.healthcare.gov/coverage/preventive-carebenefits/. This is a basic summary of the medical plan benefits. If you have questions about coverage or costs under this plan, please contact the plan administrator at the number listed on your ID card or log on to the Total Rewards Portal to access plan resources. From "My Health" you can link to the administrator's website or review the plan's Medical Plan Document (MPD) document. To view the MPD, select "Summary Plan Descriptions" from the "Resource" section under "Quick Links". 8 DH Corp Arizona CY 2017 V1-010117
Delta 1200 Delta Dental of California Network Delta Dental Providers Calendar Year Deductible $50 per person/$150 per family Calendar Year Maximum Out-of-Pocket $1,200 per person Diagnostic and Preventive Services 100% Fillings, Extractions and Oral Surgery OTHER DENTAL SERVICES Crowns, Jackets and Cast Restorations Prosthodontic Orthodontics 80% after 50% after 50% after 50% after (maximum lifetime benefit of $2,500 per person, combined with TMJ) This is a basic summary of the dental plan benefits. If you have questions about coverage or costs under this plan, please contact the plan administrator at the number listed on your ID card or log on to the Total Rewards Portal to access plan resources. From "My Health" you can link to the administrator's website or review the plan's Evidence of Coverage (EOC) document. To view the EOC, select "Summary Plan Descriptions" from the "Resource" section under "Quick Links". 9 DH Corp Arizona CY 2017 V1-010117
Delta 2500 Delta Dental of California Network Delta Dental Providers Calendar Year Deductible $25 per person/$75 per family Calendar Year Maximum Benefit $2,500 per person Diagnostic and Preventive Services 100% Fillings, Extractions and Oral Surgery OTHER DENTAL SERVICES Crowns, Jackets and Cast Restorations Prosthodontic Orthodontics 80% after 60% after 60% after 50% after (maximum lifetime benefit of $2,500 per person, combined with TMJ) This is a basic summary of the dental plan benefits. If you have questions about coverage or costs under this plan, please contact the plan administrator at the number listed on your ID card or log on to the Total Rewards Portal to access plan resources. From "My Health" you can link to the administrator's website or review the plan's Evidence of Coverage (EOC) document. To view the EOC, select "Summary Plan Descriptions" from the "Resource" section under "Quick Links". 10 DH Corp Arizona CY 2017 V1-010117
In-Network Network VSP Choice Providers Any Provider Out-of-Network Examination 1 $10 Plan pays up to $45 after $10 Lenses 1 $10 $10 then plan pays up to a maximum of: Single Vision: $45 Lined Bifocal: $65 Lined Trifocal: $85 Aphakic/Lenticular: $125 Frame 1 100% up to $125 retail allowance Plan pays up to $45 maximum 1, 2, 3 Contact Lenses Elective: Dignity Health Vision Plan 100% up to $105 maximum Medically Necessary: 100% VSP Elective: 100% to $105 maximum Medically Necessary: 100% up to $210 maximum ¹ Restrictions and limitations apply to type and freqency of coverage. Please refer to the Dignity Health Summary Plan Description for more details. ² Benefit is in lieu of glasses. ³ Contact lenses are medically necessary as opposed to elective when they meet one of the following additional standards: (1) glasses (lenses and frames) alone cannot correct a covered person s vision to 20/70 or better; (2) contact lenses are necessary following cataract surgery; (3) contact lenses are necessitated by certain conditions of keratoconus or anisometropia. Prior authorization from the Plan is required. This communication provides a basic summary of the vision plan benefits. Please refer to the Dignity Health Summary Plan Description (SPD) for more detailed benefit provisions. 11 DH Corp Arizona CY 2017 V1-010117
In-Network Network VSP Choice Providers Any Provider Out-of-Network Examination 1 $10 Plan pays up to $45 after $10 Lenses 1 $10 $10 then plan pays up to a maximum of: Single Vision: $45 Lined Bifocal: $65 Lined Trifocal: $85 Aphakic/Lenticular: $125 Frame 1 100% up to $160 retail allowance Plan pays up to $45 maximum 1, 2, 3 Contact Lenses Elective: Dignity Health Vision Plan Plus 100% up to $150 maximum Medically Necessary: 100% VSP Elective: 100% up to $105 maximum Medically Necessary: 100% up to $210 maximum ¹ Restrictions and limitations apply to type and freqency of coverage. Please refer to the Dignity Health Summary Plan Description for more details. ² Benefit is in lieu of glasses. ³ Contact lenses are medically necessary as opposed to elective when they meet one of the following additional standards: (1) glasses (lenses and frames) alone cannot correct a covered person s vision to 20/70 or better; (2) contact lenses are necessary following cataract surgery; (3) contact lenses are necessitated by certain conditions of keratoconus or anisometropia. Prior authorization from the Plan is required. This communication provides a basic summary of the vision plan benefits. Please refer to the Dignity Health Summary Plan Description (SPD) for more detailed benefit provisions. 12 DH Corp Arizona CY 2017 V1-010117
Employee Life Election Amounts¹ ² ³ 1X Pay 2X Pay 3X Pay 4X Pay 5X Pay $10,000 $50,000 Dependent Life Election Amounts Spouse: $5,000 $10,000 $25,000 $50,000 Dependent Child: $2,000 $5,000 $10,000 AD&D Election Amounts 1X Pay 2X Pay 3X Pay 4X Pay $10,000 Maximum Life/AD&D Benefit An employee can elect up to $1 million in life and/or AD&D coverage. Life Insurance Evidence of Insurability (EOI) Dignity Health Life and Accidental Death & Dismemberment (AD&D) Insurance Life Insurance Reduction of Benefit Prudential EOI is required when: an employee elects over $500,000 or three times pay during an initial enrollment. an employee increases coverage more than one times pay or over $500,000. $25,000 or more is elected for a spouse. A reduction in an employee's life insurance coverage occurs when an employee reaches: age 70 age 75 LTD Election Amounts ¹ ² Plan Limits Elimination Period Prexisting Condition Long-Term Disability (LTD) Insurance 40% of annual base pay 50% of annual base pay 60% of annual base pay Liberty Mutual $15,000 is the maximum monthly benefit. An employee may only increase coverage by one level each year. LTD payments may begin after you have been disabled 180 days. An employee is considered to have a prexisting condition if medical treatment was received within 90 days from the effective date of LTD coverage. Benefits will not be paid when a disability is related to a prexisting condition and begins in the first year of LTD coverage. ¹ Annual base pay is defined as an employee's hourly base rate times his/her regularly scheduled hours per pay period times number of pay periods. ² To qualify for insurance or to receive an increase in life insurance amount, the employee must be actively at work performing his/her regular duties at Dignity Health s normal place of business, a work site approved by Dignity Health, or at other places Dignity Health requires him/her to travel. ³ Nonsmokers are offered reduced Employee Life Insurance rates. To qualify as a nonsmoker and receive the reduced rate, an employee must have not smoked in the last 12 months. This communication provides a basic summary of the life, AD&D and LTD plan benefits. Please refer to the Dignity Health Summary Plan Description (SPD) or the plan Certificate of Insurance for more detailed benefit provisions. To view these documents, select "My Health" and click the "Summary Plan Descriptions" link in the Resources section of Quick Links. 13 DH Corp Arizona CY 2017 V1-010117
Default Plan/Rollover Plan In general, the Default plan provides minimal or, in some cases, no coverage, and you will forfeit any waive dollars if you do not complete your initial benefit enrollment. The Rollover Plan provides a comparable level of benefits and coverage to match your current elections excluding participation in the Health Care and/or Dependent Care Spending Accounts. The chart below provides default and rollover information specific to newly eligible and open enrollment elections. The affect on benefit elections due to an employment status change or transfer can vary based on the plan options available and the nature of the employment change. You will need to log on to the Dignity Health Total Rewards Portal during your enrollment window to determine what enrollment options are available to you. What happens if I do not make an election as a newly eligible employee? When you are a newly eligible employee you will be given the opportunity to elect benefits best suited to meet your needs. If you do not elect benefits, you will have the following coverage options chosen for you: Medical Plan Dignity Health AZ Preferred with Employee Only coverage Dental Plan Delta 1200 with Employee Only coverage Vision Plan Waived Coverage Employee Life $10,000 or 1 times pay; whichever is less Dependent Life-Spouse Waived Coverage Dependent Life-Child(ren) Waived Coverage Long Term Disability 40% of pay Accidental Death & Dismemberment 1 times pay Health Care Spending Account No pretax amount elected Dependent Care Spending Account No pretax amount elected What happens if I do not make an election during annual open enrollment? Your current elections will rollover into the new plan year with comparable coverage for the following: Medical Plan Dental Plan Vision Plan Employee Life Dependent Life-Spouse Dependent Life-Child(ren) Long Term Disability Accidental Death & Dismemberment Your must elect annually a contribution amount for the Health Care Spending Account following Flexible Spending Accounts (FSA): Dependent Care Spending Account If your current election is "waived" coverage, it will continue to be waived for the new plan year. 14 DH Corp Arizona CY 2017 V1-010117