2020 benefits enrollment guide
TRANSCRIPT
2020
2020 Benefits
Enrollment Guide
This guide highlights the main features of many of the benefit plans sponsored by Harcros Chemicals Inc. Full details of
these plans are contained in the legal documents governing the plans. If there is any discrepancy between the plan
documents and the information described here, the plan documents will govern. In all cases, the plan documents are the
exclusive source for determining rights and benefits under the plans. Participation in the plans does not constitute an
employment contract. Harcros Chemicals Inc. reserves the right to modify, amend or terminate any benefit plan or
practice described in this guide. Nothing in this guide guarantees that any new plan provisions will continue in effect for
any period of time.
Table of Contents
Benefits Overview 4
Wellness Matters 6
Medical & Prescription Drug Plan 7
Savings & Expense Account Options 11
Dental Plan 14 Vision Plan 15
Life And AD&D Insurance 16
Disability Coverage 17
Employee Assistance Program 18
Paid Time Off 19
Retirement 20
Employee Stock Ownership Plan 21
Annual Compliance Notices 22
Summary of Benefits & Coverage: PPO Plan
37
Summary of Benefits & Coverage: High Deductible Health Plan
44
Important Contacts 51
Turn to page 22 for important government-mandated notices pertaining to premium subsidies that may be available to certain individuals. Those notices are: • Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) • Health Insurance Marketplace Coverage Options and Your Health Coverage, and • Medicare Part D Notice
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Benefits Overview
Our Benefits Program Has You Covered Most days, we all count on our simple routines to get us through. Getting the kids to school, beating the traffic to work
and finishing dinner in time to enjoy a favorite hobby. But sometimes things don’t always go as planned. Like when your
head cold turns into the flu and you have to be out of work. Or your son’s football game ends with a broken leg. Or even
when your spouse learns he needs an extensive root canal. That’s when Harcros Chemicals Inc.’s benefits are there to
help you.
Below is an overview of our benefits program, which gives you the coverage you need for all types of things life brings
your way. Harcros allows you to choose the plans that work best for your own needs—and your pocketbook. The key to
getting the most from our benefits program is to take an active role in understanding and using the plans so that you are
getting the best value for the money you spend.
Medical Plan - UMR / UnitedHealthcare (UHC) • $800 PPO Plan
• $3,000 High Deductible Health Plan
Prescription Drug – Navitus
Delta – Delta Dental of Kansas
Vision Plan – VSP
Flexible Spending Accounts (FSA) & Health Savings Accounts (HSA) – Discovery Benefits
Basic & Optional Life/AD&D – The Standard
Long Term Disability – The Standard
Salary Continuation Program – Harcros
Business Travel Accident – Mutual of Omaha
Employee Assistance Program – LifeWorks
401k Retirement Plan – MassMutual
Employee Stock Option Program (ESOP) – Harcros
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When Coverage Begins
Initial Enrollment When you first join Harcros Chemicals Inc., you have 30 days to enroll yourself and your dependents for benefits. If you enroll on time, coverage begins the first of the month following 30 days of employment. If you do not enroll within 30 days of becoming eligible, you will automatically be enrolled in company-sponsored benefits, such as Basic Life and the Employee Assistance Program (EAP), but you will have to wait until the next annual Open Enrollment to enroll for other benefits and make changes to coverage.
Annual Enrollment During annual Open Enrollment, coverage takes effect on January 1 of the following year.
Who Is Eligible? If you are a full-time employee scheduled to work at least 30 hours or more per week, you and your eligible dependents may enroll in the benefits described in this guide. Your eligible dependents include:
• Your legal spouse • Your dependent children to the end of the month they turn age 26 • Disabled dependents may be covered beyond the dependent limiting age. Please contact HR for information.
Medical Spousal Carve-Out Rule If your spouse works full-time and is eligible for medical coverage through his or her employer, your spouse will not be eligible for medical and prescription drug coverage under the Harcros Chemicals Employee Welfare Benefit Plan (Medical and Prescription plans). If your spouse qualifies for coverage under the Harcros Medical Plan, you will need to complete a Spousal Affidavit Form.
Making Changes to Coverage Once you make your benefit elections, these choices remain in effect until the next annual Open Enrollment unless you have a qualified status change or you or your eligible dependents become eligible for coverage through special enrollment rules. If you have a qualified status change or you have another allowable event, you can make certain changes during the plan year. However, you must make your enrollment change within 30 days of the event by completing a Benefit Changes/Enrollment form and returning it to Human Resources. If you do not return your form within 30 days, you will have to wait until the next Open Enrollment to make new elections. Qualified status changes include, but are not limited to:
• Change in number of eligible dependents due to birth, adoption, placement for adoption or death • Change in legal marital status, including marriage, divorce, or death of a spouse • Change in residence or workplace that changes you or your dependent’s eligibility for coverage • Change in employment status, such as starting or ending employment, for you, your spouse or your children
For a more complete list of qualified status changes, please contact Human Resources.
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Wellness Matters At Harcros, wellness is a part of our culture. We have a holistic approach to wellness that makes getting healthier easier and more fun. It isn’t about points. It’s about you. How you eat, how you move, and how you feel. It’s a great way for all of us, employees and families, to become healthier together.
Fitness Center Reimbursement
Regular exercise is an essential part of a healthy lifestyle. That’s why Harcros will pick up the cost of a qualified health
club membership or fitness classes taken at an approved fitness club—up to $240 per year!
Activity Tracker Reimbursement
The simplest way to get moving is to get walking! To help you get moving, Harcros will reimburse up to $56 for a smart
watch of your choice. **This benefit applies to New Hires only.
How it Works
– Employees will be eligible for reimbursement once every 12 months.
– To qualify, you will need to:
o Fill out and return the Gym Reimbursement Form, available at benefits.harcros.com.
o Provide an annual gym membership payment receipt.
o Provide validated proof of at least 8 gym visits per month.
All the details can be found on the Gym Reimbursement Form. Please return your completed form to Sabrina Harrison.
Preventive Services If you are enrolled in one of the Harcros Medical plans, Preventive Services are covered at 100% every calendar year on
both plans if there isn’t a diagnosis and you see an in-network provider. These services can include:
• Physician Examinations
• Urinalysis
• Glucose Screening
• Electrocardiogram (EKG)
• Pelvic Exam and Pap Smears
• Mammograms
• Colorectal Cancer Exams
• Immunizations
• Birth Control (generic only)
• Flu Shot
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Medical Plan Harcros Chemicals Inc.’s medical plan options provide coverage for the same types of expenses, such as doctor’s office
visits, preventive care, prescription drugs and hospitalization. You choose the option that makes the most sense for you
and your family based on your needs. The Harcros medical coverage through UMR with the United Health Care Choice
Plus network provides access to a nationwide network of high-quality physicians, hospitals, and facilities.
Plan Options When it comes to medical coverage, Harcros Chemicals Inc. offers:
• UHC Choice Plus PPO $800 Plan – Paired with Flexible Spending Account • UHC Choice Plus High Deductible Health Plan (HDHP) $3,000 – Paired with Health Savings Account
Please note that both plan options utilize the same national network for both medical and prescription drug services.
In-Network Care Both plans offer in-network and out-of-network benefits. When you need care, you decide whether to go to a
UnitedHealthcare (UHC) in-network doctor or to an out-of-network provider. If you receive care from in-network
doctors and facilities, your out-of-pocket costs will be lower than if you use out-of-network providers and facilities
because UHC network providers discount their fees. If you choose to receive care from an out-of-network provider, the
medical plan pays a lower benefit and you must file a claim to receive reimbursement for covered expenses.
Finding a Network Provider For the quickest, most up-to-date information, visit www.UMR.com and select Find a Provider. Enter
“UnitedHealthcare Choice Plus” and click search. Then, select the View Providers button.
Search by Category
– People: Doctors and other health care providers
– Places: Hospitals, clinics, imaging centers
– Tests and Imaging: Lab tests, screenings, scans
– Services and Treatments: Office visits, surgeries
– Care by Condition: Area of the body, type of illness
Search Results Include
– Preferred Provider Status
– Patient Reviews
– Average Cost for Procedure or Visit
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Choose the Right Health Care Setting Where you go for Medical services can make a big difference in how much you pay and how long you wait to see a health care provider. The chart below can assist in selecting the right setting based on your needs.
TYPE OF CARE WAIT TIME COST**
TeladocSM - 800-835-2362 or Teladoc.com You may request a consultation from a board-certified doctor any time of day, seven days a week, by phone or online. Teladoc physicians can diagnose routine ailments, recommend treatments and prescribe medications.
5 minutes Approximate
wait time for doctor to respond
$45 per consultation
When to go*
• Cold or flu
• Bronchitis
• Respiratory infection
• Sinus problems
• Allergies
• Urinary tract infection
• Pediatric care
• Poison ivy or pink eye
New for 2020: Teledoc will now offer behavioral health services! As a member, you can choose the
licensure, specialties, gender and languages of your provider and use the same provider throughout
the course of care. You may access a provider seven days a week, 7am to 9pm local time.
48 hours All behavioral health
appointment requests are accepted
$85-$95
per session. $200 initial diagnostic
evaluation.
Retail clinic/convenient care clinic Retail clinics, sometimes called convenient care clinics, are in retail stores, supermarkets and pharmacies.
15 minutes on average
$50-$100
Approximate cost per service
When to go*
• Colds or flu
• Sinus infections
• Allergies
• Vaccinations or screenings
• Minor sprains, burns, or rashes
• Headaches or sore throats
Urgent care/walk-in clinic Urgent care centers, sometimes called walk-in clinics, are often open in the evenings and on weekends.
20-30 minutes Approximate
wait time
$150 -$200 Average cost
When to go*
• Sprains and strains
• Mild asthma attacks
• Sore throats
• Minor broken bones or cuts
• Minor infections or rashes
• Earaches
Clinical care (your doctor’s office) Seeing your doctor is important. Your doctor knows your medical history and any ongoing health conditions.
When to go*
• Preventive services and vaccinations • Medical problems or symptoms that are not an immediate,
serious threat to your health or life
1 week or more
Approximate wait time for an appointment
$100-$150 Average cost
PPO Plan – Plan A
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PPO $800 Plan
Plan Benefits In-Network Out-of-Network
Deductible (Calendar Year) Employee Employee + One Family
$800
$1,600 $2,400
$7,500
$15,000 $15,000
Coinsurance (Plan pays)
80% 60%
Out-of-Pocket Max (includes Deductible) Employee Employee + One
Family
$2,200 $4,400 $4,400
$15,000 $30,000 $30,000
Office Visits 80% coinsurance after ded. 60% coinsurance after ded.
Preventive Care Covered 100%
Teladoc Visit 80% coinsurance after ded.
($45 charge) N/A
Urgent Care 80% coinsurance after ded. 60% coinsurance after ded.
Emergency Room 80% coinsurance after ded.
Inpatient Hospital Services 80% coinsurance after ded. 60% coinsurance after ded.
Outpatient Services 80% coinsurance after ded. 60% coinsurance after ded.
Labs and Radiology / x-ray 80% coinsurance after ded. 60% coinsurance after ded.
Prescription Drug Plan
Out-of-Pocket Max Employee Employee + One Family
$2,000 $4,000 $6,000
Retail Prescription Drug Coverage
(up to 31-day supply)
Tier 1: $10 copay Tier 2: $50 copay Tier 3: $75 copay
Specialty 20% up to $200
You pay for the prescription and the plan will reimburse you the
cost not to exceed the predominant Reimbursement
Rate minus the copay A 90-day prescription drug supply may be attained at your local pharmacy.
The plan covers all prescription tobacco cessation products and diabetic supplies at 100%.
Monthly Employee Contribution
Employee Only $215
Employee + One $430
Family $645
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High Deductible Health Plan – Plan B HDHP $3,000 Plan
Plan Benefits In-Network Out-of-Network
Deductible (Calendar Year) Employee Employee + One Family
$3,000 $6,000 $6,000
$7,500
$15,000 $15,000
Coinsurance (Plan pays)
100% 60%
Out-of-Pocket Max (includes Deductible & Prescription Drugs)
Employee Employee + One
Family
$3,000 $6,000 $6,000
$15,000 $30,000 $30,000
Office Visits 100% coinsurance after ded. 60% coinsurance after ded.
Preventive Care Covered 100%
Teladoc Visit 100% coinsurance after ded.
($45 charge) N/A
Urgent Care 100% coinsurance after ded. 60% coinsurance after ded.
Emergency Room 100% coinsurance after ded.
Inpatient Hospital Services 100% coinsurance after ded. 60% coinsurance after ded.
Outpatient Services 100% coinsurance after ded. 60% coinsurance after ded.
Labs and Radiology / x-ray 100% coinsurance after ded. 60% coinsurance after ded.
Prescription Drug Plan
Retail Prescription Drug Coverage
(up to 31-day supply) 100% coinsurance after ded. 60% coinsurance after ded.
A 90-day prescription drug supply may be attained at your local pharmacy.
The plan covers all prescription tobacco cessation products and diabetic supplies at 100%.
Harcros contributes monthly to your HSA based on your HDHP enrollment tier. Annual Contribution:
• Employee $500
• Employee + One $1,000
• Family $1,500
Monthly Employee Contribution
Employee Only $85
Employee + One $170
Family $255
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Savings & Expense Account Options Your eligibility to participate in the various types of savings account options depends on your medical plan election.
Health Savings Accounts A Health Savings Account (HSA) allows you to pay for current or save for future qualified medical, dental, and vision
expenses on a tax-free basis. You are eligible to open an HSA if you are:
• Covered by an HSA-qualified High Deductible Health Plan (HDHP)
• Not covered by another non-HDHP (including a spouse's plan and/or a General-Purpose healthcare FSA set up by
you or your spouse)
• Not enrolled in Medicaid, Medicare or Tricare
• Not eligible to be claimed as a dependent on another person's tax return
• You nor your spouse may have a Medical FSA
HSA funds can be used to pay for any "qualified medical expense" not covered through other plans. You can use your
funds to pay for qualified expenses for yourself as well as your spouse, and/or your tax-code dependents. Funds used
for purposes other than to pay for "qualified medical expenses" are taxable as income and subject to a 20% tax penalty.
HSA Funding
Harcros will make contributions to your HSA monthly. Individuals age 55 and older covered by a HDHP can make a
catch-up contribution of an additional $1,000 during the 2020 calendar year. However, account holders age 65+ who are
enrolled in Medicare are no longer eligible to make contributions into an HSA or receive employer contributions to an
HSA.
HDHP Enrollment Harcros Annual
Contribution Maximum Employee
Contribution 2020 IRS Mandated
Combined Maximum
Employee Only $500 $3,050 $3,550
Employee + One $1,000 $6,100 $7,100
Family $1,500 $5,600 $7,100
Tax Benefits
Heath Savings Accounts are triple tax-advantaged where balances can accumulate over time. HSAs can also be used to
accumulate savings; unused funds carry over each year and continue to earn interest, tax-free. HSAs are completely
employee-owned. All documentation and receipts must be saved for HSA transactions. The Internal Revenue Service
(IRS) administers Health Savings Accounts. For more information, please refer to IRS Publication 969 or visit
www.irs.gov.
Note: If you are not eligible to make contributions to an HSA due to your enrollment in Medicare, Tricare or if you have
a non-tax code dependent, an HRA / FSA may be available to you.
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Savings & Expense Account Options Your eligibility to participate in the various types of savings account options depends on your medical plan election.
Flexible Spending Accounts A Flexible Spending Account (FSA) allows you to reduce your taxable income by setting aside pre-tax dollars to pay for
qualified dental, vision and dependent care expenses. Harcros offers three types of FSAs:
• The Health Care FSA allows you to contribute an annual maximum amount of $2,700 to pay for qualified medical, dental, and vision related expenses.
• The Limited-Purpose FSA allows you to contribute an annual maximum amount of $2,700 to pay for dental and
vision related expenses only. Employees may not enroll in both a Medical FSA and a Limited-Purpose FSA; however,
members enrolled in a HDHP are eligible to enroll in a Limited-Purpose FSA in addition to a Health Savings Account
(HSA).
• The Dependent Care FSA allows you to contribute up to an annual maximum of $5,000 if single or married filing
jointly; $2,500 if you are married filing separately. You can use this account to pay for expenses associated with the
care of children under the age of 13 or for a disabled spouse or parent while you work. The account can be used or
daycare, preschool, after school care, summer day camp and elder care.
FSA Reimbursements
Careful planning of your expenses is recommended. Changes to your contribution elections are not permitted unless you
have a qualified life status change. The election you make when you enroll is binding for the entire plan year (January 1
to December 31), unless you have a qualifying status change.
• The Harcros plan allows for an additional 2 ½ month “grace period” to incur expenses for the Health Care and Limited Purpose FSA into the next calendar year. This “grace period” is January 1st through March 15th.
• Unused amounts are subject to the use-it-or-lose-it rule and are forfeited.
• Expenses incurred during the “grace period” may be first reimbursed from the funds remaining from the prior year, then from the current year.
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HSA & FSA Access and Claims Submission You may view your account balances, file claims online, or obtain additional information via the Discovery Benefits website
at www.discoverybenefits.com. You may also manage your account by downloading the Discovery Benefits mobile app.
Qualified Expenses This is a quick reference list of qualified FSA and HSA expenses. Expenses are eligible provided they are not reimbursed
through insurance or other sources. This list is a guide only and is subject to change by the IRS. Please refer to IRS
Publication 502 or consult a tax advisor for details.
Examples of Eligible Expenses
• Acupuncture
• Alcohol/drug dependency treatment
• Bandages
• Braille books, magazines
• Chiropractic services
• Contact lens expenses
• Crutches
• Dental expenses (non-cosmetic)
• Diagnostic/X-Ray/lab fees
• Doctor fees
• Eyeglasses/eye surgery
• Hearing aids
• Hospital services
• Insulin
• Lactation expenses
• Nursing home medical services
• Orthotic inserts
• Osteopathic services
• Prescription medications
• Prosthesis
• Special education for the handicapped
• Surgical/therapy fees
• Telephone equipment for hearing-impaired or
visually-impaired
• Wheelchairs, walkers
Examples of Eligible Over-the-Counter
Medications Requiring a Prescription
• Acid controllers
• Allergy/sinus medications
• Cold, cough, and flu medications
• Pain relief medications
• Sleep aids and sedatives
• Stomach remedies
Ineligible Expenses
• Expenses reimbursable by insurance or Medicare
• Federal itemized deduction expenses
• Cosmetic treatment and supplies
• Hair transplants
• Health/fitness club fees
• Non-prescription medication and drugs
• Nutritional/vitamin supplements
• Personal use items
• Premium payments for health, dental or vision care
coverage
• Weight loss programs (for general health)
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Dental Plan Harcros’s Dental Plan is administered by Delta Dental of Kansas. Harcros’s dental plan provides you and your family with
coverage for typical dental expenses, such as cleanings, x-rays, fillings and orthodontia for children.
Dental PPO Plan The Dental PPO allows you the freedom to visit any dentist, without referrals, for all
your dental care. If you receive care from one of Delta Dental’s preferred dentists,
you’ll pay less for your care. If you choose a non-preferred dentist, your share of costs
will generally be higher, and you may need to file your own claims.
Dental Plan Highlights Plan Feature Delta Dental PPO Network
Annual Deductible Individual Family
$50
$100
Annual Benefit Maximum $10,000
Preventive Services Exams, routine cleanings, x-rays, space maintainers, sealants, fluoride treatment
100% (no deductible)
Basic Services Fillings, periodontics, endodontics, crowns, extractions, general anesthesia.
80% after deductible
Major Services Restorative, bridges, dentures, implants
50% after deductible
Orthodontia Adult and Child Lifetime Maximum of $1,500
50% after deductible
Employee Monthly
Contribution
Employee $25
Employee + One $50
Family $75
For a list of Delta Dental preferred dentists, go to www.deltadentalks.com.
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Vision Plan The Harcros Vision Plan promotes preventive care through regular eye exams and provides coverage for corrective materials, such as glasses and contact lenses. The Vision Plan is administered through VSP.
Vision Coverage If you enroll for vision coverage, you can go to any eye care provider you choose for care. However, if you choose providers
who are part of the VSP network, you will receive a discount on services. To find a network provider, go to www.vsp.com.
The Vision Plan is designed to cover eye care needs that are visually necessary. You must pay extra if you choose certain cosmetic or elective eyewear, so be sure to ask your eye doctor what items are covered by the plan before you purchase materials.
Vision Plan Highlights Plan Feature In-Network Benefit Frequency
Eye Exam $10 copay Every calendar year
Lenses $25 copay for all lenses
• Single Vision, lined bifocal, and lined trifocal lenses
• Polycarbonate lenses for dependent children
Every calendar year
Lens Enhancements • Standard progressive lenses $50
• Premium progressive lenses $95-$105
• Custom progressive lenses $150- $175 Every calendar year
Frames • $130 allowance for a wide selection of frames
• $150 allowance for featured frame brands
• An additional 20% savings on amounts over the allowance Every other calendar
year
Contact Lenses (Instead of Glasses)
• $130 allowance for contacts, copay does not apply
• Up to $60 for contact lens exam (fitting and evaluation) Every calendar year
Employee Monthly
Contribution
Employee $6.88
Employee +Spouse $11.01
Employee + Child(ren) $11.24
Family $18.12
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Life Insurance Harcros Chemicals Inc. offers life insurance coverage to provide financial protection in the event of a loss. This coverage is administered through The Standard.
Basic Life & AD&D Insurance Harcros Chemicals Inc. provides Life and AD&D insurance for all eligible employees at no cost.
• Hourly Employees Benefit Employee $50,000, Spouse $10,000, Child $2,000
• Salaried & Chemical Technicians Employee 2x Annual Earnings ($750,000 Max)
Voluntary Life & AD&D Insurance In addition to your Basic Life and AD&D benefit, you may purchase Voluntary Life and AD&D Insurance not only for
yourself, but also for your spouse and your dependent children. However, you may only elect coverage for your spouse
and/or dependents if you enroll in Voluntary Life and AD&D coverage for yourself. You pay for the cost of Voluntary Life
and AD&D insurance on an after-tax basis through payroll deductions.
Voluntary Life
• Employee:
o You may apply for Voluntary Life insurance in increments of $10,000 to a maximum of $750,000.
o New Hire Guarantee Issue Amount: $200,000
• Spouse:
o You may apply for Voluntary Life insurance in increments of $5,000 to a maximum of $250,000.
o New Hire Guarantee Issue Amount: $20,000
• Child(ren):
o You may apply for Voluntary Life insurance for $10,000.
o New Hire Guarantee Issue Amount: $10,000
Voluntary AD&D
• Employee:
o You may apply for Voluntary AD&D insurance in increments of $10,000 to a maximum of $500,000.
or
• Family:
o You may apply for Voluntary AD&D insurance in increments of $10,000 to a maximum of $500,000.
o Spouse receives 40% of your Voluntary AD&D benefit; Child receives 20% of your Voluntary AD&D benefit.
If you wish to apply for more than the guarantee issue amounts listed above, you will be required to complete an evidence of insurability form. See Human Resources for the appropriate form.
You must designate a beneficiary for Basic and Voluntary Life Insurance benefits when you enroll.
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Disability Coverage Harcros provides disability coverage which will replace a percentage of your income if you cannot work because of
illness, injury or pregnancy.
Salary Continuation
Harcros Chemicals Inc. provides full-time employees with salary continuation benefits based on the length of time you have worked for Harcros.
ELIGIBILITY COMPANY PAID BENEFIT
Less than 2 months No Benefit
2 Months – Less than 1 Year 100% – 1 Month; 20% – 5 Months
1 Year – Less than 5 Years 100% – 2 Months; 60% – 4 Months
5 Years – Less than 10 Years 100% – 4 Months; 60% – 2 Months
10 Years or Greater 100% – 6 Months
Long Term Disability If you remain totally disabled and unable to work for more than 180 days, you may be eligible for Long Term Disability
(LTD) benefits. Harcros automatically provides you LTD benefits that replaces up to 60% of your base pay, up to a
maximum of $10,000 per month. You are eligible for LTD benefits following 30 days of service. Your monthly LTD
benefit will be reduced by Social Security and any other disability income you are eligible to receive (such as Workers’
Compensation).
Travel Assist
The Standard includes Travel Assistance through an arrangement with UnitedHealthcare Global. This provides an
additional sense of security for you and your eligible family members any time you travel more than 100 miles from
home or internationally for trips of up to 180 days. A single phone call helps you and your family with emergencies that
may arise while traveling, including a wide range of medical, legal and travel-related issues. There’s no enrollment
process – all employees are automatically covered. Contact Human Resources for more information.
Life Tool Kit
Life Services Toolkit resources are automatically available to you through The Standard. You have access to
comprehensive online resources including: estate planning assistance, identity theft prevention, financial planning,
health and wellness and funeral arrangements. Beneficiaries can also access services on grief support, financial
counseling, legal services and more for up to 12 months after the date of death. Contact Human Resources for more
information.
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Employee Assistance Program Your well-being, productiveness and happiness depend on balancing your life at home and your life at work. It’s difficult to be on task on the job if you’re worried about problems at home, and you can’t devote enough time to yourself and your family if you’re feeling overwhelmed by work issues. LifeWorks is available 24 hours a day, seven days a week, to help you and your family find answers and resolve personal problems. Confidential support, guidance and resources are available to help you be happier and more productive. The EAP provides resources and help regarding many issues, including the following: • Adoption issues
• Alcohol and drug abuse
• Anxiety
• Budgeting, financial worries, and reducing debt
• Child care and parenting issues
• Concern about another person’s alcohol or drug abuse
• Conflict at work
• Crisis and trauma
• Depression
• Elder care/caregiving issues
• Gambling and other addictions
The EAP consultant will discuss your needs and concerns with you, listen, and assess the situation. Depending on your situation, the EAP consultant may:
• Work with you and help you plan to resolve your issues or concerns
• Refer you to a support group
• Guide you to helpful resources in your community
• Refer you to a specialist or local counselor for ongoing counseling
• Help you navigate the EAP website for helpful resources, including articles, booklets, recordings, and more. Remember, no problem is too big or too small. The EAP encourages employees and those close to them to seek help early, before a minor problem becomes more serious. When in doubt, contact the EAP for help or support. Assistance is available for you or immediate household family members by calling 1-877-234-5151. You can also log onto www.lifeworks.com.
• Grief and loss
• Job burnout
• Legal matters
• Relationship issues
• Separation and divorce
• Stress
• Workplace change
• Domestic abuse
• Work-related problems and job stress
• Education issues
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Paid Time Off
Paid Holidays Harcros Chemicals Inc. recognizes ten (10) paid holidays each year. Shortly before the beginning of each year, the
Human Resources Department will post and circulate a list of the holidays to be observed for each year.
Paid Vacation Only full and part time regular employees are eligible for vacation. Part time employees receive vacation on a pro-rated
basis. Eligibility is based upon continuous length of service:
• 1 to 4 Years – 10 Vacation Days/Year
• 5 to 9 Years – 15 Vacation Days/Year
• 10 to 19 Years – 20 Vacation Days/Year
• 20 Years and above – 25 Vacation Days/Year
Employees hired before July 1st, will be eligible for 1 week of vacation after completing 4 months of continuous service. Employees hired on or after July 1st do not qualify for vacation in that calendar year. Part-time employee vacation will be a pro-rated portion of the full-time amount.
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Retirement Savings Plan We all look forward to the time when we can retire with financial security. To help you prepare for the goal, Harcros
Chemicals Inc. is pleased to work with Mass Mutual to provide you with the Retirement Savings Plan as part of your
compensation package. For eligibility requirements please contact the Human Resources Department, or the Harcros
intranet site.
Your Contributions
Before-Tax Contributions: Through payroll deduction, you may choose to make Before-Tax contributions from 1% to
100% of your eligible pay as defined in the plan. Please note, the IRS does limit the amount you can contribute to the
plan on a before-tax basis.
Roth Contributions: Through payroll deduction, you may choose Roth salary deferral contributions up to the maximum
under the law. These Roth contributions are elective deferrals that you elect to contribute to your Roth account on an
after-tax basis.
After-Tax Contributions: You may make after-tax contributions from 1% to 5% of your eligible pay. After-tax
contributions of certain highly paid employees may be future limited. You’ll be informed about any additional limits that
apply to you.
Harcros Chemicals Inc. Contributions Company Matching Contributions To help your savings grow even faster, Harcros Chemicals Inc. contributes $.6667 to your account for every dollar you
contribute up to 6% of your eligible pay. Harcros Chemicals Inc. only matches on the Before-Tax and Roth contributions.
Safe Harbor Contributions To help your savings grow faster, Harcros Chemicals Inc. will contribute 3% of eligible compensation that will be allocated
among all eligible employees.
Directing Contributions You decide how to invest all your contributions to the plan except for any contributions to the plan made by Harcros
Chemicals Inc. in company stock. You may direct these contributions to any or all the plan’s investment options in any
manner you wish, in multiples of 1%. A Roth IRA contribution model is also available for those interested. In addition,
you have the option to change how new money, or future contributions, should be invested. These changes may be made
online at www.retiresmart.com
Vesting You are always 100% vested in the value of your own contributions, the 3% Safe Harbor contribution and the investment
earnings on those contributions. There is a 3-year vesting period on employer contributions. A year of vesting for the
Harcros Chemicals Inc. contributions is based on 1,000 hours of services worked in a plan year.
• Less than three years of service - 0% Vested
• Upon completion of 3 years of service - 100% Vested
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Employee Stock Ownership Plan
Congratulations! You’re an owner!! Even though Employee Stock Ownership Plans (ESOP) have been around for many years, most of us don’t know much
about them. Here are some facts you’ll want to know about your new Harcros ESOP.
✓ An ESOP is a type of retirement plan that makes it possible for you to share in the value of our company.
✓ The ESOP is different from our 401k plan, as you cannot contribute to your ESOP account and all contributions
to the account are made by the company.
✓ There is no paperwork to complete and shares of stock will be automatically contributed to your account each
year if you are an eligible employee. You will be required to complete a beneficiary designation form.
✓ All Harcros employees are eligible to participate. Each year you will receive a statement showing how much
stock was added to your ESOP account as well as the total number of shares of stock you have in your account
and their value.
✓ Each year the company will be valued by an independent, third-party appraisal firm that is qualified to perform
business valuations.
✓ Your shares will be 100% vested after three years of service or age 65.
✓ For vesting purposes, 1,000 hours of service is considered a vesting year.
✓ Employees hired before June 30th will join the plan in that year. Employees hired after July 1st will join the plan
the following year.
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Annual Compliance Notices • Premium Assistance under Medicaid and the Children’s Health Insurance Program (CHIP)
• Health Insurance Marketplace Coverage Options and Your Health Coverage
• Notice of Privacy Practices
• Newborn & Mothers Health Protection Notice
• Medicare Part D Notice
• COBRA Rights Notice
• Women’s Health and Cancer Rights Act
• Expanded Coverage for Women’s Preventive Care
• Notice of Special Enrollment Rights
Summaries of Benefits and Coverage
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The government-required Summaries of Benefits and Coverage (SBCs), which summarize important information about
your medical plan options, are available starting on page 37 and online at Paycor, www.paycor.com
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed on the following page, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office, dial 1-877-KIDS NOW, or visit www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the States listed on the following page, you may be eligible for assistance paying your employer health plan premiums. The list of States is current as of July 31, 2019. Contact your State for further information on eligibility. To see if any other states have added a premium assistance program since July 31, 2019, or for more information on special enrollment rights, contact either:
U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272)
U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, ext. 61565
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State Website/E-mail Phone
Alabama (Medicaid) http://www.myalhipp.com 1-855-692-5447
Alaska (Medicaid) Premium Payment Program: http://myakhipp.com
Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
E-mail: [email protected]
1-866-251-4861
Arkansas (Medicaid) http://myarhipp.com/ 1-855-692-7447
Colorado (Medicaid and CHIP) Medicaid: http://www.healthfirstcolorado.com/
CHIP: http://www.colorado.gov/pacific/hcpf/child-health-plan-plus
1-800-221-3943
1-800-359-1991
State relay 711
Florida (Medicaid) http://www.flmedicaidtplrecovery.com/hipp/ 1-877-357-3268
Georgia (Medicaid) https://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp 678-564-1162 ext 2131
Indiana (Medicaid) Healthy Indiana Plan for low-income adults 19-64: http://www.in.gov/fssa/hip/
All other Medicaid: http://www.indianamedicaid.com
1-877-438-4479
1-800-403-0864
Iowa (Medicaid) http://dhs.iowa.gov/Hawki 1-800-257-8563
Kansas (Medicaid) http://www.kdheks.gov/hcf/ 1-785-296-3512
Kentucky (Medicaid) https://chfs.ky.gov 1-800-635-2570
Louisiana (Medicaid) http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 1-888-695-2447
Maine (Medicaid) http://www.maine.gov/dhhs/ofi/public-assistance/index.html 1-800-442-6003
TTY: Maine relay 711
Massachusetts (Medicaid and
CHIP)
http://www.mass.gov/eohhs/gov/departments/masshealth/ 1-800-862-4840
Minnesota (Medicaid) https://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-
programs/programs-and-services/other-insurance.jsp
1-800-657-3739
Missouri (Medicaid) https://www.dss.mo.gov/mhd/participants/pages/hipp.htm 573-751-2005
Montana (Medicaid) http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP 1-800-694-3084
Nebraska (Medicaid) http://www.ACCESSNebraska.ne.gov 1-855-632-7633
Lincoln: 402-473-7000
Omaha: 402-595-1178
Nevada (Medicaid) http://dhcfp.nv.gov/ 1-800-992-0900
New Hampshire (Medicaid) https://www.dhhs.nh.gov/oii/hipp.htm 603-271-5218 or
1-800-852-3345, ext. 5218
New Jersey (Medicaid and CHIP) Medicaid: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/
CHIP: http://www.njfamilycare.org/index.html
Medicaid: 609-631-2392
CHIP: 1-800-701-0710
New York (Medicaid) https://www.health.ny.gov/health_care/medicaid/ 1-800-541-2831
North Carolina (Medicaid) https://dma.ncdhhs.gov/ 919-855-4100
North Dakota (Medicaid) http://www.nd.gov/dhs/services/medicalserv/medicaid/ 1-844-854-4825
Oklahoma (Medicaid and CHIP) http://www.insureoklahoma.org 1-888-365-3742
Oregon (Medicaid) http://healthcare.oregon.gov/Pages/index.aspx
http://www.oregonhealthcare.gov/index-es.html
1-800-699-9075
Pennsylvania (Medicaid) http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremium
paymenthippprogram/index.htm
1-800-692-7462
Rhode Island (Medicaid and CHIP) http://www.eohhs.ri.gov/ 1-855-697-4347 or
401-462-0311
South Carolina (Medicaid) https://www.scdhhs.gov 1-888-549-0820
South Dakota (Medicaid) http://dss.sd.gov 1-888-828-0059
Texas (Medicaid) http://gethipptexas.com/ 1-800-440-0493
Utah (Medicaid and CHIP) Medicaid: https://medicaid.utah.gov/
CHIP: http://health.utah.gov/chip
1-877-543-7669
Vermont (Medicaid) http://www.greenmountaincare.org/ 1-800-250-8427
Virginia (Medicaid and CHIP) Medicaid: http://www.coverva.org/programs_premium_assistance.cfm
CHIP: http://www.coverva.org/programs_premium_assistance.cfm
Medicaid: 1-800-432-5924
CHIP: 1-855-242-8282
Washington (Medicaid) http://www.hca.wa.gov/ 1-800-562-3022, Ext. 15473
West Virginia (Medicaid) http://mywvhipp.com/ 1-855-699-8447
Wisconsin (Medicaid and CHIP) https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf 1-800-362-3002
Wyoming (Medicaid) http://wyequalitycare.acs-inc.com/ 307-777-7531
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Health Insurance Marketplace Coverage Options and Your Health Coverage
Part A: General Information
Since key parts of the health care law took effect in 2014, there is another way to buy health insurance: the Health
Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic
information about the Marketplace and employment-based health coverage offered by your employer.
What is the Health Insurance Marketplace?
The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The
Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be
eligible for a tax credit that lowers your monthly premium right away. Typically, you can enroll in a Marketplace
health plan during the Marketplace’s annual Open Enrollment period or if you experience a qualifying life event.
Can I Save Money on my Health Insurance Premiums in the Marketplace?
You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage,
or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends
on your household income.
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible
for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be
eligible for a tax credit that lowers your monthly premium or a reduction in certain cost-sharing if your employer does
not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from
your employer that would cover you (and not any other members of your family) is more than 9.5% of your
household income for the year, or if the coverage your employer provides does not meet the "minimum value"
standard set by the Affordable Care Act, you may be eligible for a tax credit.
Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your
employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this
employer contribution — as well as your employee contribution to employer-offered coverage — is often excluded
from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are
made on an after-tax basis.
How Can I Get More Information?
For more information about your coverage offered by your employer, please check your summary plan description or
contact Human Resources.
The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the
Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health
insurance coverage and contact information for a Health Insurance Marketplace in your area.
PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an
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application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application.
Here is some basic information about health coverage offered by this employer:
• As your employer, we offer a health plan to some employees.
Eligible employees are:
• All fulltime employees working 30 or more hours per week
• With respect to dependents, we do offer coverage.
Eligible dependents are:
• Legally married spouse
• Dependent children to age 26, this includes (adopted, legal guardianship, court ordered, and child dependents who cannot support themselves due to physical or mental handicap).
If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages.
**Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount.
3. Employer name Harcros Chemicals Inc.
4. Employer Identification Number (EIN) 43-1935062
5. Employer address 5200 Speaker Road
6. Employer phone number 913-321-3131
7. City Kansas City
8. State KS
9. ZIP code 66106
10. Who can we contact about employee health coverage at this job? Dana Palermo
11. Phone number (if different from above)
12. E-mail address [email protected]
X
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Harcros Chemicals Inc. Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.
Our Company’s Pledge to You This notice is intended to inform you of the privacy practices followed by Harcros Chemicals Inc. and the Plan’s legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The notice also explains the privacy rights you and your family members have as participants of the Plan. It is effective on January 1, 2020.
The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions. We want to assure the participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy. Harcros Chemicals Inc. requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined below.
Protected Health Information Your protected health information is protected by the HIPAA Privacy Rule. Generally, protected health information is information that identifies an individual created or received by a health care provider, health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions, provision of health care, or payment for health care, whether past, present or future.
How We May Use Your Protected Health Information Under the HIPAA Privacy Rule, we may use or disclose your protected health information for certain purposes without your permission. This section describes the ways we can use and disclose your protected health information.
Payment. We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits, seek reimbursement from a third party, or coordinate benefits with another health plan under which you are covered. For example, a health care provider that provided treatment to you will provide us with your health information. We use that information in order to determine whether those services are eligible for payment under our group health plan.
Health Care Operations. We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities, resolution of internal grievances, and evaluating plan performance. For example, we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs.
However, we are prohibited from using or disclosing protected health information that is genetic information for our underwriting purposes.
Treatment. Although the law allows use and disclosure of your protected health information for purposes of treatment, as a health plan we generally do not need to disclose your information for treatment purposes. Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment, payment, and health care operations.
As permitted or Required by Law. We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law. We are permitted by law to share information, subject to certain requirements, in order to communicate information on health-related benefits or services that may be of interest to you, respond to a court order, or provide information to further public health activities (e.g., preventing the spread of disease) without your written authorization. We are also permitted to share protected health information during a corporate restructuring such as a merger, sale, or acquisition. We will also disclose health information about you when required by law, for example, in order to prevent serious harm to you or others.
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Pursuant to Your Authorization. When required by law, we will ask for your written authorization before using or disclosing your protected health information. Uses and disclosures not described in this notice will only be made with your written authorization. Subject to some limited exceptions, your written authorization is required for the sale of protected health information and for the use or disclosure of protected health information for marketing purposes. If you choose to sign an authorization to disclose information, you can later revoke that authorization to prevent any future uses or disclosures.
To Business Associates. We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan. We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information. For example, we may disclose your protected health information to a Business Associate to administer claims. Business Associates are also required by law to protect protected health information.
To the Plan Sponsor. We may disclose protected health information to certain employees of Harcros Chemicals Inc. for the purpose of administering the Plan. These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA, unless you have authorized additional disclosures. Your protected health information cannot be used for employment purposes without your specific authorization.
Your Rights
Right to Inspect and Copy. In most cases, you have the right to inspect and copy the protected health information we maintain about you. If you request copies, we will charge you a reasonable fee to cover the costs of copying, mailing, or other expenses associated with your request. Your request to inspect or review your health information must be submitted in writing to the person listed below. In some circumstances, we may deny your request to inspect and copy your health information. To the extent your information is held in an electronic health record, you may be able to receive the information in an electronic format.
Right to Amend. If you believe that information within your records is incorrect or if important information is missing, you have the right to request that we correct the existing information or add the missing information. Your request to amend your health information must be submitted in writing to the person listed below. In some circumstances, we may deny your request to amend your health information. If we deny your request, you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information.
Right to an Accounting of Disclosures. You have the right to receive an accounting of certain disclosures of your protected health information. The accounting will not include disclosures that were made (1) for purposes of treatment, payment or health care operations; (2) to you; (3) pursuant to your authorization; (4) to your friends or family in your presence or because of an emergency; (5) for national security purposes; or (6) incidental to otherwise permissible disclosures.
Your request for an accounting must be submitted in writing to the person listed below. You may request an accounting of disclosures made within the last six years. You may request one accounting free of charge within a 12-month period.
Right to Request Restrictions. You have the right to request that we not use or disclose information for treatment, payment, or other administrative purposes except when specifically authorized by you, when required by law, or in emergency circumstances. You also have the right to request that we limit the protected health information that we disclose to someone involved in your care or the payment for your care, such as a family member or friend. Your request for restrictions must be submitted in writing to the person listed below. We will consider your request, but in most cases are not legally obligated to agree to those restrictions.
Right to Request Confidential Communications. You have the right to receive confidential communications containing your health information. Your request for restrictions must be submitted in writing to the person listed below. We are required to accommodate reasonable requests. For example, you may ask that we contact you at your place of employment or send communications regarding treatment to an alternate address.
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Right to be Notified of a Breach. You have the right to be notified in the event that we (or one of our Business Associates) discover a breach of your unsecured protected health information. Notice of any such breach will be made in accordance with federal requirements.
Right to Receive a Paper Copy of this Notice. If you have agreed to accept this notice electronically, you also have a right to obtain a paper copy of this notice from us upon request. To obtain a paper copy of this notice, please contact the person listed below.
Our Legal Responsibilities We are required by law to maintain the privacy of your protected health information, provide you with this notice about our legal duties and privacy practices with respect to protected health information and notify affected individuals following a breach of unsecured protected health information.
We may change our policies at any time and reserve the right to make the change effective for all protective health information that we maintain. In the event that we make a significant change in our policies, we will provide you with a revised copy of this notice. You can also request a copy of our notice at any time. For more information about our privacy practices, contact the person listed below.
If you have any questions or complaints, please contact:
Harcros Chemicals Inc. 5200 Speaker Road, Kansas City, KS 66106 913-321-3131
Complaints If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the person listed above. You also may send a written complaint to the U.S. Department of Health and Human Services — Office of Civil Rights. The person listed above can provide you with the appropriate address upon request or you may visit www.hhs.gov/ocr for further information. You will not be penalized or retaliated against for filing a complaint with the Office of Civil Rights or with us.
NEWBORN & MOTHERS HEALTH PROTECTION NOTICE For maternity hospital stays, in accordance with federal law, the Plan does not restrict benefits, for any hospital length of stay in connection 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 delivery. However, federal law generally does not prevent the mother’s or newborn’s attending care provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours, as applicable). The plan cannot require a provider to prescribe a length of stay any shorter than 48 hours (or 96 hours following a Cesarean delivery).
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Important Notice from Harcros Chemicals Inc. About Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Harcros Chemicals Inc. and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this
coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO)
that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by
Medicare. Some plans may also offer more coverage for a higher monthly premium.
Navitus has determined that the prescription drug coverage offered by the Harcros Chemicals Inc. plans are, on
average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage
pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you
can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current plan will not be affected. If you do decide to join a Medicare drug plan and drop your current plan coverage, be aware that you and your dependents may not be able to get this coverage back until next open enrollment.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.
For More Information About This Notice Or Your Current Prescription Drug Coverage…
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Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Harcros Chemicals Inc. changes. You also may request a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.
For more information about Medicare Prescription drug coverage:
• Visit www.medicare.gov.
• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of “Medicare & You”
handbook for their telephone number) for personalized help • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this creditable coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).
January 1, 2020
Harcros Chemicals Inc. 5200 Speaker Road, Kansas City, KS 66106 913-321-3131
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COBRA Rights Notice
You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage.
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.
You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.
What Is COBRA Continuation Coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.
If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:
• Your hours of employment are reduced; or • Your employment ends for any reason other than your gross misconduct.
If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:
• Your spouse dies; • Your spouse’s hours of employment are reduced; • Your spouse’s employment ends for any reason other than his or her gross misconduct; • Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events:
• The parent-employee dies; • The parent-employee’s hours of employment are reduced; • The parent-employee’s employment ends for any reason other than his or her gross misconduct; • The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a “dependent child.”
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Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to Harcros Chemicals Inc., and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.
When Is COBRA Coverage Available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events:
• The end of employment or reduction of hours of employment; • Death of the employee; • Commencement of a proceeding in bankruptcy with respect to the employer • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).
For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing
eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the
qualifying event occurs.
How Is COBRA Continuation Coverage Provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.
COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.
There are also ways in which this 18-month period of COBRA continuation coverage can be extended:
Disability Extension of 18-Month Period of Continuation Coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage.
Second Qualifying Event Extension of 18-Month Period of Continuation Coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.
Are There Other Coverage Options Besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s
33
plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.
If You Have Questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov.
Keep Your Plan Informed of Address Changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.
Plan Contact Information January 1, 2020
Harcros Chemicals Inc. 5200 Speaker Road, Kansas City, KS 66106 913-321-3131
34
Women’s Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy, you may be entitled 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 consultations with the attending physician and the patient, for:
• All states of reconstruction of the breast on which the mastectomy was performed • Surgery and reconstruction of the other breast to produce a symmetrical appearance • Prostheses • Treatment of physical complications of the mastectomy, including lymphedema
These benefits will be provided subject to the same deductibles, copays and coinsurance applicable to other medical and surgical benefits provided under your medical plan. For more information on WHCRA benefits, contact your medical plan administrator.
January 1, 2020
Harcros Chemicals Inc. 5200 Speaker Road, Kansas City, KS 66106 913-321-3131
Expanded Coverage for Women’s Preventive Care Under the Affordable Care Act, Harcros Chemicals Inc. provides female plan participants with expanded access to
recommended in-network preventive services, including contraceptives, without cost sharing.
Additional women’s preventive services that will be covered without cost sharing requirements include:
• Well-woman visits
• Gestational diabetes screening
• HPV DNA testing
• STI counseling, and HIV screening and counseling
• Contraception and contraceptive counseling
• Breastfeeding support, supplies, and counseling
• Domestic violence screening
For a description of what these items include, visit https://www.healthcare.gov/preventive-care-women/.
.
35
HIPAA Notice of Special Enrollment Rights
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires group health plans to provide a special enrollment opportunity to an employee (or COBRA enrollee) upon the occurrence of specific events. This Chart summarizes the qualifying events and the corresponding special enrollment rights. This notice is being provided to insure that you understand your right to apply for the Harcros Chemicals Inc. Group Health Care Plan. You should read this notice even if you plan to waive coverage at this time.
EVENT SPECIAL ENROLLMENT RIGHT
Acquisition of New Dependent(s) due to Marriage • Employee may enroll the employee (if not previously
enrolled).
• Employee may also enroll newly-eligible spouse and/or newly-eligible stepchild(ren).
Acquisition of New Child due to birth or adoption (including placement for adoption)
• Employee may enroll the employee (if not previously enrolled).
• Employee may also enroll spouse and/or newly-eligible child(ren).
Gain Eligibility for Premium Assistance Subsidy under Medicaid or CHIP
• Employee may enroll the employee and the spouse or child(ren) who have become eligible for the premium assistance.
Loss of Other Health Coverage if due to:
• Loss of eligibility. o Death of spouse; divorce, legal separation o Child loses status (e.g. reaches age limit) o Employment change (e.g. termination, reduction in
hours, unpaid FMLA)
• Expiration of COBRA maximum period
• Moving out of HMO plan’s service area
• Other employer terminates its plan (or discontinues employer contributions)
• Employee may enroll the employee (if not previously enrolled).
• Employee may also enroll spouse and/or children who have lost other health coverage.
Note: Person losing the Other Health Coverage must have had the other coverage since the date of this employer plan’s most recent enrollment opportunity.
Loss of Medicaid or CHIP coverage • Employee may enroll the employee and the spouse or
child(ren) who have lost Medicaid/CHIP entitlement.
Notes:
1. HIPAA Special Enrollees must be given 31 days (from the date of the event) to enroll.
2. For events related to Medicaid/CHIP, the special enrollment period is 60 days.
3. Special enrollment, if elected, must take effect no later than the first day of the month following the enrollment request. If the event is the birth or adoption of a child, the special enrollment must take effect retroactively on the date of birth or adoption (or placement for adoption).
To request special enrollment or obtain more information, please contact:
Harcros Chemicals Inc. 5200 Speaker Road, Kansas City, KS 66106 913-321-3131
36
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e: W
hat t
his
Pla
n C
over
s &
Wha
t Y
ou P
ay F
or C
over
ed S
ervi
ces
C
ove
rag
e P
erio
d:
01/0
1/20
20 –
12/
31/2
020
UM
R:
HA
RC
RO
S C
HE
MIC
AL
S IN
C.:
767
0-0
0-41
3652
001
C
ove
rag
e fo
r: In
divi
dual
+ F
amily
| P
lan
Typ
e: P
PO
Pag
e 1
of
7
Th
e S
um
mar
y o
f B
enef
its
and
Co
vera
ge
(SB
C)
do
cum
ent
will
hel
p y
ou
ch
oo
se a
hea
lth
pla
n. T
he
SB
C s
ho
ws
you
ho
w y
ou
an
d t
he
pla
n w
ou
ld
shar
e th
e co
st f
or
cove
red
hea
lth
car
e se
rvic
es. N
OT
E:
Info
rmat
ion
ab
ou
t th
e co
st o
f th
is p
lan
(ca
lled
th
e p
rem
ium
) w
ill b
e p
rovi
ded
sep
arat
ely.
T
his
is o
nly
a s
um
mar
y. F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge, o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e, v
isit
ww
w.u
mr.
com
or
by c
allin
g 1-
800-
826-
9781
. For
gen
eral
def
initi
ons
of c
omm
on te
rms,
suc
h as
allo
wed
am
ount
, bal
ance
bill
ing,
coi
nsur
ance
, cop
aym
ent,
dedu
ctib
le, p
rovi
der,
or
othe
r un
derli
ned
term
s se
e th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at w
ww
.um
r.co
m o
r ca
ll 1-
800-
826-
9781
to r
eque
st a
cop
y.
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y th
is M
atte
rs:
Wh
at is
th
e o
vera
ll d
edu
ctib
le?
$8
00 p
erso
n / $
2,40
0 fa
mily
In-n
etw
ork
$7,5
00 p
erso
n / $
15,0
00 fa
mily
Out
-of-
netw
ork
Gen
eral
ly, y
ou m
ust p
ay a
ll th
e co
sts
from
pro
vide
rs u
p to
the
dedu
ctib
le a
mou
nt
befo
re th
is p
lan
begi
ns to
pay
. If y
ou h
ave
othe
r fa
mily
mem
bers
on
the
plan
, eac
h fa
mily
mem
ber
mus
t mee
t the
ir ow
n in
divi
dual
ded
uctib
le u
ntil
the
tota
l am
ount
of
dedu
ctib
le e
xpen
ses
paid
by
all f
amily
mem
bers
mee
ts th
e ov
eral
l fam
ily
dedu
ctib
le.
Are
th
ere
serv
ices
co
vere
d b
efo
re y
ou
mee
t yo
ur
ded
uct
ible
?
Yes
. Pre
vent
ive
care
ser
vice
s ar
e co
vere
d be
fore
you
mee
t you
r de
duct
ible
.
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven’
t yet
met
the
dedu
ctib
le a
mou
nt. B
ut a
cop
aym
ent o
r co
insu
ranc
e m
ay a
pply
. For
exa
mpl
e, th
is
plan
cov
ers
cert
ain
prev
entiv
e se
rvic
es w
ithou
t cos
t-sh
arin
g an
d be
fore
you
mee
t yo
ur d
educ
tible
. See
a li
st o
f cov
ered
pre
vent
ive
serv
ices
at
http
s://w
ww
.hea
lthca
re.g
ov/c
over
age/
prev
entiv
e-c
are-
bene
fits/
Are
th
ere
oth
er
ded
uct
ible
s fo
r sp
ecif
ic
serv
ices
?
No.
Y
ou d
on’t
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es.
Wh
at is
th
e o
ut–
of–
po
cket
lim
it f
or
this
pla
n?
$2
,200
per
son
/ $4,
400
fam
ily In
-net
wor
k $1
5,00
0 pe
rson
/ $3
0,00
0 fa
mily
Out
-of-
netw
ork
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es.
If
you
have
oth
er fa
mily
mem
bers
in th
is p
lan,
they
hav
e to
mee
t the
ir ow
n ou
t-of
-po
cket
lim
its u
ntil
the
over
all f
amily
out
-of-
pock
et li
mit
has
been
met
.
Wh
at is
no
t in
clu
ded
in
the
ou
t–o
f–p
ock
et li
mit
?
Cop
aym
ents
for
cert
ain
serv
ices
, pen
altie
s,
prem
ium
s, b
alan
ce b
illin
g ch
arge
s, a
nd h
ealth
ca
re th
is p
lan
does
n’t c
over
.
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
don’
t cou
nt to
war
d th
e ou
t-of
-poc
ket
limit.
Will
yo
u p
ay le
ss if
yo
u
use
a n
etw
ork
pro
vid
er?
Y
es. S
ee w
ww
.um
r.co
m o
r ca
ll 1-
800-
826-
9781
fo
r a
list o
f net
wor
k pr
ovid
ers.
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork.
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
’s n
etw
ork.
You
will
pay
the
mos
t if y
ou u
se a
n ou
t-of
-net
wor
k pr
ovid
er, a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
er’s
ch
arge
and
wha
t you
r pl
an p
ays
(a b
alan
ce b
illin
g). B
e aw
are,
you
r ne
twor
k pr
ovid
er m
ight
use
an
out-
of-n
etw
ork
prov
ider
for
som
e se
rvic
es (
such
as
lab
wor
k). C
heck
with
you
r pr
ovid
er b
efor
e yo
u ge
t ser
vice
s.
Do
yo
u n
eed
a r
efer
ral t
o
see
a sp
ecia
list?
N
o.
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l.
37
P
age
2 o
f 7
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et, i
f a d
educ
tible
app
lies.
Co
mm
on
M
edic
al E
ven
t S
ervi
ces
Yo
u M
ay N
eed
Wh
at Y
ou
Will
Pay
L
imit
atio
ns,
Exc
epti
on
s, &
Oth
er
Imp
ort
ant
Info
rmat
ion
In
-net
wo
rk
(Yo
u w
ill p
ay t
he
leas
t)
Ou
t-o
f-n
etw
ork
(Y
ou
will
pay
th
e m
ost
)
If y
ou
vis
it a
h
ealt
h c
are
pro
vid
er’s
o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
trea
t an
inju
ry
or il
lnes
s 20
% C
oins
uran
ce
40%
Coi
nsur
ance
N
one
Spe
cial
ist v
isit
20%
Coi
nsur
ance
40
% C
oins
uran
ce
Non
e
Pre
vent
ive
care
/scr
eeni
ng/
imm
uniz
atio
n N
o ch
arge
; D
educ
tible
Wai
ved
No
char
ge;
Ded
uctib
le W
aive
d
You
may
hav
e to
pay
for
serv
ices
that
ar
en't
prev
entiv
e. A
sk y
our
prov
ider
if
the
serv
ices
you
nee
d ar
e pr
even
tive.
T
hen
chec
k w
hat y
our
plan
will
pay
fo
r.
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y, b
lood
wor
k)
20%
Coi
nsur
ance
40
% C
oins
uran
ce
Non
e
Imag
ing
(CT
/PE
T s
cans
, MR
Is)
20
% C
oins
uran
ce
40%
Coi
nsur
ance
N
one
38
P
age
3 o
f 7
Co
mm
on
M
edic
al E
ven
t S
ervi
ces
Yo
u M
ay N
eed
Wh
at Y
ou
Will
Pay
L
imit
atio
ns,
Exc
epti
on
s, &
Oth
er
Imp
ort
ant
Info
rmat
ion
In
-net
wo
rk
(Yo
u w
ill p
ay t
he
leas
t)
Ou
t-o
f-n
etw
ork
(Y
ou
will
pay
th
e m
ost
)
If y
ou
nee
d
dru
gs
to t
reat
yo
ur
illn
ess
or
con
dit
ion
. M
ore
info
rmat
ion
abou
t pr
escr
iptio
n dr
ug c
over
age
is a
vaila
ble
at
ww
w.n
avitu
s.co
m
Gen
eric
dru
gs (
Tie
r 1)
30
Day
Sup
ply:
$10
90
Day
Sup
ply:
$30
N
ot C
over
ed
Effe
ctiv
e Ja
nuar
y 1,
202
0, W
algr
eens
ph
arm
acie
s ar
e no
long
er a
n in
-ne
twor
k ph
arm
acy.
If y
ou h
ave
ques
tions
, abo
ut a
ltern
ativ
e ph
arm
acie
s, p
leas
e co
ntac
t Nav
itus
at
866-
333-
2757
.
Pre
ferr
ed b
rand
dru
gs (
Tie
r 2)
30
Day
Sup
ply:
$50
90
Day
Sup
ply:
$15
0 N
ot C
over
ed
Non
-pre
ferr
ed b
rand
dru
gs (
Tie
r 3)
30
Day
Sup
ply:
$75
90
Day
Sup
ply:
$22
5 N
ot C
over
ed
Spe
cial
ty d
rugs
(T
ier
4)
30 D
ay S
uppl
y: 2
0%, $
100
min
imum
, $20
0 m
axim
um
90 D
ay S
uppl
y: N
/A
Not
Cov
ered
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(e
.g.,
ambu
lato
ry s
urge
ry c
ente
r)
20%
Coi
nsur
ance
40
% C
oins
uran
ce
Pre
auth
oriz
atio
n is
req
uire
d. If
you
do
n’t g
et p
reau
thor
izat
ion,
ben
efits
co
uld
be r
educ
ed b
y $5
00 o
f the
tota
l co
st o
f the
ser
vice
Out
-of-
netw
ork.
Phy
sici
an/s
urge
on fe
es
20%
Coi
nsur
ance
40
% C
oins
uran
ce
Non
e
If y
ou
nee
d
imm
edia
te
med
ical
at
ten
tio
n
Em
erge
ncy
room
car
e 20
% C
oins
uran
ce
20%
Coi
nsur
ance
In
-net
wor
k de
duct
ible
app
lies
to
Out
-of-
netw
ork
bene
fits
Em
erge
ncy
med
ical
tran
spor
tatio
n 20
% C
oins
uran
ce
20%
Coi
nsur
ance
In
-net
wor
k de
duct
ible
app
lies
to
Out
-of-
netw
ork
bene
fits
Urg
ent c
are
20%
Coi
nsur
ance
40
% C
oins
uran
ce
Non
e
39
P
age
4 o
f 7
Co
mm
on
M
edic
al E
ven
t S
ervi
ces
Yo
u M
ay N
eed
Wh
at Y
ou
Will
Pay
L
imit
atio
ns,
Exc
epti
on
s, &
Oth
er
Imp
ort
ant
Info
rmat
ion
In
-net
wo
rk
(Yo
u w
ill p
ay t
he
leas
t)
Ou
t-o
f-n
etw
ork
(Y
ou
will
pay
th
e m
ost
)
If y
ou
hav
e a
ho
spit
al s
tay
Fac
ility
fee
(e.g
., ho
spita
l roo
m)
20%
Coi
nsur
ance
40
% C
oins
uran
ce
Pre
auth
oriz
atio
n is
req
uire
d. If
you
do
n’t g
et p
reau
thor
izat
ion,
ben
efits
co
uld
be r
educ
ed b
y $5
00 o
f the
tota
l co
st o
f the
ser
vice
Out
-of-
netw
ork.
Phy
sici
an/s
urge
on fe
e 20
% C
oins
uran
ce
40%
Coi
nsur
ance
N
one
If y
ou
hav
e m
enta
l hea
lth
, b
ehav
iora
l h
ealt
h, o
r su
bst
ance
ab
use
nee
ds
Out
patie
nt s
ervi
ces
20%
Coi
nsur
ance
40
% C
oins
uran
ce
Pre
auth
oriz
atio
n is
req
uire
d. If
you
do
n’t g
et p
reau
thor
izat
ion,
ben
efits
co
uld
be r
educ
ed b
y $5
00 o
f the
tota
l co
st o
f the
ser
vice
for
Par
tial
hosp
italiz
atio
n O
ut-o
f-ne
twor
k.
Inpa
tient
ser
vice
s 20
% C
oins
uran
ce
40%
Coi
nsur
ance
Pre
auth
oriz
atio
n is
req
uire
d. If
you
do
n’t g
et p
reau
thor
izat
ion,
ben
efits
co
uld
be r
educ
ed b
y $5
00 o
f the
tota
l co
st o
f the
ser
vice
Out
-of-
netw
ork.
If y
ou
are
p
reg
nan
t
Offi
ce v
isits
N
o ch
arge
; D
educ
tible
Wai
ved
No
char
ge;
Ded
uctib
le W
aive
d C
ost s
harin
g do
es n
ot a
pply
to c
erta
in
prev
entiv
e se
rvic
es. D
epen
ding
on
the
type
of s
ervi
ces,
ded
uctib
le,
copa
ymen
t or
coin
sura
nce
may
app
ly.
Mat
erni
ty c
are
may
incl
ude
test
s an
d se
rvic
es d
escr
ibed
els
ewhe
re in
the
SB
C (
i.e. u
ltras
ound
).
Chi
ldbi
rth/
deliv
ery
prof
essi
onal
se
rvic
es
20%
Coi
nsur
ance
40
% C
oins
uran
ce
Chi
ldbi
rth/
deliv
ery
faci
lity
serv
ices
20
% C
oins
uran
ce
40%
Coi
nsur
ance
40
P
age
5 o
f 7
Co
mm
on
M
edic
al E
ven
t S
ervi
ces
Yo
u M
ay N
eed
Wh
at Y
ou
Will
Pay
L
imit
atio
ns,
Exc
epti
on
s, &
Oth
er
Imp
ort
ant
Info
rmat
ion
In
-net
wo
rk
(Yo
u w
ill p
ay t
he
leas
t)
Ou
t-o
f-n
etw
ork
(Y
ou
will
pay
th
e m
ost
)
If y
ou
nee
d
hel
p
reco
veri
ng
or
hav
e o
ther
sp
ecia
l hea
lth
n
eed
s
Hom
e he
alth
car
e 20
% C
oins
uran
ce
40%
Coi
nsur
ance
100
Max
imum
vis
its p
er c
alen
dar
yea
r;
Pre
auth
oriz
atio
n is
req
uire
d. If
you
do
n’t g
et p
reau
thor
izat
ion,
ben
efits
co
uld
be r
educ
ed b
y $5
00 o
f the
tota
l co
st o
f the
ser
vice
Out
-of-
netw
ork.
Reh
abili
tatio
n se
rvic
es
20%
Coi
nsur
ance
40
% C
oins
uran
ce
Non
e
Hab
ilita
tion
serv
ices
N
ot c
over
ed
Not
cov
ered
N
one
Ski
lled
nurs
ing
care
20
% C
oins
uran
ce
40%
Coi
nsur
ance
100
Max
imum
day
s pe
r ca
lend
ar y
ear;
P
reau
thor
izat
ion
is r
equi
red.
If y
ou
don’
t get
pre
auth
oriz
atio
n, b
enef
its
coul
d be
red
uced
by
$500
of t
he to
tal
cost
of t
he s
ervi
ce O
ut-o
f-ne
twor
k.
Dur
able
med
ical
equ
ipm
ent
20%
Coi
nsur
ance
40
% C
oins
uran
ce
Pre
auth
oriz
atio
n is
req
uire
d fo
r D
ME
in
exc
ess
of $
500
for
rent
als
or $
1,50
0 fo
r pu
rcha
ses.
If y
ou d
on’t
get
prea
utho
rizat
ion,
ben
efits
cou
ld b
e re
duce
d by
$50
0 pe
r oc
curr
ence
O
ut-o
f-ne
twor
k.
Hos
pice
ser
vice
20
% C
oins
uran
ce
40%
Coi
nsur
ance
N
one
If y
ou
r ch
ild
nee
ds
den
tal
or
eye
care
Chi
ldre
n’s
eye
exam
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
n’s
glas
ses
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
n’s
dent
al c
heck
-up
Not
cov
ered
N
ot c
over
ed
Non
e
41
P
age
6 o
f 7
Exc
lud
ed S
ervi
ces
& O
ther
Co
vere
d S
ervi
ces:
Ser
vice
s Y
ou
r P
lan
Do
es N
OT
Co
ver
(Ch
eck
you
r p
olic
y o
r p
lan
do
cum
ent
for
mo
re in
form
atio
n a
nd
a li
st o
f an
y o
ther
exc
lud
ed s
ervi
ces.
)
•
Acu
punc
ture
•
Infe
rtili
ty tr
eatm
ent
•
Rou
tine
eye
care
(A
dult)
•
Cos
met
ic s
urge
ry
•
Long
-ter
m c
are
•
Rou
tine
foot
car
e
•
Den
tal c
are
(Adu
lt)
•
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
U.S
. •
Wei
ght l
oss
prog
ram
s O
ther
Co
vere
d S
ervi
ces
(Lim
itat
ion
s m
ay a
pp
ly t
o t
hes
e se
rvic
es. T
his
isn
’t a
co
mp
lete
list
. Ple
ase
see
you
r p
lan
do
cum
ent.
)
•
Bar
iatr
ic s
urge
ry
•
Hea
ring
aids
•
Priv
ate-
duty
nur
sing
(O
utpa
tient
car
e)
•
Chi
ropr
actic
car
e
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e: T
here
are
age
ncie
s th
at c
an h
elp
if yo
u w
ant t
o co
ntin
ue y
our
cove
rage
afte
r it
ends
. The
con
tact
info
rmat
ion
for
thos
e ag
enci
es is
: U.S
. Dep
artm
ent o
f Lab
or's
Em
ploy
ee B
enef
its S
ecu
rity
Adm
inis
trat
ion
at 1
-866
-444
-EB
SA
(32
72)
or w
ww
.Hea
lthC
are.
gov.
Oth
er c
over
age
optio
ns m
ay
be a
vaila
ble
to y
ou to
o, in
clud
ing
buyi
ng in
divi
dual
insu
ranc
e co
vera
ge th
roug
h th
e H
ealth
Insu
ranc
e M
arke
tpla
ce. F
or m
ore
info
rmat
ion
abou
t the
Mar
ketp
lace
, vis
it w
ww
.Hea
lthC
are.
gov
or c
all 1
-800
-318
-259
6.
Yo
ur
Gri
evan
ce a
nd
Ap
pea
ls R
igh
ts:
The
re a
re a
genc
ies
that
can
hel
p if
you
have
a c
ompl
aint
aga
inst
you
r pl
an fo
r a
deni
al o
f a c
laim
. Thi
s co
mpl
aint
is c
alle
d a
grie
vanc
e or
app
eal.
For
mor
e in
form
atio
n ab
out y
our
right
s, lo
ok a
t the
exp
lana
tion
of b
enef
its y
ou w
ill r
ecei
ve fo
r th
at m
edic
al c
laim
. You
r pl
an d
ocum
ents
als
o pr
ovid
e co
mpl
ete
info
rmat
ion
to s
ubm
it a
clai
m, a
ppea
l or
a gr
ieva
nce
for
any
reas
on to
you
r pl
an. F
or m
ore
info
rmat
ion
abou
t you
r rig
hts,
this
not
ice,
or
assi
stan
ce,
cont
act:
U.S
. Dep
artm
ent o
f Lab
or's
Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istr
atio
n at
1-8
66-4
44-E
BS
A (
3272
) or
ww
w.H
ealth
Car
e.go
v. A
dditi
onal
ly, a
con
sum
er
assi
stan
ce p
rogr
am m
ay h
elp
you
file
your
app
eal.
A li
st o
f sta
tes
with
Con
sum
er A
ssis
tanc
e P
rogr
ams
is a
vaila
ble
at w
ww
.Hea
lthC
are.
gov
and
http
://cc
iio.c
ms.
gov/
prog
ram
s/co
nsum
er/c
apgr
ants
/inde
x.ht
ml.
Do
es t
his
pla
n P
rovi
de
Min
imu
m E
ssen
tial
Co
vera
ge?
Yes
If
you
don’
t hav
e M
inim
um E
ssen
tial C
over
age
for
a m
onth
, you
’ll h
ave
to m
ake
a pa
ymen
t whe
n yo
u fil
e yo
ur ta
x re
turn
unl
ess
you
qual
ify fo
r an
exe
mpt
ion
from
the
requ
irem
ent t
hat y
ou h
ave
heal
th c
over
age
for
that
mon
th.
Do
es t
his
pla
n M
eet
the
Min
imu
m V
alu
e S
tan
dar
d?
Yes
If
your
pla
n do
esn’
t mee
t the
Min
imum
Val
ue S
tand
ards
, you
may
be
elig
ible
for
a pr
emiu
m ta
x cr
edit
to h
elp
you
pay
for
a pl
an th
roug
h th
e M
arke
tpla
ce.
––––––––––––––––––––––
To
see
exam
ples
of ho
w thi
s pl
an m
ight
cov
er c
osts
for
a s
ampl
e m
edical
situa
tion
, se
e th
e ne
xt pa
ge.––––––––––––––––––––––
42
T
he p
lan
wou
ld b
e re
spon
sibl
e fo
r th
e ot
her
cost
s of
thes
e E
XA
MP
LE c
over
ed s
ervi
ces.
P
age
7 o
f 7
Man
agin
g J
oe’
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
’s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w u
p ca
re)
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les:
◼
Th
e p
lan
's o
vera
ll d
edu
ctib
le
$800
◼
Sp
ecia
list
coin
sura
nce
20
%
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
20
%
◼ O
ther
co
insu
ran
ce
20%
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e:
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth/
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth/
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12,
800
In t
his
exa
mp
le, P
eg w
ou
ld p
ay:
Cos
t Sha
ring
Ded
uctib
les
$800
Cop
aym
ents
$0
Coi
nsur
ance
$1
,400
Wha
t isn
’t co
vere
d
Lim
its o
r ex
clus
ions
$1
00
Th
e to
tal P
eg w
ou
ld p
ay is
$2
,300
◼ T
he
pla
n's
ove
rall
ded
uct
ible
$8
00
◼ S
pec
ialis
t co
insu
ran
ce
20%
◼
Ho
spit
al (
faci
lity)
co
insu
ran
ce
20%
◼
Oth
er c
oin
sura
nce
20
%
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like:
P
rimar
y ca
re p
hysi
cian
offi
ce v
isits
(in
clud
ing
dise
ase
educ
atio
n)
Dia
gnos
tic te
sts
(blo
od w
ork)
P
resc
riptio
n dr
ugs
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
To
tal E
xam
ple
Co
st
$7,4
00
In t
his
exa
mp
le, J
oe
wo
uld
pay
:
Cos
t Sha
ring
Ded
uctib
les*
$8
00
Cop
aym
ents
$0
Coi
nsur
ance
$8
0
Wha
t isn
’t co
vere
d
Lim
its o
r ex
clus
ions
$6
,000
Th
e to
tal J
oe
wo
uld
pay
is
$6,8
80
◼ T
he
pla
n's
ove
rall
ded
uct
ible
$8
00
◼ S
pec
ialis
t co
insu
ran
ce
20%
◼
Ho
spit
al (
faci
lity)
co
insu
ran
ce
20%
◼
Oth
er c
oin
sura
nce
20
%
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like:
E
mer
genc
y ro
om c
are
(incl
udin
g m
edic
al s
uppl
ies)
D
iagn
ostic
test
s (x
-ray
) D
urab
le m
edic
al e
quip
men
t (cr
utch
es)
Reh
abili
tatio
n se
rvic
es (
phys
ical
ther
apy)
To
tal E
xam
ple
Co
st
$1,9
00
In t
his
exa
mp
le, M
ia w
ou
ld p
ay:
Cos
t Sha
ring
Ded
uctib
les*
$8
00
Cop
aym
ents
$0
Coi
nsur
ance
$2
00
Wha
t isn
’t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal M
ia w
ou
ld p
ay is
$1
,000
Th
is is
no
t a
cost
est
imat
or.
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are.
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive,
the
pric
es y
our
prov
ider
s ch
arge
, and
man
y ot
her
fact
ors.
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s, c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
. Use
this
info
rmat
ion
to c
ompa
re th
e p
ortio
n of
co
sts
you
mig
ht p
ay u
nder
diff
eren
t hea
lth p
lans
. Ple
ase
note
thes
e co
vera
ge e
xam
ples
are
bas
ed o
n se
lf-on
ly c
over
age.
Not
e: T
hese
num
bers
ass
ume
the
patie
nt d
oes
not p
artic
ipat
e in
the
plan
’s w
elln
ess
prog
ram
. If y
ou p
artic
ipat
e in
the
plan
’s w
elln
ess
prog
ram
, you
may
be
able
to
redu
ce y
our
cost
s. F
or m
ore
info
rmat
ion
abou
t the
wel
lnes
s pr
ogra
m, p
leas
e co
ntac
t: w
ww
.um
r.co
m o
r ca
ll 1-
800-
826-
9781
. *N
ote:
Thi
s pl
an h
as o
ther
ded
uctib
les
for
spec
ific
serv
ices
incl
uded
in th
is c
over
age
exam
ple.
See
"A
re th
ere
othe
r de
duct
ible
s fo
r sp
ecifi
c se
rvic
es?”
" ro
w a
bove
.
43
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e: W
hat t
his
Pla
n C
over
s &
Wha
t You
Pay
For
Cov
ered
Ser
vice
s
Co
vera
ge
Per
iod
: 01
/01/
2020
– 1
2/31
/202
0
UM
R:
HA
RC
RO
S C
HE
MIC
AL
S IN
C.:
767
0-0
0-41
3652
002
C
ove
rag
e fo
r: In
divi
dual
+ F
amily
| P
lan
Typ
e: H
DH
P
Pag
e 1
of
7
Th
e S
um
mar
y o
f B
enef
its
and
Co
vera
ge
(SB
C)
do
cum
ent
will
hel
p y
ou
ch
oo
se a
hea
lth
pla
n. T
he
SB
C s
ho
ws
you
ho
w y
ou
an
d t
he
pla
n w
ou
ld
shar
e th
e co
st f
or
cove
red
hea
lth
car
e se
rvic
es. N
OT
E:
Info
rmat
ion
ab
ou
t th
e co
st o
f th
is p
lan
(ca
lled
th
e p
rem
ium
) w
ill b
e p
rovi
ded
sep
arat
ely.
T
his
is o
nly
a s
um
mar
y. F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge, o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e, v
isit
ww
w.u
mr.
com
or
by c
allin
g 1-
800-
826-
9781
. For
gen
eral
def
initi
ons
of c
omm
on te
rms,
suc
h as
allo
wed
am
ount
, bal
ance
bill
ing,
coi
nsur
ance
, cop
aym
ent,
dedu
ctib
le, p
rovi
der,
or
othe
r un
derli
ned
term
s se
e th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
at w
ww
.um
r.co
m o
r ca
ll 1-
800-
826-
9781
to r
eque
st a
cop
y.
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y th
is M
atte
rs:
Wh
at is
th
e o
vera
ll d
edu
ctib
le?
$3,0
00 p
erso
n / $
6,00
0 fa
mily
In-n
etw
ork
$7,5
00 p
erso
n / $
15,0
00 fa
mily
Out
-of-
netw
ork
$3,0
00 In
-net
wor
k / $
7,50
0 O
ut-o
f-ne
twor
k M
axim
um a
mou
nt th
at a
ny o
ne p
erso
n w
ill
satis
fy to
war
ds th
e an
nual
fam
ily d
educ
tible
Gen
eral
ly, y
ou m
ust p
ay a
ll th
e co
sts
from
pro
vide
rs u
p to
the
dedu
ctib
le a
mou
nt
befo
re th
is p
lan
begi
ns to
pay
. If y
ou h
ave
othe
r fa
mily
mem
bers
on
the
plan
, eac
h fa
mily
mem
ber
mus
t mee
t the
ir ow
n in
divi
dual
ded
uctib
le u
ntil
the
tota
l am
ount
of
dedu
ctib
le e
xpen
ses
paid
by
all f
amily
mem
bers
mee
ts th
e ov
eral
l fam
ily
dedu
ctib
le.
Are
th
ere
serv
ices
co
vere
d b
efo
re y
ou
mee
t yo
ur
ded
uct
ible
?
Yes
. Pre
vent
ive
care
ser
vice
s ar
e co
vere
d be
fore
you
mee
t you
r de
duct
ible
.
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven’
t yet
met
the
de
duct
ible
am
ount
. But
a c
opay
men
t or
coin
sura
nce
may
app
ly. F
or e
xam
ple,
this
pl
an c
over
s ce
rtai
n pr
even
tive
serv
ices
with
out c
ost-
shar
ing
and
befo
re y
ou m
eet
your
ded
uctib
le. S
ee a
list
of c
over
ed p
reve
ntiv
e se
rvic
es a
t ht
tps:
//ww
w.h
ealth
care
.gov
/cov
erag
e/pr
even
tive
-car
e-be
nefit
s/
Are
th
ere
oth
er
ded
uct
ible
s fo
r sp
ecif
ic
serv
ices
?
No.
Y
ou d
on’t
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es.
Wh
at is
th
e o
ut–
of–
po
cket
lim
it f
or
this
pla
n?
$3,0
00 p
erso
n / $
6,00
0 fa
mily
In-n
etw
ork
$15,
000
pers
on /
$30,
000
fam
ily O
ut-o
f-ne
twor
k $3
,000
In-n
etw
ork
/ $15
,000
Out
-of-
netw
ork
Max
imum
am
ount
that
any
one
per
son
will
sa
tisfy
tow
ards
the
annu
al fa
mily
out
-of-
pock
et
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es.
If yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n, th
ey h
ave
to m
eet t
heir
own
out-
of-
pock
et li
mits
unt
il th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it ha
s be
en m
et.
Wh
at is
no
t in
clu
ded
in
the
ou
t–o
f–p
ock
et li
mit
?
Cop
aym
ents
for
cert
ain
serv
ices
, pen
altie
s,
prem
ium
s, b
alan
ce b
illin
g ch
arge
s, a
nd h
ealth
ca
re th
is p
lan
does
n’t c
over
.
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
don’
t cou
nt to
war
d th
e ou
t-of
-poc
ket
limit.
Will
yo
u p
ay le
ss if
yo
u
use
a n
etw
ork
pro
vid
er?
Y
es. S
ee w
ww
.um
r.co
m o
r ca
ll 1-
800-
826-
9781
fo
r a
list o
f net
wor
k pr
ovid
ers.
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork.
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
’s n
etw
ork.
You
will
pay
the
mos
t if y
ou u
se a
n ou
t-of
-net
wor
k pr
ovid
er, a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
er’s
ch
arge
and
wha
t you
r pl
an p
ays
(a b
alan
ce b
illin
g). B
e aw
are,
you
r ne
twor
k pr
ovid
er m
ight
use
an
out-
of-n
etw
ork
prov
ider
for
som
e se
rvic
es (
such
as
lab
wor
k). C
heck
with
you
r pr
ovid
er b
efor
e yo
u ge
t ser
vice
s.
Do
yo
u n
eed
a r
efer
ral t
o
see
a sp
ecia
list?
N
o.
You
can
see
the
spec
ialis
t you
cho
ose
with
out
a re
ferr
al.
44
P
age
2 o
f 7
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et, i
f a d
educ
tible
app
lies.
Co
mm
on
M
edic
al E
ven
t S
ervi
ces
Yo
u M
ay N
eed
Wh
at Y
ou
Will
Pay
L
imit
atio
ns,
Exc
epti
on
s, &
Oth
er
Imp
ort
ant
Info
rmat
ion
In
-net
wo
rk
(Yo
u w
ill p
ay t
he
leas
t)
Ou
t-o
f-n
etw
ork
(Y
ou
will
pay
th
e m
ost
)
If y
ou
vis
it a
h
ealt
h c
are
pro
vid
er’s
o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
trea
t an
inju
ry
or il
lnes
s N
o ch
arge
40
% C
oins
uran
ce
Non
e
Spe
cial
ist v
isit
No
char
ge
40%
Coi
nsur
ance
N
one
Pre
vent
ive
care
/scr
eeni
ng/
imm
uniz
atio
n N
o ch
arge
; D
educ
tible
Wai
ved
No
char
ge;
Ded
uctib
le W
aive
d
You
may
hav
e to
pay
for
serv
ices
that
ar
en't
prev
entiv
e. A
sk y
our
prov
ider
if
the
serv
ices
you
nee
d ar
e pr
even
tive.
T
hen
chec
k w
hat y
our
plan
will
pay
fo
r.
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y, b
lood
wor
k)
No
char
ge
40%
Coi
nsur
ance
N
one
Imag
ing
(CT
/PE
T s
cans
, MR
Is)
N
o ch
arge
40
% C
oins
uran
ce
Non
e
45
P
age
3 o
f 7
Co
mm
on
M
edic
al E
ven
t S
ervi
ces
Yo
u M
ay N
eed
Wh
at Y
ou
Will
Pay
L
imit
atio
ns,
Exc
epti
on
s, &
Oth
er
Imp
ort
ant
Info
rmat
ion
In
-net
wo
rk
(Yo
u w
ill p
ay t
he
leas
t)
Ou
t-o
f-n
etw
ork
(Y
ou
will
pay
th
e m
ost
)
If y
ou
nee
d
dru
gs
to t
reat
yo
ur
illn
ess
or
con
dit
ion
. M
ore
info
rmat
ion
abou
t pr
escr
iptio
n dr
ug c
over
age
is a
vaila
ble
at
ww
w.n
avitu
s.co
m
Gen
eric
dru
gs (
Tie
r 1)
$0
afte
r de
duct
ible
N
ot C
over
ed
Effe
ctiv
e Ja
nuar
y 1,
202
0, W
algr
eens
ph
arm
acie
s ar
e no
long
er a
n in
-ne
twor
k ph
arm
acy.
If y
ou h
ave
ques
tions
, abo
ut a
ltern
ativ
e ph
arm
acie
s, p
leas
e co
ntac
t Nav
itus
at
866-
333-
2757
.
Pre
ferr
ed b
rand
dru
gs (
Tie
r 2)
$0
afte
r de
duct
ible
N
ot C
over
ed
Non
-pre
ferr
ed b
rand
dru
gs (
Tie
r 3)
$0
afte
r de
duct
ible
N
ot C
over
ed
Spe
cial
ty d
rugs
(T
ier
4)
$0 a
fter
dedu
ctib
le
Not
Cov
ered
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(e
.g.,
ambu
lato
ry s
urge
ry c
ente
r)
No
char
ge
40%
Coi
nsur
ance
Pre
auth
oriz
atio
n is
req
uire
d. If
you
do
n’t g
et p
reau
thor
izat
ion,
ben
efits
co
uld
be r
educ
ed b
y $5
00 o
f the
tota
l co
st o
f the
ser
vice
Out
-of-
netw
ork.
Phy
sici
an/s
urge
on fe
es
No
char
ge
40%
Coi
nsur
ance
N
one
If y
ou
nee
d
imm
edia
te
med
ical
at
ten
tio
n
Em
erge
ncy
room
car
e N
o ch
arge
N
o ch
arge
In
-net
wor
k de
duct
ible
app
lies
to
Out
-of-
netw
ork
bene
fits
Em
erge
ncy
med
ical
tran
spor
tatio
n N
o ch
arge
N
o ch
arge
In
-net
wor
k de
duct
ible
app
lies
to
Out
-of-
netw
ork
bene
fits
Urg
ent c
are
No
char
ge
40%
Coi
nsur
ance
N
one
46
P
age
4 o
f 7
Co
mm
on
M
edic
al E
ven
t S
ervi
ces
Yo
u M
ay N
eed
Wh
at Y
ou
Will
Pay
L
imit
atio
ns,
Exc
epti
on
s, &
Oth
er
Imp
ort
ant
Info
rmat
ion
In
-net
wo
rk
(Yo
u w
ill p
ay t
he
leas
t)
Ou
t-o
f-n
etw
ork
(Y
ou
will
pay
th
e m
ost
)
If y
ou
hav
e a
ho
spit
al s
tay
Fac
ility
fee
(e.g
., ho
spita
l roo
m)
No
char
ge
40%
Coi
nsur
ance
Pre
auth
oriz
atio
n is
req
uire
d. If
you
do
n’t g
et p
reau
thor
izat
ion,
ben
efits
co
uld
be r
educ
ed b
y $5
00 o
f the
tota
l co
st o
f the
ser
vice
Out
-of-
netw
ork.
Phy
sici
an/s
urge
on fe
e N
o ch
arge
40
% C
oins
uran
ce
Non
e
If y
ou
hav
e m
enta
l hea
lth
, b
ehav
iora
l h
ealt
h, o
r su
bst
ance
ab
use
nee
ds
Out
patie
nt s
ervi
ces
No
char
ge
40%
Coi
nsur
ance
Pre
auth
oriz
atio
n is
req
uire
d. If
you
do
n’t g
et p
reau
thor
izat
ion,
ben
efits
co
uld
be r
educ
ed b
y $5
00 o
f the
tota
l co
st o
f the
ser
vice
for
Par
tial
hosp
italiz
atio
n O
ut-o
f-ne
twor
k.
Inpa
tient
ser
vice
s N
o ch
arge
40
% C
oins
uran
ce
Pre
auth
oriz
atio
n is
req
uire
d. If
you
do
n’t g
et p
reau
thor
izat
ion,
ben
efits
co
uld
be r
educ
ed b
y $5
00 o
f the
tota
l co
st o
f the
ser
vice
Out
-of-
netw
ork.
If y
ou
are
p
reg
nan
t
Offi
ce v
isits
N
o ch
arge
; D
educ
tible
Wai
ved
No
char
ge;
Ded
uctib
le W
aive
d C
ost s
harin
g do
es n
ot a
pply
to c
erta
in
prev
entiv
e se
rvic
es. D
epen
ding
on
the
type
of s
ervi
ces,
ded
uctib
le,
copa
ymen
t or
coin
sura
nce
may
app
ly.
Mat
erni
ty c
are
may
incl
ude
test
s an
d se
rvic
es d
escr
ibed
els
ewhe
re in
the
SB
C (
i.e. u
ltras
ound
).
Chi
ldbi
rth/
deliv
ery
prof
essi
onal
se
rvic
es
No
char
ge
40%
Coi
nsur
ance
Chi
ldbi
rth/
deliv
ery
faci
lity
serv
ices
N
o ch
arge
40
% C
oins
uran
ce
47
P
age
5 o
f 7
Co
mm
on
M
edic
al E
ven
t S
ervi
ces
Yo
u M
ay N
eed
Wh
at Y
ou
Will
Pay
L
imit
atio
ns,
Exc
epti
on
s, &
Oth
er
Imp
ort
ant
Info
rmat
ion
In
-net
wo
rk
(Yo
u w
ill p
ay t
he
leas
t)
Ou
t-o
f-n
etw
ork
(Y
ou
will
pay
th
e m
ost
)
If y
ou
nee
d
hel
p
reco
veri
ng
or
hav
e o
ther
sp
ecia
l hea
lth
n
eed
s
Hom
e he
alth
car
e N
o ch
arge
40
% C
oins
uran
ce
100
Max
imum
vis
its p
er c
alen
dar
year
; P
reau
thor
izat
ion
is r
equi
red.
If y
ou
don’
t get
pre
auth
oriz
atio
n, b
enef
its
coul
d be
red
uced
by
$500
of t
he to
tal
cost
of t
he s
ervi
ce O
ut-o
f-ne
twor
k.
Reh
abili
tatio
n se
rvic
es
No
char
ge
40%
Coi
nsur
ance
N
one
Hab
ilita
tion
serv
ices
N
ot c
over
ed
Not
cov
ered
N
one
Ski
lled
nurs
ing
care
N
o ch
arge
40
% C
oins
uran
ce
100
Max
imum
day
s pe
r ca
lend
ar y
ear;
P
reau
thor
izat
ion
is r
equi
red.
If y
ou
don’
t get
pre
auth
oriz
atio
n, b
enef
its
coul
d be
red
uced
by
$500
of t
he to
tal
cost
of t
he s
ervi
ce O
ut-o
f-ne
twor
k.
Dur
able
med
ical
equ
ipm
ent
No
char
ge
40%
Coi
nsur
ance
Pre
auth
oriz
atio
n is
req
uire
d fo
r D
ME
in
exc
ess
of $
500
for
rent
als
or $
1,50
0 fo
r pu
rcha
ses.
If y
ou d
on’t
get
prea
utho
rizat
ion,
ben
efits
cou
ld b
e re
duce
d by
$50
0 pe
r oc
curr
ence
O
ut-o
f-ne
twor
k.
Hos
pice
ser
vice
N
o ch
arge
40
% C
oins
uran
ce
Non
e
If y
ou
r ch
ild
nee
ds
den
tal
or
eye
care
Chi
ldre
n’s
eye
exam
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
n’s
glas
ses
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
n’s
dent
al c
heck
-up
Not
cov
ered
N
ot c
over
ed
Non
e
48
P
age
6 o
f 7
Exc
lud
ed S
ervi
ces
& O
ther
Co
vere
d S
ervi
ces:
Ser
vice
s Y
ou
r P
lan
Do
es N
OT
Co
ver
(Ch
eck
you
r p
olic
y o
r p
lan
do
cum
ent
for
mo
re in
form
atio
n a
nd
a li
st o
f an
y o
ther
exc
lud
ed s
ervi
ces.
)
•
Acu
punc
ture
•
Infe
rtili
ty tr
eatm
ent
•
Rou
tine
eye
care
(A
dult)
•
Cos
met
ic s
urge
ry
•
Long
-ter
m c
are
•
Rou
tine
foot
car
e
•
Den
tal c
are
(Adu
lt)
•
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
U.S
. •
Wei
ght l
oss
prog
ram
s O
ther
Co
vere
d S
ervi
ces
(Lim
itat
ion
s m
ay a
pp
ly t
o t
hes
e se
rvic
es. T
his
isn
’t a
co
mp
lete
list
. Ple
ase
see
you
r p
lan
do
cum
ent.
)
•
Bar
iatr
ic s
urge
ry
•
Hea
ring
aids
•
Priv
ate-
duty
nur
sing
(O
utpa
tient
car
e)
•
Chi
ropr
actic
car
e
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e: T
here
are
age
ncie
s th
at c
an h
elp
if yo
u w
ant t
o co
ntin
ue y
our
cove
rage
afte
r it
ends
. The
con
tact
info
rmat
ion
for
thos
e ag
enci
es is
: U.S
. Dep
artm
ent o
f Lab
or's
Em
ploy
ee B
enef
its S
ecu
rity
Adm
inis
trat
ion
at 1
-866
-444
-EB
SA
(32
72)
or w
ww
.Hea
lthC
are.
gov.
Oth
er c
over
age
optio
ns m
ay
be a
vaila
ble
to y
ou to
o, in
clud
ing
buyi
ng in
divi
dual
insu
ranc
e co
vera
ge th
roug
h th
e H
ealth
Insu
ranc
e M
arke
tpla
ce. F
or m
ore
info
rmat
ion
abou
t the
Mar
ketp
lace
, vis
it w
ww
.Hea
lthC
are.
gov
or c
all 1
-800
-318
-259
6.
Yo
ur
Gri
evan
ce a
nd
Ap
pea
ls R
igh
ts:
The
re a
re a
genc
ies
that
can
hel
p if
you
have
a c
ompl
aint
aga
inst
you
r pl
an fo
r a
deni
al o
f a c
laim
. Thi
s co
mpl
aint
is c
alle
d a
grie
vanc
e or
app
eal.
For
mor
e in
form
atio
n ab
out y
our
right
s, lo
ok a
t the
exp
lana
tion
of b
enef
its y
ou w
ill r
ecei
ve fo
r th
at m
edic
al c
laim
. You
r pl
an d
ocum
ents
als
o pr
ovid
e co
mpl
ete
info
rmat
ion
to s
ubm
it a
clai
m, a
ppea
l or
a gr
ieva
nce
for
any
reas
on to
you
r pl
an. F
or m
ore
info
rmat
ion
abou
t you
r rig
hts,
this
not
ice,
or
assi
stan
ce,
cont
act:
U.S
. Dep
artm
ent o
f Lab
or's
Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istr
atio
n at
1-8
66-4
44-E
BS
A (
3272
) or
ww
w.H
ealth
Car
e.go
v. A
dditi
onal
ly, a
con
sum
er
assi
stan
ce p
rogr
am m
ay h
elp
you
file
your
app
eal.
A li
st o
f sta
tes
with
Con
sum
er A
ssis
tanc
e P
rogr
ams
is a
vaila
ble
at w
ww
.Hea
lthC
are.
gov
and
http
://cc
iio.c
ms.
gov/
prog
ram
s/co
nsum
er/c
apgr
ants
/inde
x.ht
ml.
Do
es t
his
pla
n P
rovi
de
Min
imu
m E
ssen
tial
Co
vera
ge?
Yes
If
you
don’
t hav
e M
inim
um E
ssen
tial C
over
age
for
a m
onth
, you
’ll h
ave
to m
ake
a pa
ymen
t whe
n yo
u fil
e yo
ur ta
x re
turn
unl
ess
you
qual
ify fo
r an
exe
mpt
ion
from
the
requ
irem
ent t
hat y
ou h
ave
heal
th c
over
age
for
that
mon
th.
Do
es t
his
pla
n M
eet
the
Min
imu
m V
alu
e S
tan
dar
d?
Yes
If
your
pla
n do
esn’
t mee
t the
Min
imum
Val
ue S
tand
ards
, you
may
be
elig
ible
for
a pr
emiu
m ta
x cr
edit
to h
elp
you
pay
for
a pl
an th
roug
h th
e M
arke
tpla
ce.
800-
826-
9781
.
––––––––––––––––––––––
To
see
exam
ples
of ho
w thi
s pl
an m
ight
cov
er c
osts
for
a s
ampl
e m
edical
situa
tion
, se
e th
e ne
xt pa
ge.––––––––––––––––––––––
49
T
he p
lan
wou
ld b
e re
spon
sibl
e fo
r th
e ot
her
cost
s of
thes
e E
XA
MP
LE c
over
ed s
ervi
ces.
P
age
7 o
f 7
Man
agin
g J
oe’
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
’s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w u
p ca
re)
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les:
◼
Th
e p
lan
's o
vera
ll d
edu
ctib
le
$3,0
00
◼ S
pec
ialis
t co
insu
ran
ce
0%
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
0%
◼
Oth
er c
oin
sura
nce
0%
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e:
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth/
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth/
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12,
800
In t
his
exa
mp
le, P
eg w
ou
ld p
ay:
Cos
t Sha
ring
Ded
uctib
les
$3,0
00
Cop
aym
ents
$0
Coi
nsur
ance
$0
Wha
t isn
’t co
vere
d
Lim
its o
r ex
clus
ions
$1
00
Th
e to
tal P
eg w
ou
ld p
ay is
$3
,100
◼ T
he
pla
n's
ove
rall
ded
uct
ible
$3
,000
◼
Sp
ecia
list
coin
sura
nce
0%
◼
Ho
spit
al (
faci
lity)
co
insu
ran
ce
0%
◼ O
ther
co
insu
ran
ce
0%
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like:
P
rimar
y ca
re p
hysi
cian
offi
ce v
isits
(in
clud
ing
dise
ase
educ
atio
n)
Dia
gnos
tic te
sts
(blo
od w
ork)
P
resc
riptio
n dr
ugs
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
To
tal E
xam
ple
Co
st
$7,4
00
In t
his
exa
mp
le, J
oe
wo
uld
pay
:
Cos
t Sha
ring
Ded
uctib
les*
$1
,200
Cop
aym
ents
$0
Coi
nsur
ance
$0
Wha
t isn
’t co
vere
d
Lim
its o
r ex
clus
ions
$6
,000
Th
e to
tal J
oe
wo
uld
pay
is
$7,2
00
◼ T
he
pla
n's
ove
rall
ded
uct
ible
$3
,000
◼
Sp
ecia
list
coin
sura
nce
0%
◼
Ho
spit
al (
faci
lity)
co
insu
ran
ce
0%
◼ O
ther
co
insu
ran
ce
0%
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like:
E
mer
genc
y ro
om c
are
(incl
udin
g m
edic
al s
uppl
ies)
D
iagn
ostic
test
s (x
-ray
) D
urab
le m
edic
al e
quip
men
t (cr
utch
es)
Reh
abili
tatio
n se
rvic
es (
phys
ical
ther
apy)
To
tal E
xam
ple
Co
st
$1,9
00
In t
his
exa
mp
le, M
ia w
ou
ld p
ay:
Cos
t Sha
ring
Ded
uctib
les*
$1
,900
Cop
aym
ents
$0
Coi
nsur
ance
$0
Wha
t isn
’t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal M
ia w
ou
ld p
ay is
$1
,900
Th
is is
no
t a
cost
est
imat
or.
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are.
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive,
the
pric
es y
our
prov
ider
s ch
arge
, and
man
y ot
her
fact
ors.
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s, c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
. Use
this
info
rmat
ion
to c
omp
are
the
port
ion
of
cost
s yo
u m
ight
pay
und
er d
iffer
ent h
ealth
pla
ns. P
leas
e no
te th
ese
cove
rage
exa
mpl
es a
re b
ased
on
self-
only
cov
erag
e.
Not
e: T
hese
num
bers
ass
ume
the
patie
nt d
oes
not p
artic
ipat
e in
the
plan
’s w
elln
ess
prog
ram
. If y
ou p
artic
ipat
e in
the
plan
’s w
elln
ess
prog
ram
, you
may
be
able
to
redu
ce y
our
cost
s. F
or m
ore
info
rmat
ion
abou
t the
wel
lnes
s pr
ogra
m, p
leas
e co
ntac
t: w
ww
.um
r.co
m o
r ca
ll 1-
800-
826-
9781
. *N
ote:
Thi
s pl
an h
as o
ther
ded
uctib
les
for
spec
ific
serv
ices
incl
uded
in th
is c
over
age
exam
ple.
See
"A
re th
ere
othe
r de
duct
ible
s fo
r sp
ecifi
c se
rvic
es?”
" ro
w a
bove
.
50
Important Contacts
Benefit Company Phone Number Website
Medical UMR
UnitedHealthcare Network
800-826-9781 www.umr.com
Prescription Drug Navitus 866-333-2757 www.navitus.com
Dental Delta Dental of Kansas 800-234-3375 www.deltadentalks.com
Vision VSP 800-877-7195 www.vsp.com
Health Savings Account (HSA) Discovery Benefits 866-451-3399 www.discoverybenefits.com
Flexible Spending Accounts (FSA)
Discovery Benefits 866-451-3399 www.discoverybenefits.com
Life Insurance The Standard 800-877-5176 www.thestandard.com
Long Term Disability The Standard 800-877-5176 www.thestandard.com
Retirement 401k Plan MassMutual 800-743-5274 www.retiresmart.com
Employee Assistance Plan (EAP)
LifeWorks 877-234-5152 www.lifeworks.com
Travel Assistance The Standard
UnitedHealthcare Global
240-330-1380 Global 866-455-9188 US &
Canada Email: [email protected]
51
The information in this Enrollment Guide is presented for illustrative purposes and is based on information
provided by the employer. The text contained in this Guide was taken from various summary plan descriptions
and benefit information. While every effort was taken to accurately report your benefits, discrepancies, or errors
are always possible. In case of discrepancy between the Guide and the actual plan documents the actual plan
documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and
Accountability Act of 1996. If you have any questions about your Guide, please refer to your Employee Manual
for additional information or contact your benefits manager.
52