920 Fort Duquesne Blvd., Pittsburgh, PA 15222 hendersonbrothers.com

WELCOME TO OPEN ENROLLMENT!

MEDICAL PLAN ELECTIONS

2018 HSA CONTRIBUTIONS

SPOUSAL AFFIDAVIT

DENTAL PLAN ELECTIONS

ALLEGHENY COLLEGEOPEN ENROLLMENT CHECKLIST

The strict deadline to complete your 2018/2019 annual open enrollment is June 8, 2018. Below is a checklist of items that will need to be completed and submitted to Human Resources by June 8th.

Yes, I am enrolling, changing, or cancelling medical coverage

Yes, my spouse will be enrolling in Allegheny College’s medical plan

There will be a $200 monthly surcharge if your spouse chooses to enroll in Allegheny College’s medical plan AND they have access to their employer’s group health plan.

No, I do not intend to make changes to my medical coverage

Single: $3,450 Family: $6,900

Please complete the medical enrollment form included in the appendix on page 8

Please complete the medical payroll authorization form included in the appendix on page 9

See criteria for Spousal Affidavit below

See criteria for Spousal Affidavit below

- Allegheny College will fund $500 individual/$1,000 family for employees earning less than $40,000

If enrolling in the QHDHP, please complete the Pre-Tax Health Savings Account (HSA) Election Form included on page 10

No action is required

No action is required

Please complete the spousal affidavit included in the appendix on page 7- If Human Resources does not receive this form back by June 8th, the employee will pay the monthlysurcharge

Yes, I am enrolling, changing, or cancelling dental coveragePlease complete the dental enrollment form included in the appendix on page 12

Please complete the dental payroll authorization form included in the appendix on page 17

No, I do not intend to make changes to my dental coverage

VISION PLAN ELECTIONSYes, I am enrolling, changing, or cancelling vision coverage

No, I do not intend to make changes to my vision coverageNo action is required

Please complete the vision enrollment form included in the appendix on page 15

Please complete the vision payroll authorization form included in the appendix on page 17

920 Fort Duquesne Blvd., Pittsburgh, PA 15222 hendersonbrothers.com

ALLEGHENY COLLEGEOPEN ENROLLMENT CHECKLIST

FLEXIBLE SPENDING ACCOUNT ELECTION

VOLUNTARY SUPPLEMENTAL TERM LIFE/AD&D

Yes, I am enrolling in the Flexible Spending Account (FSA) - available only for PPO plan participants (annual election required each year for FSA)

Employees may purchase voluntary supplemental term life/ADD for you and/or your spouse or dependents through MetLife.

Employees can purchase supplemental term life/ADD coverage up to 5x their annual salary or $500,000 in increments of $10,000 with no age reduced benefit. Employees will receive a guaranteed issue amount of $100,000.

Employees can also purchase supplemental term life/ADD coverage for their spouse or child dependent. Note, the employee cost is on a post-tax basis only.

Note: At Open Enrollment, an enrolled member can increase their benefit amount by $10,000 without a SOH. If you elect any amount over $100,000 you are required to complete of a Statement of Health (SOH) with medical questions. If you elect any amount under $100,000 you are required to answer one underwriting question - has the member been hospitalized on an inpatient basis within the last 90 days?

• The spousal benefit is available in $5,000 increments up to $100,000 however this amount cannot exceed 50% of theemployee’s optional life benefit. The rates for spousal coverage are based on the employee’s age.• The child benefit available in increments up to $10,000 however the benefit amount elected cannot exceed the spouse’sbenefit amount.

Please complete the Flexible Spending Account election form included in the appendix on page 11

To enroll in employee, spouse or child Supplemental Term life/ADD coverage employees will need to complete the MetLife enrollment form included in the appendix on pages 18-20.

Please complete the Statement of Health (SOH) in the appendix on page 21, if one of the following applies:-if you are increasing your benefit amount by more than $10,000-you did not purchase coverage at the initial offering and wish to purchase during openenrollment-you are electing a benefit amount over $100,000

2018 FSA CONTRIBUTION$2,650 Healthcare, $5,000 Dependent Care

920 Fort Duquesne Blvd., Pittsburgh, PA 15222 hendersonbrothers.com

ALLEGHENY COLLEGEOPEN ENROLLMENT CHECKLIST

For your information, please review the required annual disclosures at the end of the enrollment guide.

ADDITIONAL BENEFIT PROGRAMS: AFLAC OPEN ENROLLMENT ACCIDENT, CANCER CARE, HOSPITAL & CRITICAL CARE

Yes, I am interested in learning more and/or purchasing these additional benefit offerings

Please visit The Campus Center, Room 202 on May 30th. Representatives from AFLAC will be conducting presentations and available to answer questions. Presentations will begin at 10am, Noon, and 2pm.

You can also contact Alynn Maginness at alynn_maginness@us.aflac.com if you have further questions on the plans.

Summary of PPO Blue Benefits On the chart below, you'll see what your plan pays for specific services. You may be responsible for a facility fee, clinic charge or similar fee or charge (in addition to any professional fees) if your office visit or service is provided at a location that qualifies as a hospital department or a satellite building of a hospital.

Allegheny College Benefit Network Out-of-Network

General Provisions Benefit Period(1) Contract Year Deductible (per benefit period)

Individual Family

$500 $1,000

$1,000 $2,000

Plan Pays – payment based on the plan allowance 90% after deductible 70% after deductible Out-of-Pocket Maximums (Once met, plan pays 100% for the rest of the benefit period)

Individual Family

$1,000 $2,000

$2,000 $4,000

Total Maximum Out of Pocket (Includes deductible, coinsurance, copays and other qualified medical expenses, Network only)(8) Once met, plan pays 100% of covered services for the rest of the benefit period. Individual Family

$7,350 $14,700

Not applicable

Lifetime Maximums Unlimited, except as notated below Autism Spectrum Disorders (ASD) Maximum (per person)(2)

90% after deductible 70% after deductible

Office/Clinic/Urgent Care Visits Retail Clinic Visits 100% after $30 copayment 70% after deductible Primary Care Provider Office Visits 100% after $20 copayment 70% after deductible Specialist Office Visits 100% after $30 copayment 70% after deductible Urgent Care Center Visits / Retail Clinic Visits 100% after $30 copayment 70% after deductible Telemedicine (7) 100% after $15 copayment

Preventive Care(3) Routine Adult

Physical exams 100% (deductible does not apply) Not Covered Adult immunizations 100% (deductible does not apply) 70% after deductible Colorectal cancer screening 100% (deductible does not apply) 70% after deductible Routine gynecological exams, including a Pap Test 100% (deductible does not apply) 70% (deductible does not apply) Mammograms, annual routine and medically necessary

Routine: 100% (deductible does not apply)

Medically Necessary: 90% after deductible

70% after deductible

Diagnostic services and procedures 100% (deductible does not apply) 70% after deductible Routine Pediatric

Physical exams 100% (deductible does not apply) Not Covered Pediatric immunizations 100% (deductible does not apply) 70% (deductible does not apply) Diagnostic services and procedures 100% (deductible does not apply) 70% after deductible

Hospital and Medical/Surgical Expenses (including maternity) Hospital Inpatient

90% after deductible 70% after deductible Hospital Outpatient Maternity (non-preventive facility & professional services) Medical/Surgical (except office visits)

Emergency Services Emergency Room Services 100% after $100 copayment (waived if admitted) Ambulance 90% after deductible

Therapy and Rehabilitation Services Physical Medicine 100% after $10 copayment 70% after deductible Respiratory Therapy 90% after deductible Speech & Occupational Therapy 100% after $10 copayment 70% after deductible Spinal Manipulations 100% after $20 copayment 70% after deductible

Limit: 20 visits per calendar year

1

Benefit Network Out-of-Network Other Therapy Services (Cardiac Rehab, Infusion Therapy, Chemotherapy, Radiation Therapy and Dialysis)

90% after deductible 70% after deductible

Mental Health/Substance Abuse Inpatient 90% after deductible 70% after deductible Inpatient Detoxification/Rehabilitation Outpatient 100% after $10 copayment 70% after deductible

Other Services Allergy Extracts and Injections 90% after deductible 70% after deductible Assisted Fertilization Procedures 90% after deductible 70% after deductible Applied Behavior Analysis for Autism Spectrum Disorders(2)

90% after deductible 70% after deductible

Dental Services Related to Accidental Injury 90% after deductible 70% after deductible Diabetes Treatment 90% after deductible 70% after deductible Diagnostic Services

Advanced Imaging (MRI, CAT, PET scan, etc.) 90% after deductible 70% after deductible Basic Diagnostic Services (standard imaging, diagnostic medical, lab/pathology, allergy testing)

90% after deductible 70% after deductible

Durable Medical Equipment, Orthotics and Prosthetics

90% after deductible 70% after deductible Home Health Care Hospice Infertility Counseling, Testing and Treatment(4) Home Infusion Therapy 90% after deductible Private Duty Nursing Enteral Formulae 90% (deductible does not apply) 70% (deductible does not apply) Skilled Nursing Facility Care 90% after deductible 70% after deductible Transplant Services 90% after deductible 70% after deductible Pre-Existing Condition Clause No Precertification Requirements(5) Yes

Prescription Drugs Prescription Drug Deductible

Individual Family

None None

Prescription Drug Program(6) Mandatory Generic Defined by the National Plus Pharmacy Network - Not Physician Network. Prescriptions filled at a non-network pharmacy are not covered.

Your plan uses the Comprehensive Formulary.

Retail Drugs (31-day Supply) $10 generic copayment

$35 formulary brand copayment $70 non-formulary brand copayment

Maintenance Drugs through Mail Order (90-day Supply) $20 generic copayment

$70 formulary brand copayment $140 non-formulary brand copayment

(1) Your group's benefit period is based on a Contract Year which runs from July 1 to June 30.(2) Coverage for eligible members to age 21. Services will be paid according to the benefit category (e.g. speech therapy). Treatment for autism spectrum

disorders does not reduce visit/day limits.(3) Services are limited to those listed on the Highmark Preventive Schedule. Gender, age and frequency limits may apply.(4) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be

covered depending on your group’s prescription drug program. Excludes coverage for services related to in-vitro fertilization and artificial insemination.(5) Highmark Medical Management & Policy (MM&P) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or

maternity-related inpatient admission. Be sure to verify that your provider is contacting MM&P for precertification. If not, you are responsible for contactingMM&P. If this does not occur and it is later determined that all or part of the inpatient stay was not medically necessary or appropriate, you will beresponsible for payment of any costs not covered.

(6) The formulary is an extensive list of Food and Drug Administration (FDA) approved prescription drugs selected for their quality, safety and effectiveness. Itincludes products in every major therapeutic category. The formulary was developed by the Highmark Pharmacy and Therapeutics Committee made up ofclinical pharmacists and physicians. Your program includes coverage for both formulary and non-formulary drugs at the specific copayment or coinsuranceamounts listed above. You are responsible for the payment differential when a generic drug is authorized by your provider and you purchase a brand namedrug. Your payment is the price difference between the brand name drug and generic drug in addition to the brand name drug copayment or coinsuranceamounts, which may apply.

(7) Services are provided for acute care for minor illnesses. Services must be performed by a Highmark approved telemedicine provider. Virtual BehavioralHealth visits provided by a Highmark approved telemedicine provider are eligible under Outpatient Mental Health benefit.

(8) Effective with plan years beginning on or after January 1, 2014, the Network Total Maximum Out-of-Pocket as mandated by the federal government mustinclude deductible, coinsurance, copays, and any qualified medical expenses.

This is not intended as a contract of benefits. It is designed purely as a reference of the many benefits available under your program. Effective 07/01/14 Allegheny College 011804-00, 01, 60, 70 2

Allegheny College - HDHP This program is a qualified high deductible plan as defined by the Internal Revenue Service. It is designed for use with a Health Savings Account (HSA). On the chart below, you'll see what your plan pays for specific services. You may be responsible for a facility fee, clinic charge or similar fee or charge (in addition to any professional fees) if your office visit or service is provided at a location that qualifies as a hospital department or a satellite building of a hospital. If you enroll as an individual, the deductible and out-of-pocket maximums for the “Employee Only Plan” apply. If you enroll as a family, the deductible and out-of-pocket maximums for the “Family Plan” apply and can be satisfied by one or more of your family members.

Benefit Network Out-of-Network General Provisions

Benefit Period(1) Contract Year Deductible per benefit period (Applies to Medical and Prescription Drug benefits)

Employee Only Plan Family Plan

$1,500 Combined $3,000 Combined

Plan Pays – payment based on the plan allowance 90% after deductible 70% after deductible Out-of-Pocket Maximums (Once met, plan pays 100% for the rest of the benefit period)

Employee Only Plan Family Plan

$1,500 $3,000

$3,000 $6,000

Total Maximum Out of Pocket (7) Includes deductible, coinsurance, copays and other qualified medical expenses, network only. Once met, plan pays 100% of covered services for the rest of the benefit period. Individual

Family $3,000 $6,000

Not applicable

Lifetime Maximums Unlimited, except as notated below Autism Spectrum Disorders (ASD) Maximum (per person)(2)

90% after deductible 70% after deductible

Office/Clinic/Urgent Care Visits Retail Clinic Visits 90% after deductible 70% after deductible Primary Care Provider Office Visits 90% after deductible 70% after deductible Specialist Office Visits 90% after deductible 70% after deductible Urgent Care Center Visits 90% after deductible 70% after deductible Telemedicine (8) 90% after deductible

Preventive Care(3) Routine Adult

Physical exams 100% (deductible does not apply) Not Covered Adult immunizations 100% (deductible does not apply) 70% after deductible Colorectal cancer screening 100% (deductible does not apply) 70% after deductible Routine gynecological exams, including a Pap Test 100% (deductible does not apply) 70% (deductible does not apply) Mammograms, annual routine and medically necessary

Routine: 100% (deductible does not apply)

Medically Necessary: 90% after deductible

70% after deductible

Diagnostic services and procedures 100% (deductible does not apply) 70% after deductible Routine Pediatric

Physical exams 100% (deductible does not apply) Not Covered Pediatric immunizations 100% (deductible does not apply) 70% (deductible does not apply) Diagnostic services and procedures 100% (deductible does not apply) 70% after deductible

Hospital and Medical/Surgical Expenses (including maternity) Hospital Inpatient

90% after deductible 70% after deductible Hospital Outpatient Maternity (non-preventive facility & professional services) Medical/Surgical (except office visits)

Emergency Services Emergency Room Services 90% after deductible Ambulance 90% after deductible

Therapy and Rehabilitation Services Physical Medicine 90% after deductible 70% after deductible

3

Benefit Network Out-of-Network Respiratory Therapy 90% after deductible Speech & Occupational Therapy 90% after deductible 70% after deductible

Spinal Manipulations 90% after deductible 70% after deductible Limit: 20 visits/benefit period

Other Therapy Services (Cardiac Rehab, Infusion Therapy, Chemotherapy, Radiation Therapy and Dialysis)

90% after deductible 70% after deductible

Mental Health/Substance Abuse Inpatient 90% after deductible 70% after deductible Inpatient Detoxification/Rehabilitation Outpatient 90% after deductible 70% after deductible

Other Services Allergy Extracts and Injections 90% after deductible 70% after deductible Assisted Fertilization Procedure 90% after deductible 70% after deductible Applied Behavior Analysis for Autism Spectrum Disorders(2)

90% after deductible 70% after deductible

Dental Services Related to Accidental Injury 90% after deductible 70% after deductible Diabetes Treatment 90% after deductible 70% after deductible Diagnostic Services

Advanced Imaging (MRI, CAT, PET scan, etc.) 90% after deductible 70% after deductible Basic Diagnostic Services (standard imaging, diagnostic medical, lab/pathology, allergy testing)

90% after deductible 70% after deductible

Enteral Formulae 90% after deductible 70% after deductible Durable Medical Equipment, Orthotics and Prosthetics

90% after deductible 70% after deductible Home Health Care Hospice Infertility Counseling, Testing and Treatment(4) Private Duty Nursing Home Infusion Therapy

90% after deductible

Skilled Nursing Facility Care 90% after deductible 70% after deductible Limit: 100 days/benefit period

Transplant Services 90% after deductible 70% after deductible Precertification Requirements(5) Yes

Prescription Drugs Prescription Drug Deductible

Individual Family

Integrated with medical deductible Integrated with medical deductible

Prescription Drug Program(6)Defined by the National Plus Pharmacy Network - Not Physician Network. Prescriptions filled at a non-network pharmacy are not covered.

Your plan uses the Comprehensive Formulary.

Retail Drugs (31-day Supply) Plan pays 90% after deductible

Maintenance Drugs through Mail Order (90-day Supply) Plan pays 90% after deductible

(1) Your group's benefit period is based on a Contract Year which runs from July 1 to June 30. (2) Coverage for eligible members to age 21. Services will be paid according to the benefit category (e.g. speech therapy). Treatment for autism spectrum

disorders does not reduce visit/day limits. (3) Services are limited to those listed on the Highmark Preventive Schedule. Gender, age and frequency limits may apply. (4) Treatment includes coverage for the correction of a physical or medical problem associated with infertility. Infertility drug therapy may or may not be

covered depending on your group’s prescription drug program. Excludes coverage for services related to in-vitro fertilization and artificial insemination. (5) Highmark Medical Management & Policy (MM&P) must be contacted prior to a planned inpatient admission or within 48 hours of an emergency or

maternity-related inpatient admission. Be sure to verify that your provider is contacting MM&P for precertification. If not, you are responsible for contacting MM&P. If this does not occur and it is later determined that all or part of the inpatient stay was not medically necessary or appropriate, you will be responsible for payment of any costs not covered.

(6) The formulary is an extensive list of Food and Drug Administration (FDA) approved prescription drugs selected for their quality, safety and effectiveness. It includes products in every major therapeutic category. The formulary was developed by the Highmark Pharmacy and Therapeutics Committee made up of clinical pharmacists and physicians. Your program includes coverage for both formulary and non-formulary drugs at the specific copayment or coinsurance amounts listed above. You are responsible for the payment differential when a generic drug is authorized by your provider and you purchase a brand name drug. Your payment is the price difference between the brand name drug and generic drug in addition to the brand name drug copayment or coinsurance amounts, which may apply.

(7) Effective with plan years beginning on or after January 1, 2014, the Network Total Maximum Out-of-Pocket as mandated by the federal government must include deductible, coinsurance, copays, and any qualified medical expenses.

(8) Services are provided for acute care for minor illnesses. Services must be performed by a Highmark approved telemedicine provider. Virtual Behavioral Health visits provided by a Highmark approved telemedicine provider are eligible under Outpatient Mental Health benefit.

This is not intended as a contract of benefits. It is designed purely as a reference of the many benefits available under your program. 02/20/2014- Allegheny College QHDHP 7.1.14_ 4

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9

6

THIS FORM MUST BE COMPLETED BY ALL EMPLOYEES WHO ARE ENROLLING THEIR SPOUSE IN ALLEGHENY COLLEGE’S MEDICAL PLAN FOR 2018-19

Affidavit for Spousal Coverage

Overview:

Allegheny College requires employees to contribute an extra $200 towards their medical premium each month when a spouse is enrolled in Allegheny College’s medical coverage and the spouse is eligible to enroll in his / her employer-sponsored health plan. Please read the information below, and select the correct statement that applies to you and your spouse. Certification:

Employee Name _____________________________________

I certify that my spouse, ______________________________, is

� Eligible to enroll in his / her employer-sponsored health plan, but I prefer to have him/her

to enroll in Allegheny’s medical plan and incur the $200 monthly surcharge, or

� Not eligible to enroll in his / her employer-sponsored health plan due to (circle one of the

two options below):

• Option 1: Employer does not offer health coverage

• Option 2: Spouse not employed

If your spouse’s employer does not offer coverage (Option 1), please complete the below:

Employer’s Name:___________________________________________________________

Employer’s Address:__________________________________________________________

Contact Name:_______________________________________________________________

Contact’s Telephone Number:___________________________________________________

I, _________________________________, give permission for Allegheny College to verify

the above information is accurate and contact my spouse’s employer.

I understand that it is my responsibility to notify my employer within 31 days of my spouse losing eligibility under their employer’s medical plan in order for me to either:

a) Enroll them in Allegheny College’s medical plan as a dependent under my plan; orb) Reduce my current contribution by the applicable additional spousal premium in the event they becomeineligible for their employer’s plan.

I also understand my employer may ask at any time if the status of my spouse’s eligibility for his/her employer’s plan has changed. I am aware of the additional premium set forth by my employer requiring the payment of any back premiums if this certification is determined to be inaccurate or in the event I fail to notify my employer of a change in my spouse’s status.

I certify that the foregoing is true and accurate to the best of my knowledge.

Employee Signature _________________________________ Date _______________

7

8

Allegheny College

Payroll Authorization Form – Medical Coverage Coverage Effective July 1, 2018

Name: __________________________________________________________________________________________

Social Security Number: _____________________________________________________________________________

Marital Status: ____Single ____Married ____Partner _____# of Dependents

_____ Elect or Change Coverage OR _____ Cancel/Waive Coverage (check plan & classification below)

Highmark PPO Option Highmark Qualified High Deductible Option _____ Single* _____ Single* _____ Employee & Child(ren)* _____ Employee & Child(ren)* _____ Employee & Spouse/Partner* _____ Employee & Spouse/Partner* _____ Family* _____ Family*

*The cost to the employee for the medical coverage will be at a percent of premium based on the attached schedule.

Salary Reduction Agreement (check appropriate arrangement):

_____ By checking this line, I authorize Allegheny College to reduce my future earnings on a pre-tax basis, effective __________________________.

_____ By checking this line, I authorize Allegheny College to reduce my future earnings on a post-tax basis, effective __________________________.

If my dependents or I have a change in family or employment status, I may be able to change the choices made by completing a new enrollment form and payroll authorization form within 30 days of the date of the status change. I also understand that adding dependents to the coverage at a later date other than as a result of a change in family status (late enrollment) will require that I will be subject to the underwriting requirements of the carrier before the coverage can be provided, and the coverage can only be effective as of the next July 1st.

Signature: _____________________________________________ Date: ______________________

9

Rev.3/14

**COMPLETE ONLY IF YOU HAVE ELECTED THE HIGH DEDUCTIBLE HEALTH PLAN**

This form enables you to elect to have a Federal “pre-tax” payroll deduction into your Health Savings Account (HSA) for those that enroll in the Qualified High Deductible Health Plan option.

There are contribution limits that are set each calendar year by tax law, so check with Human Resources if you have any questions about these limits.

This form is to elect what amount you would like to contribute to your HSA above and beyond the $500 individual coverage and $1,000 for individual + dependents. You must earn $40,000 or less annually to qualify for the College’s contribution. In addition to what the College contribution, you can contribution as well.

Complete 1 or 2 below:

NOTE: If you are enrolled in Medicare Part A and/or B, you cannot contribute to an HSA. Additionally, the month you enroll in Medicare (typically the month of your 65th birthday), the College must change your HSA contribution to zero and cannot continue any additional employer contribution.

1. □ Yes, I want a payroll deduction in addition to the College contribution into my HSA as noted below.

- Complete both the Amount Per Paycheck AND Amount per Year below.

$ _______________ x 12 or 26 = $______________ Amount Per Paycheck Number of Paychecks Amount per Year

2. □ No, I DO NOT want a payroll deduction in addition to the College contribution into my HSA, as noted below.

By signing this form, I certify that I am not currently enrolled in Medicare Part A or B and will notify the College if I enroll in Medicare Part A or B.

Employee PRINTED Name: _______________________________

Employee Signature: ____________________________________ Date: _______________

If you are using another bank for your Health Savings Account, please include the Account and Routing Number below. Contributions will NOT be deposited until this portion is completed.

_________________________________________________________________________________________________________ Bank Name Routing Number Account Number

Allegheny College Pre-Tax Health Savings Account (HSA) Election Form

10

Health/Dependent Care Flexible Spending Account Enrollment Form

Social Security

Number (SSN)

First Name M.I. Last Name

Address

City State

Day PhoneZip Code

Email

$. x .

CONTRIBUTION PER PAY PERIODNUMBER OF PAY PERIODS

REMAINING IN THE PLAN YEAR YOUR ANNUAL ELECTION AMOUNT

I decline enrollment in my employer’s Flexible Spending Account Plan.

Employee Signature Date

Employer Section: Control # Employee Company Code Effective Date of Employee Election

© 2017 WageWorks, Inc. All rights reserved. 24448 - ADPWW FSA_Enroll (201709)

Need help deciding how much to elect or how much you will save using a Flexible Spending Account?

VISIT OUR WEBSITE at www.spendingaccounts.info

=

DEPENDENT CARE

FLEXIBLE SPENDING

ACCOUNT

CANNOT EXCEED $5,000 PER HOUSEHOLD PER YEAR*

This form is designed to be completed by using your computer and tabbing through the designated fields. If completing a printed copy by hand, please use black or blue ink, print clearly and only in the spaces provided.

I elect to participate in my employer’s Flexible Spending Account Plan and agree to be bound by the terms of my employer’s Plan. I

understand that the contribution(s) I have elected will be made with pre-tax salary reductions and that such reductions reduce my

compensation for Social Security benefit purposes. I understand that this agreement is only for eligible services and treatment

provided during the Plan Year and that said services must be provided before the submission of claims for reimbursement. I also

understand that I am making a binding election for the entire Plan Year unless I have a qualified change of status as defined by my

employer’s Plan. Any salary deductions that have not been used for expenses incurred in the Current Plan Year noted above will be

forfeited unless your Plan offers certain exceptions (e.g., grace period or carryover).

If the Plan Administrator determines that an expense I submitted for reimbursement was not a qualified expense under the Plan

Documents, I shall immediately reimburse the Plan for the entire amount of the unqualified expense. If I fail to timely reimburse the

Plan, I understand that amounts may be withheld from wages or from otherwise valid expenses under the Plan in order to reimburse

the unqualified expense.

Please select your enrollment option below, sign and date your form and submit to your benefit services department:

Prior to completing this form, contact your benefit services group to determine your employer’s preferred enrollment method .

I have reviewed the terms of my employer’s Plan and I understand that I may elect coverage under either or both of the accoun ts below, subject to the

terms of the Plan, for the Plan Year .

,

* Your employer’s maximum contribution may be less than the statutory limit. Please verify your employer’s Plan limit prior to enrolling in the Plan.

$. x .

CONTRIBUTION PER PAY PERIODNUMBER OF PAY PERIODS

REMAINING IN THE PLAN YEAR YOUR ANNUAL ELECTION AMOUNT

=

HEALTH CARE

FLEXIBLE SPENDING

ACCOUNT

CANNOT EXCEED $2,650 PER PERSON PER YEAR*

,

11

12

13

Dental Benefits Summary for Allegheny College

Effective Date: July 1, 2018 Network: Concordia Advantage

Benefit Category1 CONCORDIA FLEX

In-Network2 Non-Network2 DeductibleClass I – Diagnostic/Preventive Services (Excluded from Annual Program Maximum)

Exams

100% 100% None Bitewing X-rays Cleanings & Fluoride Treatments (includes 1 additional cleaning during pregnancy)

Class II – Basic Services All Other X-rays

80% 80% $50

Sealants Basic Restorative (Fillings) Simple Extractions Space Maintainers Palliative Treatment

Class III – Major Services Repairs of Crowns, Inlays, Onlays, Bridges & Dentures

50% 50% $50

Inlays, Onlays, Crowns Prosthetics (Bridges, Dentures) Endodontics Complex Oral Surgery General Anesthesia Nonsurgical Periodontics Surgical Periodontics

Orthodontics for dependent children to age 19 Diagnostic, Active, Retention Treatment Not Covered Not Covered Not Applicable

Maximums & Deductibles (cumulative of network and non-network) Annual Program Maximum (per person) $1,000

Excludes Class I $1,000

Excludes Class I Annual Program Deductible (per person/per family) $50/$150

Excludes Class I $50/$150

Excludes Class I Lifetime Orthodontic Maximum (per person) Not Applicable Not Applicable

Representative listing of covered services – certificate of coverage provides a detailed description of benefits. 1. Dependent children covered to age 26.2. Reimbursement is based on our schedule of maximum allowable charges (MACs). Network dentists agree to accept our allowancesas payment in full for covered services. Non-network dentists may bill the member for any difference between our allowance and their fee. United Concordia Dental’s standard exclusions and limitations apply.

1-800-332-0366 www.unitedconcordia.com

14

15

Allegheny College Exam Plus Program

for VBA #1035 Effective: 7/1/18 – 6/30/20

$0 Exam / $0 Materials Copay FREQUENCY OF SERVICE Last Date of Service: DEPENDENT AGE: 26

Employee Spouse Children Vision Exam 12 Months 12 Months 12 Months Lenses 12 Months 12 Months 12 Months Frames 24 Months 24 Months 24 Months BENEFITS: Employee can select either:

VBA Participating Provider

Amount Covered/Benefit

Non-Participating Provider

Amount Reimbursed (Zero Copayment) (Zero Copayment)

Vision Exam (Glasses or Contacts) 100% $40 Clear Standard Lenses (Pair):

Single Vision 100% $40 Bifocal 100% $50 Blended Bifocal 100% $50 Trifocal 100% $75 Progressives D Controlled CostE $75 Lenticular 100% $100 Polycarbonate C 100% N/A Scratch Coat-1 Yr 100% N/A

Frame B 100% $50 -OR- Elective Contacts (in lieu of eyeglass benefits)

Material Allowance $160 $160 Fitting Fee 15% off UCRA N/A

-OR- Medically Necessary ContactsF 100% $320 Low Vision Aids (Per 24 Months. No Lifetime Max) $650 $650

A Usual, Customary, and Reasonable. B Within the program’s $50 wholesale allowance (approximately $125 to $150 retail). C Available In-Network at no charge for children under age 19. D Progressive lenses typically retail from $150 to $400, depending on lens options. VBA’s controlled costs generally range from $45

to $175. E Unless otherwise prohibited by law. F Medically Required Contacts may only be selected in lieu of all other material benefits listed herein.

Allegheny College Payroll Authorization Form - Dental/Vision Coverage

July 1, 2018

Name:

Social Security Number:

Marital Status (circle one): ______Single ______Married ______Partner # of Dependents

Dental Plan (check plan and classification):

Per Pay Contribution Level Elect/Change Coverage (check classification below also)

Single Employee & Spouse/Partner Employee & Child Employee & Children Family

Decline Coverage

Paid Bi-Weekly

$11.76 23.50 24.70 24.70 35.26

Paid Monthly

$23.52 46.99 49.40 49.40 70.51

Vision Plan (check plan and classification):

Per Pay Contribution Level Elect/Change Coverage (check classification below also)

Single Employee & Spouse/Partner Employee & Child Employee & Children Family

Decline Coverage

Paid Bi-Weekly

$4.21 7.57 7.57 10.27 10.27

Paid Monthly

$8.41 15.13 15.13 20.54 20.54

Salary Reduction Agreement (check appropriate arrangement):

� By checking this line, I authorize Allegheny College to reduce my future earnings by the contribution level chosen above on a pre-tax basis effective_______________.

� By checking this line, I authorize Allegheny College to reduce my future earnings by the contribution level chosen above on a post-tax basis effective _______________..

I understand that the choices made for vision coverage will remain in effect for at least two years. If I have a change in family or employment status, I may be able to change the choices made by completing a new payroll authorization form within 30 days of the date of the status change. I also understand that adding dependents to the coverage at a later date other than as a result of a change in family status (late enrollment) will require that I will be subject to the underwriting requirements of the carrier before the coverage can be provided.

Signature: Date:_______________________

Rev. 4/06

17

18

19

20

21

22

23

24

25

SCHEDULE OF BENEFITS

Supplemental Term LifeEligible EmployeesCoverage in increments ofMinimum Amount AvailableMaximum Coverage AvailableGuarantee IssueAge Reduction Schedule

Spouse Benefit

Child Benefit: Child 15 days to 6 Months Old Child More than 6 Months Old

Supplemental Term AD&DEmployee BenefitSpouse BenefitChild Benefit: Child 15 days to 6 Months Old

Child More than 6 Months Old

Age Bracket Employee LifeRate per $1,000

Spouse* LifeRate per $1,000

0-19 $0.049 $0.04920-24 $0.049 $0.04925-29 $0.049 $0.04930-34 $0.052 $0.05235-39 $0.064 $0.06440-44 $0.097 $0.09745-49 $0.150 $0.15050-54 $0.230 $0.23055-59 $0.378 $0.37860-64 $0.563 $0.56365-69 $0.904 $0.90470+ $1.709 $1.709Dependent Child Life**Employee Supplemental AD&DSpouse Supplemental AD&DChild(ren) Supplemental AD&D**

100% of Supplemental Term Life Benefit100% of the Dependent Supplemental Life Benefit

Options of $1,000, $2,000, $4,000, $5,000 or $10,000not to exceed the spouse's benefit amount

$5,000 increments to a max of $100,000;not to exceed 50% of employee's optional life benefit

$1,000Options of $1,000, $2,000, $4,000, $5,000 or $10,000

No Age Reduction

MetLifeSupplemental Term Life & AD&D

Lesser of 5X earnings or $500,000$100,000

All Active full Time Employees (30 Hours)$10,000$10,000

* Spouse rates are based on the employee's age

$1,000

This is not intended as a contract of benefits.** Child(ren) rates are per $1,000, per child unit. A child unit may consist of more than one child.

$0.240 per $1,000$0.018 per $1,000$0.018 per $1,000$0.051 per $1,000

26

IMPORTANT DISCLOSURES ABOUT OUR PLAN

Rights under the Women’s Health and Cancer Rights Act

Under Federal law, group health plans and health insurance issuers that provide medical and surgical benefits with respect to a mastectomy must provide certain benefits to a participant or beneficiary who is receiving benefits in connection with mastectomy and who elects breast reconstruction.

Specifically, the group health plan and issuer must provide coverage in a manner determined in consultation with the attending physician and the patient, for (i) reconstruction of the breast on which the mastectomy has been performed; (ii) surgery and reconstruction of the other breast to produce a symmetrical appearance; and (iii) prostheses and physical complications during all stages of mastectomy, including lymphedemas. This coverage may be subject to annual deductibles and coinsurance provisions, consistent with other benefits under the medical coverage option.

Genetic Information Nondiscrimination Act

Allegheny College is intended to comply with the Genetic Information Nondiscrimination Act of 2009. What that means to you generally is that you will not be asked or required to provide any genetic information in connection with the medical benefits before enrolling in the Plan and your genetic information will not be used for underwriting purposes. It is important that you refer to the insurance booklet for the medical benefits to more fully understand how the Genetic Information Nondiscrimination Act applies to you.

Newborns’ & Mothers Health Protection Act The Newborns’ and Mothers’ Health Protection Act (the Newborns’ Act) provides protections for mothers and their newborn children relating to the length of their hospital stays following childbirth. Our group health plan generally may not, under Federal law, 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 section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours or 96 hours.

Summary of Privacy Practices This Summary of Privacy Practices summarizes how medical information about you may be used and disclosed by Allegheny College or others in the administration of your claims, and certain rights that you have.

We are committed to protecting your personal health information. We are required by law to (1) make sure that any medical information that identifies you is kept private; (2) provide you with certain rights with respect to your medical information; (3) make certain you are notified of our legal duties and privacy practices; and (4) follow all privacy practices and procedures currently in effect.

In the course of providing health, dental, vision, and flexible spending account benefits we may use and disclose health information about you and your participating dependents without your permission for the administration of these plans and for any other health care operation as allowed or required by law. Allegheny College employees who are responsible for maintaining eligibility for these benefit programs may not share your information for employment-related purposes. Otherwise, we must obtain Rev.HBI September 2017

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your written authorization for any other use and disclosure of your medical information. We cannot retaliate against you if you refuse to sign an authorization or revoke an authorization you had previously given.

You have the right to inspect and copy your protected health information, to request corrections of your medical information, and to obtain an accounting of certain disclosures of your medical information. You also have the right to request that additional restrictions or limitations be placed on the use or disclosure of your protected health information, or that communications about your protected health information be made in different ways or at different locations.

If you believe your privacy rights have been violated, you have the right to file a complaint with us or with the Office for Civil Rights. We will not retaliate against you for making a complaint.

Notice of Special Enrollment Rights If you are declining coverage for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

If you have a new dependent as a result of a marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, or placement for adoption.

Additionally, if you or your dependents lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or become eligible for a premium assistance subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents. You must request enrollment within 60 days of the loss of Medicaid or CHIP coverage or the determination of eligibility for a premium assistance subsidy.

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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 below, 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 or dial 1-877-KIDS NOW or 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 following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of August 10, 2017. Contact your State for more information on eligibility –

ALABAMA – Medicaid FLORIDA – Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447

Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268

ALASKA – Medicaid GEORGIA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: http://dch.georgia.gov/medicaid - Click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507

ARKANSAS – Medicaid INDIANA – MedicaidWebsite: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone 1-800-403-0864

COLORADO – Health First Colorado (Colorado’s Medicaid Program) &

Child Health Plan Plus (CHP+)IOWA – Medicaid

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: Colorado.gov/HCPF/Child-Health-Plan-Plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711

Website: http://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp Phone: 1-888-346-9562

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KANSAS – Medicaid NEW HAMPSHIRE – Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218

KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570

Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

LOUISIANA – Medicaid NEW YORK – MedicaidWebsite: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447

Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831

MAINE – Medicaid NORTH CAROLINA – Medicaid Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711

Website: https://dma.ncdhhs.gov/ Phone: 919-855-4100

MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-862-4840

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP Website: http://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/medical-assistance.jsp Phone: 1-800-657-3739

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

MISSOURI – Medicaid OREGON – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

MONTANA – Medicaid PENNSYLVANIA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

Website: http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htm Phone: 1-800-692-7462

NEBRASKA – Medicaid RHODE ISLAND – Medicaid Website: http://www.ACCESSNebraska.ne.gov Phone: (855) 632-7633 Lincoln: (402) 473-7000 Omaha: (402) 595-1178

Website: http://www.eohhs.ri.gov/ Phone: 855-697-4347

NEVADA – Medicaid SOUTH CAROLINA – Medicaid Medicaid Website: https://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900

Website: https://www.scdhhs.gov Phone: 1-888-549-0820

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To see if any other states have added a premium assistance program since August 10, 2017, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137 (expires 12/31/2019)

SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059

Website: http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-program Phone: 1-800-562-3022 ext. 15473

TEXAS – Medicaid WEST VIRGINIA – Medicaid Website: http://gethipptexas.com/ Phone: 1-800-440-0493

Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-362-3002

VERMONT– Medicaid WYOMING – Medicaid Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531

VIRGINIA – Medicaid and CHIP Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282

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