employee benefits guide - university of rio grande€¦ · 2018 employee benefit guide welcome to...

2018 Employee Benefit Guide

Employee Benefits Guide


Table of Contents

Benefit Plan Contact Information…………………………………………………………………………………………………………….2

Benefit Overview…………………………………………………………………………………………………………………………………….3

Medical Insurance………………………………………………………………………………………………………………………………….12

Glossary of Terms………………………………………………………………………………………………………………………………….83

Health Savings Account………………………………………………………………………………………………………………………….87

Dental Insurance……………………………………………………………………………………………………………………………………88

Vision Insurance….......................................................................................................................................89

Basic Life and AD&D Insurance………………………………………………………………………………………………………………90

Long Term Disability Insurance………………………………………………………………………………………………………………92

Family Status Changes……………………………………………………………………………………………………………………………94

Required Annual Notices……………………………………………………………………………………………………………………….95

Bi-Weekly Insurance Rates……………………………………………………………………………………………………..……………111

Monthly Insurance Rates……………………………………………………………………………………………………………..………112


Welcome to your 2018 Employee Benefits Guide. Enclosed you will find summaries of University-paid, as well as, optional benefits offered to eligible employees at the University of Rio Grande.

An eligible employee is regularly scheduled to work at least 30 hours a week for medical insurance and 40 hours a week for all other benefits.

In this guide you will find resources that will better assist you in understanding the benefits offered to you and your families.

The following list highlights the benefits and providers enclosed in this booklet:

BENEFIT PROVIDER CONTRIBUTION(S) WEBSITE CUSTOMER SERVICE

Health Care United Health Care (UHC)

University of Rio Grande & Employee

www.myuhc.com 1-866-314-0335

Pharmacy Optum RX

University of Rio Grande & Employee

www.optumrx.com 1-800-562.6223

Dental CoreSource University of Rio Grande & Employee

www.coresource.com 1-800-282-3920

Vision VSP University of Rio Grande & Employee

www.vsp.com 1-800-877-7195

Health Savings Account (HSA)

Ohio Valley Bank University of Rio Grande & Employee

www.ovbc.com 740-446-2631

Long Term Disability

The Hartford University of Rio Grande

www.thehartford.com 1-800-523-2233

Group Term Life The Hartford University of Rio Grande

www.thehartford.com 1-800-231-5453

Retirement Savings Plan (401k)

Voya University of Rio Grande & Employee

www.voya.com 1-855-ONE-VOYA

Paid Time Off - Vacation, Personal, and Sick Leave

University of Rio Grande

University of Rio Grande

www.rio.edu 740-245-7170

Supplemental Group Life Insurance

AFLAC Employee (Voluntary)

www.aflacgroupinsurance.com 1-800-433-3036

Short Term Disability


www.aflac.com 1-800-992-3522

Critical Illness



Accident Insurance AFLAC Employee (Voluntary)


For details about your benefits, please refer to the summary plan descriptions. We have made every effort to report the information accurately in this guide; however, if a discrepancy exists between this guide and the plan document, the plan documents will govern.

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http://www.myuhc.com/

http://www.ovbc.com/

http://www.voya.com/

http://www.rio.edu/


BENEFIT CONTRIBUTION TYPE ELIGIBILITY

Medical Insurance

Employer and Employee Available first day of employment

Dental Insurance

Employer and Employee Available first day of employment

Vision Insurance Employer and Employee Available first day of the month following the hire date.

Life & Accidental Death Insurance

Employer

Available first day of employment

Long Term Disability Insurance

Employer Available after 90 days of full time employment

Retirement Savings Plan (401k)

Employer and Employee Employees may contribute first day of employment. University contributions are provided after one year of employment.

Paid Leave

Vacation Personal Sick Leave

Faculty

12 Sick Days

2 Personal Days Administrative Staff

20 Vacation Days

15 Sick Days

3 Personal Days Hourly Staff

15 Sick Days

3 Personal Days

Accrued Vacation by Service:

- 0-4 years = 10 days - 5-9 years = 15 days - >10 years = 20 days

Vacation Leave: Hourly staff earn 10 to 20 days per fiscal year based on years of service (see chart on left); Administrative staff earn 20 days per fiscal year; Faculty do not earn vacation time. Vacation leave must be taken within the fiscal year (does not roll over). Personal Leave: Faculty receive 2 personal days per academic year. Administrative and hourly employees receive 3 personal days per fiscal year. Personal leave must be taken within the fiscal year (does not roll over). Paid Sick Leave: Staff accumulate sick leave at the rate of 1.25 days per month (15 days per year). Faculty accumulate sick leave at the rate of 1.0 days per month (12 days per year). Sick leave rolls over up to a maximum of 90 days. NOTE: New employees accumulate, but are not permitted to take, paid vacation leave within their initial 90 day probationary period. New employees may take accumulated sick and/or personal leave upon hire.

Education Benefits

On-Campus – Rio Tuition Remission Benefits Off-campus - Council of Independent Colleges - Tuition Exchange Program

Tuition remission is available to full-time employees and eligible dependents at all Rio campuses. Employees are limited to 6 hours per semester and must complete their probationary period to qualify. Dependents are eligible at hire and are not limited by credit hours. Full-time employees and eligible dependents can apply for tuition-free benefits at a participating institution based on admissions requirements and availability. Please note, most institutions in the exchange accept only three (3) students per academic year so benefits are not guaranteed.

Othere Benefits:

HSA (Health Savings Account)

Payroll Direct Deposit

Use of Library, Health Services, Fitness Center, and other recreational Facilities

Free and Designated Employee Parking

Christmas and Vacation Savings Club Memberships

Bookstore and Misc. Discounts

Free admission to University-sponsored events (i.e. athletic and fine arts events)

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Medical Insurance - Full-time employees have the opportunity

to enroll in a University-sponsored medical insurance plan

within 30 days of hire or qualifying event (marriage, birth,

adoption, loss of other coverage, etc.) or during the annual

open enrollment period. These group plans are comprehensive medical plans that cover all in and out-

patient hospital services, laboratory fees, medical and mental health services, and prescription drug

benefits which are subject to deductibles and out of network copays, on a “usual, customary and

reasonable” basis. The cost of the HSA deductibles, as elected by each participating member, shall be

borne entirely by the employee. Prescription drugs (including mail order options) are included under

the medical deductible.

The University currently offers three (3) high deductible Health Savings Account (“HSA”) plans. The

employee’s share of medical insurance premiums will be based on the following:

1) Medical plan choice (option 1, 2, or 3 – see below) 2) Coverage type (employee only, employee + spouse, employee + child(ren), and employee + family) 3) Employee’s annual base pay

Please see appendix to determine your individualized rate. Premiums will be deducted from participant’s pay on a pre-tax basis.

Medical Plan 1

Preventative services (which may include immunizations, vaccines, annual wellness exams, and

medically-appropriate health screenings) are covered at 100% by insurance. All other in-

network services are subject to $3,000 (single) or $6,000 (family) embedded deductible. After

meeting the deductible, coverage is 100% (no coinsurance) for in-network services. Out-of-

network services and other terms, conditions, and exclusions are as outlined in the provider’s

certificate of coverage or summary plan description (SPD).

Medical Plan 2


medically-appropriate health screenings) are covered at 100% by insurance. All other services

are subject to $3,000 (single) or $6,000 (family) embedded deductible. After meeting the

deductible, participants must pay 10% co-insurance up to maximum out-of-pocket expenses of

$4,000 (single) or $8,000 (family) for network services. Out-of-network services and other

terms, conditions, and exclusions are as outlined in the provider’s certificate of coverage or

summary plan description (SPD).

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Medical Plan 3


medically-appropriate health screenings) are covered at 100% by insurance. All other services

are subject to $5,000 (single) or $10,000 (family) embedded deductible. After meeting the

deductible, participants must pay 25% co-insurance and pharmacy (Rx) copays of $10 (Tier 1),

$35 (Tier 2), and $60 (Tier 3) up to maximum out-of-pocket expenses of $6,000 (single) or

$12,000 (family) for network services. Out-of-network services and other terms, conditions,

and exclusions are as outlined in the provider’s certificate of coverage or summary plan

description (SPD).

Contributions to HSA - The University will contribute $500 per year (prorated for new hires) to each

employee that participates in the University’s medical plan (typically in January or February). To be

eligible, a member must establish an HSA account at Ohio Valley Bank. Employees may also make

voluntarily pre-tax contributions (via payroll deduction) to their HSA up to the IRS established limits.

Please contact Human Resources for additional information and forms.

Working Spouse Rule - Effective January 1, 2016, the University implemented a “Working Spouse” for

medical coverage. It requires a working spouse (if applicable) must enroll in his/her employer’s group

medical plan in order to be eligible to be enrolled in the University’s group medical plan. In these cases,

the spouse’s employer’s plan provides primary coverage for the spouse and the University’s medical

plan provides secondary coverage. Please contact Human Resources for additional information and

forms.

Dental Insurance - Full-time employees have the opportunity to

enroll in either a single or family University-sponsored dental

insurance plan within 30 days of hire or qualifying event

(marriage, birth, adoption, loss of other coverage, etc.) or during

the annual open enrollment period. The current plan provides benefits for preventative, restorative and

orthodontia services subject to applicable deductibles, percentage limitations and other terms and

conditions set forth in the contract with University’s insurance provider. Presently, the coverage set

forth covers: Group I (non-orthodontic preventive) paid at 100% with no deductible; Group II (Non-

orthodontic basic dental services) $25.00 deductible and paid at a rate of 80%; Group III (non-

orthodontic major dental services) $25.00 deductible and paid at a rate of 50%; Group IV (orthodontic

services) paid at a rate of 50% to a maximum benefit of $1000 per insured individual.

While the University pays the majority of the dental insurance cost (75% or more), participating

employees are responsible for portion of the premium. Employee contribution rates are outlined in the

Appendix of this guide.

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Vision Insurance - Full-time employees have the opportunity to enroll in either a

single or family University-sponsored vision insurance plan within 30 days of hire or

qualifying event (marriage, birth, adoption, loss of other coverage, etc.) or during the

annual open enrollment period. Vision coverage is offered as a stand-alone benefit.

The current plan that provides benefits for an annual eye exam, annual lens (or

contact lens) replacement, and biannual frame replacement subject to applicable deductibles,

percentage limitations and other terms and conditions set forth in the contract with University’s

insurance provider.

While the University pays the majority of the vision insurance cost (75% or more), participating

employees are responsible for portion of the premium. Employee contribution rates are outlined in the

Appendix of this guide.

Basic Life and Accident Insurance – The University provides all full-time employees

basic life and accidental death and dismemberment insurance benefits according to

the following:

A. Life Insurance – Base annual salary (X 1) rounded to the next higher

$1,000 up to $190,000 maximum.

B. Accidental Death & Dismemberment Insurance – Base annual salary (X 1) rounded to the

next higher $1,000 up to $190,000 maximum

Please note: The benefit amounts above will reduce by 35% at age 70 and 50% at age 75.

These benefits terminate when employee separates from the University.

Long-Term Disability (LTD) Insurance - The University provides full-time employees with monthly

income-protection benefits in cases of a (non-work related) long-term disability, injury, illness. The

coverage is effective one month after employment and is based on 70% of the monthly earnings or

$5,000 per month, whichever is less, and has a waiting period of ninety (90) days. Other restrictions

(such as reduced payments for age) may apply.

Social Security Retirement - All employees are covered by Social Security at the University of Rio

Grande. University contributions and employee deductions, as mandated by law, are submitted each

pay.

Retirement Savings Plan

The University of Rio Grande offers a “defined contribution” plan under which

eligible employees and the University make contributions to a 401(k) retirement

saving account managed by the member. Under this type of plan, the employee

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selects how assets are invested and investment results (market gains or losses) are credited to the

member’s account. Upon retirement, employees may elect a lump sum payment or monthly installment

payments.

Employee Contributions (Elective Deferrals) – Full-time employees may make elective (voluntary)

deferrals to the plan immediately upon date of hire. Contributions (% of pay or fixed amount per pay)

are made on a pre-tax basis and can be changed at any time. Annual IRS contribution limits apply.

Employer Contributions –The University will make an employer contribution for AY 2017-2018 for

eligible participants in an amount equal to 4% of his/her Compensation for the AY.

Eligibility - Full-time employees, age 21+, are eligible for the plan upon completing one (1) year

of eligibility service. A "Year of Eligibility Service" is the 12-month period beginning on the date

an employee is hired and ending on the following one-year anniversary date. In order to be

credited with a Year of Eligibility Service, an employee must complete 1,000 hours of service

within the 12-month period. If the employee does not complete 1,000 hours of service in the

initial 12-month period, each following 12-month period of employment ending on the

anniversary date will be reviewed until the employee completes 1,000 hours of service within an

anniversary year.

Investments under the Retirement Savings Plan - Each employee will have the opportunity to

direct the investment of his/her account balance among any of the investments permitted by

the plan. The plan administrator will select the investment options to be offered to participants

and will monitor the selected investment choices to ensure that they continue to meet the

stated investment objectives for which they were selected, as well as performance criteria

relative to other investment alternatives of the same type or class. Employees will be provided

detailed information about the investment options and will be responsible for reviewing

investment information, plus any other information necessary to make informed decisions with

respect to selections made.

Distributions from the Retirement Savings Plan - An employee’s account balance will become

payable when he/she separates employment, including retirement, resignation, termination,

lay-off, death or disability. Benefit will be paid as soon as administratively feasible following the

employment separation.

Benefit Payments – Upon separation of employment, retirement savings plan members will be

given the opportunity to elect either a single lump sum payment or equal monthly installments

for a period of up to sixty (60) months. Subject to federal law and contrary plan provisions, a

member may “rollover” his/her payment to another tax-qualified retirement plan or to an IRA.

On-Campus Education Benefits – The University provides all full-time employees and eligible

dependents (see definition below) tuition benefits for courses offered by the University of Rio Grande

and Rio Grande Community College. Employees and their eligible dependents must first apply annually

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for available grants and scholarships for tuition and fees (up to 100% of the actual cost of such tuition

and fees). Should such available grant and scholarship funding be insufficient to pay the full cost of

attendance, then the University will only charge $5.00 per credit hour for tuition for employees and

eligible dependents.

Dependents - Defined as any child or spouse who qualifies as a dependent on an employee’s

federal tax return per current IRS Guidelines.

Limitations - The fee remittance is limited to six (6) credit hours per semester for employees.

Dependents are not limited to the number of hours attempted.

Approval – Employees requesting education benefits for themselves or eligible family members

must apply for benefits and seek approval according to the following:

1. Obtain a Tuition Remission Form from the Office of Human Resources.

2. Complete the form including course details and cost information.

3. Seek approval from immediate supervisor, Human Resources Director, and

Division Head prior to the completion of registration (for credit-bearing courses)

and prior to the second meeting of the class (for continuing education/non-

credit courses).

Repayment - If an employee resigns while utilizing the tuition benefits, the employee and/or

dependent shall be responsible for the cost of the course(s) on a prorated basis.

Off-Campus Education Benefits - University of Rio Grande continues

to be a proud member of the Council for Independent Colleges (CIC).

One of the benefits for being a member is the Tuition Exchange

Program (CIC-TEP) for our employees and family members. This

benefit is tax free to employees.

The CIC Tuition Exchange Program (CIC–TEP) is a network of CIC colleges and universities willing to

accept, tuition-free, students from families of full-time employees of other CIC–TEP institutions. CIC–

TEP was planned and developed more than two decades ago with a goal of creating a true-access

program, without any costly fees or cumbersome credit-debit limitations. Each participating institution

in the network agrees to import a limited number of students on the same admission basis as they

accept all other students, without regard to the number of students it exports. The true-access

component is only one of the many special features that the program offers.

With a current membership of nearly 425 participating institutions in CIC–TEP, participation is at its

highest level yet, allowing for a large selection of institutions. Please visit the link below of participating

colleges and universities at: https://www.cic.edu/member-services/tuition-exchange-

program/participating-institutions

You or your family can attend tuition-free to a participating member’s institution based on several

items. You will need to notify the Human Resource Office of your intentions to apply so we can send a

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https://www.cic.edu/member-services/tuition-exchange-program/participating-institutions

https://www.cic.edu/member-services/tuition-exchange-program/participating-institutions


form to them and then you will need to apply just like any other student to that institution. Most

institutions will have a limit of three (3) students they will accept each school year. Our

recommendation would be that you or your family members apply to several schools in case you do not

make the top three (3) at the school of your choice.

Worker’s Compensation Insurance - All employees are covered by Worker’s Compensation Insurance

paid by the University. Employees are required to file the appropriate State of Ohio form when leaving

the state on University-related business. Insurance for payment of certain medical expenses and loss of

income caused by injuries incurred in work-related accidents must be reported immediately to the

employee’s supervisor and Office of Human Resources and filed on the appropriate Incident Form.

Unemployment Insurance - All employees are covered by Unemployment Insurance paid by the

University. Coverage is provided to eligible claimants for loss of employment through no fault of their

own. The Ohio Bureau of Employment Services determines eligibility of claims and payments.

Use of University Facilities

Davis Library - All employees are accorded use of Davis Library without payment of fines or fees.

Fitness Center – All employees are accorded use of the Fitness Center, located Lyne Center, at

no cost. Memberships for spouses and/or dependents (age 18 or older) are available at

a discounted rate.

Health Services - All employees are accorded use of Health Service, located in the Rhodes

Student Center, for treatment of minor ailments, emergencies and specified

inoculations, either free or for a nominal fee.

Parking Facilities – All employees will be provided one free parking pass.

Admission to University Activities - The University Employee identification card entitles

employees and dependents free or reduced admission to University sponsored events

including: athletic events (except NAIA Conference and Tournament games), open

recreation, fitness center and swimming, community forums, plays, concerts and all

other activities sponsored by the Student Programming Board or the University.

Bookstore Discounts – All employees shall, upon presentation of a valid Employee Identification

Card, be given a 10% discount on textbooks and 15% on non-textbook items purchased at the

University Bookstore.

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Voluntary Aflac Coverage - The University of Rio Grande is pleased to offer

Group Voluntary Benefits Offerings through AFLAC. These group products are

being offered at DISCOUNTED GROUP RATES. Information packets have been

created to help you understand your options and costs and are available in the

Office of Human Resources (Allen Hall, Room 101).

Coverage is available to all regularly scheduled full and part-time URG/RGCC employees who work 20+

hours per week (adjunct faculty, student employees, and other seasonal/temporary employees are not

eligible).

PLAN OPTIONS, DESCRIPTIONS, AND FEATURES:

1. Group Accident Insurance –Plan pays a benefit for the treatment of injuries suffered as the result of a covered accident (i.e. fractures, dislocations, lacerations, etc.). Benefits are paid regardless of any other health insurance benefits the insured may receive. This plan includes an annual wellness benefit.

Plan Features:

GUARANTEED ISSUE FOR ALL EMPLOYEES

No limit on the number of claims.

Benefits available for Spouse and/or Dependent Children.

Provides 24-hour (on and off-job) protection.

Supplements and pays regardless of any other insurance programs.

Benefits for both inpatient and outpatient Treatment of covered accidents.

Payroll Deduction - Premiums are paid by convenient payroll deduction.

2. Group Critical Illness Insurance –Plan provides a lump-sum benefit payment to cover out-of-pocket medical expenses and the costs associated with life-changes following a covered critical illness (i.e. cancer, heart attack, stroke, etc.).

Plan Features:

$10,000 GUARANTEED ISSUE FOR ALL NEW EMPLOYEES

Cash benefits paid directly to the Insured following the diagnosis of each covered critical illness.

Spouse coverage available.

Each Dependent Child is covered at 25% of the primary Insured amount at no additional charge.

Benefit amounts available for $5,000 up to $50,000 for employees and $25,000 for spouse.

Annual Health Screening Benefits included.

The plan is portable (with certain stipulations).

Level premium rates based upon the applicant's age as of the time of application. Rates cannot be individually increased on a particular Insured due to a change in age, health or individual claim.

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http://www.aflac.com/


3. Group Term Life Insurance – Offered in 10 or 20 year terms, these life and accidental death policies provide benefits to protect your families in times of need. Plans can be customized to meet individual needs.

Guaranteed-Issue Coverage for new employees

$25,000 employee, $10,000 spouse and $5,000 per child (with 10% employee participation in Term Life)

Simplified-Issue Coverage: (subject to evidence of insurability)

Employee: Up to $100,000 Spouse: Up to $50,000, not to exceed employee’s amount Children: Up to $25,000, not to exceed employee’s amount

Plan Features:

The Accidental Death, Loss of Sight and Dismemberment Benefit Riders are included with the plan, and pays an additional benefit for covered losses.

A Waiver of Premium for Total Disability Benefit is built into the plan (for employee only) and waives all plan premiums if the insured is totally disabled for more than six consecutive months.

An Accelerated Benefit for Terminal Illness is built into the plan and will pay 50% of the Death Benefit if an insured is diagnosed with a terminal illness.

Employees do not have to take a physical to be eligible for coverage; however, if the coverage elected is above the guaranteed-issue amount, evidence of insurability will be required.

This plan is portable, which means you can take the coverage with you (with certain stipulations).

4. Individual Short-Term Disability – Plan offers income protection in the event of a short-term illness or injury requiring you to be off-work. These plans are offered on an individual basis (not group rated) to meet your personal needs and budget.

Plan Features:

GUARANTEED ISSUE FOR ALL EMPLOYEES

No medical underwriting

Available for purchase to the age of 74

Guaranteed Renewable to the age of 75

Up to $3,000 per month in coverage

Waiver of Premium benefit for prolonged disability

Individual coverage allows you to personalize your coverage

Portable – Stays with you even if you change or leave employment

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You have three options for your medical coverage-

Please review the following information to determine which plan is right for you and your family. All medical plans will be administered by United Health Care of Ohio. Plan 1 has an embedded deductible and plans 2 and 3 have a non-embedded deductible.

Medical Plan 1: Health Savings Account (HSA) 3,000/6,000 100

This plan offers a choice between network and out-of-network benefits. You make this choice each time you or a covered family member needs medical care. You have a $3,000 individual deductible or a $6,000 family (Embedded) deductible. (Embedded) The individual deductible is per person up to two dependents per plan. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use.


This plan is similar to the 4XT plan offering you the greatest level of benefits through the United Health Care of Ohio network. With this plan you have a $3,000 individual or a $6,000 family deductible. After meeting the deductible, participants must pay 10% co-insurance up to maximum out-of-pocket expenses of $4,000 (single) or $8,000 (family) for network services. (Embedded) The individual deductible is per person up to two dependents per plan. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use.


With this plan you have a $5,000 individual or a $10,000 family deductible. After meeting the

deductible, participants must pay 25% co-insurance up to maximum out-of-pocket expenses of $6,000

(single) or $12,000 (family) for network services. (Embedded) The individual deductible is per person up

to two dependents per plan. You must pay all the costs up to the deductible amount before this plan

begins to pay for covered services you use.

Prescription Plan

The prescription plan for Medical Plans 1 and 2 are based on a 4-tiered formulary. Prescriptions are subject to the deductibles. After the deductible is met, your formulary prescriptions will be paid at 100% the rest of the calendar year. The prescription plan for Medical Plan 3 is also subject to the deductible and participants must pay 25% co-insurance and pharmacy (Rx) copays of $10 (Tier 1), $35 (Tier 2), and $60 (Tier 3) up to maximum out-of-pocket expenses of $6,000 (single) or $12,000 (family) for network services. This is only a summary. If you need more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.myuhc.com or by calling 1-866-314-0335.

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Benefit Summary

Ohio - Choice Plus HSA - Plan AG4I Modified

What is a benefit summary? This is a summary of what the plan does and does not cover. This summary can also help you understand your share of the costs. It’s always best to review your Certificate of Coverage (COC) and check your coverage before getting any health services, when possible.

What are the benefits of the Choice Plus Plan with an HSA? Get network freedom and an HSA.

A network is a group of health care providers and facilities that have a contract with UnitedHealthcare. You can receive care and services from anyone in or out of our network, but you save money when you use the network. You can save money when you use the health savings account (HSA) and the network. Are you a member?

Easily manage your benefits online at myuhc.com® and on the go with the UnitedHealthcare Health4Me™ mobile app. For questions, call the member phone number on your health plan ID card.

> There's coverage if you need to go out of the network. Out-of-network means that a provider does not have a contract with us. Choose what's best for you. Just remember out-of-network providers will likely charge you more.

> There's no need to choose a primary care provider (PCP) or get referrals to see a specialist. Consider a PCP; they can be helpful in managing your care.

> Preventive care is covered 100% in our network.

> You can open a health savings account (HSA). An HSA is a personal bank account to help you save and pay for your health care, and help you save on taxes.

Not enrolled yet? Learn more about this plan and search for network doctors or hospitals at welcometouhc.com/choiceplushsa or call 1-866-873-3903, TTY 711, 8 a.m. to 8 p.m. local time, Monday through Friday.

Benefits At-A-Glance What you may pay for network care

This chart is a simple summary of the costs you may have to pay when you receive care in the network. It doesn’t include all of the deductibles and co-payments you may have to pay. You can find more benefit details beginning on page 2.

Co-insurance (Your cost for an office visit)

0%

Individual Deductible Co-insurance (Your cost before the plan starts to pay) (Your cost share after the deductible)

$3,000 0%

This Benefit Summary is to highlight your Benefits. Don't use this document to understand your exact coverage for certain conditions. If this Benefit Summary conflicts with the Certificate of Coverage (COC), Riders, and/or Amendments, those documents are correct. Review your COC for an exact description of the services and supplies that are and are not covered, those which are excluded or limited, and other terms and conditions of coverage.

Benefits are underwritten by UnitedHealthcare Insurance Company

Page 1 of 18

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Your Costs In addition to your premium (monthly) payments paid by you or your employer, you are responsible for paying these costs.

Your cost if you use Network Benefits

Your cost if you use Out-of-Network Benefits

Deductible - Combined Medical and Pharmacy What is a deductible?

The deductible is the amount you have to pay for covered health care services (common medical event) before your health plan begins to pay. The deductible may not apply to all services. You may have more than one type of deductible.

> All individual deductible amounts will count towards meeting the family deductible, but an individual will not have to pay more than the individual deductible amount.

Medical Deductible - Individual

Medical Deductible - Family

$3,000 per year

$6,000 per year

$3,000 per year

$6,000 per year Out-of-Pocket Limit - Combined Medical and Pharmacy

What is an out-of-pocket limit?

The most you pay during a policy year before your health plan begins to pay 100%. Once you reach the out-of-pocket limit, your health plan will pay for all covered services. This will not include any amounts over the amount we allow when you see an out-of-network provider.

> Your co-pays, co-insurance and deductibles (including pharmacy) count towards meeting the out-of-pocket limit.

> All individual out-of-pocket limit amounts will count towards meeting the family out-of-pocket limit, but an individual will not have to pay more than the individual out-of-pocket limit amount.

Out-of-Pocket Limit - Individual

Out-of-Pocket Limit - Family

$3,000 per year

$6,000 per year

$6,000 per year

$12,000 per year

NOTICE: If you or your family members are covered by more than one health care plan, you may not be able to collect benefits from both plans. Each plan may require you to follow its rules or use specific doctors and hospitals, and it may be impossible to comply with both plans at the same time. Read all of the rules very carefully, including the coordination of benefits section, and compare them with the rules of any other plan that covers you or your family.

Page 2 of 18

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Your Costs What is co-insurance?

Co-insurance is your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. Co-insurance is not the same as a co-payment (or co-pay). What is a co-payment?

A co-payment (co-pay) is a fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. You will pay a co-pay or the allowed amount, whichever is less. The amount can vary by the type of covered health care service. Please see the specific common medical event to see if a co-pay applies and how much you have to pay. What is Prior Authorization?

Prior Authorization is getting approval before you can get access to medicine or services. Services that require prior authorization are noted in the list of Common Medical Events. To get approval, call the member phone number on your health plan ID card.

Want more information?

Find additional definitions in the glossary at justplainclear.com.

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Your Costs Following is a list of services that your plan covers in alphabetical order. In addition to your premium (monthly) payments paid by you or your employer, you are responsible for paying these costs.

Common Medical Event Your cost if you use Network Benefits


Ambulance Services Emergency 0% co-insurance, after the medical

deductible has been met. 0% co-insurance, after the network medical deductible has been met.

30% co-insurance, after the medical deductible has been met.

Prior Authorization is required for Non-Emergency Ambulance.

Non-Emergency 0% co-insurance, after the medical deductible has been met.


Clinical Trials (Including Cancer Clinical Trials) The amount you pay is based on where the covered health service is provided.

Prior Authorization is required. This prior authorization requirement does not apply to cancer clinical trials.


Congenital Heart Disease (CHD) Surgeries 0% co-insurance, after the medical deductible has been met.


Prior Authorization is required.

Dental Services - Accident Only 0% co-insurance, after the medical deductible has been met.

0% co-insurance, after the network medical deductible has been met.

Prior Authorization is required. Prior Authorization is required.

Diabetes Services Diabetes Self Management and Training/Diabetic Eye Examinations/ Foot Care:

Diabetes Self Management Items:

The amount you pay is based on where the covered health service is provided.

The amount you pay is based on where the covered health service is provided under Durable Medical Equipment or in the Prescription Drug Rider.

Prior Authorization is required for Durable Medical Equipment that costs more than $1,000.

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Your Costs Common Medical Event Your cost if you use

Network Benefits Your cost if you use

Out-of-Network Benefits

Durable Medical Equipment Limited to a single purchase of a type of Durable Medical Equipment (including repair and replacement) every 3 years. This limit does not apply to wound vacuums.




Emergency Health Services - Outpatient 0% co-insurance, after the medical deductible has been met.


Notification is required if confined in an Out-of-Network Hospital.

Gender Dysphoria The amount you pay is based on where the covered health service is provided.

Prior Authorization is required for certain services.

Hearing Aids Limited to $2,500 per year and a single purchase (including repair and replacement) per hearing impaired ear every 3 years.



Home Health Care Limited to 60 visits per year. 0% co-insurance, after the medical

deductible has been met. 30% co-insurance, after the medical deductible has been met.


Hospice Care 0% co-insurance, after the medical deductible has been met.


Prior Authorization is required for Inpatient Stay.

Hospital - Inpatient Stay 0% co-insurance, after the medical deductible has been met.



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Lab, X-Ray and Diagnostics - Outpatient 0% co-insurance, after the medical deductible has been met.



Lab, X-Ray and Major Diagnostics - CT, PET, MRI, MRA and Nuclear Medicine - Outpatient 0% co-insurance, after the medical deductible has been met.



Mental Health Services Inpatient: 0% co-insurance, after the medical

deductible has been met.







Outpatient:

Partial Hospitalization/Intensive Outpatient Treatment:

Neurobiological Disorders – Autism Spectrum Disorder Services Inpatient: 0% co-insurance, after the medical








Outpatient:


Ostomy Supplies 0% co-insurance, after the medical deductible has been met.


Pharmaceutical Products - Outpatient This includes medications given at a doctor’s office, or in a Covered Person’s home.



Physician Fees for Surgical and Medical Services 0% co-insurance, after the medical deductible has been met.


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Physician’s Office Services - Sickness and Injury Primary Physician Office Visit 0% co-insurance, after the medical


30% co-insurance, after the medical deductible has been met. 30% co-insurance, after the medical deductible has been met. Prior Authorization is required for Breast Cancer Genetic Test Counseling (BRCA) for women at higher risk for breast cancer.

Specialist Physician Office Visit

Pregnancy - Maternity Services The amount you pay is based on where the covered health service is provided.

Prior Authorization is required if the stay in the hospital is longer than 48 hours following a normal vaginal delivery or 96 hours following a cesarean section delivery.

Prescription Drug Benefits Prescription drug benefits are shown in the Prescription Drug benefit summary.

Preventive Care Services Physician Office Services, Scopic Procedures, Lab, X-Ray or other preventive tests. The total amount payable for screening mammography performed within the State of Ohio shall not exceed 130% of the lowest Medicare reimbursement rate in Ohio for screening mammography or a component of screening mammography. For Network Benefits, you are not responsible for any amount. For Out-of-Network Benefits, you are only responsible for deductibles and Co-payments and/or Co-insurance up to the total amount payable.

You pay nothing. A deductible does not apply.


Certain preventive care services are provided as specified by the Patient Protection and Affordable Care Act (ACA), with no cost-sharing to you. These services are based on your age, gender and other health factors. UnitedHealthcare also covers other routine services that may require a co-pay, co-insurance or deductible.

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Prosthetic Devices Limited to a single purchase of each 0% co-insurance, after the medical 30% co-insurance, after the medical


Prior Authorization is required for Prosthetic Devices that costs more than $1,000.

type of prosthetic device every 3 years. deductible has been met.

Reconstructive Procedures The amount you pay is based on where the covered health service is provided.


Rehabilitation and Habilitative Services - Outpatient Therapy and Manipulative Treatment Limited to: 20 visits of physical therapy. 20 visits of occupational therapy. 20 visits of speech therapy. 20 visits of pulmonary rehabilitation. 36 visits of cardiac rehabilitation. 30 visits of post-cochlear implant aural therapy. 20 visits of cognitive rehabilitation therapy. 20 visits of manipulative treatments.




Scopic Procedures - Outpatient Diagnostic and Therapeutic Diagnostic/therapeutic scopic procedures include, but are not limited to colonoscopy, sigmoidoscopy and endoscopy.



Skilled Nursing Facility / Inpatient Rehabilitation Facility Services Limited to 60 days per year. 0% co-insurance, after the medical



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Substance Use Disorder Services Inpatient: 0% co-insurance, after the medical








Outpatient:


Surgery - Outpatient 0% co-insurance, after the medical deductible has been met.



Therapeutic Treatments - Outpatient Therapeutic treatments include, but are not limited to dialysis, intravenous chemotherapy, intravenous infusion, medical education services and radiation oncology.




Transplantation Services Network Benefits must be received at a designated facility.

The amount you pay is based on where the covered health service is provided. Prior Authorization is required. Prior Authorization is required.

Urgent Care Center Services 0% co-insurance, after the medical deductible has been met.


Virtual Visits Network Benefits are available only when services are delivered through a Designated Virtual Visit Network Provider. Find a Designated Virtual Visit Network Provider Group at myuhc.com or by calling Customer Care at the telephone number on your ID card. Access to Virtual Visits and prescription services may not be available in all states or for all groups.



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Services your plan does not cover (Exclusions) It is recommended that you review your COC, Amendments and Riders for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.

Alternative Treatments Acupressure; acupuncture; aromatherapy; hypnotism; massage therapy; rolfing; art therapy, music therapy, dance therapy, horseback therapy; and other forms of alternative treatment as defined by the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health. This exclusion does not apply to Manipulative Treatment and non-manipulative osteopathic care for which Benefits are provided as described in Section 1 of the COC.

Dental Dental care (which includes dental X-rays, supplies and appliances and all associated expenses, including hospitalizations and anesthesia). This exclusion does not apply to accident-related dental services for which Benefits are provided as described under Dental Services - Accident Only or to dental services as described under Surgery - Outpatient in Section 1 of the COC. This exclusion does not apply to dental care (oral examination, X-rays, extractions and non-surgical elimination of oral infection) required for the direct treatment of a medical condition for which Benefits are available under the Policy, limited to: Transplant preparation; prior to initiation of immunosuppressive drugs; the direct treatment of acute traumatic Injury, cancer or cleft palate. Dental care that is required to treat the effects of a medical condition, but that is not necessary to directly treat the medical condition, is excluded. Examples include treatment of dental caries resulting from dry mouth after radiation treatment or as a result of medication. Endodontics, periodontal surgery and restorative treatment are excluded. Preventive care, diagnosis, treatment of or related to the teeth, jawbones or gums. Examples include: extraction, restoration and replacement of teeth; medical or surgical treatments of dental conditions; and services to improve dental clinical outcomes. This exclusion does not apply to preventive care for which Benefits are provided under the United States Preventive Services Task Force requirement or the Health Resources and Services Administration (HRSA) requirement. This exclusion also does not apply to accidental-related dental services for which Benefits are provided as described under Dental Services - Accidental Only in Section 1 of the COC. Dental implants, bone grafts and other implant-related procedures. This exclusion does not apply to accident-related dental services for which Benefits are provided as described under Dental Services - Accident Only in Section 1 of the COC. Dental braces (orthodontics).

Devices, Appliances and Prosthetics Devices used specifically as safety items or to affect performance in sports-related activities. Orthotic appliances that straighten or re-shape a body part. Examples include foot orthotics and some types of braces, including over-the-counter orthotic braces. Cranial banding. The following items are excluded, even if prescribed by a Physician: blood pressure cuff/monitor; enuresis alarm; non-wearable external defibrillator; trusses and ultrasonic nebulizers. Devices and computers to assist in communication and speech except for speech aid devices and tracheo-esophogeal voice devices for which Benefits are provided as described under Durable Medical Equipment in Section 1 of the COC. Oral appliances for snoring. Repairs to prosthetic devices due to misuse, malicious damage or gross neglect. Replacement of prosthetic devices due to misuse, malicious damage or gross neglect or to replace lost or stolen items.

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Services your plan does not cover (Exclusions)

Drugs Prescription drug products for outpatient use that are filled by a prescription order or refill. Self-injectable medications. This exclusion does not apply to medications which, due to their characteristics (as determined by us), must typically be administered or directly supervised by a qualified provider or licensed/certified health professional in an outpatient setting. Non-injectable medications given in a Physician's office. This exclusion does not apply to non-injectable medications that are required in an Emergency and consumed in the Physician's office. Over-the-counter drugs and treatments. Growth hormone therapy. New Pharmaceutical Products and/or new dosage forms until the date they are assigned to a tier by our Pharmaceutical Product List Management Committee or December 31st of the following calendar year. A Pharmaceutical Product that contains (an) active ingredient(s) available in and therapeutically equivalent (having essentially the same efficacy and adverse effect profile) to another covered Pharmaceutical Product. Such determinations may be made up to six times during a calendar year. A Pharmaceutical Product that contains (an) active ingredient(s) which is (are) a modified version of and therapeutically equivalent (having essentially the same efficacy and adverse effect profile) to another covered Pharmaceutical Product. Such determinations may be made up to six times during a calendar year. A Pharmaceutical Product with an approved biosimilar or a biosimilar and therapeutically equivalent (having essentially the same efficacy and adverse effect profile) to another covered Pharmaceutical Product. For the purpose of this exclusion a "biosimilar" is a biological Pharmaceutical Product approved based on showing that it is highly similar to a reference product (a biological Pharmaceutical Product) and has no clinically meaningful differences in terms of safety and effectiveness from the reference product. Such determinations may be made up to six times per calendar year. Certain Pharmaceutical Products for which there are therapeutically equivalent (having essentially the same efficacy and adverse effect profile) alternatives available, unless otherwise required by law or approved by us. Such determinations may be made up to six times during a calendar year.

Experimental, Investigational or Unproven Services Experimental or Investigational and Unproven Services and all services related to Experimental or Investigational and Unproven Services are excluded. The fact that an Experimental or Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Benefits if the procedure is considered to be Experimental or Investigational or Unproven in the treatment of that particular condition. Refer to External Review for Experimental or Investigational Services in Section 6 of the COC for exceptions to this exclusion. This exclusion does not apply to Covered Health Services provided during a clinical trial for which Benefits are provided as described under Clinical Trials in Section 1 of the COC.

Foot Care Routine foot care. Examples include the cutting or removal of corns and calluses. This exclusion does not apply to preventive foot care for Covered Persons with diabetes for which Benefits are provided as described under Diabetes Services in Section 1 of the COC. Nail trimming, cutting, or debriding. Hygienic and preventive maintenance foot care. Examples include: cleaning and soaking the feet; applying skin creams in order to maintain skin tone. This exclusion does not apply to preventive foot care for Covered Persons who are at risk of neurological or vascular disease arising from diseases such as diabetes. Treatment of flat feet. Treatment of subluxation of the foot. Shoes. Shoe orthotics. Shoe inserts.

Gender Dysphoria Cosmetic Procedures including the following: Abdominoplasty. Blepharoplasty. Breast enlargement, including augmentation mammoplasty and breast implants. Body contouring, such as lipoplasty. Brow lift. Calf implants. Cheek, chin, and nose implants. Injection of fillers or neurotoxins. Face lift, forehead lift, or neck tightening. Facial bone remodeling for facial feminizations. Hair removal. Hair transplantation. Lip augmentation. Lip reduction. Liposuction. Mastopexy. Pectoral implants for chest masculinization. Rhinoplasty. Skin resurfacing. Thyroid cartilage reduction; reduction thyroid chondroplasty; trachea shave (removal or reduction of the Adam’s Apple). Voice modification surgery. Voice lessons and voice therapy.

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Medical Supplies Prescribed or non-prescribed medical supplies and disposable supplies. Examples include: compression stockings, ace bandages, gauze and dressings, urinary catheters. This exclusion does not apply to:

• Disposable supplies necessary for the effective use of Durable Medical Equipment for which Benefits are provided as described under Durable Medical Equipment in Section 1 of the COC.

• Diabetic supplies for which Benefits are provided as described under Diabetes Services in Section 1 of the COC. • Ostomy supplies for which Benefits are provided as described under Ostomy Supplies in Section 1 of the COC.

Tubing and masks, except when used with Durable Medical Equipment as described under Durable Medical Equipment in Section 1 of the COC.

Mental Health, Neurobiological/Autism Spectrum, and Substance Use Disorders Services performed in connection with conditions not classified in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Outside of an initial assessment, services as treatments for a primary diagnosis of conditions and problems that may be a focus of clinical attention, but are specifically noted not to be mental disorders within the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. This does not apply to sleep apnea treatment and sleep apnea monitors. Outside of initial assessment, services as treatments for the primary diagnoses of learning disabilities, conduct and impulse control disorders, pyromania, kleptomania, gambling disorder, and paraphilic disorder. Educational services that are focused on primarily building skills and capabilities in communication, social interaction and learning. Tuition or services that are school-based for children and adolescents required to be provided by, or paid for, by the school under the Individuals with Disabilities Education Act. Outside of initial assessment, unspecified disorders for which the provider is not obligated to provide clinical rationale as defined in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Transitional Living services.

Nutrition Individual and group nutritional counseling including non-specific disease nutritional education such as general good eating habits, calorie control or dietary preferences. This exclusion does not apply to preventive care for which Benefits are provided under the United States Preventive Services Task Force requirement. This exclusion also does not apply to medical nutritional education services that are provided as part of treatment for a disease by appropriately licensed or registered health care professionals when both of the following are true:

• Nutritional education is required for a disease in which patient self-management is an important component of treatment.

• There exists a knowledge deficit regarding the disease which requires the intervention of a trained health professional.

Enteral feedings, even if the sole source of nutrition. Infant formula and donor breast milk. Nutritional or cosmetic therapy using high dose or mega quantities of vitamins, minerals or elements and other nutrition-based therapy. Examples include supplements, electrolytes, and foods of any kind (including high protein foods and low carbohydrate foods).

Personal Care, Comfort or Convenience Television; telephone; beauty/barber service; guest service. Supplies, equipment and similar incidental services and supplies for personal comfort. Examples include: air conditioners, air purifiers and filters, dehumidifiers; batteries and battery chargers; breast pumps (This exclusion does not apply to breast pumps for which Benefits are provided under the Health Resources and Services Administration (HRSA) requirement); car seats; chairs, bath chairs, feeding chairs, toddler chairs, chair lifts, recliners; exercise equipment; home modifications such as elevators, handrails and ramps; hot and cold compresses; hot tubs; humidifiers; Jacuzzis; mattresses; medical alert systems; motorized beds; music devices; personal computers, pillows; power-operated vehicles; radios; saunas; stair lifts and stair glides; strollers; safety equipment; treadmills; vehicle modifications such as van lifts; video players, whirlpools.

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Physical Appearance Cosmetic Procedures. See the definition in Section 9 of the COC. Examples include: pharmacological regimens, nutritional procedures or treatments. Scar or tattoo removal or revision procedures (such as salabrasion, chemosurgery and other such skin abrasion procedures). Skin abrasion procedures performed as a treatment for acne. Liposuction or removal of fat deposits considered undesirable, including fat accumulation under the male breast and nipple. Treatment for skin wrinkles or any treatment to improve the appearance of the skin. Treatment for spider veins. Hair removal or replacement by any means. Replacement of an existing breast implant if the earlier breast implant was performed as a Cosmetic Procedure. Note: Replacement of an existing breast implant is considered reconstructive if the initial breast implant followed mastectomy. See Reconstructive Procedures in Section 1 of the COC. Treatment of benign gynecomastia (abnormal breast enlargement in males). Physical conditioning programs such as athletic training, body- building, exercise, fitness, flexibility, and diversion or general motivation. Weight loss programs whether or not they are under medical supervision. Weight loss programs for medical reasons are also excluded. Wigs regardless of the reason for the hair loss.

Procedures and Treatments Excision or elimination of hanging skin on any part of the body. Examples include plastic surgery procedures called abdominoplasty and brachioplasty. Medical and surgical treatment of excessive sweating (hyperhidrosis). Medical and surgical treatment for snoring, except when provided as a part of treatment for documented obstructive sleep apnea. Rehabilitation services and Manipulative Treatment to improve general physical condition that are provided to reduce potential risk factors, where significant therapeutic improvement is not expected, including routine, long-term or maintenance/preventive treatment. Rehabilitation services for speech therapy except as required for treatment of a speech impediment or speech dysfunction that results from Injury, stroke, cancer, Congenital Anomaly or Autism Spectrum Disorder. Outpatient cognitive rehabilitation therapy except as Medically Necessary following a post- traumatic brain Injury or cerebral vascular accident. Psychosurgery. Physiological modalities and procedures that result in similar or redundant therapeutic effects when performed on the same body region during the same visit or office encounter. Biofeedback. Services for the evaluation and treatment of temporomandibular joint syndrome (TMJ) and craniomandibular joint disorders (CMJ), whether the services are considered to be medical or dental in nature. Upper and lower jawbone surgery, orthognathic surgery, and jaw alignment. This exclusion does not apply to reconstructive jaw surgery required for Covered Persons because of a Congenital Anomaly, acute traumatic Injury, dislocation, tumors, cancer, obstructive sleep apnea or as necessary to safeguard a Covered Person's health due to a non-dental physiological impairment. Surgical and non-surgical treatment of obesity. This exclusion does not apply to screening and counseling for obesity for which Benefits are provided under the "A" and "B" recommendations of the United States Preventive Services Task Force under Preventive Care Services in Section 1 of the COC. Stand-alone multi-disciplinary smoking cessation programs. These are programs that usually include health care providers specializing in smoking cessation and may include a psychologist, social worker or other licensed or certified professional. The programs usually include intensive psychological support, behavior modification techniques and medications to control cravings. This exclusion does not apply to tobacco use screening and counseling as provided under Preventive Care Services in Section 1 of the COC. Breast reduction surgery except as coverage is required by the Women's Health and Cancer Rights Act of 1998 for which Benefits are described under Reconstructive Procedures in Section 1 of the COC. In vitro fertilization regardless of the reason for treatment.

Providers Services performed by a provider who is a family member by birth or marriage. Examples include a spouse, brother, sister, parent or child. This includes any service the provider may perform on himself or herself. Services performed by a provider with your same legal residence. Services provided at a Freestanding Facility or diagnostic Hospital-based Facility without an order written by a Physician or other provider. Services which are self-directed to a Freestanding Facility or diagnostic or Hospital-based Facility. Services ordered by a Physician or other provider who is an employee or representative of a Freestanding Facility or diagnostic Hospital-based Facility, when that Physician or other provider has not been actively involved in your medical care prior to ordering the service, or is not actively involved in your medical care after the service is received. This exclusion does not apply to mammography.

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Reproduction Health services and associated expenses for infertility treatments, including assisted reproductive technology, regardless of the reason for the treatment. This exclusion does not apply to services required to treat or correct underlying causes of infertility. Surrogate parenting, donor eggs, donor sperm and host uterus. Storage and retrieval of all reproductive materials. Examples include eggs, sperm, testicular tissue and ovarian tissue. The reversal of voluntary sterilization and voluntary sterilization. The voluntary sterilization exclusion does not apply to services identified as preventive care services for women under Federal Healthcare Reform requirements.

Services Provided under Another Plan Health services for which other coverage is required by federal, state or local law to be purchased or provided through other arrangements. Examples include coverage required by workers' compensation, or similar legislation. If coverage under workers' compensation or similar legislation is optional for you because you could elect it, or could have it elected for you, Benefits will not be paid for any Injury, Sickness, or Mental Illness that would have been covered under workers' compensation or similar legislation had that coverage been elected. Services resulting from accidental bodily injuries arising out of a motor vehicle accident to the extent the services are payable under a medical expense payment provision of an automobile insurance policy. Health services for treatment of military service-related disabilities, when you are legally entitled to other coverage and facilities are reasonably available to you. This exclusion does not apply if you have continued coverage during a call to military duty as described under Continuation of Coverage During Military Service in Section 4 of the COC. Health services while on active military duty. This exclusion does not apply if you have continued coverage during a call to military duty as described under Continuation of Coverage During Military Service in Section 4 of the COC.

Transplants Health services for organ and tissue transplants, except those described under Transplantation Services in Section 1 of the COC. Health services connected with the removal of an organ or tissue from you for purposes of a transplant to another person. (Donor costs that are directly related to organ removal are payable for a transplant through the organ recipient's Benefits under the Policy.) Health services for transplants involving permanent mechanical or animal organs.

Travel Health services provided in a foreign country, unless required as Emergency Health Services. Travel or transportation expenses, even though prescribed by a Physician. Some travel expenses related to Covered Health Services received from a Designated Facility or Designated Physician may be reimbursed at our discretion. This exclusion does not apply to ambulance transportation for which Benefits are provided as described under Ambulance Services in Section 1 of the COC.

Types of Care Multi-disciplinary pain management programs provided on an inpatient basis for acute pain or for exacerbation of chronic pain. Custodial care or maintenance care; domiciliary care. Private Duty Nursing. Respite care. This exclusion does not apply to respite care that is part of an integrated hospice care program of services provided to a terminally ill person by a licensed hospice care agency for which Benefits are provided as described under Hospice Care in Section 1 of the COC. Rest cures; services of personal care attendants. Work hardening (individualized treatment programs designed to return a person to work or to prepare a person for specific work).

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Vision and Hearing Purchase cost and fitting charge for eye glasses and contact lenses. Implantable lenses used only to correct a refractive error (such as Intacs corneal implants). Eye exercise or vision therapy. Surgery that is intended to allow you to see better without glasses or other vision correction. Examples include radial keratotomy, laser, and other refractive eye surgery. Bone anchored hearing aids except when either of the following applies: For Covered Persons with craniofacial anomalies whose abnormal or absent ear canals preclude the use of a wearable hearing aid. For Covered Persons with hearing loss of sufficient severity that it would not be adequately remedied by a wearable hearing aid. More than one bone anchored hearing aid per Covered Person who meets the above coverage criteria during the entire period of time the Covered Person is enrolled under the Policy. Repairs and/or replacement for a bone anchored hearing aid for Covered Persons who meet the above coverage criteria, other than for malfunctions. Routine vision examinations, including refractive examinations to determine the need for vision correction.

All Other Exclusions Health services and supplies that do not meet the definition of a Covered Health Service - see the definition in Section 9 of the COC. Covered Health Services are those health services, including services, supplies, or Pharmaceutical Products, which we determine to be all of the following: Medically Necessary; described as a Covered Health Service in Section 1 of the COC and Schedule of Benefits; and not otherwise excluded in Section 2 of the COC. Physical, psychiatric or psychological exams, testing, vaccinations, immunizations or treatments that are otherwise covered under the Policy when: required solely for purposes of school, sports or camp, travel, career or employment, insurance, marriage or adoption; related to judicial or administrative proceedings or orders, conducted for purposes of medical research (This exclusion does not apply to Covered Health Services provided during a clinical trial for which Benefits are provided as described under Clinical Trials in Section 1 of the COC); required to obtain or maintain a license of any type. Health services received after the date your coverage under the Policy ends. This applies to all health services, even if the health service is required to treat a medical condition that arose before the date your coverage under the Policy ended. This exclusion does not apply when coverage is extended as described under Extended Coverage If You Are an Inpatient in Section 4 of the COC. Health services for which you have no legal responsibility to pay, or for which a charge would not ordinarily be made in the absence of coverage under the Policy. In the event an Out-of-Network provider waives, does not pursue, or fails to collect co-payments, co-insurance, any deductible or other amount owed for a particular health service, no Benefits are provided for the health service for which the Copayments, Coinsurance and/or deductible are waived. Charges in excess of Eligible Expenses or in excess of any specified limitation. Long term (more than 30 days) storage. Examples include cryopreservation of tissue, blood and blood products. Autopsy. Foreign language and sign language services. Health services related to a non-Covered Health Service: When a service is not a Covered Health Service, all services related to that non-Covered Health Service are also excluded. This exclusion does not apply to services we would otherwise determine to be Covered Health Services if they are to treat complications that arise from the non-Covered Health Service. For the purpose of this exclusion, a "complication" is an unexpected or unanticipated condition that is superimposed on an existing disease and that affects or modifies the prognosis of the original disease or condition. Examples of a "complication" are bleeding or infections, following a Cosmetic Procedure, that require hospitalization.

For Internal Use only: OHXG07AG4I17 Modified Item# Rev. Date XXX-XXXX 0317_rev01Base/Value HSA/Comb/Emb/28592/2011


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Benefits are underwritten by UnitedHealthcare Insurance Company does not treat members differently because of sex, age, race, color, disability or national origin.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to Civil Rights Coordinator. Online: [email protected] Mail: Civil Rights Coordinator. United HealthCare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130

You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again.

If you need help with your complaint, please call the toll-free member phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m.

You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

We provide free services to help you communicate with us. Such as, letters in others languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free member phone number listed on your health plan ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m. ET.

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mailto:[email protected]

http://www.hhs.gov/ocr/office/file/index.html

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Benefit SummaryOutpatient Prescription Drug

Ohio0/0/0 Plan MM

Your Co-payment and/or Co-insurance is determined by the tier to which the Prescription Drug List (PDL) Management Committee has assigned the Prescription Drug Product. All Prescription Drug Products on the Prescription Drug List are assigned to Tier 1, Tier 2 or Tier 3. Find individualized information on your benefit coverage, determine tier status, check the status of claims and

search for network pharmacies by logging on to www.myuhc.com® or calling the Customer Care number on your ID card.

Out-of-Pocket Limit does not apply Non-Network.

A deductible and out-of-pocket limit may apply. Please refer to the medical plan documents for the annual deductible and out-of-pocket limit amounts, which include both medical and pharmacy expenses. This means that you will pay the full amount we have contracted with the pharmacy to charge for your prescriptions (not just your co-payment), until you have satisfied the deductible. Once the deductible is satisfied, your prescriptions will be subject to the co-payments outlined below. If you reach the out-of-pocket limit, you will not be required to pay a co-payment.

* Only certain Prescription Drug Products are available through mail order; please visit www.myuhc.com or call Customer Care at the telephone number on the back of your ID card for more information.

Annual Deductible - Network and Non-NetworkIndividual Deductible

Family Deductible

See Medical Benefit Summary


Out-of-Pocket Limit - NetworkIndividual Out-of-Pocket Limit

Family Out-of-Pocket Limit



Tier Level RetailUp to 31-day supply

*Mail OrderUp to 90-day supply

Network Non-Network NetworkTier 1 No Co-payment No Co-payment No Co-payment

Tier 2 No Co-payment No Co-payment No Co-payment

Tier 3 No Co-payment No Co-payment No Co-payment

This summary of Benefits is intended only to highlight your Benefits for Outpatient Prescription Drug Products and should not be relied upon to determine coverage. Your plan may not cover all of your Outpatient Prescription Drug expenses. Please refer to your Outpatient Prescription Drug Rider and Certificate of Coverage for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage. If this description conflicts in any way with the Outpatient Prescription Drug Rider or the Certificate of Coverage, the Outpatient Prescription Drug Rider and Certificate of Coverage shall prevail.

OHMRABMM16Item# Rev. Date290-7756 0815_rev02 Benefits are underwritten by UnitedHealthcare Insurance Company

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If you purchase a Prescription Drug Product from a Non-Network Pharmacy, you are responsible for any difference between what the Non-Network Pharmacy charges and the amount we would have paid for the same Prescription Drug Product dispensed by a Network Pharmacy.

You are responsible for paying the lower of the applicable Co-payment and/or Co-insurance or the retail Network Pharmacy's Usual and Customary Charge, or the lower of the applicable Co-payment and/or Co-insurance or the mail order Network Pharmacy's Prescription Drug Cost.

For a single Co-payment and/or Co-insurance, you may receive a Prescription Drug Product up to the stated supply limit. Some products are subject to additional supply limits.

Specialty Prescription Drug Products supply limits are as written by the provider, up to a consecutive 31-day supply of the Specialty Prescription Drug Product, unless adjusted based on the drug manufacturer's packaging size, or based on supply limits. Supply limits apply to Specialty Prescription Drug Products whether obtained at a retail pharmacy or through a mail order pharmacy.

Some Prescription Drug Products or Pharmaceutical Products for which Benefits are described under the Prescription Drug Rider or Certificate are subject to step therapy requirements. This means that in order to receive Benefits for such Prescription Drug Products or Pharmaceutical Products you are required to use a different Prescription Drug Product(s) or Pharmaceutical Product(s) first.

Also note that some Prescription Drug Products require that you obtain prior authorization from us in advance to determine whether the Prescription Drug Product meets the definition of a Covered Health Service and is not Experimental, Investigational or Unproven.

If you require certain Prescription Drug Products, we may direct you to a Designated Pharmacy with whom we have an arrangement to provide those Prescription Drug Products. If you are directed to a Designated Pharmacy and you choose not to obtain your Prescription Drug Product from the Designated Pharmacy, you will be subject to the Non-Network Benefit for that Prescription Drug Product.

You may be required to fill an initial Prescription Drug Product order and obtain one refill through a retail pharmacy prior to using a mail order Network Pharmacy.

Benefits are available for refills of Prescription Drug Products only when dispensed as ordered by a duly licensed health care provider and only after 3/4 of the original Prescription Drug Product has been used.

If you require certain Maintenance Medications, we may direct you to the Mail Order Network Pharmacy to obtain those Maintenance Medications. If you choose not to obtain your Maintenance Medications from the Mail Order Network Pharmacy, you may opt-out of the Maintenance Medication Program each year through the Internet at myuhc.com or by calling Customer Care at the telephone number on your ID card.

Certain Preventive Care Medications maybe covered. Log on to www.myuhc.com or call the Customer Care number on your ID card for more information.

Other Important Information about your Outpatient Prescription Drug Benefits

32

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PHARMACY EXCLUSIONS

Exclusions from coverage listed in the Certificate apply also to this Rider. In addition, the exclusions listed below apply.

• Coverage for Prescription Drug Products for the amount dispensed (days' supply or quantity limit) which exceeds the supply limit.

• Coverage for Prescription Drug Products for the amount dispensed (days' supply or quantity limit) which is less than the minimum supply limit.

• Prescription Drug Products dispensed outside the United States, except as required for emergency treatment.

• Drugs which are prescribed, dispensed or intended for use during an Inpatient Stay.

• Experimental, Investigational or Unproven Services and medications; medications used for experimental indications and/or dosage regimens determined by us to be experimental, investigational or unproven. This exclusion does not apply to Prescription Drug Products that have been approved by the U.S. Food and Drug Administration (FDA), but have not been approved by the FDA to be lawfully marketed for the proposed use, if the Prescription Drug Product has been recognized as safe and effective for treatment of a particular indication in one or more of the standard medical reference compendia adopted by the United States Department of Health and Human Services under 42 U.S.C. 1395x(t)(2), as amended or in the medical literature listed below. Contact us for details. Two articles from major peer-reviewed professional medical journals have recognized, based on scientific or medical criteria, the drug's safety and effectiveness for treatment of the indication for which it has been prescribed. No article from a major peer-reviewed professional medical journal has concluded, based on scientific or medical criteria, that the drug is unsafe or ineffective or that the drug's safety and effectiveness cannot be determined for the treatment of the indication for which it has been prescribed. Each article meets the uniform requirements for manuscripts submitted to biomedical journals established by the International Committee of Medical Journal Editors or is published in a journal specified by the United States Department of Health and Human Services as acceptable peer-reviewed medical literature.

• Prescription Drug Products furnished by the local, state or federal government. Any Prescription Drug Product to the extent payment or benefits are provided or available from the local, state or federal government whether or not payment or benefits are received, except as otherwise provided by law.

• Prescription Drug Products for any condition, Injury, Sickness or Mental Illness arising out of, or in the course of, employment for which benefits are available under any workers' compensation law or other similar laws, whether or not a claim for such benefits is made or payment or benefits are received.

• Any product dispensed for the purpose of appetite suppression or weight loss.

• A Pharmaceutical Product for which Benefits are provided in your Certificate. This exclusion does not apply to Depo Provera and other injectable drugs used for contraception.

• Durable Medical Equipment. Prescribed and non-prescribed outpatient supplies, other than the diabetic supplies and inhaler spacers specifically stated as covered.

• General vitamins, except the following which require a Prescription Order or Refill: prenatal vitamins, vitamins with fluoride, and single entity vitamins.

• Unit dose packaging or repackagers of Prescription Drug Products.

• Medications used for cosmetic purposes.

• Prescription Drug Products, including New Prescription Drug Products or new dosage forms, that we determine do not meet the definition of a Covered Health Service.

• Prescription Drug Products as a replacement for a previously dispensed Prescription Drug Product that was lost, stolen, broken or destroyed.

• Prescription Drug Products when prescribed to treat infertility.

• Compounded drugs that do not contain at least one ingredient that has been approved by the U.S. Food and Drug Administration (FDA) and requires a Prescription Order or Refill. Compounded drugs that contain a non-FDA approved bulk chemical. Compounded drugs that are available as a similar commercially available Prescription Drug Product. (Compounded drugs that contain at least one ingredient that requires a Prescription Order or Refill are assigned to Tier 3.)

• Drugs available over-the-counter that do not require a Prescription Order or Refill by federal or state law before being dispensed, unless we have designated the over-the-counter medication as eligible for coverage as if it were a Prescription Drug Product and it is obtained with a Prescription Order or Refill from a Physician. Prescription Drug Products that are available in over-the-counter form or comprised of components that are available in over-the-counter form or equivalent. Certain Prescription Drug Products that we have determined are Therapeutically Equivalent to an over-the-counter drug or supplement. Such determinations may be made up to six times during a calendar year, and we may decide at any time to reinstate Benefits for a Prescription Drug Product that was previously excluded under this provision. This exclusion does not apply to over-the-counter drugs used for smoking cessation.

• Certain New Prescription Drug Products and/or new dosage forms until the date they are reviewed and assigned to a tier by our PDL Management Committee.

• Growth hormone for children with familial short stature (short stature based upon heredity and not caused by a diagnosed medical condition).

Exclusions

33

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PHARMACY EXCLUSIONS CONTINUED

• Any product for which the primary use is a source of nutrition, nutritional supplements, or dietary management of disease and prescription medical food products, even when used for the treatment of Sickness or Injury except as required under ACA Preventive Care Services for items such as flouoride treatment and iron supplements for children.

• A Prescription Drug Product that contains (an) active ingredient(s) available in and Therapeutically Equivalent to another covered Prescription Drug Product. Such determinations may be made up to six times during a calendar year, and we may decide at any time to reinstate Benefits for a Prescription Drug Product that was previously excluded under this provision.

• A Prescription Drug Product that contains (an) active ingredient(s) which is (are) a modified version of and Therapeutically Equivalent to another covered Prescription Drug Product. Such determinations may be made up to six times during a calendar year, and we may decide at any time to reinstate Benefits for a Prescription Drug Product that was previously excluded under this provision.

• Certain Prescription Drug Products that have not been prescribed by a Specialist Physician.

• A Prescription Drug Product that contains marijuana, including medical marijuana, unless FDA approved.

• Dental products, including but not limited to prescription fluoride topicals.


34

Benefit Summary














10%


$3,000 10%



Page 1 of 18

35









$3,000 per year

$6,000 per year

$5,000 per year








$4,000 per year

$8,000 per year

$6,000 per year

$12,000 per year


Page 2 of 18

36







Page 3 of 18

37
























Page 4 of 18

38

























Page 5 of 18

39


















Outpatient:










Outpatient:









Page 6 of 18

40















Page 7 of 18

41




















Page 8 of 18

42












Outpatient:
















Page 9 of 18

43





Page 10 of 18

44






Page 11 of 18

45












Page 12 of 18

46





Page 13 of 18

47







Page 14 of 18

48






Page 15 of 18

49











Page 16 of 18

50



of 18

51


Page 18 of 18

52

Benefit Summary Outpatient Prescription Drug Ohio10%/30%/50% Plan H9 Modified

Your Co-payment and/or Co-insurance is determined by the tier to which the Prescription Drug List (PDL) Management Committee has assigned the Prescription Drug Product. All Prescription Drug Products on the Prescription Drug List are assigned to Tier 1, Tier 2 or Tier 3. Find individualized information on your benefit coverage, determine tier status, check the status of claims and search for network pharmacies by logging on to www.myuhc.com® or calling the Customer Care number on your ID card.

Annual Deductible - Network and Non-Network Individual Deductible Family Deductible

See Medical Benefit Summary See Medical Benefit Summary

Out-of-Pocket Limit - Network Individual Out-of-Pocket Limit Family Out-of-Pocket Limit

See Medical Benefit Summary See Medical Benefit Summary

Out-of-Pocket Limit does not apply Non-Network and Coupons.

A deductible and out-of-pocket limit may apply. Please refer to the medical plan documents for the annual deductible and out-of- pocket limit amounts, which include both medical and pharmacy expenses. This means that you will pay the full amount we have contracted with the pharmacy to charge for your prescriptions (not just your co-payment), until you have satisfied the deductible. Once the deductible is satisfied, your prescriptions will be subject to the co-payments outlined below. If you reach the out-of-pocket limit, you will not be required to pay a co-payment.

Benefit Plan Co-payment/Co-insurance - The amount you pay.

Network Non-Network Network Tier 1 10% 30% 10%

Tier 2 10% 30% 10%

Tier 3 10% 30% 10%

* Only certain Prescription Drug Products are available through mail order; please visit www.myuhc.com or call Customer Care at the telephone number on the back of your ID card for more information. If you choose to opt out of Mail Order Network Pharmacy but do not inform us, you will be subject to the non-Network Benefit for that Prescription Drug Product after the allowed number of fills at the Retail Network Pharmacy.

This summary of Benefits is intended only to highlight your Benefits for Outpatient Prescription Drug Products and should not be relied upon to determine coverage. Your plan may not cover all of your Outpatient Prescription Drug expenses. Please refer to your Outpatient Prescription Drug Rider and Certificate of Coverage for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage. If this description conflicts in any way with the Outpatient Prescription Drug Rider or the Certificate of Coverage, the Outpatient Prescription Drug Rider and Certificate of Coverage shall prevail.

OHXRABH917 Modified Item# Rev. Date XXX-XXXX 0317_rev01 Benefits are underwritten by UnitedHealthcare Insurance Company

Page 1 of 6

Tier Level Retail Up to 31-day supply

*Mail Order Up to 90-day supply

53



of 6


You are responsible for paying the lowest of the applicable Co-payment and/or Co-insurance, the retail Network Pharmacy's Usual and Customary Charge or the Prescription Drug Charge for that Prescription Drug Product, or the lowest of the applicable Co- payment and/or Co-insurance, the mail order Network Pharmacy's Usual and Customary Charge or Prescription Drug Charge for that Prescription Drug Product.








If you require certain Maintenance Medications, we may direct you to the Mail Order Network Pharmacy to obtain those Maintenance Medications. If you choose not to obtain your Maintenance Medications from the Mail Order Network Pharmacy, you may opt-out of the Maintenance Medication Program each year through the Internet at myuhc.com or by calling Customer Care at the telephone number on your ID card. If you choose to opt out of Mail Order Network Pharmacy but do not inform us, you will be subject to the non-Network Benefit for that Prescription Drug Product after the allowed number of fills at Retail Network Pharmacy.



54


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PHARMACY EXCLUSIONS


Exclusions • Coverage for Prescription Drug Products for the amount dispensed (days' supply or quantity limit) which exceeds the supply

limit. • Coverage for Prescription Drug Products for the amount dispensed (days' supply or quantity limit) which is less than the

minimum supply limit. • Prescription Drug Products dispensed outside the United States, except as required for Emergency treatment. • Drugs which are prescribed, dispensed or intended for use during an Inpatient Stay. • Experimental, Investigational or Unproven Services and medications; medications used for experimental indications and/or

dosage regimens determined by us to be experimental, investigational or unproven. This exclusion does not apply to Prescription Drug Products that have been approved by the U.S. Food and Drug Administration (FDA), but have not been approved by the FDA to be lawfully marketed for the proposed use, if the Prescription Drug Product has been recognized as safe and effective for treatment of a particular indication in one or more of the standard medical reference compendia adopted by the United States Department of Health and Human Services under 42 U.S.C. 1395x(t)(2), as amended or in the medical literature listed below. Contact us for details. Two articles from major peer-reviewed professional medical journals have recognized, based on scientific or medical criteria, the drug's safety and effectiveness for treatment of the indication for which it has been prescribed. No article from a major peer-reviewed professional medical journal has concluded, based on scientific or medical criteria, that the drug is unsafe or ineffective or that the drug's safety and effectiveness cannot be determined for the treatment of the indication for which it has been prescribed. Each article meets the uniform requirements for manuscripts submitted to biomedical journals established by the International Committee of Medical Journal Editors or is published in a journal specified by the United States Department of Health and Human Services as acceptable peer-reviewed medical literature.

• Prescription Drug Products furnished by the local, state or federal government. Any Prescription Drug Product to the extent payment or benefits are provided or available from the local, state or federal government (for example, Medicare) whether or not payment or benefits are received, except as otherwise provided by law.

• Prescription Drug Products for any condition, Injury, Sickness or mental illness arising out of, or in the course of, employment for which benefits are available under any workers' compensation law or other similar laws, whether or not a claim for such benefits is made or payment or benefits are received.

• Any product dispensed for the purpose of appetite suppression or weight loss. • A Pharmaceutical Product for which Benefits are provided in your Certificate. This exclusion does not apply to Depo Provera

and other injectable drugs used for contraception. • Durable Medical Equipment, including insulin pumps and related supplies for the management and treatment of diabetes, for

which Benefits are provided in your Certificate. Prescribed and non-prescribed outpatient supplies, other than the diabetic supplies and inhaler spacers specifically stated as covered.


• Unit dose packaging or repackagers of Prescription Drug Products. • Medications used for cosmetic purposes. • Prescription Drug Products, including New Prescription Drug Products or new dosage forms, that we determine do not meet the

definition of a Covered Health Service. • Prescription Drug Products as a replacement for a previously dispensed Prescription Drug Product that was lost, stolen, broken

or destroyed. • Prescription Drug Products when prescribed to treat infertility. • Compounded drugs that do not contain at least one ingredient that has been approved by the U.S. Food and Drug

Administration (FDA) and requires a Prescription Order or Refill. Compounded drugs that contain a non-FDA approved bulk chemical. Compounded drugs that are available as a similar commercially available Prescription Drug Product. (Compounded drugs that contain at least one ingredient that requires a Prescription Order or Refill are assigned to Tier 3.)

• Drugs available over-the-counter that do not require a Prescription Order or Refill by federal or state law before being dispensed, unless we have designated the over-the-counter medication as eligible for coverage as if it were a Prescription Drug Product and it is obtained with a Prescription Order or Refill from a Physician. Prescription Drug Products that are available in over-the-counter form or comprised of components that are available in over-the-counter form or equivalent. Certain Prescription Drug Products that we have determined are Therapeutically Equivalent to an over-the-counter drug or supplement. Such determinations may be made up to six times during a calendar year, and we may decide at any time to reinstate Benefits for a Prescription Drug Product that was previously excluded under this provision. This exclusion does not apply to over-the- counter drugs used for smoking cessation.



55

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• Any oral non-sedating antihistamine or antihistamine-decongestant combination. • Any product for which the primary use is a source of nutrition, nutritional supplements, or dietary management of disease and

prescription medical food products, even when used for the treatment of Sickness or Injury. • A Prescription Drug Product that contains (an) active ingredient(s) available in and Therapeutically Equivalent to another

covered Prescription Drug Product. Such determinations may be made up to six times during a calendar year, and we may decide at any time to reinstate Benefits for a Prescription Drug Product that was previously excluded under this provision.

• Prescription Drug Products designed to adjust sleep schedule, such as for jet lag or shift work. • Prescription Drug Products when used for sleep aids. • A Prescription Drug Product that contains (an) active ingredient(s) which is (are) a modified version of and Therapeutically

Equivalent to another covered Prescription Drug Product. Such determinations may be made up to six times during a calendar year, and we may decide at any time to reinstate Benefits for a Prescription Drug Product that was previously excluded under this provision.

• Certain Prescription Drug Products for which there are Therapeutically Equivalent alternatives available, unless otherwise required by law or approved by us. Such determinations may be made up to six times during a calendar year, and we may decide at any time to reinstate Benefits for a Prescription Drug Product that was previously excluded under this provision.

• Certain Prescription Drug Products that have not been prescribed by a Specialist Physician. • A Prescription Drug Product that contains marijuana, including medical marijuana, unless FDA approved. • Dental products, including but not limited to prescription fluoride topicals. • A Prescription Drug Product with an approved biosimilar or a biosimilar and Therapeutically Equivalent to another covered

Prescription Drug Product. For the purpose of this exclusion a "biosimilar" is a biological Prescription Drug Product approved based on showing that it is highly similar to a reference product (a biological Prescription Drug Product) and has no clinically meaningful differences in terms of safety and effectiveness from the reference product. Such determinations may be made up to six times during a calendar year, and we may decide at any time to reinstate Benefits for a Prescription Drug Product that was previously excluded under this provision.

• Diagnostic kits and products. • Publicly available software applications and/or monitors that may be available with or without a Prescription Order or Refill.


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If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to Civil Rights Coordinator.

Online: [email protected]

Mail: Civil Rights Coordinator. United HealthCare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130









57



of 6

58

Benefit Summary














25%


$5,000 25%



Page 1 of 18

59









$5,000 per year

$10,000 per year

$8,000 per year








$6,000 per year

$12,000 per year

$14,000 per year

$28,000 per year


Page 2 of 18

60







Page 3 of 18

61
























Page 4 of 18

62

























Page 5 of 18

63


















Outpatient:










Outpatient:









Page 6 of 18

64















Page 7 of 18

65




















Page 8 of 18

66












Outpatient:
















Page 9 of 18

67





Page 10 of 18

68






Page 11 of 18

69












Page 12 of 18

70





Page 13 of 18

71







Page 14 of 18

72






Page 15 of 18

73











Page 16 of 18

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75


Page 18 of 18

76

Benefit SummaryOutpatient Prescription Drug

Ohio10/35/60 Plan 2V

Your Co-payment and/or Co-insurance is determined by the tier to which the Prescription Drug List (PDL) Management Committee has assigned the Prescription Drug Product. All Prescription Drug Products on the Prescription Drug List are assigned to Tier 1, Tier 2 or Tier 3. Find individualized information on your benefit coverage, determine tier status, check the status of claims and search for network pharmacies by logging on to www.myuhc.com® or calling the Customer Care number on your ID card.

Out-of-Pocket Limit does not apply Non-Network and Coupons.

A deductible and out-of-pocket limit may apply. Please refer to the medical plan documents for the annual deductible and out-of-pocket limit amounts, which include both medical and pharmacy expenses. This means that you will pay the full amount we have contracted with the pharmacy to charge for your prescriptions (not just your co-payment), until you have satisfied the deductible. Once the deductible is satisfied, your prescriptions will be subject to the co-payments outlined below. If you reach the out-of-pocket limit, you will not be required to pay a co-payment.

Benefit Plan Co-payment/Co-insurance - The amount you pay.

* Only certain Prescription Drug Products are available through mail order; please visit www.myuhc.com or call Customer Care at the telephone number on the back of your ID card for more information. If you choose to opt out of Mail Order Network Pharmacy but do not inform us, you will be subject to the non-Network Benefit for that Prescription Drug Product after the allowed number of fills at the Retail Network Pharmacy.

Annual Deductible - Network and Non-NetworkIndividual DeductibleFamily Deductible

See Medical Benefit SummarySee Medical Benefit Summary

Out-of-Pocket Limit - NetworkIndividual Out-of-Pocket LimitFamily Out-of-Pocket Limit

See Medical Benefit SummarySee Medical Benefit Summary

Tier Level RetailUp to 31-day supply

*Mail OrderUp to 90-day supply

Network Non-Network NetworkTier 1 $10 $10 $25

Tier 2 $35 $35 $87.50

Tier 3 $60 $60 $150

This summary of Benefits is intended only to highlight your Benefits for Outpatient Prescription Drug Products and should not be

Page 1 of 6

relied upon to determine coverage. Your plan may not cover all of your Outpatient Prescription Drug expenses. Please refer to your Outpatient Prescription Drug Rider and Certificate of Coverage for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage. If this description conflicts in any way with the Outpatient Prescription Drug Rider or the Certificate of Coverage, the Outpatient Prescription Drug Rider and Certificate of Coverage shall prevail.

OHMRAB2V17Item# Rev. Date290-9066 0317_rev01 Benefits are underwritten by UnitedHealthcare Insurance Company

77


You are responsible for paying the lowest of the applicable Co-payment and/or Co-insurance, the retail Network Pharmacy's Usual and Customary Charge or the Prescription Drug Charge for that Prescription Drug Product, or the lowest of the applicable Co-payment and/or Co-insurance, the mail order Network Pharmacy's Usual and Customary Charge or Prescription Drug Charge for that Prescription Drug Product.








If you require certain Maintenance Medications, we may direct you to the Mail Order Network Pharmacy to obtain those Maintenance Medications. If you choose not to obtain your Maintenance Medications from the Mail Order Network Pharmacy, you may opt-out of the Maintenance Medication Program each year through the Internet at myuhc.com or by calling Customer Care at the telephone number on your ID card. If you choose to opt out of Mail Order Network Pharmacy but do not inform us, you will be subject to the non-Network Benefit for that Prescription Drug Product after the allowed number of fills at Retail Network Pharmacy.



Page 2 of 6

78

PHARMACY EXCLUSIONS


• Coverage for Prescription Drug Products for the amount dispensed (days' supply or quantity limit) which exceeds the supply limit.

• Coverage for Prescription Drug Products for the amount dispensed (days' supply or quantity limit) which is less than the minimum supply limit.

• Prescription Drug Products dispensed outside the United States, except as required for Emergency treatment.• Drugs which are prescribed, dispensed or intended for use during an Inpatient Stay. • Experimental, Investigational or Unproven Services and medications; medications used for experimental indications and/or

dosage regimens determined by us to be experimental, investigational or unproven. This exclusion does not apply to Prescription Drug Products that have been approved by the U.S. Food and Drug Administration (FDA), but have not been approved by the FDA to be lawfully marketed for the proposed use, if the Prescription Drug Product has been recognized as safe and effective for treatment of a particular indication in one or more of the standard medical reference compendia adopted by the United States Department of Health and Human Services under 42 U.S.C. 1395x(t)(2), as amended or in the medical literature listed below. Contact us for details. Two articles from major peer-reviewed professional medical journals have recognized, based on scientific or medical criteria, the drug's safety and effectiveness for treatment of the indication for which it has been prescribed. No article from a major peer-reviewed professional medical journal has concluded, based on scientific or medical criteria, that the drug is unsafe or ineffective or that the drug's safety and effectiveness cannot be determined for the treatment of the indication for which it has been prescribed. Each article meets the uniform requirements for manuscripts submitted to biomedical journals established by the International Committee of Medical Journal Editors or is published in a journal specified by the United States Department of Health and Human Services as acceptable peer-reviewed medical literature.

• Prescription Drug Products furnished by the local, state or federal government. Any Prescription Drug Product to the extent payment or benefits are provided or available from the local, state or federal government (for example, Medicare) whether or not payment or benefits are received, except as otherwise provided by law.

• Prescription Drug Products for any condition, Injury, Sickness or mental illness arising out of, or in the course of, employment for which benefits are available under any workers' compensation law or other similar laws, whether or not a claim for such benefits is made or payment or benefits are received.

• Any product dispensed for the purpose of appetite suppression or weight loss.• A Pharmaceutical Product for which Benefits are provided in your Certificate. This exclusion does not apply to Depo Provera

and other injectable drugs used for contraception.• Durable Medical Equipment, including insulin pumps and related supplies for the management and treatment of diabetes, for

which Benefits are provided in your Certificate. Prescribed and non-prescribed outpatient supplies, other than the diabetic supplies and inhaler spacers specifically stated as covered.


• Unit dose packaging or repackagers of Prescription Drug Products.• Medications used for cosmetic purposes.• Prescription Drug Products, including New Prescription Drug Products or new dosage forms, that we determine do not meet the

definition of a Covered Health Service.• Prescription Drug Products as a replacement for a previously dispensed Prescription Drug Product that was lost, stolen, broken

or destroyed.• Prescription Drug Products when prescribed to treat infertility.• Compounded drugs that do not contain at least one ingredient that has been approved by the U.S. Food and Drug

Administration (FDA) and requires a Prescription Order or Refill. Compounded drugs that contain a non-FDA approved bulk chemical. Compounded drugs that are available as a similar commercially available Prescription Drug Product. (Compounded drugs that contain at least one ingredient that requires a Prescription Order or Refill are assigned to Tier 3.)

• Drugs available over-the-counter that do not require a Prescription Order or Refill by federal or state law before being dispensed, unless we have designated the over-the-counter medication as eligible for coverage as if it were a Prescription Drug Product and it is obtained with a Prescription Order or Refill from a Physician. Prescription Drug Products that are available in over-the-counter form or comprised of components that are available in over-the-counter form or equivalent. Certain Prescription Drug Products that we have determined are Therapeutically Equivalent to an over-the-counter drug or supplement. Such determinations may be made up to six times during a calendar year, and we may decide at any time to reinstate Benefits for a Prescription Drug Product that was previously excluded under this provision. This exclusion does not apply to over-the-counter drugs used for smoking cessation.



Exclusions

Page 3 of 6

79


• Any oral non-sedating antihistamine or antihistamine-decongestant combination.• Any product for which the primary use is a source of nutrition, nutritional supplements, or dietary management of disease and

prescription medical food products, even when used for the treatment of Sickness or Injury.• A Prescription Drug Product that contains (an) active ingredient(s) available in and Therapeutically Equivalent to another

covered Prescription Drug Product. Such determinations may be made up to six times during a calendar year, and we may decide at any time to reinstate Benefits for a Prescription Drug Product that was previously excluded under this provision.

• Prescription Drug Products designed to adjust sleep schedule, such as for jet lag or shift work.• Prescription Drug Products when used for sleep aids.• A Prescription Drug Product that contains (an) active ingredient(s) which is (are) a modified version of and Therapeutically

Equivalent to another covered Prescription Drug Product. Such determinations may be made up to six times during a calendar year, and we may decide at any time to reinstate Benefits for a Prescription Drug Product that was previously excluded under this provision.

• Certain Prescription Drug Products for which there are Therapeutically Equivalent alternatives available, unless otherwise required by law or approved by us. Such determinations may be made up to six times during a calendar year, and we may decide at any time to reinstate Benefits for a Prescription Drug Product that was previously excluded under this provision.

• Certain Prescription Drug Products that have not been prescribed by a Specialist Physician.• A Prescription Drug Product that contains marijuana, including medical marijuana, unless FDA approved.• Dental products, including but not limited to prescription fluoride topicals.• A Prescription Drug Product with an approved biosimilar or a biosimilar and Therapeutically Equivalent to another covered

Prescription Drug Product. For the purpose of this exclusion a "biosimilar" is a biological Prescription Drug Product approved based on showing that it is highly similar to a reference product (a biological Prescription Drug Product) and has no clinically meaningful differences in terms of safety and effectiveness from the reference product. Such determinations may be made up to six times during a calendar year, and we may decide at any time to reinstate Benefits for a Prescription Drug Product that was previously excluded under this provision.

• Diagnostic kits and products.• Publicly available software applications and/or monitors that may be available with or without a Prescription Order or Refill.

Page 4 of 6
80


If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to Civil Rights Coordinator.

Online: [email protected]

Mail: Civil Rights Coordinator. United HealthCare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130









Page 5 of 6 Page 5 of 6 81

of 6 82

Glossary of Health Coverage and Medical Terms Page 1 of 4

Glossary of Health Coverage and Medical Terms • This glossary has many commonly used terms, but isn’t a full list. These glossary terms and definitions are intended

to be educational and may be different from the terms and definitions in your plan. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs. (See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan document.)

• Bold blue text indicates a term defined in this Glossary. • See page 4 for an example showing how deductibles, co-insurance and out-of-pocket limits work together in a real

life situation.

Allowed Amount Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.)

Appeal A request for your health insurer or plan to review a decision or a grievance again.

Balance Billing When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.

Co-insurance Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.

Complications of Pregnancy Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency caesarean section aren’t complications of pregnancy.

Co-payment A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.

Deductible The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.

Durable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

Emergency Medical Condition An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.

Emergency Medical Transportation Ambulance services for an emergency medical condition.

Emergency Room Care Emergency services you get in an emergency room.

Emergency Services Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.

(See page 4 for a detailed example.)

Jane pays 100%

Her plan pays 0%


Jane pays 20%

Her plan pays 80%

OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 83


Excluded Services Health care services that your health insurance or plan doesn’t pay for or cover.

Grievance A complaint that you communicate to your health insurer or plan.

Habilitation Services Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

Health Insurance A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.

Home Health Care Health care services a person receives at home.

Hospice Services Services to provide comfort and support for persons in the last stages of a terminal illness and their families.

Hospitalization Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.

Hospital Outpatient Care Care in a hospital that usually doesn’t require an overnight stay.

In-network Co-insurance The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance.

In-network Co-payment A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments.

Medically Necessary Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

Network The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.

Non-Preferred Provider A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.

Out-of-network Co-insurance The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network co-insurance usually costs you more than in-network co-insurance.

Out-of-network Co-payment A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network co-payments usually are more than in-network co-payments.

Out-of-Pocket Limit The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.

Physician Services Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.


Jane pays 0%

Her plan pays 100%

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Plan A benefit your employer, union or other group sponsor provides to you to pay for your health care services.

Preauthorization A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.

Preferred Provider A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.

Premium The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.

Prescription Drug Coverage Health insurance or plan that helps pay for prescription drugs and medications.

Prescription Drugs Drugs and medications that by law require a prescription.

Primary Care Physician A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.

Primary Care Provider A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.

Provider A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.

Reconstructive Surgery Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.

Rehabilitation Services Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

Skilled Nursing Care Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.

Specialist A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.

UCR (Usual, Customary and Reasonable) The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.

Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

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How You and Your Insurer Share Costs - Example Jane’s Plan Deductible: $1,500 Co-insurance: 20% Out-of-Pocket Limit: $5,000

Jane reaches her $1,500 deductible, co-insurance begins Jane has seen a doctor several times and paid $1,500 in total. Her plan pays some of the costs for her next visit.

Office visit costs: $75 Jane pays: 20% of $75 = $15 Her plan pays: 80% of $75 = $60

Jane hasn’t reached her $1,500 deductible yet Her plan doesn’t pay any of the costs.

Office visit costs: $125 Jane pays: $125 Her plan pays: $0

January 1st Beginning of Coverage Period

December 31st End of Coverage Period

more costs

more costs

Jane reaches her $5,000 out-of-pocket limit Jane has seen the doctor often and paid $5,000 in total. Her plan pays the full cost of her covered health care services for the rest of the year.

Office visit costs: $200 Jane pays: $0 Her plan pays: $200

Jane pays 100%

Her plan pays 0%

Jane pays 20%

Her plan pays 80%

Jane pays 0%

Her plan pays 100%

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What is a Health Savings Account (HSA)? A health savings account (HSA) combines high deductible health insurance with a tax-favored savings account. Money in the savings account can help pay the deductible. Once the deductible is met, the insurance starts paying. Money left in the savings account earns interest and is yours to keep. Health Savings Account Advantages:

• Tax-deductible Contributions to the HSA are 100% deductible (up to the legal limit) — just like an IRA.

• Tax-free Withdrawals to pay qualified medical expenses, including dental and vision, are never taxed.

• Tax-deferred Interest earnings accumulate tax-deferred, and if used to pay qualified medical expenses, are tax-free.

• HSA money is yours to keep Unlike a flexible spending account (FSA), unused money in your HSA isn’t forfeited at the end of the year; it continues to grow tax-deferred.

Why High Deductible Health Insurance? To get the benefits of an HSA, the law requires that the savings account be combined with high deductible health insurance. High deductible health insurance costs less than traditional $250 or $500 deductible coverage because the insurance company doesn’t have to process and pay claims for routine, low-dollar medical care. A health savings account (HSA) is a tax-favored savings account created for the purpose of paying medical expenses

Contribution Limits for Health Savings Accounts 2018

HSA contribution limit (employer + employee)

Individual: $3,450

Family: $6,900

HSA catch-up contributions (age 55 or older)*

$1,000

* Catch-up contributions can be made any time during the year in which the HSA participant turns 55

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DENTAL BENEFIT INFORMATION UNIVERSITY OF RIO GRANDE

A MEMBER OF THE OASIS TRUST - ADMINISTERED BY CORESOURCE Group Number 8985

CoreSource Customer Service: (800) 282-3920 Claim Address: CoreSource

PO Box 2821 Clinton, IA 52733-2821 www.coresource.com

For participating providers call: Dentemax (800) 752-1547 www.dentemax.com

ALL PROVIDERS Individual Calendar Year Deductible $25 Family Calendar Year Deductible $75

Deductible applies to classes II and III services only Fourth quarter deductible carryover

Class I - Preventive & Diagnostic Cleanings, exams, fluorides, x-rays, sealants, palliative

treatment, and space maintainers.

The Plan Pays 100% of Usual & Customary Charges

Class II - Basic Restorative

Amalgams, extractions, root canals, oral surgery, bruxism

appliances, crown/denture repair, re-cement crowns, anesthesia and

periodontics.


Class III - Major Restorative Bridges, crowns, inlays/onlays, implants and dentures.


Class IV - Orthodontics Initial study, appliances, full banding, and retention.


Calendar Year Maximum Payable Per Person Includes Classes I, II, & III $1,000 Orthodontic Lifetime Maximum Includes Class IV $1,000 ADULT ORTHO Yes BITEWINGS Class I EXAMINATIONS 1 in 6 months FAMILY SECURITY BENEFIT 2 Years FLUORIDE TREATMENTS 1 in 6 months FULL MOUTH X-RAYS/PANOREX 1 per 36 consecutive months IMPLANTS NOT COVERED PROPHYLAXIS (CLEANINGS) 1 in 6 months PROSTHODONTICS 5 Year Replacement Clause SEALANTS Class I - to age 14

This is a summary of benefits only and does not represent a contract.

88

http://www.coresource.com/

http://www.dentemax.com/

your At

benefit

for right

Exam

information. Review your

Lined Trifocal Lenses ........................................up to $50 Frame .......................................up to $70

....up to $100 Single Vision Lenses

Progressive Lenses........

provider who’s

appointment,

Your Coverage with a VSP Doctor

WellVision Exam

• Focuses on your eyes and overall wellness • Every 12 months

Your Vision Benefit Summary Prescription Glasses

Keep your eyes healthy with UNIVERSITY OF RIO GRANDE/RIO GRANDE COMMUNITY COLLEGE and VSP Vision Care.

Using your VSP benefit is easy. Find an eyecare

• $130 allowance for a wide selection of frames • 20% off amount over your allowance • Every 24 months • Single vision, lined bifocal, and lined trifocal lenses • Polycarbonate lenses for dependent children • Every 12 months

Included in Prescription Glasses

Included in Prescription Glasses

• Standard progressive lenses • Premium progressive lenses • Custom progressive lenses • Average 35-40% off other lens options

$50 $80 - $90 $120 - $160

Visit vsp.com your plan coverage before your appointment.

them you Contacts (instead of glasses)

• $130 allowance for contacts; copay does not apply • Contact lens exam (fitting and evaluation) • Every 12 months

Up to $60

That’s it! We’ll handle the rest—there are no claim forms

to complete when you see a VSP doctor.

A VSP doctor provides personalized care that focuses

on keeping you and your eyes healthy year after year.

Plus, when you see a VSP doctor, you'll get the most out

of your benefit, have lower out-of-pocket costs, and your

satisfaction is guaranteed.

From classic styles to the latest designer frames, you’ll find hundreds of options for you and your family. You'll have access to great brands, like bebe , Calvin Klein, Disney,

FENDI, Nike, and Tommy Bahama .

Extra Savings and Discounts

Glasses and Sunglasses • 30% off additional glasses and sunglasses, including lens options, from the same VSP doctor on the same day as your WellVision Exam. Or get 20% off from any VSP doctor within 12 months of your last WellVision Exam. Retinal Screening • Guaranteed pricing on retinal screening as an enhancement to your WellVision Exam. Laser Vision Correction • Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities • After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor

Your Coverage with Other Providers Visit vsp.com for details, if you plan to see a provider other than a VSP doctor.

VSP Coverage Effective Date: 06/01/2013

VSP Doctor Network: VSP Signature ......up to $50 Contacts................................

Visit vsp.com or call 800.877.7195 for more details on your vision coverage and exclusive savings and promotions for VSP members.

©2010 Vision Service Plan. All rights reserved. VSP and WellVision Exam are registered trademarks of Vision Service Plan. All other company names and brands are trademarks or registered trademarks of their respective owners.

up to $75 Lined Bifocal Lenses

up to $105 .....up to $75

VSP guarantees coverage from VSP doctors only. Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract will prevail.

you. With open access to see any eyecare provider, you can

see the one who's right for you. Choose a VSP doctor or any other provider. To find a VSP doctor, visit vsp.com or

call 800.877.7195. to review

tell no ID card necessary.

Personalized Care

Choice in Eyewear

Plan Information

$20

$20

Frame

Lenses

Lens Options

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89

http://www.rio.edu/index.php

Basic Life and AD&D Insurance

90

Employer Paid Long Term Disability

92


For All Benefit Plans: The following chart shows the family status changes that can trigger a benefit change opportunity and the required proof for those family status changes.

Family Status Changes Required Proof Items

(send to the HR/Benefits Department)

Send By This Date

Marriage Original or copy of the marriage certificate or

marriage license.

Within 30 days of marriage.

Divorce or other legal dissolution of marriage

Original or copy of the court order granting divorce.

Within 30 days of the date of final divorce decree.

Birth of a child Original or copy of birth certificate.

Within 30 days of birth.

Adoption of a child Original or copy of the court

order approving the final adoption.

Within 30 days of adoption.

Placement of a child with you for adoption

Copy of the court order approving the final adoption.

Within 30 days of adoption.

Death of a spouse or dependent child

Original or copy of death certificate.

Within 30 days of spouse’s or dependent’s death.

A change in employment status classification, ie from full-time to part

time

Copy of employer communication reflecting change in classification.

Within 30 days of change in hours of employment.

Significant change in your or your spouse’s health coverage due to spouse’s employment

including open enrollment

Copy of employer communication reflecting

change in health coverage.

Within 30 days of effective date of change in coverage.

Termination of employment

HR is notified by supervisor or copy of employment offer

letter or letter of resignation.

Within 30 days of the date of employment termination.

It is your responsibility to notify the HR/Benefits Department of any family status changes as soon as possible and before 30 days has passed. If you wait longer than 30 days, you will not be permitted to make a benefit change until the next open enrollment due to IRS rules. **You must notify the HR/Benefits Department and provide documentation with proof of the event. ** Short Term Disability, 401K and Health Savings Accounts are not subject to open enrollment penalties.

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Women’s Health and Cancer Rights Act Required Annual Notice The Women’s Health and Cancer Rights Act of 1998 (“Act”) requires that a group health plan that provides medical and surgery benefits for mastectomies to participants and beneficiaries provide coverage for reconstructive surgery and related services that may follow mastectomies. In compliance with the Act, the Medical Program component of the University of Rio Grande Group Benefit Plan (“Plan”) covers the following: All stages of reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; and Prostheses and treatment of physical complications of all stages of the mastectomy, including

lymphedemas.

Coverage will be provided in a manner determined in consultation with the attending physician and the patient. The Plan’s deductibles, coinsurance, and co-payments that are in effect at the time service is provided will apply to the coverage described above. Please refer to the Plan’s summary plan description for details on the Plan’s deductibles, coinsurance, and co-payments. In addition to the above, the Plan may not: Deny a patient eligibility, or continued eligibility, to enroll, or to renew coverage, in the Plan,

solely for the purpose of avoiding the requirements of the Act; or Penalize or otherwise reduce or limit the reimbursement of an attending provider, or provide

incentives (monetary or otherwise) to an attending provider, to induce such provider to provide care to an individual participant or beneficiary in a manner inconsistent with the Act.

If you have any questions regarding these requirements, you may contact the insurer for the Plan or you

may contact the plan administrator at:

University of Rio Grande Attn: Human Resources Office

218 North College Street Rio Grande, Ohio 45674

Telephone Number: (740) 245-7170

Newborns’ and Mother’s Health Protections Act Under federal law, group health plans and health insurance issuers generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother of the newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, the law generally does not prohibit the mother’s or newborn’s attending providers, 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 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 as applicable).

95


HIPAA Notice of Special Enrollment Rights

A federal law called the Health Insurance Portability and Accountability Act of 1996, as amended (“HIPAA”), requires the University of Rio Grande to notify you about an important provision in the Medical Program component of the University of Rio Grande Group Benefit Plan (“Plan”). The provision is your right to enroll in the Plan under its “special enrollment provision” if you acquire a new dependent that is eligible for coverage under the Plan, or if you decline coverage under the Plan for yourself or your eligible dependent while other coverage is in effect and later lose that other coverage for certain reasons. Loss of Other Coverage (Excluding Medicaid or a State Children’s Health Insurance Program) –If you decline enrollment in the Plan for yourself or for your eligible dependent (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your eligible dependents in the Plan if you or your eligible 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). Loss of Coverage for Medicaid or a State Children’s Health Insurance Program – If you decline enrollment in the Plan for yourself or for your eligible dependent (including your spouse) while Medicaid coverage or coverage under a state children’s health insurance program is in effect, you may be able to enroll yourself and your dependents in the Plan if you or your dependent lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or your dependents’ coverage ends under Medicaid or a state children’s health insurance program. New Dependent as a Result of Marriage, Birth, Adoption or Placement for Adoption – If you have a new eligible dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your new dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. Eligibility for Medicaid or a State Children’s Health Insurance Program – If you or your eligible dependent (including your spouse) becomes eligible for a state premium assistance subsidy from Medicaid or through a state children’s health insurance program with respect to coverage under the Plan, you may be able to enroll yourself and your eligible dependents in the Plan. However, you must request enrollment within 60 days after your or your dependents’ determination of eligibility for such assistance.

HIPAA 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.

Effective Date of Notice

96


This Notice of Privacy Practices (“Notice”) is effective September 23, 2013 Group Health Plans

This Notice applies to the plans and programs under the University of Rio Grande Group Benefit Plan which meet the definition of a “group health plan” (including the health, dental, and vision programs) (collectively referred to herein as the “Plan”). General Information The Plan is required by the Health Insurance Portability and Accountability Act of 1996 and its regulations (“HIPAA Privacy Rules”) to maintain the privacy of your protected health information (“PHI”) and to provide you with a notice of its legal duties and privacy practices with respect to your PHI. In addition, the Health Information Technology for Economic and Clinical Health Act of 2009 and its regulations ( “HITECH Act”), among other things, requires the Plan to notify you upon an unauthorized disclosure of “unsecured PHI” (that is, PHI that is not rendered unreadable, unusable or indecipherable). PHI is any individually identifiable health information in electronic, written, or oral form, created or received by a health care provider, such as a physician or hospital, health care clearinghouse, health plan, or your employer that relates to your past, present or future mental or physical condition, the provision of health care services to you, and the past, present or future payment for the provision of health care services to you. The Plan will abide by the terms of this Notice, but it reserves the right to revise or amend this Notice at any time and to make the revised or amended Notice effective for all PHI that it maintains, even if created or received prior to the effective date of the revision or amendment. The Plan will provide you with notice of any revisions or amendments to this Notice, or changes in the law affecting this Notice, by mail or electronically within sixty (60) days of the effective date of such revision, amendment or change. Uses and Disclosures of Your PHI Required Disclosures. The Plan is required to disclose your PHI to:

• You, in accordance with your rights with respect to your PHI, as discussed below; and • To the Secretary of the Department of Health and Human Services in connection with an

investigation to determine the Plan's compliance with the HIPAA Privacy Rules. Treatment, Payment and Healthcare Operations. The Plan and its business associates (described below) may use and disclose your PHI for purposes of treatment, payment, and healthcare operations.

• Payment purposes include, but are not limited to, billing, claims management, determinations of eligibility for Plan benefits, collection activities and related healthcare data processing. For example, the Plan may disclose your PHI to a health care provider so that it can make authorization decisions.

• Health care operations purposes include, but are not limited to, the business functions conducted by the Plan. These activities may include such operational activities as quality assessment and improvement, performance measures and outcome assessment, preventive health, disease management, case management and care coordination. For example, the Plan may use the information to provide disease management programs for covered persons with specific conditions such as diabetes, asthma or heart failure. Other operational activities requiring the use and disclosure of your PHI may include medical review of claims, analysis of Plan design, establishment of premiums, underwriting, administration of reinsurance and stop loss, legal services, and audit

97


services. The Plan will not use or disclose your PHI that is genetic information for underwriting purposes.

• Treatment purposes include, but are not limited to, disclosures to a healthcare provider to facilitate medical treatment or services by the provider. For example, the Plan may disclose to a treating orthodontist the name of the treating dentist so that the orthodontist may request dental records from the treating dentist.

Disclosures to the Plan Sponsor and Adopting Employers. The Plan may disclose your PHI to designated employees of the Plan Sponsor (the University of Rio Grande) so they can carry out their Plan-related administrative functions, including the uses and disclosures described in this Notice. Such disclosures will be made only to employees involved in Plan-related administration. These employees will protect the privacy of your health information and ensure it is used and disclosed only as described in this Notice or as permitted by law. Unless authorized by you in writing, your health information may not be disclosed by the Plan to any other employee of the Plan Sponsor or an adopting employer and will not be used by the Plan Sponsor for any employment-related actions and decisions or in connection with any other employee benefit plan sponsored by the Plan Sponsor. Disclosures to other Covered Entities and Business Associates. Certain services are provided to the Plan by third parties known as “business associates.” The Plan may disclose your PHI to other covered entities and business associates for purposes of treatment, payment and/or certain health care operations. For example, the Plan may disclose your PHI to the Plan’s COBRA administrator in order that the COBRA administrator may offer you COBRA coverage, if applicable. However, the Plan will require its business associates, through contract, to appropriately safeguard your health information. Treatment Alternatives and Health-Related Benefits and Services. The Plan may use and disclose your PHI to tell you about possible treatment options or alternatives that may be of interest to you. Also, the Plan may use and disclose your PHI to tell you about health-related benefits or services that may be of interest to you. The Plan may disclose your PHI to a business associate to assist in these activities. Personal Representative. The Plan will generally disclose your PHI to an individual you designate as your personal representative when the personal representative has been properly designated through appropriate written documentation. Individuals Involved in Your Care or Payment of Your Care. In certain circumstances, the Plan may disclose PHI to a close friend or family member involved in or who helps pay for your health care. The Plan may also advise a family member or close friend about your condition, your location (for example, that you are in the hospital) or death. Required by Law. The Plan may use or disclose your PHI to the extent such use or disclosure is required by federal, state or local law (e.g., national security laws or public health disclosure laws) and the use or disclosure complies with and is limited to the relevant requirements of the law. Public Health Activities. The Plan may disclose your PHI for the public health activities of:

• A public health authority that is authorized by law to collect or receive information for the purpose of preventing or controlling disease, injury or disability;

• A public health authority that is authorized to receive reports of child abuse or neglect;

98


• A person that has responsibility to the Food and Drug Administration (“FDA”) regarding the quality, safety or effectiveness of an FDA-regulated product or activity (e.g., to report reactions to mediations or to notify people of recalls of products they may be using);

• A person who may have been exposed to a communicable disease or who may be at risk of contracting or spreading the disease if the Plan is authorized by law to notify the person; and

• An employer regarding work-related illness or injury or for the employer to comply with its legal obligations (e.g., under the Occupational Safety and Health Act (“OSHA”) or other similar laws).

Avert Serious Threat to Health and Safety.

• The Plan may disclose PHI to notify the appropriate government authority that an individual has been the victim of abuse, neglect or domestic violence (if the individual agrees to the disclosure or when required or authorized by law).

• The Plan may use or disclose PHI when it believes in good faith that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public, but only to someone who can prevent or lessen the threat.

Health Oversight Activities. The Plan may disclose your PHI to a health oversight agency for health oversight activities authorized by law such as audits, inspections, and licensure or disciplinary actions. Judicial and Administrative Proceedings. The Plan may disclose your PHI in response to court and administrative orders and other lawful processes. Law Enforcement Purposes. The Plan may disclose your PHI to law enforcement officials pursuant to subpoenas and other lawful process, concerning crime victims, suspicious deaths, crime on the Plan Sponsor’s or an adopting employer’s premises, reporting crimes in emergencies, and for purposes of identifying or locating a suspect or other person. Disclosures About Decedents. The Plan may disclose PHI to a coroner, medical examiner or funeral director to allow them to perform their duties with respect to the decedent. Tissue and Organ Donation. If you are an organ donor, the Plan may disclose your PHI after your death for organ or tissue donation purposes. Specialized Government Functions. The Plan may disclose PHI:

• Of armed forces personnel as required by appropriate military command authorities; • To authorized federal officials for lawful intelligence, counter intelligence and other

national security activities authorized by law; and • To correctional institutions or law enforcement officials if you are an inmate of a

correctional institution or are in the custody of a law enforcement official. Workers’ Compensation. The Plan may disclose PHI when authorized by and to the extent necessary to comply with laws relating to workers’ compensation and similar programs that provide benefits for work-related injuries or illness.

99


Research. The Plan may disclose your PHI to researchers when either the individual identifiers have been removed or when an institutional review board or privacy board has reviewed the research proposal and established protocols to ensure the privacy of the required information, and approves the research. Your Authorization. Uses and disclosures of your PHI not described in this Notice will be made only with your written authorization. For those purposes for which an authorization is needed, you may give us written authorization to use your PHI or to disclose your PHI to another person and for the purpose you designate. If you give us an authorization, you may revoke it, in writing, at any time. Your revocation will not affect any action taken by the Plan in reliance on the authorization while it was in effect. Unless you give us written authorization, we cannot use or disclose your PHI for any reason except those described in this Notice.

• The Plan will use or disclose psychotherapy notes only with your authorization. Psychotherapy notes are the notes taken by your mental health professional during a counseling session. The Plan may use these notes to defend any litigation brought by you.

• The Plan will not use or disclose your PHI for marketing without your authorization except if the communication is in the form of a face-to-face communication made by the Plan to you or a promotional gift of nominal value provide by the Plan. For example, a communication by the Plan about a product or service which encourages you to purchase or use the product or service will be considered a marketing activity under HIPAA and will require your authorization. If the marketing involves financial remuneration to the Plan from a third party, the authorization must state that such remuneration is involved.

• The Plan will not sell your PHI without your authorization. Any such authorization must state that the disclosure will result in remuneration to the Plan. For this purpose, a sale of PHI is a disclosure of PHI by the Plan where the Plan directly or indirectly receives remuneration from or on behalf of the recipient of the PHI in exchange for the PHI. However, a sale of PHI does not include a disclosure of PHI : (a) for public health activities; (b) for research purposes (if the only remuneration received by the Plan is a reasonable cost-based fee to cover the cost of preparation and transmittal of the information); (c) for treatment and payment purposes; (d) for the sale, transfer, merger or consolidation of all or part of the Plan and for related due diligence; (e) to or by a business associate for activities that the business associate undertakes on behalf of the Plan or on behalf of a business associate in the case of a subcontractor if the only remuneration provided by the Plan to the business associate , or by the business associate to the subcontractor, if applicable, for the performance of such activities; (f) to an individual when requested pursuant to the individual’s right to access PHI or right to an accounting of disclosures of PHI; (g) required by law; or (h) for any other purpose permitted by and in accordance with the HIPAA Privacy Rules where the only remuneration received by the Plan is a reasonable, cost-based fee to cover the cost of preparation and transmittal of the PHI for such purpose or a fee otherwise expressly permitted by other law.

The Plan’s Duties With Respect to Use and Disclosure of Your PHI

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The Plan will use and disclose (and will request disclosure of) only the minimum amount of PHI about you as needed under the circumstances, taking into consideration any practical and technological limitations. This requirement does not apply when disclosing information to a provider for treatment, when disclosing information to you, when disclosing information pursuant to your authorization, when disclosing information to the Secretary of the Department of Health and Human Services, or when disclosing information that is required by law or regulations. To the extent practicable, the Plan will limit uses, disclosures and requests of PHI to the “limited data set,” or, if necessary, to the minimum necessary to accomplish the intended purpose of a use, disclosure or request of PHI. Generally, a “limited data set” is PHI that excludes direct identifiers of the individual or of relatives, employers, or household members of the individual, including names, post address information (other than city, state, and zip code), telephone numbers, social security numbers, email addresses, etc. This Notice does not apply to information that has been de-identified. De-identified information is information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual. In addition, the Plan may use or disclose “summary health information” to the Plan Sponsor for obtaining premium bids or modifying, amending or terminating the Plan, which summarizes the claims history, claims expenses or type of claims experienced by individuals for whom the Plan Sponsor has provided health benefits under the Plan, and from which identifying information has been deleted in accordance with the HIPAA Privacy Rules. Your Rights The HIPAA Privacy Rules provide you with the following rights with respect to your PHI that the Plan and its business associates or subcontractors maintain: Right to Request Restrictions. You have the right to request restrictions on certain uses and disclosures of your PHI. You may request restrictions on the following uses or disclosures of your PHI:

• To obtain payment, treatment or with respect to healthcare operations of the Plan; • Disclosures to your family members, relatives or close personal friends of your PHI

directly relevant to payment related to your healthcare, or your location, general condition or death;

• Instances in which you are not present or when your permission cannot practicably be obtained due to your incapacity or an emergency circumstance;

• Permitting other persons to act on your behalf to pick-up filled prescriptions, medical supplies, x-rays or other similar forms of PHI; or

• Disclosure to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.

You cannot request to restrict uses or disclosures that are otherwise required by law. The Plan is not required to agree to a requested restriction except a request to restrict disclosure of your PHI to a health plan if:

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• The disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and

• The PHI pertains solely to a health care item or service for which the health care provider involved has been paid in full by you or another person other than the health plan.

Any additional restrictions to the use and disclosure of your PHI that the Plan agrees to abide by except in an emergency must be in writing signed by a person authorized to make such an agreement. The Plan will not be bound unless the agreement is in writing and properly executed. If the Plan agrees to your request for a restriction, the Plan will comply with the restriction, except in an emergency situation, unless and until you revoke it or the Plan notifies you. Confidential Communications. You may request, in writing, to receive confidential communications of your PHI. Your written request for confidential communications must include an alternative address or method of contact. The Plan is required by law to accommodate reasonable requests to receive communications of PHI by alternative means or at alternative locations if you clearly state in your written request for confidential communications that disclosure of all or part of the information could endanger you. Right to Inspect and Copy. You have the right, with limited exceptions, to look at or get copies of your PHI contained in a Designated Record Set. A “Designated Record Set” is a group of records maintained by or for the Plan that consists of: (i) the medical records and billing records about individuals maintained by or for the Plan, (ii) the enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for the Plan, or (iii) records used, in whole or in part, by or for the Plan to make decisions about individuals. As used herein, the term “record” means any individual item, collection, or grouping of information that includes PHI and is maintained, collected, used, or disseminated by or for the Plan. You may request a copy of the PHI in your Designated Record Set. If the Plan uses or maintains an electronic health record with respect to your PHI, you may request a copy of the PHI in your Designated Record Set in an electronic format and, if you choose, direct the Plan to transmit such copy directly to an entity or person designated by you (provided such choice is clear, conspicuous, and specific). A reasonable fee may be charged for producing and mailing copies of the PHI in your Designated Record Set. The fee that the Plan will charge for providing a copy of the PHI in your Designated Record Set in an electronic form shall not be greater than the Plan’s labor costs in responding to the request for the copy. If access is denied, you or your personal representative will be provided with a written denial setting forth the basis for the denial, how you may request a review of the denial, if applicable, and a description of how you may complain to the Secretary of the U.S. Department of Health and Human Services. Right to Request Amendment. You have the right, with limited exceptions, to request that the Plan amend your PHI. Your request must be in writing and must explain why the information should be amended. Within 60 days after the written request is received, the Plan will respond. A single 30-day extension is permitted if the Plan is not able to comply with this deadline. The Plan may deny your

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request, in whole or in part. For example, the Plan may deny your request if you ask it to amend information that:

• Was not created by the Plan; • Is not part of your PHI kept by the Plan; • Is not part of the information which you would be permitted to inspect and copy; or • Is accurate and complete.

If the Plan denies your request, the Plan will provide you with a written denial that clearly explains why the Plan denied it. You will then be given the opportunity to give the Plan a statement of disagreement. The Plan will include your statement with the PHI that is the subject of your request. Right to Receive an Accounting. You have the right to receive a written accounting of all disclosures of your PHI that the Plan has made within the six (6) year period immediately preceding the date on which the accounting is requested. You may request an accounting of disclosures for a period of time of less than six (6) years. An accounting of disclosures will include the date of each disclosure, the name and, if known, the address of the entity or person who received the information, a brief description of the information disclosed and a brief statement of the purpose and basis of the disclosure. The Plan is not required to provide accountings of disclosures for certain purpose, including, but not limited to, the following:

• Payment, treatment and healthcare operations; • Disclosures pursuant to your authorization; • Disclosures to you; • Disclosures made to persons involved in your care; • Disclosures for national security purposes; • Disclosures occurring prior to April 14, 2003; or • Disclosures incident to an otherwise permitted use or disclosure.

The Plan will provide you with the accounting within 60-days after receiving your request, except that a 30-day extension is allowed if the Plan provides you a written statement of the reasons for the delay and a date by which the accounting will be provided. The Plan will provide the first accounting to you in any twelve (12) month period without charge If you request more than one accounting within a 12-month period, the Plan will charge you a reasonable cost-based fee for responding to each subsequent request. All requests for an accounting should be submitted in writing on the form available from the Privacy Officer. If the Plan uses or maintains an electronic health record (“EHR”) with respect to PHI, you have the right to receive an accounting of disclosures which includes all disclosures for purposes of payment, health care operations, or treatment over the past three (3) years, in accordance with the laws and regulations currently in effect. Copy of Notice. You have the right to request a copy of this Notice at any time. If you receive this Notice by electronic means, you are also entitled to request a paper copy of the Notice. In order to exercise any of these rights, you will be required to complete a form that the Plan will provide to you upon request. All requests should be made to the Privacy Officer listed at the end of this Notice.

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Breach Notification The Plan is required to notify an affected individual following a breach of his or her unsecured PHI. A breach is the acquisition, access, use, or disclosure of PHI in a manner not permitted by the HIPAA Privacy Rules which compromises the security or privacy of the PHI. A breach does not include: (i) any unintentional acquisition, access, or use of PHI by a workforce member or person acting under the authority of the Plan if the acquisition, access, or use was made in good faith and within the scope of the person’s authority and does not result in further use or disclosure in a manner not permitted under the HIPAA Privacy Rule, (ii) any inadvertent disclosure by a person who is authorized to access the Plan’s PHI to another person authorized to access the Plan’s PHI and the information received as a result of such disclosure is not further used or disclosed in a manner not permitted under the HIPAA Privacy Rule. (iii) a disclosure of PHI where the Plan has a good faith belief that an unauthorized person to whom the disclosure was made would not reasonably have been able to retain such information. The notice must be made within 60 days from when the Plan becomes aware of the unauthorized disclosure and will include, to the extent possible: (a) a brief description of the disclosure, including the date it occurred and the date it was discovered; (b) a description of the types of unsecured PHI disclosed or used during the breach; (c) the steps you can take to protect your identity; (d) a description of the Plan’s or business associate’s actions to investigate the disclosure and mitigate any harm now and in the future; and (e) contact procedures (including a toll-free telephone number) for affected individuals to find additional information. The Plan must notify you in writing by first class mail (unless you have opted for electronic communications with the Plan). However, if the Plan has insufficient contact with you, an alternative notice method (posting on website, broadcast media, etc.) may be used. Complaints If you feel that your privacy rights have been violated, you may file a complaint with the Plan by contacting you’re the Human Resources Office. You may also file a complaint with the U.S. Department of Health and Human Services, Office of Civil Rights. For information regarding filing a complaint with the U.S. Department of Health and Human Services, you may access the following website at http://hhs.gov/ocr/privacyhowtofile.htm. Alternatively, you may file a complaint with the regional office in the state or jurisdiction where the Plan is located. A complaint must name the entity that is the subject of the complaint and describe the acts or omissions believed to be in violation of the applicable requirements of the HIPAA Privacy Rules or this Notice. A complaint must be received by the Plan or filed with the U.S. Department of Health and Human Services, Office for Civil Rights, within 180 days of when you knew or should have known that the act or omission complained of occurred. You will not be penalized or otherwise retaliated against for filing a complaint. Contact Information If you have any questions about this Notice or would like to file a complaint with the Plan, you may contact your local Human Resources Department. You may also contact the Plan’s Privacy Officer at:

University of Rio Grande Attn: Human Resources Office

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http://hhs.gov/ocr/privacyhowtofile.htm


218 North College Street Rio Grande, Ohio 45674

Telephone Number: (740) 245-7170

Premium Assistance Under Medicaid and the Children’s Health Insurance

Program (CHIP) Notice If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your employer, your State may have a premium assistance program that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for these programs, but also have access to health insurance through their employer. If you or your children are not eligible for Medicaid or CHIP, you will not be eligible for these premium assistance programs. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can 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, you can 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, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must permit you to enroll in your employer plan if you are not 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, you can contact the Department of Labor electronically at www.askebsa.dol.gov or by calling toll-free 1-866-444-EBSA (3272). Below are states in in the vicinity of the University of Rio Grande that currently offer a program. If you live in another state, you should contact your state for further information on eligibility.

KENTUCKY – Medicaid WEST VIRGINIA – Medicaid

Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570

Website: www.dhhr.wv.gov/bms/ Phone: 1-877-598-5820, HMS Third Party Liability

To see if any more States have added a premium assistance program since July 31, 2013, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services

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http://www.askebsa.dol.gov/


www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Medicare Part D Creditable Coverage Notice This notice - intended for healthcare participant’s age 65 or older, disabled under Social Security or who have end-stage renal disease - has information about your current prescription drug coverage with University of Rio Grande (URG) for 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: 1. 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. 2. University of Rio Grande has determined that the prescription drug coverage offered by the URG plan

is, 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 University of Rio Grande coverage will be affected. For those individuals who elect Part D coverage, coverage under the entity’s plan will end for the individual and all covered dependents. If you do decide to join a Medicare drug plan and drop your current URG coverage, be aware that you and your dependents will not be able to get this coverage back. 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 with URG 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

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http://www.dol.gov/ebsa

http://www.cms.hhs.gov/


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… University of Rio Grande Human Resources Office, 218 N. College Ave, Rio Grande, OH 45674. 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 URG 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 the “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).

COBRA Continuation Coverage Election Notice This notice describes how your group health coverage may be continued following the occurrence of certain qualifying events. Please review it carefully. This notice is to advise you of your rights, only. This is not a letter of termination. No action is necessary on your part. This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. 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 when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage. For additional 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. What is COBRA Continuation Coverage?

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COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as 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 are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happens:

• Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct. • If you are the spouse of an employee, you will become a qualified beneficiary if you lose your

coverage under the Plan because any of the following qualifying events happens: • 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 any of the following qualifying events happens: • 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

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. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, or the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), the employer must notify the Plan Administrator of the qualifying event. You Must Give Notice of Some Qualifying Events For the 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. You must provide this notice to: Chris Nourse, HR Benefits Manager, University of Rio Grande, 218 North College Street, Rio Grande, OH 45674. How is COBRA 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.

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COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), your divorce or legal separation, or a dependent child's losing eligibility as a dependent child, COBRA continuation coverage lasts for up to a total of 36 months. When the qualifying event is the end of employment or reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months. There are two 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 the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total 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 continuation coverage. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event while receiving 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 notice of the second qualifying event is properly given to the Plan. This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Keep Your Plan Informed of Address Changes In order to protect your family’s rights, you should keep the Plan Administrator informed of 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 University of Rio Grande Human Resources Office 218 North College Street,

Rio Grande, OH 45674 1-740-245-7170

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www.rio.edu 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 ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), 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 the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.)

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Plan Monthly Premium < $30,000 $30,001 - $45,000 $45,001 - $60,000 >$60,000

20% 30% 40% 45%

Employee 968.09$ $89.36 $134.04 $178.72 $201.06

Employee + Spouse 1,936.18$ $178.72 $268.09 $357.45 $402.13

Employee + Children 1,839.37$ $169.79 $254.68 $339.58 $382.02

Employee + Family 2,642.89$ $243.96 $365.94 $487.92 $548.91


12.5% 20% 25% 30%

Employee 926.89$ $53.47 $85.56 $106.95 $128.34

Employee + Spouse 1,853.76$ $106.95 $171.12 $213.90 $256.67


Employee + Family 2,530.40$ $145.98 $233.58 $291.97 $350.36


12.5% 20% 25% 30%

Employee 796.50$ $45.95 $73.52 $91.90 $110.28

Employee + Spouse 1,593.00$ $91.90 $147.05 $183.81 $220.57


Employee + Family 2,174.44$ $125.45 $200.72 $250.90 $301.08

Medical Plan 1: 3,000/6,000 100% Coinsurance




University of Rio Grande Bi-Weekly Premiums

DENTAL INSURANCEURG Total Monthly Premium Per Pay Employee Contribution

Single $27.40 $1.58

Family $82.63 $4.77

VISION INSURANCEURG Total Monthly Premium Per Pay Employee Contribution

Single $9.55 $0.55

Family $21.61 $1.25

CORESOURCE

VSP

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Plan Total Premium < $30,000 $30,001 - $45,000 $45,001 - $60,000 >$60,000

20% 30% 40% 45%

Employee 968.09$ $193.62 $290.43 $387.24 $435.64

Employee + Spouse 1,936.18$ $387.24 $580.85 $774.47 $871.28


Employee + Family 2,642.89$ $528.58 $792.87 $1,057.16 $1,189.30


12.5% 20% 25% 30%

Employee 926.89$ $115.86 $185.38 $231.72 $278.07

Employee + Spouse 1,853.76$ $231.72 $370.75 $463.44 $556.13


Employee + Family 2,530.40$ $316.30 $506.08 $632.60 $759.12


12.5% 20% 25% 30%

Employee 796.50$ $99.56 $159.30 $199.13 $238.95

Employee + Spouse 1,593.00$ $199.13 $318.60 $398.25 $477.90


Employee + Family 2,174.44$ $271.81 $434.89 $543.61 $652.33




DENTAL INSURANCEURG Total Monthly Premium Per Pay Employee Contribution

Single $27.40 $6.85

Family $82.63 $20.66

VISION INSURANCEURG Total Monthly Premium Per Pay Employee Contribution

Single $9.55 $2.39

Family $21.61 $5.40

CORESOURCE

VSP


University of Rio Grande Monthly Premiums

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2018 Version 1

Derek T. Rhodes, MBA Payroll and Benefits

Manager Human Resources

[email protected]

Office: (740)245-7140

Cell: (740)853-0265

Fax: (740)245-5266

J. Chris Nourse Director of Human

Resources [email protected]

Office: (740) 245-7228 Cell: (740) 352-8959 Fax: (740) 245-5266

Susie Fitch Administrative Assistant

Human Resources

[email protected]

Office: (740)-245-7170

Fax: (740)-245-5266

The Department of Human Resources partners with members of the University community to foster a work environment that attracts and inspires excellence in

people so the University is successful in its mission.




employee benefits guide - university of rio grande€¦ · 2018 employee benefit guide welcome to...

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