health care open enrollment (coverage effective 1/1/2010) 1

Health Care Open Enrollment (coverage effective

1/1/2010)

1

Benefit Summary

You may review your current benefits summary by: Clicking on myUT at the top of the

www.utoledo.edu homepage Sign in to myUT Click on Benefit Summary in the left-

hand column of the Employee tab Then click the select button

2

http://www.utoledo.edu/

Open Enrollment Pharmacy will now be bundled with

medical for both campuses (no longer available as a stand alone election except for AFSCME)

Main Campus Full re-enrollment

Health Science Campus Full re-enrollment

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Open Enrollment Website

No packets will be mailed – post card notification only If you do not have computer access, you can pick up a packet

in HR http://hr.utoledo.edu Click on Open Enrollment Option Read general directions Click on either Main Campus, Health Science Campus Non-

Union or AFSCME Click each needed form and type in the information, then print

the form and go on to the next form to complete Turn in all completed forms at one time as one packet to

Human Resources HR is located on the Main Campus in the Transportation Center

and is open M-F 7:30 AM to 5:00 PM

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http://hr.utoledo.edu/

Main Campus Health Insurance Choices…

Ohio Benefit Administrators/FrontPath PPO 90/10 FrontPath & PHCS networks – (Promedica & Mercy) 70/30 Out-of-network

Paramount Employer Select 100 UTMC, UTP, UT community faculty

The following teaching facilities: Defiance, Flower, Fostoria, Lima, Toledo Hospital & Toledo Children’s Hospital for inpatient services and outpatient surgeries

Tier 1 list is available on the http://hr.utoledo.edu website 90/10 Paramount & PHCS networks 70/30 Out-of-network

Medical Mutual of Ohio CDHP 100 UTMC & UTP

Tier 1 list is available on the http://hr.utoledo.edu website 90/10 MMO (Mercy & Paramount) & PHCS (and Cofinity for

Michigan) networks 70/30 Out-of-network

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Health Science Campus Health Insurance Choices…

Paramount Employer Select 100 UTMC, UTP, UT community faculty

The following teaching facilities: Defiance, Flower, Fostoria, Lima, Toledo Hospital & Toledo Children’s Hospital for inpatient services and outpatient surgeries

Tier 1 list is available on the http://hr.utoledo.edu website

90/10 Paramount & PHCS networks 70/30 Out-of-network

Medical Mutual of Ohio CDHP 100 UTMC & UTP

Tier 1 list is available on the http://hr.utoledo.edu website

90/10 MMO (Mercy & Paramount) & PHCS (and Cofinity for Michigan) networks

70/30 Out-of-network

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Main Campus OBA/FrontPath Co-Pays

FrontPath & PHCS Networks

Out of Network

Office Visit Co-Pay: $15

Office Visit covered 70%

after deductible

Specialist Visit Co-Pay: $30

Specialist Visit covered 70%

after deductible

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Main CampusOBA/FrontPath Deductibles

FrontPath & PHCS Networks

Out of Network

$100 Single$200 Single + 1

$300 Family

$300 Single$600 Single + 1

$900 Family

90%Coverage

70% Coverage

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Main & Health Science Campus Paramount ES Co-Pays

Tier 1UTMC &Tier 1

Providers

Tier 2 Paramount

& PHCS Networks

Tier 3 Out of

Network



Office Visit covered 70%

after deductible



Specialist Visit covered 70%

after deductible

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Main & Health Science Campus Paramount ES Deductibles

Tier 1UTMC &Tier 1

Facilities

Tier 2 Paramount

& PHCS Networks

Tier 3 Out of

Network

No Deductible $100 Single$150 Single +

1$200 Family

$500 Single$750 Single +

1$1,000 Family

100% Coverage

90%Coverage

70% Coverage

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Paramount ES 2010 Changes

No longer requires selection of Primary Care Physician (PCP)

No longer requires referrals Rates have decreased 11% Non-network co-insurance now

70%/30% rather than 60%/40%

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What is a Consumer Directed Health Plan?

Consumer Directed Health Plans (CDHPs) are made up of three elements:

1. A health plan2. A fund or account that you can use to help pay for qualified, out-of-pocket medical expenses (known as a Health Savings Account or HSA)3. Interactive tools and information to help you make more informed health care decisions

Cannot be enrolled in another health plan as secondary unless it is also a high deductible health plan. No one enrolled in the CDHP may be covered by Medicare.

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How Much May I Contribute to my HSA?

The University of Toledo contributions ($800/single, $1,600/family) will be accessible on January 4th in 2010.

You may contribute by payroll deduction on a pre-tax basis.

Payroll contributions you make are prorated over 24 pay periods but can be changed throughout the year by contacting UT HR.

Your HSA contribution limits are $3,050 for persons with individual coverage and $6,150 for persons with family coverage. This includes contributions made by UT.

Individuals age 55 to 64 may contribute an additional $1,000 annually

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Using Your HSA:

You may use HSA funds towards your medical plan deductible or any coinsurance or copayments.

You may use your HSA funds for qualified health care expenses as allowed by the IRS. The following list provides some typical examples:

Medical deductibles

Braces

Dental care Contact lenses

Prescription drugs Hearing aids LASIK eye surgery Eyewear 14

CDHP Design Highlights Deductible

$1,200 Single $2,400 Family

Health Savings Account Employer Contribution $800 Single $1,600 Family

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CDHP Highlights

Meet the plan deductible then pay coinsurance

Prescription drug costs count towards deductible

Out-of-pocket maximum limits amount you pay annually

Preventive care not subject to the deductible and covered at 100% with UTMC providers, 90% with MMO Providers

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Must be enrolled in HSA-compatible health plan to open & contribute to HSA

What is an HSA?

17© 2009 Wells Fargo Bank, N.A. All rights reserved. For public use.

• Pay for Qualified Medical expenses with Tax Free dollars

• No use it or lose it provision – like Flexible Spending Accounts

• Your balance plus investment earnings carry over year to year

- Tax Free

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Triple tax savings*

Pay for qualified medical expenses tax free

Interest and investment earningsare tax free

Contributions are pre-tax ortax deductible

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Increase your spending and savings power

* All taxes are at the federal level. State taxes vary. Please consult a tax advisor.

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Increase your buying power

Your HSA Contribution

Tax savings from your HSA

contribution*

Increased Buying Power

$500 $125 $625

$1,000 $250 $1,250

$2,000 $500 $2,500

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This example is for illustrative purposes only. Tax consequences may differ based on individual circumstances. Please consult your tax advisor regarding your individual situation. This chart assumes all distributions are used for qualified medical expenses.

*Estimated federal tax savings of 25% based on 2008 tax table for a single taxpayer with income of $60,000. For more information, go to www.ustreas.gov and click on “Health Savings Accounts (HSAs).” Please consult your tax advisor.

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What you receive with your new Wells Fargo HSA

If you elect the Medical Mutual product a Wells Fargo HSA will be opened in your name

You will receive a confirmation letter mailed to your home, including: Web site information Toll-free customer service number

Your Visa HSA Debit Card card will arrive separately Activate the card before you use it

Sample of the envelope the HSA Visa Debit card comes in.

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Rollover process to Wells Fargo for Employees with an existing HSA account

Employee completes and signs Wells Fargo rollover form provided in packet.

Send completed form to University of Toledo Human Resources Benefits.

Money will be transferred to Wells Fargo HSA for new plan enrollment year.

Questions contact: (University of Toledo HR)

wellsfargo.com/hsa

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MMO CDHP PlanPlan Design Feature Tier 1

University Medical Center

Tier 2 MMO Network

Providers

Tier 3Out of

Network

UT HSA Contribution $800 Single$1,600 Family

Employee HSA Contribution

$2,250 Single$4,550 Family

Deductible $1,200 Single$2,400 Family

Out-of-Pocket Maximum (Includes Deductible)

$2,000 Single$4,000 Family

Coinsurance (Most Services)Subject to deductible

100% 90% / 10% 70/30

Preventive CareNot subject to deductible

100% 90% / 10% 70% / 30% 22

CDHP Prescription Drug Coverage

When you fill prescriptions you pay the cost of the prescription until the deductible has been met. Once the deductible has been met you pay the copay or coinsurance detailed below:

Prescription Drugs 30 day supply 90 day supply

UT pharmacies or at any MMO network Pharmacy.

Deductible does not apply to certain preventive medications.

$5 generic

20% formulary (up to $80 max per prescription)

30% non-formulary

$10 generic

20% formulary (up to $200 max per prescription)

30% non-formulary

Once the out-of-pocket maximum has been met, all prescriptions are covered at 100%. 23

Preventive Drugs (partial listing)not subject to CDHP deductible

Antiasthmastics drugs & supplies

Antidiabetic drugs & supplies

Antiemetics/antivertigo agents

Antiestrogens

Anti-infectives

Antimalarials

Anti-ulcer agents

Antivirals

Blood Thinning Agents

Contraceptives, oral

Estrogen replacement products

Gout

High Cholesterol drugs

Hypertension drugs

Osteoporosis drugs

Prenatal vitamins

Prescription vitamins

Smoking Cessation medications

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Spousal/Domestic Partner Provision (for full-time and part-time employees)

Does not apply to the MMO CDHP Must be completed annually if covering

a spouse/domestic partner on health insurance

For Spouse to be Primary: Unemployed, Self-Employed, Retired, No other

benefits offered Or makes less than $25,000/yr and benefits cost

more than $75/month for a single plan Spouse may be Secondary HSC AFSCME will continue to use existing HSC

spousal/domestic partner provision25

Main Campus / Health Science Campus Non-Union

Spousal/Domestic Partner Healthcare Eligibility Affidavit

Employee Name _________________________ R# or SS# ____________________ (Please Print)

Spouse/Domestic Partner Name _________________________ (Please Print)

A. Who must complete this form? If you are a Main Campus / HSC Non-Union employee who wishes to select UT’s health insurance coverage for your spouse/domestic partner, you MUST complete sections A and B of this form. If your spouse/domestic partner is employed, their employer MUST complete section C. The spousal/domestic partner criteria is as follows:

If a spouse/domestic partner has accessibility to health insurance through their employer, they must enroll in that plan as primary for a minimum of single coverage and may stay on the UT plan as secondary. If the spouse/domestic partner makes $25,000 or less per year and the employee contribution for health insurance through their employer would cost them more than $75/month for a single plan, they may be carried on the UT plan as primary.

a. Spouse/Domestic Partner is: employed @ UT-HSC employed @ UT-MC employed full time employed part time unemployed self employed retired disabled

I hereby certify that the information provided above is correct. I understand that any misrepresentation in the information I have provided above will permit UT to terminate the spouse/domestic partner’s coverage and seek any other legal remedies available including possible prosecution for insurance fraud. Employee Signature _______________________________________ Date __________________

I authorize the release of the health care plan coverage information requested below and authorize its use in accepti ng the application for UT health benefit coverage. Spouse/Domestic Partner Signature _________________________________________ Date __________________

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A. Eligibility for Other Benefit Coverage To be completed by spouse/domestic partner’s employer: 1. Is the person named as spouse/domestic partner above eligible for medical coverage?

NO If no, STOP. You do not need to complete the rest of this form. Please sign, date and return to the address listed below.

YES If yes, continue to question 2. 2. Is the person named as spouse/domestic partner above making $25,000/year or less?

NO If no, continue to question 4. YES If yes, continue to question 3.

3. Do you offer the person named as spouse/domestic partner a health plan that would cost them more than $75/month for a single plan/employee contribution?

NO If no, continue to question 4. YES If yes, STOP. You do not need to complete the rest of this form. Please sign, date and return to the

employee. 4. Has the person named as spouse/domestic partner above taken the coverage for which he or she is eligible? NO If no, date coverage was waived or cancelled ____________. Yes If yes, ____ Single or ____ Family Coverage effective ___________ Insurance Company ____________________________ Group # _____________________ Policy #_____________________

Employer Name ________________________________________________________________________ Employer Address ______________________________________________________________________ Employer Phone Number _________________________________________________________________ Authorized Employer Signature ____________________________________________________________ Title ____________________________________________________ Date _________________________

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Please note… If you and your spouse are both

employed by UT and are both eligible for benefits coverage, you may either enroll together on one form or separately on individual forms, but not both.

Your dependent children may only be enrolled on one form, either yours or your spouses, but not both.

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Dependent Coverage

For dependents age 19-24 (25 for the CDHP), they must be claimed as an IRS dependent by the UT employee, be a full time student and unmarried to be eligible for benefits.

As long as a dependent meets this criteria they may remain covered on your plans until the end of the year in which they reach age 24 (25 for the CDHP).

A Dependent Verification Affidavit must be completed annually.

Same requirements will be used for Fee Waiver eligibility.

Dependents under age 19 do not need a form.

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Dependent Verification Affidavit (please complete a separate form for each dependent)

____________________________________ ___________________________ Employee Name (Last, First MI) Social Security Number or Rocket Number I hereby certify that __________________________, _______________________, (Name of Dependent) (Social Security Number of Dependent)

____/____/____ is: (Date of Birth)

FOR ALL PLANS: age 19-24 (end of calendar year), unmarried, claimed as a dependent for IRS

tax purposes, AND

full-time student (at an accredited educational institution)

FOR MMO CDHP: age 19-25 (end of calendar year), unmarried,

AND a full-time student (at an accredited

educational institution)

(Educational Institution: high school, college, university, other)

(City, State, Zip)

For the semester ____/____/____ to ____/____/____ or school year____________. Expected graduation date: ____/____/____

I hereby certify that the information provided above is correct. I understand that I am obligated to inform UT of any change in noted dependent’s student status. I ensure accuracy, I acknowledge and agree that UT may investigate the status of the noted dependent during the period in which the dependent is claiming full-time student standing. I understand that any misrepresentation in the information I have provided above will permit UT to terminate the dependent’s coverage and seek any other legal remedies available including possible prosecution for insurance fraud. Date: ____/____/____ ______________________________ (Signature) Employee ______________________________ (Relation to Dependent)

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Prescription

AFSCME will remain on current HSC plan SXC changing their name to “Informed

Rx a division of SXC” Bundled with Medical Coverage (except for

AFSCME)

Co-pays go by tiers Tier 1 – Generic Tier 2 – Preferred Brand Tier 3 – Non-Preferred Brand

Formulary can be found at http://hr.utoledo.edu/benefits 31

Prescription Cost Sharing

UT 30-day supply co-pays:(except for AFSCME) TIER 1: $6.60 per prescription TIER 2: $16.50 per prescription TIER 3: $33.00 per prescription

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UT 90-day supply co-pays:(except for AFSCME) TIER 1: $16.50 per prescription TIER 2: $30.80 per prescription TIER 3: $61.10 per prescription

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Main Campus Retail co-pays for a 30 day supply: Tier 1: $11 Tier 2: 20% Tier 3: 40%

Health Science Campus Non-Union Retail co-pays: Tier 1: Only a 10 day emergency supply is available

@$6.60 Tier 2: Only a 10 day emergency supply is available

@$16.50 Tier 3: Only a 10 day emergency supply is available

@$33.0034

Dental Plan AFSCME will remain on current HSC plan Enhanced for HSC non-union (same plan as

MC except for annual maximum) Preventive Services covered at 100%

2 cleanings in 12-month period Minor & Major work covered at 80%

$100 deductible per calendar year per person Orthodontia (dep <19) at 60% ($1500

lifetime max) Main Campus $3,000 annual max per

person Health Science Campus $1,500 annual max

per person35

HSC Dental (Non-Union)

Current New

per person per year max $750 $1,500

crowns 50% 80%

periodontic services 50% 80%

oral surgery 50% 80%

prosthodontic services 50% 80%

implants 50% 80%

orthodontic services 50% 60%

ortho lifetime limit $500 $1,500

deductible $50 $100

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HSC Dental (Non-Union)

Old

Charged

50/50 crown $ 800 $400 employee cost

New

80/20 crown $ 800 $160 employee cost

Old

50/50 oral surgery $1,200 $600 employee cost

New

80/20 oral surgery $1,200 $240 employee cost

old cap $ 750

new cap $1,500

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Vision Coverage

AFSCME will remain on current HSC plan Enhanced for HSC non-union (same plan

as MC) Eye examination with a $10 co-pay once

every 24 months Every 12 months for students & children

Prescription lenses once every 24 months Every 12 months for students & children

Frames/Contacts allowance of $120 every 24 months

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HSC Vision (Non-Union)

Current New

exam $15 $10

lens (student & child) every 24 mo every 12 mo

exam (student & child) every 24 mo every 12 mo

Contacts/lenses (student & child) every 24 mo every 12 mo

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Flexible Spending Account

Must be set up annually Allows you to set aside additional money

on a pre-tax basis May be used for out-of-pocket medical

and/or dependent care expenses You will be reimbursed for charges

incurred once claim form is submitted Reimbursements may be direct deposited Account DOES NOT rollover Reminder: If electing MMO CDHP medical

coverage, you are only eligible for dependent care.

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Main Campus Employee Clinic

Location:Main Campus Medical Center

Phone Number:419-530-3451

Clinic Hours:Monday - Friday 8:15 am - 11:00am and 1:00pm - 4:00 pm

Can generally be seen the same day, if not then within 24 hours

No office visit co-pay

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Health Science Campus Employee Clinic Location:

Room 2410, Dowling Hall

Phone Number:(419) 383-3000

Clinic Hours:Monday - Friday 7:30 am - 4:30 pm

Can generally be seen the same day, if not then within 24 hours

No office visit co-pay

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Full-Time Single $29.41Single +1 $58.82Family $90.09

Part-Time (20%)* Single $39.21Single +1 $78.42Family $120.12



Full-Time Single $12.10Family $35.57

Part-Time (20%)* Single $16.14Family $47.42


Part-Time (20%) Single $3.62Single +1 $7.25Family $11.10



Dental Plan

Vision Plan

OBA/FrontPath PPO and Rx

Paramount 3-Tier Employer Select and Rx

MMO CDHP and Rx

University of ToledoMain Campus

2010 Twelve Month Premiums

Employee Per Pay

Effective January 1, 2010





Full-Time Single $16.14Family $47.42

Part-Time (20%)* Single $21.52Family $63.23





University of ToledoMain Campus

2009 Nine Month Premiums

Employee Per Pay

Effective January 1, 2010

Dental Plan

Vision Plan

OBA/FrontPath (PPO) and Rx

Paramount 3-Tier PPO and RX

MMO CDHP Plan and Rx

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Per Pay

Full-Time Single 28.84Single + 1 57.41

Family 84.75 Part-Time Single 57.67

Single + 1 114.82Family 169.49

Full-Time Single 17.75Family 52.16

Part-Time Single 35.50Family 104.33

Full-Time Single 2.03Single +1 5.19


Single +1 10.38Family 15.33




University of ToledoHealth Science Campus - Non-union

2010 Monthly Premiums Effective January 1, 2010

Employee

MMO CDHP & Rx

DENTAL

VISION SERVICE PLAN

PARAMOUNT 3-TIER EMPLOYER SELECT & Rx

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Per Pay

Full-Time Single 28.84Single + 1 57.41


Single + 1 114.82Family 169.49

Full-Time Single 17.75Family 52.16

Part-Time Single 35.50Family 104.33










Employee

MMO CDHP and Rx

PHARMACY

DENTAL

VISION SERVICE PLAN

Paramount 3-Tier Employer Select

University of ToledoHealth Science Campus - AFSCME

2010 Monthly Premiums Effective January 1, 2010

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SECTION I: PERSONAL INFORMATION

Employee's Last Name FIrst M.I. Social Security Number

Home Address City State Zip Home Phone Number Daytime Phone Number

SECTION II: REASON FOR COMPLETING FORMDate of event: _____ / _____ / _____ (return form within 30 days of event date)Qualifying status change (please specify)

Hired/Newly Eligible Birth/Adoption/Legal Guardianship1 Loss of Other Coverage1

Open Enrollment Marriage1 Addition of Domestic Partner Coverage2

Other1(please describe): Addition of Dependent due to Eligibility1

1Documentation may be required. 2Affidavit required.

SECTION III: HEALTH PLAN COVERAGE SELECTION

Please select: Main Campus Employee ______ HSC Employee ______ For HR Office Use Only

I elect Medical/Rx coverage -- make plan selection below E-Class F/T or P/T

OBA/FrontPath PPO (Main Campus Only) I elect Dental coverage Deduction Code

Paramount Healthcare ES I waive Dental coverage Medical

Medical Mutual CDHP (HSA Form must also be completed) Rx

I waive Medical/Rx coverage I elect Vision coverage Dental

I waive Vision coverage Vision

SECTION IV-A: ELIGIBLE DEPENDENT ENROLLMENT INFORMATION

(Please list all family members to show new coverage)

Date of BirthName (M/D/Y) M F Social Security Number Yes No Yes No Yes No Yes No

*If dependent's address differs from employee's address, provide dependent's address in SECTION IV-C on back. Additional dependents may be added on back as well.

Please use the following numbers and letters to indicate Relationship to Employee

1 Employee 2 Spouse 3 Dependent Child (under age 24 unless fully disabled). 4 Domestic Partner3A Dependent Child of Employee3B Dependent Child of Employee's Spouse3C Dependent Child of Employee's Domestic Partner

NOTE:

AUTHORIZATION

Signature Date

Date of Birth

Main Campus / Health Science Non-Union

HEALTHCARE Election Form: Medical/Rx, Dental, Vision

Address

Dental

Choose coverage for

Rocket #

to Employee

PDADEDN

BENE

I hereby apply to The University of Toledo Healthcare Benefits Program for the coverage indicated above. I have read and understand the material explaining the terms and conditions of The University of Toledo Healthcare Plans. I declare that any individual for whom I am requesting healthcare coverage meets the definition of an eligible dependent. I understand that any person who knowingly and with intent to defraud applies for coverage or files a claim containing any materially false information is guilty of fraud and is thereby subject to disciplinary action, up to and including termination of benefits and/or employment as well as possible prosecution for insurance fraud. I understand that my elections may not be changed or voluntarily cancelled at any time during the plan year unless a qualifying status change occurs, as defined by the plan. The Benefits Office must receive notification on the appropriate form(s) within 30 days. I understand that the kind of coverage for which I am making application contains coordination of benefits, workers' compensation and subrogation provisions, and I acknowledge The University of Toledo's right to enforce these provisions. I authorize The University of Toledo to deduct the required semi-monthly contribution from my pay on a pre-tax and/or after tax basis. I understand that The University of Toledo's contribution amount for coverage for Domestic Partner and his or her dependent(s) is considered imputed income and I will be taxed on that value. I certify that all information provided on this form is true and correct to the best of my knowledge.

Vision

If Dependent Child is between the age of 19 and 24 (or 25 for CDHP), a Dependent Verification Affidavit is required.

(see below)Gender employee?*

For HR Office Use Only

each eligible dependent:Medical/Rx

Does anyone listed above have other coverage? NO YES, If yes please list on back under "Other Coverage"

different fromRelationship

BCOV

46

SECTION I: PERSONAL INFORMATION

Employee's Last Name First M.I. Date of Birth Social Security Number

Home Address Street City State Zip Home Phone Number Daytime Phone Number

SECTION II: REASON FOR COMPLETING FORMDate of event: _____ / _____ / _____ (return form within 30 days of event date)Qualifying status change (please specify)

Hired/Newly Eligible Birth/Adoption/Legal Guardianship1 Loss of Other Coverage1

Open Enrollment Marriage1 Addition of Domestic Partner Coverage2

Other1(please describe): Addition of Dependent due to Eligibility1

1Documentation may be required. 2Affidavit required.

SECTION III: HEALTH PLAN COVERAGE SELECTIONA. I elect Medical coverage -- make plan selection below

Paramount Healthcare ES For HR Office Use Only

Medical Mutual CDHP C. I elect Dental coverage E-Class F/T or P/T(HSA Form must also be completed)

I waive Medical coverage I waive Dental coverage Deduction Code PDADEDN

Medical

B. I elect Pharmacy (Rx) coverage D. I elect Vision coverage Rx

I waive Pharmacy (Rx) coverage I waive Vision coverage Dental

Vision

SECTION IV-A: ELIGIBLE DEPENDENT ENROLLMENT INFORMATION

(Please list all family members to show new coverage)

Date of BirthName (M/D/Y) M F Social Security Number Yes No Yes No Yes No Yes No

*If dependent's address differs from employee's address, provide dependent's address in SECTION IV-C on back. Additional dependents may be added on back as well.

Please use the following numbers and letters to indicate Relationship to Employee

1 Employee 2 Spouse 3 Dependent Child (under age 24 unless fully disabled). 4 Domestic Partner3A Dependent Child of Employee3B Dependent Child of Employee's Spouse3C Dependent Child of Employee's Domestic Partner

NOTE:

AUTHORIZATION

Signature Date

BCOV

Rocket #

If Dependent Child is between the age of 19 and 24 (or 25 for the CDHP), a Dependent Verification Affidavit is required.

to Employee

Health Science Campus - AFSCMEHEALTHCARE Election Form: Medical, Rx, Dental, Vision

Dental

Choose coverage for

each eligible dependent:

VisionGender Medical

Relationship

Rx

If you or your dependents have other coverage, please list on back under "Other Coverage"

I hereby apply to The University of Toledo Healthcare Benefits Program for the coverage indicated above. I have read and understand the material explaining the terms and conditions of The University of Toledo Healthcare Plans. I declare that any individual for whom I am requesting healthcare coverage meets the definition of an eligible dependent. I understand that any person who knowingly and with intent to defraud applies for coverage or files a claim containing any materially false information is guilty of fraud and is thereby subject to disciplinary action, up to and including termination of benefits and/or employment as well as possible prosecution for insurance fraud. I understand that my elections may not be changed or voluntarily cancelled at any time during the plan year unless a qualifying status change occurs, as defined by the plan. The Benefits Office must receive notification on the appropriate form(s) within 30 days. I understand that the kind of coverage for which I am making application contains coordination of benefits, workers' compensation and subrogation provisions, and I acknowledge The University of Toledo's right to enforce these provisions. I authorize The University of Toledo to deduct the required semi-monthly contribution from my pay on a pre-tax and/or after tax basis. I understand that The University of Toledo's contribution amount for coverage for Domestic Partner and his or her dependent(s) is considered imputed income and I will be taxed on that value. I certify that all information provided on this form is true and correct to the best of my knowledge.

(see below)

BENE

47

SECTION IV-B: EMPLOYEE AND ELIGIBLE DEPENDENT ENROLLMENT INFORMATION (cont'd)

Use the space below to record additional eligible dependent information as needed.

PCPBirth Date (If PHC

Name (M/D/Y) M F Social Security Number Yes No Yes No Yes No Yes No is selected)

*If dependent's address differs from employee's address, provide dependent's address in SECTION IV-C below.

SECTION IV-C: DEPENDENT ADDRESS INFORMATION (if different from employee's address)

If you indicated in SECTION IV-A or IV-B that any dependent's address differs from the employee's address, please provide that dependent's name and mailing

address below:

Dependent's Name

Street Address

City State Zip

Policy Holder Name Effective Date Policy Number

Insurance Company Family Members Covered

If you have questions, contact the Office of Human Resources Benefits Department at (419) 530-4747

Return completed form to: Office of Human Resources, Benefits Department, MS #205, 15115 South Towerview Blvd., Toledo, OH 43606. Fax: (419) 530-1492

OTHER INSURANCE

to Employee

different from and each eligible dependent:Relationship Gender employee?* Medical/Rx Dental Vision

Address Choose coverage for employee

HEALTH Election Form: Medical, Rx, Dental, Vision

48

HIPAA additional changes

Due to additional changes to HIPAA that were effective 9/23/2009, you will need to contact the vendors personally when you have a claims issue

Benefits vendor contact information is available on the http://hr.utoledo.edu benefits website or on the back of your ID card

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Open Enrollment Website

http://hr.utoledo.edu

Please remember Open Enrollment runs from October 15 to November 13. All forms must be turned into HR and time stamped by 5:00 pm on November 13.

Any questions that may come up can be emailed to [email protected]

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mailto:[email protected]

health care open enrollment (coverage effective 1/1/2010) 1

Documents

paramount phcs networks

utmc tier

network office visit

network paramount employer

facilities tier

utmc utp tier

high deductible health

afscme main campus