Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 38 Page 39 Page 40 Page 41 Page 42 Page 43 Page 44Table of Contents The purpose of this Open Enrollment Guide is to give you basic information about your benefit options and how to enroll for coverage or make changes to existing coverage. This guide is only a summary of your choices and does not fully describe each benefit option. For a more detailed description of benefits, please refer to the plan’s benefit booklet, brochure, summary plan description (SPD), summary of benefits and coverage (SBC) or evidence of coverage (EOC). You may also call the plan using the customer service phone number on the last page of this booklet. Please note that plans will not cover a service if it is not considered medically necessary. Additionally, if your physician or facility discontinues participation in a plan, you will not be allowed to change plans outside the window of Open Enrollment as this is NOT considered a qualifying life event for you or your dependents. Every effort has been made to make the information contained in this booklet accurate; however, if there are discrepancies between this document and the contract with the carrier, the contract will govern. Important Information About Your Benefits for 2017 and Beyond. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Highlights Of Plan Changes For 2017. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Open Enrollment Timeline. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Benefits Open Enrollment Schedule. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 2017 Medical, Dental and Vision Plan Rates For Employees. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Important Things To Remember. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 One Source Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Insurance Coverage For Dependents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Change Of Life Events. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Health & Wellbeing Fair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-10 U.S. Legal Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 2017 Calendar Year Medical Summary of Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12–14 CVS/caremark Personal Prescription Benefit Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 CVS/caremark Maintenance Choice for Long-Term Medications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Kaiser Permanente Prescription Benefits At-A-Glance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 National Vision Administrators. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Delta Dental Plan Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19–20 UnitedHealthcare — Right care. Right place. Right Savings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Kaiser Permanente — When to Seek Urgent Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 MetLife Life Insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-24 Flexible Spending Accounts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25-26 Sick Leave Bank. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27–28 Employee Assistance Program (EAP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Legislative Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30–31 Certificate of Creditable Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32–33 HIPAA Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34–37 Glossary of Insurance Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38–40 Customer Service Contacts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41