Sample Enrollment Guide

2019 Benefit Guide

MEDICAL BENEFI TS

is committed to helping you and your dependents maintain your health and wellness by providing you with access to the highest

levels of care. We offer you a choice of two medical plan options for 2019:

„ „ Enhanced high-deductible health plan (enhanced HDHP) „ „ Basic high-deductible health plan (basic HDHP)

If you choose, you can open a health savings account (HSA) with either of these plans. To learn more about HSAs, please see page xx.

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Medical and prescription drug plan summary Side-by-side Medical Enhanced HDHP plan Basic HDHP plan

Medical and prescription bi-weekly employee payroll contributions (effective Jan. 1, 2018)

Out-of- network

Out-of- network

Enhanced plan

Basic plan

In-network

In-network

Employee

$

$

Deductible

Employee only Family coverage

$ $

$ $

$ $

$ $

Employee + spouse

$

$

Employee + child(ren)

$

$

Coinsurance (what the plan pays after deductible is reached)

%

%

%

%

Family

$

$

Out-of-pocket maximum (includes deductible) Employee only Family coverage

Employees can elect the medical and prescription drug plan without enrolling in the dental or vision plans.

$ $

$ $

$ $

$ $

Preventive care

% % % % % %

% % % % % %

% % % % % %

% % % % % %

Office visit (PCP and specialist)

Emergency room

Urgent care

Inpatient care Outpatient care Prescription drugs

Employee Pays

Retail (30-day supply) Tier 1 — generics

$ $ $ $ $ $

$ $ $ $ $ $

$ $ $ $ $ $

$ $ $ $ $ $

Tier 2 — preferred

Tier 3 — nonpreferred

Mail order (90-day supply) Tier 1 — generics

Tier 2 — preferred

Tier 3 — nonpreferred

Prescription drugs—100% coverage for preventive generics before the deductible applies.

Preventive brand and non-preferred brand (second and third tier) drugs are covered at the plan’s coinsurance maximum amounts as outlined in the chart. A deductible does not apply.

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TOOLS

healthcare contact information „ „ Coverage details (copays, deductibles, out-of-pocket maximums, etc.). „ „ Review your claims activity and history. „ „ Print a temporary ID card or order a new ID card. „ „ See frequently asked questions (FAQs). „ „ Registered nurses are available to provide immediate assistance and advice on medical treatment.

How to find a provider

The designation identifies doctors in the network who have achieved top results on ’s quality and cost-efficiency measures. To find one of these doctors, please visit .

How can help you „ „ enrollment information line at XXX.XXX.XXXX „ „ healthcare contact information — Find all of your information when you need it at . Call XXX.XXX.XXXX any time, day or night, 365 days a year, for assistance.

Be informed Visit for instructions and helpful tips to build and customize your medical benefits: „ „ User ID: 2019 (case-sensitive) „ „ Password: password (case-sensitive)

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