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Insurance Committee Minutes 06.07.2018
MINUTES INSURANCE COMMITTEE JUNE 7, 2018 9:00 A.M. COUNCIL CHAMBERS CONFERENCE ROOM MEMBERS PRESENT: L01 9 to 3 l 91 Kelly Strecker, Clerk's Office Stan Langve, Union 303 Monica Salo, Union 316 Sheri Phillips, Union 316 Roy Voss, Union 316 Dave Allen, Allen and Associates Eric Allen, Allen and Associates Amanda Burkhart, MMIA Dave Allen introduced himself to the group. The Insurance Committee was presented each of the options to consider for their recommendation. The presentations started with Blue Cross Blue Shield of Montana since they are the current insurance provider. Allen and Associates handed out a spreadsheet to quickly compare each of the policies, see attached. Blue Cross Blue Shield of Montana Renewal Blue Cross Blue Shield of Montana (BCBS) looked at the City's last 18 to 24 months of claims. They used this data to determine if the City would see a rate change. There would be no increase for the Fiscal Year of 2018/2019 insurance premiums. BCBS did provide a claims report that was used to obtain the other bids presented to the Committee. There is a wellness credit of $10,000 first month's premium credit. While the City would not pay this amount to BCBS, they would need to use these funds to promote wellness. Employees would receive their cards within a month of renewal. MMIA Amanda Burkhart, MMIA, presented what MMIA can offer the City. MMIA is a co-op of cities and towns. Most small cities and towns are lumped into the same pool to share the costs; some are self- funded. MMIA does not process any claims; they manage the reserve the claims are paid from. They contract with third -party companies to administer that process. MMIA requires a five-year commitment from the City; this helps ensure stability across the pool. The City of Laurel's rate was fifteen percent higher than the standard rate. After five years the City of Laurel could drop to the standard rate. If a city or town chooses to leave MMIA, they are required to wait three years before they are able to return. Every hospital in the State of Montana has signed on to accept MMIA coverage. Hospitals have the ability to set their costs for services given. MMIA found that different hospitals charged a wide range for the same procedure. To help reduce the cost they used the Medicare rate plus a percentage as the allowable billable cost, this has helped reduce costs. MMIA only offers four plans. Many Cities have set the rate they are willing to pay and allow the employee to choose the plan that will suit them best. MMIA uses Allegiance to process medical claims in the state. Out of State would be the Cigna network. The State of Montana has worked to offer Montana Health Centers, those on the MMIA plan would be able to receive care at no cost. These centers offer primary care providers, do lab work, CT, and MRI's at no cost to the employee. Council Workshop Minutes of June 7, 2018 The City would have two options for pharmacy. There is a percentage option and a copay option. The percentage option is of less cost to the City, however, may not be well liked by the employee. The copay option, through our current provider, is what the City currently uses for its pharmacy coverage. MMIA does not have pharmacy's that are not covered by their prescription plan. MMIA does participate in a program for mail -in pharmacy. This program is international, there is no copay and may be at no cost to the employee. The medications come from other tier one countries and can save the pool 60-70% on the cost of the medication. MMIA focuses on wellness and risk management. Instead of offering a premium credit like BCBS did they offer $250 to the employee if they meet certain criteria. If the City had 80% or greater participation in the wellness program, all employees would receive an additional $50.00. MMIA focuses heavily on disease and case management. As an example, the most expensive claim is for a premie baby. By having a case manager check in with an expectant mother the insurance company can ensure all possibilities to reduce the possibility of a premie baby have been taken. MMI also offers employee assistance. The offer six visits/per household member/per issue to a mental health provider or counselor for no cost. MMIA uses Delta Dental and VSP to manage their dental and vision benefits. This does require 80% participation for a City in order to participate in the dental benefit. The City would have the option to add an additional orthodontic benefit. For their vision benefits, they offer the 12/12/12 plan. This is one visit to the eye doctor every 12 months, with new glasses or contracts every 12 months. MMIA offers basic life insurance as well. MMIA employees do use the health insurance offered by MMIA. However, the MMIA plans do not directly mirror the current BCBS policy. Pacific Source Initially offered a five percent discount as compared to BCBS. Once the new claims statement came in Pacific Source refigured their quote and reduced their quote to seven percent. The Pacific Source plan mirrors the current BCBS policy. Pacific Source is based out of Oregon and has focused on the Pacific Northwest. They are currently in the process of building a storefront in Billings. They pride themselves on providing excellent customer service. Their goal is to be able to answer a customer's questions within one phone call. There are four plans to choose from including a $500 deductible and $2,500 out of pocket max. All hospitals in the state are in -network, and approximately 89%-90% of all doctors are in -network. BCBS has approximately 94% to 95% of all doctors in their network. These plans do have a $25 copay as opposed to the MMIA that does not use copays. They use tiers for their pharmacy benefits, similar to what BCBS uses. Employees can use CVS Pharmacy for their pharmacy needs. Pacific Source does offer gym memberships for $25.00 per month, however, unlike BCBS employees must choose one gym to use their benefit at. They also have an extensive preventative drug list. Drugs listed on this list are at no cost to the employee. Pacific Source moved into the Montana market approximately 10 years ago, but have been around for many years. K Council Workshop Minutes of June 7, 2018 Health Co -Op Like Pacific Source the Health Co -Op did come in at five percent under the BCBS quote. However, Dave Allen cautioned the Committee that while the rate quote was attractive, the plans were not identical to the City's current BCBS plan. They would need to review what was included carefully. Allen and Associates' recommendation is Pacific Source. They offer year to year plans, the City would not be locked into a five-year contract, their rates came in under the current rates for BCBS, and their plans are most similar to what the City currently has. Amanda Burkhart clarified why MMIA requested health questionnaires from all employees. MMIA works on money in money out system. For this reason, they needed an accurate overview of the rate utilization. Dave Allen clarified the City could look into extending their contract with BCBS for one month and pushing the start date with another insurance company to August I". Dave clarified that he does work on commission if the City chooses to go with MMIA the City could still retain his services. The Insurance Committee adjourned at 10:33 a.m. Respectfully submitted, U6 quf� Brittn boan Administrative Assistant 3 Z 0 �j I- -n m M N) (A 21 :0 0 r) r) x 0 ;r a o 'a :0 M 0 0 0 "i L CD (D M + :5, )) c CL - @ < x x q (D :; O. lz Z .. 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M 0 0 N> > co R: r - ro M 0 R 9 M 0 Ln 0 m 0 (D 01 co =0' B M 1 0 M is 0 0 N 0 tU S� 11 N -4 It- Ln 0 ID< CL om 0 n w M 0 < C:) '00 p 00 f -j :,j 4 Ln C) 4, -j w m 4t. :3 CD (D -.,- C:) 0 Ll 00 00 0 Z 'a n5 M M N :E 0 w Ln 0 0 00 Z� 00 F� Ln co 14 0 0 0 < 0 0 DJ 0 0 N w tD 0 tn Z 0 M 00) ON ptU UJ 90 !D !- 00 < ro w P� o w bi 0 N O Ln 0 Ln . -�L ! COC) -j -4 C) -,j C: 0 0 C) -< 02 U7 N X, w :3 M Cc, 0 w w Ln W w Ln to rD rD (D -< m :3 0 0 QOO O 90 Pi 9) (D 0 ;a -< m I w uj R "a =1 W LU Ln 4�, 0 (A (n Ln s ����,��� ;� �•� �3 is i rk• .. April 26, 2018 Kelly Strecker City of Laurel P.O. Box 10 Laurel, MT 59044-0010 Dear Kelly: PO Box 80826 Billings, Montana 59108 Customer Information Line: 800.447.7828 www.bcbsmt.com Blue Cross and Blue Shield of Montana (BCBSMT) is proud to present a fully insured renewal that underscores the value of our health plans. We appreciate the opportunity to continue serving you, your employees and their families. At BCBSMT, our goal is to build a stronger health care system for tomorrow while giving employers immediate solutions to the issues they are facing today — like rising health care costs and the need to engage employees in making smart decisions about their health. To drive long-term change, BCBSMT launched the most robust Value -Based Care initiatives in Montana. These programs are transforming our health care system — shifting the emphasis of health care from volume to quality, transparency and accountability — while reducing costs. t' BCBSMT launched the most robust transparent pricing initiative in Montana, giving City of Laurel employees the power to easily shop for health care based on quality and cost. The Cost Estimator is powered by BCBS AxisO, the largest database of health care quality and cost information in the health care industry — and the only data resource that includes health care information from every ZIP code in the United States. We also continue to provide the greatest savings on medical care in the industry. A January 2016 Milliman National Benchmark Comparison found that health care providers offer Blue Cross and Blue Shield (Blue) plan members almost 14 percent better savings than our competitors. In addition, it found that in -network utilization was approximately six percent higher for Blue plan members than for our competitors. As the industry leader and your health benefits partner for the past year, BCBSMT is well equipped to support your goals and objectives with cost-effective programs, exceptional account management, and new tools and resources to improve the quality and reduce the cost of your employees' health care. Your Agent, Dave Allen will contact you soon to set up a personal visit to discuss your renewal and available options. Our goal is to ensure that your annual plan renewal is understandable, that desired benefit options are promptly delivered for your consideration, and that the required documentation to complete the renewal is processed efficiently. We appreciate the continued opportunity to serve you, your employees, and their dependents. If you have questions about your renewal or if I can help in anyway, please contact me at (406) 437-6363. Sincerely, Shellie Wherley Account Executive Enclosures/cc: Dave Allen A DIVISION OF HEALTH CARE SERVICE CORPORATION, A 1.10TUAL LEGAL RESERVE COMPANY. AN INDEPENDENT LICENSEE OF THE BLUE CROSS AND BLUE SHIELD ASSOCiMION Kelly Strecker City of Laurel Page 2 7f)1R Rpnewnl Tnfnrmntian: Effective 7/1/2018 Triple Option: BIue Dimensions 80/20 PPO Plan Type Blue Dimensions PPO: 80/20 co -ins In -network; Single 65/35 Co -Ins Out -of -Network Office Visit Copay $25 Par Professional Provider services done in office setting. Deductible $1,000 Individual/$2,000 Family Out -of -Pocket Maximum $2,500 Individual/$5,000 Family Efficient RX $100 Deductible — waived on Generics Performance Formulary Retail/Value Pharmacy: $10/$40/60% up to max $200 per fill; 90 -day supply at Value Pharmacy Retail only at 3 Copays, Retail/Prime Network: $15/$50/60% up to max of $250 per fill; Mail Order: $20/$80/60% up to max of $400 per fill 90 -day supply Specialty RX: $100/$200 copays after deductible. OON Specialty: 50% co-insurance; *Performance Formulary applies at renewal Accident Process off Standard Medical Benefits Preventive Benefit In -Network: 100% coverage up to allowable fee for routine/preventive services including Well Child and routine Mammograms. Out -of -Network: Ages 19+ - Deductible applies; Well Child under 19 — deductible waived; Routine Mammo rams — first $70 is aid; deductible applies EAP*If group wishes to purchase EAP services — we can provide pricing thru Magellan Behavioral Health. COBRA HCSC Renewal Rates below do not include the $75 COBRA administered Administration Fee and Activity Fees. Blue' Dimensions- 80/20 PPO Renewal Single $803.52 Two P $1,782.60 Employee/Child/Children $1,278.42 Family $2,048.18 Single Medicare $450.15 2P/Med $899.17 Kelly Strecker City of Laurel Page 3 �A1R Renewal Tnfnrmatinn� Effective 7/1/2018 Triple Option: Blue Dimensions 70/30 PPO Plan Type Blue Dimensions PPO: 70/30 co -ins In -network; Single 55/45 Co -Ins Out -of -Network Office Visit C6pay $35 Par Professional Provider services done in office setting. Deductible $1,500 Individual/$3,000 Family Out=of Pocket Maximum $3,500 Individual/$7,000 Family Efficient RX $100 Deductible — waived on Generics Performance. Formulary Retail/Value Pharmacy: $10/$40/60% up to max $200 per fill; 90 -day supply at Value Pharmacy Retail only at 3 Copays. Retail/Prime Network: $15/$50/60% up to max of $250 per fill; Mail Order: $20/$80/60% up to max of $400 per fill 90 -day supply Specialty RX: $100/$200 copays after deductible. OON Specialty: 50% co-insurance; *Performance Formulary applies at renewal Accident Process off Standard Medical Benefits Preventive Benefit In -Network: 100% coverage up to allowable fee for routine/preventive services including Well Child and routine Mammograms. Out -of -Network: Ages 19+ - Deductible applies; Well Child under 19 — deductible waived; Routine Mammograms — first $70 is aid; deductible applies EAP* If group wishes to purchase EAP services — we can provide pricing thru Ma ellan Behavioral Health. COBRA HCSC Renewal Rates below do not include the $75 COBRA administered Administration Fee and Activity Fees. Blue Dimensions 70/30 PP0 Renewal Single $755.13 Two P $1,675.68 Employee/Child/Children $1,199.65 Family $1,924.39 Single Medicare $423.14 2P/Med $846.28 Kelly Strecker City of Laurel Page 4 Blue Choice HSA PPO 53.500 Deductible Plan— effective 7/1/18 Plan Type Blue Choice PPO/HSA Compatible Plan $627.84 100/0 co-insurance feature after deductible is met Deductible $3,500 Individual/$7,000 Family In -network $998.26 $7,000 Individual/$14,000 Family Out -of -network Out -of -Pocket Maximum $3,500 Individual/$7,000 Family In -network $7,000 Individual/$14,000 Family Out -of -network Performance Formulary Non -Preventive Covered Brand/Generic Drugs apply to Medical Deductible/OOP Out -of -Network Specialty Drugs: 50% co-insurance after deductible. *Performance Formulary applies: Non -Covered drugs; Step Therapy, Prior Authorization and dispensing limits apply. 90 -Day at retail only available thru Extended Supply Value Preferred Pharmacies Accident Process off Standard Medical Benefits Preventive Benefit 100% coverage In -Network up to allowable fee for routine/preventive services including Well Child and Mammograms. Out -of -network routine/preventive Mammograms — First $70 paid; deductible and Co-insurance applies Out -of -Network Routine/Preventive — 19+ (Adult) — Deductible and co- insurance applies Out -of -Network Well Child Services — Under 19 — co-insurance applies deductible waived COBRA. — Vendor Our records indicate COBRA is not administered thru Administered HCSCBCBSMT. Blue Choice HSA $3,500 Renewal Single $627.84 Two P $1,393.17 Em 1/Child ren $998.26 Family $1,600.36 Kelly Strecker City of Laurel Page 5 Important Notices and Enclosures: ✓ Renewal Paperwork: I will forward the Merit Group Application once you finalize the review of the renewal and determine if you are electing to make any benefit modifications. ✓ Open Enrollment Notice: Please share a copy of the enclosed open enrollment notice with your employees. ✓ HIPAA/Special Enrollment Rights Notice: Please share a copy of the enclosed Special Enrollment notice with your employees. ✓ Summary of Benefits and Coverage (SBC): BCBSMT is required to provide a Summary of Benefits and Coverage (SBC) with your renewal packet. You, as the employer, must distribute a copy of the enclosed SBC to all individuals eligible for your group health insurance policy. The requirements and timelines are detailed in the enclosed attachment. 2018 SBCs for your Blue Dimensions PPO and Blue Edge Plus PPO plans offered at renewal are enclosed for your reference. ✓ 2018 Pharmacy Changes: 2018 Notice of Pharmacy changes is enclosed that highlights the changes incorporated to applicable BCBSMT group plans effective 1/1/18 or at renewal. ✓ Participation Requirement Notice: Please review the requirement with your agent/consultant to ensure your group is meeting participation requirements. ✓ Value Added Services/Resources/Tools: The enclosed brochures provide you an overview of the additional services, resources and tools that are provided to your employees and their families. We encourage you to share this information with them. If you would like to order any of these materials, please contact me. Blue Cross ` d Blue Shield of Montana 2018 Fully Insured Large Group Business Pharmacy Changes BCBSMT has identified the following opportunities that will help manage costs while still offering our members a high quality and effective prescription drug program. The following is a summary of the changes for our customers. This is effective January 1, 2018 or upon a group's renewal unless specifically noted: ✓ Six -Tier Benefit Design: o Blue Choice/Blue Options -Standard Plans will move to a Six -Tier benefit design upon their 2018 renewal/effective date. Preferred and Non -Preferred Tiers for Generics, Brand Name Drugs and Specialty Drugs. Current Blue Choice/Blue Options Plan Designs will be discontinued and replaced with the following Plan Designs: o $01$10/$50/$100/$150/$250 — at Value Preferred Pharmacies. Blue Choice Efficient RX and 5 Tier Drug Plan replaced by plan design above. Blue Options 4 Tier Drug Pian replaced by plan design above. Separate RX Out of Pocket on Blue Options Plans removed. o $0/$10/$35/$75/$150/$250 - at Value Preferred Pharmacies Blue Choice 4 Tier Drug Plan $8/$35/$75/$150 replaced by plan design above. o 10°I%/10%/20%/30%/40%/50% -at Value Preferred Pharmacies Blue Choice HSA Plans with co -ins after deductible replaced by plan design above. ✓ HDHP/HSA Eligible Plans - $0 Copay Preventive Drug List: o Revised Drug List effective 1/1/18 and upon renewal. ✓ Terminology Change: o Formulary & Non -Formulary Drug Changing to Preferred and Non -Preferred Drug. ✓ Drug List and Pharmacy Networks: o MT Standard Insured and Custom Insured Plans will remain on their Current 2017 Drug List and Pharmacy Network for 2018. ■ Performance Drug List Value Network (Pharmacy Network) CVS/Target Pharmacies — Out -of -Network as of 1/1/17. ✓ Want more information? Find a Pharmacy or search the Performance drug list on www.mvprime.com. See www.bcbsmt.com for Drug List, Value Pharmacy and additional Pharmacy Resources. Please work with your Account Executive with any questions. Please note: This is a general overview of changes and not a guarantee of payment. Please reference the specific benefit materials and information on your plan. .•; �i .� " h of M. onta �r4 s Account Name CITY OF LAUREL Account Number 138674 Rate Effective Date 07/01/2018 Experience Period: Incurred: 11/01/2015-10/31/2017 Active Contracts as of 02/28/2018 66 Projected Claims PCPM based on Experience with Pooling: $788.14 Credibility 64.59% Adjusted Manual Claims PCPM: $756.34 Credibility 35.41% Total Projected Claims PCPM: $776.88 Desired Loss Ratio* 81.79% Calculated Premium PCPM** $949.85 Premium at Current Rates PCPM $949.85 Calculated Premium Rate Action 0.0% Final Premium Rate Action 0.0% ® Change in Demographics -0.2% a Annual Trend 7.5% *Includes provisions for Administrative Costs, State Taxes & Assessments, and Commissions **Reflects the effects of Health Insurer and Reinsurance Fees, plus any federal and state taxes applicable to these fees. A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. 04/05/2018 Registered Marks Blue Cross and Blue Shield Association 6 Preventive check-ups and screenings can help find illnesses and medical problems early and improve the health of you and everyone in your family. Your health plan covers screenings and services with no out-of-pocket costs like copays or coinsurance as long as you visit a doctor in your plan's provider network. This is true even if.you haven't met your deductible. Some examples of preventive care services covered by your plan include general wellness exams each year, recommended vaccines, and screenings for things like diabetes, cancer or depression. Preventive services are provided for women, men and children of all ages. For more details on what preventive services are covered at no cost to you, refer to the back of this flier for a listing of services, or see your benefits materials. Learn more on immunization recommendations and schedules by visiting the Centers for Disease Control and Prevention website at www.cdc.gov/vaccines. SCREENINGS FOR ❑ Abdominal aortic aneurysm ❑ Alcohol abuse and tobacco use ❑ Cardiovascular disease (CVD) including cholesterol screening and statin use for the prevention of CVD ❑ Colorectal and lung cancer ❑ Depression ❑ Falls prevention and vitamin D use for stronger bones ❑ High blood pressure, obesity, diabetes and depression ❑ Sexually transmitted infections, HIV, HPV and hepatitis ❑ Tuberculosis COUNSELING FOR ❑ Alcohol misuse ❑ Domestic violence ❑ Healthy diet and physical activity counseling for adults who are overweight or obese and have additional cardiovascular disease risk factors ❑ Obesity ❑ Sexually transmitted infections ❑ Skin cancer prevention ❑ Tobacco use, including certain medicine to stop ❑ Use of aspirin to prevent heart attacks r �s� ❑ Aspirin for preeclampsia prevention ❑ Breast cancer screening, genetic testing and counseling ❑ Breastfeeding support, supplies and counseling ❑ Certain contraceptives and medical devices, morning after pill, and sterilization to prevent pregnancy ❑ Cervical cancer screening ❑ Chlamydia, gonorrhea, syphilis, HIV and hepatitis B screenings ❑ Counseling for alcohol and tobacco use during pregnancy ❑ Folic acid supplementation during pregnancy ❑ Human papillomavirus (HPV) DNA test ❑ Osteoporosis screening ❑ Screenings during pregnancy, including screenings for anemia, gestational diabetes, bacteriuria, Rh(D) compatibility, pre- eclampsia 011"! 201 tl SCREENINGS FOR ❑ Autism ❑ Cervical dysplasia ❑ Critical congenital heart defect screening for newborns ❑ Depression ❑ Developmental delays ❑ Dyslipidemia (for children at higher risk) ❑ Hearing loss, hypothyroidism, sickle cell disease and phenylketonuria (PKU) in newborns ❑ Hematocrit or hemoglobin ❑ lead poisoning ❑ Obesity ❑ Sexually transmitted infections and HIV ❑ Tuberculosis ❑ Vision screening ASSESSMENTS AND COUNSELING ❑ Alcohol and drug use assessmentfor adolescents ❑ Obesity counseling ❑ Oral health risk assessment, dental caries prevention fluoride varnish and oral fluoride supplements ❑ Skin cancer prevention counseling KOM ❑ Diphtheria, Pertussis, Tetanus ❑ Haemophilus Influenzae Type B (Hib) ❑ Hepatitis A and B ❑ Human Papillomavirus (HPV) ❑ Inactivated Poliovirus (Polio) ❑ Influenza (Flu) ❑ Measles, Mumps, Rubella (MMR) ❑ Meningitis ❑ Pneumococcal ❑ Rotavirus ❑ Varicella (Chicken Pox) ❑ Zoster (Herpes, Shingles) ©; BlueCross BlueShield of Montana Well nT r to Make Your Fitness Program Membership Work for You! Fitness can be easy, fun and affordable. Well onTarget makes it possible with the Fitness Program. Since you are a Blue Cross and Blue Shield of Montana member, the Fitness Program is available exclusively to you and your covered dependents (age 18 and older). The program gives you unlimited access to a nationwide network of more than 10,000 fitness locations. If you want, you can choose one gym close to home and one near work. You can visit gyms while you're on vacation or traveling for work. Other program perks include: a No long-term contract: Membership is month to month. Monthly fees are $25 per month per member, with a one-time enrollment fee of $25 per member.' r ® Complementary and Alternative Medicine (CAM) \_ discounts: Save money through a nationwide network of 40,000 health and well-being providers such as acupuncturists, massage therapists and personal trainers. o Blue Points5`A: Get 2,500 points for joining the Fitness Program. Earn additional points for weekly visits. You can redeem points for apparel, books, electronics, health and personal care items, music and sporting goods." Web resources: You can go online to locate gyms and track your visits. Convenient payment: Monthly fees are paid via automatic credit card or bank account withdrawals. ARE YOU READY FOR FITNESS? It's easy to sign up: 1. Go to bcbsmt.com and log in to Blue Access for MemberssM 2. Under "Quick Links," choose "Fitness Program." On this page, you can enroll, search for nearby fitness locations and learn more about the program. 3.Click "Enroll Now." Then search and select the fitness location that is best for you. Remember, you can visit any participating fitness location after you sign up. 4.Verify your personal information and method of payment. Print or download your Fitness Program membership ID card. You may also request to receive the ID card in the mail. 5.Visit a fitness location today! Prefer to sign up by phone or have questions about the Fitness Program? Just call the toll-free number 888 -762 -BLUE (2583) Monday through Friday, between 7 a.m. and 7 p.m. CT (6 a.m. and 6 p.m. MT). The one-time enrollment fee and monthly membership fee for the Fitness Program are both subject to applicable taxes. Blue Points Program Rules are subject to change without prior notice. See the Program Rules on the Well onTarget Member Wellness Portal for more information. The Fitness Program is provided by Tivity Health", an independent contractor that administers the Prime Network of fitness locations. The Prime Network is made up of independently owned and operated fitness locations. Blue Cross and Blue Shield of Montana, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 350150218 09 BlueCross B1ueShield of Montana A a, a iNew Way to Experience Wellness Well onTarget offers personalized tools and resources to help you — no matter where you may be on the path to health and wellness. Well onTarget can give you the support you need to make healthy choices — while rewarding you for your hard work. MEMBER WELLNESS PORTAL The heart of Well onTarget is the member portal, available at wellontarget.com. It uses the latest technology to offer you an enhanced online experience. This engaging portal links you to a suite of innovative programs and tools. • Self-directed courses: These courses let you work at your own pace to reach your health goals. Learn more about nutrition, fitness, losing weight, quitting smoking and managing stress. Track your progress and reach your milestones as you make your way through each lesson. Reach your milestones and earn Blue Points"'.' • Health and wellness content: The health library teaches and empowers through evidence -based, reader -friendly articles. o Tools and trackers: These resources can help keep you on course while making wellness fun. Use a food and exercise diary, symptom checker and health trackers. Blue Points Program Rules are subject to change without prior notice. See the Program Rules on the Well onTarget Member Wellness Portal at wellontarget.com for further information. EVA HEALTH ASSESSMENT (HA) The HA uses adaptable questions to learn more about you. After you take the HA, you will get a personal wellness report. This confidential report offers you tips for living your healthiest life. Your answers will help tailor the Well onTarget portal with the programs that may help you reach your goals. BLUE POINTS PROGRAM Blue Points can help motivate you to maintain a healthy lifestyle. Earn points for participating in wellness activities. You can redeem points in the online shopping mall. The program gives you points instantly, so you can use them right away. If you want a larger reward, you can purchase additional points when you check out. FITNESS PROGRAM" Fitness can be easy, fun and affordable. The Fitness Program is a flexible membership program that gives you unlimited access to a nationwide network of more than 9,000 fitness centers. If you want, you can choose one gym close to home and one near work. And you can visit gyms while you're on vacation or traveling for work. Other program perks include: o No long-term contract: Membership is month to month. Monthly fees are $25 per month per member, with a one-time enrollment fee of $25 per member. o Blue Points: Get 2,500 points for joining the Fitness Program. Earn additional points for weekly visits. * Convenient payment: Monthly fees are paid via automatic credit card or bank account withdrawals. o Web resources: You can go online to locate gyms and track your visits. © Health and wellness discounts: Save money through a nationwide complementary and alternative medicine network of 40,000 health and well-being providers, such as massage therapists, personal trainers and nutrition counselors. It's easy to join the Fitness Program! Just call the toll-free number 888 -762 -BLUE (2583) Monday through Friday, from 8 a.m. to 9 p.m. in any continental U.S. time zone. FITNESS TRACKING Track your fitness activity using popular fitness devices and mobile apps. WELLNESS PROGRAM QUESTIONS? Call Customer Service at 877-806-9380. The Fitness Program is provided by Healthways, Inc., an independent contractor that administers the Prime Network of fitness centers. The Prime Network is made up of independently owned and operated fitness centers. Blue Cross and Blue Shield of Montana, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 350148.0616 09 BlueCross B1ueShield of Montana Care When and Where You Need It Just Got Easier Powered i((�b�y$�(J Giy"LS iY 'C " Getting sick is never convenient, and finding time to get to the doctor can be hard. Blue Cross and Blue Shield of Montana (BCBSMT) provides you and your covered dependents access to care for non- emergency medical issues and behavioral health needs through MDLIVE. Whether you're at home or traveling, access to a board-certified doctor is available 24 hours a day, seven days a week. You can speak to a doctor immediately or schedule an appointment based on your availability. Virtual visits can also be a better alternative than going to the emergency room or urgent care center.' MDLIVE doctors or therapists can help treat the following conditions and more: General Health Pediatric Care Behavioral Health Allergies Cold Anxiety/depression Asthma Flu Child behavior/learning issues Nausea Ear problems = Marriage problems Sinus infections = Pinkeye Blue Cross and Blue Shield of Montana, a Division of health Care Service Corporation, a Mutual Legal Reserve Company, a., Independent Licensee of the Blue Cross and Blue Shield Association Blue Cross", Blue Shield° and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. MDLIVE, an independent company, provides virtual visit services for Blue Cross and Blue Shield of Montana. MDLIVE operates and administers thevirtual visit program and is solely responsible for its operations and that of its contracted providers. MDLIVE and the MILK logo are registered trademarks of IADLIVE. In.. and may not be used without mitten permission. 352512.0217 W"F&I AY Getting sick is never convenient, and finding time to get to the doctor can be hard. Blue Cross and Blue Shield of Montana (BCBSMT) provides you and your covered dependents access to care for non- emergency medical issues and behavioral health needs through MDLIVE. Whether you're at home or traveling, access to a board-certified doctor is available 24 hours a day, seven days a week. You can speak to a doctor immediately or schedule an appointment based on your availability. Virtual visits can also be a better alternative than going to the emergency room or urgent care center.' MDLIVE doctors or therapists can help treat the following conditions and more: General Health Pediatric Care Behavioral Health Allergies Cold Anxiety/depression Asthma Flu Child behavior/learning issues Nausea Ear problems = Marriage problems Sinus infections = Pinkeye Blue Cross and Blue Shield of Montana, a Division of health Care Service Corporation, a Mutual Legal Reserve Company, a., Independent Licensee of the Blue Cross and Blue Shield Association Blue Cross", Blue Shield° and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. MDLIVE, an independent company, provides virtual visit services for Blue Cross and Blue Shield of Montana. MDLIVE operates and administers thevirtual visit program and is solely responsible for its operations and that of its contracted providers. MDLIVE and the MILK logo are registered trademarks of IADLIVE. In.. and may not be used without mitten permission. 352512.0217 Website: Visit the website MDLiVE.com/bcbsmt Choose a doctor Video chat with the doctor You can also access through Blue Access for Members" Mobile App: = Download the MDLIVE app from the Apple App Store', Google Play'' Store or Windows° Store Open the app and choose an MDLIVE doctor Chat with the doctor from your mobile device G{zat coma ec-ted today! To ? gister, you'll needl tonee provide your first and Jast ijfi'ssse. date Df bhuh and B6SIWIT Member ID 33aumber. ' In the event of an emergency, this service should not like die place of at emergency room or utgeni care center MOLIVE doctors do not take the place of your primary care duclur. Proper diagnosis should come Iromyour doclur. and medical advice is always between you and your doctor. Internet/Wi-Fi connection is needed for computer access. Data charges may apply when using your tablet or smartphone. Check your phone carrier's plan for details. Video 011 -demand consultations for behavioral health are available by appointment. Service is limited to inaxactive-audio consul ations (phone only), along with the ability to prescribe. udien clinically appropriate. in Iexas. Service is limited to intetactive-audio/video (video only), along with the ability to prescribe, when clinically appropriate, in Idaho, Mortara. New Mexico and Oklahoma. Virtual visits are currently not available in Arkansas. Service avadabditydepends on member's location. Virtual visits may not be available on all plans. MDLIVE is not an insurance product nor a prescription fulfillment warehouse. MDLIVE operates subject to state regulations and may not be available in certain states. h90LIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA -controlled substances, non -therapeutic drugs and certain other drugs that may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny tate for potential misuse of services. ADP Slore is a service mark of Apple Inc. Google Play Store is a trademark of Google Inc. ('Google h Windows is a registered mark of Microsoft'" Provider Finder®, from Blue Cross and Blue Shield of Montana (BCBSMT), is an innovative tool using the nation's largest claims database that helps Your employees find in -network doctors and hospitals, compare the costs and quality for more than 1500 procedures, and estimate out-of-pocket costs before making treatment decisions. Members can log in to Blue Access for Memberss ` on mobile or the web to use Provider Finder to: • Find a network primary care physician, specialist or hospital. • Filter search results by doctor, location, specialty, ZIP code, language and gender — even get directions from Google MapsTrm • Estimate the cost of a provider's procedures, treatments and tests — and estimate their out-of-pocket expenses. © Determine if a Blue Distinction°.Center is an option for treatment. o View patient feedback and add a provider review. Check the clinical quality data from Blue Cross and Blue Shield as well as independent third parties. z, Search in Spanish. Review providers' certifications, recognitions, awards and publications. `(:.iv i F Ii pm i s Searches on Provider Finder are: Accurate This tool helps members estimate the overall cost of procedures, treatments, and tests, while calculating their out-of-pocket expenses, all based on the search parameters they choose. Members are able to compare estimated costs between different providers, based on typical episodes of care. With information on over 20,000 health care facilities and more than 400,000 professional providers, as well as cost information for more than 1,500 treatment categories, Provider Finder is a robust database. Personal This tool provides information and costs that apply to a specific member's health benefit plan to estimate the cost of care. This means members can instantly see how much they will need to pay in deductible, coinsurance or copayments, in addition to seeing how much their plans may pay. Data are presented in a.format that's easy to navigate and helps your employees better understand how their benefits work. Active, Engaged Employees Lower Health Care Costs You want your employees to live healthier, happier lives while lowering your costs for their health care. Provider Finder does just that — giving accurate, transparent and personal information based on the employee's specific benefit plan. This tool is available on mobile as well, helping members where they are and when they need access to this information. Blue Cross and Blue Shield of Montana. a Division of Ileallh Care Service Corpora lion, a Mutual legal Reserve Company. an Independent Licensee of the Blue Cross and Blue Shield Association 350606.0315 aspirin chew tab 81 mg aspirin tab delayed release 81 mg 1 3 ., . Medication Covered at 0 Cost to You 1,2018 Your health plan may include certain prescription and over-the-counter (OTC) preventive medicines, as a benefit of membership, at no cost to you when you use a pharmacy or doctor in your health plan's network. There is no co -pay, deductible or coinsurance, even if your deductible or out-of-pocket maximum has not been met. Coverage for these medicines can vary according to the type of plan you are enrolled in. Call the Customer Service number listed on your member ID card to find out what drugs are covered at no cost share under your plan. Below are the preventive care drugs that may be covered under your plan for both adults and children. Please see the Women's Contraceptive Coverage List for a list of contraceptive methods that may be covered at no cost to you. Age limits, restrictions and other requirements may apply.* peg 3350-kel-na bicarb-nacl-na sulfate for soln 236 gm, 240 gm peg 3350-kei-sod bicarb-nacl for soln 420 gm raloxifene tamoxifen sodium fluoride chew tabs; 0.25 mg f (from 0.55 mg naf), 0.5 mg f (from 1.1 mg naf),1 mg f (from 22 mg naf) sodium fluoride cream 1.1% sodium fluoride gel 1.1%(0.5%f) sodium fluoride paste 1.1% sodium fluoride rinse 0.2% sodium fluoride sola; 0.125 mg/drop f (0.275 mg/drop naf), 0.5 mg/mL f (from 1.1 mg/mL naf) sodium fluoride/potassium nitrate paste 1.1-5% stannous fluoride cone 0.63% stannous fluoride gel 0.4% folio acid caps, 0.8 mg folic acid tabs, 400 mcg, 800 mcg carbonyl iron suspension FERROUS SULFATE LIQUID, 220 MG/5 ML FERROUS SULFATE SYRUP ferrous sulfate elixir, solution IRON UP NOVAFERRUM PEDIATRIC DROPS lovastatin 20 mg, 40 pravastatin bupropion hcl (smoking deterrent) tab sr 12hr 150 mg CHANTIX _ nicotine polacrilex gum 2 mg, 4 mg nicotine polacrilex lozenge 2 mg, 4 mg nicotine td patch 24hr 7 mg/24hr,14 mg/24hr, 21 mg/24 hr NICOTINE TRANSDERMAL KIT NICOTROLINHALER NICOTROL NS "" Generic Drugs = bold Brand Drugs = CAPITAL LETTERS 354674.1017 ACTHIB ADACEL AFLURIA/PF/QUADRIVALENT BEXSERO BOOSTRIX CERVARIX COMM DAPTACEL DIPHTHERIAITETANUS TOXOID ENGERIX-B FLUAD FLUBLOK FLUCELVAXAQUADRIVALENT FLULAVAL QUADRIVALENT FLUVIRIN FLUZONE/HIGH-DOSE/INTRADERMAL/QUADRIVALENT/SPLIT GARDASIL GARDASIL 9 HAVRDC HIBERIX INFANRIX IPOL INACTIVATED IPV M-M-R 11 MENACTRA MENHIBRIX MENOMUNE-A/C/Y/W-135 MENVEO PEDIARIX PEDVAX HIB PENTACEL Generic Drugs = bold Brand Drugs = CAPITAL LETTERS PNEUMOVAX 23 PREVNAR 13 PROQUAD QUADRACEL RECOMBIVAX HB ROTARIX ROTATEQ _ TENIVAC TETANUS/DIPHTHERIA TOXOIDS TRUMENBA TWINRIX VAQTA VARIVAX ZOSTAVAX cholecalciferol cap 400 unit, 1000 unit cholecalciferol chew tab 400 unit, 1000 unit cholecalciferol drops 400 unit/0.03 mL (per drop), 5000 unit/mL (1000 unit/02 mL) cholecalciferol oral liquid 400 unit/m1 cholecalciferol tab 400 unit, 1000 unit Some of these products may be covered under your medical benefit it provided by a doctor in yaw health plan's network. Prescription coverage for these drugs may vary according to the terms and conditions of the plan. A prescription may be required to cover without cost-sharing under the pharmacy benciit tot numguandfathered plans. The plan may also require a genetic thug to be tried fist before the brand version. This infumution is lot informational purposes only, does not constitute legal or other advice and should not be relied upon to Bele name coverage. beabhunt decisions are kmtt:+!t:n ifto member and his of her health core ptmidet. Coverage is ahvays subject to to limitations and exclusions of the benefit plan. For details about your plan, check your benefit materials of call the Pharmacy Program number on your mc,''.cr M card. Third -parry brand names are die property of Coir respective ov hers. c O y s o No •^ 0o m E of mE SEEM 6626.6. 666 m EmE :[ X aE EE SC :E EE -.t eC �m ;R e¢ Eo am e- X omm� - oma' a n - a n a pa a. <nnN G E o $o q i'y Q m m.a Q dQ 4a4 a Qa Qd44 m a2 a46 a3 QQ O m 4d Qd m m ¢ 4 3n m - N N N to N N N 4 a = OU'$Ti$v�'+ O 3 �v 8n X33'3 2311 _ aaSc SE 3 ttO'v Ba L'u �a u� uv '�'i I>5 iii 1'>t$ `2 E xo t3 O m � a � $ m S S O O S S S S D D O S S O O O S D8 'D •p Do a O S S S S Q 2 E $., o o� ;e: 00 nada 000 cra'o; 600 0 ooa aaa 0 wm �a• Em a'ae Em aat m �� =o 3 i{i o'o r E d o uE>ccg tE® $ 'd n ° o a mIo de $ .2 3. mmmm BEnEd<", .>_ .2 ' 3 m _ 66666 9b"'15� .2 '� ._ .2 -a o mmm dd9 2 '- a 'n >e ._ E 3 8`�rA`dv 2 n g V '," M v m m o$ E og ` # m$m3 3a 33¢33¢ ,2 3¢33¢6 31¢31 3a 3a 34 om . 3> ;NYS �v,cvoN Naw N m i° 1p� fD :c 'c8=,2 °' °o Haac ° �'a3n ain aav na an �� ¢ a: v 'g :� 'e8 `� n '^ v o' o> S. v> p>m SOS v> $' m p0 v> v> SOm v> E v S v> v SSS v> v> 'Q' 03 v' v' OS a v v $ •, �, ;.. 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Fit c N„°3U t vg eu-txmr mW`c � ul 'b %`pc2 coamDnmgW IT¢,aiz .mgm m'c 'cL°Oo°` °� ��f o Q-. am°cg uZv m°c m mga3� a`mU°�E 5' o 8o WZ °�uEa §3 c�wC"o -• Z. b S a LLmoa,=u`aC 2 o cc ='6-��n °C`o°C'- '� o•�a 'Er � - �o�oa, 9;?��c3U °°':�+`A ro°mvacmmiQ m�.�o:a ppm�•co-ora 'c o-6no"6 q'm 4 i. mwwwwlgm 9 E m O' C' Kn E LLtLa ? as L) 2 ICD-9 Codes for Disclosure Notification Please list all Plan Participants who have been diagnosed with or treated for any of the codes listed under the following categories during the current Benefit Period: 001-139 Infectious and Parasitic Diseases 038-038.9 Septicemia 042 AIDS / HIV 070-070.9 Viral Hepatitis 140-239 Neoplasms 140-149.9 Malignant Neoplasm of Lip, Major Salivary Glands, 560.0-560.9 Gum, Mouth, Oropharynx, Nasopharynx, and/or 562.1 Hypopharynx 150-150.9 Malignant Neoplasm of Esophagus 151-151.9 Malignant Neoplasm of Stomach 153-153.9 Malignant Neoplasm of Colon 154-154.8 Malignant Neoplasm of Rectum 155-155.2 Malignant Neoplasm of Liver 157-157.9 Malignant Neoplasm of Pancreas 161-161.9 Malignant Neoplasm of Larynx 162-162.9 Malignant Neoplasm of Lung 170-170.9 Malignant Neoplasm of Bone 174-174.9 Malignant Neoplasm of Female Breast 179-182.8 Malignant Neoplasm of Uterus or Cervix 183-183.9 Malignant Neoplasm of Ovary 185 Malignant Neoplasm of Prostate 186-186.9 Malignant Neoplasm ofTestis 188-189.9 Malignant Neoplasm of Bladder, Kidney, Urinary 191-191.9 Malignant Neoplasm of Brain 192-192.9 Malignant Neoplasm ofNervous System 194-194.9 Malignant Neoplasm of Endocrine Glands 195-195.8 Malignant Neoplasm of Other III -Defined Sites 196-196.9 Secondary Malignant Neo. Lymph Nodes 197-197.8 Secondary Malignant Neo. Respty and Digestive 949-949.5 Systems 198-198.89 Secondary Malignant Neo. Other Specified Sites 200-208.9 Lymphoma and/or Leukemia 235 Neoplasm Uncertain Behavior 239.2 Neoplasm Unspecified Nature- Bone, Skin 240-279 Endocrine Nutritional. Metaholic, Intmrtnity 250-250.9 Diabetes 277.0 Cystic Fibrosis 278.0 Obesity/Hyperaliment 280-289 Diseases ofthe Blood and Blood -Forming Organs 282.6 Sickle -Cell Anemia 284.9 Aplastic Anemia NOS 286-286.9 Coagulation Defects and/or Hemophilia 320-389 Diseases ofthe Nervous System and Sense Organs 330 Cerebral degenerations 344.0-344.09 Quadriplegia and Quadriparesis 331.0-331.9 Reye's Syndrome 344.1 Paraplegia 348.0-348.9 Encephalopathy 357,358 Neuropathy / Myasthenia Gravis 390-459 Diseases of file Circulatory System 410410.9 Acute Myocardial Infarction 411-411.89 Acute and Subacute Ischemic Heart Disease 414414.05 Coronary Atherosclerosis (ASHD) 4151415.19 Acute Pulmonary Heart Disease 4161116.9 Chronic Pulmonary Heart Disease 417.1 Aneurysm of Pulmonary Artery 421421.9 Acute and Subacute Endocarditis 424424.9 Valve Disorders 425425.9 Cardiomyopathy 426426.9 Conduction Disorders 427427.9 Cardiac Dysrhythmias 428428.9 Heart Failure 430,431 Subarachnoid / Intracerebral Hemorrhage 434.9 Occlusion of Cerebral Arteries 436 Acute Cerebrovascular Accident (CVA) 440441.9 Atherosclerosis / Aortic Aneurysm 460-519 Diseases ofthe Respiratory Svstem 480486 Pneumonia 490-496 Chronic Obstructive Pulmonary Disease (COPD), etc. 515 Postinflammatory Pulmonary Fibrosis 518-518.89 Pulmonary Collapse and/or Respiratory Failure 520-579 Diseases ofthe Digestive System 555-555.9 Regional Enteritis (Crohn's Disease) 560.0-560.9 Intestinal Obstruction 562.1 Diverticulitis of Colon 567-567.9 Peritonitis 569.0-569.9 Other Disorders of Intestine 570-571.9 Liver Diseases and Cirrhosis 572.8 Other Sequela of Chronic Liver Disease 573-573.9 Other Liver Disorders 577-577.9 Pancreas Diseases 578-578.9 Gastrointestinal Hemorrhage 580-629 Disenses ofthe Genitourinary System 584-584.9 Acute Renal Failure 585 Chronic Renal Failure 586 Renal Failure, Unspecified 588 Disorders resulting from impaired renal function 592 Calculus of Kidney & Uerter 630-677 ComplicatiotisofPre2nancv,Cbildbirtlr 641.1 Placenta Previa 642.5-642.7 Eclampsia, pre-eclampsia 644.0.644.2 Premature Labor 648.0 Gestational Diabetes 651 Multiple Gestation 654.5 Cervical Incompetence 710-739 Diseases of the Musculoskeletal System and Connective Tissue 715.0-715.9 Osteoartrhosis 721.3 Lumbosacrel Spondylosis 722.0-722.9 Intervertebral Disc Disorders 730-730.9 Osteomyelitis and/or Periostitis 737.3 Kyphoscoliosis and scoliosis 740-759 Contrenital Anomalies 747.2 Aortic Atresia / Stenosis 751.6 Biliary Atresia 759-759.9 Other and Unspecified Congenital Anomalies 760-779 Conditions Originating in the Perinatal Period 765-765.1 Prematurity 769 Respiratory Distress Syndrome 770.0-770.9 Other Respiratory Conditions of Newborn 780-799 Svtngtonts Signs and Ill-De/Ined Conditions 785-785.9 Symptoms Involving Cardiovascular System 786.5-786.59 Chest Pain 800-999 Iruury and Poisoning 800-804.9 Fracture of Skull 805-805.9 Fracture of Vertebral Column 806-806.9 Fracture of Vertebral Column with Spinal Cord Injury 828-828.1 Multiple Fractures 853-854.1 Intracranial Injury 869-869.1 Internal Injury 887-887.7 Traumatic Amputation of Arm and Hand 897-897.7 Traumatic Amputation of Leg 949-949.5 Bums 952-952.9 Spinal Cord Injury 996-997.0 Complications peculiar to certain specified conditions V23 Supervision of High Risk Pregnancy V42 - V58.9 Transplants, etc N V �t i t to N f N � e-1 III � O :opo c E •'- v o N � � a cj a- C G o Ln ut0 _ C Q U fn D W 1 N Q p, p Q. d o in N N to �d v c Q v o oma` m m� •p Q a Q�a Q v "O to N N 04 c0 N wn N C C ID a`f olo�ola t o f0 1 o v o a o g' .� i j i C n i c v A u co � o � ( o'S � oy � w'S £ c c v m v ti m m N VY i t to N f N � e-1 III � O :opo C N � � a- C G _ C Q U MO [D W Ln O �d v c Q a v c v ! a`f olo�ola t PO Box 6669 • Helena, MT 59604-6669 NNU Toll Free: (800) 635-3089 • Tel: (406) 443-0907 • Fax: (406) 449-7440 The MMIA is pleased to offer what we believe are very competitive rates for a group term life insurance product for our membership. UNUM Life Insurance Company has rates specifically for members of the MMIA Employee Benefit program that may generate savings for your city/town. Basic Life & AD&D Plan Description Eligibility: Each active full-time employee working the minimum hours required per your city or town, and no less than 20 hours, is eligible to participate in the MMIA Life Insurance program. Participation: 100% of eligible employees. Employer Contribution: 100% of employee premium cost. Benefit Amount and Cost: The cost per $1,000 basic life and AD&D is $0.28. Listed in the table below are varying levels of insurance coverage and the applicable monthly cost per employee. Life and AD.&D Benefit Month l ` Cost pet:Em Oloee $10,000 $2.80 $15,000 $4.20 $20,000 $5.60 $25,000 $7.00 $50,000 $14.00 $100,000 $28.00 Each employee within the group or bargaining unit must have the same benefit level. Benefit Descriptions: Guarantee Issue: Per schedule AD&D Included Waiver of Premium Included Conversion of Benefits Available Travel Assistance Included Age Reduction: The Principal sum of the life insurance coverage will be reduced by 50% at age 70. MMLIL PO Box 6669 • Helena, MT 59604-6669 MONTANA MUNICIPAL INTERLOCAL AUTHORITY Toll Free: (800) 635-3089 • Tel: (406) 443-0907 • Fax: (40"'11111111110P 7-7 6) 449-7 Accidental Death and Dismemberment: In the event of death, loss of limbs, loss of eyesight, loss of speech or hearing due to an accidental injury, additional benefits, based on the selected life insurance amount, will be paid based on the selected life insurance amount. Additional benefits include: Seat Belt Benefit Airbag Benefit Common Carrier Benefit Accelerated Benefits Living Care Benefit Pays up to additional $25,000 Pays up to additional $5,000 Included Included Included This benefit is paid in addition to any other benefits provided bV the Pian, subject to the terms and conditions contained in the Group Insurance Policy. Dependent Group Life Insurance is also available at $0.35 per $1,000 of benefit. Each employee with dependents (spouse or children) must have the same dependent benefit level The monthly unit cost covers an employee's eligible dependents. Eligible children must be less than 26 years of age. MMIA PO Box 6669 • Helena, MT 59604-6669 MONTANA MUHICTDAL INTERLOCAL AUTHORITY L» R ;w µY : A; Toll Free: (800) 635-3089 • Tel: (406) 443-0907 • Fax: (406) 449-7440 o4/ VOLUNTARY TERM LIFE AND AD&D The MMIA Employee Benefits Program now offers a very competitively -priced Voluntary Term Life and AD&D program for our membership. The carrier is the same as the Basic Group Life and AD&D - UNUM Life Insurance Company. Voluntary Life can be offered without providing the Basic Life. Each employee can select an amount of life insurance benefits that best fits their circumstances and needs. Rates are based on the age of the covered person. Employer Contribution: None; this program requires the premium be paid 100% by the employee. Coverage Amount: The maximum amount an employee can apply for is 5x their salary up to the maximum of $500,000. Employees may purchase benefits increments of $5,000. Spouses may receive coverage, up to 100% of the employee amount, not to exceed $500,000. Guarantee Issue Amount: Up to $200,000 for Employee; $25,000 for spouse. Amounts in excess of the Guarantee Issue Amount will require a health statement. _Voluntary Life and AD&D Monthly Premium Rates per Thousand: Rates are age -banded and are shown below. Age Voluntary Ltfe Voluntary Ltfe Wth F � jGategory Rate Per AD&D Rate Perk. Thousand =Thousand < , 15-34 $0.08 $0.13 35-39 $0.11 $0.16 40-44 $0.15 $0.20 45-49 $0.26 $0.31 50-54 $0.47 $0.52 55-59 $0.72 $0.77 60-64 $1.37 $1.42 65-69 $2.17 $2.22 70+ $3.82 $3.87 Dependent Child Benefit: Employees can cover their child(ren) in increments of $2,000, up to a maximum of $10,000. The cost is the same for one child or multiple children. The rate is $.16 per $1,000 of coverage. Employee coverage is required. AD&D coverage is not available for children. Eligible children must be less than 26 years of age. Benefit Descriptions: Waiver of Premium: Included Portability Available Accelerated Benefits Included Travel Assistance Included Benefits are paid subject to the terms and conditions contained in the Group Insurance Policy. Please share this information with your employees, whether or not they are covered by our group health benefits. All employees are eligible to participate in this program if minimum participation requirements are met. For additional information or enrollment forms, contact the MMIA Employee Benefits Department at 1-800-635-3089. MMIA Employee Benefits Programs -- Standard Plan Offerings Effective Date 711118 This Document is a Summary of Coverage Only. The MMIA Employee Benefits Program Plan Documents are available at www.mmia.net and must be referenced for details of all coverages. Medical Benefits - Cost Sharing Provisions Dildger Plan Madison Plan Mission Plan HDHP - HSA Qualified Annual Deductible (January 1 - December 31) $500 (Individual) -51,000 (Family) $500 (Individual) - $1,000 (Family) $1,000 (Individual) - S2,000 (Family) $2,700 (Individual) - S5,400 (Family) Benefit Percentage of Allowable - All Montana & Non -Montana Participating' Before satisfaction of Out -of -Pocket Maximum After satisfaction of Out-of-pocket Maximum -Applies to all benefils unless otherwise listed in schedule below or SPD 80% 100% 70% 100% 60% 100% 80% 100% Benefit Percentage of Allowable - Non -Montana, Non -Montana Participating' Before satisfaction of Out-of-pocket Maximum After satisfaction of Out-of-pocket Maximum Applies to all benefits for Non -Montana Non -Participating prividers 60% 100% 50% 100% 40% 100% 60% 100% Annual Outof-PocketMaximum Includes Deductible PreventiveCare $1.500(Individual)-$3,000(Family)_$_2_000{Individua1 All MT & Non -MT Participating -S4_000(Familyl_1 All MT & Non -MT Participating $3,000 (Individual)- $6,000(Family) $5,250 (Individual)- Individual-Preventive All MT & Non -MT Participating All MT & Non -MT Participating Preventive Benefit (as recommended by US Preventive Services Task Force, CDC, and Health Resources & Services Administration at www.healthcare.gov) Medical Services Deductible waived, 100% All MT & Non -MT Participating Deductible waived, 100% All MT & Non -MT Participating Deductible waived, 100% All MT & Non -MT ParticipatingI Deductible waived. 100% All MT & Non -MT Participating Accidental Injury Benefit 100% to $300; then standard benefits 100% to $300; then standard benefits 100% to $300: then standard benefits Deductible Applies, 80% Alternative Medicine Benefit Deductible Waived, 80% up to 5500 Deductible Waived, 70% up to $500 Deductible Waived, 60% up to 5500 Deductible Applies. 80% up to $500 Chiropractic Care Deductible Waived, 80% to 5400 plus Deductible Waived, 70% to $400 plus $100 x-ray benefit $100 x-ray benefit Deductible Waived, 60% to $400 plus Deductible Applies, 80% to $400 plus $100 x-ray benefit $100 x-ray benefit Diabetic Education Benefit Deductible Waived, 100% Deductible Waived, 100% Deductible Waived, 100% Deductible Applies, 100% Diagnostic Services Professional Provider Expenses Facility Provider Ex enses Deductible Waived, 80% Deductible Applies, 80% Deductible Waived, 70% Deductible Applies, 70% Deductible Waived, 60% Deductible Applies, 60% Deductible Applies, 80% Deductible Applies, 80% Durable Medical Equipment Rental or purchase Repair and Replacement Deductible Waived, 80% Deductible Waived, 80% Deductible Waived, 70% Deductible Waived, 70% Deductible Waived, 60% Deductible Waived, 60% Deductible Applies, 80% Deductible Applies. 80% Emergency Room Care (regardless of Participating Provider status Deductible Applies, 80% Deductible Applies, 70% Deductible Applies, 60% Deductible Applies, 80% Home Health Care Deductible Waived, 80% Deductible Waived, 70% Deductible Waived, 60% Deductible A plies. 80% Hospice Care Deductible Waived, 100% Deductible Waived. 100% Deductible Waived, 100% Deductible Applies, 80% Hospital Facility Services Deductible Applies. 80% Deductible Applies, 70% Deductible Applies. 60% Deductible Applies, 80% Maternity Services Professional Provider Expenses Facility Provider Expenses Deductible Waived, 80% Deductible Applies. 80% Deductible Waived, 70% Deductible Applies. 70% Deductible Waived, 60% Deductible Applies, 60% Deductible Applies, 80% Deductible Applies, 80% Newborn Initial Care Deductible Waived, 80% Deductible Waived, 70% Deductible Waived, 60% Deductible Applies, 80% Nutritional Counseling limit of 10 visits per ear Deductible Waived, 80% Deductible Waived, 70% Deductible Waived, 60% Deductible Applies. 80% Obesity Surgery - One per lifetime Benefit Max for Procedure Deductible Applies, 80% $30,000 Deductible Applies, 70% $30,000 Deductible Applies, 60% 530,000 Deductible Applies, 80% $30,000 Organtnssue Transplants - Center of Excellence only Professional Provider Expenses Facility Provider Expenses Deductible Waived, 80% Deductible Applies, 80% Deductible Waived, 70% Deductible Applies, 70% Deductible Waived, 60% Deductible Applies, 60% Deductible Applies, 80% Deductible Applies, 80% Professional Provider Services Deductible Waived. 80% Deductible Waived, 70% Deductible Waived, 60% Deductible Applies, 80% Rehabilitation Therapy Professional Provider Expenses Facility Provider Expenses Deductible Waived, 80% Deductible Applies, 80% Deductible Waived, 70% Deductible Waived. 70% Deductible Waived, 60% Deductible Applies, 60% Deductible Applies, 80% Deductible Applies. 80% Mental Illness Professional Provider Expenses Facility Provider Expenses Deductible Waived, 80% Deductible Applies, 80% Deductible Waived, 70% Deductible Applies, 70% Deductible Waived, 60% Deductible Applies, 60% Deductible Applies, 80% Deductible Ap lies, 80% Therapies - Physical, Occupational, Speech, Cardiac Professional Provider Expenses Facility Provider Expenses Deductible Waived, 80% Deductible Applies, 80% Deductible Waived. 70% Deductible Waived, 70% Deductible Waived, 60% Deductible Applies, 60% Deductible Applies, 80% Deductible Applies, 80% Chemical Dependency Treatment Professional Provider Expenses Facility Provider Expenses Prescription Drug Plan - Group Choice of: Deductible Waived, 80% Deductible Applies, 80% Deductible Waived, 70% Deductible Waived, 70% _ Deductible Waived, 60% Deductible Applies, 60% Deductible Applies, 80% Deductible Applies, 80 1) Prescription Drug Percentage, or Genetic Deductible Waived, 80% Deductible Waived, 70% Deductible Waived, 60% DeductibleApplies.80% Brand - Formulary or Non -Formulary Deductible Applies, 80% Deductible Applies, 70% Deductible Applies, 60% Deductible Applies, 80% 2) Prescription Drug Copay Pian Generic 54Co-pay RelaNs8Co-pay Mal Order 54Co-pay Retail $8co-pay MaaOrder Saco- RetaiV $8 Go -pay Mal Order Deductible Applies, 80% Brand -Formulary 520 Co -pay Retailt 540 Ca -pay Mail Order 520 Copay Retail 540 Co -pay Mal Order $20 Co -pay Retail $40 Copay Mal Order Deductible Applies, 80% Non -Formulary 2018 - 2019 Monthly Contributions - Rx Percentage $50Co-pay RetaiV$100Cc-pay Mal Order $50Co-pay Retal/$100Co-pay Mal Order 550Co-pay RetaV$100CopayMal Order Deductible Applies, 80% EE - Employee Only $683 $661 $610 $515 ES - Employee & Spouse $1,366 $1,322 $1,220 $1,030 EC - Employee & Child $1,195 $1,157 $1,068 $901 EF - Employee & Family $1,878 $1,818 $1,678 $1,416 Med - Retiree Only Medicare $444 $430 $397 $335 2Med - Retiree & Spouse Medicare $888 $860 $794 $670 1-/1+65- One with Medicare & One without Medicare 2018 - 2019 Monthly Contributions - Rx Copay $1,127 _$1,0.91 _ $1,007 $850 EE - Employee Only $792 $768 $706 $515 ES - Employee & Spouse $1,584 $1,536 $1,412 $1,030 EC - Employee & Child $1,386 $1,344 $1,236 $901 EF -Employee&Famil $2,178 $2,112 $1,942 $1,416 Med - Retiree Only Medicare $515 $499 $459 $335 2Med - Retiree & Spouse Medicare $1,030 $998 $918 $670 1-/1+65 - One with Medicare & One without Medicare $1,307 $1,267 $1,165 $850 This rate quote expires after 9/30118. New claims data will be required to provide updated rates after that date. Exclusions: All claims will be excluded from coverage if they were not disclosed prior to the effective date of coverage (7/1118), and were known to: 1. Be currently disabled, confined to Medical Facility, or have been precertified within the last three months. 2. Have received medical services during the current plan year the cost of which exceeds 550,000, and for which bills have been received by the Claims Administrator and entered into their Claims System. 3. Have been identified as a candidate for Case Management and has having the potential to exceed during the policy period 550,000. 4. Have been diagnosed, during the current plan year, with a condition represented by any of the ICD-9 codes contained in the attached list and have also received medical services costing 55,000 during the same period. mi�m PO Box 6669 • Helena, MT 59604-6669 L1.ONTANA MUNICIPAL INTERLOCAL AUTHORITY (800) 635-3089 (406) 443-0907 (406) 449-7440 BASIC GROUP DIFF AND AD&D The MMIA is pleased to offer what we believe are very competitive rates for a group term life insurance product for our membership. UNUM Life Insurance Company has rates specifically for members of the MMIA Employee Benefit program that may generate savings for your city/town. Basic Life & AD&D Plan Description Eligibility: Each active full-time employee working the minimum hours required per your city or town, and no less than 20 hours, is eligible to participate in the MMIA Life Insurance program. Participation: 100% of eligible employees. Employer Contribution: 100% of employee premium cost. Benefit Amount and Cost: The cost per $1,000 basic life and AD&D is $0.28. Listed in the table below are varying levels of insurance coverage and the applicable monthly cost per employee. Life and AD&D Benefit Monthly Cost per Employee $10,000 $2.80 $15,000 $4.20 $20,000 $5.60 $25,000 $7.00 $50,000 $14.00 $100,000 $28.00 Each employee within the group or bargaining unit must have the same benefit level. Benefit Descriptions: Guarantee Issue: Per schedule AD&D Included Waiver of Premium Included Conversion of Benefits Available Travel Assistance Included Age Reduction: The Principal sum of the life insurance coverage will be reduced by 50% at age 70. IVImn PO Sox 6669 m Helena, MT 59604-6669 MONTANA MUNICIPAL INTERLOCAL AUTHORITY (80G) 635 3089 it:(406) 443-0907 (406) 449-7440 VOLUNTARY TERM LIFE AND A®&® The MMIA Employee Benefits Program now offers a very competitively -priced Voluntary Term Life and AD&D program for our membership. The carrier is the same as the Basic Group Life and AD&D - UNUM Life Insurance Company. Voluntary Life can be offered without providing the Basic Life. Each employee can select an amount of life insurance benefits that best fits their circumstances and needs. Rates are based on the age of the covered person. Employer Contribution: None; this program requires the premium be paid 100% by the employee. Coverage Amount: The maximum amount an employee can apply for is 5x their salary up to the maximum of $500,000. Employees may purchase benefits increments of $5,000. Spouses may receive coverage, up to 100% of the employee amount, not to exceed $500,000. Guarantee Issue Amount: Up to $200,000 for Employee; $25,000 for spouse. Amounts in excess of the Guarantee Issue Amount will require a health statement. Voluntary Life and AD&D Monthly Premium Rates per Thousand: Rates are age -banded and are shown below. Age Category Voluntary Life Rate Per Thousand Voluntary Life With AD&D Rate Per Thousand 15-34 $0.08 $0.13 35 —39 $0.11 $0.16 40-44 $0.15 $0.20 45 —49 $0.26 $0.31 50-54 $0.47 $0.52 55 —59 $0.72 $0.77 60-64 $1.37 $1.42 65 —69 $2.17 $2.22 70+ 1 $3.82 $3.87 Dependent Child Benefit: Employees can cover their child(ren) in increments of $2,000, up to a maximum of $10,000. The cost is the same for one child or multiple children. The rate is $.16 per $1,000 of coverage. Employee coverage is required. AD&D coverage is not available for children. Eligible children must be less than 26 years of age. Benefit Descriptions: Waiver of Premium: Included Portability Available Accelerated Benefits Included Travel Assistance Included Benefits are paid subiect to the terms and conditions contained in the Group Insurance Policy. Please share this information with your employees, whether or not they are covered by our group health benefits. All employees are eligible to participate in this program if minimum participation requirements are met. For additional information or enrollment forms, contact the MMIA Employee Benefits Department at 1-800-635-3089. 'i. � a) Q vi O C J N U 00 O w O Y O N ro ro ro n O t 1— s s a +1 3 m •U t Q , ro a) U O (D -0s Z N O a) a% U a o ro + ro O U '� M a) : Z� vm +° u W N c ma) ro u 0 ro E=.. W 3 v o u �Z a) 2 T o °' �! E c O Ly W ti 3 OFA fu In V J T-0 O O Wa ro O C C �Qm o >o � Q J O w 1— rig CJ 2 Lr)In Q z a o Jz Z� = J O O `D Q Qz �! z a w J W 2 N N 00 NO 0 0 N ui N co Z" LZOL£ Nl'POOMIuaa8 OSE alinS'AeM eiui611A LV LS N L 0 ro m y U y Y N N d N N O c? ± N a) O C ro m U -O J a) ro ro O -u -OWO Q in c mc: .j c 2 ro O -0d ro O> a) O Q a) O N S Q) 3 C a) U U ro 0 O_ -O i+ N ro ro C O1 CD -C- rn .N .0 C p= C O � 3 'E °' o z �' O Z to 4J (D0 N ro u>= o 0 E O C v= a_ o In D- U W ro •E •L 7 Z- ?' O. ro U 0 06 F— ro T 6+ N • O O N U O C6- 2 Q U = ro o6 3> .S rn �> s W L ro o s ro 0 3 S 0- u �J W v Z �� U W 3 N ro i 0 0 UO Y u C� v v Co -j D- F- _ . E O` a` '3s � O a° 2 Teladoc" Getting started with f eladoce ' ^4 t � i MONTANA MUNICIPAL INTERLOCAL AUTHORITY FW Teladoc's U.S. board-certified doctors are available 24/7/365 to resolve many of your medical issues through phone or video consults. Set up your account today so when you need care now, a Teladoc doctor is just a call or click away. SET UP YOUR ACCOUNT It's quick and easy online. Visit the Teladoc website at Teladoc.com, click "Set up account" and provide the required information. You can also call Teladoc for assistance over the phone. REQUEST A CONSULT Once your account is set up, request a consult anytime you need care. PROVIDE MEDICAL HISTORY Your medical history provides Teladoc doctors with the information they need to make an accurate diagnosis. Online: Log into the Teladoc website at Teladoc.com and click "My Medical History". Mobile app: Log into your account and complete the "My Health Record" section. Visit Teladoc.com/mobile to download the app. Call Teladoc: Teladoc can help you complete your medical history over the phone. Teladoc.com r 1-800-Teladoc (835-2362) 0■'r{ 0■ Facebook.com/Teladoc Fs` l Teladoc.com/mobile 0, . ;��..I �,,_. ,, ;1:111. .. � � ,. •. � �. ,. pnmary care physician. 1 eladuc docs not goal antee that a p uaippun will be c: ritteu. Teladoc operates sublcct to sty tc leLu44iun 3111' 1113y nut be 61'oiloble in certain r„tcs. Iclauoc duQE not prescribe DEA controlled substances, non therapeutic drues and certain other drugs which may be harmful bccause of their potential for ab a=_c. Teladoc physicians r scrve the right to deny care for 10E-101 /=`AIlecgiameM MATERNITY MANAGEMENT Care Management PROVIDING SUPPORT AND REDUCING THE RISK OF COMPLICATIONS The Allegiance Care Management maternity management program provides support to expectant parents with pregnancy related education and support offerings. Experienced maternity nurse specialists are connected with the member and their family as early in the pregnancy as possible to ensure the member receives the right care at the right time. Allegiance ensures the best possible outcome is achieved through: e Collaboration with their attending physician o Prenatal and lifestyle education • Educational material on prenatal care, trimester expectations and newborn care One-on-one support throughout the pregnancy and following the birth of the child ® Customized incentives offered to members who participate in the program PROGRAM HIGHLIGHTS Allegiance works to minimize potential complications through health management and continuous assessment The program provides early intervention and management of high-hisk pregnancy and neonatal cases by referring to case management as appropriate Provides support and education while also watching for potential complications throughout the term of the pregnancy MyRBH.com At MyRBH.com you can access current health news, tools for parenting, health topic movies, wellness resources, financial To find out more about your EAP services calculators, legal forms, and over 50 online trainings. call, 866.750.1327, or visit us online at Lunch + Learn Webinars MyRBH.com. Free supervisor and employee webinars are presented each month. Visit MyRBH.com for more information or to register. Archived webinars can be accessed on the RBH YouTube Once you're incode ,use channel. the same accesss ccoode for Personal Advantage. ll`1 Your MyRBH Access Code is: RBH "R Reliant Behavioral Health X10W_MMIA MyRBH.com 1866.750.1327 Work -Life Tools n The EAP\:/- Legal Services — access a free, half-hour consultation, by phone or in person, for SolvesProblems any non -work related issue, followed with a 25% discount in legal fees. Free. Fast. Confidential. • • • • - • • •take life briahtel Financial Services — access free phone support for up to 30 days for each new financial issue, such as debt counseling, The EAP (Employee Assistance Program) helps you privately budgeting, and college or retirement solve problems that may interfere with your work, family, and planning. life in general. EAP services are FREE to you, your dependents, all household members. EAP services are always confidential Mediation Services — request free and provided by experts. consultations for personal, family, and Confidential Counseling non -work related issues such as divorce, 24-hour Crisis Help — toll-free access for you or a family member neighbor disputes, or real estate. experiencing a crisis. In-person Counseling — up to 6 face-to-face counseling sessions Online Legal Forms — create, save, print, are available for each new issue. Simply call for access to qualified, and revise online legal forms including local counselors who can help you with a variety of problems wills, contracts, leases, and many more. such as family, parenting, relationship, stress, anxiety, and other challenges. Home Ownership Program — get free Online Consultations — convenient access to online consultations support and information about making with licensed counselors through RBH eAccess at MyRBH.com. smarter choices when shopping for a Online consultations are a great way to get support for brief new home; making financing decisions; issues, even when time is limited. relocating; or selling a home. Worksite Tools All supervisors have fast access to phone consultations, trainings Identity Theft Services — access support about the EAP and management topics, critical incident in planning the recovery process for response, and online supervisor resources for using the EAP and restoring your identity and credit after making employee referrals during workplace challenges. an incident. MyRBH.com At MyRBH.com you can access current health news, tools for parenting, health topic movies, wellness resources, financial To find out more about your EAP services calculators, legal forms, and over 50 online trainings. call, 866.750.1327, or visit us online at Lunch + Learn Webinars MyRBH.com. Free supervisor and employee webinars are presented each month. Visit MyRBH.com for more information or to register. Archived webinars can be accessed on the RBH YouTube Once you're incode ,use channel. the same accesss ccoode for Personal Advantage. ll`1 Your MyRBH Access Code is: RBH "R Reliant Behavioral Health X10W_MMIA MyRBH.com 1866.750.1327 0111Z5crrpts Foi- More hifoi-iiiatioit: Call 1-866-488-7874 Toll Free ABILIFY DISCMELT 10MG CLIMARA PATCH (G) 76MCG GLEEVEC 100MG NESINA 25MG SUTENT 12.5MG ABILIFY DISCMELT 15MG CLIMARA PRO 0.045/0.015MG GLEEVEC 400MG NEUPRO 1MG SUTENT 25MG ACCOLATE (G) 20MG COMBIGAN 0.2-0.5% GLUCAGEN HYPOKIT IMG NEUPRO 2MG SUTENT 50MG ACIPHEX (G) 20MG COMBIVENT RESPIMAT GLUMETZA ER 1000MG NEUPRO 3MG SYNAREL NASAL ACTONEL 5MG 20MCG/100MCG IMITREX AUTOINJECTOR STATDOSE NEUPRO 4MG SYNJARDY 5MG1500MG ACTONEL 30MG COMPLERA 200/251300MG (G) 6MG/0.5ML NEUPRO 6MG SYNJARDY 5MG/1000MG ACTONEL 35MG CORGARD (G) 80MG IMITREX NASAL SPRAY (G) NEUPRO 8MG SYNJARDY 12.5MG/500MG ACTONEL 150MG CRESTOR 5MG 5MG-2DOSE NEXAVAR 200MG SYNJARDY 12.5MG/1000MG ACTOPLUS (G) ISMG-850MG CRESTOR 10MG IMITREX NASAL SPRAY (G) NEXIUM 20MG TABLOID 40MG ACULAR LS SOL (G) 0.4% CRESTOR 20MG 20MG-213OSE NEXIUM 40MG TARKA 2/180MG ACZONE 5% CRESTOR 40MG INCRUSE ELLIPTA 62.5 MCG NEXIUM DR 10MG TARKA 4/240MG ACZONE 7.5% CRINONE GEL 8% INLYTA 1MG NORITATE CREAM 1°% TASIGNA 150MG ADGIRCA 20MG CRIXIVAN 200MG INLYTA 5MG NORVIR TABLET 100MG TASIGNA 200MG ADVAIR DISKUS 100MCG CRIXIVAN 400MG INSPRA (G) 25MG ODEFSEY 200MG-25MG-25MG TASMAR 100MG ADVAIR DISKUS 250MCG DALIRESP 500MCG INSPRA (G) 50MG OLYSIO 150MG TAZORAC CREAM 0.05% ADVAIR DISKUS 500MCG DERMOTIC OIL 0.01% INTELENCE 100MG OMNARIS NASAL SPRAY 50MCG TAZORAC CREAM 0.1% ADVAIR HFA 45/21MCG DESCOVY 200MG/25MG INTELENCE 200MG ONGLYZA 2.5MG TAZORAC GEL 0.05% ADVAIR HFA 115/21 MCG DETROL LA 2MG INVEGA 3MG ONGLYZA 5MG TAZORAC GEL 0.1% ADVAIR HFA 230/21MCG DETROL LA 4MG INVEGA 6MG ORACEA 40MG TECFIDERA 120MG AFINITOR 2.5MG DEXILANT DR 30MG INVEGA 9MG OTEZLA 30MG TECFIDERA 240MG AFINITOR 5MG DEXILANT DR 60MG INVIRASE 500MG PATADAY 0.2% TEGRETOL (G) 200MG AFINITOR 10MG DIFFERIN CREAM (G) 0.1% INVOKAMET 50MG-500MG PATANOL OPHTH SOL 0.1% TEGRETOL XR (G) 200MG AGGRENOX 200/25MG DIFFERIN GEL (G) 0.1% INVOKAMET 50MG-1000MG PENTASA 500MG TEGRETOL XR (G) 400MG ALOCRIL OPHTH 2% DIFFERIN GEL 0.3% INVOKAMET 150MG-500MG PLAQUENIL (G) 200MG TEKTURNA 150MG ALOMIDE 0.1 % DIPENTUM 250MG INVOKAMET 150MG-1000MG PRADAXA 75MG TEKTURNA 300MG ALPHAGAN-P OPHTH SOL (G) DIPROLENE LOTION (G) 0.05% INVOKANA 100MG PRADAXA 150MG TEKTURNA HCT 150-12.5MG 0.15% DIPROLENE DINT (G) 0.05% INVOKANA 300MG PRED FORTE (G) 1°% TEKTURNA HCT 150-25MG ALREX 0.2% DIVIGEL 0.5MG ISENTRESS 400MG PREMARIN 0.3MG TEKTURNA HCT 300-12.5MG ALVESCO 80MCG 100MCG DIVIGEL 1MG ISOPTO CARPINE 1°% PREMARIN 0.625MG TEKTURNA HCT 300-25MG ALVESCO 160MCG 200MCG DOVONEX CREAM (G) 50MCG ISOPTO CARPINE 2% PREMARIN 1.25MG TIVICAY 50MG AMITIZA 24MCG DUAVEE 0.45-20MG ISOPTO CARPINE 4% PREMARIN VAG 0.625MG/GM TOBREX OINT 0.3% ANORO ELLIPTA 62.5/25MCG DULERA 100MCG/5MCG JADENU 90MG PREMPRO 0.3MG/1.5MG TOVIAZ 4MG ANZEMET 100MG DULERA 200MCG/5MCG JADENU 180MG PREMPRO 0.625MG/5MG TOVIAZ 8MG ARCAPTA NEOHALER 75MCG DYMISTA NASAL SPRAY JADENU 360MG PREVACID SOLUTAB 15MG TRACLEER 62.5MG ARNUITY ELLIPTA 100MCG 137150MCG JAKAFI 5MG PREVACID SOLUTAB 30MG TRACLEER 125MG ARNUITY ELLIPTA 200MCG EDARBI 40MG JAKAFI 10MG PREZCOBIX 800MG/150MG TRADJENTA 5MG ARTHROTEC (G) 50MG EDARBI 80MG JAKAFI 15MG PREZISTA 600MG TRAVATAN Z OPHTH SOL 0.004°% ARTHROTEC (G) 75MG EDARBYCLOR 40MG/25MG JAKAFI 20MG PREZISTA B00MG TRIBENZOR 20/5/12.5MG ASACOL HD 800MG EDECRIN 25MG JALYN 0.5MG/0.4MG PRISTIQ 50MG TRIBENZOR 40/5/12.5MG ASMANEX TWISTHALER 110MCG EDURANT 25MG JANUMET 50/500MG PRISTIQ 100MG TRIBENZOR 40/5/25MG ASMANEX TWISTHALER 220MCG EFFIENT 5MG JANUMET 50/1000MG PROMETRIUM (G)100MG TRIBENZOR 40/10/12.5MG ASTAGRAF XL 5MG EFFIENT 10MG JANUMET XR 50MG/500MG PROTOPIC DINT 0.03°% TRIBENZOR 40/10/25MG ATACAND(G)4MG ELIDEL 1% JANUMET XR 50MG/1000MG PROTOPIC DINT 0.1°% TRINTELLIX 5MG ATACAND(G)8MG ELIQUIS 2.5MG JANUMET XR 100MG/1000MG QVAR 40MCG 50MCG TRINTELLIX 10MG ATACAND (G) 16MG ELIQUIS 5MG JANUVIA 25MG QVAR 80MCG 100MCG TRINTELLIX 20MG ATACAND (G) 32MG ELMIRON 100MG JANUVIA 50MG RANEXA 500MG TRIUMEQ TABLET ATACAND HCT (G)16MG/12.5MG EMADINE 0.05% JANUVIA 100MG RAPAFLO 4MG TRUVADA 200-300MG ATACAND HCT (G) 32MG/12.5MG ENABLEX 7.5MG JARDIANCE 10MG RAPAFLO 8MG TUDORZA PRESSAIR 400MCG ATELVIA DR 35MG ENABLEX 15MG JARDIANCE 25MG RAPAMUNE (G) 0.5MG TWYNSTA 40/5MG ATRIPLA 600-200-300MG ENTOCORT (G) 3MG JENTADUETO 2.5MG-500MG RAPAMUNE (G) 1MG TWYNSTA 40/10MG ATROVENT HFA 20UG ENTRESTO 24MG-26MG JENTADUETO 2.5MG-850MG RAPAMUNE (G) 2MG TWYNSTA 80/5MG AUBAGIO 14MG ENTRESTO 49MG-51MG JENTADUETO 2.5MG-1000MG RELPAX 20MG TWYNSTA 80/10MG AVANDAMET 4MG/500MG ENTRESTO 97MG-103MG JUBLIA 10% RELPAX 40MG ULORIC 80MG AVANDAMET 4MG/1000MG EPIDUO GEL PUMP 0.1%/2.5% KAZANO 12.5/1000MG RENAGEL 800MG UROCIT-K (G) 10MEQ AVANDIA 2MG EPIPEN 0.3MG KOMBIGLYZE XR 2.5MG/1000MG RENVELA 800MG URSO (G) 250MG AVANDIA 4MG EPIPEN JR 0.15MG KOMBIGLYZE XR 5MG/500MG RESTASIS VIALS 0.05°% VAGIFEM 10MCG AVANDIA 8MG EPIVIR (G) 150MG KOMBIGLYZE XR 5MG/1000MG RETIN A CREAM (G) 0.06% VECTICAL (G) 3MCG/GM AVODART 0.5MG EPIVIR / HBV (G) 100MG LATUDA 20MG RETIN A MICRO GEL PUMP (G) VENTOLIN HFA 90MCG AXERT 6.25MG EPZICOM LATUDA 40MG 0.04% VESICARE 5MG AXERT 12.5MG ESTROGEL 0.06% LATUDA 60MG RETIN-A MICRO GEL PUMP (G) VESICARE 10MG AZILECT 0.5MG EVISTA 60MG LATUDA 80MG 0.1% VIMOVO 375120MG AZILECT 1 MG EXELON 3MG LATUDA 120MG REXULTI 0.25MG VIMOVO 500/2OMG AZOPT OPHTH DROPS 1 % EXELON 6MG LESCOL XL 80MG REXULTI 0.5MG VIRAMUNE XR 400MG AZOR 20/5MG EXELON 4.6MG/24HR LEXIVA 700MG REXULTI 2MG VIREAD 300MG AZOR 40/5MG EXELON 9.5MG/24HR LIALDA 1.2GM REXULTI 4MG VIVELLE-DOT 25MCG AZOR 40/10MG EXELON 13.3MG/24HR LINZESS 145MCG REYATAZ 150MG VIVELLE-DOT 37.5MCG BACTROBAN NASAL DINT 2% EXFORGE HCT 160/12.5/5MG LINZESS 290MCG REYATAZ 200MG VIVELLE-DOT 50MCG BANZEL 200MG EXFORGE HCT 160/12.5/10MG LIPITOR (G)10MG REYATAZ 300MG VIVELLE-DOT 75MCG BANZEL 400MG EXFORGE HCT 160/25/5MG LIPITOR (G) 20MG SAPHRIS 6MG VIVELLE-DOT 100MCG BARACLUDE 0.5MG EXFORGE HCT 160/25/10MG LIPITOR (G) 40MG SAPHRIS 10MG VOLTAREN GEL BARACLUDE 1MG EXFORGE HCT 320/25/10MG LIPITOR (G) 80MG SEASONIQUE (G) VYTORIN 10110MG BECONASE AQ 42MCG EXJADE 125MG LOCOID LIPOCREAM 0.1 % 0.15/0.03/0.01MG VYTORIN 10/20MG BENICAR 20MG EXJADE 250MG LOTEMAX GEL 0.5% SENSIPAR 30MG VYTORIN 10140MG BENICAR 40MG EXJADE 500MG LOTEMAX SUSP 0.5% SENSIPAR 60MG VYTORIN 10/80MG BENICAR HCT20MG/12.5MG FARESTON 60MG LOTRISONE CREAM (G) SENSIPAR 90MG WELCHOL 625MG BENICAR HCT 40MG/12.5MG FARXIGA 5MG 1%/0.05°% SEREVENT DISKUS 50MCG XALKORI 200MG BENICAR HCT 40MG/25MG FARXIGA 10MG LOVENOX (G) 40MG SEROQUEL XR 50MG XALKORI 250MG BENZACLIN PUMP FELDENE 10MG LOVENOX (G) 60MG SEROQUEL XR 150MG XARELTO 10MG BETIMOL 0.25% FELDENE 20MG LOVENOX (G) 80MG SEROQUEL XR 200MG XARELTO 15MG BETIMOL 0.5% FETZIMA 20MG LOVENOX (G) 100MG SEROQUEL XR 300MG XARELTO 20MG BETOPTIC S OPHTH 0.25°% FETZIMA 40MG LUMIGAN OPHTH 0.01% SEROQUEL XR 400MG XELJANZ 5MG BONIVA (G)150MG FETZIMA 80MG MESNEX 400MG SIMBRINZA 1%/0.2% XELODA (G)150MG BREO ELLIPTA 100/25MCG FETZIMA 120MG MESTINON TS 180MG SOLARAZE (G) 3% XELODA (G) 600MG BRED ELLIPTA 200/25MCG FINACEA GEL 15% METRO CREAM (G) 0.75% SOOLANTRA 1°% XIGDUO XR 5/1000MG BRILINTA 60MG FLAREX 0.1% METROGEL PUMP 1% SPIRIVA 18MCG XIGDUO XR 10/500MG BRILINTA 90MG FLOVENT 44MCG 50MCG MICARDIS HCT (G) 40/12.5MG SPIRIVA RESPIMAT 2.5MCG XIGDUO XR 10/1000MG BYSTOLIC 2.5MG FLOVENT 110MCG 125MCG MICARDIS HCT (G) 80/12.5MG SPRYCEL 20MG ZANAFLEX (G) 2MG BYSTOLIC 5MG FLOVENT 220MCG 250MCG MICARDIS HCT (G) 80/25MG SPRYCEL 50MG ZELAPAR 1.25MG BYSTOLIC 10MG FLOVENT DISKUS 100MCG MIGRANAL NASAL SPRAY 4MG/ML SPRYCEL 70MG ZETIA 10MG BYSTOLIC 20MG FLOVENT DISKUS 250MCG MIRAPEX ER 0.375MG SPRYCEL 100MG ZOMIG NASAL SPRAY 5MG CADUET (G) 5110MG FORADIL +AEROLIZER 12MCG MIRAPEX ER 0.75MG STIOLTO RESPIMAT 2.5/2.5MCG ZORTRESS 0.25MG CADUET (G) 5120MG FOSRENOL CHEW 500MG MIRAPEX ER 1.5MG STIVARGA 40MG ZORTRESS 0.5MG CADUET (G) 5/40MG FOSRENOL CHEW 750MG MIRAPEX ER 2.25MG STRATTERA 10MG ZORTRESS 0.75MG CADUET (G) 10/10MG FOSRENOL CHEW 1000MG MIRAPEX ER 3MG STRATTERA 18MG ZOVIRAX CREAM 5% CADUET (G)10120MG FOSRENOL POWDER 750MG MIRAPEX ER 3.75MG STRATTERA 25MG ZYCLARA 3.75% CAMBIA 50MG FOSRENOL POWDER 1000MG MIRAPEX ER 4.5MG STRATTERA 40MG ZYTIGA 250MG CARDIZEM CD (G) 360MG FROVA 2.5MG MIRVASO 0.33% STRATTERA 60MG CARDIZEM LA (G)180MG GELNIQUE 10% MULTAQ 400MG STRATTERA 80MG CARDIZEM LA (G) 360MG GENVOYA 150-150-200-10MG MYRBETRIQ 25MG STRATTERA 100MG CARDURA XL 4MG GILENYA 0.5MG MYRBETRIQ 50MG STRIBILD CARDURA XL 8MG GILOTRIF 20MG NASONEX 50MCG SUSTIVA 50MG CLIMARA PATCH (G) 25MCG GILOTRIF 30MG NESINA 6.25MG SUSTIVA 200MG CLIMARA PATCH (G) 50MCG GILOTRIF 40MG NESINA 12.5MG SUSTIVA 600MG NOTE: Medication names appearing with (G) are available in a Generic version from your local or U.S. mail order pharmacy. This list is subject to change. Please call 1-866-488-7874 toll free to verify the availability of your medication through this program. November 2017 GET THY, MMIA Employee Benefits HealthSpective` WELLNESS PROGRAM 2098 Engage- https://portaLhealthspective. com/mmia The MMIA Employee Benefits Program is continuing to build on its successful Wellness Program. In 2018, we are making some changes to make the program even more effective. Big Changes • Five new incentive categories reward you for taking proactive steps to improve your health and make the most of your benefits. • A new way to trackyour well-being. Register on the HealthSpective Engage portal found at httl2s:./,/.portal.healthspective.com/i-nmia. This system shows what incentives you've earned, your screening results, and more. No physical gift cards. You must log into the Engage portal at to access your incentive. You can select from multiple vendor gift cards, direct deposit to your bank account, or a combination of both. Incentive Activities You must register in the Engage portal in order to access your incentive. See more details on each activity and how to register for the portal on the next page or by visiting www.mmiametZgetwell ft. &+ $50 —Fill out the Health Risk Assessment and watch a short video on the Engage platform. $50 — Get a biometric screening through It Starts With Me or the Montana Health Center between July 1 and September 30. Iwo $50 — If 80% of eligible employees get health screenings, all eligible employees, spouses and retirees who get health screenings will get an extra $50. The Fine Print Total Possible Incentive: $250 In order to receive an incentive, you must be enrolled on an MMIA medical plan and registered with the Engage portal. If you are no longer on an MMIA plan, you will not have access to Engage and will not be eligible to receive an incentive. Montana Municipal Interlocal Authority Employee Benefits reserves the right to alter the Wellness Program at any time. This program is developed in compliance with the EEOC wellness rules and does not violate anti -discrimination laws as determined by the Americans with Disabilities Act and Genetic Information Nondiscrimination Act. Participation in this program is voluntary. MMIA maintains the privacy and security ofyour personally identifiable health information. For more information, visit www.mmia.net eeoc-notice% M�^a£s_t xi 44"tcKxi [u rt,..d. t Montana Municipal Interlocal Authority EMPLOYEE BENEFITS PROGRAM ENROLLMENT FORM Please fax to: 406-449-7440 or submit to: PO Box 6669 — Helena, MT 59604-6669 Please use this form for New Enrollments, Changes and Terminations -disregard all previous Enrollment, Change & Termination forms Please pant clearly on entire fame. Last Name First Name Initial Work Phone Home Phone Cell Phone Current Address City State Zip SECTION 3 - OTHER INSURANCE: Will you, your spouse or your children have any other coverage while on any of the coverages listed above? If yes, please provide the required information below: Employer Name, Insurance Carrier Name & Address Employee's Email Address: Employer Group Number: SECTION I - Please fill out the section below that applies to a new enrollment, enrollment changes or termination of coverage 1t waiving coverage stop here and proceed to the back side of this form PartA -New Enrollment Effective Date of Coverage: First Day of Work: Hours worked per week: Plan Status: ❑ Active Employee ❑ Retiree ❑ Elected Official ❑ Surviving Spouse Marital Status: ❑ Single ❑ Married ❑ Divorced ❑ Widowed ❑ Separated Medical Plan Choice - Please check only one appropriate box below: ❑ Bridger ❑ Madison ❑ Mission ❑ HDHP ❑ Custom Part - Enrollment Chan s Add/Drop spouse or dependent Open enrollment & Qualifying Event Date Event Only) Medicare eligible(provide copy of card or letter ❑ Retiree Status ❑ ❑ Death Other (reason): ❑ Ineligible Dependent (reason): ❑ ❑ Address Change (former address): Name Change (former name): ❑ Part - Termination ofCovera a IfsYaying on covers a as a retiree see Part 8 Medical Plan Choice Open Enrollment &Qualifying Events Only ❑ Bridger ❑ Madison ❑ Mission ❑ HDHP ❑ Custom (if applicable) Last day worked Last day eligible for benefits ❑ Voluntary by employee O Involuntary by employer Type of Qualifying Event (Term, Resignation, Reduce Hrs, Death): Coverage will end the last day of the month in which employee was terminated. Must provide su tin i al documentation of d voice, mania e, adoption, etc. with this form Notes: Use this space for clarification on an y of the above SECTIONZ— rNDrcArEENRoLtmrNrR£QUEsrsoycHEcxnvaoNlysoxEsrHArAPPLYTOcuRRENTCNMtGE(S)oRNEwENROuNENT Note: Yourgroup maynot orTeralrmverages I&W FIRST MI LAST SOCIAL SECURITY # (Required) New enrollee - must complete employee info also DATE OF BIRTH RELATIONSHIP Fmk g�a� Q®� �S Q, ,o Add Drop —1 DMP Add JDoV add Dred Ada Employee: ❑ ❑ ❑ ❑ ❑ 01 ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ 01 ❑ ❑ ❑ ❑ ❑ 0101010101 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spouse: Child(ren): (list) NOTE: IF YOU OR YOUR DEPENDENTS ARE ENROLLING DUE TO A LOSS OF OTHER COVERAGE, PLEASE ATTACH VERIFICATION OF CREDITABLE COVERAGE PARTICIPATION CERTIFICATION: I CERTIFY THAT THE ABOVE ANSWERS ARE TRUE TO THE BEST OF MY KNOWELDGE AND I HAVE READ AND UNDERSTAND THE PARTICIPANT AUTHORIZATION AND STATEMENT OF HIPAA PORTABILITY RIGHTS ON THE REVERSE SIDE OF THIS FORM. I HEREBY AUTHORIZE MY EMPLOYER TO DEDUCT FROM MY EARNINGS ANY REQUIRED CONTRIBUTIONS FOR THE COST OF BENEFITS FOR WHICH 1 AM OR MAY BECOME ELIGIBLE. Participant's Signature (New enrollment or changes only) Date: Employer's Signature Date: Please refer to reverse side of form Rev. 4/13/17 SECTION 3 - OTHER INSURANCE: Will you, your spouse or your children have any other coverage while on any of the coverages listed above? If yes, please provide the required information below: Employer Name, Insurance Carrier Name & Address ❑ Yes ❑ No Self TYPE OF COVERAGE MED DEN VIS Spouse ❑ ❑ ❑ Child (ren) ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ PARTICIPATION CERTIFICATION: I CERTIFY THAT THE ABOVE ANSWERS ARE TRUE TO THE BEST OF MY KNOWELDGE AND I HAVE READ AND UNDERSTAND THE PARTICIPANT AUTHORIZATION AND STATEMENT OF HIPAA PORTABILITY RIGHTS ON THE REVERSE SIDE OF THIS FORM. I HEREBY AUTHORIZE MY EMPLOYER TO DEDUCT FROM MY EARNINGS ANY REQUIRED CONTRIBUTIONS FOR THE COST OF BENEFITS FOR WHICH 1 AM OR MAY BECOME ELIGIBLE. Participant's Signature (New enrollment or changes only) Date: Employer's Signature Date: Please refer to reverse side of form Rev. 4/13/17 If enrollment differs by 10% or more, the rate guarantee is void and subject to a new rating evaluation. If plan(s) quoted below are not purchased with 75 days of effective date stated above, the rate guarantee is void and subject to a new rating evaluation. Contract Period: 12 month rate only * Medical Deductible Credit: Included at no charge Medical OOP Credit: NOT Included, unavailable option Rx, Dental, Vision and other deductible and OOP credits are not available. Commissions: 1.32% COBRA Administration: COBRA administration through PacificSource Administrators is included in premium. Eligibility: Employees must work a normal workweek minimum of 20 or more hours PacificSource requires a minimum of 75% of all eligible employees to participate in the plan. Note: Waiving to Individual coverage is counted against participation • PacificSource requires that the employer contribute a minimum of 75% to the employee rate or 50% of the total rate. Based on the information submitted, this is at 100% EE and fixed varying amount for dep and must be maintained by employer. Yes No ✓ Are there retirees under 65 (Early Retirees)? ✓ Are there retirees over 65 (Medicare Eligible)? ✓ Are there COBRA participants? Other: Refer to Value Added Services Quote Information: Standard PacificSource benefit structure, limitations and exclusions apply. Yes No ✓ Matching, as best as possible, Groups Ded/Coins/OOP/Copay structure ONLY? ✓ Benefits are Standard "chassis" PacificSource structure, limitations and exclusion? ✓ Matching Groups current benefit limitations and exclusions? ✓ If applicable, is the Copay bundling option defined (PS Standard, Option B, Option A)? —MDL—Rx Formulary? ]Which Which Copay bundling option? Any other Notes: ER Copay match does not apply ificsource HEA! Till P ANS P • ' • t Date Printed: May 31, 2018 Group Name: City Of Laurel Effective Date: July 1, 2018 Agent: Eric Allen Enrollment: Enrolled Employees: 67 If enrollment differs by 10% or more, the rate guarantee is void and subject to a new rating evaluation. If plan(s) quoted below are not purchased with 75 days of effective date stated above, the rate guarantee is void and subject to a new rating evaluation. Contract Period: 12 month rate only * Medical Deductible Credit: Included at no charge Medical OOP Credit: NOT Included, unavailable option Rx, Dental, Vision and other deductible and OOP credits are not available. Commissions: 1.32% COBRA Administration: COBRA administration through PacificSource Administrators is included in premium. Eligibility: Employees must work a normal workweek minimum of 20 or more hours PacificSource requires a minimum of 75% of all eligible employees to participate in the plan. Note: Waiving to Individual coverage is counted against participation • PacificSource requires that the employer contribute a minimum of 75% to the employee rate or 50% of the total rate. Based on the information submitted, this is at 100% EE and fixed varying amount for dep and must be maintained by employer. Yes No ✓ Are there retirees under 65 (Early Retirees)? ✓ Are there retirees over 65 (Medicare Eligible)? ✓ Are there COBRA participants? Other: Refer to Value Added Services Quote Information: Standard PacificSource benefit structure, limitations and exclusions apply. Yes No ✓ Matching, as best as possible, Groups Ded/Coins/OOP/Copay structure ONLY? ✓ Benefits are Standard "chassis" PacificSource structure, limitations and exclusion? ✓ Matching Groups current benefit limitations and exclusions? ✓ If applicable, is the Copay bundling option defined (PS Standard, Option B, Option A)? —MDL—Rx Formulary? ]Which Which Copay bundling option? Any other Notes: ER Copay match does not apply 6r :B CV) HEALTH PLANS City of Laurel Rates: Medical Plans: PSN 500 25_20 2500 $779.77 $1,729.93 $1,240.65 $1,987.66 $584.83 $1,169.66 2x Family Ded/OOP Rx 100, 10/40/60% to $200 2x Mail Order Note: EAP is not included Benefit Period: Calendar Year PSN 1500 35 30 PSN 1000 25_20 3500 2500 $701.93 EE 1 $746.91 $1,557.63 $1,295.02 ES 1 $1,657.02 $1,788.82 $1,487.62 EC $1,188.36 $1,052.90 EF $1,903.89 Rx 100, 10/40/60% to $200 2x OON Ded/OOP Smed $560.18 Prev Rx 2P Med $1,120.36 2x Family Ded/OOP Rx 100, 10/40/60% to $200 2x Mail Order PSN 500 25_20 2500 $779.77 $1,729.93 $1,240.65 $1,987.66 $584.83 $1,169.66 2x Family Ded/OOP Rx 100, 10/40/60% to $200 2x Mail Order Note: EAP is not included Benefit Period: Calendar Year PSN 1500 35 30 3500 PSN 3500+Rx $701.93 $583.61 $1,557.63 $1,295.02 $1,115.14 $927.94 $1,788.82 $1,487.62 $526.45 $1,052.90 2x Family Ded/OOP 2x Family Ded/OOP Rx 100, 10/40/60% to $200 2x OON Ded/OOP 2x Mail Order Embedded Ded Prev Rx Conditions: Offer assumes the contract situs and issuance of contract is in Montana This quote assumes PacificSource will be the only carrier providing coverage to the employer group's employees Open Enrollment will be one month prior to the renewal;date f Regulations require PacificSource to determine, based on the information provided in the quoting process, whether an employer is subject to Chapter 26 of the Montana Code Annotated. This proposal is made on the condition you are not a Small Employer Employer will promptly notify PacificSource of any change in participation and Employer contribution ACA established a number of taxes and fees that are incorporated into your premiums. Two of those fees are: (1) the Annual Fee on Health Insurers or "HIT(Health Insurer Tax)"; and (2) the Transitional Reinsurance Fee. Both fees began in 2014. (1) Section 9010(x) of ACA requires that ("health insurers") pay an annual fee to the federal government, commonly referred to as the Health Insurer Fee. The amount of this fee will be determined by the federal government. This fee helps fund premium tax credits and cost-sharing subsidies offered to certain individuals who purchase coverage on health insurance exchanges. As of late 2015, this fee currently has been suspended for 2017 only. The fee stili applies in 2016 and, pending any further legislation, could recontinue in 2016. (2) Section 1341 of ACA provides for the establishment of a temporary reinsurance program (for a three year period (2014-2016) which is funded by Reinsurance Fees collected from health insurance issuers and self-funded group health plans. Federal and state governments provide information as to how these fees are calculated. Federal regulations establish a flat, per member, per month fee. The temporary reinsurance programs, funded by these Reinsurance Fees, help to stabilize premiums in the individual market. PetiiiiiSdu�ce.cGrti o• PaciticSource HEALTH PLANS City of Laurel Outline of Coverage PSN 500+25_20 S2 Option B Bundling This outline of coverage provides a very brief description of important policy features. Please note: this outline is not intended to be part of the insurance contract. Only the actual policy provisions are final and binding. The policy details your rights and obligations, as well as those of PacificSource. Provider Network: PSN Trend Data PacificSource bases large group premiums on data accumulated from the entire Montana large group population. Certain factors such as demographics are incorporated into the rating process. PacificSource bases trend projections on a combination of PacificSource Montana large group data and the PacificSource Oregon group book of business. The large group premium increases for the last five years were 2017 7.4%, 2016 15.0%, 2015 4.6%, 2014 10.1 %, and 2013 9.7%. The member is responsible for the above deductible and the following amounts: Service Well baby/Well child care No charge =- ���,.,� _ .. - Well woman visits Preventive mammograms Immunizations Preventive colonoscopy h, q .ig tj N" Le 7ffi.� C' L R Ring R. 'AM 4 , Prostate cancer screeningNtochar e* 2" once 3 NU � U M gwi' ;g'M Office and home visits 25"pay/visit ri, (Calt ph I Naturopath office visits :20 TLe [4: Specialist office and home Me $25 co pay/visit ed ti -U0 hmu an" -no ps-M a, visits Telemedicine visits PSGOOC.MT.LG.0118 Office procedures and F ib e .hANA- � fid c No charge*ROOM- su 6es supplies 20°lo et[ e e Y "°o c a Surgery Deductible then co msurance Dei: . Outpatient rehabilitation Deductible then 20% Go msurance' r U ti = _ eK�°p`o services ' '.X.,.. �Z....c.: 4 ii 3 S .� �' G..lt' "1. S.s. . .. ....::..1 .5.'•_:,'tJ.... —`.'. x._... s�5a �_ _. .. Inpatient room and boardDeductible then 20% co msurance,dct �f `e=°Yeo (ns `arae Inpatient rehabilitation � � � �'' � - services Skilled nursing facility care Deductible then 20% ca msurance�,educb eft era ° insrae ✓ x t' 'r ....i Z" 7rN..'..��t�as"t' l''g?�'';s. Y?-c`4x` 7` Y`t#••.iv',,.D^'Ty'+. x.54 ...T.- 19�� Outpatienf�Sexuic�es.�.��. _ Outpatient surgery/services a MW 0 Deductible then 20%$co insurance®uc [ .:e 7, MA Advanced diagnostic Deductible there 20 to co msurancer�De 11ra + i;e imagingw ,�tc�t , . Diagnostic and therapeutic Detluctible then 20% co msurance edcti ;e the �.:°ox o [ s [ a a� radiology/lab 'ka L Y tJrgentand Emergency Services { F Y R ST 9 S i. 4 . C.. �....E... __ .._.... .... ._ /visit*ce Urgent care center visits .$25 co pay Emergency room visits — Deductible theh $100 co pay/visitbedUcti" e hemi =0�.0 a/vis medical emergency lus 20%co msurance^ Emergency room visits — Deductible then $100 co pay/v®edrix�t=ezOnc'o°pavist y u5°lo non-emer enc lus 20°I°_co insurance^ x cilaC Ambulance, ground Deductible,then 201° co insurance#. Ambulance, air Deductible then 20%'co msurance c [ r 44"T"', � p . M 1„Skj"$`wX°� SerSu[cesx 1V(aternaty ii�'S" S"2 «-+..-y.....3:..5k.3W u.F;x+...%.h>fkSY.G*;;; .- ,4e i r._ .6 Physician/Provider services Y-b�"+.. 2 C h c�-'u —'41. `�c rte^ : '^. _ �„ y �m ; s+�w. r" -^. .•", 20% co msurance ®ed:uctib lobal char e Deductible then Y Hospital/Facility services Detluctible then�20°lo-co msurance S �cSery Menai HealthlChem icai Dependeny ices<' '^1 q!r ,;3"TE" �'t Y, "r{e..--�./:.." .. .W_n "frtm'GLs.,.a��: "%r.'i.. .Y..... L.. _!""._•�s«. iaSM_f,eY..P'-^..�zt" $25 co Spay/uieit* = su a c Office visits D.ec [_ �o � ur-aj Inpatient care Deduetiblexthen 20loFco msurance Residential programs Deductible then 20°lo co insurance reed~ 5°° ds ;� ..,.Je a?a s;,`la, &e , Allergy injections $5 co pay*616, Durable medical equipment De ductib)erthen�20°A° co msurance" Home health care Deductible then 20% co msurance °` 'd o b t e Chiropractic manipulations ` $25,co pay/visit* and acupuncture Trancnlnnt.-, «`..D.e'ductible then ,No,charge_ _ �s®,fid c :i �, e e`' o r o This is a brief summary of benefits. Refer to your handbook for additional information or a further explanation of benefits, limitations, and exclusions. - ^ Co -pay waived if admitted into hospital. PSGOOC.MT.LG.0118 * Not subject to annual deductible. + Non -participating air ambulance coverage is covered at 200 percent of the Medicare allowance, except as required by law. You may be held responsible for the amount billed in excess. Please see your handbook for additional information or contact our Customer Service team with questions. PSGOOC.MT.LG.0118 Opaci t - Prescription Drug Benefit Summary HEALTH PIANS MT 10-40-60P 100D S2 MDL City of Laurel This PacificSource health plan includes coverage for prescription drugs and certain other pharmaceuticals, subject to the information below. This plan complies with federal health care reform. PRESCRIPTION DRUG DEDUCTIBLE $100 per person The deductible is an amount of covered pharmacy expenses the member pays for brand medications each calendar year before the following benefits begin. Co -payments, differential between brand and generic drugs, drugs obtained without using the PacificSource member ID card, and non -participating pharmacy charges do not accumulate toward the deductible. The deductible does not apply to Tier one drugs. The amount you pay for covered prescriptions at participating and non -participating pharmacies applies toward your plan's participating medical out-of-pocket limit, which is shown on the Medical Benefit Summary. The co -payment and/or co-insurance for prescription drugs obtained from a participating or non -participating pharmacy are waived during the remainder of the calendar year in which you have satisfied the medical out-of-pocket limit. Each time a covered pharmaceutical is dispensed, you are responsible for the amounts below: "h F Pa.rtic�pating Reta�I Pharmacy Deductible then the Deductib{e then Up to a 30 day supply: $10 co pay* „ lesser of $200 co pay $40 co pay ; Pa"rt !61pat►ngr1111ai1rOrder Pharmacy' _ Deductifjle then the Deductible then Up to a 30 day supply: $10 co pay* lesser of $200 co pay _ ° or„6.0 /°, co, insurance; Deductible therf the Deductibe hen I t 31 — 90 day supply: $20 co pay* lesser of $400 co pay $80 co pa 'y__or,60%_c0 _,._ _- ._ .... _..:. , . _ :... . . ... ....... _.. insurance; Non partic�pat�ng Pharmacy 30 day max fill, no more than Deductible then 90% co insurance three fills allowed per year: y Tier 4 Specialty Dru 's Partici atm S ecia! Pharmac Up to a 30 day supply:;Deductible then the lesser of $200 co=pay or 20°I°Jco insurance 5 _ , Tier 4sSpe`c�alty Drugs Not frlle�d through�Parficipating�Special�yEPha£rmacy� � � '�` 30 day max fill, no more than - ° Deductible then 90 /° co insurance three fills allowed per year: CompouniiDrugs** 3 ...�.. Up to a 30 day supply: then the lesser of $200 co pay :or 60% co s rDeductib)e Lnsurance� ^ Remember to show your PacificSource member ID card each time you fill a prescription at a retail pharmacy. If your ID card is not used, your benefits cannot be applied and may result in higher out-of-pocket cost. * Not subject to annual prescription drug and/or medical deductible. **Compounded medications are subject to a preauthorization process. Compounds are generally covered only when all commercially available formulary products have been exhausted and all the ingredients in the compounded medication are on the applicable formulary. MAC B - Unless the prescribing provider requires the use of a brand name drug, the prescription PSGBS.MT.LG.RX.0118 Will automatically be tilled with a generic drug when available and permissible by state law. If you receive a brand name drug when a generic is available, you will be responsible for the brand name drug's co -payment and/or co-insurance plus the difference in cost between the brand name drug and its generic equivalent after the deductible is met. if your prescribing provider requires the use of a brand name drug, the prescription will be tilled with the brand name drug and you will be responsible for the brand name drug's co -payment and/or co-insurance after the deductible is met. The cost difference between the brand name and generic drug does not apply toward the medical plan's deductible or out-of-pocket limit. See your member handbook for important information about your prescription drug benefit, including which drugs are covered, limitations, and more. PSGBS.MT.LG.RX.0118 6--paciticsource Outline of Coverage HEALTH PLANS PSN 1000+25_20 S2 City of Laurel Option B Bundling This outline of coverage provides a very brief description of important policy features. Please note: this outline is not intended to be part of the insurance contract. Only the actual policy provisions are final and binding. The policy details your rights and obligations, as well as those of PacificSource. PLEASE READ YOUR MEMBER HANDBOOK CAREFULLY. Provider Network: PSN + 6_e •V10 - $2,000 All Providers $1,000 All Providers $2,500 $5,000 Please note: Your actual costs for services provided by a non -participating provider may exceed this policy's out-of-pocket limit for non -participating provider services. In addition, non -participating providers can bill you for the difference between the amount charged by the provider and the amount allowed by the insurance company, and this amount is not counted toward the non -participating out- of-pocket limit. Trend Data PacificSource bases large group premiums on data accumulated from the entire Montana large group population. Certain factors such as demographics are incorporated into the rating process. PacificSource bases trend projections on a combination of PacificSource Montana large group data and the PacificSource Oregon group book of business. The large group premium increases for the last five years were 2017 7.4%, 2016 15.0%, 2015 4.6%, 2014 10.1 %, and 2013 9.7%. The member is responsible for the above deductible and the following amounts: Pk Service a NMI e • . • . • • • - Preuentive Gare' Wel( baby/Well child care No char e*; 02=000K 0� Vin, JR. _ .. .. ........ ..._.._... 9_ .'_.._-_... Preventive physicals No char e* MEN Y p Y g �3 No charge's Well woman visits No charged i� ,,_��WON-, Preventive mammograms No charge�to _ Immunizations No char e�' Y� No Lha e012 9 �A Preventive colonoscopy _ _ No charge Deduct�bfest�/�o�canstarane x . w 5%cis cel AWProstate cancer screening N Profess►ona[ Serv►ces _ - Office and home visits t. __. r$25 co paylvisit__. .. `°_ ... , ,'Dcfii ato °- !an Naturopath office visits $25 co a Iv�sit D de ucb e hent °oc n p Y ,.._ ?� .0_ Specialist office and home��`���� visits $25 co pay/visit educt�ble the �5 orGo saance 1 Telemedicine visits $25 co a Juisitecus ib ettie 35° ' cos anc PSGOOC.MT.LG.0118 Service • • a o • . • . r • Office procedures and No charges ®e aye Abe e 'fi°,o .' sr!zt�e supplies Ix� Deductible then 20% co insuranceDeducflbl en,x, o�co = se Surgery Outpatient rehabilitation Deductible then.20°lo co insurance De cube t e Via°°" s.. ante services ��_�� RI �"h' a. ¢+ t 4 � � � `� Ffosprt'alwSerrvices � � .i Inpatient room and board Deductible Cheri 20°loco insurance "NUM, e er ca i sura Inpatient rehabilitation �or�s cel Deductible Cheri 20% co insurance Deduct b� a 4 services fiOW- ,r s �.��� ARe nsaan e Skilled nursing facility care Deductible then 20% co insurance ReducibleWtf5°°c° then 20% co insun35� o consuance: Outpatient surgery/services Deductible Advanced diagnostic MOR Deductible Cheri 20°!o co insurance�buedulehe w, 5°o CY rsurance _ imaging �.r.;.•.t3- ' `'"�v'.,."�23.4. '"" �',v '^'--`a r ti.,. Mrs... Diagnostic and therapeutic Deductible Cheri 20%.`co mstrance' Dedactlble the 35loco aqsurancAy. radiology/lab" r. tlrgerit'and Emergency Services .r-H' `i2TS5s $25 cq # ubdu�ct ble the 5". -o insurance Urgent care center visits pay%visit* Emergency room visits — Deductible then $10Q co pay/visit'3educeg�$ OOeo�an ' o ^ lus20 qhs pance�: medical emer enc lus 20 /o co insurance �, .�ocQ t Emergency room visits — a s x sr :rcrvx Deductible then $100 co pay/vDeductblerhe �100co P yzuisi on -emergency., n�r lus 20%'co insurance^ _. lus5°I'co tns�uc� _, ,. - Deductk le Cheri 20% co insurance v.19e u'ctlb e th 20° ��s afi ce Ambulance, ground then 20°/o'co insurance 1[] d0A tie 2p ca s b �� Ambulance, air Deductible r ..f •` � � ''� ��� � �� } � ��� Services_ x� � `�. z ,IUlaierrt�ty Physician/Provider services ota , 2010 'co insurance De then3°oNeor�sujartce (global charge)Deductible then .uciible then 20% co insurance De uC,ble Hospital/Facility services I Deducible §en°race F c Y,'i'f zo1,Y. Menta�4Health`/CfiemrcalDependency Services �- .. ;��,_ � z _< yy `. $25 eo pay /visits a ecjuctrblRe ;et x3 to IN] -11„ Office visits rtcs �vaa.r a.'s.., , ..e: �5%i saran e Inpatient care Deductible then 20%''co insurance ODed C ibletf r -°� Ovz then 20°/o co insurance �Deduct�bie e��°/ corse an Residential programs Deductible z ether cauered Seruicesyr > ;,r _ r ° :...x._..�. .....x..�,_ ...... _ en 3 o��� su�aMce Allergy injections $5 co pay/visits Deductl�6le t t a f, en& ° then 20°lo co insurance 14 �,ts3'3nce Durable medical equipment Deductible 1Reduc Deducible then 20°lo co'ins.uranceDuc#itn. °Qs Home health care Chiropractic manipulations $25 coypay/�isit�®e het bihe 5g o t�su aneet; and acupuncture then No charge Ducibl�.� _ eh350 of srr�nce Transplants „Deductible This is a brief summary of benefits. Refer to your handbook for additional information or a further explanation of benefits, limitations, and exclusions. ^ Co -pay waived if admitted into hospital. PSGOOC.MT.LG.0118 * Not subject to annual deductible. + Non -participating air ambulance coverage is covered at 200 percent of the Medicare allowance, except as required by law. You may be held responsible for the amount billed in excess. Please see your handbook for additional information or contact our Customer Service team with questions. PSGOOC.MT.LG.0118 ow Pachic Sourqe, Outline of Coverage HEALTH PLANS PSN 1500+35_30 S2 City of Laurel Option B Bundling This outline of coverage provides a very brief description of important policy features. Please note: this outline is not intended to be part of the insurance contract. Only the actual policy provisions are final and binding. The policy details your rights and obligations, as well as those of PacificSource. PLEASE READ YOUR MEMBER HANDBOOK CAREFULLY. Provider Network: PSN All Providers $1,500 $3,000 All Providers $3,500 $7,000 Please note: Your actual costs for services provided by a non -participating provider may exceed this policy's out-of-pocket limit for non -participating provider services. In addition, non -participating providers can bill you for the difference between the amount charged by the provider and the amount allowed by the insurance company, and this amount is not counted toward the non -participating out- of-pocket limit. Trend Data PacificSource bases large group premiums on data accumulated from the entire Montana large group population. Certain factors such as demographics are incorporated into the rating process. PacificSource bases trend projections on a combination of PacificSource Montana large group data and the PacificSource Oregon group book of business. The large group premium increases for the last five years were 2017 7.4%, 2016 15.0%, 2015 4.6%, 2014 10.1 %, and 2013 9.7%. The member is responsible for the above deductible and the following amounts: gli4 . Service U1. Well baby/AV/Vell child Preventive physical ante a Well woman visits 9 MY01 c. iX 'a rge Preventive mammograms Nh." Wr N ME at fi- N 7 INE _31 11 03-M 19, 10 �N h-"' I MINM115111 -0 Immunizations "R-2--lk i1ni -6 gs 'N /JP- -'N 1:16 Z Preventive colonoscopy s .,,cleny Prostate cancer screening Ed hr T prance ff -.1 pu 'm' _"u .0461 Office and home visits 2 Naturopath office visits Specialist office and home 5/visit ----'--RE-,eq1q mole visits V� d Telemedicine visits 5 P ��y V_ls E) dool ETtho§ PSGOOC.MT.LG.0118 This is a brief summary of benefits. Refer to your handbook for additional information or a further explanation of benefits, limitations, and exclusions. A Co -pay waived if admitted into hospital. PSGOOC. MT. LG.0118 * Not subject to annual deductible. + Non -participating air ambulance coverage is covered at 200 percent of the Medicare allowance, except as required by law. You may be held responsible for the amount billed in excess. Please see your handbook for additional information or contact our Customer Service team with questions. PSGOOC.MT. LG.0118 Paciticsource HEALTH PLANS of Laurel Outline of Coverage PSN HSA 3500+Rx S2 This outline of coverage provides a very brief description of important policy features. Please note: this outline is not intended to be part of the insurance contract. Only the actual policy provisions are final and binding. The policy details your rights and obligations, as well as those of PacificSource. PLEASE READ YOUR MEMBER HANDBOOK CAREFULLY. Provider Network: PSN Trend Data PacificSource bases large group premiums on data accumulated from the entire Montana large group population. Certain factors such as demographics are incorporated into the rating process. PacificSource bases trend projections on a combination of PacificSource Montana large group data and the PacificSource Oregon group book of business. The large group premium increases for the last five years were 2017 7.4%, 2016 15.0%, 2015 4.6%, 2014 10.1 %, and 2013 9.7%. The member is responsible for the above deductible and the following amounts: Service• Participating Providers $3,500 $7,000 Non -participating Providers $7,000 $1.4,0010 Participating Providers $3,500 $71000 Non -participating Providers $7,000 $14,000 Please note: Participating provider deductible and out-of-pocket limit accumulates separately from the non -participating provider deductible and out-of-pocket limit. Even though you may have the same benefit for participating and non -participating providers, your actual costs for services provided by a non -participating provider may exceed this policy's out-of-pocket limit for non -participating provider services. In addition, non -participating providers can bill you for the difference between the amount charged by the provider and the amount allowed by the insurance company, and this amount is not counted toward the non -participating out-of-pocket limit. Trend Data PacificSource bases large group premiums on data accumulated from the entire Montana large group population. Certain factors such as demographics are incorporated into the rating process. PacificSource bases trend projections on a combination of PacificSource Montana large group data and the PacificSource Oregon group book of business. The large group premium increases for the last five years were 2017 7.4%, 2016 15.0%, 2015 4.6%, 2014 10.1 %, and 2013 9.7%. The member is responsible for the above deductible and the following amounts: PSGOOC.MT.LG.0118 Service• 1 0 8 1- '2 e woman visits � -A WIN 12 9 _[ge Preventive mammograms No char e* 0111 W. Immunizations Preventive colonoscopy Prostate cancer screening gga 0 QL Office and home visits Deductible then NoYcharge ;petl ct�b�re�th�e�Noar. �. _ � Naturopath office visits Deductible then No;�charge � �e� uctible..�� t� �!�.`;� . PSGOOC.MT.LG.0118 PSGOOC.MT.LG.0118 This is a brief summary of benefits. Refer to your handbook for additional information or a further explanation of benefits, limitations, and exclusions. * Not subject to annual deductible. + Non -participating air ambulance coverage is covered at 200 percent of the Medicare allowance, except as required by law. You may be held responsible for the amount billed in excess. Please see your handbook for additional information or contact our Customer Service team with questions. PSGOOC.MT.LG.0118 0,C)Paciticsource HEALTH PLAINS Citv of Laurel Prescription Drug Benefit Summary MT 3500D S2 MDL This PacificSource health plan includes coverage for prescription drugs and certain other pharmaceuticals, subject to the information below. This plan complies with federal health care reform. MEDICAL PLAN DEDUCTIBLE You must meet the medical plan deductibles, which are shown on the Medical Benefit Summary, before your prescription drug benefits begin for Tier one, Tier two, Tier three, compound, and/or Tier four prescription drugs. The amount you pay for covered prescriptions at participating and non -participating pharmacies applies toward your plan's participating medical out-of-pocket limit, which is shown on the Medical Benefit Summary. The co -payment and/or co-insurance for prescription drugs obtained from a participating or non -participating pharmacy are waived during the remainder of the calendar year in which you have satisfied the medical out-of-pocket limit. PACIFICS©URCE PREVENTIVE RX Your prescription benefit includes certain outpatient drugs as a preventive benefit at no charge*. This includes specific drugs that are taken regularly to prevent a disease or to keep a specific disease or condition from progressing. Preventive drugs are taken to help avoid many illnesses and conditions. These preventive drugs are not subject to the deductible. You can get a list of covered preventive drugs by contacting our Customer Service team or visit PacificSource.com/drug-list/. Each time a covered pharmaceutical is dispensed, you are responsible for the amounts below: ^ Remember to show your PacificSource member 1D card each time you tilt a prescription at a retail pharmacy. If your ID card is not used, your benefits cannot be applied and may result in higher out-of-pocket cost. Not subject to annual medical deductible. "Compounded medications are subject to a preauthorization process. Compounds are generally covered only when all commercially available formulary products have been exhausted and all the ingredients in the compounded medication are on the applicable formulary. MAC B - Unless the prescribing provider requires the use of a brand name drug, the prescription PSGBS.MT.LG.RX.0118 will automatically be filled with a generic drug when available and permissible by state law. If you receive a brand name drug when a generic is available, you will be responsible for the brand name drug's co payment and/or co-insurance plus the difference in cost between the brand name drug and its generic equivalent after the deductible is met. If your prescribing provider requires the use of a brand name drug, the prescription will be filled with the brand name drug and you will be responsible for the brand name drug's co -payment andlor co-insurance after the deductible is met. The cost difference between the brand name and generic drug does not apply toward the medical plan's deductible or out-of-pocket limit. If your physician prescribes a non -formulary drug due to medical necessity it may be subject to preauthorization. See your member handbook for important information about your prescription drug benefit, including which drugs are covered, limitations, and more. PSGBS.MT.LG.RX.0118 What is the annual deductible? Your plan's deductible is the amount of money that you pay first, before your plan starts to pay. You'll see that many services, especially preventive care, are covered by the plan without you needing to meet the deductible. The individual deductible applies if you enroll without dependents. If you and one or more dependents enroll, the individual deductible applies for each member only until the family deductible has been met. Deductible expense is applied to the out-of-pocket limit. Note that there is a separate category for participating and non -participating providers when it comes to meeting your deductible. Only participating provider expense applies to the participating provider deductible and only non -participating provider expense applies to the non -participating provider deductible. What is the'out-oaf-pocket limit? The out-of-pocket limit is the most you'll pay for covered medical expenses during the plan year. Once the out-of-pocket limit has been met, the plan will pay 100 percent of covered charges for the rest of that year. The individual out-of-pocket limit applies only if you enroll without dependents. If you and one or more dependents enroll, the individual out-of-pocket limit applies for each member only until the family out-of-pocket limit has been met. Be sure to check your Member Handbook, as there are some charges, such as non-essential health benefits, penalties and balance billed amounts that do not count toward the out-of-pocket limit. Note that there is a separate category for participating and non -participating providers when it comes to meeting your out-of-pocket limit. Only participating provider expense applies to the participating provider out-of-pocket limit. Only non -participating provider expense applies to the non -participating provider out-of-pocket limit. Payments to providers Payment to providers is based on the prevailing or contracted PacificSource fee allowance for covered services. Participating providers accept the fee allowance as payment in full. Non -participating providers are allowed to balance bill any remaining balance that your plan did not cover. Services of non -participating providers could result in out-of-pocket expense in addition to the percentage indicated.. Allowable fee for non -participating providers Outside the PacificSource service area and in areas where our members do not have reasonable access to a participating provider through one of our third party provider networks, the allowable fee, depending upon the services and supply, will be based on the use of the UCR or the participating provider contracted rate, whichever is greater. For more detailed information, please refer to the Non- participating Providers section of your policy. Preauthorization Coverage of certain medical services and surgical procedures requires a benefit determination by PacificSource before the services are performed. This process is called 'preauthorization'. Preauthorization is necessary to determine if certain services and supplies are covered under this plan, and if you meet the plan's eligibility requirements. You'll find the most current preauthorization list on our website, PacificSource.com/member/preauthorization.aspx. PSGOOC.MT.LG.0118 The Patient's right to know the costs of medical procedures. The insured, or the insured's agent, may request an estimate of the member's portion of provider charges for any service or course of treatment that exceeds $500. PacificSource shall make a good faith effort to provide accurate information based on cost estimates and procedure codes obtained by the insured from the insured's health care provider. The estimate may be provided in writing or electronically. It is not a binding contract between PacificSource and the member, and is not a guarantee that the estimated amount will be the charged amount, or that it will include charges for unforeseen conditions. Contact Customer Service at (877) 590-1596 to request an estimate. Emergency medical conditions For emergency medical conditions, non -participating providers are paid at the participating provider level. Emergency medical condition means a medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain that a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would place the health of a person, or an unborn child in the case of a pregnant woman, in serious jeopardy, result in serious impairment to bodily functions; or result in serious dysfunction of any bodily organ or part. With respect to a pregnant woman who is having contractions, for which there is inadequate time to affect a safe transfer to another hospital before delivery or for which a transfer may pose a threat to the health or safety of the woman or the unborn child. PSGOOC.MT.LG.0118 4, PacificSource Health Plans Member Guide PacificSource HEALTH PLANS We're Here to Help At PacificSource, everything we do revolves around taking care of people. That's why we offer quality customer service that you can access by phone or email. Our average hold time for calls is less than 20 seconds. If you call, you'll talk with a live person—not an automated response system. Or email us, if you prefer. Our friendly, professional Customer Service Representatives will be happy to help you. Your PacificSource ID Card Your ID cards will be mailed directly to your home within a few weeks of enrollment. Once you receive them, you can discard any old cards. Please begin using your new card for your healthcare services. When you visit your doctor or pharmacy, be sure to present your card. This ensures they have the correct insurance information. If you need your ID card before it arrives, you can print a temporary ID card on our secure member site at InTouch.PacificSource.com/members/lDcard/ temporary. You may also access your ID card using our free myPacificSource mobile app. See the "Online and MobileTools" section for more information. If you have any questions or haven't received your ID cards, please contact our Customer Service Department Provider Network Your plan uses a participating provider network to ensure maximum access to providers for all members. Visit PacificSource.com/find-a-provider or call Customer Service for assistance finding participating providers in your plan's network. Tip: Be sure to select the appropriate network for your area and plan. Your network information is listed on your ID card. You can search by specialty, last name, location, or other details to access a list of providers. Or you can create your own personalized provider directory to download and print. Note that some health plans require you to select a primary care provider (PCP). Outside Our Service Areas If you live or are traveling outside of Idaho, Montana, Oregon, or select Washington counties (Clark, Cowlitz, Klickitat, Pacific, Skamania, and Wahkiakum counties), use one of these networks: • Alaska and Washington (except for the counties noted above): First Choice Health'" Network • All other states (except Alaska, Washington, and those noted above): First Health® Network To find providers in the First Choice Health Network or the First Health Network, visit PacificSource.com/find-a- provider. Dental Network Plans For Dental Advantage Network plans (Idaho and Oregon only), you can save money by using Dental Advantage Network providers. You'll pay your plan's co -pay and/or co-insurance at the participating provider (in -network) level. In most cases, when you visit an Advantage dentist, we'll waive your deductible. For Dental Advantage Essentials plans, you're only covered when you see a provider who participates in the Dental Advantage Essentials Network. Pharmacy PacificSource Drug Lists The PacificSource drug lists are guides to help your doctor identify medications that can provide the best clinical results at the lowest cost. To find out which list applies to your prescription drug plan, check your Summary of Benefits or PacificSource member ID card. If no "drug list"i is noted on your card, use the "PDL" list. Access our drug lists at PacificSource.com/drug-list. Using the CVS Caremark° Pharmacy Network We contract with CVS Caremark for pharmacy management services. If your health plan includes a prescription drug benefit, you can enjoy automatic savings from CVS Caremark. Just show your PacificSource ID card when you buy your prescriptions. CVS Caremark's network includes nearly 98% of all walk-in pharmacies in the United States. Ask your local pharmacy's staff if they participate with CVS Caremark, or look up the pharmacy at Caremark.com/wps/portal. Mail Order Services If your plan includes prescription drug coverage, mail order service may be a convenient, cost-saving option for you. We partner with both CVS Caremark and Wellpartner Pharmacy to provide you this service. Visit PacificSource. com/member/mail-order-rx for more information. (541) 225-3784 (800) 624-6052, ext. 3784 Caremark.com j (866) 329-3051 We)lipartner Wellpartner.com i (877) 568-6460 I Online and Mobile Tools At PacificSource.com, and the myPacificSource mobile app, you can access tools, information, and resources to help you make the most of your PacificSource benefits. InTouch You can access coverage and benefit information through InTouch, our secure web portal at PacificSource.com. It allows you to easily and conveniently manage your insurance coverage and health, 24/7. Sign into InTouch to: • Look up coverage information in your member handbook/policy, or read benefit summaries. • Look up claims. • View explanations of benefits. • Review your family's enrollment history. • Check deductible and your out-of-pocket status. • Track preauthorizations. • Look up your share of your family's healthcare expenses. • Change your address. • Order replacement ID cards. • Estimate healthcare costs using ourTreatment Cost Navigator. • Access the CafeWell health and wellness resource. myPacificSource Mobile App Our free mobile app gives you secure, on -the -go access to all your coverage information, no matter where you are. The myPacificSource app is available for both iPhone® and Android". Visit PacificSource.com/mobile for more information. Health Management Programs and Services Condition Support Our Condition Support Program offers education and support to members with asthma, diabetes, heart failure, chronic obstructive pulmonary disease, coronary artery disease, or juvenile diabetes. This program is available to eligible PacificSource members with medical coverage. AccordantCare With AccordantCare, we offer rare disease management and specialty pharmacy programs that provide individual support and coordination for our members with certain rare diseases, or those requiring injectable medications or biotech drugs. For more about health management programs and other health and wellness extras, visit PacificSource.com/ extras. Submitting a Claim Usually, your provider will submit claims for you. If you need to fill a covered prescription or see a provider for a covered service before you receive your new ID card, or if you see a nonparticipating provider, you can pay and then submit a copy of the provider's itemized receipt or statement for reimbursement. On our website, you'll find details about how to submit a claim. Visit PacificSource.com/YourPlan/#Claim for more information. PacificSource Health Plans Value-added Extras Your PacificSource coverage also includes the following no -cost wellness programs and services. For details about these programs and more, visit PacificSource.com/extras. 24 -Hour NurseLine Have a health-related question? Our 24 -Hour NurseLine is staffed around the clock, 7 days a week—so you'll never be without a registered nurse to talk to. Call them toll-free at (855) 834-6150. CafeWell This secure online health engagement portal helps you keep track of, and make the most of, your health. To access CafeWell, sign into InTouch, go to Benefits, and select Wellness – CafeWell. Weight Management Programs As part of your PacificSource medical coverage, you can enjoy special offers for one of the following programs: • Weight Watchers®: Be reimbursed for some program costs when you participate in person or in the online program. • Jenny Craig°: Join the Jenny All Access program for 50% off the enrollment fee, plus 5% off all Jenny Craig food. Tobacco Cessation Program With your PacificSource medical coverage, you can participate in the Quit For Life° tobacco cessation program. Kick tobacco for good with nicotine replacement therapy and one-on-one phone support. The Quit For Life° Program is brought to you by the American Cancer Society® and Optum. Virtual Healthcare Visits with Teladoc° We've partnered with Teladoc as of January 1, 2018, to offer you virtual healthcare visits. Teladoc is a national network of U.S. board-certified physicians Customer Service and pediatricians that you can see on -demand, 24/7, via phone or online video consultations, from wherever you happen to be; some limitations apply. For a )�)�� virtual visit with Teladoc, you pay the same as you would a regular office visit. Depending on your plan, this could be a co -pay amount or you may first need to Direct: (208) 333-1596 meet your deductible. Toll-free: (800) 688-5008 Assist America° Global Emergency Services IVI-Djli: Access to Administration Online Services for Your Group Health Plan At PacificSource, we're committed to providing you with flexible, personalized service. One way we do that is through PacificSource InTouch for Employers—a secure, employers -only area of our website. Once you log in, you can enroll new members in your plan, access your plan's contract documents, pay your bill, and much more -24 hours a day. If you prefer doing business online, you'll appreciate the convenience of InTouch. Use InTouch to: Administer enrollment and generate reports • Enroll new members in your plan and update information for existing members, ensuring your employees can get important benefit information as soon as possible • View, change, or download enrollment and census information • View and download enrollment totals for your group by family composition category • Verify employee and dependent enrollment by name or member number • Print temporary ID cards for one or all employees with the click of a button View and pay your bill • View statements in our Payment Center • Pay your bill online with our eCheck option and review your eCheck payment history Access information and request ID cards • View the contact information for your Membership Representative • Access the most up-to-date benefit handbook • Access your plan's contract documents and benefit summaries • Request ID cards Manage InTouch account access • Set up access for members of your administration team with the Group Administrator feature • Administer all of your groups and their subgroups through a single login InTouchAdmin salesMT0314 Getting Started Is Easy! To start using PacificSource InTouch for Employers, simply visit, PacificSource.com and click "Employers." Then click the "Register Now" link, which you'll find under the InTouch login button in the right column. MEMBERS - I PROVIDERS I AGENTS I CAREERS InTouch for Employers Access your PaclflLSoufce account Information I i 24x7 I4 (fI Once your registration is processed, you will receive an email message indicating that your new user ID has been activated. If you need to add access for additional staff members, you can log in and add them yourself (in the Group Administrator role), or we can help with the setup. continued on reverse 6 PacificSource -AL1' PLANS Questions and Answers Can I change my password? Yes, you may change your password at any time. From your InTouch home page, click "Account" in the top menu, and then click the "Change Password" link. What happens if I forget my password? If that happens, you can click the "Forgot My Password" link on the login page. You will be prompted to answer two hint questions and can then select a new password. Can 1 access multiple group accounts without having to log in and out? Yes.You can administer all of your groups and their subgroups through a single login. When you first log in, you'll be able to select from a list of your groups. Once you are logged in, you'll see the current group name on the green button near the top of the page. When you're ready to work with a different group, simply click on this green button to pull ....... "'.................................. down a list of your available groups.There's no need to log in and out. Why can't I access all of our group accounts? If you are not able to access one of your groups, it may mean that your InTouch "Group Administrator" has not yet granted you that permission.Your InTouch Group Administrator is the primary user and has access to all of your group or subgroup accounts. In this role, they can grant other staff members, "Users;" full or limited access. What if I have questions or comments? To start using PacificSource In Touch for Employers, simply visit, PacificSource, com and click "Employers." Then click the "Register Now" link, which you'll find under the InTouch login button in the right column. If you have questions or comments about InTouch, you may contactthe InTouch for EmployersTeam:...................................................................................................................................... • Call (800) 624-6052, ext. 3742 • Email intouchforemployers@pacificsource.com In addition, you are welcome to contact your Membership Services Representative. Your Representative's contact information appears on your InTouch Contact Us page and on your monthly billing statement. Or you can reach us by phone toll-free at (866) 999-5583 to be connected to the appropriate person. Paci f icsource Helena: 406.422.1008 • 855.422.1008 PacificSource.com PacificSource PacificSource Preventive Drug List The Preventive Drug List is included in our individual and small group plans*, and is an optional benefit for large groups. With this new benefit, the drugs listed below are paid at 100 percent. A full list of covered drugs can be found on our website at PacificSource.com/drug-list. Show your PacificSource ID card each time you purchase prescriptions at a participating pharmacy to ensure you're receiving the bestbenefit. If you have questions, please email our Customer Service Department at cs@pacificsource.com, or call toll-free: (800) 688-5008 in Idaho, (877) 590-1596 in Montana, or (888) 977-9299 in Oregon. Heart/Blood Pressure acebutolol HCL isradipine amiloride-HCTZ labetalol HCL amlodipine besylate lisinopril amlodipine besylate- benazepril lisinopril -HCTZ atenolol losartan potassium atenolol- chlorthalidone losartan -HCTZ benazepril HCL methyclothiazide benazepril HCTZ metolazone bisoprolol fumarate metoprolol tartrate bisoprolol -HCTZ metoprolol -HCTZ bumetanide moexipril-HCL captopril nadolol chlorothiazide nicardipine HCL chlorthalidone nifedipine ER clonidine HCL pindolol diltiazem ER propranolol HCL diltiazem HCL propranolol -HCTZ enalapril maleate quinapril HCL enalapril -HCTZ spironolactone felodiprine ER spironolactone -HCTZ fosinopril sodium torsemide fosinopril -HCTZ trandolapril furosemide triamterene -HCTZ guanfacine HCL valsartan-HCTZ hydrochlorothiazide verapamil ER indapamide verapamil ER PM irbesartan irbesartan-HCTZ verapamil HCL *Except for the Oregon Standard Bronze, Silver, or Gold plans. Bone Health alendronate sodium ibandronate sodium Cholesterol atorvastatin calcium pravastatin sodium lovastatin _ ___simvastatin Diabetes glimepiride glipizide -metformin glipizide glyburide glipizide ER metformin HCL glipizide XL metformin HCL ER Mental Health bupropion HCL olanzapine carbamazepine olanzapine ODT citalopram HBR olanzapine -fluoxetine HCL fluoxetine HCL paroxetine HCL imipramine HCL quetiapine fumarate imipramine pamoate risperidone lithium carbonate sertraline HCL nortriptyline HCL venlafaxine HCL Preventive Drug List 0916 Updated September 12, 2016 OnlineTools and Resources at PacificSource.com InTouch for Members Members can access their benefit information by logging on to the secure InTouch area of our website.They can view their claims, the status of preauthorizations and referrals, the accumulated expenses towards their plan's deductible, and more. Health Manager Health Manager is an online health and wellness center available through InTouch. Powered byWebMD®, it includes personalized wellness information and a variety of helpful, easy-to-use online tools including a health risk assessment. myPacificSource Mobile App Members can stay "InTouch" with their PacificSource coverage, no matter where they are, with our free mobile app.The myPacificSource app is available for both iPhone°i and Android' Visit PacificSource.com/mobile. WebMD Daily Victorys" Mobile App The Daily Victory mobile app helps beginners form a sustainable exercise habit, starting with as little as five minutes a day. Log in authentication and progress tracking is accessible through the Health Manager. Provider Directory Members can find up-to-date participating provider information based on their location or the provider's name. Members can also make a personalized directory. Wellness and Care Management Programs 24 -Hour NurseLine Most medical situations don't happen during business hours. Our 24 - Hour NurseLine is staffed around the clock, 7 days a week, so members will never be without a registered nurse to talk to if they have health- related questions.The member toll-free number is (855) 834-6150. Prenatal Care Program Our Prenatal Care Program helps expectant mothers learn more about their pregnancy and the development of their child. Participants receive educational materials and toll-free telephone access to a nurse consultant. High-risk members receive additional proactive nurse support. ValueAdded_salesMT0914 Prenatal Vitamins Pregnant members with pharmacy coverage are eligible to receive up to nine months of physician - prescribed prenatal vitamin supplements at no cost (all copays and deductibles are waived).This program covers two generic prenatal vitamins, which are only available through Wellpartner mail order pharmacy. Tobacco Cessation Our Quit For Life° program, brought to you by Alere Wellbeing and the American Cancer Society, can help tobacco users kick the habit. Members receive phone and online support, as well as a Quit Kit with nicotine replacement therapy patches or gum to help keep them on track. (bupropion, bupropion SR, or Chantix are doctor prescribed.) Member toll-free number: (866) 784-8454. Hospital -Based Education Classes Members can receive a reimbursement of up to $50 per eligible health and wellness class or series offered by hospitals, and up to $150 per member per plan year. Weight Management Programs Members with medical coverage can: • Participate in a Weight WatchersO program and receive an annual reimbursement of $100 ($40 if an online Weight Watchers participant) for their Weight Watchers membership. • Choose a Jenny Craig® program discount: free 30 -day trial with Jenny As You Go, or 30 percent off the enrollment fee with Jenny All Access. For full details and eligibility requirements, visit the Members > Extras and Wellness area of PacificSource.com. continued on reverse eD�) Pacif icSounrc HEALTH PLANS } Discounted Gym Membership PacificSource members have access to discounted gym memberships of up to $120 per year through GlobalFit. Brown Bag Wellness Seminars We offer Brown Bag Wellness Seminars tailored to the specific wellness interests of employers with 100 or more employees. These informational seminars for employees are held at the worksite or other convenient locations. Wellness for Kids Nine- and six -year-olds currently covered by a PacificSource medical plan may be invited by mail to join HealthKicks!, a children's program that promotes healthy behaviors. Parents will receive an invitation to enroll their child in HealthKicks! If enrolled, children will receive age-appropriate, fun activity books on health and wellness topics to encourage healthy habits. Contact us for more information. Condition Support Program Our Condition Support Program offers support and information to members with asthma and diabetes (including members age 18 and younger), heart failure (HF), chronic obstructive pulmonary disease (COPD), and coronary artery disease (CAD). The program includes personal support to help participants reach their health and wellness goals; ongoing support to help them maintain healthy lifestyle changes; and newsletters with current and helpful information about their health condition. Participants may also contact our nurses and registered dietitian via email or toll-free phone number to ask — ?y health questions. AccordantCar& Rare Disease Management Program Our members with certain chronic, rare conditions receive ongoing one-on-one support and care coordination to ensure optimal care, decrease complications, and improve health outcomes. Caremark' Specialty Pharmacy Caremark® Specialty Pharmacy Services is our provider for injectable medications and biotech drugs. A pharmacist -led CareTeam provides individual follow-up care and support to our members with certain conditions. Nurse Case Management Our Health Services Department provides individual case management for members who require specific help in managing their healthcare needs. Nurse Case Managers work collaboratively with providers and members to improve members' health, financial outcomes, and quality of life. LifeTracs-Transplant Network We partner with LifeTracTransplant Network to ensure that our members requiring transplant services have access to nationally recognized centers of excellence. Our Case Managers assist members by coordinating all phases of transplant services. Serving clients since 1988, LifeTrac is a national network of more than 50 carefully selected facilities that perform organ and bone marrow transplants— one of the most comprehensive networks in the United States. Travel Program Assist America® Global Emergency Services Members with medical coverage who experience a medical emergency when traveling 100 or more miles from home or abroad can call Assist America for help. Services include medical consultation and evaluation, medical referrals, foreign hospital admission guarantee, critical care monitoring, and when medically necessary, evacuation to a facility that can provide treatment.These services are provided at no cost to members when arranged and provided by Assist America. Member toll-free number within the United States: (800) 872- 1414; from outside the United States: 00-1-(609) 986-1234. Please note: These value-added programs are not available with all plans. Check with your PacificSource Sales Representative for details. Questions? You're welcome to contact your PacificSource Sales Representative for more information about any of these value-added programs. 16 Pace f icSource HEALTH PLANS Helena: 406.422.1008 • 855.422.1008 PacificSource.com O TELADOC,. C Paci f icSource HEALTH PLANS You have access to a doctor 24 hours, 7 days a week with Teladoco. You already have access to Teladoc and you can talk to a doctor now for or less. Set up your account by web, phone or mobile app. SET UP YOUR ACCOUNT IN 3 EASY STEPS Contact Teladoc 24/7/365 Access to Teladoc's nationwide network of board-certified doctors is available to you by phone, video or mobile app. Teladoc isjust a click or call away! Talk with a physician A doctor will review your medical history and contact you in minutes. Resolve the issue Adoctor will diagnose and prescribe medication, if medically necessary, to the pharmacy of your choice. Teladoc.comAvailable on 1-855-201-7488 ' • p • Phone- 6970(17 )01 /I Ludo[ I- X r 11115 rpstrvlvl Comnv4e 61c'o nim al 1 L'adoc Corn A—o..I No Aon.L oW an, vadMr OI Anp:o DK rclq stood n PW US and ollMt C-11— Ami St ---co Ina, W Ann n Vic Healthcare via phone, video, or mobile app As a PacificSource mernber, you have access to a U.S. board-certified doctor 24 hours a day, 7 days a week, year-round with Teladoc. Here's how to get started and what you need to know. 1. Set up your account Talk to a There are three convenient ways to get started. When asked to doctor anytime! enter the name of your employer or insurance carrier, please enter PacificSource. Teladoc.com Online: Log in or register with InTouch for Members through PacificSource.com. You'll find the Teladoc Remote link under Tools. (855) 201-7488 This will provide a direct link for you to set up your Teladoc account. Mobile app: Download the app and click "Activate account" Visit Teladoc.com/mobile to download the app. Teladoc.com/mobile By phone: Teladoc can help you register your account over the phone. Call toll-free (855) 201-7488. 2. Provide medical history Your medical history provides Teladoc doctors with the information EE_ I they need to make an accurate diagnosis. 3. Request a consult Once your account is set up, request a consult anytime you need care. And talk to a doctor by phone, web, or mobile app. See reverse for FAQ. PacificSource HEALTH PLANS Teladoc° Member Frequently Asked Questions What is Teladoc? you have anonymous call blocker on, you will be returned Teladoc is the first and largest provider of telehealth to the bottom of the waiting list. The consult request is medical consults in the United States, giving you 24/7/365 cancelled if you miss three calls. access to quality medical care through phone and video consults. Is there a time limit when talking with a doctor? Who are the Teladoc doctors? Teladoc doctors are U.S. board certified in internal medicine, family practice, or pediatrics. They average 20 years practice experience, are licensed in your state, and incorporate Teladoc into their day-to-day practice as a way to provide people with convenient access to quality medical care. Does Teladoc replace my doctor? No. Teladoc does not replace your primary care physician. Teladoc should be used when you need immediate care for nonemergent medical issues. It is an affordable, convenient alternative to urgent care and ER visits. What kind of medical care does Teladoc provide? Teladoc provides general medical care for adults and children, and behavioral healthcare for adults. Examples of common medical conditions Teladoc can address include: sinus problems, pink eye, bronchitis, allergies, flu, ear infection, urinary tract infections, and upper respiratory infections. What consult methods are available? You can talk with a Teladoc doctor via a phone consult, video consult within the secure member portal, or video consult within the Teladoc mobile app. How do I set up my Teladoc account? You can set up your account through InTouch at PacificSource.com, or through the Teladoc website or mobile app. You can also call Teladoc to get started. If setting up your account online, when asked to enter the name of your employer or insurance carrier, please make sure to enter PacificSource. How do I request a consult to talk to a doctor? Visit the Teladoc website, log into your account, and click "Request a Consult." You can also call Teladoc to request a consult by phone. How quickly can I talk to the doctor? Median call back time is just 10 minutes. If you miss the doctor's call, whether you are away from the phone or There is no time limit for consults. Can Teladoc doctors write a prescription? Yes. Teladoc doctors can prescribe short-term medication for a wide range of conditions when medically appropriate. Teladoc doctors do not prescribe substances controlled by the DEA, nontherapeutic, and/or certain other drugs, which may be harmful because of their potential abuse. How do I pay for a prescription called in by Teladoc? When you go to your pharmacy of choice to pick up the prescription, you may use your health/prescription insurance card to help pay for the medication. You will be responsible for the co -pay based on the type of medication and your plan benefits. Is the consult fee the same price, regardless of the time? The exact amount you will pay is based on your plan design. This dollar amount is shown on your summary of benefits. How do I pay for the consult? You can pay with your HSA (health savings account) card, credit card, prepaid debit card, or by PayPal. If the Teladoc doctor recommends that I see my primary care physician or a specialist, do I still have to pay the Teladoc consult fee? Yes. Just like any doctor appointment, you must pay for the consulting doctor's time. Can I provide consult information to my doctor? Yes. You have access to your electronic medical record at anytime. Download a copy online from your account or call Teladoc and ask to have your medical record mailed or faxed to you. C PacificSource HEALTH PLANS The ActiveUlt Dired' The ACtiveUlt Direct program provides you with access to a broad network of participating fitness centers and participating YMCAs. Freedom and flexibility Active&Fit Direct program gives you access to 9,000+ fitness centers nationwide. You can switch fitness centers to ensure you find the right fit. The program also includes access to the Active&Fit Direct website, which features a fitness center locator and online fitness tracking. Get started Visit PacificSource.com/ActiveAndFit for more information. A $25 enrollment fee, $25 for the current month (regardless of the enrollment date within that month), and $25 plus applicable taxes for the next month are due when you enroll ($75 plus applicable taxes). Each month's fee is $25 (plus applicable taxes). After a 3 -month commitment, participation is month-to- month. Once enrolled, you may view or print your fitness card and take it to any fitness center/YMCA in the Active&Fit Direct network. Once the fitness center verifies your enrollment in the Active&Fit Direct program, you will sign a standard membership agreement and receive a card or key tag frorn the fitness center to check in for future visits. Try out a fitness center Many fitness centers/YMCAs offer guest passes so you can try out their location. You may request a guest -pass letter through the Active&Fit Direct website to take to the fitness center, where available. Note: You will need to register and sign in to request the guest -pass letter. The Active&Fit Direct program is provided by American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH). Active&Fit Direct is a trademark of ASH and used with permission here. Direct: (208) 333-1596 Toll-free: (800) 688-5008 Direct: (406) 442-6589 Toll-free: (877) 590-1596 Direct: (541) 684-5582 Toll-free: (888) 977-9299 Toll-free: (800) 735-2900 Direct: (541) 684-5456 Toll-free: (800) 624-6052 ext. 1009 cs@pacificsource.com C Paci f idource HEALTH PLANS CL <F-70 Z< 0 U -JO • Q) L,n • 4-J > 0 0 u Ln (n CU Q) 4- -E 0 CY) D c .0 V) C) M CL Lm > V) 0 AM= 00 4-) -q u 0 0 - 4• 4-J :3 U Q) < -0 • (3) 4-J 03 6- VA DL iii 4-J o 2 4- ro rr z c6L o -0 c 0 5; C CL o 0 CL 0 > 0 4� V) 0 -0 41 0 c o m U > -C cl 0 a) 0 S- co CL O E o ca U 0 o 0 CL E -o (U CL (U C ' 5 0 0 0 cu 40- MU C 0 4-;' co 0- W cu 4- 0- 4� = L- W ru CL U L 0 C cu CL 4� 0 r_ C: cu -0 a) E -0 a) 0 E lV W 0 E u cu c CU cu -0 E a) = cu ao oo o E Ccu V) 0 < 0) u -o 1 5, E L- a) cu a) CL o- -a �: cL E cL E tn m a) CU :3 0- E -6 0 (U 00 4� 6 :3 V 4- 4- w 4. -0 V) M 0 W C: 0 -0 0 o ru u aj 4-0 0 u to E > U , C: a) cu Ul) z 0 F— CL 2 D L/) 0 CL 0 0 o vCU Q) Ln 4' c c bD o -Fo w cL cu > 40 to -0 o — =$ u -T- C- 0) 0 C — (1) Q) L- 4- G) = a) c tto 0 V) 0 4� CL C: o L) 0 0 -a 0 = 0 4- 0 a) u CL (1) 2 (1) -0 Q) 41 CU 0 - b -0 r " 4� D 0 0 m m > -a E 0 w 0 q° w >. 0 0 E 40- fq V) 0 0- 74M QV)j tn -.01 0 C) Co 4- 0 V a C: (U 0 4_ -C a") CU Q) 0 co c - *C: CL m Z -0 0) c C- 0 E Ll -c u s- , cu 0) 4-j o u CL o > 0) o 4- o E 0 0 0 0 0--o U -0 (U c 0) a) 4� 4� E cu Lo- _0 c m >- 0 0- aA v o w 0 CL 4- r- 4- E o a- ca V) -a zr � CL m V� D UD ru u w r3 c E c: -Fa u 0 a Q) 4� 4� C: -0 a-+0 m 0 4-J a) v) 4� .- 4� tu > 0 U a cu ;Z -- o CL cn E m >� 0 41 a. 0- 0 o 4-J Q) < u E U -0 0) ?, 0 fu u U Q) cu 0 0 " -0 — , 4� -0 4� 0 0 -Fu Q) -C -0 4� E -a :E -0 4� 4� V) 41 C: = C: m oa E 0 M to — 'U a) O° 0 Q. 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