Oklahoma City Firefighters Health & Welfare VEBA...

1

Oklahoma City Firefighters Health & Welfare VEBA Trust

2 MyOKCFFBenefits.com

Table of Contents

2019 Benefits Enrollment

Table of Contents ............................................... 2 Introduction ........................................................ 3 Eligibility Information ........................................... 4 How to Enroll in Benefits .................................... 5

Benefit Plans

Medical Plan Comparisons (Actives) .................... 6 Medical Plan Comparisons (Retirees) .................. 7 Kempton Premier Providers .................................. 8 1.800 MD TeleMedicine ......................................... 9 Delta Dental Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 VSP Vision Plan ................................................. 11 Hartford Basic Life Insurance ............................ 12 Hartford Voluntary Life Insurance ..................... 13 Central United Cancer Plan ............................... 14 Central United Accident Plan ............................. 16 Cincinnati Life Voluntary Insurance .................. 19 Cigna Lump Sum Heart/Stroke Plan ......................... 20 Cigna Lump Sum Cancer Plan ........................... 21 Rates .................................................................. 22

Required Notices HIPAA Notice of Privacy Policy & Procedure .......... 26 Woman’s & Dependent Health Rights ..................... 28 Newborns’ and Mother’s Health Protection Act....... 28 Michelle’s Law ........................................................ 28 The Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA ............................................ 29

GINA Warning Against Providing Genetic Information .................................................................... 29

Patient Protection Model Disclosure ...................... 29 Notice of Special Enrollment Rights ......................... 29 CHIPRA Special Enrollment Provision –

Premium Assistance Eligibility ............................ 30 Wellness Program Disclosure ................................... 30 Notice of Availability of Summary of Benefits and Coverages (SBC) ............................................. 30

Medicare Part D Prescription Drug ........................... 31 Benefit Resource Directory ....................................... 33 Notes ......................................................................... 34

The Health Insurance Portability and Accountability Act (HIPAA) requires that your health insurance plan limit the release of your health information to the minimum necessary required for your care. If you have questions about your claims, contact your insurance carrier first. If, after contacting the insurance carrier, you need a representative of the Employee Benefits Division to assist you with any claim issues, you may be required to provide written authorization to release information related to your claim. OKCFF advises you that the HIPAA Privacy Notice is available at www.MyOKCFFBenefits.com

Every reasonable effort has been made for the information provided in this booklet to be accurate. It is intended to provide the employees of OKCFF an overview of the coverages offered. It is in no way a guarantee or offer of coverage. Each carrier has the ability to underwrite based on its contract with OKCFF or its employees. Each carrier’s contract, underwriting and policies will supersede this document. Please be aware that each carrier may have exclusions or limitations and you must consult your summary plan description and / or policies for details.

http://www.myokcffbenefits.com/

MyOKCFFBenefits.com 3

Oklahoma City Fire Fighters

Dear Firefighter, Oklahoma City Fire Fighters Health & Welfare VEBA Trust has put together the following guide to help you understand the benefits offered in 2019. We recognize the importance of benefits for you and your family, which is why we took the time to carefully select providers who offer quality benefits for 2019.

We encourage you to review the following Benefit Guide prior to completing enrollment and refer to it often for benefits questions. This Benefit Guide is one of the tools available to help you through the enrollment process. Everyone will use the secure Benefits Portal on MyOKCFFBenefits.com for benefits enrollment, and we’ve made it easy for you. The system will guide you step-by-step through the enrollment process. Thank you in advance for taking the time to review this benefit guide. If you have any questions regarding the benefits outlined in this guide or your current benefits, please contact Patti Bolin at (405) 232-9543 or via email at [email protected], Monday - Thursday, 8 a.m. - 5 p.m. CST.

Your 2019 Benefit Offerings

• BCBS Preferred PPO Plan • BCBS HCA Plan (HRA) • BCBS Choice PPO Plan • BCBS Medicare Advantage Plan • BCBS Medicare Supplement Plan F • Delta Dental Plans (2 options) • VSP Voluntary Vision Plan

• The Hartford Basic Life • The Hartford Supplemental Life • Cincinnati Life Voluntary Term Life • Central United Cancer Plan • Central United Personal Accident Plan • Cigna Lump Sum Cancer Plan • Cigna Lump Sum Heart / Stroke Plan

Additional Benefits offered through the City of Oklahoma City for Active Employees In addition to the benefits offered by the Firefighters Health and Welfare Trust, you have benefits provided by the City of Oklahoma City. These benefits include: Long Term Disability, Health & Dependent Care Flexible Spending Accounts, Employee Assistance Program, Vision and American Fidelity Accident, Cancer and Individual Term Life plans. The Oklahoma City’s Employee Benefits Office is available to answer questions about these plans at 405.297.2144 or email at [email protected].

mailto:[email protected]



Plan Eligibility

Eligibility is determined by the requirements stated in the appropriate plan document or insurance policy for the year in question. Since the plans are subject to change, eligibility may also change. If you change coverage from one plan to another, you and your dependent(s) must meet the requirements of the new plan selected.

Eligibility

Employees and their eligible dependents are eligible for Oklahoma City Fire Fighters Health & Welfare VEBA Trust's benefits on the First of the month following 30 days of employment. Eligible dependents include the employee's spouse and children (under age 26).

Adding Dependents

You must add all dependents to your enrollment that you intend to cover under any benefit. If you are adding dependents to your benefit plans outside of annual open enrollment or your new hire enrollment, you must provide the following verification documentations to The Local within 30 days of Qualifying Event.

Qualifying Life Events

Other than the annual Open Enrollment Period, you cannot make changes to your coverage during the year unless you experience a change in family status, such as:

1. Loss or gain of coverage through your spouse (Retirees cannot add spouse through a qualifying life event)

2. Loss of eligibility of a covered dependent 3. Death of your covered spouse or child 4. Birth or adoption of a child 5. Marriage, divorce, or legal separation

Dependent Required Documentation

Spouse Marriage License

Domestic Partner Domestic Partner Affidavit, Copy of Joint Tax Return or Bank Acct.

Natural Children Birth Certificate

Step Children Birth Certificate and Marriage License showing both parents’ names

Dependent Child(ren): Legal guardian, adopted or foster

Birth Certificate, Final Court Order of legal guardianship with judge’s signature and/or final adoption decree with judge’s signature

Eligibility Information


Step 1: Log in to:

MyOKCFFBenefits.com and click ENROLL First Time Login

Username: Up to the first six characters of your last name, first character of your first name, and the last four digits of your Social Security number (SSN) Password: Your full (nine-digit) SSN without dashes If you have already registered, you can login in by entering the username and password that you previously created during registration.

Step 2: Welcome Page Navigate to the Welcome page. Progress to the next step by selecting the “Get Started” button at the bottom of the page. Step 3: Personal Information Complete your personal information by adding your name, address, telephone number and e-mail address as indicated. Step 4: Emergency Contact Information Add an emergency contact by completing the name, telephone number, relationship and email address in the appropriate sections, and click save. Step 5: Dependent and Beneficiary Information Select the appropriate blue button to add both dependent and beneficiary information to your account. Step 6: Elect Your Coverages After making your selections, be sure to thoroughly review your dependent elections and then click “Submit” to enroll in benefits.

How to Enroll in Benefits


Medical Plan Comparisons

Your Medical Benefit Summary

ACTIVE EMPLOYEES Blue Preferred PPO

Blue Choice HCA

Blue Choice PPO

Deductible $0 / $25,000

$2,000 / $3,000 *

$250 / $300 Individual (In-Network / Out of Network)

Family (In-Network / Out of Network) $0 / $50,000 $4,000 / $6,000 * $500 / $900

Out of Pocket Maximum

$2,000 / $50,000

$3,000 / $6,000

$5,100 / Unlimited Individual (In-Network / Out of Network)

Family (In-Network / Out of Network) $4,000 / $100,000 $6,000 / $8,000 $10,200 / Unlimited

Coinsurance (In-Network / Out of Network) 100% / 70% 80% / 60% 90% / 70%

Office Visits / Services Primary Care Physician Specialist

$20 copay

$20 copay

Deductible + Coinsurance

$15 copay

$15 copay

Emergency Room $75 copay Deductible + Coinsurance

$50 copay then Deductible + Coinsurance

Retail Prescription Drug Benefit

Deductible N/A N/A N/A

Generic $15 $10 $15

Preferred Brand $45 $30 $30

Non-Preferred Bran $75 $50 $30

Specialty $150 $50 $30

Monthly Wellness Rates** per pay period

Employee Only $66.43 $24.83 $75.57

Employee + Spouse $117.74 $86.41 $135.00

Employee + Child(ren) $104.56 $77.44 $119.65

Employee + Family $258.14 $147.29 $252.15

* VEBA pays the first $1,000 toward Individual Deductible and the first $2,000 toward the Family Deductible.

** Non-Wellness Rates ADD $12.50 per pay period

NOTE: This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater details. Should there be a difference between this summary and the contract, the contract will govern.


Medical Plan Comparisons

Your Medical Benefit Summary

RETIREES Blue Preferred PPO Blue Choice HCA Blue Choice PPO

Deductible

$2,000 / $3,000 *

$250 / $300 Individual (In-Network / Out of Network) $0 / $25,000

Family (In-Network / Out of Network) $0 / $50,000 $4,000 / $6,000 * $500 / $900

Out of Pocket Maximum

$3,000 / $6,000

$5,100 / Unlimited Individual (In-Network / Out of Network) $2,000 / $50,000

Family (In-Network / Out of Network) $4,000 / $100,000 $6,000 / $8,000 $10,200 / Unlimited

Coinsurance (In-Network / Out of Network) 100% / 70% 80% / 60% 90% / 70%

Office Visits / Services

Primary Care Physician

Specialist

$20 copay

$20 copay

Deductible + Coinsurance

$15 copay

$15 copay

Emergency Room $75 copay Deductible +

Coinsurance

$50 copay then Deductible + Coinsurance

Retail Prescription Drug Benefit

Deductible N/A N/A N/A

Generic $15 $10 $15

Preferred Brand $45 $30 $30

Non-Preferred Bran $75 $50 $30

Specialty $150 $50 $30

Monthly Wellness Rates** per month

Employee Only $463.85 $378.52 $463.01

Employee + Spouse $952.97 $765.70 $941.19

Employee + Child(ren) $827.33 $665.72 $817.71

Employee + Family $1,559.26 $1,250.09 $1,539.41

* VEBA pays the first $1,000 toward Individual Deductible and the first $2,000 toward the Family Deductible.

** Non-Wellness Rates ADD $25 per month

NOTE: This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describe the benefits in greater details. Should there be a difference between this summary and the contract, the contract will govern.


Kempton Premier Providers


1.800MD TeleMedicine


Dental Plans

Your dental benefits program allows payment for eligible services performed by any properly licensed dentist. However, maximum savings and lower out-of-pocket expenses are achieved when treatment is provided by a Delta Dental participating dentist.


Your Dental Benefit Summary Low Plan

Delta Dental PPO High Plan

Delta Dental Plus Premier

Network Benefits

Non-Network Benefits

PPO Network Benefits

Premier Network Benefits

Non-Network Benefits

General Provisions Calendar Year Deductible $50 Individual $50 Individual $150 Family $150 Family Calendar Year Maximum per Participant $1,500 $2,000

CLASS I Services

100%

Diagnostic and Preventive Care Benefits

100% 100% 100% 100%

Deductible Waived Oral Examinations (twice in 12 consecutive

months) Prophylaxis (twice in 12 consecutive months) Fluoride Treatments Dental X-rays Sealants Space Maintainers

CLASS II Services

80% 80% 90% 90% 90%

Restorative Services Amalgam and composite fillings Stainless steel restorations (crowns)

Oral Surgery Services

Endodontic Services Pulpal therapy Root canal treatment

Periodontic Services

Treatment of diseases of the gum and supporting structures of the teeth (excluding periodontal maintenance that is paid in Class I)

CLASS III Services

50% 50% 60% 60% 60%

Major Restorative Services Porcelain or cast restorations

Prosthodontic Services Bridges Crowns/Inlays/Onlays Construction of a fixed partial denture Removable partial dentures Complete dentures Implants Including adjustments or repair of existing prosthodontic devices

CLASS IV Services - Orthodontic Benefits 50% 50% 50% 50% 50% Eligible Dependent Children under age 26 Lifetime Maximum per Participant $1,500 $1,500


Voluntary Vision Plan

Your VSP Vision Benefit Summary

• High Quality Vision Care. You’ll get the best care from a VSP provider, including a WellVision Exam, the most comprehensive exam designed to detect eye and health conditions.

• Choice of Providers. The decision is yours to make. Choose a VSP doctor, a participating retail chain, or any out-of-network provider.

• Great Eyewear. It’s easy to find the perfect frame at a price that fits your budget.

Save with VSP Coverage Without VSP

Coverage With VSP Coverage

Eye-Exam $163 $10 Frame Single Vision Lenses

$150 $ 90

$25

Photochromic Adaptive Lenses $109 $70 Anti-Reflective Coating $113 $69 Member-Only Annual Contribution N/A $65.40 Total $625 $239.40

Average Annual Savings with a VSP Provider: $385.60

Get up to $110 back Members can save big with VSP exclusive mail-in rebates on eligible popular contact lens brands from Bausch + Lomb and CooperVision.

$500 savings on LASIK Members can save up to $500 on LASIK at NVision Eye Centers and TLC Laser Eye Centers.

Save up to $2,500 With Exclusive Member Extras, members can save more than $2,500 with special offers and rebates through VSP and other leading industry partners.

Co-Pays

Exam $10

Materials $25

Contact Lens Fitting $60

(standard & specialty)

Services / Frequency

Exam 12 months

Frame 24 months

Contact Lens Fitting 12 months

Lenses & Contact Lenses

12 months

Benefit Description Copay Frequency

Your Coverage with a VSP Provider


Basic Life Insurance

Your Basic Life Insurance Summary

Oklahoma City Fire Fighters provides basic life insurance to help protect the employee’s family in the event of a death. The employee is also eligible to purchase additional life insurance for himself / herself, and dependent life insurance for a spouse and/or dependent children.

The Hartford is OKCFF’s administrator for Group Term Life insurance plan benefits.

Eligible Classes for Coverage All Full-Time Active Employees who are citizens or legal residents of the United Sates, its territories and protectorates, excluding temporary, leased or seasonal Employees.

Class 1 All Full-Time Active Members of Local 157 Oklahoma City Fire Fighters

Class 2 All Retirees on or after 1/1/03 who were members of Local 157 Oklahoma City Fire Fighters

Full-Time Employment Eligible members must work at least 32 hours weekly

Eligibility Waiting Period for Coverage The first day of the month following the date you were hired.

Employee Benefit OKCFF provides $15,000 in basic life insurance at no additional cost.

Retiree Benefit OKCFF provides $10,000 in basic life insurance at no additional cost.

Benefit Reduction Life Insurance Benefits will be reduced by the percentage indicated in the table below. This reduction will be effective on the date you attain ages shown below. The reduction will apply to the Amount of Life Insurance in force immediately prior to the Anniversary Date.

Reductions also apply if: 1. You become covered under The Policy; or 2. Your coverage increases on or after the date you attain age 65.


Your Age % Reduction

65 35%

70 55%

75 70%

80 80%


Supplemental Term Life

Your Supplemental Life Insurance Summary

Oklahoma City Fire Fighters offers you the ability to purchase additional supplemental life insurance for you and your spouse, offered through The Hartford.

Eligible Classes for Coverage All Full-Time Active Employees who are citizens or legal residents of the United Sates, its territories and protectorates, excluding temporary, leased or seasonal Employees.

Eligibility Waiting Period for Coverage The first day of the month following the date you were hired.

Class 1 All Full-Time Active Members of Local 157 Oklahoma City Fire Fighters

Class 2 All Retirees on or after 1/1/03 who were members of

Local 157 Oklahoma City Fire Fighters

Supplemental Dependent Life Insurance Class 1 All Full-time Active Members of Local 157

Oklahoma City Fire Fighters choosing Dependent Option 1

Class 2 All Retirees of Local 157 Oklahoma City Fire

Fighters choosing Dependent Option 1 Class 3 All Full-time Active Members of Local 157

Oklahoma City Fire Fighters choosing Dependent Option 2


Fighters choosing Dependent Option 2

Class 5 All Full-time Active Members of Local 157 Oklahoma City Fire Fighters choosing Dependent Option 3


Fighters choosing Dependent Option 3

Class 1: Active Employees

Guaranteed Issue Amount: The amount you elect in increments of $10,000, subject to a maximum of $50,000 and a minimum of $10,000.

Maximum A m o u n t : The amount you elect in increments of $10,000, subject to a maximum of $100,000 and a minimum of $10,000.

Class 2: Retirees Maximum Amount: 50% of the Supplemental Amount of Life Insurance You had as an Active Employee, not to exceed a maximum of $25,000.

Supplemental Amount of Dependent Life Insurance

Option 1:

Spouse Maximum Amount

$15,000 Dependent Children: Age 14 $1,000 day(s) but under age 6 month(s) Dependent Children: Age 6 $5,000 month(s) but under age 21 year(s)

Option 2:



Option 3:



Your Age Your Spouse % Reduction

65 35% 35%

70 55% 55%

75 70% 70%

80 80% 80%

Benefit Reduction The amount of Spouse Supplemental coverage may never exceed 100% of the Supplemental Amount of Life Insurance in force for the Employee



BENEFIT PACKAGE OPTIONS Low Plan High Plan

Immunotherapy, Radiation, Chemotherapy Pays actual charges, maximum $5,000 per month

Pays actual charges, maximum $10,000 per month

Cancer Screening Test Pays $50 per calendar year

Pays $100 per calendar year

First Occurrence Benefit (Rider) Pays $2,500 Pays $10,000

Daily Hospital Confinement Benefit Pays $150 per day

Pays $300 per day

Surgical Benefit Pays maximum per surgery

$3,000

Pays maximum per surgery

$4,000

HOSPITAL AND OTHER FACILITY BENEFITS

Prescribed Drugs and Medications Actual charges up to maximum of 20% of the Daily Hospital Confinement Benefit

Physician's Attendance $50 per day

Ambulance $250 per trip 3 trips per year

Private Duty Nurse Service $150 per day

Extended Benefits $1,000 per day

Government or Charity Hospital $200 per day

Extended Care Facility $100 for each day confined to a maximum of 70 days

Hospice Care $100 per day

TRANSPORTATION BENEFITS

Transportation and Lodging for Bone Marrow Donors Actual charges to $2,500 for medical expenses related to transplant. Actual charges for round trip coach fare on common carrier or personal auto allowance of $0.50 per mile max 700 miles. Actual charges to $75 per day lodging and meal expense.

Transportation for Non-Local Treatment Requiring Hospital Confinement

Actual charges for round trip coach fare on common carrier or personal auto allowance of $0.50 per mile max 700 miles.

Transportation and Lodging for Non-Local Treatment Not Requiring Hospital Confinement

Actual charges for round trip coach fare on common carrier or personal auto allowance of $0.50 per mile max 700 miles. Maximum of $1,500 per calendar year.

Adult Companion Transportation and Lodging Actual charges for one adult companion to be near a covered person who is hospital confined in a non-local hospital. Max of $2,500 per confinement. Actual charges to $50 per day for lodging. Actual charges for round trip coach fare on common carrier or personal auto allowance of $0.50 per mile max 700 miles.

Cancer Care Plus Your Cancer Care Plus Benefits Summary


SURGICAL BENEFITS

Anesthesia Pays 25% of the surgical benefit amount

Additional Surgical Opinions $200 each opinion

Artificial Limb and Prosthesis Actual charges up to $1,500

Outpatient Surgery Benefit Pays $375 per operation for drugs, medicines and lab tests Pays a maximum of 150% of surgery shown in surgical

schedule

Skin Cancer Pays $150 per calendar year. Maximum benefit of $600

Breast Reconstruction / Breast Prosthesis Pays actual charges. Except in OK, lifetime maximum of $5,000

Bone Marrow Transplant for Cancer Pays actual charges, lifetime maximum of $10,000. Surgical Benefits

OTHER BENEFITS

Experimental Treatment Pays actual charges, to a lifetime maximum of $10,000

Physical, Occupational or Speech Therapy $50 each session to a lifetime maximum of $1,500

Outpatient Positive Diagnostic Test $250 for a diagnostic test

Blood and Blood Plasma Pays actual charges, to a maximum of $5,000 per calendar year

Home Health Care Services Pays $60 per day at home services, 180 days max per calendar year. Pays $150 per day at home private duty

nursing, 15 days max per calendar year. Pays $50 per day at home physician visits, 15 days max per calendar year.

Hairpiece Benefit Pays $100

Rental or Purchase of Durable Medical Equipment Pays actual charges, maximum $1,000 per calendar year.

Professional Mental Health Consultation $50 per session. Lifetime maximum of $250

Tutor $25 per 60 minute. Lifetime maximum of 50 sessions.

OPTIONAL RIDERS (AT ADDITIONAL COST)

Intensive Care Rider Benefit for Step Down Unit

Pays $600 per day Pays $300 per day

Critical Care Benefit Rider

Benefit For Heart Disease Benefit for Heart Attack / Stroke

Pays actual charges to a lifetime maximum of $2,500 Pays actual charges to a lifetime maximum of $5,000


Cancer Care Plus Your Cancer Care Plus Benefits Summary


Benefit Description One-Unit Two-Unit

Air Ambulance

Air transportation within 48 hours1. Once per Covered Accident.

$500

$500

Ambulance

Ground transportation within 90 days. Once per Covered Accident.

$100

$100

Accidental Death

Within 90 days1 of covered accident, and caused by resulting injury/ injuries.2

$25,000 Employee $10,000 Spouse3

$5,000 Child

$50,000 Employee $20,000 Spouse3

$10,000 Child

Accidental Death (Via Common Carrier)

Death must occur within 90 days1 of covered accident while fare-paying passenger on a common carrier (plane, bus, train).2

Accidental Benefit will be

doubled

Accidental Benefit will be

doubled

Emergency Room Treatment

Treatment sought within 72 hours1 of Covered Accident.

$200

$200

Hospital Admission

Confined within 180 days. Once per Covered Accident. (minimum of 20 hours)

$500

$1,000

Hospital Confinement

Confined within 180 days. Maximum of 90 days.

$100 per day

$200 per day

Hospital Intensive Care Unit

Within 30 days of Covered Accident. Maximum of 15 days.

$200 per day

$400 per day

Major Diagnostic Exams

Angiogram, CT and CTA scan; MRI, MRA or EEG as result of a Covered Accident.

$100 per calendar

year

$200 per calendar

year

Physician’s Office / Urgent Care

Within 60 days of Covered Accident. Once per Covered Accident.

$50

$50

Blood, Plasma & Platelets

Transfusion, administration, cross- matching, typing and processing required within 90 days of a Covered Accident. Once per Covered Accident.

$300 primary insured

$200 spouse3/dep child

$300 primary insured

$200 spouse3/dep child


Personal Accident Plan

Your 24 Hour Accident Benefits Summary


Benefit Description One-Unit Two-Unit Burn

Treated within 72 hours1 of a Covered Accident.

Once per Covered Accident.

*Spouse2 and Child

$375/150* for 2nd degree burns on at least 36% of the

body

$750/300* for 3rd degree burns on at least 1% but less

than 20% of the body

$5,000/2,000* for 3rd degree burns on 20% or more of the

body

$750/300* for 2nd degree burns on at least 36% of the

body

$1,500/600* for 3rd degree burns on at least 1% but less

than 20% of the body

$10,000/4,000* for 3rd degree burns on 20% or more of the

body

Emergency Dental Work

Once per Covered Accident regardless of teeth involved.

$150 repairs with crown $50 for extraction

$300 repairs with crown $100 for extraction

Dislocation (separated joint)

Diagnosed within 90 days, correction with anesthesia by Physician and corrected by Open (surgical) or Closed (non-surgical) reduction.

$50 - $2,000 (policy contains

complete schedule)

$100 - $4,000

(policy contains complete schedule)

Fracture (broken bone)

Fractures requiring Surgical or Non- Surgical reduction within 90 days of Covered Accident.

$25 - $2,500 (any Insured) (policy contains

complete schedule)

$50 - $5,000 (any Insured) (policy contains

complete schedule)

Gunshot Wounds

Unintentional wound requiring confinement within 24 hours and surgery within 72 hours after the injury. Primary insured only.

$500

$500

Laceration Lacerations requiring repair by a physician

within 72 hours of a Covered Accident.1 $50 - $400

based on length of lacerations, $100 - $800

based on length of lacerations,

Lodging Companion Lodging when Insured is

confined to a hospital more than 100 miles from home. Maximum of 30 days

$100 per night

$100 per night

Eye Injury Treated by a physician within 90 days of

Covered Accident. Must require surgery or removal of a foreign object.

$200

$200

Knee Cartilage - Torn

Treated by a physician within 60 days of Covered Accident. Must be repaired within 180 days.

$500 arthroscopic surgery

$100 for exploratory surgery

$1,000 arthroscopic surgery


Transportation

Round trip when hospital confined and distance is more than 100 miles round trip from residence. Three round trips per Covered Accident.

$300 round trip

$300 round trip

Surgery

Within 72 hours after a Covered Accident to repair internal injuries caused by the Covered Accident. Except in VA, hernia repair not covered. Once per Covered Accident.

$1,000 for thoracic, open abdominal


$1,000 for thoracic, open abdominal





Benefit Description Amount

Epidural Pain Management

Payable when a Covered Person is prescribed, receives and incurs a charge for an epidural administered for pain management in a hospital or a physician’s office for Off-the-Job Injuries sustained in a Covered Accident. This benefit is not payable for an epidural administered during a surgical procedure.

$100 paid no more than twice

per Covered Accident, per Covered Person.

Physical Therapy

Payable when a Covered Person receives emergency treatment for Off-the-Job Injuries sustained in a Covered Accident and later a physician advises the Covered Person to seek treatment from a licensed physical therapist. Physical therapy must be for Off-the- Job Injuries sustained in a Covered Accident and must start within 30 days of the Covered Accident or discharge from hospital. The treatment must take place within six months after the accident.

$35 per treatment per day, to a maximum of ten treatments per Covered Accident, per Covered

Person.

Rehabilitation Unit

Payable when a Covered Person is admitted for a Hospital Confinement and is transferred to a bed in a rehabilitation unit of a hospital for treatment of Off-the-Job Injuries sustained in a Covered Accident and a charge is incurred. The Rehabilitation Unit Benefit will not be payable for the same day(s) that the Accident Hospital Confinement Benefit is paid. The highest eligible benefit will be paid. No lifetime maximum.

$150 per day, limited to 30 days

for each Covered Person per period of Hospital Confinement and limited to a calendar year

maximum of 60 days.

Prosthesis

Payable when a Covered Person requires use of a prosthetic device as a result of Off-the-Job Injuries sustained in a Covered Accident. This benefit is not payable for repair or replacement of prosthetic devices, hearing aids, wigs, or dental aids, to include false teeth.

$750 once per Covered Accident, per Covered

Person.

Accidental Dismemberment

We will pay the applicable lump sum benefit indicated in the policy for dismemberment. Dismemberment must occur as a result of Off-the-Job Injuries sustained in a Covered Accident and must occur within 90 days of the accident.2 Only the highest single benefit per Covered Person will be paid for dismemberment. Benefits will be paid only once per Covered Person, per Covered Accident. If death and dismemberment result from the same accident, only the Accidental Death Benefit will be paid. Loss of use does not constitute dismemberment, except for the eye in jur ies resulting in at least 80% of vision that is permanently lost. See schedule in policy.

$625 - $40,000

Appliances

Payable when a Covered Person receives a medical appliance, prescribed by a physician, as an aid in personal locomotion for Off-the-Job Injuries sustained in a Covered Accident. Benefits are payable for the following types of appliances: a wheelchair, a leg brace, a back brace, a walker, and/or a pair of crutches.

$125 per Covered Accident,

per Covered Person.

NOTE: This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describe the benefits in greater details. Should there be a difference between this summary and the contract, the contract will govern.



Cincinnati Life’s term life insurance policies are designed to enhance your group life coverage by offering additional

financial protection for your family during your working years. Premiums are guaranteed for the first 10 or 20 years of the policy, depending on the term you choose. After the end of the term period, premiums will increase annually through age 100.

Your insurance needs may change in the future. That’s why your term life insurance policy provides you with an option to convert, without evidence of insurability, to one of Cincinnati Life’ s currently marketed, individual, permanent life insurance policies.

These Policies Include:

• Guarantee Issue Death Benefit of up to $100,000 • Coverage for you, your spouse and your children • Two Terms to Choose From: 10 Year or 20

Year Level Term • You Own The Policy– Coverage is Portable

Coverage for you and your spouse

You may apply for a term life insurance policy on you and your spouse. Available issue ages for Term 10 are 18-70. Available issue ages for Term 20 are 18-60.

Children’s Term Rider

You can cover your children, stepchildren and legally adopted children when attached to either your policy or your spouse’s policy. One premium covers all children, each with a death benefit of $10,000

You own the policy

Cincinnati Life’s Term 10 and Term 20 life insurance policies provide individual coverage. You are the owner of the policy and you can take it with you if you leave your employer.

Do You Need More Than $100,000 of Coverage? You can purchase additional life insurance above the $100,000 with Cincinnati Life’s Termsetter Term Life Insurance policy. This plan is fully underwritten, but features:

• 10 or 20 Year Level Terms

• Available Death Benefit from $100,000 to $1,000,000

• Guaranteed Level Premium & Death Benefit

• Guaranteed Renewable to age 99


Voluntary Term Life

$100,000 Additional Term Life Insurance


The thought of having a heart attack is alarming, but the truth is, it can happen to anyone. Recovery is important. This policy provides a lump sum benefits help you focus on getting well so that you can be 100% you.

Our Base Policies Provide:

• Lump sum benefit of $20,000 to use any way you like

• Coverage for you, your spouse and/or your family • Issue ages from 18 – 99 • Guaranteed Renewable for Life*

Your Heart Attack & Stroke Policy

The costs associated with an unexpected heart attack, stroke or other heart-related surgery can be overwhelming. With our Flexible Choice Heart Attack & Stroke Insurance Policy, you can receive a percentage of your lump sum benefit, should you receive a diagnosis or procedure for one of the qualifying events listed below, subject to the maximum benefit amount.

Qualifying Events

No Surprises

The Flexible Choice policy pays regardless of any other insurance you may have, and the benefits are paid directly to you, or your designee, to use any way you like.

For example, your benefit amount is $10,000 and you needed an Aortic Surgery, you would receive 25%, or $2,500. If you then suffered a stroke, you would receive the remaining balance amount of $7,500 for a total of 100% of your maximum benefit amount, or $10,000.

Heart Attack & Stroke Restoration

The extra coverage provided by this rider will pay a percentage of your selected benefit amount should you suffer subsequent heart attacks, strokes or require a heart transplant (not to exceed an additional 100% of the selected benefit amount) provided the date of your last diagnosis for a heart attack, stroke or heart transplant was at least two years from your current diagnosis.

100%

75%

0% 25%

Less than 2 2 or more but 5 or more but 10 or more less than 5 less than 10

Years Since Last

Heart Attack, Stroke or Heart Transplant


Cigna Heart / Stroke Plan

% of Benefit Max. % amount of Benefit

payable for amount each event payable

Heart Attack 100%

100%

Heart Transplant 100% Stroke 100% Coronary Artery Bypass Surgery* 25% Aortic Surgery* 25%

Heart Valve Replacement/Repair* 25%

Angioplasty* 10%

Stent* 10%


Our Base Policies Provide:

• Lump sum benefit of $20,000 to use any way you like

• Coverage for you, your spouse and/or your family • Issue ages from 18 – 99 • Guaranteed Renewable for Life*

Your Cancer Policy

A cancer diagnosis can occur at any time regardless of your lifestyle. Lacking the proper cancer coverage to help pay for additional costs associated with treatment can affect your recovery, so it’s beneficial to plan ahead. With our Flexible Choice Cancer Insurance Policy, you will receive 100% of your l u m p sum benefit amount, upon diagnosis of any cancer.

Lump Sum Cancer Coverage

No Surprises

The Flexible Choice policy pays regardless of any other insurance you may have, and the benefits are paid directly to you, or your designee, to use any way you like.

Cancer Recurrence Benefit Rider

If you are concerned with a recurring diagnosis of cancer, our Cancer Recurrence Benefit Rider may pay you additional benefits should you receive subsequent diagnoses of cancer. You will receive a percentage of your benefit amount (not to exceed an additional 100% of the selected benefit amount) upon additional diagnoses of cancer provided you have not received advice or treatment for at least two years from the date of your last diagnosis.

Less than 2 2 or more but 5 or more but 10 or more less than 5 less than 10

Years Without Advice or Treatment


Cigna Cancer Plan

100%

75%

0% 25%

% of Selected Benefit Amount

Cancer 100% Carcinoma in Situ


DELTA DENTAL PLANS COVERAGE SEMI MONTHLY DELTA DENTAL PLANS COVERAGE MONTHLY

PPO Low Plan

Employee Only $11.74

PPO Low Plan

Retiree Only $23.48

Employee + Spouse $27.53 Retiree + Spouse $55.06

Employee + Family $51.93 Retiree + Family $103.86

Premier Plus High Plan

Employee Only $17.22 Premier Plus High Plan

Retiree Only $34.44



VSP VISION PLAN COVERAGE SEMI MONTHLY VSP VISION PLAN COVERAGE MONTHLY

Employee Only $2.73

Retiree Only $5.45

Employee + One $5.46 Retiree + One $10.91


CIGNA HEART / STROKE PLAN $10,00 LUMP SUM SEMI

MONTHLY CIGNA HEART / STROKE PLAN COVERAGE MONTHLY

$10,000 Lump sum Benefit $20,000 in increments of $10,000

Employee Only $6.25 $10,000 Lump sum Benefit $20,000 in increments of $10,000

Retiree Only $12.50


Employee + Children $6.50 Retiree + Children $13.00


CIGNA CANCER $10,00 LUMP SUM SEMI MONTHLY CIGNA CANCER COVERAGE MONTHLY

$10,000 Lump sum Benefit $20,000 in increments of $10,000

Employee Only $6.00 $10,000 Lump sum Benefit $20,000 in increments of $10,000

Retiree Only $12.00




BCBS MEDICAL PLANS * COVERAGE MONTHLY

BlueChoice HCA *Non-Wellness ADD $12.50 to Rates

Retiree Only $378.52

Retiree + Spouse $765.70

Retiree + Children $665.72

Retiree + Family $1,250.09

BlueChoice PPO *Non-Wellness ADD $12.50 to Rates





BluePreferred PPO *Non-Wellness ADD $12.50 to Rates





BCBS MEDICAL PLANS * COVERAGE SEMI

MONTHLY

BlueChoice HCA *Non-Wellness ADD $12.50 to Rates


Employee + Spouse $86.41

Employee+ Children $77.44

Employee + Family $147.29

BlueChoice PPO *Non-Wellness ADD $12.50 to Rates





BluePreferred PPO *Non-Wellness Add $12.50 to Rates





2019 Rates Retirees Active Employees


2019 Rates

BCBS MEDICARE ADVANTAGE PLAN COVERAGE MONTHLY

BCBS MEDICARE SUPPLEMENT PLAN F COVERAGE MONTHLY

Retiree Only $0.00

Retiree Only $83.10

Retiree + Spouse $74.55 Retiree + Spouse $414.65

CUL CANCER PLAN 18-64

SEMI-MONTHLY 18-64

MONTHLY 65-69

SEMI-MONTHLY

Low Plan

Employee Only $15.78 $31.55 $63.16

1 Parent Family $17.72 $35.44 $63.16

2 Parent Family $25.30 $50.59 $93.74

Low Plan + CC Rider

Employee Only $17.03 $34.05 $68.66

1 Parent Family $19.10 $38.19 $68.66

2 Parent Family $27.30 $54.60 $102.00

Low Plan + ICU Rider

Employee Only $19.38 $38.75 $79.00

1 Parent Family $21.68 $43.36 $79.00

2 Parent Family $31.06 $62.11 $117.50

Low Plan + ICU & CC Rider

Employee Only $20.63 $41.25 $84.50

1 Parent Family $23.06 $46.11 $84.50

2 Parent Family $33.06 $66.12 $125.76

High Plan

Employee Only $29.90 $59.80 $97.60

1 Parent Family $33.54 $67.08 $97.60

2 Parent Family $47.99 $95.98 $145.40

High Plan + CC Rider

Employee Only $31.15 $62.30 $103.10

1 Parent Family $34.92 $69.83 $103.10

2 Parent Family $50.00 $99.99 $153.66

High Plan + ICU Rider

Employee Only $33.50 $67.00 $113.44

1 Parent Family $37.50 $75.00 $113.44

2 Parent Family $53.75 $107.50 $169.16

High Plan + ICU & CC Rider

Employee Only $34.75 $69.50 $118.94

1 Parent Family $38.88 $77.75 $118.94

2 Parent Family $55.76 $111.51 $177.42

CUL ACCIDENT PLAN COVERAGE SEMI MONTHLY CUL ACCIDENT PLAN COVERAGE MONTHLY

Low Plan


Low Plan

Retiree Only $21.33




High Plan


High Plan

Retiree Only $25.00




Disability Rider Employee Only $9.85 Disability Rider Retiree Only $19.70


HIPAA Notice of Privacy Policy and Procedures This notice describes how medical information about you may be used and disclosed and how you can get access to this information. This notice is provided to you on behalf of the Company about the Plan. It pertains only to health care coverage provided under the Plan. The Plan’s Duty to Safeguard Your Protected Health Information Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for the health care is considered “Protected Health Information” (“PHI”). The Plan is required to extend certain protections to your PHI, and to give you this Notice about its privacy practices that explains how, when and why the Plan may use or disclose your PHI. Except in specified circumstances, the Plan may use or disclose only the minimum necessary PHI to accomplish the purpose of the use or disclosure. The Plan is required to follow the privacy practices described in this Notice, though it reserves the right to change those practices and the terms of this Notice at any time. If it does so, and the change is material, you will receive a revised version of this Notice either by hand delivery, mail delivery to your last known address, or some other fashion. This Notice, and any material revisions of it, will also be provided to you in writing upon your request (ask your Human Resources Department, or contact the Plan’s HIPAA Privacy Official). You may also receive one or more other privacy notices, from insurance companies that provide benefits under the Plan. Those notices will describe how the insurance companies use and disclose PHI, and your rights with respect to the PHI they maintain. How the Plan May Use and Disclose Your Protected Health Information The Plan uses and discloses PHI for a variety of reasons. For its routine uses and disclosures it does not require your authorization, but for other uses and disclosures, your authorization (or the authorization of your personal representative (e.g., a person who is your custodian, guardian, or has your power-of-attorney) may be required. The following offers more description and examples of the Plan’s uses and disclosures of your PHI.

Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations

• Treatment: Generally, and as you would expect, the Plan is permitted to disclose your PHI for purposes of your medical treatment. Thus, it may disclose your PHI to doctors, nurses, hospitals, emergency medical technicians, pharmacists and other health care professionals where the disclosure is for your medical treatment. For example, if you are injured in an accident, and it’s important for your treatment team to know your blood type, the Plan could disclose that PHI to the team in order to allow it to more effectively provide treatment to you.

• Payment: Of course, the Plan’s most important function, as far as you are concerned, is that it pays for all or some of the medical care you receive (provided the care is covered by the Plan). In the course of its payment operations, the Plan receives a substantial amount of PHI about you. For example, doctors, hospitals and pharmacies that provide you care send the Plan detailed information about the care they provided, so that they can be paid for their services. The Plan may also share your PHI with other plans, in certain cases. For example, if you are covered by more than one health care plan (e.g., covered by this Plan, and your spouse’s plan, or covered by the plans covering your father and mother), we may share your PHI with the other plans to coordinate payment of your claims.

• Health care operations: The Plan may use and disclose your PHI in the course of its “health care operations.” For example, it may use your PHI in evaluating the quality of services you received, or disclose your PHI to an accountant or attorney for audit purposes. In some cases, the Plan may disclose your PHI to insurance companies for purposes of obtaining various insurance coverage. However, the Plan will not disclose, for underwriting purposes, PHI that is genetic information.

Other Uses and Disclosures of Your PHI Not Requiring Authorization The law provides that the Plan may use and disclose your PHI without authorization in the following circumstances: • To the Plan Sponsor: The Plan may disclose PHI to the employers (such as the Company) who sponsor or maintain the Plan for the benefit

of employees and dependents. However, the PHI may only be used for limited purposes, and may not be used for purposes of employment-related actions or decisions or in connection with any other benefit or employee benefit plan of the employers. PHI may be disclosed to: the human resources or employee benefits department for purposes of enrollments and disenrollments, census, claim resolutions, and other matters related to Plan administration; payroll department for purposes of ensuring appropriate payroll deductions and other payments by covered persons for their coverage; information technology department, as needed for preparation of data compilations and reports related to Plan administration; finance department for purposes of reconciling appropriate payments of premium to and benefits from the Plan, and other matters related to Plan administration; internal legal counsel to assist with resolution of claim, coverage and other disputes related to the Plan’s provision of benefits.

• To the Plan’s Service Providers: The Plan may disclose PHI to its service providers (“business associates”) who perform claim payment and plan management services. The Plan requires a written contract that obligates the business associate to safeguard and limit the use of PHI.

• Required by law: The Plan may disclose PHI when a law requires that it report information about suspected abuse, neglect or domestic violence, or relating to suspected criminal activity, or in response to a court order. It must also disclose PHI to authorities that monitor compliance with these privacy requirements.


• For public health activities: The Plan may disclose PHI when required to collect information about disease or injury, or to report vital statistics to the public health authority.

• For health oversight activities: The Plan may disclose PHI to agencies or departments responsible for monitoring the health care system for such purposes as reporting or investigation of unusual incidents.

• Relating to descendants: The Plan may disclose PHI relating to an individual’s death to coroners, medical examiners or funeral directors, and to organ procurement organizations relating to organ, eye, or tissue donations or transplants.

• For research purposes: In certain circumstances, and under strict supervision of a privacy board, the Plan may disclose PHI to assist medical and psychiatric research.

• To avert threat to health or safety: In order to avoid a serious threat to health or safety, the Plan may disclose PHI as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm.

• For specific government functions: The Plan may disclose PHI of military personnel and veterans in certain situations, to correctional facilities in certain situations, to government programs relating to eligibility and enrollment, and for national security reasons.

Uses and Disclosures Requiring Authorization For uses and disclosures beyond treatment, payment and operations purposes, and for reasons not included in one of the exceptions described above, the Plan is required to have your written authorization. For example, uses and disclosures of psychotherapy notes, uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI would require your authorization. Your authorizations can be revoked at any time to stop future uses and disclosures, except to the extent that the Plan has already undertaken an action in reliance upon your authorization. Uses and Disclosures Requiring You to Have an Opportunity to Object The Plan may share PHI with your family, friend or other person involved in your care, or payment for your care. We may also share PHI with these people to notify them about your location, general condition, or death. However, the Plan may disclose your PHI only if it informs you about the disclosure in advance and you do not object (but if there is an emergency situation and you cannot be given your opportunity to object, disclosure may be made if it is consistent with any prior expressed wishes and disclosure is determined to be in your best interests; you must be informed and given an opportunity to object to further disclosure as soon as you are able to do so). Your Rights Regarding Your Protected Health Information You have the following rights relating to your protected health information:

• To request restrictions on uses and disclosures: You have the right to ask that the Plan limit how it uses or discloses your PHI. The Plan will consider your request, but is not legally bound to agree to the restriction. To the extent that it agrees to any restrictions on its use or disclosure of your PHI, it will put the agreement in writing and abide by it except in emergency situations. The Plan cannot agree to limit uses or disclosures that are required by law.

• To choose how the Plan contacts you: You have the right to ask that the Plan send you information at an alternative address or by an alternative means. To request confidential communications, you must make your request in writing to the Privacy Official. We will not ask you the reason for your request. Your request must specify how or where you wish to be contacted. The Plan must agree to your request as long as it is reasonably easy for it to accommodate the request.

• To inspect and copy your PHI: Unless your access is restricted for clear and documented treatment reasons, you have a right to see your PHI in the possession of the Plan or its vendors if you put your request in writing. The Plan, or someone on behalf of the Plan, will respond to your request, normally within 30 days. If your request is denied, you will receive written reasons for the denial and an explanation of any right to have the denial reviewed. If you want copies of your PHI, a charge for copying may be imposed but may be waived, depending on your circumstances. You have a right to choose what portions of your information you want copied and to receive, upon request, prior information on the cost of copying.

• To request amendment of your PHI: If you believe that there is a mistake or missing information in a record of your PHI held by the Plan or one of its vendors, you may request, in writing, that the record be corrected or supplemented. The Plan or someone on its behalf will respond, normally within 60 days of receiving your request. The Plan may deny the request if it is determined that the PHI is: (i) correct and complete; (ii) not created by the Plan or its vendor and/or not part of the Plan’s or vendor’s records; or (iii) not permitted to be disclosed. Any denial will state the reasons for denial and explain your rights to have the request and denial, along with any statement in response that you provide, appended to your PHI. If the request for amendment is approved, the Plan or vendor, as the case may be, will change the PHI and so inform you, and tell others that need to know about the change in the PHI.

• To find out what disclosures have been made: You have a right to get a list of when, to whom, for what purpose, and what portion of your PHI has been released by the Plan and its vendors, other than instances of disclosure for which you gave authorization, or instances where the disclosure was made to you or your family. In addition, the disclosure list will not include disclosures for treatment, payment, or health care operations. The list also will not include any disclosures made for national security purposes, to law enforcement officials or correctional facilities, or before the date the federal privacy rules applied to the Plan. You will normally receive a response to your written request for such a list within 60 days after you make the request in writing. Your request can relate to disclosures going as far back as six years. There will be no charge for up to one such list each year. There may be a charge for more frequent requests.

How to Complain about the Plan’s Privacy Practices If you think the Plan or one of its vendors may have violated your privacy rights, or if you disagree with a decision made by the Plan or a vendor about access to your PHI, you may file a complaint with the person listed on the first page of these notices. You also may file a written complaint with


the Secretary of the U.S. Department of Health and Human Services. The law does not permit anyone to take retaliatory action against you if you make such complaints. Notification of a Privacy Breach Any individual whose unsecured PHI has been, or is reasonably believed to have been used, accessed, acquired or disclosed in an unauthorized manner will receive written notification from the Plan within 60 days of the discovery of the breach. If the breach involves 500 or more residents of a state, the Plan will notify prominent media outlets in the state. The Plan will maintain a log of security breaches and will report this information to HHS on an annual basis. Immediate reporting from the Plan to HHS is required if a security breach involves 500 or more people. Contact Person for Information, or to Submit a Complaint If you have questions about this Notice please contact the Plan’s Privacy Official or Deputy Privacy Official(s) (see first page). If you have any complaints about the Plan’s privacy practices, handling of your PHI, or breach notification process, please contact the Privacy Official or an authorized Deputy Privacy Official. Organized Health Care Arrangement Designation The Plan participates in what the federal privacy rules call an “Organized Health Care Arrangement.” The purpose of that participation is that it allows PHI to be shared between the members of the Arrangement, without authorization by the persons whose PHI is shared, for health care operations. Primarily, the designation is useful to the Plan because it allows the insurers who participate in the Arrangement to share PHI with the Plan for purposes such as shopping for other insurance bids.

Women’s Health and Cancer Rights Notice (WHCRA) If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: • All stages of reconstruction of the breast on which the mastectomy was performed; • Surgery and reconstruction of the other breast to produce a symmetrical appearance; • Prostheses; and • Treatment of physical complications of the mastectomy, including lymphedemas.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like more information on WHCRA benefits, contact your plan administrator. Newborns’ and Mother’s Health Protection Act Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a caesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). Michelle’s Law Federal legislation known as “Michelle's Law” generally extends eligibility for group health benefit plan coverage to a dependent child who is enrolled in an institution of higher education at the beginning of a medically necessary leave of absence if the leave normally would cause the dependent child to lose eligibility for coverage under the plan due to loss of student status. The extension of eligibility protects eligibility of a sick or injured dependent child for up to one year. The Plan currently permits an employee to continue a child’s coverage until the end of the month following the child 26th birthday if that child is enrolled at an accredited institution of learning on a full-time basis, with full-time defined by the accredited institution’s registration and/or attendance policies. Michelle's Law requires the Plan to allow extended eligibility in some cases for a dependent child who would lose eligibility for Plan coverage due to loss of full-time student status. There are two definitions that are important for purposes of determining whether the Michelle's Law extension of eligibility applies to a particular child: • Dependent child means a child of a plan participant who is eligible under the terms of a group health benefit plan based on his or her

student status and who was enrolled at a post-secondary educational institution immediately before the first day of a medically necessary leave of absence.


• Medically necessary leave of absence means a leave of absence or any other change in enrollment: • of a dependent child from a post-secondary educational institution that begins while the child is suffering from a serious illness or

injury • which is medically necessary • and which causes the dependent child to lose student status under the terms of the Plan

For the Michelle’s Law extension of eligibility to apply, a dependent child’s treating physician must provide written certification of medical necessity (i.e., certification that the dependent child suffers from a serious illness or injury that necessitates the leave of absence or other enrollment change that would otherwise cause loss of eligibility). If a dependent child qualifies for the Michelle's Law extension of eligibility, the Plan will treat the dependent child as eligible for coverage until the earlier of: • One year after the first day of the leave of absence • The date that Plan coverage would otherwise terminate (for reasons other than failure to be a full-time student)

A dependent child on a medically necessary leave of absence is entitled to receive the same Plan benefits as other dependent children covered under the Plan. Further, any change to Plan coverage that occurs during the Michelle’s Law extension of eligibility will apply to the dependent child to the same extent as it applies to other dependent children covered under the Plan. The Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) COBRA continuation coverage is a continuation of coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” Qualified beneficiaries may elect to continue their coverage under the plan for a prescribed period of time on a self-pay basis. Each qualified beneficiary has 60 days to choose whether or not to elect COBRA coverage, beginning from the later of the date the election notice is provided, or the date on which the qualified beneficiary would otherwise lose coverage under The Plan due to a qualifying event. To learn more about COBRA and your rights under COBRA, please refer to your Summary Plan Description. GINA Warning Against Providing Genetic Information The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request. “Genetic information” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. Please do not include any family medical history or any information related to genetic testing, genetic services, and genetic counseling or genetic diseases for which an individual may be at risk. Patient Protection Model Disclosure The Oklahoma City Firefighters Health and Welfare VEBA Trust group health plan generally allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. [If the plan or health insurance coverage designates a primary care provider automatically, insert: Until you make this designation, [name of group health plan or health insurance issuer] designates one for you.] For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the [plan administrator or issuer] at [insert contact information]. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from The Oklahoma City Firefighters Health and Welfare VEBA Trust or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the Blue Cross BlueShield of Oklahoma at (800) 942-5837.

HIPAA Notice of Special Enrollment Rights If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to later enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). Loss of eligibility includes but is not limited to: • Loss of eligibility for coverage as a result of ceasing to meet the plan’s eligibility requirements (i.e., legal separation, divorce, cessation of

dependent status, death of an employee, termination of employment, reduction in the number of hours of employment);


• Loss of HMO coverage because the person no longer resides or works in the HMO service area and no other coverage option is available through the HMO plan sponsor;

• Elimination of the coverage option a person was enrolled in, and another option is not offered in its place; • Failing to return from an FMLA leave of absence; and • Loss of coverage under Medicaid or the Children’s Health Insurance Program (CHIP).

Unless the event giving rise to your special enrollment right is a loss of coverage under Medicaid or CHIP, you must request enrollment by the HIPAA Special Enrollment Deadline after your or your dependent’s(s’) other coverage ends (or after the employer that sponsors that coverage stops contributing toward the coverage). If the event giving rise to your special enrollment right is a loss of coverage under Medicaid or CHIP, you may request enrollment under this plan within 60 days of the date you or your dependent(s) lose such coverage under Medicaid or CHIP. Similarly, if you or your dependent(s) become eligible for a state-granted premium subsidy towards this plan, you may request enrollment under this plan within 60 days after the date Medicaid or CHIP determine that you or the dependent(s) qualify for the subsidy. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment by the HIPAA Special Enrollment Deadline, after the marriage, birth, adoption, or placement for adoption. To request special enrollment or obtain more information, contact the Plan Administrator. Note: Additional information may be required if the plan requires that persons declining coverage under the plan state, in writing, the reason(s) for declining coverage.

CHIPRA Special Enrollment Provision – Premium Assistance Eligibility If you or your children are eligible for Medicaid or the Children’s Health Insurance Program (CHIP) and you’re eligible for health coverage from your employer, The Company may have a premium assistance program that can help pay for coverage using funds from the state’s Medicaid or CHIP programs. If you or your dependent(s) are eligible for premium assistance under Medicaid or CHIP, as well as eligible for health insurance coverage through The Company, your employer must allow you to enroll in The Company plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. In addition, you may enroll in The Company plan if you or your dependent’s Medicaid or CHIP coverage is terminated as a result of loss of eligibility. An employee must request this special enrollment within 60 days of the loss of coverage.

Wellness Program Disclosure Oklahoma City Firefighters Health & Welfare VEBA Trust Wellness Plan is a voluntary wellness program available to all employees. The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to participate in the wellness program you will be asked to complete a voluntary health risk assessment or "HRA" that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You will also be asked to complete a biometric screening, which will include a blood test for [be specific about the conditions for which blood will be tested. You are not required to complete the HRA or to participate in the blood test or other medical examinations. However, employees who choose to participate in the wellness program will receive an incentive for achieving specific criteria. Although you are not required to complete the HRA or participate in the biometric screening, only employees who do so will receive the incentive. Additional incentives of up to the specified amount may be available for employees who participate in certain health-related activities or achieve certain health outcomes. If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive, you may be entitled to a reasonable accommodation or an alternative standard. You may request a reasonable accommodation or an alternative standard by contacting your Plan Administrator. The information from your HRA and the results from your biometric screening will be used to provide you with information to help you understand your current health and potential risks, and may also be used to offer you services through the wellness program. You also are encouraged to share your results or concerns with your own doctor. Protections from Disclosure of Medical Information We are required by law to maintain the privacy and security of your personally identifiable health information. Although the wellness program and [name of employer] may use aggregate information it collects to design a program based on identified health risks in the workplace, [name of wellness program] will never disclose any of your personal information either publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment.


Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements. The only individual(s) who will receive your personally identifiable health information is (are) [indicate who will receive information such as "a registered nurse," "a doctor," or "a health coach" in order to provide you with services under the wellness program. In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records, information stored electronically will be encrypted, and no information you provide as part of the wellness program will be used in making any employment decision. Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the wellness program, we will notify you immediately. You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program, nor may you be subjected to retaliation if you choose not to participate. If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact your Plan Administrator.

Notice of Availability of Summary of Benefits and Coverage (SBC) As an employee or retiree, the health benefits available to you represent a significant component of your compensation package. They also provide important protection for you and your family in the case of illness or injury. The Company offers a series of health coverage options. Choosing your health insurance coverage is an important decision. To help you make an informed choice, The Company makes available a Summary of Benefits and Coverage (SBC), which summarizes important information about your health coverage options in a standard format, to help you compare. The SBCs are only a summary. You should consult The Company’s Summary Plan Descriptions and/or Medical Benefit Booklet to determine the governing contractual provisions of the coverage. A paper copy is also available, free of charge, by contacting your Plan Administrator.


Important Notice from the Company About Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with the Company and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. If neither you nor any of your covered dependents are eligible for or have Medicare, this notice does not apply to you or the dependents, as the case may be. However, you should still keep a copy of this notice in the event you or a dependent should qualify for coverage under Medicare in the future. Please note, however, that later notices might supersede this notice.

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. The Company has determined that the prescription drug coverage offered by the Creditable Plan(s) is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is considered “creditable” prescription drug coverage. This is important for the reasons described below.

Because your existing coverage is, on average, at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to enroll in a Medicare drug plan, as long as you later enroll within specific time periods. Enrolling in Medicare—General Rules As some background, you can join a Medicare drug plan when you first become eligible for Medicare. If you qualify for Medicare due to age, you may enroll in a Medicare drug plan during a seven month initial enrollment period. That period begins three months prior to your 65th birthday, includes the month you turn 65, and continues for the ensuing three months. If you qualify for Medicare due to disability or end-stage renal disease, your initial Medicare Part D enrollment period depends on the date your disability or treatment began. For more information you should contact Medicare at the telephone number or web address listed below. Late Enrollment and the Late Enrollment Penalty If you decide to wait to enroll in a Medicare drug plan you may enroll later, during Medicare Part D’s annual enrollment period, which runs each year from October 15th through December 7th.But as a general rule, if you delay your enrollment in Medicare Part D, after first becoming eligible to enroll, you may have to pay a higher premium (a penalty). If after your initial Medicare Part D enrollment period, you go 63 continuous days or longer without “creditable” prescription drug coverage (that is, prescription drug coverage that’s at least as good as Medicare’s prescription drug coverage), your monthly Part D premium may go up by at least 1% of the


premium you would have paid had you enrolled timely, for every month that you did not have creditable coverage. For example, if after your Medicare Part D initial enrollment period you go nineteen months without coverage, your premium may be at least 19% higher than the premium you otherwise would have paid. You may have to pay this higher premium for as long as you have Medicare prescription drug coverage. However, there are some important exceptions to the late enrollment penalty. Special Enrollment Period Exceptions to the Late Enrollment Penalty There are “special enrollment periods” that allow you to add Medicare Part D coverage months or even years after you first became eligible to do so, without a penalty. For example, if after your Medicare Part D initial enrollment period you lose or decide to leave employer-sponsored or union-sponsored health coverage that includes “creditable” prescription drug coverage, you will be eligible to join a Medicare drug plan at that time. In addition, if you otherwise lose other creditable prescription drug coverage (such as under an individual policy) through no fault of your own, you will be able to join a Medicare drug plan, again without penalty. These special enrollment periods end two months after the month in which your other coverage ends. Compare Coverage You should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. See the Plan’s summary plan description for a summary of the Plan’s prescription drug coverage. If you don’t have a copy, you can get one by contacting us at the telephone number or address listed at the beginning of the Required Notices section of this guide. Coordinating Other Coverage with Medicare Part D Generally speaking, if you decide to join a Medicare drug plan while covered under the Company Plan due to your employment (or someone else’s employment, such as a spouse or parent), your coverage under the Company Plan will not be affected. For most persons covered under the Plan, the Plan will pay prescription drug benefits first, and Medicare will determine its payments second. For more information about this issue of what program pays first and what program pays second, see the Plan’s summary plan description or contact Medicare at the telephone number or Web address listed at the end of this notice. If you do decide to join a Medicare drug plan and drop your prescription drug coverage with Oklahoma City Firefighters Health & Welfare VEBA Trust, be aware that you and your dependents may be able to get this coverage back. To regain coverage you would have to re-enroll in the Plan, pursuant to the Plan’s eligibility and enrollment rules. You should review the Plan’s summary plan description to determine if and when you are allowed to add coverage. For more information about this notice or your current prescription drug coverage… Contact the Plan Administrator for further information. Note: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through the Company changes. You also may request a copy.


For more information about your options under Medicare prescription drug coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:

• Visit www.medicare.gov • Call your State Health Insurance Assistance Program (see the inside back cover of your copy of

the “Medicare & You” handbook for their telephone number) for personalized help, • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about extra help, visit Social Security on the Web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans,

you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and whether or not you are required

to pay a higher premium (a penalty).

Nothing in this notice gives you or your dependents a right to coverage under the Plan. Your (or your dependents’) right to coverage under the Plan is determined solely under the terms of the Plan.


BlueCross BlueShield of Oklahoma PPO Plans (Choice & Preferred) (Group Number:166720) Mon-Fri, 8 a.m. - 8 p.m. CST 800-942-5837

BlueCross BlueShield of Oklahoma HCA Plan (Group Number:170719) Mon-Fri, 8 a.m. - 8 p.m. CST 800-942-5837

BlueCross BlueShield of Oklahoma Medicare Advantage PPO Plan (Group Number: P0K0001) Mon-Fri, 8 a.m. - 8 p.m. CST 800-942-5837

The Hartford Group Life Insurance (Group Number:677307) Mon-Fri, 7 a.m. - 7 p.m. CST 800-523-2233

Delta Dental of Oklahoma Dental Plan (Group Number: 0008567) Actives: PPO Plan -0003 PPO Plus Premier Plan -0004 Retirees PPO Plan -0003 PPO Plus Premier Plan -1004 Mon-Fri, 8 a.m. - 8 p.m. CST 800-522-0188

American Fidelity Assurance Company FSA Account Mon-Fri, 7 a.m. - 7 p.m. CST 800-437-1011

VSP Vision Plan (Group Number:166720) Mon-Fri, 8 a.m. - 8 p.m. CST 800-877-7195

Cincinnati Life Insurance Company Voluntary Term Life Insurance Mon-Fri, 8 a.m. - 5 p.m. CST 800-752-3419

Central United Life Voluntary Cancer & Accident Mon-Fri, 8 a.m. - 5 p.m. CST 800-752-3419

Cigna Supplemental Solutions Lump Sum Heart/Stroke & Cancer (Group Number: LA0050) Mon-Fri, 8 a.m. - 5 p.m. CST 800-752-3419

Cigna Supplemental Solutions Lump Sum Cancer Plan (Group Number: LA0050) Mon-Fri, 8 a.m. - 5 p.m. CST 800-752-3419

OKCFF Local 157 Benefits Support Patti Bolin 405-232-9543 [email protected] Mon-Thurs, 8 a.m. - 5 p.m. CST

OKCFF Health & Welfare VEBA Trust Address: 157 NW 6th St. Oklahoma City, OK 73102 405-232-9543

Willis Towers Watson Employee Benefits Advocacy Kelli Thornton, Account Manager 405-552-4892

BenefitHelp TM

Employee Benefit Enrollment Mon-Thurs, 8.am. - 5 p.m. CST Fri, 8 a.m. - 4 p.m. CST 888-663-1285 www.MyOKCFFBenefits.com

Medicare 800-633-4227 www.medicare.gov

COBRA Administrator AmeriFlex Mon-Fri, 7:30am-7pm CST 888-868-3539

Benefit Resource Directory


http://www.myokcffbenefits.com/

http://www.medicare.gov/

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This Guide is merely a brief summary. Your rights under Oklahoma City Fire Fighters benefits program are governed by the express terms and provisions of the formal executed Summary Plan Description documents. If there is any discrepancy or conflict between the Summary Plan Descriptions and the information presented here, the Summary Plan Description documents will control. Oklahoma City Fire Fighter reserves the right to change or discontinue the plans at any time. Participation in these plans is not an offer of employment or an employment contract. October 2018

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