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Published by lkristel, 2018-12-17 16:29:02

benefits Packet Spreads

benefits Packet Spreads

OVERVIEW OF EMPLOYEE BENEFITS

MEDICAL DENTAL VISION
COVERAGE COVERAGE PLAN
LONG TERM
LIFE INSURANCE 403B SAVINGS CARE
STD & LTD PLAN INSURANCE

SUPPLEMENTAL
INSURANCE

Plan Name Plan Details Anthem HMO
Out-of-Network Benefits
Primary Care Physician Anthem PPO
Election Required In-Network Benefits Out-of-Network Benefits HMO Benefits Not Covered
Outpatient Facility Charge
Diagnostic X-Ray and Lab General Plan Information
Tests
No No Yes

10% after deductible 30% after deductible No Copay Not Covered
10% after deductible No Copay Not Covered
Outpatient Services

30% after deductible

Specialist Visit $10 copay 30% after deductible $10 copay per visit Not Covered

Advanced Imaging 10% after deductible 30% after deductible $100 Copay per Test Not Covered
(subject to utilization
Emergency Services Yes Not Covered
review) No Not Covered
Yes $100 Copay
Copay/Deductible Waived if Yes $100/trip
Admitted No $100/trip
Pre-Authorization of No $100 copay and 10% after
Services Required $100 copay and 10%
deductible
Emergency Room after deductible
Ambulance
Air 10% after deductible
10% after deductible/30%
Non emergency

Ground 10% after deductible 10% after deductible/30% $100/trip $100/trip
Non emergency

Anthem Blue Cross
Your Plan: Custom Premier PPO 150/10/10
Your Network: Prudent Buyer PPO

This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and
every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review
the formal Certificate of Insurance or Evidence of Coverage (EOC). If there is a difference between this summary and the Certificate of
Insurance or Evidence of Coverage (EOC), the Certificate of Insurance or Evidence of Coverage (EOC), will prevail.

Covered Medical Benefits Cost if you use an Cost if you use a
In-Network Non-Network
Provider Provider
$150 single /
Overall Deductible $150 single / $450 family
See notes section to understand how your deductible works. Your plan may also have $450 family
a separate Prescription Drug Deductible. See Prescription Drug Coverage section. $6,000 single /
In-Network Providers and Non-Network Providers deductibles are combined. $12,000 family
Satisfying one helps satisfy the other. 30% coinsurance

Out-of-Pocket Limit $2,000 single / 30% coinsurance
When you meet your out-of-pocket limit, you will no longer have to pay cost-shares $4,000 family 30% coinsurance
during the remainder of your benefit period. See notes section for additional 30% coinsurance
information regarding your out of pocket maximum.
30% coinsurance
Preventive care/screening/immunization No charge 30% coinsurance
In-network preventive care is not subject to deductible, if your plan has a deductible.

Doctor Home and Office Services

Primary care visit to treat an injury or illness $10 copay per visit
Deductible does not apply to In-Network providers.

Specialist care visit $10 copay per visit
Deductible does not apply to In-Network providers.

Prenatal and Post-natal Care $10 copay per visit
Deductible does not apply to In-Network providers.

Other practitioner visits: $10 copay per visit
Retail health clinic $10 copay per visit
Deductible does not apply to In-Network providers.
On-line Visit
Deductible does not apply to In-Network providers.

Page 1 of 6

Covered Medical Benefits Cost if you use an Cost if you use a
In-Network Non-Network
Chiropractor services Provider Provider
Coverage for In-Network Provider and Non-Network Provider combined is $10 copay per visit 30% coinsurance
limited to 30 visit limit per benefit period. Deductible does not apply to
In-Network providers. $10 copay per visit 30% coinsurance
Acupuncture
Coverage for In-Network Provider and Non-Network Provider combined is 30% coinsurance
limited to 20 visit limit per benefit period. Deductible does not apply to 30% coinsurance
In-Network providers. 30% coinsurance
30% coinsurance
Other services in an office: 10% coinsurance
Allergy testing 10% coinsurance 30% coinsurance
Chemo/radiation therapy 10% coinsurance 30% coinsurance
Hemodialysis 10% coinsurance 30% coinsurance
Prescription drugs
For the drugs itself dispensed in the office thru infusion/injection 30% coinsurance
30% coinsurance
Diagnostic Services 10% coinsurance 30% coinsurance
Lab: 10% coinsurance
Office 10% coinsurance 30% coinsurance
Freestanding Lab 30% coinsurance
Outpatient Hospital 30% coinsurance

X-ray: 10% coinsurance
Office 10% coinsurance
Freestanding Radiology Center 10% coinsurance
Outpatient Hospital

Advanced diagnostic imaging (for example, MRI/PET/CAT scans): 10% coinsurance
Office 10% coinsurance
Freestanding Radiology Center
Coverage for Out-of-Network Provider is limited to $800 maximum per test. 10% coinsurance
Outpatient Hospital
Coverage for Out-of-Network Provider is limited to $800 maximum per test.

Page 2 of 6

Covered Medical Benefits Cost if you use an Cost if you use a
In-Network Non-Network
Emergency and Urgent Care Provider Provider
Emergency room facility services $100 copay per
Copay waived if admitted. admission and then Covered as In-Network
10% coinsurance Covered as In-Network
Emergency room doctor and other services 10% coinsurance Covered as In-Network
Ambulance (air and ground) 10% coinsurance
Urgent Care (office setting) $10 copay per visit 30% coinsurance
Deductible does not apply to In-Network providers.
Outpatient Mental/Behavioral Health and Substance Abuse $10 copay per visit; 30% after deductible
Doctor office visit deductible does not is met
apply
Facility visit: 10% coinsurance 30% after deductible
Facility fees after deductible is is met
met
Outpatient Surgery 30% coinsurance
Facility fees: 10% coinsurance 30% coinsurance
Hospital 10% coinsurance 30% coinsurance
Freestanding Surgical Center 10% coinsurance
Doctor and other services 30% coinsurance
10% coinsurance
Hospital Stay (all inpatient stays including maternity, mental / 30% coinsurance
behavioral health, and substance abuse) 10% coinsurance

Facility fees (for example, room & board)
Co-pay $250 if you do not receive preauthorization. Apply to Out-of-Network
Provider. Failure to obtain preauthorization may result in non-coverage or
reduced coverage. Apply to non-emergency admission.
Doctor and other services

Page 3 of 6

Covered Medical Benefits Cost if you use an Cost if you use a
In-Network Non-Network
Recovery & Rehabilitation Provider Provider
Home health care
Coverage for In-Network Provider and Non-Network Provider combined is 10% coinsurance 30% coinsurance
limited to 100 visit limit per benefit period.
10% coinsurance 30% coinsurance
Rehabilitation services (for example,
physical/speech/occupational therapy): 10% coinsurance 30% coinsurance
10% coinsurance 30% coinsurance
Office
Costs may vary by site of service.
Outpatient hospital
Habilitation services

Cardiac rehabilitation 10% coinsurance 30% coinsurance
Office 10% coinsurance 30% coinsurance
Outpatient hospital 10% coinsurance 30% coinsurance

Skilled nursing care (in a facility) No charge 30% coinsurance
Coverage for In-Network Provider and Non-Network Provider combined is limited
to 100 day limit per benefit period. 10% coinsurance 30% coinsurance
10% coinsurance 30% coinsurance
Hospice
Deductible does not apply to In-Network providers.

Durable Medical Equipment

Prosthetic Devices

Page 4 of 6

Notes:
 This Summary of Benefits has been updated to comply with federal and state requirements, including
applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance
and clarification on the new health care reform laws from the U.S. Department of Health and Human Services,
Department of Labor and Internal Revenue Service, we may be required to make additional changes to this
Summary of Benefits. This Summary of Benefits, as updated, is subject to the approval of the California
Department of Insurance and the California Department of Managed Health Care (as applicable).
 In addition to the benefits described in this summary, coverage may include additional benefits, depending
upon the member's home state. The benefits provided in this summary are subject to federal and California
laws. There are some states that require more generous benefits be provided to their residents, even if the
master policy was not issued in their state. If the member's state has such requirements, we will adjust the
benefits to meet the requirements.
 The family deductible and out-of-pocket maximum are embedded meaning the cost shares of one family
member will be applied to the individual deductible and individual out-of-pocket maximum; in addition,
amounts for all family members apply to the family deductible and family out-of-pocket maximum. No one
member will pay more than the individual deductible and individual out-of-pocket maximum.
 All medical services subject to a coinsurance are also subject to the annual medical deductible.
 Annual Out-of-Pocket Maximums includes deductible, copays, coinsurance and prescription drug.
 In network and out of network out of pocket maximum are exclusive of each other.
 For plans with an office visit copay, the copay applies to the actual office visit and additional cost shares may
apply for any other service performed in the office (i.e., X-ray, lab, surgery), after any applicable deductible.
 Preventive Care Services includes physical exam, preventive screenings (including screenings for cancer, HPV,
diabetes, cholesterol, blood pressure, hearing and vision, immunization, health education, intervention services,
HIV testing) and additional preventive care for women provided for in the guidance supported by Health
Resources and Service Administration.
 For Medical Emergency care rendered by a Non-Participating Provider or Non-Contracting Hospital,
reimbursement is based on the reasonable and customary value. Members may be responsible for any amount
in excess of the reasonable and customary value.
 If your plan includes an emergency room facility copay and you are directly admitted to a hospital, your
emergency room facility copay is waived.
 If your plan includes out of network benefit and you use a non-network provider, you are responsible for any
difference between the covered expense and the actual non-participating providers charge.
 Non-emergency, out-of-network air ambulance services are limited to Anthem maximum payment of $50,000
per trip.
 Certain services are subject to the utilization review program. Before scheduling services, the member must
make sure utilization review is obtained. If utilization review is not obtained, benefits may be reduced or not
paid, according to the plan.
 Certain types of physicians may not be represented in the PPO network in the state where the member
receives services. If such physician is not available in the service area, the member's copay is the same as for
PPO (with and without pre-notification, if applicable). Member is responsible for applicable copays,
deductibles and charges which exceed covered expense.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of
the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue
Cross Association.

Questions:(855) 333-5730 or visit us at www.anthem.com/ca
CA/L/F/PPO/ C- LP2037/01-18/Printed 12-17

Page 5 of 6

 Additional visits maybe authorized if medically necessary. Pre-service review must be obtained prior to
receiving the additional services.

 If your plan includes out of network benefits, all services with calendar/plan year limits are combined both in
and out of network.

 Transplants covered only when performed at Centers of Medical Excellence or Blue Distinction Centers.
 Bariatric Surgery covered only when performed at Blue Distinction Center for Specialty Care for Bariatric

Surgery.
 Skilled Nursing Facility day limit does not apply to mental health and substance abuse.
 Respite Care limited to 5 consecutive days per admission.
 Freestanding Lab and Radiology Center is defined as services received in a non-hospital based facility.
 Coordination of Benefits: The benefits of this plan may be reduced if the member has any other group health

or dental coverage so that the services received from all group coverage do not exceed 100% of the covered
expense
 For additional information on limitations and exclusions and other disclosure items that apply to this plan, go
to https://le.anthem.com/pdf?x=CA_LG_PPO
 For additional information on this plan, please visit sbc.anthem.com to obtain a Summary of Benefit Coverage.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of
the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue
Cross Association.

Questions:(855) 333-5730 or visit us at www.anthem.com/ca
CA/L/F/PPO/ C- LP2037/01-18/Printed 12-17

Page 6 of 6

Anthem Blue Cross
Your Plan: Modified Premier HMO 10/100%
Your Network: California Care HMO

This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and
every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review
the formal Evidence of Coverage (EOC). If there is a difference between this summary and the Evidence of Coverage (EOC), the Evidence
of Coverage (EOC), will prevail.

Anthem Blue Cross HMO benefits are covered only when services are provided or coordinated by the primary care physician and authorized
by the participating medical group or independent practice association (IPA); except OB/GYN services received within the member's
medical group/IPA, and services for mental and nervous disorders and substance abuse. Benefits are subject to all terms, conditions,
limitations, and exclusions of the EOC.

Covered Medical Benefits Cost if you use an Cost if you use a
In-Network Non-Network
Provider Provider
$0
Overall Deductible $0
See notes section to understand how your deductible works. Your plan may also have $0 single /
a separate Prescription Drug Deductible. See Prescription Drug Coverage section. $0 family

Out-of-Pocket Limit $1,500 single / Not covered
When you meet your out-of-pocket limit, you will no longer have to pay cost-shares $3,000 family
during the remainder of your benefit period. See notes section for additional Not covered
information regarding your out of pocket maximum. Not covered
Not covered
Preventive care/screening/immunization No charge Not covered
In-network preventive care is not subject to deductible, if your plan has a deductible. Not covered

Doctor Home and Office Services

Primary care visit to treat an injury or illness $10 copay per visit

Specialist care visit $10 copay per visit

Prenatal and Post-natal Care $10 copay per visit

Other practitioner visits: Not covered
Retail health clinic $10 copay per visit
On-line Visit

Page 1 of 5

Covered Medical Benefits Cost if you use an Cost if you use a
In-Network Non-Network
Chiropractor services Provider Provider
Coverage for In-Network Provider is limited to 60 day limit per benefit $10 copay per visit Not covered
period for Physical, Occupational and Speech Therapy combined.
Chiropractor visits count towards your physical and occupational therapy $10 copay per visit Not covered
limit.
Acupuncture

Other services in an office: $10 copay per visit Not covered
Allergy testing $10 copay per visit Not covered
Chemo/radiation therapy $10 copay per visit Not covered
Hemodialysis 20% coinsurance up Not covered
Prescription drugs to $150 per visit
For the drugs itself dispensed in the office thru infusion/injection

Diagnostic Services No charge Not covered
Lab: No charge Not covered
Office No charge Not covered
Freestanding Lab
Outpatient Hospital

X-ray: No charge Not covered
Office No charge Not covered
Freestanding Radiology Center No charge Not covered
Outpatient Hospital

Advanced diagnostic imaging (for example, MRI/PET/CAT scans): $100 copay per test Not covered
Office $100 copay per test Not covered
Costs may vary by site of service. $100 copay per test Not covered
Freestanding Radiology Center
Costs may vary by site of service.
Outpatient Hospital
Costs may vary by site of service.

Page 2 of 5

Covered Medical Benefits Cost if you use an Cost if you use a
In-Network Non-Network
Emergency and Urgent Care Provider Provider
Emergency room facility services
This is for the hospital/facility charge only. The ER physician charge may be $100 copay per visit Covered as In-Network
separate. Copay waived if admitted.
Emergency room doctor and other services No charge Covered as In-Network
$100 copay per trip Covered as In-Network
Ambulance (air and ground) for ground and air
$10 copay per visit Covered as In-Network
Urgent Care (office setting)
Copay waived if admitted. Costs may vary by site of service. $10 copay for Not covered
non-preventive visit
Outpatient Mental/Behavioral Health and Substance Abuse
Doctor office visit No charge Not covered

Facility visit: No charge Not covered
Facility fees No charge Not covered
No charge Not covered
Outpatient Surgery
Facility fees: No charge Not covered
Hospital No charge Not covered
Freestanding Surgical Center
Doctor and other services $10 copay per visit Not covered

Hospital Stay (all inpatient stays including maternity, mental /
behavioral health, and substance abuse)

Facility fees (for example, room & board)
Doctor and other services

Recovery & Rehabilitation
Home health care
Coverage for In-Network Provider is limited to 100 visit limit per benefit
period.

Page 3 of 5

Covered Medical Benefits Cost if you use an Cost if you use a
In-Network Non-Network
Provider Provider

Rehabilitation services (for example, $10 copay per visit Not covered
physical/speech/occupational therapy): $10 copay per visit
$10 copay per visit Not covered
Office
Coverage for In-Network Provider is limited to 60 day limit per benefit Not covered
period for Physical, Occupational and Speech Therapy combined. Costs may
vary by site of service. Chiropractor visits count towards your physical and Not covered
occupational therapy limit. Not covered
Outpatient hospital Not covered
Coverage for In-Network Provider is limited to 60 day limit per benefit Not covered
period for Physical, Occupational and Speech Therapy combined. Costs may Not covered
vary by site of service. Not covered
Habilitation services
Habilitation and Rehabilitation visits count towards your Rehabilitation
limit.

Cardiac rehabilitation $10 copay per visit
Office $10 copay per visit
Outpatient hospital

Skilled nursing care (in a facility) No charge
Coverage for In-Network Provider is limited to 100 day limit per benefit period.

Hospice No charge

Durable Medical Equipment 20% coinsurance

Prosthetic Devices No charge

Page 4 of 5

Notes:
 This Summary of Benefits has been updated to comply with federal and state requirements, including
applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance
and clarification on the new health care reform laws from the U.S. Department of Health and Human Services,
Department of Labor and Internal Revenue Service, we may be required to make additional changes to this
Summary of Benefits. This Summary of Benefits, as updated, is subject to the approval of the California
Department of Insurance and the California Department of Managed Health Care (as applicable).
 In addition to the benefits described in this summary, coverage may include additional benefits, depending
upon the member's home state. The benefits provided in this summary are subject to federal and California
laws. There are some states that require more generous benefits be provided to their residents, even if the
master policy was not issued in their state. If the member's state has such requirements, we will adjust the
benefits to meet the requirements.
 Your plan requires a selection of a Primary Care Physician. Your plan requires a referral from your Primary
Care Physician for select covered services.
 Preventive Care Services includes physical exam, preventive screenings (including screenings for cancer, HPV,
diabetes, cholesterol, blood pressure, hearing and vision, immunization, health education, intervention services,
HIV testing) and additional preventive care for women provided for in the guidance supported by Health
Resources and Service Administration.
 For Medical Emergency care rendered by a Non-Participating Provider or Non-Contracting Hospital,
reimbursement is based on the reasonable and customary value. Members may be responsible for any amount
in excess of the reasonable and customary value.
 If your plan includes an emergency room facility copay and you are directly admitted to a hospital, your
emergency room facility copay is waived.
 Certain services are subject to the utilization review program. Before scheduling services, the member must
make sure utilization review is obtained. If utilization review is not obtained, benefits may be reduced or not
paid, according to the plan.
 Additional visits maybe authorized if medically necessary. Pre-service review must be obtained prior to
receiving the additional services.
 Skilled Nursing Facility day limit does not apply to mental health and substance abuse.
 Respite Care limited to 5 consecutive days per admission.
 Freestanding Lab and Radiology Center is defined as services received in a non-hospital based facility.
 Infertility services are not included in the out of pocket amount.
 Coordination of Benefits: The benefits of this plan may be reduced if the member has any other group health
or dental coverage so that the services received from all group coverage do not exceed 100% of the covered
expense
 For additional information on limitations and exclusions and other disclosure items that apply to this plan, go
to https://le.anthem.com/pdf?x=CA_LG_HMO
 For additional information on this plan, please visit sbc.anthem.com to obtain a Summary of Benefit Coverage.

Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem
Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

Questions:(855) 333-5730 or visit us at www.anthem.com/ca
CA/L/F/HMO/ D – LH2047/01-18/Printed 12-17

Page 5 of 5

Get paid to shop. Really!

You’re invited to join this unique rewards program that gives
Anthem members up to 15% cash back on purchases.

Here’s why this is no ordinary rewards program:
} You get serious cash back from PayForward – we’re talking up to 15% instant1 cash back when you shop at more
than 60,000 participating retailers — online and in stores like Home Depot, The Gap and Target.com.2
} You can link your own eligilble3 debit or credit card – so it’s amazingly easy! And if you already have rewards on your current
card, that’s great — you get them, plus PayForward’s.

Easy, right? It gets even better.
Once you’ve earned the cash, you decide how to use it!

Spend it Save it Share it

however you like on in your PayForward account or with friends or family, or donate
whatever you want. transfer it to your bank account. it to charity — with no fees.

You can even use rewards toward health care expenses!

Sock away reward dollars in the Anthem Health Wallet that comes with your PayForward account.
Use it to help pay for things like copays, coinsurance and deductibles!

The best part? This program is absolutely free to join — Here’s how to sign up:
and you won’t find it with any other health plan. For more
details, check out our video at payforward.com 1. Register through the PayForward app or online at
payforward.com

2. Link up your existing eligible3 debit or credit cards.
3. Shop away and watch rewards roll in.

1 Cash back is awarded at the time a transaction posts to PayForward, not when the purchase is made. Please see legal disclosures at payforward.com for details.
2 Examples of brands currently undergoing approval process.
3 Most types of Visa or MasterCards and signature-based transactions at participating merchants are eligible for the PayForward cash back program. Please see legal disclosures at payforward.com for details.
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.

65925CAMENABC VPOD Rev 09/17

Cash-back Rewards From PayForward

Frequently asked questions

Who is PayForward? Is there an app?

PayForward is an Anthem partner. They’ve developed a Yes, you can download the PayForward
unique rewards program where Anthem members can earn app from the iTunes® store for Apple
up to 15% cash back on purchases at more than 60,000 devices, or from Google PlayTM for
participating retailers. Android devices.

Why is Anthem partnering with PayForward? How do I earn cash back?

At Anthem, our goal is to focus on the whole health of our There are three ways to earn cash back from PayForward
members. This program offers a simple way to earn cash participating retailers:
back on everyday purchases you already make, which can
help to relieve stress and improve emotional well-being. If 1. Shop online — through the PayForward app or online
you wish, you can also use rewards to help pay for health at payforward.com. Select “Shop now”
care expenses, which we know can be a challenge for below the name of the store and it will forward you to
many people. the store’s website. Pay using any of your linked credit
or decit card(s) to make sure you get your cash
Does it cost anything to enroll or earn cash back? back rewards.

No, you can enroll, earn cash back, and donate funds with 2. Swipe your card — use your linked credit or debit
no fees. card(s) at your participating local store. Just remember
to select the “credit” option if you’re using a debit card.
How do I sign up?
3. Use mobile pay — when you’re in a store that uses
The easiest way is to enroll through the PayForward app. You mobile pay, just click the notification or open the
can also register online at payforward.com, just click “Sign PayForward app to pay in seconds.
up” in the upper right corner of your screen to
get started. Where can I shop to earn cash back?

You’ll need a few things to verify that you’re an Anthem PayForward has 60,000 participating retailers, and the list
member, like your zip code and date of birth. You’ll also is growing. This includes retailers like Home Depot, The
need the information to link any eligible1 debit or credit Gap and Target.com and more.2 For local merchants, enter
card(s) you already have. It only takes a few minutes, and your zip code or city in the app or online, and it will show
then you can start earning rewards. you the participating retailers in the area.

How much can I earn?

You can earn up to 15% cash back on purchases at
PayForward’s participating stores. There is no maximum on
how much cash back you can earn!

67324CAMENABC VPOD Rev. 09/17

How can I use my cash back? How do I send money to a friend or family member?

You can use it three different ways: Log into your account online at payforward.com. Click the
magnifying glass in the upper right corner, then enter a
1. Spend it — If you use mobile pay, you can use your friend or family member’s name in the search box. Click on
rewards to cover part or all of your purchase. their name, then “Send Money.” They must be a PayForward
member.
2. Save it — Link a bank account, then transfer funds back
and forth anytime. You can also save funds to your If they are an Anthem member but haven’t joined
Anthem Health Wallet. You can have some or PayForward yet, select “Invite/Suggest” to establish a
all of your rewards transferred there and use it to connection. Once you are connected, you can send money
help pay for health care costs such as copays, through the app or website.
deductibles, medications, and more.
How can I check my rewards balance?
3. Share it — You can transfer funds to a friend or You can check your balance on the PayForward app or
family member who is also a PayForward member, or online at payforward.com.
donate it to charity.
Can I keep earning rewards if I switch plans?
Do I need a special credit or debit card?
Yes, you can continue earning rewards from PayForward
No, you can use any eligible1 credit or debit card you as long as you are an Anthem member in an eligible plan.
already have. However, no other health care carrier offers this program,
so if you switch to another insurer, you will no longer be
Can I link a credit or debit card that has other rewards, able to earn rewards. But any rewards you’ve already earned
like miles or cash back? are yours to keep.

Yes! You can continue earning any rewards your card Is it available for all Anthem members?
already offers AND PayForward’s at the same time.
PayForward is available to Anthem members who have a
How soon after I shop do I earn my rewards? large or small group medical plan. Members who have an
Individual/Family, Medicare, Medicaid, or Specialty
Most of the time, it will be posted to your account within standalone plan are not eligible at this time.
seconds of making your purchase. But it can sometimes take
longer, depending on when the retailer lets PayForward know How does the Anthem Health Wallet work?
you’ve made the purchase. Occasionally the merchant has
some kind of delay in processing your transaction. But as When you sign up, you’ll automatically have an Anthem Health
soon as they post it to PayForward, the rewards are yours! Wallet set up in your account. A certain percentage of cash
back rewards will be automatically saved in your Anthem
How do I donate rewards to charity? Health Wallet. You can increase or decrease this percentage
anytime, or move funds into or out of the wallet whenever you
You’ll find a list of charities on the PayForward app and like. Find yourself needing extra money to cover health care
online at payforward.com You can also set up a private or expenses? Just transfer the money you have saved in your
public cause to help with fundraising efforts — log into your wallet into your linked bank account. It’s that simple.
account online, select “Causes,” then “Create Cause.” If you want
to create a cause for a nonprofit or charitable organization, What if I need help or have more questions?
please email [email protected] or
[email protected]. You can find more questions and answers online at support.
payforward.com or contact PayForward Member Services
by email at [email protected] or by phone toll-free
at 844-944-9273.

1 Most types of Visa or MasterCards and signature-based transactions at participating merchants are eligible for the PayForward cash back program. Please see legal disclosures at payforward.com for details.
2 Examples of brands currently undergoing approval process.
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.

Overview of Benefits: Date Prepared: 01-12-2018
The Preferred Dentist Program was designed to help you get the dental care you need and help lower your costs.

You get benefits for a wide range of covered services — both in and out of the network. The goal is to deliver

affordable protection for a healthier smile and a healthier you.

Coverage Type In-Network: Out-of-Network:
% of Negotiated Fee % of R&C Fee1
Type A
Type B 100% 100%

80% 80%

Type C 50% 50%

Orthodontia 50% 50%
$50 (Type B & C) $50 (Type B & C)
Deductible:
Individual/Family* $2000 $1500
Annual Maximum
Benefit: Per Individual $1500 $1500
Orthodontia Lifetime
Maximum: Per Ortho applies to Adult and Child (Up to dependent age limit)
Individual

Understanding Your Dental Benefits Plan

With the MetLife Preferred Dentist Program you can visit the dentist of your

choice – an “in-network” dentist (a participating MetLife dentist) or an “out-of-

network” dentist.

 Plan benefits for in-network services are based on the percentage of the
Negotiated fee –the fee that in-network dentists have agreed to accept as
payment in full for covered services, subject to any co-payments,
deductibles, cost sharing and benefit maximums. Negotiated fees are
subject to change.

 Plan benefits for out-of-network services are based on a percentage of
the Reasonable and Customary (R&C) charge. If you choose a dentist
who does not participate in the network, your out-of-pocket expenses may
be more, since you will be responsible for paying any difference between
the dentist's fee and your plan's payment for the approved service. Please
refer to the Selected Covered Services and Frequency Limitations page of
this document for details regarding how R&C charges are defined under
this plan.

Certain plan benefits are based on a percentage of the negotiated fee. This is the amount that participating dentists
have agreed to accept as payment in full. If your plan benefits are based on a percentage of the Reasonable and
Customary (R&C) charges, your out-of-pocket expenses may be more, since you will be responsible for paying any
difference between the dentist's fee and your plan's payment for the approved service.

* If you are enrolled for dependent coverage, a maximum family deductible may apply.

Savings from enrolling in a dental benefits plan will depend on various factors, including the cost of the plan, how often participants visit the dentist
and the cost of services rendered.

© 2016 METLIFE, INC Page 1 of 7 Metropolitan Life Insurance Company, New York, NY
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2018-01-12_5576163_9999_9999 _Dental_19

Selected Covered Services and Frequency Limitations*

Type A 1 in 6 months.
 Oral Examinations 1 in 6 months.
 Cleanings Children to age 14 / 1 in 12 months.
 Fluoride Adult - 1 in 1 period / Children - 2 in 1 period separated by six
months.
 Bitewing X-rays 1 in 60 months.
4 in 1 year less the number of teeth cleanings.
 Full Mouth X-rays
 Periodontal Maintenance 1 per tooth in 14 years of a dependent child up to 14th birthday.
 Space Maintainers
 Sealants (1st & 2nd permanent molars)
Type B
 Emergency Palliative Treatment

 Periodontal Root Planing & Scaling 1 per quadrant in any 24 months period.

 Periodontal Surgery 1 in 36 months.
 Amalgam & Composite Fillings No Limit. Composites covered on all teeth.
 Simple Extractions

 Root Canal

 Surgical Extractions

 Repairs (Crowns)

Type C 1 in 36 months.
 Crowns 1 in 10 years.
 Dentures 1 in 10 years.
 Bridges

 Implants 1 in 60 months.

Orthodontia
 Dependent children are covered up to their 26th birthday.

 All dental procedures performed in connection with orthodontic treatment are payable as Orthodontia.

 Payments are on a repetitive basis.

 20% of the Orthodontia Lifetime Maximum will be considered at initial placement of the appliance and paid based
on the plan benefit’s coinsurance level for Orthodontia as defined in the Plan Summary.

 Orthodontic benefits end at cancellation of coverage.

The service categories and plan limitations shown in this document represent an overview of your plan benefits, but
are not a complete description of the plan. Before making any purchase or enrollment decision you should review the
certificate of insurance which is available through MetLife or your employer. In the event of a conflict between this
overview and your certificate of insurance, your certificate of insurance governs. Like most group dental insurance
policies, MetLife group policies contain certain exclusions, limitations and waiting periods and terms for keeping them
in force. The certificate of insurance sets forth all plan terms and provisions, including all exclusions and limitations.

*Alternate Benefits: Your dental plan provides that if there are two or more professionally acceptable dental treatment alternatives
for a dental condition, your plan bases reimbursement, and the associated procedure charge, on the least costly treatment
alternative. If you and your dentist have agreed on a treatment that is more costly than the treatment upon which the plan benefit is
based, you will be responsible for any additional payment responsibility. To avoid any misunderstandings, we suggest you discuss
treatment options with your dentist before services are rendered, and obtain a pretreatment estimate of benefits prior to receiving
certain high cost services such as crowns, bridges or dentures. You and your dentist will each receive an Explanation of Benefits
(EOB) outlining the services provided, your plan’s reimbursement for those services, and your out-of-pocket expense. Actual

© 2016 METLIFE, INC Page 2 of 7 Metropolitan Life Insurance Company, New York, NY
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2018-01-12_5576163_9999_9999 _Dental_19

payments may vary from the pretreatment estimate depending upon annual maximums, plan frequency limits, deductibles and
other limits applicable at time of payment.

1. The Reasonable and Customary charge is based on the lowest of the: "Actual Charge" (the dentist’s actual charge); or "Usual Charge" (the
dentist’s usual charge for the same or similar services); or "Customary Charge" (the 90th percentile charge of most dentists in the same geographic
area for the same or similar services as determined by MetLife).

© 2016 METLIFE, INC Page 3 of 7 Metropolitan Life Insurance Company, New York, NY
PEANUTS 2016 © United Feature Syndicate, Inc. L0717497231[exp0418][All States]

2018-01-12_5576163_9999_9999 _Dental_19



Exclusions

We will not pay Dental Insurance benefits for charges incurred for:
1. Services which are not Dentally Necessary, those which do not meet generally accepted standards of care for

treating the particular dental condition, or which We deem experimental in nature.
2. Services for which You would not be required to pay in the absence of Dental Insurance.
3. Services or supplies received by You or Your Dependent before the Dental Insurance starts for that person.
4. Services which are primarily cosmetic (For residents of Texas, see notice page section in your certificate).
5. Services which are neither performed nor prescribed by a Dentist except for those services of a licensed dental

hygienist which are supervised and billed by a Dentist and which are for:
 scaling and polishing of teeth; or
 fluoride treatments.
6. Services or appliances which restore or alter occlusion or vertical dimension.
7. Restoration of tooth structure damaged by attrition, abrasion or erosion.
8. Restorations or appliances used for the purpose of periodontal splinting.
9. Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco.
10. Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss.
11. Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work.
12. Missed appointments.
13. Services:
 covered under any workers’ compensation or occupational disease law;
 covered under any employer liability law;
 for which the employer of the person receiving such services is not required to pay; or
 received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital.
14. Services covered under other coverage provided by the Employer.
15. Temporary or provisional restorations.
16. Temporary or provisional appliances.
17. Prescription drugs.
18. Services for which the submitted documentation indicates a poor prognosis.
19. The following when charged by the Dentist on a separate basis:
 claim form completion;
 infection control such as gloves, masks, and sterilization of supplies; or
 local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide.
20. Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the
teeth due to chewing or biting of food.
21. Caries susceptibility tests.
22. Initial installation of a fixed and permanent Denture to replace one or more natural teeth which were missing
before such person was insured for Dental Insurance, except for congenitally missing natural teeth.
23. Other fixed Denture prosthetic services not described elsewhere in this certificate.
24. Precision attachments.
25. Adjustment of a Denture
26 Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal guards and night
guards.1
27 Diagnosis and treatment of temporomandibular joint (TMJ) disorders. This exclusion does not apply to residents
of Minnesota. 1
28. Repair or replacement of an orthodontic device.1
29. Duplicate prosthetic devices or appliances.
30. Replacement of a lost or stolen appliance, Cast Restoration, or Denture.
31. Intra and extraoral photographic images.

1 Some of these exclusions may not apply. Please see your plan design and certificate for details.

© 2016 METLIFE, INC Page 4 of 7 Metropolitan Life Insurance Company, New York, NY
PEANUTS 2016 © United Feature Syndicate, Inc. L0717497231[exp0418][All States]

2018-01-12_5576163_9999_9999 _Dental_19

COMMON QUESTIONS… IMPORTANT ANSWERS

Who is a participating dentist?
A participating dentist is a general dentist or specialist who has agreed to accept MetLife's negotiated fees as
payment in full for services provided to plan participants. Based on internal analysis by MetLife, negotiated fees
typically range from 15-45% below the average fees charged for the same services by dentists in the same
geographic area.

*Negotiated Fees refers to the fees that in-network dentists have agreed to accept as payment in full for covered services, subject to any co-
payments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change.

How do I find a participating dentist?
You can access a list of participating dentists with directions and mapping capabilities online at
www.metlife.com/dental or call 1-800-ASK-4-MET (800-275-4638) to have a list faxed or mailed to you based upon
the requested ZIP code. Please Note: Be sure to verify provider participation when you make your appointment.

May I choose a non-participating dentist?
Yes. You are always free to select the dentist of your choice. However, if you choose a dentist who does not
participate in the MetLife program, your out-of-pocket expenses may be greater, since you will be responsible to pay
for any difference between the dentist's fee and your plan's payment for the approved service. If you receive services
from a participating dentist, you are only responsible for the difference between the in-network fee for the service
provided and your plan's payment for the approved service. Please note: any plan deductibles must be met before
benefits are paid.

Can my dentist apply for participation in network?
Yes. If your current dentist does not participate in the MetLife network and you would like to encourage him or her to
apply, tell your dentist to visit www.metdental.com, or call 1-877-MET-DDS9 for an application. The website and
phone number are designed for use by dental professionals only.

How are claims processed?
Dentists may submit your claims for you, which means you have little or no paperwork. You can track your claims
online and even receive e-mail alerts when a claim has been processed. If you need a claim form, you can find one
online at www.metlife.com/dental or request one by calling 1-800-ASK-4-MET (800-275-4638).

Can I find out what my out-of-pocket expenses will be before receiving a service?
Yes. With pre-treatment estimates, you never have to wonder what your out-of-pocket expense will be. MetLife
recommends that you request a pre-treatment estimate for services in excess of $300 (This often applies to services
such as crowns, bridges, inlays, and periodontics). To receive a benefit estimate, simply have your dentist submit a
request for a pre-treatment estimate online at www.metdental.com or call 1-877-MET-DDS9 (638-3379). You and
your dentist will receive a benefit estimate online or by fax for most procedures while you are still in the office so you
can discuss treatment and payment options and have the procedure scheduled on the spot. Actual payments may
vary depending upon plan maximums, deductibles, frequency limits and other conditions at time of payment.

Do I need an ID card?
No, you do not need to present an ID card to confirm that you are eligible. You should notify your dentist that you
participate in MetLife's PDP. Your dentist can easily verify information about your coverage through a toll-free
automated Computer Voice Response system.

Do my dependents have to visit the same dentist that I select?
No, you and your dependents each have the freedom to choose any dentist.

If I do not enroll during my initial enrollment period can I still purchase Dental Insurance at a later date?
Yes, eligible employees who do not elect coverage during their 31-day application period may still elect coverage
later. Dental coverage elected after the 31-day application period is subject to the following waiting periods:*

• No waiting period for Preventive Services
• 6 months on Basic Restorative (Fillings)

© 2016 METLIFE, INC Page 5 of 7 Metropolitan Life Insurance Company, New York, NY
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2018-01-12_5576163_9999_9999 _Dental_19

• 12 months on all other Basic Services
• 24 months on Major Services
• 24 months on Orthodontia Services (if applicable)

*If the policy holder participates in a section 125 plan and has an annual open enrollment period, the dental coverage will not be subject to any waiting periods. Please consult your Benefits
Administrator or your certificate for this plan information.

Am I eligible for all benefits the first day of coverage?
Your plan may include benefit waiting periods. Please refer to the certificate of insurance or your Benefits
Administrator for details about the services that are subject to the waiting periods and the length of time they apply.

How can I learn about what dentists in my area charge for different procedures?
If you have MyBenefits you can access the Dental Procedure Tool. You can use the tool to look up average in- and
out-of-network fees for dental services in your area. * You’ll find fees for services such as exams, cleanings, fillings,
crowns, and more. Just log in at www.metlife.com/mybenefits.

* The Dental Procedure Fee Tool application is provided by VerifPoint, an independent vendor. Network fee
information is supplied to VerifPoint by MetLife and is not available for providers who participate with MetLife through
a third-party. Out-of-network fee information is provided by VerifPoint. This tool does not provide the payment
information used by MetLife when processing your claims. Prior to receiving services, pretreatment estimates through
your dentist will provide the most accurate fee and payment information

Can MetLife help me find a dentist outside of the U.S. if I am traveling?
Yes. Through MetLife’s International Dental Travel Assistance program1 you can obtain a referral to a local dentist by
calling 1-312-356-5970 (collect) when outside the U.S. to receive immediate care until you can see your dentist.
Coverage will be considered under your out-of-network2 benefits. Please remember to hold on to all receipts to submit
a dental claim.

1 International Dental Travel Assistance services are administered by AXA Assistance USA, Inc. Certain benefits provided under the Travel
Assistance program are underwritten by Virginia Surety Company, Inc. AXA Assistance and Virginia Surety are not affiliated with MetLife, and the
services and benefits they provide are separate and apart from the insurance provided by MetLife. Referral services are not available in all
locations.
2 Refer to your dental benefits plan summary your out-of-network dental coverage.

© 2016 METLIFE, INC Page 6 of 7 Metropolitan Life Insurance Company, New York, NY
PEANUTS 2016 © United Feature Syndicate, Inc. L0717497231[exp0418][All States]

2018-01-12_5576163_9999_9999 _Dental_19

© 2016 METLIFE, INC Page 7 of 7 Metropolitan Life Insurance Company, New York, NY
PEANUTS 2016 © United Feature Syndicate, Inc. L0717497231[exp0418][All States]

2018-01-12_5576163_9999_9999 _Dental_19

Life is
better in
focusT.M

Get access to the best in eye care and See why we’re consumers’ #1
eyewear with 741¥ 7JTJPO $BSF choice in vision care3.

As a VSP member, you have access to care from great eye Contact us. 800.877.7195
doctors, quality eyewear, and the affordability you deserve, vsp.com
all at the lowest out-of-pocket costs.

You’ll like what you see with VSP.

Value and Savings. You’ll enjoy more value and the lowest out-of-pocket
costs.

High Quality Vision Care. You’ll get the best care from a VSP network
doctor, including a WellVision Exam®—the most comprehensive exam
designed to detect eye and health conditions. Plus, when you see a VSP
network doctor, your satisfaction is guaranteed.

Choice of Providers. The decision is yours to make—choose a VSP
network doctor or any out-of-network provider.

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

Using your VSP benefit is easy.

Create an account at vsp.com. Once your plan is effective, review your
benefit information.
Find an eye doctor who’s right for you. Visit vsp.com or call 800.877.7195.
At your appointment, tell them you have VSP. There’s no ID card
necessary. If you’d like a card as a reference, you can print one on
vsp.com.
That’s it! We’ll handle the rest—there are no claim forms to complete when
you see a VSP provider.

Choice in Eyewear

From classic styles to the latest designer frames, you’ll find hundreds of
options. Choose from featured frame brands like bebe®, Calvin Klein,
Cole Haan, Flexon®, Lacoste, Nike, Nine West, and more.1 Visit vsp.com to
find a Premier Program location that carries these brands. Plus, save up to
40% on popular lens enhancements.2 Prefer to shop online? Check out all
of the brands at eyeconic.com®, VSP's preferred online eyewear store.

Your VSP Vision Benefits Summary

VSP XJMM provide you with an affordable eye care plan.

VSP Coverage Effective Date: 01/01/2018 VSP Provider Network: VSP Choice

Benefit Description Copay Frequency

Your Coverage with a VSP Provider

WellVision Exam Focuses on your eyes and overall wellness $10 Every 12 months

Prescription Glasses $130 allowance for a wide selection of frames $25 See frame and lenses
Frame $150 allowance for featured frame brands Every 24 months
Lenses 20% savings on the amount over your allowance Included in Every 12 months
Lens Enhancements $70 Costco® frame allowance Prescription Every 12 months
Single vision, lined bifocal, and lined trifocal lenses
Polycarbonate lenses for dependent children Glasses
Standard progressive lenses
Premium progressive lenses Included in
Custom progressive lenses Prescription
Average savings of 20-25% on other lens enhancements
Glasses
$55

$95 - $105
$150 - $175

Contacts (instead of $130 allowance for contacts; copay does not apply Up to $60 Every 12 months
glasses) Contact lens exam (fitting and evaluation)

Primary Eyecare Treatment and diagnosis of eye conditions like pink eye, vision loss $20 As needed
and monitoring of cataracts, glaucoma and diabetic retinopathy.
Limitations and coordination with medical coverage may apply. Ask
your VSP doctor for details.

Extra Savings Glasses and Sunglasses
Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details.
20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12
months of your last WellVision Exam.

Retinal Screening
No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam

Laser Vision Correction
Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities

Your Coverage with Out-of-Network Providers
Get the most out of your benefits and greater savings with a VSP network doctor. Your coverage with out-of-network providers will be less or you’ll
receive a lower level of benefits. Visit vsp.com for plan details.

Exam .............................................................................. up to $45 Lined Bifocal Lenses ........................................... up to $50 Progressive Lenses ............................................. up to $50
Frame ............................................................................ up to $70 Lined Trifocal Lenses ......................................... up to $65 Contacts .................................................................... up to $105
Single Vision Lenses ........................................... up to $30

VSP guarantees coverage from VSP network providers only. Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP,
the terms of the contract will prevail. Based on applicable laws, benefits may vary by location. In the state of Washington, VSP Vision Care, Inc., is the legal name of the corporation through which VSP
does business.

Contact us. 800.877.7195 | vsp.com

1. Brands/Promotion subject to change.
2. Savings based on network doctor's retail price and vary by plan and purchase selection; average savings determined after benefits are applied. Available only through VSP network doctors to VSP
members with applicable plan benefits. Ask your VSP network doctor for details.
3. Blueocean Market Intelligence National Vision Plan Member Research, 2014
©2017 Vision Service Plan. All rights reserved.
VSP, VSP Vision care for life, eyeconic.com, and WellVision Exam are registered trademarks, and "Life is better in focus." is a trademark of Vision Service Plan. Flexon is a registered trademark of Marchon
Eyewear, Inc. All other company names and brands are trademarks or registered trademarks of their respective owners.

Real Provider Choices

Looking for a network that offers true freedom of
choice in providers and eyewear, while lowering
out-of-pocket costs for your employees?
You're looking for VSP® Vision Care.

VSP Network Providers 81,000

Your employees can choose their provider from ACCESS POINTS
81,000 access points, including the largest national
network of independent doctors and over 5,000 Participating Retail Chains
participating retail chain locations.
Your employees get the convenience of popular
• Special savings for lowest out-of-pocket costs. retail chains like these and more.
• Extra $20 to spend on featured frame brands like

bebe®, Calvin Klein, Cole Haan, Flexon®, Lacoste,
Nike, Nine West, and more.

VSP Doctors

• 91% offer early morning, evening, and weekend
appointments. 24-hour access to emergency care.

• Integrated medical management with our Eye
Health Management Program®.

• VSP Premier Program gives members the most
out of their eye care experience at one location.

Eyeconic® Direct Pay Convenience

Employees have the option to browse and It's simple for your employees to use their
buy online at eyeconic.com®, an easy-to-use, out-of-network VSP benefits at Walmart® and
convenient online eyewear option from VSP. Sam's Club®. Employees say, “I have VSP,”
Eyeconic seamlessly connects employees and we do the rest. Hundreds of frames are
with the latest designer eyewear and the covered-in-full.

VSP doctor network.

Give your employees real provider choices with VSP.

©2017 Vision Service Plan. All rights reserved.
VSP, Eye Health Management Program, Eyeconic, and eyeconic.com are registered trademarks of Vision Service Plan. Flexon is a
registered trademark of Marchon Eyewear, Inc. All other company names and brands are trademarks or registered trademarks of
their respective owners. 2114 VCCL

Save Up to 60% on Brand-name Hearing Aids

Like vision loss, hearing loss can have a huge impact on your
quality of life. However, the cost of a pair of quality hearing aids
usually costs more than $5,000, and few people have hearing
aid insurance coverage.

TruHearing® makes hearing aids affordable by providing exclusive savings to Here’s how it works:
all VSP® Vision Care members. You can save up to 60% on a pair of hearing
aids with TruHearing. What’s more, your dependents and even extended Contact TruHearing.
family members are eligible, too. Call 877.396.7194. You and
your family members must
In addition to great pricing, TruHearing provides you with: mention VSP.
• Three provider visits for fitting and adjustments
• 45-day trial Schedule exam.
• Three-year manufacturer warranty for repairs and one-time loss TruHearing will answer
your questions and schedule
and damage replacement a hearing exam with a
• 48 free batteries per hearing aid local provider.

Plus, with TruHearing you’ll get: Attend appointment.
• Access to a national network of more than 3,800 hearing The provider will perform a
hearing exam, make a
healthcare providers recommendation, order
• Straightforward, nationally-fixed pricing on a wide selection of the latest the hearing aids through
TruHearing, and fit them
brand-name hearing aids for you.
• Deep discounts on batteries shipped directly to your door

Best of all, if you already have a hearing aid benefit from your health plan
or employer, you can combine it with TruHearing prices to reduce your
out-of-pocket expense even more!

Learn more about this VSP Exclusive Member Extra at
truhearing.com/vsp or, call 877.396.7194 with questions.

The relationship between VSP and TruHearing is that of independent contractors. VSP makes no endorsement, representations JOB#5007-16-VCXA 6/16
or warranties regarding any products or services offered by TruHearing, a third-party vendor. TruHearing is solely responsible for
the products or services offered by them. Savings based on a survey of national average retail hearing aid prices compared to
average TruHearing pricing. Actual customer savings will vary. Three follow-up visits must be used within one year after the date
of initial purchase. Forty-five-day trial and hearing aid returns, repairs, and replacements subject to provider and manufacturer
fees. For questions regarding fees, contact TruHearing customer service. Not available in the state of Washington.
©2016 Vision Service Plan. All rights reserved.
VSP is a registered trademark of Vision Service Plan. All other brands or marks are the property of their respective owners.

NCSTD1_Value�Employer Paid Short Term Disability Insurance
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�m�loyer Paid Short �erm Disability Insurance

Benefit Highlights

Desert Sands Public Charter

What is em�loyer �aid Employer paid short term disability insurance pays you a portion of your earnings if you
short term disability miss time at work because of a disabling illness or in�ury.
insurance? This highlight sheet is an overview of your employer paid short term disability insurance.
Once a group policy is issued to your employer, a certificate of insurance will be available
to explain your coverage in detail.

What is disability? Disability is defined in The Hartford’s contract with your employer. Typically, disability
means as a result of in�ury or sickness you are unable to perform with reasonable
continuity the essential duties necessary to pursue your usual occupation.

Am I eligible? You are eligible if you are an Active Full-Time Employee who works at least 30 hours per
week on a regularly scheduled basis.

How much coverage Your employer provides coverage that would pay you a benefit of 60� of your weekly
would I have? earnings. The maximum employer paid short term disability insurance benefit you could
receive is �1,386 per week.
When can I enroll? Earnings are defined as in The Hartford’s contract with your employer.

As an eligible employee, you are automatically covered by employer paid short term
disability insurance� you do not have to enroll.

When is it effective? Coverage goes into effect sub�ect to the terms and conditions of the policy. You must be
actively at work with your employer on the day your coverage takes effect.
How long do I have to wait Once you are approved for coverage, you will be eligible to collect your employer paid
before I can receive my short term disability insurance benefit starting on the 60TH day after your in�ury or 60TH day
benefit? of sickness. Your benefit could continue for up to 18 weeks.
If I�m disabled� can the Yes. As described on the following page, your weekly short-term benefit may be reduced
amount of my benefit be by other income you receive.
reduced?

Im�ortant Details
The following is an overview of your employer paid short term disability insurance. Once a group policy is issued to your
employer, a certificate of insurance will be available to explain your coverage in detail.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford 79815-0
Life Insurance Company, Hartford Life and Accident Insurance Company and Hartford Fire Insurance Company. Home
Office is Hartford, CT.

Desert Sands Public Charter NCSTD BHS
00079815

Creation Date: 1/17/2018
Page 1 of 2

Version 11/12

�����������
You cannot receive employer paid short term disability insurance benefit payments for disabilities that are caused or
contributed to by:

• war or act of war (declared or not)
• the commission of, or attempt to commit a felony
• an intentionally self-inflicted in�ury
• any case where your being engaged in an illegal occupation was a contributing cause to your disability
• sickness or in�ury for which workers� compensation benefits are paid, or may be paid, if duly claimed
• any in�ury sustained as a result of doing any work for pay or profit for another employer
You must be under the regular care of a physician to receive benefits.
Your benefit payments will be reduced by other income you receive or are eligible to receive due to your disability, such as:
• Social Security disability insurance (please see next section for exceptions)
• workers� compensation
• other employer-based insurance coverage you may have
• unemployment benefits
• settlements or �udgments for income loss
• retirement benefits that your employer fully or partially pays for (such as a pension plan)
Your benefit payments will not be reduced by certain kinds of other income, such as:
• retirement benefits if you were already receiving them before you became disabled
• retirement benefits you start to receive that are funded by your after-tax contributions
• your personal savings, investments, I��s or �eoghs
• profit-sharing
• personal disability policies
• Social Security increases
This benefit highlights sheet is an overview of the employer paid short term disability insurance being offered and is provided
for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued. Only the
insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations
and exclusions of your insurance coverage. In the event of any difference between the benefit highlights sheet and the
insurance policy, the terms of the insurance policy apply.

Desert Sands Public Charter NCSTD BHS 79815-0
00079815

Creation Date: 1/17/2018
Page 2 of 2

Version 11/12

NCLTD1_Value�Employer Paid Long Term Disability Insurance
This this text box here. A post process uses the text above to do a
"Find/Replace" of variable text and the header.
Template: NCLTD_BHS

�m�loyer Paid �ong �erm Disability Insurance

Benefit Highlights

Desert Sands Public Charter

What is em�loyer �aid long Employer paid long term disability insurance pays you a portion of your earnings if you
term disability insurance? miss time at work because of a disabling illness or in�ury.
This highlight sheet is an overview of your employer paid long term disability insurance.
Once a group policy is issued to your employer, a certificate of insurance will be available
to explain your coverage in detail.

What is disability? Disability is defined in The Hartford’s contract with your employer. Typically, disability
means that you cannot perform with reasonable continuity the essential duties necessary
to pursue your usual occupation in the usual or customary way. Once you have been
disabled for 24 months following the elimination period, you are unable to engage with
reasonable continuity in any occupation.

Am I eligible? You are eligible if you are an Active Full-Time Employee who works at least 30 hours per
week on a regularly scheduled basis.

How much coverage Your employer provides coverage that pays you a benefit of �0� of your earnings to a
would I have? maximum monthly benefit of ��,000 per month. This plan includes a minimum benefit of
the greater of: 10� of the benefit based on monthly income loss before the deduction of
When can I enroll? other income benefits or �100 per month. Earnings are defined as in The Hartford’s
contract with your employer.
As an eligible employee, you are automatically covered by employer paid long term
disability insurance� you do not have to enroll.

When is it effective? Coverage goes into effect sub�ect to the terms and conditions of the policy. You must be
How long do I have to wait actively at work with your employer on the day your coverage takes effect.
You must be disabled for at least 180 days before you can receive an employer paid long
before I can receive my term disability insurance benefit payment.
benefit?

Can the duration or Yes. Your benefit duration may be reduced once you reach certain ages as specified in
amount of my benefit be The Hartford’s contract with your employer. In addition, as described below within the
important details, your monthly long-term benefit may be reduced by other income you
reduced? receive.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford 79815-0
Life Insurance Company, Hartford Life and Accident Insurance Company and Hartford Fire Insurance Company. Home
Office is Hartford, CT.

Desert Sands Public Charter NCLTD BHS
00079815

Creation Date: 1/17/2018
Page 1 of 3

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How long will my If you become disabled prior to age 63, benefits may continue for as long as you remain
�i���ility ��yment� disabled or until the greater of your Social Security normal retirement age or 3.5 years. If
your disability occurs at age 63 or above, the number of payments may reduce.
continue?

�m�o�t�nt �et�il�
The following is an overview of your employer paid long term disability insurance. Once a group policy is issued to your
employer, a certificate of insurance will be available to explain your coverage in detail.
��clu�ion��
You cannot receive employer paid long term disability insurance benefit payments for disabilities that are caused or
contributed to by:

• war or act of war (declared or not)
• the commission of, or attempt to commit a felony
• an intentionally self-in�icted in�ury
• any case where your being engaged in an illegal occupation was a contributing cause to your disability
You must be under the regular care of a physician to receive benefits.

�ent�l �llne��� �lco�oli�m �n� �u��t�nce ��u�e�
• You can receive benefit payments for long-term disabilities resulting from mental illness, alcoholism and substance abuse
for a total of 24 months for all disability periods during your lifetime.
• Any period of time that you are confined in a hospital or other facility licensed to provide medical care for mental illness,
alcoholism and substance abuse does not count toward the 24 months lifetime limit.

��e�e�i�ting �on�ition��
This policy will not provide coverage for any period of Disability beginning within the first 12 months of the effective date of
your coverage under this policy if the period of disability is caused by or substantially contributed to by a pre-existing
condition or the medical or surgical treatment of a Pre-existing condition.
You have a Pre-existing condition if:

• You received medical treatment, care or services for a diagnosed condition or took prescribed medication for a
diagnosed condition in the 3 months immediately prior to the effective date of coverage under this Insurance� or

• You suffered from a physical or mental condition, whether diagnosed or undiagnosed, which was misrepresented or
not disclosed in your application and

• for which you received a physician’s advice or treatment within 3 months before the date of your coverage under this
policy� or

• which caused symptoms within 3 months before the date of issue for which a prudent person would usually seek
medical advice or treatment.

Your benefit payments will be reduced by other income you receive or are eligible to receive due to your disability, such as:
• Social Security disability insurance (please see next section for exceptions)
• workers� compensation
• other employer-based insurance coverage you may have
• unemployment benefits
• settlements or �udgments for income loss
• retirement benefits that your employer fully or partially pays for (such as a pension plan)

Your benefit payments will not be reduced by certain kinds of other income, such as:
• retirement benefits if you were already receiving them before you became disabled
• retirement benefits that are funded by your after-tax contributions
• your personal savings, investments, I�As or �eoghs
• profit-sharing
• most personal disability policies
• Social Security increases

Desert Sands Public Charter NCLTD BHS 79815-0
00079815

Creation Date: 1/17/2018
Page 2 of 3

Version 11/12

This benefit highlights sheet is an overview of the employer paid long term disability insurance being offered and is
provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued.
Only the insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms,
conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the benefit
highlights sheet and the insurance policy, the terms of the insurance policy apply.

Desert Sands Public Charter NCLTD BHS 79815-0
00079815

Creation Date: 1/17/2018
Page 3 of 3

Version 11/12



EEBL1_Value�Basic Life and AD&D Insurance
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"Find/Replace" of variable text and the header.
Template: Basic_Life_BHS_NE-FS

�asic �ife and AD�D Insurance

Benefit Highlights

Desert Sands Public Charter

What is basic life and Your employer provides, at no cost to you, basic life and AD&D insurance in an amount
AD�D insurance? e�ual to �50,000. Life insurance pays your beneficiary (please see below) a benefit if you
die while you are covered.
This highlight sheet is an overview of your basic life and AD&D insurance. Once a group
policy is issued to your employer, a certificate of insurance will be available to explain your
coverage in detail.

Am I eligible? You are eligible if you are an Active Full-Time Employee who works at least 30 hours per
week on a regularly scheduled basis.

When can I enroll? As an eligible employee, you are automatically covered by basic life and AD&D insurance�
you do not have to enroll. If you have not already done so, you must designate a
beneficiary as described below.

When is it effective? Coverage goes into effect sub�ect to the terms and conditions of the policy. You must be
actively at work with your employer on the day your coverage takes effect.

�enefit �eductions Your benefit will reduce by �5� at age �5, then by an additional �0� at age 70 and an
additional 20� at age 75. Reductions are based off of the already reduced benefit amount
and are rounded to the next higher increment of �500. All coverage cancels at retirement.

What is a beneficiary? Your beneficiary is the person (or persons) or legal entity (entities) who receives a benefit
payment if you die while you are covered by the policy. You must select your beneficiary
when you complete your enrollment application� your selection is legally binding.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford 79815-0
Life Insurance Company, Hartford Life and Accident Insurance Company and Hartford Fire Insurance Company. Home
Office is Hartford, CT.

Desert Sands Public Charter Basic NE-FS Life BHS
00079815

Creation Date: 1/17/2018
Page 1 of 2

Version 11/12

���� �overage AD&D provides benefits due to certain in�uries or death from an accident. The covered
in�uries or death can occur up to ��5 days after that accident. The insurance pays

• 100� of the amount of coverage you purchase in the event of accidental loss of life,
two limbs, the sight of both eyes, one limb and the sight of one eye, or speech and
hearing in both ears or �uadriplegia.

• 75� for paraplegia or triplegia (paralysis of three limbs).
• One-half (50�) for accidental loss of one limb, sight of one eye, or speech or hearing

in both ears or hemiplegia.
• One-�uarter (25�) for accidental loss of thumb and index finger of the same hand or

uniplegia.
�our total benefit for all losses due to the same accident will not be more than 100� of the
amount of coverage you purchase.

�an I �ee� �� �es, sub�ect to the contract, you have the option of:
life coverage if I leave • Converting your group life coverage to your own individual policy (policies).

�� e��lo�er�

What is the Living If you are diagnosed as terminally ill with a 12 month life expectancy, you may be eligible
�enefits ��tion� to receive payment of a portion of your life insurance. The remaining amount of your life
insurance would be paid to your beneficiary when you die.

I��ortant �etails
As is standard with most term life insurance, this insurance coverage includes certain limitations and exclusions:
• the amount of your coverage may be reduced when you reach certain ages.

AD&D insurance does not cover losses caused by or contributed by:

• sickness� disease� or any treatment for either� • in�ury sustained while in the armed forces of any
• any infection, except certain ones caused by an country or international authority�

accidental cut or wound� • taking prescription or illegal drugs unless prescribed
• intentionally self-in�icted in�ury, suicide or suicide for or administered by a licensed physician�

attempt� • in�ury sustained while committing or attempting to
• war or act of war, whether declared or not� commit a felony�

• the in�ured person�s intoxication.

Other exclusions may apply depending upon your coverage. Once a group policy is issued to your employer, a certificate of
insurance will be available to explain your coverage in detail.
This benefit highlights sheet is an overview of the insurance being offered and is provided for illustrative purposes only and is
not a contract. It in no way changes or affects the policy as actually issued. Only the insurance policy issued to the policyholder
(your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your insurance
coverage. In the event of any difference between the benefit highlights sheet and the insurance policy, the terms of the
insurance policy apply.

Desert Sands Public Charter Basic NE-FS Life BHS 79815-0
00079815

Creation Date: 1/17/2018
Page 2 of 2

Version 11/12

Can I keep my Life coverage Yes, subject to the contract, you have the option of:
if I leave my employer? • Converting your group Life coverage to your own individual policy (policies).
• If you leave your employer, Portability is an option that allows you to continue your Life
What is the Living Benefits
Option? Insurance coverage. To be eligible, you must terminate your employment prior to Social
Security Normal Retirement Age. This option allows you to continue all or a portion of your
Do I still pay my Life Life Insurance coverage under a separate Portability term policy. Portability is subject to a
Insurance premiums if I minimum of $5,000 and a maximum of $250,000 and does include coverage for your
Spouse or Domestic Partner and Child(ren) . To elect Portability, you must apply and pay
become disabled? the premium within 31 days of the termination of your Life Insurance. Evidence of
Insurability will not be required.
Dependent Spouse or Domestic Partner Portability is subject to a maximum of $50,000.
Dependent Child Portability is subject to a maximum of $10,000.

If you are diagnosed as terminally ill with a 12 month life expectancy, you may be eligible to
receive payment of a portion of your Life Insurance. The remaining amount of your Life
Insurance would be paid to your beneficiary when you die.

If you become totally disabled before age 60 and your disability lasts for at least 9 months, your
Life Insurance premium may be waived. The premium for your dependent’s coverage will also
be waived if you are disabled and approved for waiver of premium. Coverage for your
dependents will end if the policy terminates.

Important Details
As is standard with most term life Insurance, this Insurance coverage includes limitations and exclusions:

• The amount of your coverage may be reduced when you reach certain ages.
• Death by suicide (two years).
Other exclusions may apply depending upon your coverage. Once a group policy is issued to your employer, a certificate of Insurance
will be available to explain your coverage in detail.

This Benefit Highlights Sheet is an overview of the Insurance being offered and is provided for illustrative purposes only and is not a
contract. It in no way changes or affects the policy as actually issued. Only the Insurance policy issued to the policyholder (your
employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your Insurance coverage. In the event
of any difference between the Benefit Highlights Sheet and the Insurance policy, the terms of the Insurance policy apply.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company.
Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Office of both companies: Simsbury, CT. All benefits are subject to the terms and conditions of the policy. Policies
underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued.

Hartford Life and Accident Insurance Company (HLA) Newly Eligible
Rev 03/08

34092-0
Page 3 of 8



VADDA1_Value|Voluntary Accidental Death and Dismemberment Insurance
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riable text and the header.
Template: Bhs_add_ep4

Voluntary Accidental Death and Dismemberment Insurance

Benefit Highlights

What is Voluntary Accidental Voluntary Accidental Death and Dismemberment Insurance pays your beneficiary (please see
Death and Dismemberment below) a death benefit if you die due to a covered accident while you are insured. It also pays
Insurance? you a benefit for certain accidental losses. Once a group policy is issued to your employer, a
certificate of Insurance will be available to explain your coverage in detail.
Why do I need Voluntary
Accidental Death and • Death benefits are paid in addition to any life Insurance benefits.
Dismemberment • Voluntary Accidental Death and Dismemberment Insurance pays benefits for accidental
Insurance?
What does Voluntary loss of limbs, thumb and index finger, speech, hearing, and sight.
Accidental Death and • Voluntary Accidental Death and Dismemberment Insurance covers losses that occur

Dismemberment Insurance away from work or at work. Benefits are paid regardless of any Worker’s Compensation
cover? benefits you collect.
This highlight sheet is an overview of your Voluntary Accidental Death and Dismemberment
What optional benefits has Insurance.
my Employer selected as
part of my Voluntary The need to protect yourself and your family from the financial consequences of a severe injury,
Accidental Death and paralysis or death resulting from an accident at or outside of work is real. According to the
Dismemberment National Safety Council, about one in eight Americans is seriously injured in an accident each
Insurance? year1. Accident Insurance from The Hartford shields you and your family from income loss
whether at home or away from home.
1 National Safety Council: Report on Injuries in America, 2005.

You may receive benefits due to certain losses or death from an accident. The covered losses
or death can occur up to 365 days after that accident. The policy pays for:

• 100% of the amount of coverage you purchase in the event of accidental loss of life, or
speech and hearing in both ears.

• One-half (50%) for accidental loss of one hand or foot, sight of one eye, or speech or
hearing in both ears.

• One-quarter (25%) for accidental loss of thumb and index finger of the same hand.
Additionally, your Employer may have elected optional/supplemental benefits as part of your
AD&D coverage. Refer to the certificate of Insurance for further information.
Your total benefit for all losses due to the same accident will not be more than 100% of the
amount of coverage you purchase.

• Seat Belt & Air Bag

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company.
Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Office of both companies: Simsbury, CT. All benefits are subject to the terms and conditions of the policy. Policies
underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued.

Hartford Life and Accident Insurance Company (HLA) Newly Eligible
Rev 03/08

34092-0
Page 5 of 8

Am I eligible? You are eligible if you are an Active Full-Time Employee who works at least 30 hours per week
on a regularly scheduled basis.

When can I enroll? You must elect coverage within 31 days of your eligibility waiting period which is first of the
When is it effective? month following one month of employment.

How much Voluntary Coverage goes into effect subject to the terms and conditions of the policy. In no case will
Accidental Death and newly elected benefits become effective sooner than first of the month following one month of
Dismemberment Insurance employment. You must be Actively at Work with your employer on the day your coverage takes
effect.
can I purchase?
Does my coverage reduce You can purchase Voluntary Accidental Death and Dismemberment Insurance in increments of
$10,000.
as I get older? The maximum amount you can purchase cannot be more than 5 times your annual Earnings or
$500,000. Earnings are as defined in The Hartford’s contract with your employer.

Your benefit will reduce by 60% at age 75, and then by an additional 35% at age 80, 27% at
age 85, 20% at age 90, 15% at age 95 and 5% at age 100. Reductions are based off of the
already reduced benefit amount..

Do I have to provide medical No medical information is required. You are guaranteed the amount of coverage that you
information to receive select, subject to maximum amounts defined in your policy.
coverage?

What is a beneficiary? Your beneficiary is the person (or persons) or legal entity (entities) who receives a benefit
Are there other limitations to payment if you die while you are covered by the policy. You must select your beneficiary when
you complete your enrollment application; your selection is legally binding.
enrollment? You are automatically the beneficiary for any dependent coverage and for any AD&D losses
other than life.

This coverage, like most group benefit Insurance, requires that a certain percentage of eligible
Employees participate. If that group participation minimum is not met, the Insurance coverage
that you have elected may not be in effect.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company.
Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Office of both companies: Simsbury, CT. All benefits are subject to the terms and conditions of the policy. Policies
underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued.

Hartford Life and Accident Insurance Company (HLA) Newly Eligible
Rev 03/08

34092-0
Page 6 of 8

Voluntary Accidental Death You may also choose Voluntary Accidental Death and Dismemberment Insurance for your
and Dismemberment Spouse or Domestic Partner and/or dependent Children. Dependent coverage is available only
Insurance for your when you elect coverage for yourself.
dependents You may choose Voluntary Accidental Death and Dismemberment Insurance for your Spouse
or Domestic Partner in the following amounts:

• 50% of the amount you select for yourself if you do not have any Children whom you
cover under this Voluntary Accidental Death and Dismemberment Insurance policy.

• 40% if you have Children whom you cover under this Voluntary Accidental Death and
Dismemberment Insurance policy.

You may not elect coverage for your Spouse if your Spouse or Domestic Partner is already
covered as an Employee under this policy.
You may choose guaranteed Voluntary Accidental Death and Dismemberment Insurance for
each Child up to age 21 (age 24 if a student) in the following amounts:

• 15% of the amount you select for yourself if you do not have a Spouse or Domestic
Partner whom you cover under this Voluntary Accidental Death and Dismemberment
Insurance policy.

• 10% if you have a Spouse or Domestic Partner whom you cover under this Voluntary
Accidental Death and Dismemberment Insurance policy.

Important Details
As is standard with most Insurance, this Voluntary Accidental Death and Dismemberment Insurance includes limitations and exclusions.
Voluntary Accidental Death and Dismemberment Insurance does not cover losses caused by or contributed by:

• Sickness; disease; or any treatment for either; • Injury sustained while in the armed forces of any
• Any infection, except certain ones caused by an country or international authority;

accidental cut or wound; • Taking prescription or illegal drugs unless
• Intentionally self-inflicted injury, suicide or prescribed for or administered by a licensed
physician;
suicide attempt;
• War or act of war, whether declared or not; • Injury sustained while committing or attempting
to commit a felony;

• The injured person’s intoxication.

Other exclusions may apply depending upon the terms of your policy and other requirements. Once a group policy is issued to your
employer, a certificate of Insurance will be available to explain your coverage in detail.
This Benefit Highlights Sheet is an overview of the general purposes of the Voluntary Accidental Death and Dismemberment Insurance
being offered and is provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually
issued. Only the Insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions,
limitations and exclusions of your Insurance coverage. In the event of any difference between the Benefit Highlights Sheet and the
policy, the terms of the Insurance policy apply.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company.
Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Office of both companies: Simsbury, CT. All benefits are subject to the terms and conditions of the policy. Policies
underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued.

Hartford Life and Accident Insurance Company (HLA) Newly Eligible
Rev 03/08

34092-0
Page 7 of 8

Help protect your family’s financial future

What is long term care?
It is the type of care you may need if — due to an accident or serious illness— you are unable
to perform, without Substantial Assistance from another individual, two or more Activities of
Daily Living such as:

• Eating • Dressing

• Bathing • Toileting
• Continence • Transferring

How does this coverage help?
Long Term Care Insurance provides benefits to help you pay for care provided by:

• Adult Day Care • Adult Day Care Facility
• Home Health Care • Alzheimer’s Facility

• Homemaker Services • Nursing Facility

• Hospice Services • Hospice Facility
• Personal Care • Residential Care Facility
• Respite Care • Rehabilitation Facility

What your employer is offering:
Your employer is providing you with a Plan 1 Benefit amount up to $3,000/month with a
Benefit Duration of 3 years. This includes Nursing, Residential, Home & Community Based
Care.

You have the option to enroll in additional coverage up to $8,000 with an unlimited Benefit
Duration. You can also elect coverage for your spouse and dependent children.

*Guaranteed Issue: You can elect up to $6,000 monthly benefit without answering any
medical questions if you enroll within your initial eligibility period.

*Evidence of Insurability: If you enroll in the period outside of your initial eligibility, an
evidence of insurability will be required. EOI is needed for all family coverage elected.

How to enroll:
You can learn more about coverage for you and your eligible family members by visiting the
enrollment site: http://unuminfo.com/dspc/index.aspx

SCHEDULE OF BENEFITS /
PLAN HIGHLIGHTS

Your Long Term Care (LTC) insurance plan is listed below.

Elimination Period: Your plan’s Elimination Period of 90 consecutive days is the amount of time you must
wait before benefits become payable. This time period must be satisfied only once during the life of your plan.

Newly Hired Employees – once eligible for the plan, will have 30 days to sign up for Guarantee Issue
coverage. Please check with your employer for your effective date.

All Active Employees & Newly Hired Employees – who enroll after the Guarantee Issue enrollment period
or choose benefits over the Guarantee Issue limits will be required to fill out a medical questionnaire.

Medical Underwriting Effective Date – The effective date for those applicants passing medical underwriting
between the 1st and 15th of the month is the first of the month following their date of approval. For those
approved between the 16th and the end of the month, their effective date is the first of the second month
following their date of approval.
Medical Underwriting means that you must answer all questions on a medical questionnaire. In some cases,
an interview may also be necessary.

Delayed Effective Date – If you are absent from work because you are injured, sick, temporarily laid off or on
a leave of absence, your coverage will not begin on your otherwise expected effective date.

Medical Underwriting for Employees and Family: (Completion of the Benefit Election Form is required for
enrollment). EMPLOYEES: Your employer funded basic plan, as well as additional benefit amounts of up to
and including $6,000 and a Facility Benefit Duration of 3 or 6 years, is being offered on a Guarantee Issue
basis. This does not require completion of the Long Term Care Insurance Application (medical questionnaire)
if you apply during your initial eligibility period. The Long Term Care Insurance Application (medical
questionnaire) is required if enrolling after your initial eligibility period or if you choose to buy $7,000, $8,000 or
the Unlimited Duration coverage. All Family Members must complete the Benefit Election Form and Long
Term Care Insurance Application (medical questionnaire) and must be approved for coverage in order to enroll
in the Long Term Care plan. All Medical Questionnaires must accompany a signed Authorization to Request
Medical Information Form #6720-03-CA located in the enrollment kit.

Benefit Duration 3 Years 6 Years Unlimited
Duration
Nursing Facility Benefit Amount $3,000 $3,000
Per $1,000 Increments to $8,000 to $8,000 $3,000
Residential Care Facility to $8,000
70% 70%
70%

Home and Community-Based Care 50% 50% 50%

Home, Community-Based and Immediate 50% 50% 50%

Family Member Care - Option

Inflation Protection * - Option Compound Compound Compound

Uncapped Uncapped Uncapped
* If you selected an inflation option, and you terminate that inflation option at a future date, you can purchase
the inflated coverage amount at your original age.

Lifetime Maximum: The Lifetime Maximum is the maximum benefit dollar amount Unum will pay over the life
of your coverage. This dollar amount is based on the Facility Benefit Amount and Benefit Duration. For
Example: If you choose $3,000 Facility Monthly Benefit Amount & 3 Year Duration, your Lifetime Maximum is
calculated as follows, $3,000 per Month X 12 Months X 3 Years = $108,000 Lifetime Maximum.

Insurance Age: Insurance Age is used to determine the cost of your coverage. Insurance Age is your age on
the plan effective date if you enroll for coverage prior to the plan effective date. If you enroll for coverage on or
after the plan effective date, insurance age is your age on the date you sign the enrollment form.

Questions: Please call 1-800-227-4165 with questions regarding your Long Term Care Insurance.











CRITICAL ILLNESS INSURANCE

not your finances HOSPITAL ADMISSION
BENEFIT
An antidote for expenses not covered by medical insurance
For Employees
Treatment of critical illnesses such as cancer, heart attack and stroke can lead to
unexpected expenses that create an additional financial burden. Critical Illness Fills the coverage and comfort
gap when a hospitalization
include travel to treatment centers, ongoing household bills, co-pays to occurs from a non-critical
experimental treatment, and everyday expenses like groceries, rent and illnesses:
mortgage.
Payment up to $250 per
How it works day that the insured is in
the hospital for any
Choose the level of coverage $5,000 to $25,000 that works best for you and condition other than a listed
your family. As an actively at work employee, you, your spouse and your critical illness
children can be covered (spouses and children covered at 50%).
Benefit duration:
10 days per year

Two day elimination period

Critical Illness insurance pays a lump-sum amount upon diagnosis of:

COVERED EVENTS STANDARD
1st Ever Occurrence 2nd Ever Occurrence

Cancer - Category 1 (invasive) 100% 50%

Heart Attack 100% 50%

Kidney Failure 100% 50%

Organ Transplant 100% 50%

Stroke 100% 50%

Cancer - Category 2 (non-invasive) 25% 0%

Coronary Artery Bypass Graft 25% 0%

This plan will also pay for additional occurrences*. The maximum benefit payable is 300% of the selected benefit
amount. Benefits reduce by 50% at age 70.

Group Number
503357

The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004

GUARDIAN® and the GUARDIAN G® logo are registered service marks of The Guardian Life Insurance Company of America and are used with express permission.
Page 1 of 2
Group Number 503357 is offering Guardian Critical Illness Insurance to its employees.

Semi-Monthly Premiums

Critical Illness with Hospital Admission Benefit Amount of $250 ($125 for Spouse or Child)

EMPLOYEE

Benefit <20 20-24 25-29 30-34 35-39 Age 45-49 50-54 55-59 60-64 65+
Amounts $3.95 $4.57 $5.31 $5.79 $6.29 40-44 $9.47 $12.04 $15.49 $20.74 $30.80
$5.10 $5.90 $6.86 $7.71 $8.87 $7.52 $15.02 $19.92 $26.27 $35.69 $52.52
$5,000 $6.25 $7.22 $8.41 $9.64 $11.44 $11.29 $20.57 $27.79 $37.04 $50.64 $74.25
$10,000 $7.40 $8.55 $9.96 $11.56 $14.02 $15.07 $26.12 $35.67 $47.82 $65.59 $95.97
$15,000 $8.55 $9.87 $11.51 $13.49 $16.59 $31.67 $43.54 $58.59 $80.54 $117.70
$20,000 $18.84
$25,000 $2.05 $2.30 $2.54 $22.62 $4.64 $6.01 $7.75
$2.71 $3.08 $3.50 $7.41 $9.95 $13.14
$3.37 $3.85 $4.47 SPOUSE $10.19 $13.89 $18.52
$4.03 $4.63 $5.43 $12.96 $17.92 $23.91
$2,500 $1.81 $4.70 $5.40 $6.39 $2.92 $3.60 $15.74 $21.76 $29.30 $10.42 $15.67
$5,000 $2.38 $4.20 $5.48 $17.90 $26.53
$7,500 $2.96 $5.49 $7.37 $25.37 $37.39
$10,000 $3.53 $6.78 $9.26 $32.85 $48.25
$12,500 $4.11 $8.07 $11.15 $40.32 $59.12

CHILD

$2,500 $1.62
$5,000 $1.76
$7,500 $1.90
$10,000 $2.03
$12,500 $2.17

*This policy will not pay benefits for a first ever occurrence of a critical illness that occurs less than 3 months
after the first ever occurrence of a different critical illness for which this plan paid benefits. If the employee has
exhibited symptoms or received treatment within the past 12 months of a critical illness, we do not pay benefits
for the second ever occurrence of that critical illness.

Guardian Critical Illness Insurance is underwritten by The Guardian Life Insurance Company of America, New York, NY. Products are not available in all
states. Policy limitations and exclusions apply. Optional riders and/or features may incur additional costs. Plan documents are the final arbiter of coverage.
Critical Illness Policy Form #GC-CI-11 et al.

Group Number
503357

The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004

GUARDIAN® and the GUARDIAN G® logo are registered service marks of The Guardian Life Insurance Company of America and are used with express permission.
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Group Number 503357 is offering Guardian Critical Illness Insurance to its employees.

2014-10332 Exp 8/16


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