Archdiocese of Kansas City

Plan Year: 2016

Employee Benefits Enrollment Guide

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Section Page 2016 Guide to Benefits 2 Effects of Health Care Reform 4 What’s Changing for 2016? 5 Enrollment Instructions 6 Archdiocese Online Benefits Portal 9 Cost to Participate 10 Health Benefits 11 Prescription Drug Benefits 12 Medication Management – Tria Health 13 Alere Oncology Case Management 15 Naturally Slim 16 Telemedicine through Teledoc 17 Dental Insurance 18 Vision Insurance 19 Life/Disability Benefits 20 Hartford Value Added Services 22 Voluntary Supplemental Life Insurance 24 Voluntary Whole Life Insurance 25 Voluntary Accident Insurance 26 Voluntary Critical Illness 27 Flexible Spending Accounts 28 Contact Information 30 Legal Notices 31 Summary of Benefits and Coverage (Health Plan) 36 Enrollment/Application Forms 45

Archdiocese Enrollment Form

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Welcome to the Archdiocese of Kansas City in Kansas’ 2016 guide to employee benefits! 2016 Open Enrollment Information This year OPEN ENROLLMENT begins on October 19th and ends on October 31st. Elections you make during open enrollment will become effective January 1, 2016. 2016 New Hire Enrollment Information Because all benefit options are voluntary, newly hired employees are required to enroll or waive enrollment in the Archdiocese benefits. You must complete an enrollment or waiver form within 31 days of your date of hire. Coverage in all benefits will begin first of the month following your date of hire. The Archdiocese offers you and your eligible family members a comprehensive and valuable benefits program. We encourage you to take the time to educate yourself about your options and choose the best coverage for you and your family. This guide describes your benefit options for 2016. Please read it carefully for important information you will need in order to make decisions about your benefit elections.

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Who is Eligible? An employee who works at least an average of 30 hours per week for the school or calendar year is eligible to participate in all of the Archdiocese Benefit Plans. You may elect coverage for your eligible dependents which include your legal spouse or dependent child(ren) (until the end of the calendar year in which they turn 26). If you work less than 30 hours a week, you may be eligible to participate in the Flexible Spending Accounts. Please see your local benefits administrator if you have questions.

How to Enroll Open enrollment will be completed via our online self-service portal again this year. Instructions can be found on page 6. New hires are asked to continue to use the paper enrollment form located in the back of this booklet. For both open enrollment and new hire enrollment, please remember, once you have made your elections, you will not be able to change them until the next open enrollment period unless you have a qualified change in status.

When to Enroll This year Open Enrollment begins October 19th and ends October 31st, 2015. During this period you may elect, change or waive coverage in the health, dental or vision plans. Open Enrollment is the only opportunity you have to enroll in the Humana voluntary worksite plans. All employees are encouraged to go online, review their benefits to ensure you are enrolled in the desired plans, and if you have any questions, contact your local Benefits Administrator. Your next opportunity to enroll or make changes in benefits will be the next Open Enrollment period, unless you have a qualifying status change. All part-time employees working 20 or more hours per week must also enroll online, verify your information and enroll/waive the flexible spending benefit.

How to Make Changes After your initial enrollment, you cannot make changes to the benefits you elect until the next open enrollment period unless you have a qualified change in status. Qualified changes in status include: birth, death, marriage, divorce, adoption of a child, change in child’s dependent status, or a significant change in benefits coverage for you or your spouse because of your spouse’s employment. A request for change in status must be received within 31 days of the event. If you wish to enroll or make changes to your Life and Disability benefits, you will be required to provide proof of insurability before the enrollment or change is approved. Please choose your benefits carefully. Employees who elect to pay for their benefits on a post-tax basis, may discontinue their elections at anytime. Should you choose to re-enroll, you may be subject to HIPAA Special Enrollment guidelines or furnish Evidence of Insurability.

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Effects of Health Care Reform Summary of Benefits and Coverage Under the Patient Protection and Affordable Care Act (PPACA), insurance companies and group health plans will provide consumers with a concise document detailing, in plain language, simple and consistent information about health plan benefits and coverage. This Summary of Benefits and Coverage (SBC) document will help consumers better understand the coverage they have and, for the first time, allow them to easily compare different coverage options. It will summarize the key features of the plan or coverage, such as the covered benefits, cost-sharing provisions, and coverage limitations and exceptions. A copy of the SBC can be found on page 36 of this booklet. Grandfathered Status The Archdiocese Health Plan is a “grandfathered health plan” under the PPACA. As permitted by PPACA, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the PPACA that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the PPACA, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the Human Resources office of the Archdiocese. Women’s Preventive Care Guidelines In August, 2011, the US Department of Health and Human Services (HHS) announced additional preventive care services, developed by the independent Institute of Medicine, to cover women’s preventive services without charging a copayment, coinsurance or a deductible. In addition to requiring 100% coverage for well-women visits and various types of screenings, the HHS has included coverage for FDA-approved contraception methods. The Archdiocese Health Plan is a “grandfathered health plan”, these guidelines will not apply as long as we maintain “grandfathered” status.

Even though the health plan is not required to comply with these guidelines, our health plan covers routine preventive services at 100% up to a $500 benefit maximum per calendar year for all members. Once the $500 maximum is met, all services are subject to applicable coinsurance and deductible. In addition, the health plan also covers one mammogram and one colonoscopy per calendar year at 100%, regardless if it is a routine or diagnostic service. Coverage for contraception is not included in our health plan.

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Please take the time to become familiar with the changes for our upcoming plan year so that you can make informed decisions about your benefit elections. And we hope you are pleased with the generous benefits package the Archdiocese continues to provide to your total compensation. Below is a brief description of the changes taking place:

Employee Premiums – No changes to employee contributions for 2016 on the Medical, Dental or Vision plans.

Medical and Prescription Drug Plan – The plan will renew with BlueKC with no benefit plan changes for 2016. We are pleased to announce the addition of a number of benefits available to those employees enrolled in the medical plan. Naturally Slim, Alere Oncology Case Management and Teledoc. These are available at no additional cost. More details can be found on pages 15-17 of this benefit guide.

Dental Plan – The plan will renew with Delta Dental with no benefit plan changes for 2016.

Vision Plan – The plan will renew with VSP with no benefit plan changes for 2016.

Life and Disability – The Basic Life and Long Term Disability insurance will continue as a shared voluntary plan paid 50% by the employee and 50% by the employer, but the plan will have a slight reduction in premium and it will be for Basic Life/AD&D, Basic Dependent Life and Long Term Disability insurance only.

Short Term Disability – Short term disability insurance will be provided to all Archdiocesan employees who are eligible for benefits at NO COST to the employee. The cost of this insurance will be shared by the employer and the Archdiocese

The value of our work at the Archdiocese of Kansas City in Kansas makes an impact within our community and we are committed to positively impact the lives of our employees and their families. With that in mind, the Archdiocese Benefit Plan is designed to recognize the diverse needs of our workforce. Because the Archdiocese self-insures the health and dental plans, our health care costs are driven by our own claims experience and utilization of services. Having self-insured benefit plans affords us greater control over our health and dental plan designs and also helps us eliminate large administrative costs and enhance our claims processing.

What’s Changing for 2016?

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Open Enrollment Instructions You will be passively enrolled for 2016 in your current benefits with the exception of the Flexible Spending Accounts. It is recommended that you login to review your 2016 elections but it is not required for the 2016 plan year if you are not planning on making any benefit changes. There are instances where we recommend that you login. These are:

a. You would like to enroll in either the Health Care or Dependent Care Flexible Spending Account for the 2016 calendar year

b. You would like to update your beneficiary designations for either the Basic Life/AD&D or Voluntary Supplemental Life

c. You would like to add, change or drop a benefit plan for 2016. There are two ways to start the enrollment process:

1. http://archkck.benergy.com User ID: ArchKCKLayEEs Password: benefits Once on the Archdiocese Human Resources page, please take a few minutes to review a variety of human resources benefit information they have posted. Then when you are ready to enroll, click on the HUMAN RESOURCES tab at the top of the page, scroll down and click OPEN ENROLLMENT.

2. Or you can go directly to HBC via https://www.devpb.com/demo

The OPEN ENROLLMENT tab or the above HBC link will direct you to the HBC login page that looks like this:

If you haven’t logged in before, ignore the log in box above and click the “CLICK HERE” on the Employees only sentence at the bottom of the page. You will now be redirected to a page where you will create a personal log in ID and password.

When finished creating your log in ID and password you will be redirected to the login screen. If you have used our self-service portal before, log in using your username and your password as indicated below. Your user name is last name, first name, a period and then the last four digits of your social security number. Ex. SmithJohn.1234 After you have successfully logged in, you will be directed to a page that looks like this:

Note: Be sure the Compatibility icon is blue if using Microsoft Internet Explorer.

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Open Enrollment Instructions (cont’d) Start by clicking the green “Start” button. This will take you through the steps to update your personal information. Please be sure to add any relevant personal contact information such as your phone number, e-mail address and any other sections that appear blank. Ignore the employee ID field. Continue through the enrollment system by clicking the green arrows. Pay close attention to your beneficiary designations. Keeping these updated is important because it determines how your final wishes are carried out. You should consider updating beneficiary designations if you have: changed your marital status, designated someone who is now deceased or designated someone that you no longer wish to be a beneficiary. After updating your personal information, click the green arrow to continue. A summary of the benefits you are currently enrolled in will appear. Depending on the benefits you are currently enrolled in, the screen will look something like this: You are now in a position to change your current benefits and add any benefits you are currently not enrolled in. Available benefits will appear one-by-one as you go through the enrollment system. You will be asked to “DECLINE COVERAGE” or “ADD TO CART.” Continue this process until you have either accepted or declined all remaining benefits. If you have questions, please don’t hesitate to ask your local Benefit Administrator or call Bill Defoor at Primebyte directly at 913-406-2101.

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New Hire Enrollment Instructions Please complete the enclosed enrollment forms and return to your local Benefits administrator within 31 days of your hire date – or the first day you are actively at work. For teachers or school administration under contract, your hire date is the first day of your contract period. Employee Benefits Enrollment Change Form

� Please be sure to print legibly � Complete 1st page with your (and your dependents to be covered) information

∗ Be sure to check the appropriate “Coverage Selected” box for each person to be covered under your Employer’s benefits.

� Health, Dental and Voluntary Vision – On page 2, select the Archdiocese benefits you wish to participate in by checking the appropriate box (Employee Only or Family Coverage). If not electing coverage, please check the WAIVE box.

� Flexible Spending Account / Pre-tax Premium Deductions – Check the box for the account you would like to participate in (or WAIVE).

∗ If enrolling in either the Health Care or Dependent Care account, please indicate both your annual election and per pay period amounts.

∗ Check the appropriate payroll frequency box. ∗ If enrolling, please complete the beneficiary designation section. ∗ If electing pre-tax premium deductions, premiums will continue to be deducted on a pre-

tax basis in subsequent years unless you change this election during Open Enrollment. � Basic Life and Long Term Disability Package – Select Employee Only or Family coverage

or check the WAIVE box. ∗ If enrolling, please complete the beneficiary designation section. ∗ If enrolling, completion of the Premium Calculation worksheet located on page 3 of the

enrollment form is required. ∗ If enrolling, please be sure to complete the beneficiary designation section.

� Voluntary Supplemental Life – Check the box next to the benefit you are electing and indicate the amount of life insurance for yourself, your spouse and eligible dependent children (or check WAIVE).

∗ You must be enrolled in the Basic Life package to purchase Voluntary Supplemental Life.

∗ If enrolling, completion of the Premium Calculation worksheet is required. ∗ If enrolling, please be sure to complete the beneficiary designation section.

Humana Voluntary Benefits (issued through Kanawha Insurance Company)

∗ These plans are only available for enrollment during the annual Open Enrollment period. Your next opportunity to enroll will be at the Open Enrollment period in October 2016.

∗ Voluntary Accident Insurance ∗ Voluntary Whole Life (Secure Life) ∗ Voluntary Critical Illness

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Your One-Stop BENEFITS, HEALTH & WELLNESS, AND HR RESOURCE The Archdiocese is pleased to continue to provide our employees with an online Communications Portal. Our Communications Portal is your one-stop benefits, health and wellness and HR resource that is available 24 hours a day, 7 days a week. You have online access to the information and tools you need to save time and effort – and make better informed benefits, health, and wellness decisions. Information will be updated frequently so you’ll want to visit the Communications Portal often.

The Communications Portal includes four centers working together: Benefits Center • Get detailed benefit plan information and use the decision support

tools, such as multimedia presentations about our benefits plans, tips on how to use our plan, and a plan comparison tool

• Check out the financial calculators, life event checklists, and informative articles on a wide range of benefits topics

Human Resources Center • Find relevant and timely company news and communications Health & Wellness Center • Helps you and your family assess health problems, prevent and

manage conditions, and live healthier lives • Award-winning content includes articles, images, videos, checklists,

health risk assessments, calculators, and interactive modelers • All of the information provided is reviewed by teams of unbiased

medical professionals

My Info Center • Create a personal health record to keep track of your doctors,

immunizations, tests and more • Subscribe to receive Synergy, our exclusive health and wellness e-

newsletter We hope this makes it easier for you to get to the information you are

looking for. (Our goal is to provide you with the information you need without the hassle…) Check it out today!

Go to http://archkck.benergy.com User ID: ArchKCKLayEEs Password: benefits OR Visit the Human Resources page on the Archdiocese website

at www.archkck.org

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Your Benefit Choices The Archdiocese provides a wide variety of benefits. Some are provided automatically at no cost to you. Check the list to the right and select the benefits that best meet your personal needs.

Cost to participate 2016 Premium Deductions The premiums for the Health, Dental and Vision plans will remain unchanged for 2016. Your employer will pay 60% of your cost to participate in the Health and Dental plans. The chart below shows your share of the 2016 monthly cost compared to the total cost. The Vision plan is a voluntary plan; therefore you are 100% responsible for the cost to participate.

Monthly Rates 2016 Employee Contribution

2016 Employer Contribution Total Cost

Health Plan (Includes RX) Single Family

$263.68 $556.36

$395.53 $834.54

$659.21

$1,390.90 Dental Plan

Single Family

$16.98 $40.13

$25.47 $60.20

$42.45

$100.33 Voluntary Vision Plan

Single Family

$9.26

$25.56

n.a. n.a.

$9.26

$25.56 For Married Couples Both Working for Participating Agencies within the Archdiocese Married couples, of which both parties are employed by a participating agency of the Archdiocese Health and Dental Plan and are eligible for benefits, will have the premium costs paid in full by the participating agency(ies). If one employer employs both parties of the married couple, that agency will pay the entire premium. If two agencies are involved, the full premium should be divided evenly between the two employing agencies. This policy pertains to all participating agencies, except those who have been given a “special exception” to the employer/employee premium ratio. Those exempted agencies will not be required to pay full premiums if both spouses work for the exempted institution, but will be required to share equally in the cost of the premium when one party of the couple works for some non-exempted participating agency of the Plan.

Benefit Who Pays the Cost? Medical/RX Coverage Employer & Employee

Voluntary Accident Insurance Employee

Dental Coverage Employer & Employee

Voluntary Vision Employee

Short Term Disability Archdiocese & Employer

Basic Life & Long Term Disability Package Employer & Employee

Voluntary Supplemental Life Employee

Voluntary Whole Life Employee

Voluntary Critical Illness Employee Flexible Spending Accounts

Health Care Reimbursement Dependent Care Reimbursement Pre-Tax Premium Deductions

Employee Employee Employee

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Health Benefits You have the flexibility to seek care from an in-network or out-of-network provider. It is important to note that with the new enhanced benefits you receive the maximum benefits from the plan when you seek services from Catholic hospitals. The Blue Cross and Blue Shield networks offer the best national access to providers through the BlueCard PPO Program in which all Blue Cross Blue Shield Plans participate. To learn more about the BlueCard Program, or if your physician participates in the PPO network, please visit their website at www.MyHealthToolkitKC.com. Please note: St. Joseph Medical Center and St. Mary’s Medical Center will not appear in the Kansas City area online provider directory, however claims incurred at these facilities will be paid as in the PPO network and at the higher “Catholic Hospital” benefit level. You may also direct your questions to the Customer Service number located on the back of your identification card.

BENEFIT COMBINED IN-NETWORK AND OUT-OF-NETWORK PROVIDERS

Calendar Year Deductible $475 Individual / $950 Family

Catholic Hospitals (facility charges only) In-Network Providers Out-of-Network Providers

Out-of-Pocket Max - Individual - Family

$1,800 $3,600

$1,800 $3,600

$2,300 $4,100

Wellness Benefits – Routine Care Not Applicable 100% up to $500 per person, then Plan pays 80% after Deductible

100% up to $500 per person, then Plan pays 60% after

Deductible

Physician Visit Not Applicable $30 Copay Plan pays 60% after Deductible

Inpatient Hospital Services 100%, no Deductible $120 Copay, then Plan pays 80% after Deductible

$120 Copay, then Plan pays 60% after Deductible

Emergency Room $90 Copay, then Plan

pays 100%, no Deductible

$90 Copay, then Plan pays 80% after Deductible

$90 Copay, then Plan pays 60% after Deductible

Inpatient Hospice Care Services 100%, no Deductible $120 Copay, then Plan pays 80% after Deductible

$120 Copay, then Plan pays 60% after Deductible

Chiropractic Care Limit of 20 visits per calendar year combined with Out-of-Network

Not Applicable $25 Copay, then Plan pays 80% after Deductible

Plan pays 60% after Deductible

Lab Services 100%, no Deductible 100%, no Deductible Plan pays 60% after Deductible

This is a brief summary only. Certain restrictions and exclusions apply. For exact terms and conditions, please refer to your summary plan description.

Natural Family Planning

The Archdiocese will continue to provide benefits for Natural Planning Services. This benefit includes the office visits and materials and is available through programs approved by the Archdiocese. The following programs are considered to be approved: the Creighton Model, Couple to Couple and Marquette Method. The Archdiocese will cover 100% up to a maximum of $400 per year. Please contact the Archdiocese Human Resource office in order to submit a claim for benefits.

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Prescription Drug Benefits MedTrak is an independent prescription benefit management company, free of ownership ties to drug manufacturers, mail pharmacies, retail pharmacies and insurance companies. MedTrak is a local company founded in 1999 and is best known for its stellar customer service throughout the organization. At MedTrak, every individual that calls into their Customer Service department will speak with a live person, not an automated voicemail system. Your plan includes a list of prescription drugs that are preferred by the plan because they help control rising prescription drug costs. This list, sometimes called a formulary, has a wide selection of generic and brand-name medications. We recommend taking a copy of the plan’s preferred medications with you to each doctor visit to discuss whether a drug on the list is right for you. A copy of this list may be obtained on MedTrak’s website at www.medtrakservices.com. In order to manage prescription drug costs in the future, we will continue to offer cost-saving programs in our Plan. MedTrak will continue to notify eligible members directly. We encourage you to discuss the proposed options with your physician and consider taking advantage of any potential cost savings to both you and the Plan. You will want to use a participating retail pharmacy for short-term prescriptions (such as antibiotics to treat infections). Be sure to show your MedTrak prescription benefit card to the pharmacist and pay your retail copayment for each prescription. Long-term medications (those taken for three (3) months or more) may be filled through the Performance 90 retail network. You may fill your long-term medications at a local retail pharmacy like Walgreens, Target, Wal-Mart and many Kansas City grocery stores. MedTrak also offers a mail order pharmacy option through Walgreens Mail. To find a participating retail pharmacy near you, contact MedTrak’s Customer Service department at 800-771-4648 or log on to www.medtrakservices.com. Hours of Operation:

• Monday through Friday – 8:00 a.m. to 9:00 p.m. • Saturday – 9:00 a.m. to 6:00 p.m.

Prescription Drugs Benefit

Retail (30-day Supply) Generic Brand

Formulary Non-Formulary

Lesser of $7 or actual cost

After $60 Annual Deductible per covered person 25% of discounted cost or $25 min 40% of discounted cost or $40 min

Mail Order (90-day supply) Generic Brand Formulary Brand Non-Formulary

$20 Copay $60 Copay $100 Copay

This is a brief summary only. Certain restrictions and exclusions apply. For exact terms and conditions, please refer to the Medtrak summary available online

through Benergy.

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Medication Management Program Available to all health plan participants.

Helping You Manage Your Medications & Reduce Your Health Care Costs! The Tria Health Program is provided at no additional cost to you through your insurance plan with Archdiocese of Kansas City in Kansas. This confidential program is designed to improve your health, reduce your healthcare costs and ensure you’re receiving the best care from your medications. Tria Health’s programs offer you clinical guidance through the complexities of health care. Our pharmacists act as your personal medication experts and work with you and your physician to achieve 3 primary goals:

1. Your medications are safe 2. You can afford the medications you’re prescribed 3. Your medications effectively treat your conditions

Pharmacy Advocate (PA) Program: What is it? The PA program offers one-on-one confidential counseling with a Tria Health Pharmacist to discuss how effective your medications are in treating your conditions. Your Tria Pharmacist will work with you and your physicians to reduce the risk of medication-related problems.

Examples of medication-related problems include: - Nausea or other uncomfortable side effects - Your prescription is too expensive to fill every

month - The medication dosage is too low or too high and

isn’t effectively treating your condition Who participates? Individuals who have one or more chronic conditions and take multiple medications. Active participants in the PA Program will be eligible to receive 50% off brand copays and free generic copays on medications that are used primarily to treat chronic conditions.

Programs for All Plan Members: The programs below are designed to help all plan members receive the best results from their medications and reduce the risk of medication-related problems. Program: Details:

Affordable Med Saves you and money by identifying less expensive, effective alternatives for your brand medications.

Med Safety Alerts

Prevents the risks associated with taking medications that cause an adverse reaction together.

Tria Clinical Alerts

Identifies when taking an additional medication in conjunction with your current treatment can improve your condition.

Compliance Alerts

Forget to take your medications? Do side effects cause you to skip your meds? Compliance Alerts help find solutions to help you take your medications as prescribed.

Tria Help Desk Your complete and confidential resource anytime you have a medication-related question. Call us toll-free at 1.888.799.TRIA (8742).

You can enroll by… Mail Eligible individuals will receive an enrollment packet in the mail. This will include an enrollment form and envelope for you to send back to Tria Health.

Online You may enroll online by visiting our website at www.triahealth.com/patients.aspx

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Medication Management Program (cont’d) Tria Health FAQs: What services does Tria Health provide? Pharmacy Advocate Program This program is designed specifically for individuals who have chronic conditions and are taking multiple medications to control their conditions. Tria offers participating members the opportunity to speak one-on-one with a Clinical Pharmacist to review their current medications. During this personalized counseling session, the Clinical Pharmacist will answer any questions or concerns the member may have regarding their medications and work to ensure that all of their health goals are achieved. Tria Help Desk The Tria Help Desk is a toll-free resource where all members can speak directly with a Tria Health Clinical Pharmacist to receive information ranging from less expensive drug therapies to learning more about potential drug to drug interactions. Members can access the Tria Help Desk at 1.888.799.TRIA Monday - Friday from 8am to 9pm and Saturday from 9am to 8pm. On-going Ancillary Programs (See previous page for program descriptions) Program Name: Frequency: Recipient: Communication Form:

Compliance Alerts Twice a Year Plan Members Letter Campaign

Med Safety Alerts Weekly Plan Members & Prescribing Physicians Letter & Call Campaign

Tria Clinical Alerts Quarterly Plan Members & Prescribing Physicians Letter Campaign

Affordable Med Twice a Year Plan Members & Prescribing Physicians Letter & Call Campaign By participating in Tria Health, do members need to change where they get their prescriptions filled? Does this change the relationship with their physicians? No, participation in Tria Health will not require members to change where their prescriptions are filled. After a member has enrolled in the Pharmacy Advocate Program, the Tria Clinical Pharmacist will notify the member’s physician to inform them about the program. After a member has an appointment with their Tria Pharmacist, their physician will receive a summary of the discussion. Tria Health Clinical Pharmacists work with the members’ physicians in order to ensure all members are receiving the best medical and prescription care possible! How often do members speak with a Tria Health Clinical Pharmacist? Pharmacists will keep in touch with each member approximately 2 or 3 times throughout the year, depending on each member’s personal care plan which is discussed during their initial consultation. All members, however, have unlimited access to the Tria Help Desk where they can speak with a Tria Health Clinical Pharmacist regarding any medication issue. How long does an initial consultation take? The initial consultation can last anywhere from 20 to 45 minutes depending upon the complexity of your medical care. Is this like insurance? Tria Health is an enhancement to your benefit insurance that is designed to reduce your medical costs and keep you healthy. How do I check eligibility for myself and my dependents? Any plan member can check eligibility for themselves and/or dependents by calling 1.888.799.TRIA. Or take Tria Health’s online Medication Risk Quiz. Eligible members have one or more chronic conditions and take multiple medications.

www.triahealth.com | 1.888.799.8742

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Alere Oncology Case Management Support for cancer patients and their caregivers

Available to all health plan participants. Did you know that in the United States a cancer diagnosis is made every 23 seconds? A diagnosis of cancer often brings feelings of fear and uncertainty. Many difficult decisions need to be made and it can be overwhelming. Knowing what to expect physically and emotionally during the course of treatment helps cancer patients and their caregivers cope during a difficult time. For those enrolled in the Archdiocese Health Plan, the Alere Oncology Case Management program gives you access to specially trained nurses in the specific area of cancer care you need. Alere is an independent company that provides cancer advocacy services on behalf of your health plan. The program’s expert nursing staff will provide support and assistance that can help you:

• Learn about your specific diagnosis • Learn more about the treatment plan your doctor has prescribed • Learn to control or minimize the side effects of treatments • Prepare for visits to the doctor • Receive help in identifying and connecting to support services • Get help with navigating the health care system.

If you or a family member have been diagnosed with cancer, get connected to the resources of the oncology case management program.

Alere Oncology Case Management 1.855.814.5077

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Lose Weight the Right Way with Naturally Slim®

Available to all health plan participants. There are many possible paths to weight loss, but they don’t all lead to a healthier life. There’s the crash diet before swimsuit season. There’s the starvation diet before your high school reunion. There are complicated regimens of weigh-ins and calorie-counting. Naturally Slim is a different kind of program. Naturally Slim Inc. is an independent company that provides a wellness program on behalf of your health plan. It involves mindful eating — which lets you enjoy foods, think about why you’re hungry, and focus more on how you eat than what you eat. Most importantly, it has helped many people reduce their risk for an increasingly common condition called metabolic syndrome. Do you already have metabolic syndrome? You might, if you have at least three of these risk factors:

• High blood pressure • Low HDL (good cholesterol) • High triglycerides • High blood sugar • Large waist circumference

With metabolic syndrome, you are:

• 700 percent more likely to get diabetes • 300 percent more likely to get heart disease • 200 percent more likely to have a stroke

With 10 hour-long, self-paced videos, Naturally Slim is an online program that helps people lose weight for the right reasons: to avoid the costs of these serious diseases and live healthier, happier lives. Some 87 percent of participants lose weight, with an average 10-week loss of 10.1 pounds. The program teaches mindful eating and behavior modification techniques that can reduce health risks, take pounds off and keep them off. Do you think you might qualify for the Naturally Slim program? Contact the Archdiocese Human Resources department to learn more.

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Telemedicine Available to all health plan participants. For those enrolled in the Health Plan, the Archdiocese of Kansas City in Kansas is providing you and your enrolled dependents with an added medical benefit beginning January 1, 2016. Teladoc allows you to talk to a doctor anytime, anywhere by phone consult. It’s an affordable, convenient option for treating many medical conditions. There’s no need to wait for your Teladoc ID card. On January 1st, you can set up your account and request a consult. Once you are set up, a Teledoc doctor is always just a call or click away. * With your consent, Teledoc will provide information about your consult to your primary care physician. WHEN CAN I USE TELEDOC? Teledoc does not replace your primary care physician. It is a convenient and affordable option for quality care. • When you need care now • If you are considering the

ER or urgent care center for a non-emergency issue

• On vacation, on a business trip, or away from home

• For short-term prescription refills

GET THE CARE YOU NEED Teledoc doctors can treat many medical conditions, including: • Cold & flu symptoms • Allergies • Bronchitis • Urinary tract infection • Respiratory infection • Sinus problems • And more!

MEET OUR DOCTORS Teledoc is simply a new way to access qualified doctors. All Teledoc doctors: • Are practicing PCPs,

pediatricians, and family medicine physicians

• Average 15 years experience

• Are U.S. board-certified and licensed in your state

• Are credentialed every three years meeting NCQA standards

Set up your account (after January 1st) 1. Visit Teledoc.com and click “Set up

account”

2. Select “No” when asked for username. Then provide your name and date of birth

3. Follow the directions online to complete account set-up and to provide your medical history

Request a consult Once your account is set up, a doctor is always just a call or click away

1. Visit the Teledoc website and click “Request a consult”

2. Select the type of consult you want

3. Talk to a doctor within an hour *

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Dental Maintaining good dental health by getting regular checkups may prevent you from having major expenses later. Archdiocese of Kansas City in Kansas’ Dental plan covers routine checkups and comprehensive coverage for other types of dental work you might need. Our plan also offers you the flexibility to seek treatment from any Provider. As with our Health Plan, you will maximize your dental benefits if you use a Delta Dental provider due to the agreements Delta has in place with their contracted dentists. Should you decide to use a non-participating dentist, please be advised that your provider may balance bill you for any amount over the Delta Dental Maximum Plan Allowance.

Even though you are not required to use a Delta Dental provider, you have access to the largest dental network in the state of Kansas. To learn more about the Delta Dental network, if your dentist participates in the network, or for more information regarding our Dental plan provider please visit their website at www.deltadentalks.com. Please click on the “Dentist Search” link located halfway down the home page under the section titled “Searching for a Dentist.” In the “Dentist Search” section, you may choose either the “Delta Dental Premier” or Delta Dental PPO” providers. You can search for providers by name, city and state or zip code. Inquiries may also be made by calling Customer Service at (800) 234-3375 (this number can also be found on your identification card). Services Description Benefit Amount

Type I Procedures Exams, cleanings, fluoride treatments (2 per year)

Plan pays 100% of the Maximum Plan Allowance. This benefit does not apply towards the Annual Maximum

Type II Procedures Regular fillings (amalgam or composite), extractions, non-surgical root canals

After deductible, plan pays 80% of the Maximum Plan Allowance

Type III Procedures Inlays, crowns, dentures, implants After deductible, plan pays 60% of the Maximum Plan Allowance

Type IV Procedures Orthodontia services For each eligible dependent, treatment must begin prior to age 19

After deductible, plan pays 50% of the Maximum Plan Allowance up to a Lifetime Maximum Benefit of $2,500

Annual Deductible Applies to Type II, Type III and Type IV Procedures $25 per person

Annual Maximum Per covered person $2,500

This is a brief summary only. Certain restrictions and exclusions apply. For exact terms and conditions, please refer to your summary plan description.

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Vision The Archdiocese partners with VSP for your vision benefits. Our Voluntary Vision program provides comprehensive coverage for all of your routine vision needs. You pay the full cost of coverage through pre-tax payroll deductions. For more information, please refer to the benefit summary below.

Services VSP Provider Out-of-Network Provider

Exam (Every 12 months) $15 copay Up to $50

Prescription Glasses Lenses and Covered Lens Options (every 12 months) Frame (every 24 months)

$35 copay Single Vision, Lined Bifocals, Lined Trifocals, Lenticular, photochromic lenses, polycarbonate lenses for

dependent children, scratch resistant coating, UV coating $130

allowance, 20% discount on overage cost

Single Vision Up to $50

Bifocal: Up to $75 Trifocal: Up to $100

Lenticular: Up to $125 No allowance for lens options

Frame: Up to $70

Non Covered Lens Options Fixed discounted copays. Saving on average 35-40%. n.a.

Contacts (in lieu of glasses and every 12 months) Contact Lens Fitting Exam Contacts

Up to $60 maximum copay $130 allowance towards materials

Up to $105 towards fitting exam and materials

Additional Discounts Glasses Corrective Laser Surgery

20% discount on additional pair of prescription glasses and non-

prescription sunglasses

Discounts average 15% through a VSP contracted laser surgery

center. For more information contact VSP.

n.a.

n.a.

This is a brief summary only. Certain restrictions and Exclusions apply.

For exact terms and conditions please refer to your VSP certificate of coverage.

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New Employer-paid Benefit Short Term Disability

A disability can occur at any time. If the disability is severe enough, it will prevent the person from being able to work and provide for their family. Food, mortgage payments, and other monthly bills cannot be paid without a steady income. Disability insurance provides some income replacement should you become disabled and unable to work due to a non-work related injury or illness. The Archdiocese and your employer provide short term disability insurance at no cost to you and eligible employees are automatically enrolled.

Maternity leave (though not a sickness) does qualify for short term disability benefits. Please contact your local benefit administrator for more information on filing a claim. Company Paid Short Term Disability

Premiums are paid by The Archdiocese and your employer

Elimination Period

Accidents: You must be unable to work for 7 days due to a qualified disability in order to be eligible for benefits. Benefits may begin on the eighth day of disability Sickness: You must be unable to work for 7 days due to a qualified disability in order to be eligible for benefits. Benefits may begin on the eighth day of disability

Benefit Amount Payout The benefit amount is 67% of your pre-disability earnings up to a maximum of $500 per week.

Taxable Benefit Yes

Benefit Duration Benefits may be payable for up to 13 weeks.

This is a brief summary only. Certain restrictions and Exclusions apply.

For exact terms and conditions please refer to your summary plan description.

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Life & Long Term Disability Insurance The Archdiocese offers Basic Life and Long Term Disability Income benefits as a package through Hartford Life. This includes employee Life insurance and Accidental Death and Dismemberment (AD&D), spouse and child(ren) Life Insurance and Long Term Disability. These benefits must be purchased as a package and are not available separately. The monthly cost for this package is based on your salary as of January each year. You and your Employer share equally in the cost of the coverage. To determine your cost for this package of benefits, complete the Basic Life and Long Term Disability worksheet below. You are eligible for Life and Disability benefits if you are an active employee working a minimum of 30 hours per week, per school or calendar year (whichever is appropriate). Your spouse and dependent children (from 15 days old to the end of the calendar year they turn 26) are eligible for Dependent Life coverage. If you enroll within 31 days of your eligibility date, coverage is guarantee issue.

Coverage is effective the date the enrollment form is signed and dated by the employee during the eligibility period.

Basic Package Benefit Employee Pays 50%

Employer Pays 50% Total Cost

Employee Life * AD&D *

$20,000 $20,000

$0.88 $0.10

$0.88 $0.10

$1.76 $0.20

Dependent Life Spouse Child(ren)

$4,000 $2,000

$0.588 $0.588 $1.176

Long Term Disability Benefit is 50% of monthly

income to a maximum benefit of $3,000. Benefits

begin after 13 weeks.

To calculate your monthly cost: Annual salary divided by 12 = $______________ (monthly income not to exceed $6,000) divided by 100 x $0.241 = $_________ (total cost). Divide in half to determine your cost. One-half is paid by your employer and one-half is paid by you.

This is a brief summary only. Certain restrictions and Exclusions apply.

For exact terms and conditions please refer to your summary plan description.

If you waived participation in the Basic Life and Long Term Disability package during your initial eligibility period, you must provide evidence of insurability by completing a Personal Health Statement and be approved by the Hartford for coverage.

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Hartford Life Value-Added Services These services are available for those employees participating in the Basic Life and Long Term Disability package. Ability Assist Counseling Services Available Services

Emotional or work-life counseling

Helps address stress, relationship or other personal issues you or your family members may face. It’s staffed by GuidanceExperts℠ – highly trained master’s and doctoral level clinicians – who listen to concerns and quickly make referrals to in-person counseling or other valuable resources. Situations may include: • Job pressures • Relationship/marital conflicts • Stress, anxiety and depression • Work/school disagreements • Substance abuse • Child and elder care referral services

Financial information and resources

Provides support for the complicated financial decisions you or your family members may face. Speak by phone with a Certified Public Accountant and Certified Financial Planners on a wide range of financial issues. Topics may include: • Managing a budget • Retirement • Saving for college • Getting out of debt • Tax questions

Legal support and resources

Offers assistance if legal uncertainties arise. Talk to an attorney by phone about the issues that are important to you or your family members. If you require representation, you’ll be referred to a qualified attorney in your area with a 25% reduction in customary legal fees thereafter. Topics may include: • Debt and bankruptcy • Guardianship • Divorce

HealthChampion Health care support service If you become disabled from an accident or are diagnosed with a critical illness, your first priority should be focusing on your treatment and recovery. What you don’t need is more stress about your care options, medical benefits, co-pays and other expenses. To help, there’s ComPsych® HealthChampion℠ – a service that helps take some of the burden off your shoulders. No matter what kind of health plan you have - whether a self-funded plan or a public or private health care exchange - the HealthChampion program can:

• Guide you through health care options • Connect you with the right resources • Advocate for timely and fair resolution of issues

How does it work? HealthChampion specialists walk you through all aspects of your health care issue. Helping to ensure that you’re fully supported with employee assistance programs and/or work-life services.

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Hartford Life Value-Added Services (cont’d) Travel Assistance and ID Theft Protection Services The best laid travel plans can go awry, leaving you vulnerable and, possibly, unable to communicate your needs. When the unexpected happens far from home, it’s important to know whom to call for assistance. If you are covered under a Hartford Group Policy, you and your family have access to Travel Assistance Services provided by Europ Assistance USA. With a local presence in 200 countries and territories around the world, and numerous 24/7 assistance centers, they are available to help you anytime, anywhere. Identity theft, America’s fast growing crime, victimizes almost 10 million American consumers each year. Europ Assistance USA helps protect you and your family from its consequences 24/7, at home and when you travel. In addition to prevention education, this service provides advice and help with administrative tasks resulting from identity theft. Estate Guidance Will Services As a covered employee under a Hartford Group Life insurance policy, you have access to EstateGuidance® Will Services provided by ComPsych®. It helps you create a simple, legally binding will quickly and conveniently online, saving you the time and expense of a private legal consultation. Other advantages include:

• Online assistance from licensed attorneys should you have questions. • The ability to save drafts for up to six months. During this period, you can revise your will at no

cost, as long as you haven’t already printed or downloaded it. • Additional estate planning services are also available for purchase, including the creation of

living wills and trusts, guidance about divorce Beneficiary Assist Counseling Services Beneficiary Assist provides you, your eligible beneficiaries and immediate family members with unlimited 24/7 phone access to help related to the death of yourself or a loved one. That includes:

• Legal advice, financial planning and emotional counseling for up to one year from the date the claim is filed.

• Up to five face-to-face sessions or equivalent professional time for one service or a combination.

Funeral Planning and Concierge Services The death of a loved one is one of life’s most stressful situations. Quick, often costly decisions must be made while emotions are at their peak. Yet, how many people know how to plan a funeral? That’s why your employer offers a funeral planning and concierge service through The Hartford’s Group Life insurance program— provided by Everest the first to offer this service nationwide.

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Voluntary Supplemental Life Insurance The Archdiocese offers a Voluntary Supplemental Life Insurance benefit that can be purchased at your expense for you and your dependents. You will receive group rates and the premium is conveniently deducted from your payroll. The cost is determined by the age of the employee and spouse as of January of each calendar year or date of hire for a new employee. For benefit and rate information, please see the table below. You are eligible to purchase additional life insurance if you participate in the Basic Life and Disability package. If you enroll within 31 days of your date of hire no evidence of insurability is required. Also, during our annual enrollment period you will be able to enroll or increase your enrollment by $10,000 and your spouse’s by $5,000 without having to provide evidence of insurability. Any amounts over the $10,000 will be subject to approval by Hartford Life.

Coverage Employee Paid Benefit

Employee $10,000 increments to $150,000 maximum

Spouse $5,000 increments to $75,000 maximum, cannot exceed 50% of employee’s benefit

Children Option 1 - $5,000 on each child; Option 2 - $10,000 on each child

Monthly Cost for Each $1,000 of Employee & Spouse Life Insurance Coverage

Age <30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75 +

Life $0.06 $0.08 $0.10 $0.14 $0.23 $0.36 $0.56 $0.71 $1.27 $2.10 $3.70

Children All children are covered for one monthly cost. Option 1: $5,000 - $0.35; Option 2: $10,000 - $0.70

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Available During Open Enrollment Only Voluntary Whole Life Issued through Kanawha Insurance Company (a Humana Company) Humana’s Secure Life Select is a voluntary individual non-participating whole life policy with premiums payable to age 99. Secure Life Select provides guaranteed renewable protection that cannot be reduced. The policy builds cash value which can be withdrawn at the policy’s surrender, borrowed against as a loan, annuitized or used to purchase extended or reduced paid-up insurance. Standalone policies for employees, spouse and children (or grandchildren) may be purchased. Employee purchase is not required to purchase life insurance for your spouse, child or grandchild. Secure Life Select also provides a Facility Care Acceleration Benefit. This is a monthly benefit for nursing home, assisted living or adult day care services. Rates are age specific and will be calculated at time of enrollment.

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Voluntary Accident Insurance

Available During Open Enrollment Only I ssued through Kanawha Insurance Company (a Humana Company) Humana’s Accident Plus provides off-the-job coverage for accidental injuries, ambulance, and hospital care and includes an accidental death benefit. Benefits are payable for the actual expenses up to the coverage amount selected. Accident Plus pays regardless of any other coverage you may have, including the Archdiocese Health Plan. After an accident, you may have expenses you’ve never thought about before. It’s reassuring to know that an accident insurance policy can be there for you through the many stages of care, from the initial emergency treatment or hospitalization, to follow up treatments or physical therapy. Accident Plus Benefits Level 2 Level 4

Accident Medical Expense

Pays the actual expenses up to the amount selected for diagnosis or treatment by a Physician or in an Emergency Room. Emergency Room service is subject to a $50 deductible.

$1,000 $2,000

Ambulance Benefit Pays actual charges up to the amount selected if injury requires ground or air ambulance transportation. $500 $1,000

Hospital Indemnity

Pays a benefit equal to amount selected if injury requires inpatient hospital confinement, includes room charge, and starts within 30 days after accident. Benefit is limited to 30 days per accident.

$150 $300

Accidental Death & Dismemberment $10,000 $20,000

Bone Fracture and Dislocation (Optional Benefit)

Pays a benefit when a covered person suffers one of the fractures or dislocations listed in the policy $1,500 $1,500

Hospital Intensive Care Unit (Optional Benefit Rider)

Pays a daily benefit when a covered person is confined to a Hospital Intensive Care Unit as a result of injuries suffered in a covered accident. The benefit is payable for a maximum of 30 days for any one accident

$300 $300

Plan Features • No waiting period • No pre-existing condition limitation • Unisex rates for ages 18 to 67 • Provides benefits beginning with the first day • Coverage is fully portable

• If you have family coverage, newborn children are covered from birth provided they are added to the policy within 31 days

• Benefits are paid directly to the insured • All children are covered for one rate

This is a brief summary only. Certain restrictions and exclusions apply.

For exact terms and conditions, please refer to your benefit booklet from Humana Rates are age banded and based on the level o f benef i t e lec ted.

Benefit Employee Employee & Spouse Employee & Children Family 18-50 51-67 18-50 51-67 18-50 51-67 18-50 51-67

Level 2 $15.15 $17.05 $30.30 $34.10 $34.85 $36.75 $50.00 $53.80 Level 4 $19.20 $21.10 $38.40 $42.20 $46.50 $48.40 $65.70 $69.50

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Available During Open Enrollment Only Voluntary Critical Illness Issued through Kanawha Insurance Company (a Humana Company) Humana’s Voluntary Critical Illness is voluntary coverage that helps protect you, your family, and your assets in the event of a critical illness. It offers specialized benefits to supplement other health insurance when you and your family may be most vulnerable: during the working years. Benefit payments can assist in covering a variety of expenses associated with a critical illness: out-of-pocket medical care costs, home health care, travel to and from treatment facilities, rehabilitation, and other expenses. Rates are age specific and will be calculated at time of enrollment.

Coverage Type Voluntary Critical Illness is a group policy that includes coverage for heart/stroke, cancer and other critical illnesses

Benefit Amount

Benefit amounts are available at various levels. You can choose: • $5,000 to $50,000 for employees You can also add coverage for your dependents: • Spouse: $2,500 to $25,000. Spouse coverage benefit is equal to exactly half

of the employee’s coverage • Child: $2,500 to $5,000 for each eligible child

Coverage for Vascular Conditions

Percent of benefit amount paid at initial diagnosis: • Heart Attack • Transplant as a result of heart failure • Stroke • Coronary artery bypass surgery as a result of coronary

artery disease

100% 100% 100% 25%

Coverage for Cancer Conditions

Percent of benefit amount paid at initial diagnosis: • First diagnosis of internal cancer or malignant

melanoma • Carcinoma in situ

100% 25%

Coverage for Other Critical Illnesses

Percent benefit amount paid at initial diagnosis: • Transplant other than heart • End stage renal failure • Loss of sight, speech, or hearing • Coma • Severe burns • Permanent paralysis due to an accident • Occupational HIV

100% 100% 100% 100% 100% 100% 100%

Additional Included Benefits

Waiver of premium for disability: This waives an employee’s premium if he or she becomes totally disabled for at least 180 days after the effective date of coverage. For employees ages 18-55. Benefit Recurrence: This provides an additional benefit for the same condition if a covered participant is treatment-free for at least 12 months. Health Screening: Benefit pays $150 per calendar year for covered health screenings. There are 18 covered tests including mammograms, colonoscopies, and stress tests.

This is a brief summary only. Certain restrictions and exclusions apply.

For exact terms and conditions, please refer to your benefit booklet from Humana

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Health Care and Dependent Care Flexible Spending Accounts

What is a Flexible Spending Account (FSA)? A Flexible Spending Account (FSA) is an account in which you set aside pre-tax dollars to pay for eligible health care or dependent care expenses not covered by insurance. The annual amount you elect to contribute to each account will be divided into equal amounts and deducted from your paycheck pre-tax. You are eligible to participate in both the Health Care Reimbursement account and the Dependent Care Reimbursement Account if you work a minimum of 20 hours per week. Health Care Account: You may elect an amount up to $2,500 per plan year to be used for medical, prescription drug, dental and vision expenses for you and eligible dependents. Some eligible expenses include (but are not limited to) the following:

• Medical or Dental Deductibles and Coinsurance • Office Visit and Prescription Drug Copays • Eyeglasses and Contact Lenses • Hearing Aides

Dependent Care Account: You may elect an amount up to $5,000 per plan year ($2,500 maximum per year if married and filing a separate tax return) to be used for child day care or elder day care expenses for your eligible dependents. Some eligible expenses include (but are not limited to) the following:

• Child Daycare • Before and/or After School Care

• Adult Day Care for Seniors

Why Should I Participate? By setting aside pre-tax dollars to pay for out-of-pocket expenses you would normally pay for using after-tax dollars, you are reducing your “taxable income” because it reduces the amount of federal, state and FICA taxes you pay. This means more take-home pay for you! How Does an FSA Work? Your contributions are taken pre-tax and divided equally among your pay periods. Funds can be used for expenses incurred from January 1st through March 15th of the following year (a total of 14.5 months). Federal tax laws require that your FSA operate on a “use it or lose it” basis meaning any unused funds in the account at the end of the calendar year will be forfeited. You have until March 31st following the close of the plan year to submit your claims and receipts for reimbursements from the prior plan year. Additionally, the IRS imposes some rules and restrictions on the way you can use FSAs. Unused funds left in the account(s) from the previous year that are not used to reimburse expenses incurred by the end of the plan year are subject to the use-it-or-lose-it rule and are forfeited. For additional rules and restrictions, please see Human Resources.

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Health Care and Dependent Care Flexible Spending Accounts (cont’d) Can Orthodontia be reimbursed through your FSA? Orthodontia expenses can be reimbursed through your Flexible Spending Account (FSA), but the reimbursement process governed by the Internal Revenue Service can be challenging to understand. In short, your FSA reimbursement aligns with the payment/treatment schedule set up with your orthodontist/dentist. Reimbursement can span as much as two years if the treatment time is that long. Even if you pay for orthodontia in full prior to treatment, your reimbursement schedule will align with the treatment months. Additional detailed information can be found on the Archdiocese Benergy site or you may contact NueSynergy FSA Customer Service at (855) 890-7239 or email at customerservice@NueSynergy.com. REIMBURSEMENTS – 2 OPTIONS • File a claim – complete the Claim for Reimbursement form and submit it with itemized receipts to our FSA

administrator, NueSynergy. Reimbursement for your expenses may be paid to you via check or direct deposit.

• Debit Card –Allows you to pay directly from your flexible spending account at the point of service, eliminating the hassles associated with having to “pay twice.”

• By electing to use the debit card, you agree to save all invoices and receipts related to any expense paid with the debit card. Upon request you must submit these documents for review by NueSynergy. Failure to submit the requested documents will cause the expense to be treated as a non-qualified expense and you will be required to remit payment to your employer.

• Note debit cards may no longer be used to purchase OTC medicines and drugs. You will need to use another form of payment and file a claim for reimbursement.

• A debit card fee of $12 per year will be deducted from your account at the beginning of the calendar year. Tips & Reminders Estimate your expenses and plan carefully so that you don’t leave a balance in your account at the end

of the year because the user-it-or-lose-it rule does apply to both the Health Care and Dependent Care FSAs.

Keep your receipts! Even if you use the debit card successfully, you may still be asked to submit a receipt in order to comply with IRS regulations.

Most over-the-counter medications are not eligible expenses. You can find a full list of eligible expenses on NueSynergy website.

Debit card will be mailed to your home in a plain white envelope labeled “Important Benefit Information”. You can’t use funds in your Health Care FSA to pay for Dependent Care expenses, and vice versa. You can use your Health Care FSA to purchase over-the-counter (OTC) medications as long as you

have a prescription. Some OTC items do not require prescriptions like insulin, diabetic supplies, band aids, and contact lens

solution. PRE-TAX PREMIUM DEDUCTIONS Premium deductions for the Archdiocese Health, Dental, Voluntary Vision and Voluntary Accident plans may be deducted from your paycheck on a pre-tax basis. By electing to participate in the Pre-Tax Premium plan you may take advantage of tax savings. Please note that your social security benefits may be affected due to the pre-tax reduction in your salary. Benefits elected to be paid with pre-tax premium may not be changed mid-year unless you experience a family status change.

NueSynergy gives you access to your account status 24 hours a day, seven days a week, through an interactive voice

response system. Call (855) 890-7239, email customerservice@NueSynergy.com or visit the website at www.NueSynergy.com

Health Care and Dependent Care Flexible Spending Accounts (cont’d)

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Contact Information

Archdiocese of Kansas City in Kansas, in partnership with the following vendors, strives to meet your benefit needs. If you have any questions regarding your benefits, please visit http://archkck.benergy.com and follow the login information below (Benergy can also be accessed through the Human Resources page on the Archdiocese website at www.archkck.org) or contact the corresponding vendor listed below. If you still have questions, please contact your local Benefits Coordinator or the Human Resources office of the Archdiocese.

Benefit Vendor Name Customer Service

Health Care Plan Blue Cross Blue Shield of Kansas City

(888) 495-9340 www.MyHealthToolkitKC.com

Prescription Drug Benefits Medtrak Services (800) 771-4648 www.medtrakservices.com

Medication Management Tria Health (888) 799-8742 www.triahealth.com

Cancer Care Advocacy Alere Oncology Management (855) 814-5077

Telemedicine Teledoc (800) TELADOC (835-2362) www.teladoc.com

Dental Plan Delta Dental of Kansas (800) 234-3375 / (316) 264-4511 www.deltadentalks.com

Vision Plan VSP (800) 877-7195 www.vsp.com

Hartford Life Value Added Services Hartford Life (800) 96-HELPS

www.thehartford.com/employeebenefits

Voluntary Whole Life Voluntary Accident Insurance & Voluntary Critical Illness

Humana Specialty Benefits (877) 378-1505 www.humanaworkplacevoluntary.com/members

Flexible Spending Accounts NueSynergy (855) 890-7239 or

customerservice@NueSynergy.com www.NueSynergy.com

Enrollment Assistance (only available during Open Enrollment)

Primebyte

Bill Defoor (913) 406-2101

Mark Defoor (913) 832-0072

Archdiocese Human Resources Art Walsh

awalsh@archkck.org (913) 647-0362

The information in this Enrollment Guide is presented for illustrative purposes and is based on information provided by the employer. The text contained in this Guide was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of discrepancy between the Guide and the actual plan documents the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any questions about your Guide, contact Human Resources.

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Legal Notices The Archdiocese of Kansas City in Kansas Benefit Program qualifies as a “church plan” as defined under IRS Code 414(e). By meeting this definition, the Archdiocese Benefit Program is permanently exempt from meeting certain requirements including, but not limited to, the Employee Retirement Income Security Act (ERISA) and Consolidated Omnibus Budget Reconciliation Act (COBRA) regulations. The Archdiocese offers continuation of benefits for employees either who terminate their employment or otherwise lose eligibility for benefits. All members enrolled in the benefit plan who lose eligibility (employees, spouses and dependent children) are eligible to receive benefits under the continuation provision. Women’s Health and Cancer Rights Act If you had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights of 1998. For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with attending physician and the patient, for:

1. All stages of reconstruction of the breast on which the mastectomy was performed. 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; 3. Prostheses; and 4. Treatment of physical complications during all stages of the mastectomy, including lymphedemas.

These benefits will be provided subject to the same deductible, copays, and coinsurance applicable to other medical and surgical benefits under the plan. Mothers & Newborn Act Group health plans and health insurance issuers generally may not, under Federal Law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours or (96 hours). HIPAA Privacy Notice The Archdiocese of Kansas City in Kansas Health Care Plan is required by law to take reasonable steps to ensure the privacy of your personally identifiable health information and to inform you about the uses of protected health information (PHI) and your privacy rights. PHI use and disclosure by the Archdiocese Health Care Plan is regulated by federal law known as HIPAA (the Health Insurance Portability and Accountability Act). A copy of this notice will be included in the Blue Cross Blue Shield of Kansas City Health Care Summary Plan Description.

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Legal Notices Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free or Low-Cost Health Coverage to Children and Families If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2015. Contact your State for more information on eligibility –

ALABAMA – Medicaid GEORGIA – Medicaid

Website: www.myalhipp.com Phone: 1-855-692-5447

Website: http://dch.georgia.gov/ - Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: 1-800-869-1150

ALASKA – Medicaid INDIANA – Medicaid Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529

Website: http://www.in.gov/fssa Phone: 1-800-889-9949

COLORADO – Medicaid IOWA – Medicaid Medicaid Website: http://www.colorado.gov/hcpf Medicaid Customer Contact Center: 1-800-221-3943

Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562

FLORIDA – Medicaid KANSAS – Medicaid Website: https://www.flmedicaidtplrecovery.com/ Phone: 1-877-357-3268

Website: http://www.kdheks.gov/hcf/ Phone: 1-800-792-4884

KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218

LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP

Website: http://www.lahipp.dhh.louisiana.gov Phone: 1-888-695-2447

Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

MAINE – Medicaid NEW YORK – Medicaid Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-977-6740 TTY 1-800-977-6741

Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831

MASSACHUSETTS – Medicaid and CHIP NORTH CAROLINA – Medicaid Website: http://www.mass.gov/MassHealth Phone: 1-800-462-1120

Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100

33

MINNESOTA – Medicaid NORTH DAKOTA – Medicaid Website: http://www.dhs.state.mn.us/id_006254 Click on Health Care, then Medical Assistance Phone: 1-800-657-3739

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-800-755-2604

MISSOURI – Medicaid OKLAHOMA – Medicaid and CHIP Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

MONTANA – Medicaid OREGON – Medicaid

Website: http://medicaid.mt.gov/member Phone: 1-800-694-3084

Website: http://www.oregonhealthykids.gov http://www.hijossaludablesoregon.gov Phone: 1-800-699-9075

NEBRASKA – Medicaid PENNSYLVANIA – Medicaid Website: www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633

Website: http://www.dpw.state.pa.us/hipp Phone: 1-800-692-7462

NEVADA – Medicaid RHODE ISLAND – Medicaid Medicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900

Website: www.ohhs.ri.gov Phone: 401-462-5300

SOUTH CAROLINA – Medicaid VIRGINIA – Medicaid and CHIP

Website: http://www.scdhhs.gov Phone: 1-888-549-0820

Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282

SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059

Website: http://www.hca.wa.gov/medicaid/premiumpymt/pages/ index.aspx Phone: 1-800-562-3022 ext. 15473

TEXAS – Medicaid WEST VIRGINIA – Medicaid Website: https://www.gethipptexas.com/ Phone: 1-800-440-0493

Website: www.dhhr.wv.gov/bms/ Phone: 1-877-598-5820, HMS Third Party Liability

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP Website: Medicaid: http://health.utah.gov/medicaid CHIP: http://health.utah.gov/chip Phone: 1-866-435-7414

Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002

VERMONT– Medicaid WYOMING – Medicaid Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

Website: http://health.wyo.gov/healthcarefin/equalitycare Phone: 307-777-7531

To see if any other states have added a premium assistance program since July 31, 2015, or for more information on special enrollment rights, contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 OMB Control Number 1210-0137 (expires 10/31/2016)

Legal Notices

34

Legal Notices

Important Notice from Archdiocese of Kansas City in Kansas About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Archdiocese of Kansas City in Kansas and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this

coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. Archdiocese of Kansas City in Kansas has determined that the prescription drug coverage offered by the

Archdiocese of Kansas City in Kansas Employee Health Care Plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

__________________________________________________________________________ When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current coverage with Archdiocese of Kansas City in Kansas will not be affected. Archdiocese of Kansas City in Kansas Employee Health Care Plan will coordinate benefits with Part D coverage. Please be advised that our group medical plan will be primary and the Medicare Part D plan will be secondary. If you do decide to join a Medicare drug plan and drop your current Archdiocese of Kansas City in Kansas coverage, be aware that you and your dependents may not be able to get this coverage back. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Archdiocese of Kansas City in Kansas and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to join.

35

Legal Notices For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Archdiocese of Kansas City in Kansas changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:

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

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

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

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Date: October 1, 2015 Name of Entity/Sender: Archdiocese of Kansas City in Kansas Contact--Position/Office: Kathleen Thomas Address: 12615 Parallel Parkway Kansas City KS 66109 Phone Number: 913.647.0328

Page 1 of 9

Coverage Period: 01/01/2016 - 12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual | Plan Type: 3 Tier PPO

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.MyHealthToolkitKC.com or by calling 1-888-495-9340 (for prescription drug coverage questions, contact MedTrak at 1-800-771-4648)

Important Questions Answers Why this Matters: What is the overall deductible?

Tier 1 $475 person/$950 family. In-Network $475 person/$950 family. Out-of-Network $475 person/$950 family. Doesn't apply to preventive care.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

No. You don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.

Is there an out–of–pocket limit on my expenses?

Yes. Tier 1 $1,800 person/$3,600 family. In-Network $1,800 person/$3,600 family. Out-of-Network $2,300 person/$4,100 family.

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in the out-of-pocket limit?

Per Admission Copayment, Per Occurrence Copayment, Premiums, balance-billed charges and health care this plan doesn't cover.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Is there an overall annual limit on what the plan pays?

No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

Does this plan use a network of providers?

Yes. See www.MyHealthToolkitKC.com or call 1-800-810-BLUE (2583) for a list of participating medical providers. To find a participating pharmacy near you, log on to www.medtrakservices.com or call 1-800-771-4648.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to see a specialist?

No.

You can see the specialist you choose without permission from this plan.

Are there services this plan doesn’t cover?

Yes. Some of the services this plan doesn’t cover are listed in the Excluded Services

and Other Covered Services section. See your policy or plan document for additional information about excluded services.

Questions: Call BlueKC 1-888-495-9340 or visit us at www.MyHealthToolkitKC.com. If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-888-495-9340 to request a copy.

Blue Cross and Blue Shield of Kansas City is an independent licensee of the Blue Cross and Blue Shield Association.

NA AR20141117103613682778

Archdiocese of Kansas City in Kansas: PPO Plan

Page 2 of 9

• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the

plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.

• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

• This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts.

Common Medical Event

Services You May Need

Your cost if you use

Tier 1 In-Network Provider

Out-of-Network Provider

Limitations & Exceptions

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

Not Covered $30 Copay per visit 40% Coinsurance Allergy injections, dialysis, surgeries, x-rays, and second surgical opinions are covered with 20% Coinsurance In-Network. Tier 1 and In-Network labs are covered at No Charge. Tier 1 x-rays are not covered.

Specialist visit Not Covered $30 Copay per visit 40% Coinsurance

Allergy injections, dialysis, surgeries, x-rays, and second surgical opinions are covered with 20% Coinsurance In-Network. Tier 1 and In-Network labs are covered at No Charge. Tier 1 x-rays are not covered.

Other practitioner office visit Not Covered $25 Copay per visit then 20% Coinsurance

40% Coinsurance

Chiropractic services are limited to 20 visits per benefit year.

Page 3 of 9

Common Medical Event

Services You May Need

Your cost if you use

Tier 1 In-Network Provider

Out-of-Network Provider

Limitations & Exceptions

Preventive care/screening/immunization No Charge No Charge No Charge

Preventive care services are limited to $500 per benefit year, excluding mammograms and colonoscopies. Once the $500 is met, services are covered at No Charge Tier 1, 20% Coinsurance In-Network, and 40% Coinsurance Out-of-Network. Mammograms and colonoscopies are covered at No Charge and are each limited to one per benefit year.

If you have a test Diagnostic test (x-ray, blood work) No Charge 20% Coinsurance 40% Coinsurance In-Network labs are covered at No Charge.

Imaging (CT/PET scans, MRIs) No Charge No Charge 40% Coinsurance

Pre-authorization is required. Penalty for not obtaining pre-authorization is denial of all charges.

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at www.medtrakservices.com

Generic drugs (Retail) Not Covered $7 Copay per prescription (up to a 30-day supply)

$7 Copay per prescription (up to a 30-day supply) plus balance bill

Prior authorizations on select medications; formulary drug list

Generic drugs (Mail Order) Not Covered $20 Copay per prescription up to a 90-day supply)

$20 Copay per prescription up to a 90-day supply) plus balance bill

Prior authorizations on select medications; formulary drug list

Preferred brand drugs (Retail) Not Covered The greater of $25 copay or 25% coinsurance per prescription (30-day supply)

The greater of $25 copay or 25% coinsurance per prescription (30-day supply) plus balance bill

Prior authorizations on select medications; formulary drug list

Page 4 of 9

Common Medical Event

Services You May Need

Your cost if you use

Tier 1 In-Network Provider

Out-of-Network Provider

Limitations & Exceptions

Preferred brand drugs (Mail Order) Not Covered $60 copay per prescription (up to 90-day supply)

$60 copay per prescription (up to 90-day supply) plus balance bill

Prior authorizations on select medications; formulary drug list

Non-preferred brand drugs (Retail) Not Covered The greater of $40 copay or 40% coinsurance per prescription (30-day supply)

The greater of $40 copay or 40% coinsurance per prescription (30-day supply) plus balance bill

Prior authorizations on select medications; formulary drug list

Non-preferred brand drugs (Mail Order) Not Covered $100 copay per prescription (up to 90-day supply)

$100 copay per prescription (up to 90-day supply) plus balance bill

Prior authorizations on select medications; formulary drug list

Specialty drugs Not Covered Coverage based on tier level above

Coverage based on tier level above

Prior authorizations on select medications; formulary drug list

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

No Charge $50 Copay per visit then 20% Coinsurance

$50 Copay per visit then 40% Coinsurance

––––––––––none–––––––––––

Physician/surgeon fees 20% Coinsurance 20% Coinsurance 40% Coinsurance

––––––––––none–––––––––––

If you need immediate medical attention

Emergency room services $90 Copay per visit $90 Copay per visit then 20% Coinsurance

$90 Copay per visit then 40% Coinsurance

Copayment will be waived if admitted.

Emergency medical transportation 20% Coinsurance 20% Coinsurance 20% Coinsurance

––––––––––none–––––––––––

Urgent care Not Covered $30 Copay per visit 40% Coinsurance

––––––––––none–––––––––––

If you have a hospital stay

Facility fee (e.g., hospital room) No Charge $120 Copay per admission then 20% Coinsurance

$120 Copay per admission then 40% Coinsurance

Pre-authorization is required. Penalty for not obtaining pre-authorization is $200.

Page 5 of 9

Common Medical Event

Services You May Need

Your cost if you use

Tier 1 In-Network Provider

Out-of-Network Provider

Limitations & Exceptions

Physician/surgeon fee 20% Coinsurance 20% Coinsurance 40% Coinsurance ––––––––––none–––––––––––

If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services

No Charge 20% Coinsurance 40% Coinsurance In-Network office visits are covered with a $30 Copay. Tier 1 office visits are not covered.

Mental/Behavioral health inpatient services

No Charge $120 Copay per admission then 20% Coinsurance

$120 Copay per admission then 40% Coinsurance

Pre-authorization is required. Penalty for not obtaining pre-authorization is $200.

Substance use disorder outpatient services

No Charge 20% Coinsurance 40% Coinsurance

In-Network office visits are covered with a $30 Copay. Tier 1 office visits are not covered.

Substance use disorder inpatient services No Charge $120 Copay per admission then 20% Coinsurance

$120 Copay per admission then 40% Coinsurance

Pre-authorization is required. Penalty for not obtaining pre-authorization is $200.

If you are pregnant

Prenatal and postnatal care Not Covered $30 Copay per visit 40% Coinsurance No additional copayment for ongoing routine care.

Delivery and all inpatient services No Charge $120 Copay per admission then 20% Coinsurance

$120 Copay per admission then 40% Coinsurance

Pre-authorization is required. Penalty for not obtaining pre-authorization is $200.

If you need help recovering or have other special health needs

Home health care Not Covered 20% Coinsurance 40% Coinsurance Pre-authorization is required. Penalty for not obtaining pre-authorization is denial of all charges.

Rehabilitation services No Charge 20% Coinsurance 40% Coinsurance Tier 1 and In-Network office visits are covered with a $25 Copay then 20% Coinsurance.

Habilitation services No Charge 20% Coinsurance 40% Coinsurance Tier 1 and In-Network office visits are covered with a $25 Copay then 20% Coinsurance.

Skilled nursing care No Charge $120 Copay per admission then 20% Coinsurance

$120 Copay per admission then 40% Coinsurance

Pre-authorization is required. Penalty for not obtaining pre-authorization is $200.

Durable medical equipment Not Covered 20% Coinsurance 40% Coinsurance ––––––––––none–––––––––––

Page 6 of 9

Common Medical Event

Services You May Need

Your cost if you use

Tier 1 In-Network Provider

Out-of-Network Provider

Limitations & Exceptions

Hospice service No Charge 20% Coinsurance 40% Coinsurance Pre-authorization is required. Penalty for not obtaining pre-authorization is $200 for In-Network inpatient services and denial of all charges for In-Network outpatient and all Out-of-Network services.

If your child needs dental or eye care

Eye exam Not Covered Not Covered Not Covered See your Employer for benefit details.

Glasses Not Covered Not Covered Not Covered See your Employer for benefit details.

Dental check-up Not Covered Not Covered Not Covered See your Employer for benefit details.

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

• Acupuncture

• Cosmetic Surgery

• Dental Care (Adult)

• Dental Care (Child)

• Hearing Aids

• Infertility Treatment

• Long-Term Care

• Prescription Drugs

• Routine Eye Care (Adult)

• Routine Eye Care (Child)

• Routine Foot Care

• Weight Loss Programs

Other Covered Services. (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

• Bariatric Surgery

• Chiropractic Care

• Most coverage provided outside the U.S. See www.MyHealthToolkitKC.com

• Non-emergency care when traveling outside the U.S.

• Private-Duty Nursing, if part of pre-authorized home health care

Page 7 of 9

Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at 1-888-495-9340. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact any or all of the following:

• 1-888-495-9340 or visit us at www.MyHealthToolkitKC.com Language Access Services:

To obtain assistance in your specific language, call the customer service number shown on the first page of this notice. Spanish: Para obtener asistencia en español, llame al número de atención al cliente que aparece en la primera página de esta notificación. Tagalog: Upang makakuha ng tulong sa Tagalog, tawagan ang numero ng customer service na makikita sa unang pahina ng paunawang ito. Chinese:

Navajo:

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

Page 8 of 9

Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540

Deductibles $480 Copays $210 Coinsurance $210 Limits or exclusions $2,930 Total $3,830

Deductibles $480 Copays $150 Coinsurance $0 Limits or exclusions $170 Total $800 These numbers assume the patient has given notice of her pregnancy to the plan. If you are pregnant and have not given notice of your pregnancy, your costs may be higher. For more information, please contact: 1-888-495-9340.

Amount owed to providers: $7,540 Amount owed to providers:

$5,400 Plan pays $6,740 Plan pays $1,570 Patient pays $800

Sample care costs:

Patient pays $3,830

Sample care costs:

About these Coverage Examples:

These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

This is not a cost estimator.

Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different.

See the next page for important information about these examples.

Patient pays:

Having a baby (normal delivery)

Managing type 2 diabetes (routine maintenance of

a well-controlled condition)

Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400

Patient pays:

Page 9 of 9

Questions and answers about the Coverage Examples:

What are some of the assumptions behind the Coverage Examples?

— Costs don't include premiums. — Sample care costs are based on national

averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.

— The patient’s condition was not an excluded or preexisting condition.

— All services and treatments started and ended in the same coverage period.

— There are no other medical expenses for any member covered under this plan.

— Out-of-pocket expenses are based only on treating the condition in the example.

— The patient received all care from

What does a Coverage Example show?

For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Does the Coverage Example predict my own care needs?

O No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Can I use Coverage Examples to compare plans?

PYes. When you look at the Summary of

Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should consider when comparing plans?

PYes. An important cost is the premium you pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket costs, such

in-network providers. If the patient had received care from out-of-network

as copayments, deductibles, and coinsurance. You should also consider

providers, costs would have been higher. Does the Coverage Example predict my future expenses?

O No. Coverage Examples are not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

Questions: Call BlueKC 1-888-495-9340 or visit us at www.MyHealthToolkitKC.com. If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-888-495-9340 to request a copy.

Page 10 of

NA AR20141117103613682778

EMPLOYEE BENEFITS (PLEASE PRINT) ENROLLMENT / CHANGE FORM

REVISED 09.18.2015/Page 1 Continued on next page

ENROLLMENT New Enrollment Waiver Transfer

Open Enrollment ‘Change of Status’ Change

STATUS CHANGE / CHANGE OF COVERAGE (Proof must be provided with completed form in order to document changes)

LOCATION TODAY’S DATE

/ / Birth Adoption / Placement Marriage Divorce Death Last Name / Address Beneficiary Change Loss of other Coverage Termination of Employment – PROVIDE DATE / /

EMPLOYEE FIRST NAME LAST NAME M.I SOCIAL SECURITY # - -

DATE OF BIRTH / /

GENDER MALE FEMALE

HIRE DATE / /

HOME PHONE

CELL PHONE

EMAIL ADDRESS MARITAL STATUS Single Married

EFFECTIVE DATE OF COVERAGE / /

STREET ADDRESS

CITY

STATE

ZIP CODE

AVERAGE HOURS /WEEK ANNUAL SALARY

WAIVE ALL COVERAGES By checking the box, I elect to waive participation in ALL of the following Archdiocese’s Benefit Plans – Health, Dental, Voluntary Vision, Flexible Spending Account, Basic Life and Long Term Disability and Voluntary Supplemental Life. I understand

that if I waive participation at this time that I will not have another opportunity to enroll except during the Archdiocese Open Enrollment. I also understand if I later wish to enroll in the LIFE insurance I may be required to furnish evidence of insurability before my coverage will become effective. (PLEASE BE SURE TO SIGN AND DATE LAST PAGE OF THIS FORM.)

FAMILY INFORMATION - COMPLETE THE FOLLOWING INFORMATION FOR EACH FAMLY MEMBER TO BE COVERED BY THE PLAN. IF ADDITIONAL SPACE IS NEEDED, PLEASE ATTACH A SEPARATE PAGE WITH THE ADDITIONAL INFORMATION.

ACTION LAST, FIRST & M.I. COVERAGE ELECTED RELATIONSHIP SOCIAL SECURITY # GENDER DATE OF BIRTH

New Terminate Change

SELF Health Vol Vision Supplemental Life

Dental Basic Life/Disability Flexible Spending Acct Decline ALL

EMPLOYEE SEE ABOVE SEE ABOVE SEE ABOVE

New Terminate Change

Health Vol Vision Supplemental Life

Dental Basic Life Decline ALL

SPOUSE - - Male Female / /

New Terminate Change

Health Vol Vision Supplemental Life

Dental Basic Life Decline ALL

- - Male Female / /

New Terminate Change

Health Vol Vision Supplemental Life

Dental Basic Life Decline ALL

- - Male Female / /

New Terminate Change

Health Vol Vision Supplemental Life

Dental Basic Life Decline ALL

- - Male Female / /

PREEXISTING CONDITIONS - PRIOR COVERAGE Your Employer’s group contract imposes a preexisting condition waiting period for members age 19 and older. This exclusion applies to conditions for which medical advice, diagnosis, care or treatment was recommended or received within the six-month period prior to enrolling in the health plan and the exclusion may last up to 12 months. The exclusion does not apply to pregnancy nor to a child who is enrolled in the Plan within 30 days after birth, adoption or placement for adoption. Your Employer’s group contract will provide credit for preexisting conditions if you were previously covered under creditable coverage. The period of any preexisting condition exclusion that would otherwise apply to a person will be reduced by the number of days of creditable coverage the person has as of the enrollment date. In order to receive credit towards the preexisting condition exclusion period, you must provide copies of the Certificates of the Creditable Coverage or other acceptable proof of coverage from the prior plan(s) or the following information for the verification of prior creditable medical coverage you or any listed dependents currently have, or previously had, including continuation of coverage. Should you need additional information or assistance regarding any preexisting condition exclusion, contact the Blue Cross Blue Shield of Kansas City Customer Services Department at (888) 495-9340 (for the Kansas City area (913) 642-4276). Insurance Company Name:

Name as Listed on Policy:

Name(s) of Person Covered in Prior Plan:

Effective Date: Termination Date:

REVISED 09.18.2015/Page 2 Continued on next page

OTHER INSURANCE COVERAGE / MEDICARE

Are you, or any other person listed above, covered by any other MEDICAL, DENTAL OR MEDICARE plan? NO YES If YES, Medical Dental Medicare AND complete the following: Name and Address of Insurance Company:

Policy #:

Member Name:

Family Members Covered:

1 Please see page 3 for Basic Life and Long Term Disability Package PREMIUM CALCULATION. 2 A beneficiary may be changed by completing this change request form. The beneficiary for life insurance on the lives of your spouse or children will automatically be you, if surviving, otherwise your estate, subject to the policy provisions.

HEALTH – Blue Cross Blue Shield of Kansas City & MedTrak (Employee & Employer share the Cost)

DENTAL – Delta Dental of Kansas (Employee & Employer share the Cost)

VOLUNTARY VISION – VSP (Employee pays 100% of Cost)

EMPLOYEE ONLY FAMILY WAIVE – Do Not elect Coverage

EMPLOYEE ONLY FAMILY WAIVE – Do Not elect Coverage

EMPLOYEE ONLY FAMILY WAIVE – Do Not elect Coverage

FLEXIBLE SPENDING ACCOUNT / PRE-TAX PREMIUM DEDUCTIONS – NueSynergy (Employee pays 100% of Cost) HEALTH CARE ACCOUNT $____________________ Annual Election

Payroll Frequency Monthly (12/year) Semi-monthly (24/year) Bi-weekly (26/year) Other: _______________________

$____________________ Per Pay Period

DEPENDENT CARE ACCOUNT $____________________ Annual Election

Payroll Frequency Monthly (12/year) Semi-monthly (24/year) Bi-weekly (26/year) Other: _______________________

$____________________ Per Pay Period

Debit Card Option One card – Must provide email address (Cost of $12 annually plus $2 setup fee for card) Additional Card (Cost of $2 annually) Name on card ____________________

Direct Deposit Authorization Enroll Be sure to complete the Direct Deposit Authorization form.

Pre-Tax Premium Deductions By checking the box above, I elect to participate in the Archdiocese’s Premium Only Plan for benefits made available under Section 125 of the Internal Revenue Code. I hereby authorize the contributions for MEDICAL, DENTAL, VOLUNTARY VISION, VOLUNTARY ACCIDENT and/or FLEXIBLE SPENDINGACCOUNT(S) to be deducted from my paycheck for the coverage selected including any additional deductions due to an increase in a selected program’s cost during the plan year. I understand that I may NOT change my elections during the plan year except as allowed by the plan for a “Change in Family Status”, following IRS guidelines. I understand that by participating in the plan, my social security benefits may be affected because certain elections will be deducted before my salary is taxed. I understand that it is my responsibility to report to the plan any changes in eligibility of my dependents or myself.

WAIVE – I do Not elect Pre-tax Premium Deductions

WAIVE – Do Not elect Coverage

WAIVE – Do Not elect Coverage

WAIVE – Do NOT

elect Debit Card

WAIVE – Do NOT

enroll in Direct Deposit

BENEFICIARY DESIGNATION APPLIES TO THE FLEXIBLE SPENDING ACCOUNT. IF ELECTING TO PARTICIPATE, BENEFICIARY DESIGNATION MUST BE COMPLETED. (Last Name) (First & M.I.) (Relationship) (Address)

1. BASIC LIFE and LONG TERM DISABILITY PACKAGE - Hartford Life (Employee pays 50% of Cost) 1 By checking one of the boxes below, I elect to participate in the Archdiocese’s BASIC LIFE and DISABILITY Package. Below is an outline of the benefits provided through this package. EMPLOYEE ONLY FAMILY

BASIC LIFE & AD&D BENEFIT Employee Basic Life - $20,000 Employee Basic AD&D - $20,000 Spouse Life $4,000 Dependent Child $2,000

LONG TERM DISABILITY BENEFIT Benefit is 50% of monthly income to a maximum benefit of $3,000. Benefits begin after 13 weeks.

WAIVE – Do Not elect Coverage LIFE/AD&D BENEFICIARY APPLIES TO BASIC LIFE. BENEFICIARY DESIGNATIONS MUST BE COMPLETED. PROVIDE A COMPLETE ADDRESS IF DIFFERENT THAN EMPLOYEE’S. 2

PRIMARY BENEFICIARY CONTINGENT BENEFICIARY (Last Name) (First & M.I.) (Relationship) (Address) (Last Name) (First & M.I.) (Relationship) (Address)

1. 1.

2. 2.

REVISED 09.18.2015/Page 3 Continued on next page

1 A beneficiary may be changed by completing this change request form. The beneficiary for life insurance on the lives of your spouse or children will automatically be you, if surviving, otherwise your estate, subject to the policy provisions.

BASIC LIFE and LONG TERM DISABILITY PACKAGE (continued from page 2) Premium Calculation: Basic Package (Includes BASIC LIFE & AD&D AND LONG TERM DISABILITY (Employee pays 50% of Cost)

Salary: (As of September 1 or Date of Hire for new employees)

Weekly $ _______________________________ (Weekly salary is calculated by dividing your annual salary by 52)

Monthly $ _______________________________ (Monthly salary is calculated by dividing your annual salary by 12.)

Coverage Cost per Unit Monthly Cost EMPLOYEE COST (MONTHLY COST divided by 2)

EMPLOYEE BASIC LIFE $20,000 x $0.088 / $1,000 $1.76 $0.88

EMPLOYEE BASIC AD&D $20,000 x $0.01 / $1,000 $0.20 $0.10

SPOUSE and/or DEPENDENT CHILD LIFE $1.176 per covered SPOUSE & ALL listed eligible dependent CHILDREN $1.176 $0.588

LONG TERM DISABILITY MONTHLY Salary $ __________________ (not to exceed $6,000)/ 100 x $0.241 $ $

Total Monthly Cost $ $

VOLUNTARY SUPPLEMENTAL LIFE – Hartford Life (Employee pays 100% of Cost) EMPLOYEE MUST ENROLL IN THE BASIC LIFE and LONG TERM DISABILITY PACKAGE IN ORDER TO ELECT VOLUNTARY LIFE EMPLOYEE LIFE $____________________ (available in $10,000 increments, $150,000 max) SPOUSE LIFE $ _____________________ (available in $5,000 increments, $75,000 max or 50% of EMPLOYEE’S amount whichever is less) DEPENDENT CHILD(REN) - Option 1 ($5,000 on each child) * DEPENDENT CHILD(REN) - Option 2 ($10,000 on each child) * WAIVE – Do Not elect Coverage * May pick only ONE coverage option for ALL dependent children

LIFE/AD&D BENEFICIARY APPLIES TO VOLUNTARY LIFE. BENEFICIARY DESIGNATIONS MUST BE COMPLETED. PROVIDE A COMPLETE ADDRESS IF DIFFERENT THAN EMPLOYEE’S. 1 PRIMARY BENEFICIARY CONTINGENT BENEFICIARY SAME AS BASIC LIFE & AD&D (if different, please complete sections below) SAME AS BASIC LIFE & AD&D (if different, please complete sections below) (Last Name) (First & M.I.) (Relationship) (Address) (Last Name) (First & M.I.) (Relationship) (Address)

1. 1.

2. 2.

Premium Calculation: VOLUNTARY LIFE INSURANCE (Employee pays 100% of Cost) Rates based on Age as of Jan 1 of this year

Under 30 30 – 34 35 – 39 40 – 44 45 – 49 50 – 54 55 – 59 60 – 64 65 – 69 70 – 74 75 and over $0.06 $0.08 $0.10 $0.14 $0.23 $0.36 $0.56 $0.71 $1.27 $2.10 $3.70

Coverage Cost per Unit Monthly Cost

EMPLOYEE $ _____________________ (Amount elected above) / $1,000 x $ ________ (Employee’s age rate as above) $

SPOUSE $ _____________________ (Amount elected above) / $1,000 x $ ________ (Spouse’s age rate as above) $

DEPENDENT CHILD(REN) Option 1 or 2 as elected above. Option 1 $0.35 or Option 2 $0.70 $

Total Monthly Payroll Deduction $

REVISED 09.18.2015/Page 4 End of form

COVERAGE / CHANGE OF COVERAGE / AUTHORIZATION TO RELEASE INFORMATION By signing this form, I am applying for covered services for which my family and I are eligible and I authorize my employer to deduct from my earnings any required contributions. I agree on behalf of myself and those family members enrolled (“Dependents”), for whom I have the authority to enroll and to consent on their behalf (collectively my Dependents and I shall be referred to as my “Enrolled Family”), that Archdiocese of Kansas City in Kansas or their authorized representatives (collectively referred to as “Health Plan”) may use or disclose to third parties the information contained on this enrollment form and individually identifiable health information relating to my Enrolled Family for purposes of administering my insurance benefits, including for treatment, payment or health care operations, as those terms are explained in detail in Health Plan’s Notice of Privacy Practices and to the extent permitted by law. I understand, if I waive any of the LIFE insurance coverages offered to me, that if I desire to apply for these coverages at a later date, I may be required to furnish, at my own expense, medical evidence in support of insurability that is satisfactory with the current insurance carrier, before my coverage will become effective. I represent the information to be complete and accurate to the best of my knowledge. I understand that my answers will be used to determine my eligibility for coverage. I further understand that if any material is omitted or misrepresented, it could provide a basis to refuse / rescind coverage and to refund any premiums paid as though coverage had never been in force. EMPLOYEE Signature Date EMPLOYER Signature Print EMPLOYEE Name Print EMPLOYER Name

EMPLOYEE Instructions Please be sure to complete the EMPLOYEE BENEFITS ENROLLMENT / CHANGE FORM in its entirety and return within the requested timeframe to your EMPLOYER. Also be sure to retain a copy for your personal files.

EMPLOYER Instructions

Please retain a copy for the EMPLOYEE’s personnel file. The original copy should be forwarded to the Archdiocese of Kansas City in Kansas Human Resource office.

Archdiocese of Kansas City in Kansas 12615 Parallel Parkway Kansas City, KS 66109