Benefit Summary for the Employees of Shodair Children’s HospitalEffective Date: July 1st, 2019– June 30th, 2020

These materials are produced by Leavitt Great West for the sole use of its clients, prospective clients, and their representatives. Certain information contained in these materials are considered proprietary information created by Leavitt Great West and/or their licensed and appointed insurance carriers. Such information and any insurance designs furnished by Leavitt Great West are considered “Confidential Material.” Such information shall not be used in any way, directly or indirectly, detrimental to Leavitt Great West and clients and/or potential clients and any of their representatives will keep that information confidential.

Your Benefits PlanShodair Children’s Hospital is pleased to offer a comprehensive benefits program to our valued employees.

In the following pages, you will learn more about the benefits Shodair Children’s Hospital offers. You will also see how choosing the right combination of benefits can help protect you and your family’s health and financial future.

Benefit Carrier

Medical and Vision CoverageBlue Cross Blue Shield

Medical Management ProgramVideo Consult with Physician MD Live

Patient Advocacy with Remote Second Opinion VezaHealthDental Insurance Delta Dental

Employer-Paid Life/AD&D InsuranceThe Hartford

Voluntary Life/AD&D InsuranceIndividual Life Insurance (Term and Permanent)

American Fidelity

Voluntary Short Term and Long Term Disability InsuranceCritical Illness Insurance

Accident InsuranceCancer Insurance

Health Savings AccountFlexible Spending Account

Eligibility‘Class I’ Employees working at least 20 hours per week are eligible for benefits the first of the month following a 60 day waiting period and upon completion of an enrollment form.

‘Class II’ Variable Hour Employees must complete a 12 month Measurement Period, and work an average of 130 hours per month during the Measurement Period, to be eligible for medical coverage. Coverage will begin the first of the month following the end of the Measurement Period.

Children are eligible for benefits up to age 26 regardless of dependent, student or marital status.

Spouses and ‘common law’ domestic partners are eligible for benefits. To enroll your domestic partner, please see HR for the additional required forms.

When can you enroll?You can sign up for Benefits at any of the following times:

• After completing initial eligibility period• During the annual open enrollment period• Within 60 days of a qualified family-status change

If you do not enroll or make changes at the above times, you must wait for the next annual open enrollment period.

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Making ChangesGenerally, you can only change your benefit elections during the annual benefits enrollment period. However, you may be able to change some of your benefit elections upon the occurrence of certain change in status events, provided you properly notify your HR Manager and the change is permitted under the plan terms. Examples of these changes in status events may include:

• Your marriage• Your divorce or legal separation• Birth or adoption of an eligible child• Death of your spouse or covered child• Change in your spouse’s work status that affects his or her benefits• Change in your work status that affects your benefits• Change in your child’s eligibility for benefits• Receiving Qualified Medical Child Support Order (QMCSO)

If you have a family status change, you must notify your HR Manager within 60 days of the change and complete the necessary forms. For more information, refer to your benefit plan documents.

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Medical PlansShodair Children’s Hospital offers a choice between three medical plans through Blue Cross Blue Shield of Montana. Each medical plan has three benefit tiers; Tier 1 -Blue Options Provider with highest level of benefit, Tier 2- Blue Cross Participating Provider, Tier 3- Out-of-Network Provider with the lowest level of benefit. You can find a Tier 1 (Blue Options) and Tier 2 (Blue Preferred PPO) providers on BCBSMT’s website at www.bcbsmt.com or by calling BCBS at 1-855-258-3489. Please see your Booklet or Carrier Benefit Summary for more information.

(dw) stands for deductible waived

Group #200281 Traditional Option 1Tier 1 / Tier 2 / Tier 3

Traditional Option 2Tier 1 / Tier 2 / Tier 3

HDHPTier 1 / Tier 2 / Tier 3

Annual Deductible – starts over on July 1st Tiers 1, 2 and 3 deductibles are separate deductibles and do not accumulate toward each otherPer Person $350 / $2,000 / $5,000 $1,100 / $3,000 / $5,000 $2,700 / $5,000 / $6,000

Maximum Per Family $700 / $4,000 / $10,000 $2,200 / $6,000 / $10,000 $5,400 / $10,000 / $12,000

Annual Out-of-Pocket Maximum- starts over on July 1st

Tier 1 and Tier 2 accumulate toward each other; however, Tier 3 does not accumulate to any other out-of-pocket amount.Per Person $1,850 / $4,000 / $6,000 $2,200 / $5,000 / $6,000 $2,700 / $5,000 / $6,000

Maximum Per Family $3,700 / $8,000 / $12,000 $4,400 / $10,000 / $12,000 $5,400 / $10,000 / $12,000Preventive Care

Office Visit Tier 1 & 2: Covered in Full (dw)Tier 3: ded and coins.

Tier 1 & 2: Covered in Full (dw)Tier 3: ded and coins.

Tier 1 & 2: Covered in Full (dw)Tier 3: ded and coins.

Well-Child Care Tier 1 & 2: Covered in Full (dw)Tier 3: ded and coins.

Tier 1 & 2: Covered in Full (dw)Tier 3: ded and coins.

Tier 1 & 2: Covered in Full (dw)Tier 3: ded and coins.

Member Pays portion after deductible is met is indicated below, unless otherwise statedProfessional

Primary Care Office VisitTier 1- $30 (dw)

Tier 2- 30%Tier 3- 50%

Tier 1- $30 (dw) Tier 2- 30%Tier 3- 50%

0%

Outpatient Specialist Visit 10% / 30% / 50% 10% / 30% / 50% 0%Hospital/FacilityInpatient Care 10% / 30% / 50% 10% / 30% / 50% 0%

Outpatient Care 10% / 30% / 50% 10% / 30% / 50% 0%Mental Health/Substance AbuseInpatient 10% / 30% / 50% 10% / 30% / 50% 0%

Outpatient $30 or 10% / 30% / 50% $30 or 10% / 30% / 50% 0%Other Services

Accidental Injury Benefit Covered in Full up to $300, then deductible and coinsurance apply

Covered in Full up to $300, then deductible and coinsurance

applyN/A

Diagnostic X-Ray and Lab Tests

10% / 30% / 50%10% / 30% / 50%

0%

Major Imaging (PET/CAT scans, MRIs)

10% / 30% / 50%10% / 30% / 50%

0%

Emergency Room 10% / 30% / 50% 10% / 30% / 50% 0%

Urgent Care 10% / 30% / 50% 10% / 30% / 50% 0%Chiropractic Care35 visit max per benefit period

10% $25 Plan Max Allowable

Naturopathic Care6 visit max per benefit period

Tier 1- 10% (dw)Tier 2- 30%Tier 3- 50%

$75 Plan Max Allowable

Tier 1- 10% (dw) Tier 2- 30%Tier 3- 50%

$75 Plan Max Allowable

After deductible, Covered at 100% up to $75 Plan Max

Allowable

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Continued… VISION BENEFIT

(Medical Plans Continued)Routine Vision Benefit- available to members covered on the medical plan

All Network Tiers: Vision Exam covered at 100% up to $100 once per benefit period. (dw)All Network Tiers: Frames/Lenses/Contacts are covered at 100% up to $150 once per benefit

period. (dw)

Prescription DrugsBelow is a brief overview of what you can expect to pay for a prescription drug, depending on which “tier” category it falls under in the Preferred Drug List for your plan when using an In-Network Pharmacy. To find out more details regarding your prescription drug plan, please see the following websites:

If you have a Maintenance Drug, one you take every day, week or month, take advantage of the Mail Order Programs with your medical plan. See your packet or go online for details.

BCBSMTTraditional Plan Option 1 and Option

2Member Cost Below, these copays

will accumulate towards the Medical max-out-of-pocket:

BCBSMTHDHP

Member Cost Below, prescription costs will accumulate towards the medical

deductible. With select preventive medications, deductible is waived and you pay the applicable copays which

will go towards your max-out-of-pocket:

Network* Value Network/ Participating Network Mail Order Value Network/ Participating

Network Mail Order

Deductible None Prescription drug cost goes towards Medical Deductible, then:

Preferred Generic $0 copay / $5 copay 2 x Value copay 0% 0%Non-Preferred Generic $10 copay / $15 copay 2 x Value copay 0% 0%

Preferred Brand $50 copay / $60 copay 2 x Value copay 0% 0%Non-Preferred Brand

$100 copay / $110 copay 2 x Value copay 0% 0%

Specialty $150 NA 0% NA

Preventive Medication Benefit (HDHP Plan) Generic: $0 / $5 (dw)Brand: $50 / $60 (dw) 2 x Value copay

Maximum Day Supply 30/90 days 90 days 30/90 days 90 days

*You can view a list of Value Network and Participating Network pharmacies at www.bcbsmt.com or by calling BCBS at 855-258-3489.

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IMPORTANT: Member must pay the difference between a brand name drug and the generic equivalent, in addition to the

Dental Plans

Patient Advocacy with Remote Second OpinionAs a patient, if you receive a new diagnosis or if your doctor is suggesting a surgery, it can be a frightening time. How do you know if your doctor got it right? According to a recent Mayo study, 79% of the time a diagnosis is wrong or is lacking clarity due to other health issues. Let’s say your doctor does have your diagnosis right, do you know if he or she presented you with all your options? Let’s say they did that as well. How do you know, especially in situations where surgery is recom-mended, that your physician is one of the best?

Due to Shodair Children’s Hospital’s commitment to the health and well-being of all its employee and health plan members, Shodair is providing VezaHealth Patient Advocacy services at no cost to you on a voluntary basis. If you decide to engage with VezaHealth, VezaHealth will gather all your medical information (records, images), have an in-depth conversation with you to better understand what you have been told, what your health goals are, what your lifestyle is. From there, they de-liver your information to one of their high quality, reputable physicians to review. They then will have up to an hour-long telephone call or web-based conversation with you to discuss your options. This is what is known as a remote second opin-ion.

Beyond receiving a remote second opinion, there are other facets to VezaHealth services you may find helpful in your healthcare experience.

- Receive a remote second opinion from an elite physician- Know your treatment options and the associated costs- Have direct access to a nurse throughout your experience- Feel confident in managing your illness- Receive support in selecting a local physician or traveling to a physician who has expertise in your condition- Discover programs and resources available to you

You should call VezaHealth if you…

…have been told you need surgery,

…have a new diagnosis and want to know all your treatment options,

…are struggling with a diagnosis and believe you and/or your physician is not properly managing it

Shodair is offering a $200 taxable cash incentive for receiving a second remote opinion!

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IMPORTANT: Member must pay the difference between a brand name drug and the generic equivalent, in addition to the

Dental PlansShodair Children’s Hospital offers a choice between two dental plans. The Benefit Year runs from July 1st through June 30th.

Delta DentalLow Option

Delta DentalHigh Option

Benefits- July 1st through June 30th Benefit Year Maximum $1,000 $2,000Annual DeductibleIndividual $50 $50Family $150 $150Dental CategoriesPreventive & Diagnostic Care 100% (dw) 100% (dw)Basic Restorative Care 80% 80%Major Restorative Care (dental implants are excluded from coverage)

50% 50%

TMJ TreatmentBenefit 50% 50% Lifetime TMJ Maximum $1,000 $2,000OrthodontiaBenefits (Dependent Children Only) Not Covered 50%Lifetime Orthodontia Maximum Not Covered $2,000

Voluntary Pre-AuthorizationIn the event you need to have dental work estimated to cost $300 or more, we recommend you have your dentist submit the charges to Delta Dental for pre-authorization. Delta Dental will review the intended treatment plan and let your dentist know how much of the bill they will cover. We recommend this to avoid any billing issues.

NetworkYou have access to both Delta’s PPO network and Premier network. The PPO network provides the deepest discount so that your maximum benefit stretches farther. You can view a list of PPO and Premier Dentists in your area at www.deltadentalins.com or by calling Delta Dental at 1-800-521-2651.

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Discount ProgramDelta Dental members now have access to discounts on hearing aids and LASIK surgery through network providers. For access to the hearing aid discount, visit www.amplifonusa.com/deltadentalins or call 1-888-779-1429 and an average of 62%. For access to the LASIK discount, visit www.qualsight.com/-delta-dental or call 1-855-248-2020 and save up to 50%.

Group Life/AD&D BenefitsCompany Paid

Shodair Children’s Hospital provides Group Life and AD&D insurance to all benefit eligible employees at no additional cost. Please be sure to select a beneficiary.

Group #00073392 The Hartford EmployeeBenefit Amount $25,000 Accelerated Benefit 80% of benefit for less than a 12 month life expectancyPortable Yes

Optional Life Benefits

Shodair Children’s Hospital offers Voluntary Life and AD&D insurance to all benefit eligible employees. Voluntary life is paid by employees via payroll deductions. An application for coverage must be submitted and approved.

Group #00073395 The HartfordEmployeeBenefit Amount Current: $10,000 increments not to exceed 5 times Earnings or $500,000Guarantee Issue Amount $100,000Overall Maximum 5 times earnings Spouse

Benefit Amount $5,000 increments to $250,000 not to exceed 100% of Employee’s voluntary life amount

Guarantee Issue Amount $25,000Overall Maximum 100% of Employee’s voluntary life amountChild(ren)

Benefit Amount Live birth to 6 months- $2,0006 months to age- Increments of $2,000 to a max of $10,000

Guarantee Issue Amount $10,000Overall Maximum $10,000

Benefit ReductionCoverage amount reduces by 35% at age 70 and by 50% of original amount at age 75.

TaxationIRS regulations require taxation of life benefits above $50,000 to the employee. This amount will be deducted automatically through payroll deductions.

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Voluntary Life Guarantee Issue (GI)Amounts of coverage are available without answering health questions if applying within the first 31 days of becoming eligible. Applicants requesting coverage after 31 days of first becoming eligible, or applying for an amount that exceeds the GI amount, must answer health questions by completing an Evidence of Insurability form and be approved for coverage.

Voluntary Short Term Disability To provide short-term salary protection, Shodair Children’s Hospital offers a short-term disability benefit to all benefit eligible employees, subject to approval from the carrier. The employee pays 100% of the premium.

American FidelityWhen Benefits Begin Accident and Sickness 14 day elimination (waiting) periodBenefit Features

Benefit Amount Flexibility to elect a flat weekly benefit amount. Election cannot exceed 60% of monthly earnings.

Pre-existing Condition Limitation 12 month look back/12 months insured

Benefit Duration 180 days

Contribution Definition: ContributoryYour premium for this benefit will be taken post-tax so that in the event of a disability claim, payments received under this plan will not be considered taxable income.

Voluntary Long Term Disability To provide short or long-term salary protection, Shodair Children’s Hospital offers a long-term disability benefit to all benefit eligible employees, subject to approval from the carrier. The employee pays 100% of the premium.

American FidelityWhen Benefits Begin Accident and Sickness Choice of 8th, 15th, 31st, 61st, 91st and 181st day following incidentBenefit Features

Benefit Amount Flexibility to elect a flat weekly benefit amount from $500 to $10,000 in increments of $100. Election cannot exceed 60% of monthly earnings.

Pre-existing Condition Limitation 12 month look back/12 months insured

Benefit Duration Up to 24 months for Own Occupation, and up to Social Security Normal Retirement Age (SSNRA) if unable to work in any occupation

Contribution Definition: ContributoryYour premium for this benefit will be taken post-tax so that in the event of a disability claim, payments received under this plan will not be considered taxable income.

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Critical Illness Shodair Children’s Hospital offers a Critical Illness policy. This policy pays a lump sum amount (the amount you choose and are approved for) in the event you are diagnosed with a covered critical illness. This policy is intended to help cover the costs associated with a covered critical illness so that you can pay your out-of-pocket medical expenses (deductible and coinsurance), however the money received through this policy can be used towards all non-medical expenses as well (e.g.; mortgage, car payment, groceries, daycare, ect).

Group # 460129 American Fidelity

Benefit Features

Benefit AmountEmployee: Choice of $10,000, $20,000 or $30,000

Spouse: 50% of Employee’s ElectionChild (to age 25): Up to 25% of Employee’s Election provided at no additional cost

NEW HIRES ONLY: Guarantee Approval/Issue Threshold $30,000

Benefit Reduction 50% reduction for you and your dependents when you reach age 70

Covered Illnesses

Vascular Conditions: Heart Attack; StrokeOther Conditions: Major Organ Failure; End State Renal Failure;

ParalysisLimited Benefit Conditions: Coronary Artery Bypass Graft

Pre-Existing Condition Limitation

12 month look back from effective date/ no coverage on pre-existing condition unless diagnosed after 12 months of continuous coverage under this policy

Health Screening Benefit Pays $50 benefit once each year for each covered person when one (or more) specified health screening tests occurs (EKG, Stress Test, Glucose Testing, Echo, ect)

Portable Yes- within 31 days of termination off group policy

AccidentShodair Children’s Hospital offers an Accident policy. This policy helps cover the costs associated with a covered accident so that you can pay your out-of-pocket medical expenses (deductible and coinsurance), however the money received through this policy can be used towards all non-medical expenses as well (e.g. mortgage, car payment, groceries, daycare, etc.).

Group # 460130 American Fidelity

Benefit Features

Benefit Amount Varies by condition and treatment type. Refer to Hartford’s Policy. Can purchase coverage for spouse and children as well.

Coverage 24 hour coverage (on and off job)

Portable Yes- within 31 days of termination off group policy. Benefits reduce by 50% when porting.

Contribution Definition: Contributory

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Contribution Definition: ContributoryYour premium for this benefit will be taken post-tax so that in the event of a disability claim, payments received under this plan will not be considered taxable income.

If your premium is taken pre-tax, In the event of a claim, payments received under this plan would be considered taxable income.

Health Savings AccountIf you are enrolled on the HDHP medical plan, Shodair will contribute the following amount into your Health Savings Account:

Employee-Only Coverage: $540 annually

Employee+ Dependent(s): $1,080 annually

To be eligible for a Health Savings Account (HSA), you must:

• be covered under a Qualified High Deductible Health Plan (QHDHP) on the first day of the month;• not be enrolled in Medicare;• have no other non-QHDHP coverage, and• not be claimed as a dependent on another person’s tax return.• cannot have dollars in a medical flex account

The money in the HSA is to be used for eligible medical expenses, as defined by the IRS (see IRS Publication 502, Medical and Dental Expenses for more details). Distributions from the HSA for ineligible expenses are subject to taxation and penalties.

For the 2019 tax year, you may contribute up to $3,500 each year to your HSA if you have self-only QHDHP coverage or up to $7,000 if you have family QHDHP coverage. Any money left in the account at the end of the year will roll forward to the next year.

If you are an eligible individual who is age 55 or older at the end of the tax year, you may contribute an additional $1,000 as a catch-up contribution each year. Beginning with the first month you enrolled in Medicare, you may not contribute to your HSA as you are no longer eligible.

For additional guidelines, please go online to www.afhsa.americanfidelity.com/ or call 1-800-662-1113. See also IRS Publication 969, Heath Savings Accounts and Other Tax Favored Health Plans.

Why should I elect an HSA?

1. Cost Savings 2. Long-term Financial Benefits 3. Choice- Tax-exempt dollars

- Reduction in medical plan contribution

- Interest-bearing sav-ings account

- Save for future medical ex-penses

- Funds roll over year-to-year

- This is your account; you take it with you

- You control and manage your health care ex-penses.

What if I am a healthy single person?

Individual Deductible $2,700 Incurred Medical Expenses/Year

Coinsurance 100/0 Office Visit $85

Out-of-pocket Limit $2,700 Office Visit + Lab $115

HSA Employer Funds $540 Urgent Care Visit $185

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HSA Employee Funds $0 Total Incurred Expenses $385

Total HSA Funds* $540 Total Amount Applied to Deductible $385*The annual HSA contribution limit for 2017 is $3,400 for individuals. For 2018, it is $3,450 for individuals. Total Subject to Coinsurance $0

HSA Account Balance ($540 HSA minus $385 incurred expenses) $155

Medical Flexible Spending AccountHealthcare Expense AccountThe health account allows you to fund your out-of-pocket medical, dental and vision expenses, such as copays and deductibles, with pre-tax dollars. By paying for out-of-pocket medical expenses with pre-tax dollars, you will save a minimum of $.23 per dollar because you do not pay State Income Tax, Federal Income Tax or FICA tax on your contributions. Shodair Children’s Hospital allows a voluntary contribution of up to $2,700 per plan year (July 1st – June 30th) into your healthcare expense account.

Important note regarding Healthcare Reform and the impact to FSA plans: Effective January 1, 2011 over the counter (OTC) drugs and medicines were no longer eligible for reimbursement from your FSA Healthcare Expense Account, unless prescribed by a doctor.

What are the risks of FSAs?FSAs should only be considered for anticipated expenses. You should be conservative when estimating the amount to contribute to each account because FSA’s are subject to the “use-it-or-lose-it” rule. If you overestimate your expenses and have money left in the account at the end of the plan year, it will be forfeited, however the health FSA plan includes a 2 ½ month grace period that begins the day after the end of the plan year to use FSA funds incurred through the end of the grace period.

Also, you may not change your election during the plan year unless you experience a permitted qualifying event (for example, birth of child or marriage).

For a small percentage of participants, Social Security retirement benefits may be affected by participating in FSAs. Participation in this plan reduces your W-2 income, on which retirement benefits are based.

NOTE: IRS Regulations do not allow Domestic Partner claims to be submitted for reimbursement through the Flex plan unless they qualify as a tax dependent under Code Section 152.

Telehealth via MD LiveMD LIVE allows you access to a board-certified physician 24/7 via video consult for $44.00 or less for illness related consults and between $80-$175 for behavioral consults. This cost will be processed towards your medical benefits. Should the physician prescribe medication, your prescription will go towards your pharmacy benefits.

You can use this service to treat non-emergency medical issues, such as:

Cold & Flu

Bronchitis & sinus infections

Pediatric Concerns

Eye Issues

UTI’s & yeast infections

Rashes & skin issues

Allergies

Anxiety

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Depression

Go to MDLIVE.com/bcbsmt to get started or download the MDLIVE app in Apple or Google Play app stores.

Medical Management Program

Blue Cross Blue Shield of Montana allows you access to medical management programs at no cost to you through their Blue Care Connections program. Registered nurses and health professional are standing by to help you manage your health. If you are identified through Blue Cross Blue Shield of Montana’s nurses as having a condition that qualifies for free assistance through this program, you may receive a call from a Blue Care Connection Advisor who is a licensed clinician with special training to help manage your condition. If you feel that you could benefit from the Blue Care Connection program, you can self-refer by calling 1-855-313-8912 to join the program. You can also access this program online at www.careontarget.com to gain access to many tools, including ability to chat with a clinician online.

Many conditions and health needs qualify for this program, such as:

Asthma and chronic obstructive pulmonary disease

Congestive heart failure

Coronary artery disease

Depression

Diabetes

Low Back Pain

Maternity

Losing weight or quitting tobacco

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2019 Premiums Per Month

Medical/Rx/Vision- 0% Increase to employee premiumBCBSMT Tradition 1 Employee Pays Shodair Children’s Hospital

Pays Total Premium

Employee Only $352.00 $643.70 $995.70Employee + Spouse $1,136.00 $722.66 $1,858.66Employee + Child(ren) $892.00 $701.11 $1,593.11Employee + Family $1,616.00 $773.71 $2,389.71

BCBSMT Tradition 2Employee Only $84.00 $619.64 $703.64Employee + Spouse $634.00 $680.33 $1,314.33Employee + Child(ren) $424.00 $664.64 $1,088.64Employee + Family $988.00 $724.62 $1,712.62

BCBSMT HDHPEmployee Only $62.00 $590.35 $652.35Employee + Spouse $602.00 $616.54 $1,218.54Employee + Child(ren) $390.00 $619.29 $1,009.29Employee + Family $916.00 $671.77 $1,587.77

Dental- 0% increase to employee premiumDelta Dental Low Employee Pays Shodair Children’s Hospital

Pays Total Premium

Employee Only $6.00 $20.11 $26.11Employee + Spouse $12.00 $46.43 $58.43Employee + Child(ren) $12.00 $69.08 $81.08Employee + Family $24.00 $101.54 $125.54

Delta Dental HighEmployee Only $20.00 $8.92 $28.92Employee + Spouse $30.00 $34.60 $64.60Employee + Child(ren) $30.00 $56.97 $86.97Employee + Family $40.00 $95.46 $135.46

Voluntary Life and AD&D through The HartfordEmployee and Spouse separately pays the below rate per

$1,000 of Coverage. Spouse rate is based on Employee’s age.Child Coverage, rate per

$1,000 of CoverageAD&D Coverage, rate

per $1,000 of Coverage

Age Monthly Rate Age Monthly Rate Monthly Rate Monthly Rate

0-24 $0.05 55-59 $0.63 $0.20 Employee: $0.03625-29 $0.05 60-64 $0.93 Spouse: $0.03630-34 $0.06 65-69 $1.35 Child: $0.04

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35-39 $0.07 70-74 $3.4040-44 $0.11 75+ $6.3445-4950-54

$0.20$0.31

American Fidelity Critical Illness Policy- EMPLOYEE MONTHLY RATES$10,000 $20,000 $30,000

Age Non-Tob Tobacco Non-Tob Tobacco Non-Tob Tobacco

18-29 $3.98 $6.30 $6.46 $11.10 $8.94 $15.90

30-39 $6.26 $9.90 $11.02 $18.30 $15.78 $26.70

40-49 $11.38 $17.98 $21.26 $34.46 $31.14 $50.94

50-59 $18.74 $29.66 $35.98 $57.82 $53.22 $85.98

60 & Over $30.66 $48.58 $59.82 $95.66 $88.98 $142.74

American Fidelity Critical Illness Policy- SPOUSE MONTHLY RATES$5,000 $10,000 $15,000

Age Non-Tob Tobacco Non-Tob Tobacco Non-Tob Tobacco

18-29 $2.40 $4.18 $3.30 $6.86 $4.20 $9.54

30-39 $3.76 $6.58 $6.02 $11.66 $8.28 $16.74

40-49 $6.84 $11.96 $12.18 $22.42 $17.52 $32.88

50-59 $11.30 $19.74 $21.10 $37.98 $30.90 $56.22

60 & Over $18.50 $32.32 $35.50 $63.14 $52.50 $93.96

American Fidelity Accident PolicyCoverage Type Total Monthly PremiumEmployee $19.90Employee + Spouse $28.30Employee + Child(ren) $31.50Family $39.90

American Fidelity Short Term Disability90 Day Benefit Duration Total Monthly Premium per

$100 weekly benefitUnder 40 $2.6040-49 $2.7250-59 $2.9260+ $3.70

180 Day Benefit Duration Total Monthly Premium per $100 weekly benefit

Under age 40 $2.8640-49 $2.9650-59 $3.2260+ $40.04

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American Fidelity Long Term Disability- MONTHLY RATES90 Day Elimination Period Total Monthly Premium per

$100 weekly benefitUnder 40 $2.1240-49 $2.7250-59 $4.0260+ $4.74

180 Day Elimination Period Total Monthly Premium per $100 weekly benefit

Under age 40 $1.5440-49 $1.8050-59 $2.7060+ $2.74

Carrier Contact InformationIf you have any further questions concerning your benefits, please contact:

Carrier Plan Website Phone NumberBlue Cross and Blue Shield of

Montana

Medical, Rx and Vision Coverage www.bcbsmt.com 1-855-258-3489

Blue Cross and Blue Shield of

Montana

Blue Care Connections Medical Management www.careontarget.com 855-313-8912

VezaHealth Patient Advocacy and Remote Second Opinion www.vezahealth.com

800-970-6571 or consultant@vezahealth.co

m

Delta Dental Dental Insurance www.deltadentalins.com 1-800-521-2651

The Hartford Employer and Voluntary

Life and AD&D Insurance

www.thehartford.com 1-800-523-2233

American Fidelity

Disability, Accident, Cancer, Critical Illness, Individual Life, Medical

Flex, Health Savings Account

www.Americanfidelity.com/Login

800-662-1113

MD Live Video Consult with Physician

www.MDLIVE.com/bcbsmtand the MDLive App 888-684-4233

Clarity Benefits Cobra www.claritybenefitsolutions.com 888-423-6359

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Benefit Resource CenterThe Benefit Resource Center is designed to provide you with a responsive, consistent, hands-on approach to benefit inquiries. Benefit Specialists are available to research and solve elevated claims, unresolved eligibility problems, and any other benefit issues with which you might need assistance. The Benefit Specialists are experienced professionals and their primary responsibility is to assist you.

The Specialists in the Benefit Resource Center are available Monday through Friday 8:30 a.m. to 5:00 p.m. If you need assistance outside of regular business hours, please leave a message and one of the Benefit Specialists will promptly return your call or e-mail message by the end of the following business day.

Phone: 406-443-1060 Email: ShodairBenefits@leavitt.com Fax: 406.442.1913

Benefit Administration Contact Information:Melissa Moore - Director of Human ResourcesShodair Children’s Hospital2755 Colonial Drive/P.O. Box 5539Helena, MT 59604406-444-7506mmoore@shodair.org

Angela Austin - HR AssistantShodair Children’s Hospital2755 Colonial Drive/P.O. Box 5539Helena, MT 59601406-444-7579aaustin@shodair.org

Heather Brewer – Account ExecutiveLeavitt Great West3390 Colton Drive, Ste AHelena, MT 59602406-443-1060heather-brewer@leavitt.com

Mary Kay Puckett - Senior ConsultantLeavitt Great West3390 Colton Drive, Ste AHelena, MT 59602406-443-1060marykay-puckett@leavitt.com

Disclosure17

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.

These materials are produced by Leavitt Great West for the sole use of its clients, prospective clients, and their representatives. Certain information contained in these materials are considered proprietary information created by Leavitt Great West and/or their licensed and appointed insurance carriers. Such information and any insurance designs furnished by Leavitt Great West are considered “Confidential Material.” Such information shall not be used in any way, directly or indirectly, detrimental to Leavitt Great West and clients and/or potential clients and any of their representatives will keep that information confidential.

IRS Circular 230 Disclosure: Leavitt Great West Insurance Services does not provide tax advice. Accordingly, any discussion of U.S. tax matters contained herein (including any attachments) is not intended or written to be used, and cannot be used, in connection with the promotion, marketing or recommendation by anyone unaffiliated Leavitt Great West Insurance Services of any of the matters addressed herein or for the purpose of avoiding U.S. tax-related penalties. Also, the information contained in this benefit summary should not be construed as medical or legal advice.

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