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Plan Document and

Summary Plan Description for the

City of Muncie Health and Welfare Benefit Plan

• Medical and Prescription Drug Benefits

• Dental Benefits

• Vision Benefits

Effective Date: January 1, 2017

ii

Introduction

City of Muncie (the “Employer” or “Company”) is pleased to offer you this benefit plan. It is a valuable and important part of your overall compensation package.

This booklet describes your medical and prescription drug benefits, dental benefits, vision benefits and serves as the Summary Plan Description (SPD) and Plan document for the City of Muncie employee Health and Welfare Benefit Plan (“the Plan”).

We encourage you to read this booklet and become familiar with your benefits. You may also wish to share this information with your enrolled family members.

This SPD and Plan replace all previous booklets you may have in your files. Be sure to keep this booklet in a safe and convenient place for future reference.

Patient Protection and Affordable Care Act. City of Muncie Benefit Plan believes this plan is not a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). For more information, contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to grandfathered health plans.

City of Muncie

Restated - Effective January 1, 2017

Table of Contents

Introduction ...................................... .................................................................................... ii Plan Overview ..................................... ................................................................................. 1

Your Eligibility .................................................................................................................... 1 Proof of Dependent Eligibility ............................................................................................ 2 When Coverage Begins .................................................................................................... 2

For You ......................................................................................................................... 2 For Your Dependents .................................................................................................... 2

Your Cost for Coverage ..................................................................................................... 3 Enrolling for Coverage....................................................................................................... 3

New Hire Enrollment ..................................................................................................... 3 Late Entrant .................................................................................................................. 3

Annual Open Enrollment ................................................................................................... 3 Effect of Section 125 Tax Regulations on this Plan ............................................................ 4 Qualifying Change in Status .............................................................................................. 4 Special Enrollment Rights ................................................................................................. 5 When Coverage Ends ....................................................................................................... 5 Cancellation of Coverage .................................................................................................. 9 Rescission of Coverage .................................................................................................... 9 Coverage While Not at Work ............................................................................................. 9 If You Take a Military Leave of Absence ............................................................................ 9

Your Medical Benefits ............................. ........................................................................... 10 Your Deductible ............................................................................................................... 10

Deductible Accumulation: PPO, HSA and HRA– Embedded Plans ............................. 10 Deductible Accumulation: HSA and HRA - Non-Embedded Plan ................................. 11 Deductible Three-Month Carryover – PPO Plan .......................................................... 11

Your Co-payment ............................................................................................................. 11 Your Coinsurance ............................................................................................................. 11 Out-of-Pocket Maximum – PPO, HSA and HRA Plans Embedded ................................... 11 Out-of-Pocket Maximum – HSA and HRA Plans Non-Embedded .................................... 12 Out-of-Pocket Accumulation ............................................................................................ 12 High Deductible Health Plan............................................................................................ 12 Health Reimbursement Arrangement (“HRA”) ................................................................. 12 Maximum Allowed Amount (Reasonable/Usual and Customary Limits) ........................... 13 Summaries of Medical Benefits ....................................................................................... 15 Summary of Medical Benefits Plan A – PPO Plan ........................................................... 15 Summary of Medical Benefits Plan C – PPO Plan ........................................................... 20 Summary of Medical Benefits Red Plan – PPO Plan ....................................................... 24 Summary of Medical Benefits White Plan – HSA and HRA Plan – Non-Embedded ......... 29 Summary of Medical Benefits Blue Plan – HSA and HRA Plan - Embedded ................... 33 Eligible Expenses ............................................................................................................ 37 Expenses Not Covered ................................................................................................... 42

Your Prescription Drug Benefits ................... .................................................................... 50

City of Muncie


How the Plan Works ................................................................................................... 50 Retail Pharmacy ......................................................................................................... 50 Participating Pharmacy ............................................................................................... 50 Designated Pharmacy ................................................................................................ 50 Reimbursement Levels ............................................................................................... 50 Specialty Pharmacy Schedule of Benefits per Person ................................................ 51 Direct Member Reimbursement .................................................................................. 52 Clinical Trial Coverage ................................................................................................ 52 Limitation of Pharmacy Selection ................................................................................ 53 Supply Limits .............................................................................................................. 53 “Dispensed as Written” Drug Provision ....................................................................... 53 Prescriptions Drugs Lost as a Direct Result of Natural Disaster .................................. 54 Covered Expenses ..................................................................................................... 54 Limits and Exclusions ................................................................................................. 54 Out-of-Pocket Maximum ............................................................................................. 55 Prior Authorization Program ........................................................................................ 55 Appealing a denied Prior Authorization claim .............................................................. 56 Preventive Care Schedule of Benefits per Person per Calendar Year ......................... 56 Medicare Part D Creditable Coverage ........................................................................ 58

Administrative Information ........................ ....................................................................... 59 Plan Sponsor and Administrator ...................................................................................... 59 Plan Year ........................................................................................................................ 60 Type of Plan .................................................................................................................... 60 Identification Numbers..................................................................................................... 60 Plan Funding and Type of Administration ........................................................................ 60 Claims Administrators...................................................................................................... 60 No Obligation to Continue Employment ........................................................................... 61 Non-Alienation of Benefits ............................................................................................... 61 Severability ..................................................................................................................... 61 Payment of Benefits ........................................................................................................ 61 Payment of Benefits to Others ......................................................................................... 62 Expenses ........................................................................................................................ 62 Fraud .............................................................................................................................. 62 Indemnity ........................................................................................................................ 62 Compliance with Federal Mandates ................................................................................ 62 Non-discrimination .......................................................................................................... 62 Discrimination is Against the Law .................................................................................... 63 Future of the Plan ............................................................................................................ 65

Claims Procedures ................................. ........................................................................... 66 Time Frames for Processing a Claim............................................................................... 66

Coordination of Benefits .......................... ......................................................................... 73 Non-Duplication of Benefits / Coordination of Benefits .................................................... 73 How Non-Duplication Works ............................................................................................ 73 Determining Primary and Secondary Plans ..................................................................... 73

City of Muncie


Coordination with Medicare ............................................................................................. 74 Coordination with Auto Insurance Plans .......................................................................... 74 For Maximum Benefit ...................................................................................................... 75 Subrogation and Reimbursement .................................................................................... 75 Right of Recovery ............................................................................................................ 75 Right to Subrogation ....................................................................................................... 75 Right to Reimbursement .................................................................................................. 76 Third Parties .................................................................................................................... 76 When This Provision Applies To You ............................................................................... 76

Your HIPAA/COBRA Rights ........................... .................................................................... 78 Health Insurance Portability and Accountability Act (HIPAA) ............................................ 78 Certificate of Creditable Coverage................................................................................... 79 Continuing Health Care Coverage through COBRA ........................................................ 79 COBRA Qualifying Events and Length of Coverage ........................................................ 80 COBRA Notifications ....................................................................................................... 81 Cost of COBRA Coverage ............................................................................................... 81 COBRA Continuation Coverage Payments ...................................................................... 81 How Benefit Extensions Impact COBRA ......................................................................... 82 When COBRA Coverage Ends ........................................................................................ 82

Definitions ....................................... ................................................................................... 83 Your Dental Benefits .............................. ............................................................................ 92

Coinsurance .................................................................................................................... 92 Covered Services ............................................................................................................ 92 Dental Exclusions ............................................................................................................ 93 For More Information ....................................................................................................... 94

Your Vision Benefits ............................. ............................................................................ 95 Your Coinsurance ............................................................................................................ 95 Vision Exclusions ............................................................................................................ 96 For More Information ....................................................................................................... 97

Adoption of the Plan .............................. ............................................................................ 98

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Plan Overview

Your Eligibility

You are eligible for benefits if you are:

• A full-time active employee normally scheduled to work a minimum of 30 hours per week;

• On the regular payroll of the Company; and

• In a class of employees eligible for coverage.

The following individuals are not eligible for benefits: part-time employees, employees of a temporary or staffing firm, payroll agency, or leasing organization, contract employees, and other individuals who are not on the Company payroll, as determined by the Company, without regard to any court or agency decision determining common-law employment status.

Coverage for Eligible Employees begins the first day of employment with the Company. Completion of an enrollment form is also a Plan requirement.

NOTE: Plan C Option enrollment is closed to any eligible Employees hired after January 1, 2006. Any Eligible Employee may enroll in Plan Options Red, White or Blue. If you cease coverage in Plan C you will not be permitted re-enroll in that Option.

Eligible Dependents

You may enroll your eligible dependents on your coverage. Your eligible dependents include:

• your legal spouse (as determined by Federal law);

• your child under age 26 regardless of financial dependency, residency with you, marital status, or student status;

• your unmarried child of any age who is not capable of self-support due to a physical or mental disability that occurred before age 26, whose disability is continuous, and who is principally supported by you.

“Principally supported by you” means that the child is dependent on you for more than one-half of his or her support, as defined by Code Section 152 of the Internal Revenue Code.

For purposes of the Plan, your child includes:

• your biological child;

• your legally adopted child (including any child under age 18 placed in the home during a probationary period in anticipation of the adoption where there is a legal obligation for support);

• a child for whom you are the court-appointed legal guardian;

• an eligible child for whom you are required to provide coverage under the terms of a Qualified Medical Child Support Order (QMCSO) or a National Medical Support Notice (NMSN).

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An eligible dependent does not include:

• a person enrolled as an employee under the Plan;

• any person who is in active military services;

• a former Spouse; or

• a person who is covered as a dependent of another employee covered under the Plan. If you and your spouse are both employed by the Company, each of you may elect your own coverage (based on your own eligibility for benefits) or one of you may be enrolled as a dependent on the other’s coverage, but only one of you may cover your dependent children.

In addition, an eligible dependent who lives outside the U.S. cannot be covered as your dependent, unless the dependent has established his or her primary residence with you.

It is your responsibility to notify the Company if your dependent becomes ineligible for coverage.

Proof of Dependent Eligibility

The Company reserves the right to verify that your dependent is eligible or continues to be eligible for coverage under the Plan. If you are asked to verify a dependent’s eligibility for coverage, you will receive a notice describing the documents that you need to submit. To ensure that coverage for an eligible dependent continues without interruption, you must submit the required proof within the designated time period. If you fail to do so, coverage for your dependent may be canceled retroactively.

When Coverage Begins

For You

Your health care coverage begins on the date of hire and after you meet all eligibility requirements.

If you terminate employment and are subsequently rehired, you will be treated as a new employee and will need to satisfy all eligibility requirements in order to be covered under the Plan. However, if you return to work within 12 months from your date of termination, you will be covered under the Plan as of the date of rehire.

For Your Dependents

If you enroll your eligible dependents within 31 days of your initial eligibility, their coverage begins at the same time as yours.

Coverage for newly eligible dependents will begin on the date they become a dependent as long as you enroll them within 31 days of the date on which they became eligible. If you acquire a new dependent, such as through marriage, coverage will begin on the date they become an eligible dependent (such as of the date of marriage) as long as you enroll the dependent within 31 days of the date on which they became eligible. If you wait longer than 31 days, you may not be able to enroll them until the next annual open enrollment period.

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A newborn child born while you are enrolled for medical coverage will be automatically covered for the first 31 days under your coverage. To continue coverage for your newborn child, you must enroll the child on your coverage no later than 31 days after the date of birth.

Charges for nursery or physician care will be initially applied toward the plan of the covered parent. If the newborn child is not enrolled in the Plan on a timely basis, the covered parent will be responsible for all costs.

Your Cost for Coverage

You pay your portion of this cost through pre-tax payroll deductions taken from your pay each pay period. Your actual cost is determined by the coverage you select and the number of dependents you cover. You must elect coverage for yourself in order to cover your eligible dependents.

Enrolling for Coverage

New Hire Enrollment

As a newly eligible employee, you will receive enrollment information when you first become eligible for benefits. To enroll in medical and/or prescription drug and/or dental and/or vision coverage, you will need to make your coverage elections by the deadline shown in your enrollment materials. When you enroll in the Plan, you authorize the Company to deduct any required premiums from your pay.

The elections you make will remain in effect until the next December 31, unless you have a qualifying change in status. After your initial enrollment, you will enroll during the designated annual open enrollment period. You will automatically receive identification (ID) cards for you and your eligible dependents when your enrollment is processed.

Late Entrant

Your enrollment will be considered timely if your completed enrollment form is received within 31 days after you become eligible for coverage. You will be considered a “late entrant” if:

• You elect coverage more than 31 days after you first become eligible

• You again elect coverage after cancelling

Annual Open Enrollment

Each year during a designated open enrollment period, you will be given an opportunity to make your elections for the upcoming year. Your open enrollment materials will provide the options available to you and your share of the premium cost, as well as any default coverage you will be deemed to have elected if you do not make an election by the specified deadline. The elections you make will take effect on the following January 1 and stay in effect through December 31, unless you have a qualifying change in status.

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Effect of Section 125 Tax Regulations on this Plan

This Plan is designed and administered in accordance with Section 125 regulations of the Internal Revenue Code. This enables you to pay your share of the cost for coverage on a pre-tax basis. Neither the Company nor any fiduciary under the Plan will in any way be liable for any taxes or other liability incurred by you by virtue of your participation in the Plan.

Because of this favorable tax-treatment, there are certain restrictions on when you can make changes to your elections. Generally, your elections stay in effect for the Plan Year and you can make changes only during each annual open enrollment. However, at any time throughout the year, you can make changes to your coverage within 31 days of the following:

• The date you have a qualifying change in status as described below;

• The date you meet the Special Enrollment Rights criteria described below.

Qualifying Change in Status

If you experience a change in certain family or employment circumstances that results in you or a covered dependent gaining or losing eligibility under a health plan, you can change your coverage to fit your new situation without waiting for the next annual open enrollment period.

As defined by the Internal Revenue Service (IRS), status changes applicable to health care coverage include:

• your marriage;

• the birth, adoption, or placement for adoption of a child;

• your death or the death of your spouse or other eligible dependent;

• your divorce, annulment, or legal separation;

• a change in a dependent child’s eligibility due to age or eligibility for other coverage;

• a change in employment status for you or your spouse that affects benefits (including termination or commencement of employment, strike or lockout, or commencement of or return from an unpaid leave of absence);

• a significant change in coverage or the cost of coverage;

• a reduction or loss of your or a dependent’s coverage under this or another plan;

• a court order, such as a QMCSO or NMSN, that mandates coverage for an eligible dependent child.

If you experience a change in certain family or employment circumstances, you can change your coverage. Changes must be consistent with status changes as described above. For example, if you get married, you may change your coverage level from you only to you and your spouse. If you move, and your current coverage is no longer available in the new area, you may change your coverage option.

You should report a status change as soon as possible, but no later than 31 days, after the event occurs.

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Special Enrollment Rights

If you decline enrollment for yourself or your dependents (including your spouse) because you have other health coverage, you may be able to enroll yourself and your dependents in this Plan, if you or your dependents lose eligibility for that other coverage (or if the employer stopped contributing towards your or your dependents' other coverage). However, you must request enrollment within 31 days after your or your dependents' other coverage ends (or after the employer stops contributing toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.

You or an affected eligible dependent may also enroll in coverage if eligibility for coverage is lost under Medicaid or the Children’s Health Insurance Program (CHIP), or if you become eligible for premium assistance under Medicaid or CHIP. You must enroll under this Plan within 60 days of the date you lose coverage or become eligible for premium assistance.

This “special enrollment right” exists even if you previously declined coverage under the Plan. You will need to provide documentation of the change. Contact the Plan Administrator to determine what information you will need to provide.

When Coverage Ends

Your coverage under this Plan ends unless benefits are extended.

Coverage for your covered dependents ends when your coverage ends or at the end of the month they either become no longer eligible to be on the plan or they become eligible for coverage under another employer’s plan.

Coverage will also end for you and your covered dependents as of the date the Company terminates this Plan or, if earlier, the date you request termination of coverage for you and your covered dependents. Coverage will also end as of the date you or a covered dependent has a claim denied due to exceeding a maximum benefit, if applicable, under the Plan.

If your coverage under the Plan ends for reasons other than the Company’s termination of all coverage under the Plan or you exceeding a Plan limit, you and/or your eligible dependents may be eligible to elect to continue coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) as described below.

1. Continuation of Coverage, in the event of Retiremen t, Employer Approved Leave

of Absence or Employer Approved Disability Leave. The below continuations of coverage are generally stated pursuant to the minimum required under applicable law. However such continuations of coverage are in addition subject to any Company handbook policies and union agreements that may be more generous.

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2. Continuation During Periods of Approved Leave of Ab sence . An Eligible

Employee may remain eligible for a limited time if full-time work ceases due a leave of absence approved by the Company provided he or she pays any required premium. This continuance will end the earlier of:

(a) the date this Plan terminates; (b) the end of the month of termination of employment; (c) the date the leave of absence ends; or (d) the last day of the month containing the end of the ninety (90) day period

immediately following the last day of active work (time runs consecutive to FMLA, if applicable).

3. Continuation of Coverage for Public Safety Emplo yees During Periods of

Disability . Public safety employees who are receiving disability benefits under IC 36- 8-6, IC 36-8-7, IC 36-8-7.5, IC 36-8-8 or IC 36-8-10 may remain eligible for a limited time if full-time work ceases due to the disability provided he or she pays any required premium. This continuance will end the earlier of:

(a) the date this Plan terminates; (b) the end of the month of termination of employment; (c) the end of the month the Eligible Employee becomes Medicare Eligible (unless due to End Stage Renal Disease (ESRD); (d) the end of the month the Eligible Employee is no longer considered Disabled; (time runs consecutive to FMLA, if applicable).

4. Continuation of Coverage for Public Safety Employee Survivors. Surviving

spouses and/or child(ren) of public safety employees who die in the line of duty may continue coverage for a limited time provided he or she pays any required premium. This continuation will end the earlier of:

(a) the date this Plan terminates; (b) with regard to the spouse, the end of the month he/she turns age 65; or (c) with regard to the spouse or child, the end of the month he/she become Medicare eligible (unless due to ESRD).

NOTE: Survivors of Public Safety Employees must file a written request to continue coverage with the Company within ninety (90) days of the Public Employees death for coverage to continue.

5. Continuation of Coverage for Retirees (Applies to C ivilian Employees only).

Eligible Employees classified as a retiree by the company may continue coverage for

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a limited time provided he or she pays any required premium. This continuation will end the earlier of:

(a) the date this Plan terminates; (b) the end of the month the retiree becomes Medicare eligible (unless due to

ESRD).

In the event of the death of the retiree, the spouse may continue coverage for a limited time provided he or she pays any required premium. This continuation will end the earlier of:

(a) The date this Plan terminates; (b) The end of the month the spouse become Medicare eligible (unless due to

ESRD); (c) The end of the month two years from the date of the retirees death; or

(d) The end of the month of the spouses remarriage. NOTE: Retirees and survivors of retirees must file a written request to continue coverage with the Company within ninety (90) days of the date of retirement or retirees death.

Retiree coverage for the medical portion of this plan terminates for the Retiree or Retiree Spouse the end of the month he or she attains age 65 or otherwise becomes Medicare eligible, except for end stage renal disease, in which case coverage shall continue until the end of the month of attaining age 65. Dental Coverage continues. Notwithstanding anything to the contrary, if the Retiree or covered spouse of a Retiree is still under the age of 65 as of the date the Retiree or Retiree Spouse turns 65, he or she will be permitted to retain medical coverage under this Plan and for any covered Dependents until the end of the month he or she attains age 65 or is otherwise Medicare eligible except for end stage renal disease, in which case coverage shall continue until he or she attains age 65.

NOTE: In the Event a retiree becomes married after retirement his or her new spouse and any acquired eligible dependents shall be able to enroll in this plan if a timely completed enrollment form is submitted. Such persons shall be considered special enrollees here under.

6. Continuation of Coverage for Retired Fire Fighter under the Age of 65. A retired Fire Fighter under the age of 65 shall be entitled to participate in the group insurance provided that:

(a) The Fire Fighter is a retiree and participating in such coverage on January, 1, 1994 or

(b) Who retires on or after January 1, 1994. (c) Who has not yet reached the age of 65 (d) Who does not qualify for Medicare.

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A retired Fire Fighter must elect to participate in Plan A, Plan C, or the Red Plan (unless discontinued) within the first thirty (30) calendar days after the date of his or her retirement; a Fire Fighter who fails to select within the said time period will forfeits any right to participate in such coverage. In order to participation in the health insurance program, retires must be a member in good standing with the UNION, or in the alternative. The city shall pay the full amount of the cost of coverage less the retiree’s contribution for single, employee plus 1 or family coverage based upon a percentage of the fully insured equivalent of the annual premium for the plan selected. See UNION contract for contribution amounts.

In the event of the death of the Fire Fighter retiree the spouse/dependents may continue coverage for a limited time provided he or she pays any required premium. This continuation will end the earlier of:

(a) The date this Plan terminates (b) 90 days after the date of death of retired Fire Fighter, if surviving spouse has

not elected to maintain coverage (c) The end of the month the spouse become Medicare eligible (unless due to

ESRD) (d) The end of the month of the spouse remarries. In regards to dependents, their coverage will terminate at the end of the month following;

i. Become age 26.

Transition Provision. Retirees and their eligible spouses currently enrolled on this Plan that are Medicare eligible and failed to enroll in Medicare Part B may remain covered under this Plan until July 1, 2012.

Coverage during Layoff . Eligible Employees in the Muncie Firefighters Local 1348 Union, F.O.P. Lodge #87 Union and AFSCME Local #3656 Union are eligible to continue coverage in the event of layoff pursuant to applicable hand book policies. Employees that are not members of the above mentioned Unions upon layoff will become eligible for COBRA. Part-Time to Full-Time Employees . Part-time employees who become full time will not be given credit toward the waiting period for time served as a part-time employee. Rehiring a Terminated Employee. A terminated Employee who is rehired will be treated as a new hire and be required to satisfy all eligibility and Enrollment requirements. USERRA. Federal law requires that if coverage would otherwise end because of entrance into active military duty, coverage may be continued (including Dependent coverage) for up to

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twenty-four (24) months in accordance with the provisions of Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), as amended from time to time.

Cancellation of Coverage

If you fail to pay any required premium for coverage under the Plan, coverage for you and your covered dependents will be canceled and no claims incurred after the effective date of cancellation will be paid.

Rescission of Coverage

Coverage under the Plan may be rescinded (canceled retroactively) if you or a covered dependent perform an act, practice, or omission that constitutes fraud, or you make an intentional misrepresentation of material fact as prohibited by the terms of the Plan. Coverage may also be rescinded for failure to pay required premiums or contributions as required by the Plan.

Coverage may be rescinded to your date of divorce if you fail to notify the Plan of your divorce and you continue to cover your ex-spouse under the Plan. Coverage will be canceled prospectively for errors in coverage or if no fraud or intentional misrepresentation was made by you or your covered dependent. You will receive 30 days advance written notice of any cancellation of coverage to be made on a prospective basis.

The Plan reserves the right to recover from you and/or your covered dependents any benefits paid as a result of the wrongful activity that are in excess of the premiums paid. In the event the Plan terminates or rescinds coverage for gross misconduct on your behalf, continuation coverage under COBRA may be denied to you and your covered dependents.

Coverage While Not at Work

In certain situations, health care coverage may continue for you and your dependents when you are not at work, so long as you continue to pay your share of the cost. If you continue to be paid while you are absent from work, any premium payments will continue to be deducted from your pay on a pre-tax basis. If you are not receiving your pay during an absence, you will need to make arrangements for payment of any required premiums. You should discuss with your supervisor what options are available for paying your share of costs while you are absent from work.

If You Take a Military Leave of Absence

If you are absent from work due to an approved military leave, health care coverage may continue for up to 24 months under both the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) and COBRA, which run concurrently, starting on the date your military service begins.

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Your Medical Benefits

Your medical benefits are delivered through a network of participating doctors, hospitals, laboratories, home health care agencies, and other health care providers, who have agreed to provide services at a discounted cost.

You do not need prior authorization from the Plan or claims administrator, or from any other person (including your PCP) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology. The health care provider, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals.

A network of providers gives you the flexibility to choose providers inside or outside the network each time you need care. In most cases, the Plan covers the same medical services whether you receive care in- or out-of-network. Refer to the Summary of Medical Benefits chart below for more information.

If you use in-network providers, the Plan pays a higher percentage of covered expenses (after you meet any applicable deductible). Generally, you will not be required to file a claim form when you receive in-network benefits but in some cases, the provider or claims administrator may require you to do so.

If you receive professional services for anesthesiology, radiology, emergency room physician services, or pathology which are provided by an out-of-network provider but rendered at in-network facility, those services will be paid at the in-network level of benefits.

If you use out-of-network providers, the Plan pays a lower percentage of covered expenses (after you meet any applicable deductible), up to the reasonable and customary limit or maximum plan allowance (see explanation below). You are responsible for charges in excess of this limit and this excess amount may not apply to your deductible or any out-of-pocket maximum. You may also pay a higher deductible and out-of-pocket maximum (if applicable) out-of-network, and you may be required to file claim forms. See the Summary of Medical Benefits chart below for additional information.

Your Deductible

A deductible is money you must pay for certain covered expenses before the Plan pays benefits. It is calculated on a calendar year basis. In and Out of Network Deductibles accumulate together. Consult the Summary of Medical Benefits chart for more information.

Deductible Accumulation: PPO, HSA and HRA– Embedded Plans

The Plan uses an embedded deductible which means when any one individual reaches the individual deductible limit, the Plan coverage takes effect for that member only. If there are multiple Participants covered under the Plan, the remaining family deductible amount may be met by a combination of Participants at which time the Plan coverage takes effect for the family.

As an additional requirement, an individual deductible must be satisfied before the benefit

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plan coverage takes effect. For single coverage, the Participant must simply meet the individual deductible prior to coverage taking effect. However, if there is more than one (1) Enrollee covered under a Participant’s plan, at least one individual must satisfy the individual deductible before the family deductible can be satisfied.

Deductible Accumulation: HSA and HRA - Non-Embedded Plan

At least one individual must satisfy the individual deductible before the family deductible is satisfied. Both in-network and out-of-network charges will apply to the deductible amount. For single coverage, the Covered Person must meet the individual deductible before the benefit plan coverage takes effect. For family coverage the deductible is “non-embedded ” meaning the entire family deductible must be met before the benefit plan coverage takes effect. The family deductible may be met by any one or a combination of family members.

Deductible Three-Month Carryover – PPO Plan

Covered expenses incurred in, and applied toward the Deductible in October, November, and December will be applied toward the Deductible. Carryover does not apply to the out of pocket. Once you meet the deductible, some services may require a co-payment – a fixed dollar amount you must pay before the Plan pays for that service. This amount applies regardless of whether the deductible has been satisfied. Any co-payments will be shown in the Summary of Medical Benefits Chart below. This benefit does not apply to the HSA Plans.

Your Co-payment

Some services may require a co-payment – a fixed dollar amount you must pay before the Plan pays for that service. This amount applies regardless of whether the deductible has been satisfied. Co-payments apply toward the Out-of-Pocket Maximum. Any co-payments will be shown in the Summary of Medical Benefits Chart.

Your Coinsurance

Coinsurance is the shared costs for Covered Expenses between the Plan Participant and the Plan. The amounts shown in the Summary of Medical Benefits are the percentages that the Plan will pay for Covered Expenses after the Deductible has been met, unless otherwise noted. The Plan Participant is responsible for the remaining percentage amount. The Coinsurance Stop-Loss Amount is the total amount a Plan Participant or Covered Family must pay (after the Deductible) before the Plan begins paying 100% for Covered benefits for the remainder of the Calendar Year.

The amount or percentage you pay depends on the type of provider you see, where you receive services, and how you are billed for these services. In and Out of Network coinsurance amounts accumulate together. The Summary of Medical Benefits chart below shows the coinsurance levels for common medical services in-network and out-of-network.

Out-of-Pocket Maximum – PPO, HSA and HRA Plans Embe dded

Covered Charges are payable at the percentages shown each Calendar Year until the out of pocket maximum shown in the Summary of Medical Benefits is reached. Then, Covered

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Charges incurred by a Plan Participant will be payable at 100% (except for the charges excluded) for the rest of the Calendar Year. The out-of-pocket limit combines the co-payment (for the PPO Plan), deductible and coinsurance stop-loss amounts. When a Covered Family reaches the out of pocket limit, Covered Charges for that Covered Family will be payable at 100% (except for the charges excluded) for the rest of the Calendar Year. Charges that are excluded from the out-of-pocket limits are as follows:

• Premiums;

• Balance Billed Charges;

• Precertification Penalties;

• Healthcare this Plan does not cover;

Out-of-Pocket Maximum – HSA and HRA Plans Non-Embed ded

Covered Charges are payable at the percentages shown each Calendar Year until the out of pocket limit shown in the Summary of Medical Benefits is reached. The out-of-pocket maximum combines the deductible, and coinsurance amounts. For Family coverage, the Covered Family must meet the Family Out-of-Pocket Maximum amount (after the Family Deductible) before the Plan begins paying 100% for Covered benefits (except for the charges excluded) for the remainder of the Calendar Year. Charges that are excluded from the out-of-pocket limits are as follows:

• Premiums;

• Balance Billed Charges;

• Precertification Penalties; and

• Healthcare this Plan does not cover.

Out-of-Pocket Accumulation

Both in-network and out-of-network charges accumulate together and will apply to the out-of-pocket maximum.

High Deductible Health Plan

The Plan option described is designed to protect Plan Participants against certain catastrophic health expenses. A qualified High Deductible Health Plan (HDHP) provides comprehensive coverage for high cost medical events. The Plan gives you greater control over how health care benefits are used. An HDHP satisfies certain statutory requirements with respect to minimum deductibles and out-of-pocket expenses for both single and family coverage. These minimum deductibles and limits for out-of-pocket expenses limit are set forth by the U.S. Department of Treasury and will be indexed for inflation in the future.

Health Reimbursement Arrangement (“HRA”)

If you elect medical coverage that includes an HRA option, you are automatically covered by the HRA. An HRA is an arrangement funded entirely by the Employer. The purpose of the HRA

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is to reimburse you, up to certain limits, for you and your covered dependents’ out-of-pocket health care expenses. Reimbursements paid by the HRA generally are excluded from taxable income.

Maximum Allowed Amount (Reasonable/Usual and Custom ary Limits)

If you use out-of-network providers, covered medical expenses are subject to certain limits under the Plan, and you are responsible for paying any charges above this limit. The maximum benefit payable is based on the amount determined by the Plan to be the prevailing charge for a covered service or supply. Determination of the prevailing charge is based on the:

• complexity of the service and level of specialty of the provider;

• range of services provided; and

• the geographic area where the provider is located and other geographic areas with similar medical cost experience.

Required Pre-Authorization for Services

Prior authorization does not guarantee coverage and/or payment for respective hospital admission or related charges. Eligibility, as well as any applicable limitations or exclusions on coverage are determined by Plan benefits. This process should be completed at least seven (7) days in advance of the planned procedure. For Emergency admissions, authorization is required within forty-eight (48) hours, or the next business day.

Prior Authorization forms are available on the www.iuhealthplans.com/cityofmuncie website by clicking on the Provider Information and Support box on the lower left of the screen, then clicking on Medical Management Authorization Request Form. The form should be faxed to the number on the top of the form.

• All Inpatient Admissions • All Outpatient Surgeries (other than those performed in a Physician’s office) • MRIs, CT Scans, and PET Scans • Durable Medical Equipment over $500 (including Prosthetic, Orthotic, and Orthopedic

Devices)

Please Note: Pregnancy is not subject to Prior Authorization for hospital confinements which follow the minimum required periods of forty-eight (48) hours for a normal delivery and ninety six (96) hours for a caesarean section. However, prior authorization is required for labor induction and days beyond the above time periods. Required Pre-Authorization for Prescription Drugs TrueScripts has been retained by the Plan Administrator to provide Prior Authorization services for a particular set of drugs. The Plan has approved a predetermined set of criteria to be applied to this Prior Authorization process. In order for a drug which is subject to Prior Authorization to be covered by this Plan; the pharmacist, Covered Person, or prescriber must call the TrueScripts Customer Care Department to obtain Prior Authorization before the drug

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is purchased. TrueScripts will fax the prescriber the necessary forms to obtain the information necessary to determine whether or not the drug will be a covered expense, based upon the predetermined set of criteria and the information supplied by the prescriber. TrueScripts will notify the pharmacy/covered person or prescriber who submitted the request for Prior Authorization within 72 hours (once the letter of medical necessity is received from the prescriber) that the drug is or is not covered by the Plan. The request for Prior Authorization is considered to be a pre-service claim as described in the U.S. Department of Labor Regulations 2560.503-1 (issued November 21, 2000).

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Summaries of Medical Benefits

Summary of Medical Benefits Plan A – PPO Plan

This plan is only available to current City of Muncie retirees and those employees who have agreed to retire prior to December 31, 2017.

Benefit IUHBS Encore Out of Network

Primary Care (PCP) Office Visit (Muncie Clinic – no cost)

$50 copay then 100%

$50 copay then 100%

$50 copay then 100%

Specialist Office Visit $25 copay then 100%

$30 copay then 100%

$35 copay then 100%

Allergy Injection Only 75% after deductible

65% after deductible


X-Rays 75% after deductible



Lab Tests 75% after deductible



Urgent Care $30 copay then 100%

$35 copay then 100%


Chemotherapy/Radiation 75% after deductible



MRI/CT Scans 75% after deductible



In-Network Out-of-Network

Annual Maximum (per participant [all services combined])

None

Annual Deductible (applies to expenses below unless otherwise noted)

Single $500 Family $1000

Annual Out-of-Pocket Maximum (includes covered expenses under the Plan)

IUHBS Network $1750/$3500 Encore Network $2250/$4500 Out of Network $2750/$5500

Please Note: In and out of Network Deductibles and Out-of-Pocket amounts accumulate together. Deductible amounts are included in the out- of -pocket limit amounts. Copays do apply to the out of-pocket limit.

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Surgery Performed in Office w/o Office Visit/charge




All Other Services in Office w/o Office Visit charge




Wellness Benefit (See Exhibit A for list of covered services)

100% 100% 100%

Emergency Room

***If Emergency Room is used and the visit is deemed as non-emergent there is no coverage.

75% plus $100 copay

65% plus $100 copay

55% plus $100 copay

Ambulance 100% 100% 100%

Outpatient Surgery and Physician Billing




Outpatient Diagnostic X-Ray and Physician Billing




Outpatient Diagnostic Labs and Physician Billing




Outpatient CT Scan/MRI and Physician Billing




Outpatient Chemotherapy/Radiation and Physician Billing




All Other Outpatient Services and Physician Billing




Occupational/Speech/Physical Therapy




Chiropractic Care (26 Office Visit in Calendar Year Unless Authorized

$25 copay then 100%

$30 copay then 100%

$35 copay then 100%

Manipulations & X-rays 75% after deductible



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Mental Health Inpatient Services (Prior Authorization Required)




Mental Health Outpatient $25 copay then 100%

$30 copay then 100%

$35 copay then 100%

Substance Use Disorder Inpatient Services (Prior Authorization Required)




Substance Use Disorder Outpatient

$25 copay then 100%

$30 copay then 100%

$35 copay then 100%

Medical – Inpatient Room & Board: Coverage Set at Semi-Private Room Rate When Available




Medical – Inpatient Ancillary 75% after deductible



Pre-Admission Testing 75% after deductible



Voluntary Second Surgical Opinion




Inpatient Hospital Visit 75% after deductible



Inpatient Anesthesia 75% after deductible



Inpatient Maternity 75% after deductible



Durable Medical Equipment (DME)




Orthotics (custom-designed) 75% after deductible



TMJ – Limited to surgical treatment: All services resulting from surgery to treat TMJ




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Prosthetics 75% after deductible



Acute Rehab Hospital 75% after deductible



Home Health Care 75% after deductible



Convalescent Care 75% after deductible



Hospice Care 75% after deductible



Clinical Trials 75% after deductible



Pharmacy Drug Benefit – TrueScripts

Retail – Member Pays 1-30 Day Supply 31-90 Day Supply

Generic $10 copay plus 10%

coinsurance $20 copay plus 10%

coinsurance

Name Brand Drug with no Generic equivalent or when prescribed “Dispense as Written”

$10 copay plus 20% coinsurance


Other Name Brand Drugs

$10 copay plus 20% coinsurance, then 100% refill plus the difference between

the brand name and its generic equivalent

$20 copay plus 20% coinsurance, then 100% refill plus the difference between

the brand name and its generic equivalent

Specialty Medication

Tier 1 : $10 copay then 20% coinsurance

Tier 2 : 50% coinsurance

Not Covered

Co-payments and Coinsurance apply toward the maximum out-of-pocket. Prescriptions are limited to 90-day supply

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The Gap plan is applicable to covered person’s under Plan A and/or Red Plan. Total benefits payable during a Calendar Year for the Gap plan is limited to $750 per covered person, up to a Calendar Year maximum of $2,250 (3x amount per covered person). Dollars that apply to the Gap plan are as follows, unless otherwise indicated:

• Any deductible amount that would otherwise be applied to covered charges; • Any coinsurance amount that would otherwise be applied to covered charges

Services that apply to the Gap benefit are as follows:

• Treatment in a Hospital Emergency Room or Urgent Care Center for an injury only due to an accident (not illness) when the Covered Person is not subsequently considered an Inpatient.

• Surgery performed in a Hospital Outpatient Facility, Free-Standing Outpati ent Surgery Center, including Anesthesia.

• Outpatient Surgery performed in a Physician’s Offic e at a limited benefit up to $100 per surgery.

• Radiological diagnostic testing performed in a Hospital Outpatient Facility or a Magnetic Resonance Imaging (MRI) Facility. ( This benefit will also include any copayment amount that would otherwise be applied to covered charges).

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Summary of Medical Benefits Plan C – PPO Plan

This plan is only available to current City of Muncie retirees and those employees who have agreed to retire prior to December 31, 2017.



None




IUHBS $450/$900 Encore $700/$1400

Out of Network $950/$1900

Please Note: In and out of Network Deductibles and Out-of-Pocket amounts accumulate together. Deductible amounts are included in the out-of-pocket limit amounts. Copays do apply to the out of-pocket limit.



$50 copay then, 90% after deductible



Specialist Office Visit 90% after deductible






X-Ray and Lab Tests 90% after deductible



Urgent Care 90% after deductible









Surgery Performed in Office 90% after deductible



All Other Services in Office 90% after deductible



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100% 100% 100%

Emergency Room

** If the Emergency Room is used and the visit is deemed as non-emergent there is no coverage.

90% plus $100 copay

80% plus $100 copay

70% plus $100 copay

Ambulance 100% 100% 100%





Outpatient Diagnostic X-Ray and Lab and Physician Billing































Mental Health Outpatient 90% after deductible







Substance Use Disorder Outpatient 90% after deductible



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Voluntary Second Surgical Opinion 90% after deductible












Durable Medical Equipment (DME) 90% after deductible




























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Pharmacy Drug Benefit – TrueScripts


Generic $10 copay plus 5% coinsurance $20 copay plus 5%

coinsurance


$10 copay plus 5% coinsurance $20 copay plus 5%

coinsurance


$10 copay plus 20% coinsurance, then 100% refill

plus the difference between the brand name and its generic

equivalent

$20 copay plus 20% coinsurance, then 100% refill plus the difference

between the brand name and its generic equivalent




Not Covered

Co-payments and Coinsurance apply toward the maximum out-of-pocket. Prescriptions are limited to a 90-day supply.

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Summary of Medical Benefits Red Plan – PPO Plan



None


Single $500

Family $1000


IUHBS $1500/$3000 Encore $2000/$4000


Please Note: In and out of Network Deductibles and Out-of-Pocket amounts accumulate together. Deductible amounts are included in the out-of-pocket limit amounts. Copays do apply to the out of-pocket limit.



$50 copay, then 100%



Specialist Office Visit $25 copay, then 100%









Urgent Care $35 copayment, then 100%

$40 copayment, then 100%

$45 copayment, then 100%














100% 100% 100%

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Emergency Room

** If Emergency Room is used and the visit is deemed as non-emergent there is no coverage.

80% plus $100 copayment



Ambulance 80% after deductible































Manipulations & X-Rays 80% after deductible







Mental Health Outpatient $25 copay, then 100%











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Durable Medical Equipment 80% after deductible






















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Pharmacy Drug Benefit - TrueScripts


Generic $10 copay plus 10%

coinsurance $20 copay plus 10%

coinsurance





$10 copay plus 20% coinsurance, then 100% refill

plus the difference between the brand name and its generic

equivalent

$20 copay plus 20% coinsurance, then 100% refill plus the difference

between the brand name and its generic equivalent




Not Covered

Co-payments and Coinsurance apply toward the maximum out-of-pocket. Prescriptions are limited to a 90-day supply.

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The Gap plan is applicable to covered person’s under Plan A and/or Red Plan. Total benefits payable during a Calendar Year for the Gap plan is limited to $750 per covered person, up to a Calendar Year maximum of $2,250 (3x amount per covered person). Dollars that apply to the Gap plan are as follows, unless otherwise indicated:

• Any deductible amount that would otherwise be applied to covered charges; • Any coinsurance amount that would otherwise be applied to covered charges

Services that apply to the Gap benefit are as follows:

• Treatment in a Hospital Emergency Room or Urgent Care Center for an injury only due to an accident (not illness) when the Covered Person is not subsequently considered an Inpatient.

• Surgery performed in a Hospital Outpatient Facility, Free-Standing Outpati ent Surgery Center, including Anesthesia.

• Outpatient Surgery performed in a Physician’s Offic e at a limited benefit up to $100 per surgery.

Radiological diagnostic testing performed in a Hospital Outpatient Facility or a Magnetic Resonance Imaging (MRI) Facility. ( This benefit will also include any copayment amount that would otherwise be applied to covered charges).

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Summary of Medical Benefits White Plan – HSA and HR A Plan – Non-Embedded



None




IUHBS $2000/$4000 Encore $2500/$5000


Please Note: Deductible and Out-of Pocket Maximums are Non-Embedded. In and out of Network Deductibles and Out-of-Pocket amounts accumulate together. Deductible amounts are included in the out-of-pocket limit amounts. Copays do apply to the out of-pocket limit.































100% 100% 100%

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Emergency Room ** If the Emergency Room is used and the visit is deemed as non-emergent there is no coverage.





















































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Prescription Drug Benefit - TrueScripts


Generic 100% until deductible is met, then 10%


100% until deductible is met, then 10%

Other Name Brand Drugs 100% until deductible is met, then 10%

Specialty Medication 100% until deductible is met,

then 10% Not Covered

Deductible applies to the maximum out-of-pocket. Entire family must meet the family deductible and out-of-pocket maximum (by one or

combination of members) before the Plan pays at 100%. This is called Non-Embedded. Prescriptions are limited to a 90-day supply.

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Summary of Medical Benefits Blue Plan – HSA and HRA Plan - Embedded



None




IUHBS $2600/$5200 Encore $3100/$5700


Please Note: In and out of Network Deductibles and Out-of-Pocket amounts accumulate together. Deductible amounts are included in the out-of-pocket limit amounts.































100% 100% 100%

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Emergency Room ** If the Emergency Room is used and the visit is deemed as non-emergent there is no coverage.



































Manipulations & X-Rays 100% after deductible


















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100% after deduc

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