2018 benefits guide - university of louisvillelouisville.edu/hr/2018benefitsguide_web.pdf · (30...

2018 Benefits Guide For New Employees

WHAT’S INSIDE

Benefit Coverage Overview..................................................3

Health Insurance .................................................................... 4

Dependent Coverage ........................................................... 5

Pharmacy Benefits ................................................................. 6

Dental Coverage ..................................................................... 7

Vision Coverage .................................................................... 7

Flexible Spending Accounts ............................................... 8

Other Benefits ....................................................................... 9

Retirement Plans .................................................................. 10

Making Your Elections .........................................................12

2018 Rates Summary ...........................................................13

Who to Contact ......................................................................14

Welcome New Employees!

We are pleased to have you join our Cardinal family at the University ofLouisville. We encourage you to thoroughly review our overview of benefitoptions listed in this guide. In addition to this overview, we would encourage youto review the Summary of Benefits forour health, dental and vision plans. TheseSummary of Benefits can be found on theUofL Benefits website at louisville.edu/hr/benefits.

Disclaimer:

This presentation and benefit communication highlights many of the University Of Louisville’s benefits. Every effort has been made to ensure the

accuracy of this information. However, the actual administration of the plans is governed by the plan documents and insurance agreements. In the event of a discrepancy between this communication and the plan documents and agreements, the plan documents and agreements take precedence.

2018 Benefits Guide | Human Resources | (502) 852-6258 | louisville.edu/hr | 2

http://louisville.edu/hr

BENEFIT COVERAGE OVERVIEW: WHO, WHAT, WHEN AND HOW

Who is eligible for benefits?

Regular status employees (faculty and staff) with a full time equivalency (FTE) of 80% or greater.

Regular status part-time employees and temporary part-time lecturers with FTE 40% up to 79%.

Eligible dependents of employees that meet the above requirements for health, dental and vision. See health plans page for detailed dependent information.

What benefits are available?

The University of Louisville has a generous benefits package for faculty and staff that includes; health &pharmacy, dental, vision and life insurance. Also available are flexible spending accounts, short term and longterm disability coverage and 403(b) and 457(b) retirement savings plans.

When do my benefits begin?

Benefit coverage for employees that meet the eligibility requirements begin on the first date of employment orat the time of a qualifying event.

HOW DO I ENROLL? You have 30 days from your date of hire or your qualifying event to make your benefit elections. You will make your benefit elections online via the employee self-service portal, ULink. Typically within your first week, you will receive an email notification that you are set up to enroll. The email willprovide access directions. If you do not receive an email within two weeksof your start date, contact Benefits at (502) 852-6258. Remember you have 30 days from your start date to make your elections, not the date you receive the email.

ULink can be accessed from any computer with internet access. Computersare also available at the Human Resources office (1980 Arthur Street) if you need any additional assistance.

30 Days



HEALTH INSURANCE There are four different health plans to choose from with Anthem Blue Cross Blue Shield. Each health planutilizes the Anthem Blue Access PPO Network.

Four Health Plan Options

EPO (Employer Provider Organization) PCA High with HealthEquity Account PPO (Preferred Provider Organization) PCA Low with Health Equity Account

Basic Comparison Overview

EPO

In-network level of coverage only

NO out-of-network level of coverage

NO annual deductible

Has required copayments andcoinsurance to meet

PPO

Both in-network and out-of-network coverage

Has required copayments andcoinsurance to meet

Encourages you to use networkproviders by charging lowerdeductibles, copayments andcoinsurance amounts

PCA High and Low

Both in-network and out-of-network coverage

University funded benefitallowance based on level coverageyou select

Separate “preloaded” HealthEquity(PCA) debit card usable first day ofeffective coverage

What is a PCA High or Low Plan and how does it work?

PCA High or Low Plan with a Health Equity Account generally have a higher deductible than PPO and EPOplans. However, with the HealthEquity Account, the university will contribute a set amount to your accountthat can be used towards your deductible. Any unused balances roll to the next year, up to three times the annual amount.

Deductibles

How much will the university contribute to the HealthEquity Account you can use toward your deductible?

PCA High PCA Low Per person $1,000 $2,000 Per family $3,000 $4,000

Employee $500 Employee + Spouse/QA $1,000

Employee + Child(ren) / Family $2,000



What Happens After Deductible is Reached?

The plan generally pays 90% PCA High/ 80% PCA Low (for participating providers). You then pay the remaining balance (10% PCA High / 20% PCA Low).

PCA High Per person $4,000 Per family $9,000

PCA Low $5,000 $10,000

Maximum Out of Pocket for PCA High and Low Plans

Health Management Program Premium Incentive

Employees that are enrolled in the group health plan are eligible for a $40 monthly premium incentive byparticipating in Get Healthy Now, UofL’s health management program.

For enrollment information with Get Healthy Now and information about what participating entails and whatit can do for you, visit louisville.edu/gethealthynow or call 852-7755.

Dependent Coverage Dependents can be covered under the health, dental and vision plans as long as they meet the followingcriteria:

* Spouses or qualifying adults of covered UofL employees. Refer to the definition of a qualifying adult below for more detail.

* Child(ren) (natural children, step children,foster children, legally adopted children, andchildren placed for adoption) to the end of thecalendar year in which they turn 26 even if theyare married; not living with parents; attendingschool; not financially dependent on theirparents; or eligible to enroll in their employer’shealth plan.

Who can be a qualifying adult?

* Child(ren) of the employee or the employee’s spouse of any age when such children are incapable of self-support because of a total and permanent disability; and

* Child(ren) age 26 and under for whom the employee is required to provide health care coverage under a qualified medical childsupport order (QMCSO), regardless of wherethe child resides or if the child is dependentupon the employee for support.

To be considered a qualifying adult, the person must meet ALL of the following criteria. They must be:

; Over 18 years old

; the same or younger generation of theemployee (as used in KRS 391.010), if a bloodrelative (or relative by adoption or marriage)

; residing in the employee's household for atleast 12 months

; financially interdependent (i.e., have jointchecking account or joint mortgage) for atleast 12 months

; unmarried

; not eligible for Medicare


http://louisville.edu/hrhttp://louisville.edu/gethealthynow

PHARMACY BENEFITS All employees enrolled in a health plan are automatically enrolled inthe Express Scripts Pharmacy Benefit plan. For your convenience, yourAnthem BlueCross BlueShield ID card will be a combination ID card for health and Express Scripts prescription coverage. You can find the Express Scripts formulary (list of covered drugs and pricing online at louisville. edu/hr/benefits/pharmacy).

Benefit ID Card

When you enroll in ahealth plan you will

receive a combination Retail

(30 day supply)

Generic $8.00

Brand Formulary You pay 25% up to $60 max

Non-Formulary You pay 40% up to $100 max

$16.00

You pay 15% up to $120 max

You pay 35% up to $200 max

Anthem BlueCrossMail/Home Delivery(90 day supply for approx. 2 co-pays) BlueShield ID card for

health and Express Scriptspharmacy benefits foreach covered member. You must present your insurance ID card for

medical and pharmacybenefits.

KY Rx Coalition

The Know Your Rx Coalition can help you to control prescription costs, by offering free prescription counseling services for any University of Louisville health plan member. You can contact them M-F 8:00 a.m. to 6:00 p.m., at 855-218-KYRx or online at www.kyrx.org. You can contact the KY Rx Coalition about the following topics and more:

* To find lower cost alternatives * To help with mail order * To ask about side effects, drug interactions, and over the counter medications

2018 HEALTH PLAN RATES The following monthly rates1 are for full time active employees that are paid over 12 months. See pg 14 for all rates.

EPO PPO PCA High PCA Low

Employee Coverage 136.12 118.58 67.12 65.00

Employee + Spouse/QA 495.04 456.46 343.24 211.64

Employee + Children 268.21 236.63 144.01 65.00

Employee + Family 553.24 500.62 346.24 166.78

Two Employee Family 2 135.52 109.21 52.50 52.50

1 The health plan rates do not include the $40 per month premium incentive from participation in the health management program, Get Healthy Now. If you plan to participate in Get Healthy Now, deduct $40 from the monthly rate above to get your final cost.

2 Spouse/QA must be full-time employee and also have child(ren) covered in plan.


http://louisville.edu/hrhttp://louisville.edu/hr/benefits/pharmacyhttp://louisville.edu/hr/benefits/pharmacyhttp://www.kyrx.org

DENTAL COVERAGE There are two options with MetLife for dental insurance, the basic plan and the enhanced plan. The enhanced plan offers a greater annual maximum benefit and adult orthodontia.

You may visit any dentist, however, out-of pocket expense is less with greater savings when utilizing an in-network provider. Remember, when visiting an out-of-network provider you will be responsible for charges above the in-network covered benefit allowance by the MetLife plan.

Find a Provider

To find a participating dentist, visit www.metlife.com/mybenefits and enter ‘University of Louisville’ or call 1-866-832-5756.

VISION COVERAGE The vision provider, Davis Vision, has a national network of credentialedpreferred providers. With Davis Vision, you have access to great in-network benefits at provider locations nationwide, including increasedallowance towards frames and contacts when selecting from the DavisVision collection, or using a VisionWorks store location.

Find a Provider

To find a network provider, visit davisvision.com and click “Find a Provider” to locate a provider near you, including Visionworks locations.

Dependent Coverage for Dental and Vision

Dependents can be covered on the dental and vision plans. The criteria is the same as for health insurance. Please refer to page 5 for full dependent coverage details.

2018 DENTAL AND VISION RATES The following monthly rates are for full & part time active employees that are paid over 12 months. See pg 14 for all rates.

DENTAL RATES BASIC ENHANCED

Employee Coverage 21.27 42.52 50.20 77.62

24.93 49.83 58.82 90.96

Employee + Spouse/QA Employee + Children Employee + Family

VISION RATES

3.70 6.71 7.11 10.21


http://louisville.edu/hrhttp://www.metlife.com/mybenefitshttp://davisvision.com

FLEXIBLE SPENDING ACCOUNTS (FSA) With a Flexible Spending Account (FSA), you can set aside pre-tax dollars to pay for eligible health and daycare expenses. You may enroll in one or both, but you need to be aware of the contribution limits. Any moneydeposited in your FSA and not used by the end of the university’s grace period (which extends to March 15 each year), will be forfeited. For more detailed information about FSAs, visit louisville.edu/hr/benefits/fsa.

HEALTH CARE FSA Annual contributions can be from $150 to $2,600 per calendar year.

* The total annual contribution is available from the account start date.

* Eligible expenses are any healthcare expense approved by the IRS for reimbursement through the plan.

* You will receive a FSA card to use at locations such as pharmacies, medical, dental and vision offices and hospitals. Expenses canalso be submitted for reimbursement to Discovery Benefits(www.discoverybenefits.com).

Eligible expenses

You can find a comprehensive list of eligible expenses on Discovery Benefits website at www.discoverybenefits.com/employees/eligible-expenses.

DEPENDENT CARE FSA Annual employee contributions can be from $150 up to $5,000 per household per calendar year.

* Dependent Care can be used on your natural, adopted and foster children who have not reached theirthirteenth birthday and family members who cannot care for themselves. All dependents must live withyou for more than half the year and be claimed on your federal tax return.

* Participants receive reimbursements up to the total amount contributed through each payroll deduction.

* Reimbursements are received by faxing, emailing or mailing claim forms to Discovery Benefits (www.discoverybenefits.com).

Keep your Receipts! You must submit substantiation for expenses when requested by Discovery Benefits. The expenses must have been made from your account(s) between now and March 15th of the following year for reimbursement.


http://louisville.edu/hrhttp://louisville.edu/hr/benefits/fsahttp://www.discoverybenefits.comhttp://www.discoverybenefits.com/employees/eligible-expenseshttp://www.discoverybenefits.com

OTHER BENEFITS Life insurance, AD&D, Long & Short Term Disability & More

LIFE INSURANCE The university provides life insurance at twice your base annual salary adjusted to the nearest $1000 (maximumof $200,000). There is no cost to eligible employees, but you need to complete the MetLife enrollment/beneficiary form.

ACCIDENTAL DEATH & DISMEMBERMENT The university provides Accidental Death and Dismemberment (AD&D) insurance equal to the amount of lifeinsurance. There is no cost to eligible employees.

ADDITIONAL TERM LIFE INSURANCE Additional term life insurance is available as a supplement to your basic life insurance coverage provided byUofL. If you purchase additional coverage for yourself, you also can purchase it for your spouse or child(ren).Rates are listed on the enrollment form, provided to you at New Employee Orientation.

* Employees may purchase additional term life coverage of up to $300,000. Maximum coverage for spousesis $25,000.

* This is a one time guaranteed issue offer. During future annual open enrollments you may bump upone level of coverage if you have already elected additional term life, without a statement of health.Otherwise, any initial enrollment (other than at your time of hire) or any increase above one level ofcoverage would require approval by MetLife through a statement of health.

LONG TERM DISABILITY Long term disability is a benefit provided at no cost to you. If you become totally disabled while insured andremain so for six months, the university's LTD plan will pay the greater of 60% of your monthly base salary or 60% of your monthly average earnings from the past two years up to a monthly max benefit amount of $5,000.Note: LTD benefit begins when your university retirement contributions begin.

OPTIONAL SHORT TERM DISABILITY An Income Protector Plan is available as an option to university employees. This supplements lost wagesdue to a covered off-the-job injury or sickness. You can enroll or drop coverage at anytime. You do not need a qualifying event. For more details, call Humana’s enrollment center at 800-463-7420 or email [email protected].

US LEGAL SERVICES Pre-paid legal services are available through US Legal at a monthly rate of $18.75. For more detail on what is covered and how it works, visit louisville.edu/hr/benefits/additional/pre-paid-legal.


http://louisville.edu/hrmailto:yourenrollment%40ebcoh.com?subject=http://louisville.edu/hr/benefits/additional/pre-paid-legal

RETIREMENT SAVINGS 403(b) PLAN The university offers a 403(b) retirement plan to all regular status (80% or greater full time

equivalency) faculty and staff. After one year of eligible service, you are eligible to receive the 7.5% university contribution and 2.5% match. You can participate with your own contributions at any time.

HOW THE UNIVERSITY CONTRIBUTION WORKS After one year of eligible service, the university will contribute 7.5% of your base salary to your retirementwith no contribution needed from you. In addition, if you contribute 2.5%, the university will match the 2.5% for a total of 10% salary contribution to your retirement savings.

How to Enroll in the University Contribution

After one year of eligible service at the university, you will be automatically enrolled into the 7.5% contribution.You will receive a notification letter from the university with additional instructions on how to access the account and set up the 2.5% match, if desired.

GET STARTED INVESTING NOW You have the option of participating by investing your own money before completing one year of service. The Employee Supplemental option is agreat opportunity to start saving.

How to Enroll

To get started investing your own money at your time of hire, notify our Retirement Administrators at (502) 852-3555 or by email at [email protected], to set up an account on the Netbenefits website for you.

Once the account has been established, notification will be sent to yourUofL email address. The email will contain a set of instructions to guideyou through the process of completing the enrollment online.

The Netbenefits website is the master administrator for the Universityof Louisville Retirement Plans. Employees will enter all contribution elections and investment changes on this website.

PROVIDERS You can invest your savings and the university’s contributions with one or both investment providers.

Fidelity: 1-800-343-0860 | www.fidelity.com/atwork or www.netbenefits.com.

TIAA: 1-800-842-2252 | www.tiaa.org

Schedule a One-on-one Retirement Investment

Consultation

Retirement investment representatives from Fidelity

and TIAA are available on both the University

of Louisville Belknap orHealth Sciences Campuses

throughout each month.

To schedule;

Fidelity: Call 1-800-642-7131 or go online to www.

fidelity.com/atwork/reservations.

TIAA: Call 1-800-732-8353 or go online at tiaa.org/

schedulenow.


http://louisville.edu/hrmailto:retplan%40louisville.edu?subject=mailto:retplan%40louisville.edu?subject=http://www.fidelity.com/atworkhttp://www.netbenefits.comhttp://www.tiaa.orghttp://www.fidelity.com/atwork/reservationshttp://www.fidelity.com/atwork/reservationshttp://www.fidelity.com/atwork/reservationshttp://tiaa.org/schedulenowhttp://tiaa.org/schedulenow

403(b) RETIREMENT PLAN (CONTINUED)

Three Year Cliff Vesting Schedule

The University of Louisville has a three year cliff vesting schedule for the 403(b) plan. Employer contributionsand earnings will be fully 100% Vested upon completion of three years of continuous service.

* Employees who return to the University after a break in service, will be subject to the same Vesting requirements as for new hires, regardless of the duration of the separation. Credit will be given for prioryears of service.

* Employees who voluntarily resign or are dismissed from the University prior to completing three years ofservice will forfeit all University contributions and earnings.

WAIVING THE 12-MONTH WAITING PERIOD If you worked at another college or university, a non-profit research organization, or a Kentucky state governmental agency (with no break in service between jobs) prior to joining the university, you may be able towaive the waiting period for the retirement plan. Break in service means that you were not employed betweenthe time you left your former employer and before joining the University of Louisville. You may also waive the 12-month wait if you have been rehired at U of L and previously participated in the retirement plan.

When coming from another institution:

On your previous employer’s letterhead, signed by your department head or human resources director, pleaseprovide the following information to our Retirement Administrators. (852-3555 or [email protected]).

Name Date of termination SSN (last 4 digits) Job title Date of hire FTE (your full time equivalency)

457(b) DEFERRED COMPENSATION PLANS Another place to invest pre tax dollars for retirement, in addition to the UofL 403(b) Plan. IRS contribution limits are the same as 403(b). Employees can participate in both the 403(b) and the 457(b) at the same time. Two Plans are offered:

* UofL 457(b) Plan: You may participate with either Fidelity Investments or TIAA-CREF or both. Enrollment applications and salary deferral forms are available online at louisville.edu/hr/forms.

* KY Deferred Compensation: Contact Customer Service Center (Frankfort, KY): 1-800-542-2667; or www.kentuckydcp.com.


http://louisville.edu/hrmailto:retplan%40louisville.edu?subject=http://louisville.edu/hr/formshttp://www.kentuckydcp.com

MAKING YOUR ELECTIONS You must make your selections within 30 days of your start date.

MAKING YOUR ELECTIONS Remember, you have 30 days from your start date to make your selections.

* Benefits are effective on your date of hire. Any missed premiums will bededucted on your next paycheck.

* You may only make your selection once during those 30 days.

* Allow three weeks to receive your ID cards from the day you make yourelections online.

What if I don’t make an election in my first 30 days?

If you do not make an election in your first 30 days, you will not have any health, dental or vision insurance. You will be able to add insurance during the annual open enrollment period, or if you have a qualifying event.

ADDING YOUR BENEFICIARIES Once you have received your email to enroll in your benefits via ULink, you can also update your beneficiariesfor your basic and/or additional term life insurance.

To select or update basic life beneficiaries: Login to ULink > click on the Faculty & Staff tab > click on Benefits Summary > click on Basic Life. Then select edit to add a beneficiary and choose the allocation percent.Select the beneficiary’s name to edit the individual’s personal information (i.e. if you need to add a socialsecurity number). You can update your beneficiaries at any time.

If you elect additional term life insurance and wish to have a different beneficiary than your basic life, youjust need to click on the Addl Term Life – Employee link in ULink, and edit to add a beneficiary. Please note that you must wait one business day after you enroll to return to ULink and update your additional term lifebeneficiaries.

Annual QUALIFYING EVENT Open

Enrollment You may only make changes to your health, dental, vision and flexible spending coverage during our annual open enrollment period or within 30 days of a Benefits qualifying event. Examples of a qualifying event are: coverage at the university

* Birth or adoption of a child * Change in your employment is by calendar year. Everystatus (ex: full time to part time) fall, there is an annual open

* Marriage, divorce or legal enrollment to make yourseparation * Dependent loses or gainsinsurance eligibility benefit elections for the

* Spouse’s change in insurance upcoming calendar year,eligibility due to loss or gain of * Death beginning January 1.employment.

30 Days



2018 RATES SUMMARY The health plan rates listed below do not include the $40 per month premium incentive from participation in the health management program, Get Healthy Now. If you plan to participate in Get Healthy Now, deduct $40from the monthly rate above to get your final cost.

HEALTH PLAN RATES FOR FULL TIME ACTIVE EMPLOYEES

12 Month Employee Monthly Rate 10 Month Employee Monthly Rate

EPO PPO PCA High PCA Low EPO PPO PCA High PCA Low

Employee Coverage $136.12 $118.58 $67.12 $65.00 $163.34 $142.30 $80.54 $78.00

Employee + Spouse/QA $495.04 $456.46 $343.24 $211.64 $594.05 $547.75 $411.89 $253.97

Employee + Children $268.21 $236.63 $144.01 $65.00 $321.85 $283.96 $172.81 $78.00

Employee + Family $553.24 $500.62 $346.24 $166.78 $663.89 $600.74 $415.49 $200.14

Two Employee Family 1 $135.52 $109.21 $52.50 $52.50 $162.62 $131.05 $63.00 $63.00 1 Spouse/QA must be a full-time employee and also have child(ren) covered in the plan.

HEALTH PLAN RATES FOR PART-TIME ACTIVE EMPLOYEES

12 Month Employee Monthly Rate 10 Month Employee Monthly Rate

EPO PPO PCA High PCA Low EPO PPO PCA High PCA Low

Employee Coverage $353.24 $334.96 $281.18 $247.74 $423.89 $401.95 $337.42 $297.29

Employee + Spouse/QA $850.91 $810.70 $692.39 $555.33 $1,021.09 $972.84 $830.87 $666.40

Employee + Children $631.43 $598.52 $501.73 $403.93 $757.72 $718.22 $602.08 $484.72

Employee + Family $1,092.16 $1,037.32 $876.00 $689.10 $1,310.59 $1,244.78 $1,051.12 $826.92

DENTAL RATES VISION RATES

12 Month Employee 10 Mo Employee

Basic Enhanced Basic Enhanced

Employee Coverage $21.27

$42.52

$50.20

$77.62

$24.93

$49.83

$58.82

$90.96

$25.52 $29.92

$51.02 $59.80

$60.24 $70.58

$93.14 $109.15

Employee + Spouse/QA

Employee + Children

Employee + Family

12 Month Employee 12 Mo 10 Mo

Employee Coverage $3.70

$6.71

$7.11

$10.21

$4.44

$8.05

$8.53

$12.25

Employee + Spouse/QA

Employee + Children

Employee + Family



WHO DO I CONTACT? For anything not listed below, or for general questions, please do not hesitate to contact the University of Louisville Human Resources Benefits Department at (502) 852-6258.

IMPORTANT INFORMATION FOR FUTURE REFERENCE (FILL IN THE BLANK)

Your Employee ID# Your UofL User Name:

Who Phone Email/Website What to Contact About UNIVERSITY OF LOUISVILLE CONTACT INFORMATION

University of LouisvilleBenefits Department

University of LouisvillePayroll Department

University of LouisvilleIT Help Desk

University of LouisvilleGet Healthy Now

(502) 852-6258 www.louisville.edu/hr or [email protected]

[email protected]

louisville.edu/it/departments/consulting/helpdesk

louisville.edu/gethealthynow

General questions

(502) 852-2978 Paychecks, deductions, W-4 tax form updates

(502) 852-7997 Questions about email accounts and other IT related topics

(502) 852-7755 Premium incentive for health planparticipants and general wellness

center questions

INSURANCE CONTACT INFORMATION

Anthem Blue Cross Blue Shield (Medical)

MetLife (Dental)

Davis Vision (Vision)

Discovery Benefits

Express Scripts

KY Rx Coalition

1-855-747-1137 www.anthem.com

metlife.com/mybenefits

www.davisvision.com

www.discoverybenefits.com

www.express-scripts.com

www.kyrx.org

Questions for health planparticipants about coverage

1-866-832-5756 Questions about dental coverage

1-877-923-2847 (client code 7631) Questions about vision coverage

1-866-451-3399 Questions about your flexiblespending accounts

1-800-298-6890 Any pharmacy issues

1-855-218-KYRx Help find lower cost prescriptions, etc. RETIREMENT ACCOUNT CONTACT INFORMATION

Fidelity

TIAA

Fidelity Individual Consultations

TIAA Individual Consultations

Kentucky Deferred Compensation

1-800-343-0860 www.fidelity.com/atwork

www.tiaa.org

www.fidelity.com/atwork/reservations

www.tiaa.org/schedulenow

www.kentuckydcp.com

Retirement account information

1-800-842-2252 Retirement account information

1-800-642-7131 To schedule a one-on-one consultation

1-800-732-8353 To schedule a one-on-one consultation

1-800-542-2667 Retirement account information for 457(b) KY deferred comp plan OTHER CONTACT INFORMATION

Human Development Company(EAP)

1-800-877-8332 or (502) 589-HELP www.humandev.com

Any personal needs (counseling,etc)


http://louisville.edu/hrhttp://www.louisville.edu/hrmailto:[email protected]:[email protected]://louisville.edu/it/departments/consulting/helpdeskhttp://louisville.edu/it/departments/consulting/helpdeskhttp://louisville.edu/gethealthynowhttp://www.anthem.comhttp://metlife.com/mybenefitshttp://www.davisvision.comhttp://www.discoverybenefits.comhttp://www.express-scripts.comhttp://www.kyrx.orghttp://www.fidelity.com/atworkhttp://www.tiaa.orghttp://www.fidelity.com/atwork/reservationshttp://www.fidelity.com/atwork/reservationshttp://tiaa.org/schedulenowmailto:www.kentuckydcp.com?subject=http://www.humandev.com

ADDITIONAL BENEFITS

INFORMATION & SUMMARY OF

BENEFITS DOCUMENTS

Includes: 2018 Plan Comparison Chart

Summary of Benefits EPO PPO

PCA High PCA Low Dental Vision

Short Term Disability

Notice of Privacy Practices

For more detailed summary of benefits (SBC) forms,

visit louisville.edu/hr/benefits.

http://louisville.edu/hr/benefits

University of Louisville 2018 Health Plan Comparison

EPO PPO PCA HIGH PCA LOW

TYPE OF SERVICE Network (Anthem Blue Access PPO

Network) Out-of-network

Network (Anthem Blue Access PPO


Network (Anthem Blue Access PPO


Network (Anthem Blue Access PPO Network)

Out-of-network

Annual Allowance Does not apply Does not apply Does not apply Does not apply

$500 Individual

Does not apply

$500 Individual

Does not apply

$1,000 Employee+ Spouse

$1,000 Employee+ Spouse

$2,000 Employee+ Child(ren)

$2,000 Employee+ Child(ren)

$2,000 Family $2,000 Family

Annual Deductible None

None $250 per person $500 per person $1,000 per person $2,000 per person $2,000 per person $4,000 per person

None $750 per family $1,500 per family $3,000 per family $6,000 per family $4,000 per family $8,000 per family Annual Medical Out-of-pocket Maximum (Copays and deductibles accumulate toward the out-of-pocket maximum)

$2,000 per person

N / A

$2,250 per person $4,500 per person $4,000 per person $8,000 per person $5,000 per person $10,000 per person

$4,000 per family $4,750 per family $13,500 per family $9,000 per family $18,000 per family $10,000 per family $20,000 per family

Physician office ( OBGYN visits covered as Primary Care ) PCP= Primary Care Physician

$20 PCP; $0 PCP UofL Physicians

Not Covered $15 PCP;

$0 PCP UofL Physicians 60% after deductible

90% after deductible; UofL PCP will apply a

$20 discount off the normal network

discount

60% after deductible

80% after deductible; UofL PCP will apply a

$20 discount off the normal network

discount


$35 Specialist Not Covered $30 Specialist

Preventive Care Routine physicals, Well-child check-ups and routine immunizations

100% Not Covered 100% 60% after deductible 100% 60% after deductible 100% 50% after deductible

Mammography screenings Routine GYN exams 100% Not Covered 100% 60% after deductible 100%

60% after deductible 100%


Lab, X-ray or other preventive tests 100% Not Covered 100% 60% after deductible 100%

60% after deductible 100%


Inpatient Hospital

Inpatient care Plan pays 90% Not Covered 90% after deductible 60% after deductible 90% after deductible 60% after deductible



Physician Inpatient care Plan pays 90% Not Covered 90% after deductible 60% after deductible 90% after deductible 60% after deductible



TYPE OF SERVICE EPO PPO PCA High PCA Low

Outpatient Network Out-of-network Network Out-of-network Network Out-of-network Network Out-of-network

Outpatient surgery - facility 100% after $100 copay Not Covered 90% after deductible 60% after deductible 90% after deductible




Physician Outpatient services (other than office visit)

90% Not Covered

100% after copays ULP $0 copay

Anthem Network $15 copay $30 Specialist

60% after deductible 90% after deductible 60% after deductible



Lab Services 100% Not Covered 100% 60% after deductible 100% 60% after deductible 100% 50% after deductible

X-Ray and Major Diagnostics Plan pays 90% Not Covered 90% after deductible 60% after deductible





Emergency Room 100% after $100

copay 100% after $100

copay 100% after $100

copay 60% after deductible 90% after deductible

90% after deductible. 60% non-emergency


80% after deductible. 60% non-emergency

Mental Health & Substance Abuse

Inpatient care Plan pays 90% Not Covered 90% after deductible 60% after deductible 90% after deductible 60% after deductible



Outpatient care - per visit $20 copay or $0 copay if UofL Physician

Not Covered $15 copay or $0 copay if UofL Physician

60% after deductible 90% after deductible 60% after deductible



Vision

Vision Exam (one routine exam per year)

100% after $20 copay Not Covered

100% after copays ULP $0 copay Anthem

Network $15 copay $30 Specialist

60% 90% after deductible 60% after deductible



Prescription Drugs EPO PPO PCA HIGH PCA LOW Retail Prescription Drug Generic Retail

Generic Retail - $8.00 Generic Retail - $8.00 Generic Retail - $8.00 Generic Retail - $8.00

Prescription Drug Brand Formulary Retail

Brand Formulary Retail - You Pay 25%, up to $60 maximum




Prescription Drug Non Formulary Retail

Non- Formulary Retail - You Pay 40%, up to $100 maximum




Mail Order (90 day supply) Prescription Drug Generic Mail Order

Generic Mail Order - $16.00 Generic Mail Order - $16.00 Generic Mail Order - $16.00 Generic Mail Order - $16.00

Prescription Drug Brand Formulary Mail Order

Brand Formulary Mail Order - You Pay 15%, up to $120 maximum




Prescription Drug Non-Formulary Mail Order

Non-Formulary Mail Order - You Pay 35%, up to $200 maximum




Brand with Generic Available Prescription Drug Brand for which a Generic equivalent is available - retail or mail order

Plan Pays Cost of Generic Drug- You Pay remainder, no maximum




Annual Prescription Out-of-pocket Maximum

$4,600 per person N / A




$9,200 per family $9,200 per family $4,200 per family $3,200 per family

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Your Summary of Benefits EPO

Anthem Blue Cross and Blue Shield and University of Louisville want to help you take control and make the most of your health care benefits. That’s why we provide convenient services to get your health care questions answered quickly and accurately:

• Anthem.com – Take advantage of easy, time-saving online tools. You can check your eligibility, benefits, claims, claim payments, search for a doctor, hospital and much more.

• 24/7 NurseLine – Always there for you. A nurse is a phone call away as well as other health resources, all available 24-hours a day, 7-days a week to provide you with information that can help you make informed decisions. Call toll free at 888.279.5378.

• Customer Care telephone support – Need more help? Contact your designated member services team at 855.747.1137. Get answers to your benefit questions or receive guidance when looking for a doctor or hospital.

The Benefit Summary is intended only to highlight your Benefits and should not be relied upon to fully determine your coverage. If this Benefit Summary conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.

Plan Highlights

Types of Coverage Network Benefits

Annual Deductible

Individual Deductible No deductible Family Deductible No deductible

Out of Pocket Maximum (Member copayments (excluding Pharmacy) accumulate toward the OOP maximum)

Individual Out-of-Pocket Maximum $2,000 per year Family Out-of-Pocket Maximum $4,000 per year

Benefit Plan Coinsurance (The amount the Plan pays)

90% coverage

Lifetime Maximum

There is no dollar limit to the amount the Plan will pay for essential No lifetime maximum benefit benefits during the entire period you are enrolled in this Plan.

Prescription Drug Benefits

Prescription drug benefits are shown under separate cover.

Information of Precertification

Precertification is required for certain services. Please refer to your Benefit Plan Document.

Information on Benefit Limits

Out-of-pocket maximum and benefit limits are calculated on a calendar year basis. All benefits are reimbursed based on eligible expenses. For a definition of eligible expenses, please refer to your plan SPD. When benefit limits apply, the limit refers to any combination of network and non-

network benefits unless specifically stated in the benefit category.

http:Anthem.com

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Benefits

Types of Coverage Network Benefits

Ambulance Services (Emergency and non emergency)

100% after you pay a $100 copayment per trip

Dental Services (Accident only)

90% coverage

Durable Medical Equipment (DME)

100% coverage

Emergency Health Services Outpatient

100% after you pay a $100 copayment per visit. If you are admitted as an inpatient to a network hospital directly from the emergency

room, you will not have to pay this copayment. The benefits for an inpatient stay in a network hospital will apply instead.

Hearing Aids

One per year every 36 months 100% coverage

Home Health Care

Benefits are limited to 100 visits per year 100% coverage

Hospice Care

100% coverage

Hospital Inpatient Stay

90% coverage

Lab, X Ray and Major Diagnostics Outpatient

Lab 100% coverage X-Ray and Diagnostics 90% coverage

Lab, X Ray and Major Diagnostics (CT, PET, MRI and Nuclear Medicine)

Lab 100% coverage X-Ray and Diagnostics 90% coverage

Mental Health Services

Inpatient - 90% coverage Outpatient - 100% after you pay a $20 copayment per visit

ULP Providers – covered in full

Neurobiological Disorders Mental Health Services for Autism Spectrum Disorders



Pharmaceutical Products Outpatient

This includes medications administered in an outpatient setting, Physician’s office – 100% coverage in the physician’s office and by a home health agency. All other place of service – 100% after you pay a $35 copay

Physician Fees for Surgical and Medical Services

90% coverage

Physician s Office Services Sickness and Injury

100% - copay waived if ULP Provider Primary Physician $20 Copayment per visit for Anthem PCP

Specialist Physician 100% after you pay a $35 Copayment per visit for Anthem PCP

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Types of Coverage

Pregnancy Maternity Services

Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each covered Health Service

category in this Benefit Summary.

For services provided in the physician’s office, a copayment will only apply to the initial office visit

Infertility treatment (Limited to $5,000 per lifetime)

Preventive Care Services (Covered health services include but not limited to:)

Primary Physician Office Visit 100% coverage

100% coverage Specialist Physician Office Visit

100% coverage Lab, X-Ray or other preventive tests

Prosthetic Devices

100% coverage

Reconstructive Procedures

Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service category in this Benefit Summary.

Rehabilitation Services Outpatient Therapy and Manipulative Treatment

Benefits are limited as follows: PT/OT 100% copay waived for ULP Providers

50 visits combined of physical and occupational therapy $20 Copayment per visit for Anthem PCP 25 visits combined of speech and cognitive therapy Manipulative and all other therapies - 100% after you pay a $35

30 visits of manipulative treatment copayment per visit 25 visits combined of respiratory and pulmonary therapy

Scopic Procedures Outpatient Diagnostic and Therapeutic

Diagnostic scopic procedures include, but are not limited to: Colonoscopy; Sigmoidoscopy; Endoscopy.

90% coverage For Preventive Scopic Procedures, refer to the

Preventive Care Services category.

Skilled Nursing Facility / Inpatient Rehabilitation Facility Services

Benefits are limited as follows: 120 days per year 100% coverage

Substance Use Disorder Services



Surgery Outpatient

$100 coverage after you pay $100 copayment

Transplantation Services

90% coverage

For network benefits, services must be received at a Blue Distinction Center for Transplant.

Urgent Care Center Services

100% coverage after you pay a $35 copayment per visit

Vision Examinations

Benefits are limited as follows: 1 routine exam every year 100% coverage after you pay a $20 copayment per visit

Medical Notes

It is recommended that you review your SPD for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.

In network deductibles and out of pocket amounts apply to the out of network accumulations. However, out of network deductible and out of pocket amounts are not included in the in network accumulations.

Dependent Age: to the end of the calendar year the child attains age 26. When choosing a non-network provider, the member is responsible for any balance due after the plan

payment.

Benefit Period: Equals calendar year Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with

the Federal Mental Health Parity.

Precertification: Members are encouraged to always obtain prior approval when using non network providers. Precertification will help avoid any unnecessary reduction in benefits for non-covered or non-medically necessary services.

Primary Care Physician: Network Provider who is a practitioner that specializes in family and general practice,

internal medicine and pediatrics.

Specialist Physician: Network Provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice.

Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits are covered.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Kentucky, Inc. Independent licensee of the Blue Cross and Blue Shield Association.

ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and

Blue Shield Association.

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Your Summary of Benefits PPO






Plan Highlights

Types of Coverage Network Benefits Non Network Benefits

Annual Deductible (Member copayments do not accumulate towards the deductible)

Individual Deductible $250 per year $500 per year Family Deductible $750 per year $1,500 per year

Out of Pocket Maximum (Both deductibles and member copayments (excluding Pharmacy) accumulate towards the OOP maximum)

Individual Out-of-Pocket Maximum $2,250 per year $4,500 per year Family Out-of-Pocket Maximum $4,750 per year $13,500 per year


90% after deductible has been met 60% after deductible has been met

Lifetime Maximum Benefit

There is no dollar limit to the amount the Plan will pay for essential benefits during the entire No lifetime maximum benefit No lifetime maximum benefit

period you are enrolled in this Plan.






The annual deductible, out-of-pocket maximum and benefit limits are calculated on a calendar year basis. All benefits are reimbursed based on eligible expenses. For a definition of eligible expenses, please refer to your plan SPD. When benefit limits apply, the limit refers to any

combination of network and non-network benefits unless specifically stated in the benefit category.

http:Anthem.com

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Benefits





Notification required for non-emergency ambulance services


90% after deductible has been met 90% after network deductible

has been met




100% after you pay a $100 copayment per visit. If you are admitted as an inpatient to a

network hospital directly from the emergency room, you will not have to pay this

copayment. The benefits for an inpatient stay in a network hospital will apply instead.

100% after you pay a $100 copayment per visit

Hearing Aids

One per ear every 36 months 90% after deductible has been met 60% after deductible has been met

Home Health Care

Benefits are limited to 100 visits per year 90% after deductible has been met 60% after deductible has been met

Hospice Care

100% 60% after deductible has been met




Lab 100% X-ray and Diagnostic services 90% after deductible has been met

60% after deductible has been met

Lab, X Ray and Major Diagnostics (CT, PET, MRI and Nuclear Medicine)



Inpatient - 90% after deductible has been met Outpatient- 100% after you pay a

$15 copayment per visit ULP Providers – covered in full



Inpatient - 90% after deductible has been met Outpatient - 100% after you pay a




This includes medications administered in an outpatient setting, in the physician’s office and 90% after deductible has been met

by a home health agency. 60% after deductible has been met

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University of Louisville Primary Care 100% - copay waived

Primary Physician 100% after you pay a $15 copayment per visit 60% after deductible has been met

Specialist Physician 100% after you pay a $30 Copayment per visit 60% after deductible has been met


For services provided in the physician’s office, Depending upon where the Covered Health a copayment will only apply to the initial

Service is provided, Benefits will be the same as office visit. those stated under each covered Health Service Infertility treatment (Limited to $5,000 per

category in this Benefit Summary. lifetime)

Precertification is required if inpatient stay exceeds 48 hours following a normal

vaginal delivery or 96 hours following a cesarean section delivery.

Preventive Care Services (Covered health services include but are not limited to:)

Primary Physician Office Visit 100% - deductible does not apply 60% after deductible has been met

Specialist Physician Office Visit 100% - deductible does not apply 60% after deductible has been met

Lab, X-Ray or other preventive tests 100% - deductible does not apply 60% after deductible has been met

Prosthetic Devices



Depending upon where the Covered Health Service is provided, Benefits will be the same as those stated under each Covered Health Service


Precertification is required for certain services


Benefits are limited as follows:

50 visits combined of physical and occupational 90% after deductible has been met therapy

25 visits combined of speech and cognitive Chiropractic Treatment - 100% after you pay a therapy

$30 copayment per visit 30 visits of manipulative treatment 25 visits combined of respiratory and pulmonary

therapy



Diagnostic scopic procedures include, but are not limited to:

Colonoscopy; Sigmoidoscopy; Endoscopy. 90% after deductible has been met

For Preventive Scopic Procedures, refer to the Preventive Care Services category.



Benefits are limited as follows: 90% after deductible has been met 120 days per year 60% after deductible has been met


Inpatient - 90% after deductible has been met Outpatient - 100% after you pay a



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Surgery Outpatient





Benefits are limited to $35,000 per covered transplant


100% after you pay a $30 copayment per visit


Vision Examinations

Benefits are limited as follows: 1 routine exam every year

100% after you pay a $15 copayment per visit 60% after deductible has been met

Medical Notes




payment.




Primary Care Physician: Network Provider who is a practitioner that specializes in family and general practice, internal medicine and pediatrics.


Preventive Care Services that meet the requirements of federal and state law, including certain screenings,

immunizations and physician visits are covered.




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Your Summary of Benefits PCA High PPO

(HRA High Medical Plan with HealthEquity) Network includes University of Louisville and Blue Cross Blue Shield PPO Providers






Plan Highlights



Individual Deductible $1,000 per year $2,000 per year Family Deductible $3,000 per year $6,000 per year

Out of Pocket Maximum (Member copayments for Pharmacy does not accumulate towards the Out of Pocket Maximum)


Personal Care Account

Annual Allowances that can be applied per year toward the member’s portion of covered medical costs, such as plan deductibles or coinsurance: $500 – Employee $2,000 – Employee + Child(ren) $1,000 – Employee + Spouse $2,000 – Employee + Family


90% after Deductible has been met 60% after Deductible has been met







Precertification is required for certain services. Please refer to Benefit Plan Document.


The annual deductible, out-of-pocket maximum and benefit limits are calculated on a calendar year basis. All benefits are reimbursed based on eligible expenses. For a definition of eligible expenses, please refer to your plan SPD. In network deductible and out of pocket amounts apply to

the out of network accumulations. However, out of network deductible and out of pocket do not apply to in network.

http:Anthem.com

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Benefits




90% after network deductible has been met




has been met





90% after network deductible has been met for Emergency 60% after network deductible

has been met for Non-Emergency

Hearing Aids


Home Health Care


Hospice Care





Lab 100% coverage X-Ray and Diagnostics 90% after deductible has been met


Lab, X Ray and Major Diagnostics Outpatient (CT, PET, MRI and Nuclear Medicine)











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90% after deductible has been met; University of Louisville Primary Care

Primary Physician Physicians will apply a $20 discount off the normal network discount


Specialist Physician 90% after deductible has been met 60% after deductible has been met


Depending upon where the Covered Health Infertility treatment (Limited to Service is provided, Benefits will be the same as $5,000 per lifetime) those stated under each covered Health Service


Pre-certification is required if inpatient stay exceeds 48 hours following a normal






Prosthetic Devices








50 visits combined of physical and occupational therapy

90% after deductible has been met 25 visits of speech and cognitive therapy

30 visits of manipulative treatment 25 visits combined of respiratory and pulmonary

treatment








Benefits are limited as follows: 90% after deductible has been met 120 days per year 60% after deductible has been met



Surgery Outpatient


-Types of Coverage Network Benefits Non Network Benefits






Vision Examinations

One Routine Exam per year 90% after deductible has been met; 60% after deductible has been met

Medical Notes




payment.

Benefit Period: Equals calendar year Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with the

Federal Mental Health Parity.









Anthem Blue Cross and Blue Shield and University of Louisville want to help you take control and make the most of your

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Your Summary of Benefits PCA Low PPO

(HRA Low Medical Plan with HealthEquity) Network includes University of Louisville and Blue Cross and Blue Shield PPO Providers

health care benefits. That’s why we provide convenient services to get your health care questions answered quickly and accurately:





Plan Highlights



Individual Deductible $2,000 per year $4,000 per year Family Deductible $4,000 per year $8,000 per year

Out of Pocket Maximum (Member copayments for Pharmacy do not accumulate towards the Out of Pocket Maximum)


Personal Care Account

Annual Allowances that can be applied per year toward the member’s portion of covered medical costs, such as plan deductibles or coinsurance: $500 – Employee $2,000 – Employee + Child(ren) $1,000 – Employee + Spouse $2,000 – Employee + Family


80% after Deductible has been met 50% after Deductible has been met









The annual deductible, out-of-pocket maximum and benefit limits are calculated on a calendar year basis. All benefits are reimbursed based on eligible expenses. For a definition of eligible expenses, please refer to your plan SPD. In network deductible and out of pocket amounts apply to

the out of network accumulations. However, out of network deductible and out of pocket do not apply to in network.

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Benefits




80% after network deductible has been met




has been met





80% after network deductible has been met Emergency

50% after deductible has been met for Non-Emergency

Hearing Aids


Home Health Care


Hospice Care





Lab 100% coverage X-Ray and Diagnostics 80% after deductible has been met


Lab, X Ray and Major Diagnostics Outpatient (CT, PET, MRI and Nuclear Medicine)











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80% after deductible has been met; University of Louisville Primary Care

Primary Physician Physicians will apply a $20 discount off the normal network discount


Specialist Physician 80% after deductible has been met 50% after deductible has been met


Depending upon where the Covered Health Infertility treatment (Limited to $5,000 per

Service is provided, Benefits will be the same as lifetime)

those stated under each covered Health Service category in this Benefit Summary.

Precertification is required if inpatient stay exceeds 48 hours following a normal






Prosthetic Devices








50 visits combined of physical and occupational therapy

80% after deductible has been met 25 visits of speech and cognitive therapy 30 visits of manipulative treatment

25 visits combined of respiratory and pulmonary treatment








Benefits are limited as follows: 80% after deductible has been met 120 days per year




Surgery Outpatient


-Types of Coverage Network Benefits Non Network Benefits






Vision Examinations

Benefits are limited as follows: 1 routine exam every year


Medical Notes




payment.








solution for your insurance needs

Dental Insurance

Now offering 2 Dental Plan Options.

Routine dental exams do more than protect your teeth. They can help protect your health by catching serious problems, such as diabetes and heart disease. In fact, more than 90% of all diseases produce oral signs and symptoms.

1 And without dental coverage,

out-of-pocket costs for cleanings, exams, and dental procedures can really add up.

Network: PDP Plus

PLAN OPTION 1 BASIC PLAN

PLAN OPTION 2 ENHANCED PLAN

Coverage Type In-Network % of Negotiated Fee*

Out-of-Network % of R&C Fee**

In-Network % of Negotiated Fee*

Out-of-Network % of R&C Fee**

Type A: Preventive (cleanings, exams, X-rays)

100% 75% 100% 75%

Type B: Basic Restorative (filings, extractions)

80% 60% 80% 60%

Type C: Major Restorative (bridges, dentures)

60% 40% 60% 40%

Type D: Orthodontia 50% 50% 50% 50%

Deductible

Individual $25 $25 $25 $25

Family $75 $75 $75 $75

Annual Maximum Benefit

Per Person $1,000 $1,000 $3,000 $3,000

Orthodontia Lifetime Maximum

Per Person $1,000 Child(ren) Only

$1,000 Child(ren) Only

$1,500 Adult & Child(ren)

$1,500 Adult &

Child(ren)

Child(ren)’s eligibility for dental coverage is from birth up to age 26. * Negotiated Fee refers to the fees that participating dentists have agreed to accept as payment in full, subject to any copayments, deductibles, cost sharing and benefit maximums. Negotiated fees are subject to change ** R&C fee refers to the Reasonable and Customary (R&C) charge, which is based on the lowest (1) the dentist’s actual charge, (2) the dentist’s usual charge for the same or similar services, or (3) the charge of the most dentists in the same geographic area for the same or similar services as determined by MetLife

Applies to Type B & C Services

Don’t worry, you’re covered.

You have the flexibility to go to any licensed dentist. Just remember you usually save more when you stay in-network. That’s because participating dentists accept negotiated fees for covered services that are typically 15 to 45% less than average charges in the same community.

2 Services standardly include:

Preventative care (exams, sealants, x-rays)

Fillings

Crowns, dentures and bridges

Root canals and extractions

General anesthesia

Oral surgery

Adult and child orthodontics (Enhanced Plan) Child orthodontics (Basic Plan)

To locate a participating dentist visit at www.metlife.com/mybenefits. You can also call MetLife at 1-866-832-5756 for more information.

Metropolitan Life Insurance Company

200 Park Avenue

New York, NY 10166

www.metlife.com

1 Academy of General Dentistry. The Importance of Oral Health to Overall Health.

http://www.knowyourteeth.com/infobites/abc/article/?abc=T&iid=320&aid=1289 (last accessed November 4, 2014). 2 Based on internal analysis. Savings from enrolling in a dental benefits plan will depend on various factors,

including the cost of the plan, how often participants visit the dentist and the costs of services received. Negotiated

fees are subject to any deductibles, copayments, cost sharing and benefit maximums and are subject to change.

Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions,

exceptions, waiting periods, reductions, limitations and terms for keeping them in force. Please contact MetLife or

your plan administrator for complete details.

1405-1414 L1015441552[exp1016][All States][DC,GU,MP,PR,VI]

© 2015 METLIFE, INC. PEANUTS © 2015 Peanuts Worldwide LLC

http://www.metlife.com/mybenefitshttp://www.knowyourteeth.com/infobites/abc/article/?abc=T&iid=320&aid=1289http:www.metlife.com

Healthy eyes and clear vision are an important part of your overall health and quality of life. Your vision plan helps you care for your eyes while saving you money by offering:

Paid-in-full eye examinations, eyeglasses and contacts, after applicable copayments!

Frame Collection: Your plan includes a selection of designer, name brand frames that are completely covered in full./1

Contact Lens Collection: Select from the most popular contact lenses on the market today with Davis Vision’s Contact Lens Collection./1

One-year eyeglass breakage warranty included on plan eyewear at no additional cost!

How to locate a Network Provider... Just log on to the Member site at davisvision.com and click “Find a Provider” to locate a provider near you including:

IN-NETWORK BENEFITS

Eye Examination Every January 1, Covered in full after $10 copayment

Eyeglasses

Spectacle Lenses Every January 1, Covered in full For standard single-vision, lined bifocal, or trifocal lenses after $20 copayment

Frames

Every other January 1, Covered in full Any Fashion or Designer frame from Davis Vision’s Collection/1 (value up to $160)

OR $120 retail allowance toward any frame from provider, plus 20% off balance/3

OR $170 allowance, plus 20% off balance/3 to go toward any frame from a Visionworks store locations./5

Contact Lenses

Contact Lens Evaluation, Fitting & Follow Up Care

Every January 1 Collection Contacts: Covered in full

Non Collection Contacts: 15% discount/3

Contact Lenses

Every January 1, Covered in full Any contact lenses from Davis Vision’s Contact Lens Collection/1

OR $120 retail allowance toward provider supplied contact lenses, plus 15% off balance/3

ADDITIONAL DISCOUNTED LENS OPTIONS & COATINGS

MOST POPULAR OPTIONS Savings based on in-network usage and average retail values.

Without Davis Vision

With Davis Vision

Scratch-Resistant Coating $25 $0 Polycarbonate Lenses $66 $0/2-$30 Standard Anti-Reflective (AR) Coating $83 $35 Standard Progressives (no-line bifocal) $198 $50 Photochromic Lenses (i.e. Transitions®, etc.)/4 $110 $65

Designer Vision Plan

For more details about the plan, just log on to davisvision.com or call 1.877.923.2847 and enter Client Code 7631

Lower costs and more benefits! See the savings!

Employee Contributions Monthly Annually Employee $3.70 $44.40 Employee plus Spouse $6.71 $80.52 Employee plus Child(ren) $7.11 $85.32 Employee plus Family $10.21 $122.52

Service Estimated

Cost Without Davis Vision

With Davis Vision

Eye Examination $103 $10 Lenses

Bifocals $116 $20 Scratch-Resistant Coating $25 $0 Transitions®/5 $110 $65

Frame $160 $0

Total $514 $95

Savings up to:

$419 1/ The Davis Vision Collection is available at most participating independent provider locations. 2/ For dependent children, monocular patients and patients with prescriptions of 6.00 diopters or greater. 3/ Additional discounts not applicable at Walmart, Sam’s Club or Costco locations.. 4/ Transitions® is a registered trademark of Transitions Optical Inc. 5/ Allowance is available at all Visionworks store locations.

Davis Vision has made every effort to correctly summarize your vision plan features. In the event of a conflict between this information and your organization’s contract with Davis Vision, the terms of

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