Starmark Healthy Incentives®

PPO Plan Designs

Compliant with the

Affordable Care Act

as it applies to self-funded plans

Self-Funded Health Plan Designs and Stop-Loss Insurance for Small to Mid-Size Businesses

Why Starmark?

Starmark’s expertise in group healthcare benefits has served employers for nearly 30 years.

More than great benefits!•ExperienceStarmark’sunparalleled

personal service.

•Choosefromflexible plan designs to create a plan to meet your needs and budget.

•Employershavetrusted Starmark® to serve the healthcare benefit needs of their employees since 1985.

Starmark: Personal. Flexible. Trusted.

Healthy Incentives Means Healthy Savings for YouA Starmark Healthy Incentives® self-funded plan design and stop-loss insurance coverage may help you save money while maintaining traditional health benefits for your employees.

With self-funding, you finance your company’s healthcare benefit plan by funding eligible claim expenses up to a predetermined amount. If actual eligible expenses are less, you have the opportunity to receive a refund – a healthy incentive. If eligible expenses are greater, there is a limit on your financial risk through stop-loss insuranceprotectionprovidedbyTrustmarkLifeInsuranceCompany.

To learn more, refer to the separate brochure, Self-Funding: A guide for small to mid-size businesses.

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Control costs and customize benefits through truly flexible mix-and-match plan designs.

Achieve greater network access and in-network discounts with nationwide access to national and regional PPO networks, including Aetna Signature Administrators®(ASA)PPONetwork,CignaPPONetwork(GWH-CignaPPO Network in Illinois and Missouri) and Private Healthcare Systems (PHCS),aMultiPlannetwork.

Experience cost-effective pharmaceutical care through prescription drug management programs that use a nationwide network of retail pharmacies as well as home delivery and mail order pharmacy services.

Encourage your employees to get and stay healthy with the CareChampion24/7® health advocacy service, and Healthy Foundations® health and wellness management suite.

Make enrollment easy with Express Connect®, Starmark’s paperless employee enrollment process.

Starmark is headquartered with the Trustmark Companies in this prairie-style building in Lake Forest, Illinois.

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Famil iar benef i t of fer ing. A heal thier bot tom l ine.

Starmark Healthy Incentives® PPO Gettheadvantageofafamiliarbenefitofferingwiththecost-savingfeatureofseparateaccruals;oneforin-networkandanother for out-of-network services.

Customize Your Health Plan Design Starmark® self-funded plan designs are flexible and offer a wide range of choices so you can customize your plan to meet your needs and budget. Refer to the separate insert (MK85) for a comparison of state-mandated benefits for fully insured plans to Starmark self-funded plan designs. Ask your broker for details.

Family Deductible1 and Out-of-Pocket Limit1 Multiplier

A multiple of the individual deductible and out-of-pocket limit.n One timen Two times

Lifetime Maximum Benefit

Individual Deductible1

(in-network/out-of-network)

Coinsurance (in-network/out-of-network) n 100/70 2 n 90/70 n 80/60 n 70/50 n 50/50

Unlimited for essential health benefits (as defined by federal regulation)

1 In- and out-of-network deductibles and in- and out-of-network out-of-pocket limits accrue separately. The sum of the in-network deductible, emergency room copay, and inpatient admission and outpatient surgery access fees must be less than the in-network out-of-pocket limit.2Whenthe$0/$2,000individualdeductibleisselectedwiththe100/70coinsurance,thephysician/specialistofficevisitcopayandtheprescriptiondrugcard must also be selected.

3 Whenthe$0/$5,000individualout-of-pocketlimitisselected,the$0/$2,000individualdeductibleand100/70coinsurancemustbeselected;however,the inpatient admission and outpatient surgery access fees, and copays for office visits, urgent care, emergency room, therapies and alternative medicine cannot be selected. Additionally, the outpatient diagnostic x-ray and lab benefit must be subject to the deductible and coinsurance.

n Calendar Year –The12-monthperiodfromJanuary1toDecember31duringwhichcoveredexpensescanbeappliedtosatisfythedeductible.TheaccumulationperiodresetseveryJanuary1.

n Plan Year – The12-monthperiodduringwhichcoveredexpensescanbeappliedtosatisfythedeductible. Theplanyearbeginswiththegroup’seffectivedateandtheaccumulationperiodresets12monthslater,onthe plan’s anniversary.

n $0/$2,0002

n $ 250/$750n $ 500/$1,500n $ 750/$1,500

n $1,000/$2,000n $1,500/$3,000n $2,000/$4,000n $2,500/$5,000

n $3,000/$6,000n $3,500/$7,000n $4,000/$8,000n $4,500/$9,000

n $5,000/$10,000n $6,000/$12,000

Individual Out-of-Pocket Limit1 (in-network/out-of-network)

The individual medical plan out-of-pocket limit is the amount of covered charges the member must pay each year. The out-of-pocket limit includes the plan deductible, copayments, coinsurance and access fees, but does not include precertification penalties, prescription deductibles and prescription copayments.

n $0/$5,0003

n $ 250/$4,000n $ 500/$5,000n $ 750/$6,000n $1,000/$6,500n $1,250/$5,500

n $1,500/$6,000n $1,750/$6,500n $2,000/$7,000n $2,250/$7,500n $2,500/$8,000n $2,750/$7,500

n $ 3,000/$8,000n $ 3,250/$8,500n $ 3,500/$9,000n $ 3,750/$9,500n $4,000/$10,000n $4,500/$11,000

n $5,000/$12,000n $5,500/$12,500n $6,350/$12,500

Physician/Specialist Office VisitCoveredchargesarepaidinfullafterthein-networkphysician/specialistofficevisitcopay.Thisincludescharges for the visit, professional fees for allergy injections and certain non-surgical injections performed at the same office visit, and billed by the attending physician. Additionally, the copay applies to in-network manipulative therapy and includes procedures provided at the office visit. Diagnosticx-raysaresubjecttotheoutpatientdiagnosticx-rayandlabbenefitselected.RefertotheCoveredServices section of this brochure for more information.

Thephysician/specialistofficevisitcopaydoesnotapplyto preventive care services, allergy testing and allergy serum,oranysurgicalprocedure.CoverageforpreventivecareservicesisdescribedintheSelf-FundedPlanDesignFeatures section of this brochure. Surgical procedures, as well as services when a copay is not selected, are subject to the plan deductible and coinsurance.

Therapies Speech, occupational and physical therapyThe therapy copay applies to in-network speech, occupational and physical therapies. Therapies provided ataphysician/specialistofficevisitmayalsobesubjecttotheseparatephysician/specialistofficevisitcopay.Therapies received at a hospital are subject to the plan deductible and coinsurance, and count toward the maximum visit limit. If a copay is not selected, covered services are subject to the plan deductible and coinsurance.

Alternative MedicineThe alternative medicine copay applies to in-network services. If a copay is not selected, covered services are subject to the plan deductible and coinsurance. For a list of covered alternative medicine services, refer to the CoveredServicessectionofthisbrochure.

Urgent CareCoveredchargesarepaidinfullafterthein-networkurgentcare copay. This includes charges for x-ray, lab, pathology and radiology services performed at the same visit and billed by the urgent care center.

The urgent care copay does not apply to preventive care servicesoranysurgicalprocedure.CoverageforpreventivecareservicesisdescribedintheSelf-FundedPlanDesignFeatures section of this brochure. Surgical procedures, as well as services when a copay is not selected, are subject to the plan deductible and coinsurance.

Emergency RoomCopay Choices: n $150 n$200n$250n $500Coveredchargesarepaidinfullafterthecopay.Thecopay is not waived if admitted as inpatient.

Chargesfornon-emergencytreatmentreceivedintheemergency room, or services received when a copay is not selected, are subject to the plan deductible and coinsurance.Copaysapplytowardtheout-of-pocketlimit,butdo not apply toward the plan deductible. For information on emergency admissions, see page 10.

Copays provide employees a sense of securi ty.

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Selectaphysician/specialistofficevisitcopay,urgentcarecopayandemergencyroomcopaytopersonalizeyourself-fundedplandesign.Ifdesired,atherapyand/oralternativemedicinecopaycanbeselected,withtheamountdependentonthephysician/specialistofficevisitcopayselected.Copaysapplytowardtheout-of-pocketlimit,butdonotapplytowardtheplan deductible.

Benefit Options

1Theurgentcarecopaymustbeequaltoorgreaterthanthephysician/specialistofficevisitcopay.

Physician/Specialist Office Visit

Therapies (optional copay)

Alternative Medicine (optional copay) Urgent Care1

n $20copay

n $25copay

n $30 copay

n $35 copay

n $40copay

n $45copay

n $50 copay

n $60copay

n Deductibleand coinsurance

$20copay

$25copay

$30 copay

$35 copay

$40copay

$45copay

$50 copay

$60copay

Deductibleand coinsurance

$20copay

$25copay

$30 copay

$35 copay

$40copay

$45copay

$50 copay

$60copay

Deductibleand coinsurance

n $40copay

n $45copay

n $60copay

n $65copay

n $75copay

n $80 copay

n $85 copay

n $100 copay

n Deductibleand coinsurance

Outpatient Diagnostic X-Ray and LabChoices:n 100%upto$250perperson,peryearn 100% up to $500 per person, per yearn 100% up to $1,000 per person, per yearn 100% unlimited (no dollar limit per person, per year)n Coinsuranceonly(deductiblewaived)1

n Deductibleandcoinsurance

Coverageincludesin-networkx-ray,lab,pathology and radiology services. This benefit does not apply to diagnosticimagingtestssuchasCT,MRIandPETscans.Diagnosticimagingtests,coveredchargesexceeding the maximum or services received out-of-network, are subject to the plan deductible and coinsurance.

Inpatient Admission and Outpatient Surgery Access Fees OptionChoices: n $500 n $750 n $1,000When the optional inpatient admission and outpatient surgery access fees are selected, an additional access fee applies to facility charges for each hospital admission, and to facility charges for each outpatient surgical visit. After these access fees are paid, covered charges are subject to the plan deductible and coinsurance. These access fees apply toward the out-of-pocket limit, but do not apply toward the plan deductible. For information on emergency admissions, see page 10.

Note: These access fees cannot be selected individually.

Supplemental Accident OptionChoosesupplementalaccidentbenefitstohelpprepareyour employees for an unexpected accident or injury by providing first-dollar coverage.

•Thefirst$500ofcoveredchargesperaccident is paid at 100 percent under your self-funded plan design.

•Additionalcoveredchargesaresubjecttotheplandeductible and coinsurance.

•Coverageincludesmedicalchargesresultingfromaccidental injury incurred within 90 days of the accident.

Maternity OptionSelecting the maternity option provides your employees with peace of mind when planning for pregnancy and delivery. Normal maternity and nursery care covered charges are subject to the plan deductible and coinsurance.

CareChampion 24/7® OptionCareChampion24/7isanoptionalhealthadvocacyservice that supports members as they navigate through the healthcare system. Advisors are available anytime, day or night, and can help members find a doctor or hospital in-network, understand healthcare benefits and claim payments, identify cost-saving opportunities, handle eldercare issues and more!

YourCare Option ChoosetheoptionalYourCarehealthandwellnessprogramto help your employees protect their most important asset – their health. YourCareprovidesmemberswithproactive,timely and personalized information, including:

•Wellnessreminderstoencouragepreventivetestsandscreenings based on age and gender.

•Personalized,detailedreminderstohelpmembersstaycurrent with recommended guidelines for managing a chronic condition.

•Outreachfromregisterednursestoassistmemberswhohave one or more serious health conditions.

•Accesstoonlineself-directedcoachingtohelpmemberscreate a personalized plan to meet their health goals.

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Starmark® Provides Unparalleled Personal Service•Starmark calls each new group to welcome them

and follows up to ensure satisfaction continues throughout the year.

•Representativesassisttomake renewal easy.

•Starmark’swebsite provides information and resources to help groups manage their plan and to help members better manage their healthcare.

•Membershavequick access to important documents and benefit information at www.starmarkinc.com and can quickly access claim status using their telephone keypad.

1 Thecoinsuranceonlyoptionisnotavailablewhenthe100/70 coinsurance is selected.

This program provides prescription drug savings atparticipatingpharmaciesnationwide.Coveredprescription drugs are subject to the in-network plan deductible and coinsurance when the prescription is filled at a participating pharmacy.

WhenmemberspresenttheirmedicalIDcard at a participating pharmacy, they receive:

•Thelowestpriceavailableinthatstore,onthatday

•Genericdrugsavings

•Drugutilizationreview

The Price Assurance Program includes most drugs that, by federal law, require a prescription. If a prescription drug is excluded from coverage under your self-funded plan design, members may still receive a discount on their prescription through this program.

Prescriptiondrugout-of-pocketexpensesaccumulatetowarda$6,350individualand$12,700familyprescriptiondrugout-of-pocketlimit,whichisseparate from the medical plan out-of-pocket limit. The prescription copay and deductible do not apply toward the medical plan deductibles or out-of-pocket limits.Creditfrompriorplandrugcarddeductiblesandcarry-overprovisionsdo not apply to the prescription benefit.*$75or50%,whicheverisgreater,upto$200perprescription

1 | Prescription Drug Card 2 | Price Assurance Program

Retail Copay (up to a 30-day supply)

Mail Service Copay(up to a 90-day supply)

Prescription DeductibleMust be met in full every year by each member before the copay applies.

The prescription deductible does not apply to generics.

Generic Preferred Nonpreferred Brand Brand

Generic Preferred Nonpreferred Brand Brand

n $0 per person n $100 per person n $250 per person n $500 per person

OR

Tai lor your sel f - funded plan to meet your group’s needs.

Outpatient Prescription Drug Benefit Choices Offer FlexibilityStarmark Healthy Incentives®self-fundedplandesignsoffer2prescriptiondrugbenefitoptionstomeetyourgroup’sneeds: a prescription drug card or the Price Assurance Program.

Prescription SafeguardsTo encourage the safe and appropriate use of prescription drugs, Starmark® plan designs utilize quantity limits and prior authorization for certain drug classes covered by the prescription benefit. These limits and prior authorizations are intendedtoensureproperprescriptionutilizationandclinicallyappropriatequantities.Additionally,SpecialtyGuidelineManagement, provided by Starmark’s contracted pharmacy benefit manager, helps to ensure members receive the most appropriate specialty medication for managing their complex medical conditions. Refer to the separate brochure, Safety, Savings and Convenience, for more information.

To learn more about the prescription drug benefit, specialty pharmacy services and ways to save on prescriptions, refer to the separate brochure, Making the Most of Your Prescription Benefit.

Visit a Participating Pharmacy to Maximize BenefitsParticipating pharmacies have contracted with Starmark’s contracted pharmacy benefit manager to charge a fixed amount for prescription drugs. Nonparticipating pharmacies may charge a price significantly above this amount, which may mean higher prescription expenses for members. When a nonparticipating pharmacy is used, the member pays the full price of the prescription drug at the time of purchase.

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n

n

n

n

n

n

n

n

$50

$75

$45

$50

$75or50%*

$60

$75

$90

$150

$225

$135

$150

$200

$180

$225

$270

$ 0

$ 0

$7

$10

$10

$15

$ 15

$20

$ 0

$ 0

$14

$20

$20

$30

$30

$40

$30

$45

$25

$30

$30

$30

$45

$60

$75

$110

$60

$75

$75

$75

$110

$150

Self-Funded Plan Design FeaturesSelf-funded plan designs can have many of the same features as a traditional health plan.

Preventive Care ServicesCoveredpreventivecareservicesreceivedin-networkwillbepaid under your self-funded plan design at 100 percent.1 Out-of-network services are subject to the plan deductible andcoinsurance.Coveredpreventivecareservicesinclude,but are not limited to:

•Routinephysicalexam•Bloodandotherlaboratorytests•ScreeningECG(electrocardiogram)•Immunizations•Mammograms:baselineandannual•PSA(prostate-specificantigen)•Colorectalcancerscreening•Counselingfortobaccouse•Women’spreventiveservices – Well-woman visits, including prenatal routine office visits – Pap smear – HPV (human papillomavirus) testing – Contraceptivemethodsandcounseling – Breastfeedingsupport,suppliesandcounseling

Age and frequency schedules apply. For a complete list of preventive care services, visit www.hhs.gov/healthcare/prevention/index.html.

In no event will benefits for preventive care services be less than that which is required by state or federal law, as applicable.

Discount Program Means Big SavingsThis program helps members save money and maintain their overall health, and offers discounts on:

• Visionservicesandsupplies• Hearingservicesandsupplies• Vitamins

Note:ThisprogramfromNewBenefits,Ltd.,adiscountmedicalplanorganization, is not insurance and is not available to Vermont residents. Trustmark and Starmark®arenotaffiliatedwithNewBenefits,Ltd.

Lab Card® ProgramHealthy Incentives PPO plan designs include the Lab CardProgram.Thisvoluntaryprogramoffers100percentcoverage for covered outpatient laboratory testing when testingisdirectedtoaparticipatingQuestDiagnosticslaboratoryaspartoftheLabCardProgram.Providercollection and handling fees may apply and are subject to health benefit plan provisions. For more information, visit www.labcard.com.

Note:TheLabCardProgramisnotavailablewhentheCignaPPO Network or the SuperMed®Networkisselected.QuestDiagnostics Incorporated is a provider of laboratory testing, information and services, and is not affiliated with Trustmark or Starmark.

Physician/Hospital PPO Network SelectionOffering employees a choice of PPO networks encourages in-network utilization while maintaining freedom of choice in provider care.

• Youmayselecttwonetworksperbusinesslocationupto a maximum of five networks.

• Byusingin-networkproviders,youremployeescantakeadvantage of negotiated discounts. If an out-of-network provider is used, the member is responsible for any amountexceedingtheReasonableandCustomaryFee2.

Note: Some networks have guidelines that may limit availability with other networks.

Receive Network Access While Outside the Primary PPO Service AreaWhen members and their eligible dependents encounter an unexpected illness or need medical treatment while outside their primary PPO network’s coverage area, they can take advantage of in-network benefit levels, subject to thetermsofyourplan,andPHCS-negotiateddiscountsbyusingPHCSHealthyDirections.MemberscanvisitaPHCSHealthyDirectionsproviderwhen:

• Travelingforbusinessorvacation• Attendinganout-of-areaeducationalinstitution• ResidingoutsidetheirprimaryPPOnetwork’s

coverage areaMembers who have the Aetna Signature Administrators® (ASA)PPONetwork,CignaPPONetworkorPrivateHealthcareSystems(PHCS)astheirnetworkmaintainprovider access through these networks when outside the primary PPO service area.

FormoreinformationaboutPHCSHealthyDirections, refertotheseparateflyer(MK60b).

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1 Preventive care benefits are in accordance with guidelines from the U.S. Preventive Services Task Force, Health Resources and Services Administration, and theAdvisoryCommitteeonImmunizationPracticesoftheCentersforDiseaseControlandPrevention.2ReasonableandCustomaryFeeisthelesseroftheprovider’sactualcharge,orapercentageoftheMedicarereimbursementrateineffectatthetimeservicesare provided.

Covered ServicesWhen medically necessary, eligible charges for the following services are payable under your self-funded plan design subject to the plan deductible, coinsurance and, for out-of-networkproviders,ReasonableandCustomaryFee1.

Hospital and Provider Services• Semiprivatehospitalroom,boardandgeneral

inpatient nursing care• Intensivecareunit• Miscellaneousservicesandsuppliesprovided

by a hospital on an inpatient basis• Miscellaneousservicesandsuppliesprovidedby

a hospital or free-standing surgical center and related to outpatient surgery or outpatient treatment of injury

• Anestheticsandtheiradministration• Physician’sfees,exceptasotherwisenoted• Preventivecareservices2

• Emergencyservices

Other Services and Supplies• Prescriptiondrugs(Seepage6fordetailsonoutpatient

prescription drug benefits.) • Bloodandbloodplasma,oxygenandrental

of equipment for its administration• Locallicensedambulanceservicetoorfromahospital• X-rays(notdentalx-rays)andlaboratorytestsperformed

for diagnosis and treatment• X-ray,radium,cobaltandradioactiveisotopetherapy• Artificiallimbsandeyes• Casts,splints,trusses,crutchesandnondentalbraces• Rentalofawheelchair,hospital-typebedorother

durable medical equipment• Habilitativeandrehabilitativedevices• Complicationsofpregnancy• Outpatientpre-admissionstesting• Hospicecare – Maximumof6monthsperlifetime• Homehealthcare – Maximum of 100 days per year• Skillednursingcare – Maximum of 81 days per year• RNandLPNfeesforprivate-dutynursingrecommended

by a physician• Nondentaltreatmentoftemporomandibularjointdysfunction(TMJ)

• Chronicpaintreatmentprograms – Maximum of 10 visits per year

Therapies• Habilitativeandrehabilitativeservices,including

speech, occupational and physical therapist’s fees, when prescribed by a physician – 60-visitlimitpertherapyperyear

• Manipulativetherapy – 20-visitlimitperyear

Alternative Medicine• Acupuncture,massagetherapyandnaturopathicservices – 12-visitlimitpertherapy,peryear• Nutritionalcounseling3 – 3-visit limit per lifetime, except for diabetic counseling

Comprehensive plan designs provide peace of mind.

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1ReasonableandCustomaryFeeisthelesseroftheprovider’sactualcharge, or a percentage of the Medicare reimbursement rate in effect at the time services are provided.2CoverageforpreventivecareservicesisdescribedintheSelf-Funded PlanDesignFeaturessectionofthisbrochure.

3Nutritional counseling may be covered under preventive care services.

Healthy Foundations® Helps Members Get and Stay Healthy Healthy Foundations provides a comprehensive suite of health and wellness management tools to help members get andstayhealthy,whichcanhelpcontrolyourplancosts.HealthyFoundationsincludes:MyNurse24/7SM,aURAC-accreditednurseline;MaternaLink®maternitywellnessprogram;onlinesupporttoolsandtheHealthyFoundationswellnesse-newsletter. Plus, you can elect to add the optional YourCarehealthandwellnessprogramwithpersonalizedoutreachtohelp employees protect their most important asset – their health.

To learn more, visit www.starmarkinc.com.

1 CoveredchargesmaybepayableundertheEnhancedHealthBenefitsPackage, if selected.

Mental Illness, Nervous Disorders, Substance Abuse and Alcohol AbuseGroups with up to 50 employees1

• Outpatientexpenses – 40-visitlimitperyear;120visitsperlifetime – Coveredchargesarepaidat60percentfor

anin-networkprovider;50percentforan out-of-network provider.

• Inpatientexpenses – 20daysperyear;40daysperlifetime.Theselimits

do not apply to inpatient alcohol abuse treatment. – Coveredchargesarepaidaccordingtothein-and

out-of-network coinsurance selected.

Groups with 51 or more employees• Outpatientandinpatientexpenses – Coveredchargesarepaidthesameasanyother

covered service.

Organ Transplants• Designatedtransplantfacility – Coveredchargesforapprovedtransplantservices,

including organ procurement or acquisition, are paid at 100 percent.

– Coverageisprovidedfortransportation,lodgingandmeals for a companion, subject to the following limits:

a. Transportation benefit: maximum of $1,000 per approved transplant procedure

b.Lodgingandmealsbenefit:maximumof$250perday;$10,000perlifetime

• Nondesignatedtransplantfacility – Coveredchargesforapprovedtransplantservices

at an out-of-network facility, including organ procurementoracquisition,arepaidat70percent.

– No coverage is provided for transportation, lodging or meals for a companion.

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Optional Health Benefits Packages for Your Plan DesignOffer your employees a more complete benefit package by choosing these optional health benefits packages. SincethepassageoftheAffordableCareAct,employees may expect these benefits in their health plan. Packages may be selected individually.

Enhanced Health Benefits Package• Mentalillness,nervousdisorders,substanceabuse

and alcohol abuse – Coveredchargesarepaidthesameasany

other covered service.• Routineadultvisionscreening – 100% coverage for one exam per year for

adults ages 19 and older• Routineadulthearingscreening – 100% coverage for one exam per year for

adults ages 19 and older• Hearingaids – Coveredchargesarepaidthesameasany

other covered service and are limited to a single purchase, including repair and replacement, every24months.

Infertility Health Benefits Package Female members are eligible for benefits up to age 40.Coveredchargesarepaidthesameasanyothercovered service for the following:• Ovulationinduction• Intrauterineinsemination• In-vitrofertilization(IVF),gameteintra-fallopiantransfer(GIFT),zygoteintra-fallopiantransfer(ZIFT)or low tubal ovum transfer

• Pre-implantationgenetictesting,when medically necessary

• Prescriptiondrugstotreatinfertility – Limitedto6cyclesperlifetimeExclusionsandlimitationsapply.

Precertification Precertification is required for all hospital, rehabilitation or skilled nursing admissions, behavioral health residential treatment, hospice, home healthcare or transplant-related services, and high-tech outpatient radiology services, includingCT,MRIandPETscans.

• Toprecertify,themembermustcallthetoll-freenumberlisted on the medical identification card.

• Failuretoprecertifywillresultina$300penaltyperoccurrence. This penalty will not count toward the plan deductible, or toward the out-of-pocket limit.

• Precertificationdoesnotguaranteeself-fundedplanbenefits are payable. The person must be eligible at the time of service.

Emergency AdmissionsIn the case of an emergency admission, the member must call the toll-free number listed on the medical identification cardwithin48hoursaftertheadmissionoronthenextregular business day after the start of treatment, if later.

Failure to call will result in a $300 penalty per occurrence. This penalty will not count toward the plan deductible, or toward the out-of-pocket limit.

Note: If selected, the inpatient admission fee also applies.

Pre-existing ConditionsInaccordancewiththeAffordableCareAct,self-fundedplanswithaneffectivedateonorafterJanuary1,2014,areprohibited from excluding or limiting pre-existing conditions from coverage. This means that self-funded plans must cover eligible expenses for pre-existing conditions beginning with the effective date of the self-funded plan.

Deductible Credit for New GroupsA member continuously covered under a prior individual or group health plan with a calendar-year deductible will be credited for any portion of the deductible satisfied under thepriorplanduringthesamecalendaryear.Deductiblecredit will not be given if moving to or from a health plan with a plan-year deductible.

Creditisnotprovidedforout-of-pocketamountsorforemployees added to a self-funded plan after the group’s initial effective date.

EnrollmentAnnual Open Enrollment PeriodEligibleemployeesmayenrollthemselvesandtheireligibledependents during the annual open enrollment period, which is the month prior to the start of the new plan year.

Waiting PeriodThe waiting period is the amount of time the employee must wait before he or she is eligible for coverage under your self-funded plan. The waiting period cannot exceed 90 days.

Timely EnrolleesTimely enrollees are eligible employees who complete and signanEmployeeEligibilityStatementforthemselvesand/ortheirdependentsduringtheemployer’swaitingperiod and prior to the end of the initial enrollment period. The initial enrollment period is the 31 days following the waiting period.

Special EnrolleesSpecial enrollees are employees or dependents who previously waived self-funded coverage, but may now be eligible because they have involuntarily lost their othercoverage,hadabenefit/coveragechangeorhad a life-changing event. The enrollment period for a special enrollee is the 31 days following the special enrollmentevent(60daysforspecialenrolleeswhohavelosttheirMedicaidorStateChildren’sHealthInsurance Program coverage).

Special guidelines apply for special enrollees. For more details, refer to the Important Notice (UW105 SF) or ask your broker.

Limited Occupational/ 24-Hour CoverageWork-related injuries and illnesses are covered under your self-funded plan design when the member is not covered by workers’ compensation or similar coverage and is not eligible for such coverage.

Hospital Bill Reward ProgramIf a member detects and resolves an error when reviewing hospital bills, he or she will be rewarded 50 percent of the savings, up to $1,000, under your self-funded plan design.

General information about your sel f - funded plan design.

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Starmark® HRA: Seamless. Innovative. Bottom-line friendly.Save money and help your employees manage healthcare costs. Pair a higher-deductible health plan with the Starmark HRA (health reimbursement arrangement) for lower health plan costs and cash-flow control – with the added bonus of:

• Seamless claims and HRA integration, which means no claims to file

•No prefunding; HRA expenses are funded only as incurred

•Easy fund management for employees

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Exclusions and LimitationsMajor MedicalNo benefits are payable under your self-funded plan design for the following expenses:

•Servicesandsuppliesnotprescribedbyaphysician or required to treat a covered condition, or in excess oftheReasonableandCustomaryFee1, or not medically necessary

•Dentalcareandtreatment;hearingaids2, eyeglasses, eyeglassframesandcontactlenses;eyeorhearingexams2,3;allothervisioncareservices;some foot treatment

•Cosmeticsurgery;hairprosthesisandtransplants;treatment for abnormal male breast enlargement

•Chargesthememberisnotlegallyrequiredtopay;chargesformissedappointments;surchargesforweekend nonemergency office visits and home visits byaphysician;treatmentrenderedbyamemberofthemember’sfamily;occupationalsicknessandinjury,except for members who are not covered by workers’ compensation or similar coverage and are not eligible for such coverage

•Normalpregnancy,electiveabortionsandroutinenurserycare,unlessmaternitybenefitsareselected;treatment for infertility, except for services related to the diagnosis of infertility, unless the Infertility Health BenefitsPackageisselected;surrogateparenting;reversal of sterilization

•Weightreduction3;smokingdeterrentmedications3;sextransformationoritsreversal;restorationorenhancementof sexual activity

•Mosttreatmentforsnoring;excessivesweating;phonophoresis;surfaceelectromyogram;therapeutic colddevices;x-raysortestsnotrelatedtodiagnosis or treatment of sickness or injury, unless otherwise specified

•Mostdietarysupplements3;experimental/investigationaldrugsortreatment;itemsforcomfortorconvenience;expensesatahealthspa;familyormarriagecounseling,aversion therapy, nonmedical self-care or self-help programs;custodialcare

•Suicide,attemptedsuicideorintentionalself-inflictedinjury,ifnottheresultofamedicalcondition;injuryresulting from one’s own illegal use of alcohol, drugs or over-the-counter medications

•Actsofwar;participationinariot;commissionof orattempttocommitafelony;engaginginan illegal occupation

Optional Infertility Health Benefits PackageNo benefits are payable under your self-funded plan design for the following expenses:

•Cryopreservation(freezing)orbankingofeggs,embryosorsperm;medicationsforsexualdysfunction;recruitment, selection and screening, and any other expensesofdonors;surrogateparenting;reversal of sterilization

1ReasonableandCustomaryFeeisthelesseroftheprovider’sactualcharge,orapercentageoftheMedicarereimbursementrateineffectatthetimeservices are provided.2IftheEnhancedHealthBenefitsPackageisselected,hearingaidsandroutineadulthearingandvisionscreeningsarecovered,subjecttoplanprovisions.3No benefits are payable under your self-funded plan design for these expenses, except as required under federal guidelines for preventive care.

©2014 Star Marketing and Administration, Inc. MK83-er (1-1-14) rev1

400FieldDrive•LakeForest,ILwww.starmarkinc.com

Self-funded plans are administered by Starmark®, and stop-loss insurance is provided by Trustmark Life Insurance Company.

Trustmark: An employee benefits company for more than 100 years

•TheTrustmarkCompaniesservemorethan2millioncoveredlivesorplanparticipants. •TrustmarkLifeInsuranceCompanyisratedA-(Excellent)byA.M.Best.

Starmark: Serving the healthcare benefit needs of employer groups for nearly 30 years

With expertise in group healthcare benefits, Starmark offers self-funded plan designs, tools to manage healthcare costs, paperless employee enrollment, nationwide network access and seamless HRA administration for small to mid-size businesses.

Our mission:

Helping people increase well-being through better health and greater financial security.

The information contained in this product brochure is a general description of features, benefits, requirements and restrictions of the self-funded benefit plan designs. More details are provided in the self-funded plan document, which is the prevailing document and the basis for benefit payment. Plan designs are subjecttochangetocomplywithfederalhealthcarereform,asnecessary.Plandesignavailabilityand/orstop-losscoveragemayvarybystate.Ifthestop-lossinsurance contract is terminated before the end of the contract period, the annual aggregate attachment point will be deemed not satisfied and the employer remains responsible for funding eligible claims incurred during the time the self-funded plan was in force. Subchapter S corporations should consult their tax advisorasbenefitsfromaself-fundedplanmaybetaxable.MyNurse24/7SMisaservicemarkofHealthFitnessCorporation,aTrustmarkCompany.