Benefits Focused on You!

Health and Welfare Benefits 2012 - 2013

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Benefit Basics

Elections you make now will remain in effect through December 31st, 2013

You can only make changes if there is a qualified “Life Event”

Changes must be made within 30 days of experiencing a qualifying event

Review benefits-make selections wisely

Designed to recognize diverse needs

Competitive and comprehensive benefits

Provides plans based on individual needs

Offer plans that provide long-term financial security for you and your family

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Qualifying Events Change in status including marital, employment,

number of dependents and residence

Dependent’s employer’s Open Enrollment

Significant cost or coverage changes

HIPAA special enrollment rights

FMLA special requirements

Changes due to a judgment, decree or court order

Entitlement to Medicare or Medicaid

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BENEFIT In-Network Out-of-Network

Annual Deductible

Single

Family

$1,000

$3,000

$2,000

$6,000

Out-of-Pocket Maximum

Single

Family

$2,500

$5,000

$4,000

$6,000

Office Visit (PCP/Specialist) $25 / $50 Copay 40% after deductible

Preventive Care

Well-Child/Adult Preventive Care

Mammograms/PAP Tests/Physicals

100%

100%

40% after deductible

40% after deductible

Emergency Room $200 Copay $200 Copay

Urgent Care $75 Copay 40% after deductible

Inpatient Hospital Services (Room/Board & Surgery)

20% after deductible 40% after deductible

Prescription Drugs

Retail (up to 31-day supply)

Generic

Preferred Brand

Non-Preferred Brand

Mail Order (up to 90-day supply)

Generic

Preferred Brand

Non-Preferred Brand

*NOTE: If you purchase prescription drugs from an out-of-network pharmacy, you are responsible for any difference between the out-of-network pharmacy charges and the amount paid for the same prescription drug dispensed by an in-network pharmacy.

$10

$30

$50

$25

$75

$125

$10

$30

$50

N/A

N/A

N/A

UHCMEDICAL

MONTHLY DEDUCTIONS

Employee $140.00

Employee & Spouse

$659.45

Employee & Child(ren)

$607.51

Family $1282.78

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The dental plan allows you to use any dentist you want, although there is a network that can be accessed for enhanced benefits.

Visit www.guardianlife.com to locate a participating dentist.

BENEFITGUARDIAN

(In Network)

GUARDIAN

(Out-of-Network)

Annual Deductible – Single Annual Deductible – Family

$25

$75

$50

$150

Preventive Treatment 100% 100%

Basic Treatment 100% 80%

Major Treatment 60% 50%

Orthodontia Not Available Not Available

Calendar Year Maximum Benefit

$2,500

GuardianDENTAL MONTHLY DEDUCTIONS

Employee $16.72

Employee & Spouse $67.27

Employee & Child(ren) $53.38

Family $103.93

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BENEFITGUARDIAN

(In Network)

GUARDIAN

(Out-of-Network)

Exams (every 12 months) $10 Copay $10 Copay

Glasses

Frames (every 24 months)

Single Vision Lenses (every 12 months)

Bifocal Lenses (every 12 months)

Trifocal Lenses (every 12 months)

Lenticular (every 12 months)

$120; 20% discount on amount over $120

$25 copay

$25 copay

$25 copay

$25 copay

Up to $47

Up to $47

Up to $66

Up to $85

Up to $125

Contacts (every 12 months)

Elective & Conventional

Medically Necessary

Up to $120

$25 copay

Up to $105

Up to $210

GuardianVISION MONTHLY DEDUCTIONS

Employee $7.06

Employee & Spouse $12.85

Employee & Child(ren) $12.59

Family $20.32

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BENEFIT COVERAGE

Short Term Disability Benefit begins on the 1st day of injury and 8th day of illness

The benefit pays 50% of your weekly base salary up to a maximum of $1,250 per week

Long Term Disability Benefit begins after 180 days of disability

The benefit pays 40% of your monthly base salary to a monthly maximum of $3,500

Disability (Short Term and Long Term) - Unum

ScripNet provides coverage for basic life, accidental death and dismemberment, short term and long term disability. Once you meet the eligibility requirements, you are automatically enrolled in these benefits at no cost to you.

Basic Life and AD&D - Unum

BENEFIT COVERAGE

Life Benefit 1 times your annual salary

Accidental Death and Dismemberment

1 times your annual salary

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Flexible Spending Accounts

Flexible Spending Accounts (FSA) allow you to set aside pre-tax money from each paycheck to reimburse yourself for eligible healthcare or dependent care expenses. Reimbursements can be requested by completing a claim form and providing proper documentation (e.g., pharmacy receipts, explanation of benefits [EOB]).

Other Company Benefits

•401(K) Savings Plan •AFLAC Benefits •Fitness Center Membership & Weight Programs

ACCOUNT USE FOR CONTRIBUTION

Health Care Spending Most medical, dental and vision care expenses (e.g., copayments, deductibles, eyeglasses)

$2,500 annual maximum

Dependent Care Spending

Dependent care expenses such as after-school programs and elder care programs

$5,000 annual maximum

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Need additional information?

Have a question about one of your benefits?

PLAN ADMINISTRATOR WEBSITE PHONE NUMBER

Medical Benefits UnitedHealthcare www.myuhc.com 866-633-2446

Dental Benefits Guardian www.guardianlife.com 888-600-1600

Vision Benefits Guardian www.guardianlife.com 888-600-1600

Life/AD&D Unum www.unumprovident.com 888-857-0157

Short Term Disability Unum www.unumprovident.com 888-857-0157

Long Term Disability Unum www.unumprovident.com 888-857-0157

Flexible Spending Accounts OptumHealth www.optumhealthfinancial.com 866-898-4584

Benefits Broker Willis www.willis.com 800-874-2244

If there is ever a question about one of these plans, or if there is a conflict between the information in this guide and the formal language of the plan documents, the formal wording in the plan documents will govern.

Please note that the benefits described in this guide may be changed at any time and do not represent a contractual obligation on the part of ScripNet, Inc.