2020Employee Benefits Guide

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2020 INSIDE THIS GUIDE

YOUR 2020 EMPLOYEE BENEFITS The Archdiocese of Galveston-Houston is proud to offer a comprehensive benefits package that can be

customized to meet the needs of you and your family. We are committed to promoting better health for our

Lay personnel and their eligible dependents. This means you have access to annual physicals, cancer

screenings, and more—all at no cost to you. Please review this guide and carefully consider your options so

that you can make the best choices for you and your dependents.

Have questions about your benefits? The Archdiocese of Galveston-Houston Benefits Help Line is here to

help! Simply call 855-664-8164 or email agh_benefits@ajg.com. Trained advocates are available to help

Monday through Friday, 7:00 AM to 6:00 PM CST.

The Summary of Benefits and Coverage (SBC) documents are located on the ADP portal. For hard copy

requests, please contact the Human Resources Department by calling 713-652-8265.

TABLE OF CONTENTS

What’s New for 2020? 2

2020 Employee Contributions 3

Eligibility and Annual Enrollment 4

How Do I Enroll? 5

The Benefits Help Line 6

Your Medical/Rx Benefits 7

Virtual Visits 10

BCBSTX Resources 11

Your Dental Benefits 12

Your Vision Benefits 13

Life and AD&D Benefits 14

Disability Benefits and FMLA 15

Additional Services from The Standard 16

Important Contact Information 18

If you or your dependents have Medicare or will become eligible for Medicare in the next 12

months, a Federal law gives you more choices about your prescription drug coverage. Please

see the separate legal disclosure booklet for more information.

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WHAT’S NEW FOR 2020?

IMPORTANT REMINDERS FREE PREVENTIVE CARE The Archdiocese of Galveston-Houston Medical Plans cover in-network preventive care at 100%. This means you can receive your annual physical, well woman exam, prostate exams, mammograms, immunizations, and other routine preventive services on an annual basis at no cost to you! Remember to ask your doctor if the services are classified as preventive—you may have to pay for services received during your visit if they are not classified as preventive.

MANDATORY MAIL ORDER If you take a prescription on an ongoing basis, you must fill your prescription through the mail order program. You may fill your prescription at a retail pharmacy for the first two months. For the third prescription, you must fill it through OptumRx Home Delivery.

QUESTIONS ABOUT YOUR BENEFITS? The Benefits Help Line is here to help!

The Archdiocese of Galveston-Houston Benefits Help Line is available to answer any questions you and your covered dependents may have. See page 6 for more details.

CALL: 855-664-8164 | EMAIL: agh_benefits@ajg.com

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MEDICAL & DENTAL COVERAGE Effective January 1, 2020, your medical and dental coverage will be administered by Blue Cross Blue Shield of Texas (BCBSTX). Your Archdiocese of Galveston-Houston Medical Plans will utilize the Blue Choice PPO Network. Some providers who participate in the Aetna network may not participate in the Blue Choice PPO Network. To verify whether or not your doctor will be in-network, you can navigate to www.bcbstx.com and click on “Find a Doctor or Hospital” to search BCBSTX’s provider directory. If you have questions about the transition to BCBSTX or whether or not your provider participates in the Blue Choice PPO Network, please contact the Benefits Help Line at 855-664-8164.

NEW ID CARDS You will soon receive a welcome packet from BCBSTX in the mail, which will include new medical and dental ID cards. OptumRx will continue to administer our prescription drug coverage in 2020; however, your new BCBSTX medical ID card will display your OptumRx pharmacy information. Please continue to use your current OptumRx ID card at the pharmacy for the remainder of 2019. Effective January 1, 2020, your new BCBSTX medical ID card will be the ONLY ID card you need. On or after January 1, 2020, your current OptumRx ID card will no longer be valid—you will need to have your new BCBSTX medical ID card ready to present at the doctors office or at the pharmacy when filling a prescription. If you have questions about these changes, please contact Human Resources.

VIRTUAL VISITS WITH MDLive Effective January 1, 2020, you will have access to virtual visits through MDLive. Whether you’re at home or traveling, access to a board-certified doctor is available 24 hours a day, 7 days a week via the BCBSTX Mobile App, online video, or telephone service. You can speak to a doctor immediately or schedule an appointment based on your availability. Please see page 10 for more details about this service.

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2020 2020 EMPLOYEE CONTRIBUTIONS

MEDICAL/Rx

COVERAGE TIER STANDARD PLAN ECONOMY PLAN

Biweekly Premium: Monthly Premium: Biweekly Premium: Monthly Premium:

Employee Only $0.00 $0.00 N/A N/A

Employee + Spouse $210.46 $456.00 $179.08 $388.00

Employee + Child(ren) $161.54 $350.00 $104.77 $227.00

Employee + Family $263.08 $570.00 $183.23 $397.00

DENTAL AND VISION DENTAL PLAN VISION PLAN

COVERAGE TIER Biweekly Premium: Monthly Premium: Biweekly Premium: Monthly Premium:

Employee Only $0.00 $0.00 $4.21 $9.13

Employee + One Dependent $25.22 $54.65 $6.08 $13.18

Employee + Family $42.04 $91.08 $11.72 $25.40

SUPPLEMENTAL LIFE INSURANCE EMPLOYEE COVERAGEEmployee Age Bracket <25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+

Monthly Premium Per $1,000 of Benefit

$0.042 $0.050 $0.067 $0.076 $0.084 $0.126 $0.194 $0.362 $0.555 $1.068 $2.060

DEPENDENT CHILD COVERAGE

Premium Per Family

Biweekly Premium: $0.57 Monthly Premium: $1.23

YOUR BENEFIT PREMIUMS BENEFIT WHO PAYS THE COST?

Medical & Prescription Drug Coverage Employee-Only Premium: The Archdiocese of Galveston-Houston

Premium for Dependent Coverage: You

Dental Coverage Employee-Only Premium: The Archdiocese of Galveston-Houston

Premium for Dependent Coverage: You

Vision Coverage You pay the full premium amount

Basic Life/AD&D Insurance The Archdiocese of Galveston-Houston pays the entire cost

Voluntary Life Insurance You pay the full premium amount

Short-Term Disability Insurance The Archdiocese of Galveston-Houston pays the entire cost

Long-Term Disability Insurance The Archdiocese of Galveston-Houston pays the entire cost

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ANNUAL ENROLLMENT 2020 Annual Enrollment will begin October 1 and end November 4, 2019. Any changes you make to your benefit elections during Annual Enrollment will become effective on January 1, 2020. To enroll or make changes, you must log on to the ADP web portal. For more details, please see page 5.

WHO IS ELIGIBLE FOR COVERAGE? EMPLOYEES All regular, full-time employees scheduled to work 30 hours or more per week are eligible to participate in the Archdiocese of Galveston-Houston benefit plans.

Clergy, Religious, School Teachers & Principals become eligible on the first of the month following or coinciding with date of hire.

Lay Persons become eligible on the first of the month following or coinciding with 60 days of employment.

New employees may choose to decline or opt-out of the Medical, Dental or Vision benefits on the enrollment form. Remember: new employees have 31 days from your date of hire to enroll in benefits.

DEPENDENTS For the purposes of coverage under the self-funded Archdiocese of Galveston-Houston Medical Plan, a spouse is defined as an individual of the opposite sex of the employee and to whom the employee is married.

Dependent children must be under age 26 to be eligible for coverage. Eligible dependent children include: Biological children and stepchildren; Legally adopted children, including a child for whom legal adoption proceedings have been initiated; Any child over the age of 26 who is handicapped and chiefly depends on you for support; Any child whose parent is your child and your child is covered as a dependent under the plan; and Any child for whom you have obtained legal guardianship or for whom benefits must be provided under a

Qualified Medical Child Support Order (QMCSO).

The Archdiocese of Galveston-Houston requires documentation to establish confirmation of dependent eligibility at any time. Please review the above eligibility criteria and ensure your dependents meet the definition of an eligible dependent. Dependents will not be enrolled in the plan without supporting documentation. If you have questions about the documentation required to confirm eligibility for your dependent(s), please contact Human Resources.

MAKING CHANGES DURING THE YEAR During each Annual Enrollment period, you will have the opportunity to review your benefit elections and make changes for the coming year. In most cases, the benefit elections you make during Annual Enrollment remain in effect for the entire plan year (January 1 — December 31), unless you experience a Qualifying Life Event (QLE). If you have a QLE, you may make limited changes to your benefit elections. Qualifying Life Events include:

Marriage, divorce or death of your spouse;

Birth, adoption, or placement for adoption of an eligible child;

A change in residence or work status that affects your or your spouse’s coverage eligibility;

A significant change in your spouse’s health coverage attributable to your spouse’s employment;

A change in your child’s eligibility for benefits, or death of a child; and

A change in your eligibility for Medicare or Medicaid during the year.

The change to your benefit elections must be consistent with the Qualifying Life Event. You have 31 days from the date of the Qualifying Life Event to submit your benefit election changes. Please note that supporting documentation for Qualifying Life Events is required. Otherwise, you must wait until the next Annual Enrollment period to make a change to your elections.

ELIGIBILITY & ANNUAL ENROLLMENT

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2020

ADP ONLINE ENROLLMENT INSTRUCTIONS You must make your benefit elections online using the ADP web portal. To access the ADP web portal and start your enrollment, simply follow the instructions below:

1. LOG ON Log on to the ADP web portal at www.workforcenow.adp.com - You may want to save this link as an internet favorite.

Enter in your User ID and Password then click on LOGIN. If you forgot your User ID or Password, click on “Forgot Your User ID/Password?”

2. START YOUR ENROLLMENT Once logged in, you will see a pop-up screen that will show you important information about this Open Enrollment

period. This pop-up screen will continue to appear each time you log in until you complete your enrollment. Click Start This Enrollment. Review your current benefits then begin your enrollment process – click on Enroll Now.

After reading the Welcome Message – click Continue. If you close out of this screen and want to get back in later, you can do so by going to Myself > Benefits > Enrollments

and click on Start or Resume.

3. REVIEW YOUR CURRENT BENEFITS Review your current benefits — to move between benefit plan categories, click on the plan name located to the left of

the screen, or click on Continue To Next Benefit, which is located at the bottom of the screen.

If applicable, review your Dependent(s): ○ To add a dependent, click on Manage Dependents then click the Add Dependent button. ○ To view dependent information, click on a dependent’s name. You are only able to view existing dependents.

If a change to their information is required please call the Benefits Hotline at 713-652-2865.

4. MAKE YOUR BENEFIT ELECTIONS To elect Medical, Dental and/or Vision coverages, select the Plan and if applicable, your Dependents who are to be

enrolled in the coverage. Once you complete the Medical, click on Continue To Next Benefit.

To elect or increase Employee Supplemental Life Insurance, click on Select Plan and select the amount you want. If electing new coverage or increasing your existing coverage amount, you must complete an Evidence of Insurability (EOI) Form, which can be found by clicking on the (i) icon in this section, and submit your completed form to Human Resources. Note that coverage will not become effective until and unless approved by The Standard.

To elect Supplemental Child Life Insurance, you must have Employee Supplemental Life coverage. To elect coverage for your child(ren), click on Enroll in Plan and enroll your dependent(s). Please note that if you were previously eligible but did not enroll, you were previously denied coverage, or you are applying for an increase in current coverage, Evidence of Insurability (EOI) is required. Coverage will not become effective until and unless approved by the Standard.

If you want to un-enroll from any of these plans, click Waive This Benefit and select Waive Reason.

5. REVIEW & COMPLETE YOUR ENROLLMENT Once you have made all of your selections, review your benefits selections and then click on Submit Enrollments to

finish your enrollment. Make sure to print a copy of your Final Benefits Summary when finished.

Please note that Supplemental Spouse Life is no longer available. If you currently have coverage for your spouse, it is grandfathered; however, if you choose to drop the coverage, you will not be able to elect it again.

HOW DO I ENROLL?

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THE ARCHDIOCESE OF

GALVESTON-HOUSTON

BENEFITS HELP LINE IS

HERE FOR YOU & YOUR

DEPENDENTS

QUESTIONS ABOUT YOUR BENEFITS? CONTACT THE BENEFITS HELP LINE! You have a busy life. With so much going on, it can be difficult to slow down and focus on the small details. Who can you turn to when you need help understanding your benefits? The Archdiocese of Galveston-Houston Benefits Help Line is available to answer your questions and address any issues. When you call or email the Help Line, an experienced benefits advocate will be ready to help. Below are examples of the many ways the Archdiocese of Galveston-Houston Benefits Help Line can assist you and your dependents:

Explain your plan options and answer enrollment questions

Call 1-855-664-8164 or email agh_benefits@ajg.com Monday - Friday, 7:00 AM - 6:00 PM (CST)

Help you understand your claims

Find an in-network doctor, facility or pharmacy

Answer questions about covered services and expenses

Clarify benefits eligibility

Request replacement benefit ID cards

THE BENEFITS HELP LINE

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2020 YOUR MEDICAL/Rx BENEFITS

THINK HEALTHY, LIVE WELL Effective January 1, 2020, our medical coverage will be administered by Blue Cross Blue Shield of Texas (BCBSTX), utilizing the Blue Choice PPO Network. The Archdiocese of Galveston-Houston pays 100% of the “employee only” premium for all eligible employees. If you have eligible dependents, you pay a premium for dependent coverage (see page 3). Employees choosing “employee only” coverage are enrolled in the Standard Plan. Employees who wish to cover their eligible dependents have two plan options from which to choose: the Standard Plan and the Economy Plan.

CHOOSING THE RIGHT PLAN The best Medical coverage for you depends on a number of factors:

What are your anticipated medical expenses for next year?

How much will you have to pay toward these expenses in deductibles, copays and monthly payroll deductions?

What is the most you could afford to pay out-of-pocket?

Do you have additional coverage elsewhere?

While both plan options offer choice and savings through the Blue Choice PPO Network, each reflects different levels of cost and coverage. We encourage you to review both options available to you and select the plan that best meets you and your family’s needs. Please note that this guide provides a summary of your coverage options and is not a complete list of benefits. For more detailed information about your benefits and coverage, refer to the plan documents, which can be obtained on the AGH website or by contacting Human Resources.

FINDING AN IN-NETWORK PROVIDER With a PPO plan, you have the ability to see the doctor of your choice. However, you will pay less out-of-pocket if you choose physicians, hospitals, and other healthcare providers within the Blue Choice PPO Network. If you choose to go to an out-of-network provider, your financial responsibility will be greater, and you may have to file your own claims. To find an in-network provider, go to www.bcbstx.com and click on “Find a Doctor or Hospital” or contact the Benefits Help Line by emailing agh_benefits@ajg.com or call 1-855-664-8164.

LABCORP Using LabCorp for all of your lab work is a smart and easy way to save at your doctor’s visit. With your BCBSTX plan, you can save on blood work and other lab services by making sure your testing is performed by LabCorp. Here’s how to guarantee you receive the best benefit for your lab work:

If your doctor collects your sample in the office: ask your doctor to send your labs to LabCorp.

If your doctor sends you outside the office to collect your sample: ask your doctor for a LabCorp requisition form.

Finding a LabCorp location near you is easy! Simply visit www.bcbstx.com and click on “Find a Doctor or Hospital” or contact the Benefits Help Line by emailing agh_benefits@ajg.com or call 1-855-664-8164.

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YOUR MEDICAL/Rx BENEFITS

STANDARD PLAN ECONOMY PLAN BCBSTX BLUE CHOICE NEWTORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK

Annual Deductible Individual / Family

$800 / $1,600 $1,600 / $3,200 $1,200 / $2,400 $2,400 / $4,800

Annual Out-of-Pocket Limit Includes deductible and copays

Individual / Family $3,300 / $6,600 $6,000 / $12,000 $7,000 / $14,000 $12,000 / $24,000

Annual Benefit Maximum Unlimited Unlimited

Coinsurance Your share of the costs of covered services 20% after deductible 50% after deductible 30% after deductible 50% after deductible

COVERED SERVICES IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK

Physician Office Visit (OV) Primary Care Physician Specialist

$25 copay per visit $40 copay per visit

50% after deductible 50% after deductible

$35 copay per visit $50 copay per visit

50% after deductible 50% after deductible

Preventive Care No charge 50% after deductible No charge 50% after deductible

MDLive Virtual Visit $25 copay per visit N/A $35 copay per visit N/A

Urgent Care $40 copay per visit 50% after deductible $40 copay per visit 50% after deductible

Inpatient Hospital Care 20% after deductible 50% after deductible 30% after deductible 50% after deductible

Outpatient Surgery 20% after deductible 50% after deductible 30% after deductible 50% after deductible

Emergency Room Services Only for true emergencies based on diagnosis

$170 copay per visit $170 copay per visit $230 copay per visit $230 copay per visit

LABS, TESTS & IMAGING IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK

Diagnostic Tests X-ray, labs, blood work

No charge for labs at LabCorp ONLY*;

$25 copay per x-ray 50% after deductible

No charge for labs at LabCorp ONLY*;

$35 copay per x-ray 50% after deductible

Imaging MRI, CT/PET Scan

20% after deductible 50% after deductible 30% after deductible 50% after deductible

PHARMACY IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK

Retail Pharmacy Generic Preferred Brand** Non-Preferred Brand**

For a 30-day supply: $10 copay $50 copay $75 copay

For a 30-day supply: 50% after $10 copay 50% after $50 copay 50% after $75 copay

For a 30-day supply: $10 copay $55 copay $80 copay

For a 30-day supply: 50% after $10 copay 50% after $55 copay 50% after $80 copay

OptumRx Home Delivery Generic Preferred Brand** Non-Preferred Brand**

For a 90-day supply: $5 copay

$95 copay $145 copay

Out-of-network mail order not covered

For a 90-day supply: $5 copay

$105 copay $155 copay

Out-of-network mail order not covered

* $0 copay for lab services and blood work at LabCorp facilities ONLY. Ask your doctor to only use LabCorp for your lab needs in order to receive the greatest benefit. For more details, please see page 7. **For certain preferred brand and non-preferred brand drugs, you may be required to try a generic equivalent first. For more details, please see page 9.

The guide on this page is a summary of covered services and is not a complete list of benefits. For comprehensive information about the benefits covered under these plans, please refer to the Summary Plan Description.

The Archdiocese of Galveston-Houston believes its Medical and Pharmacy Plan as described in this guide is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (PPACA). As permitted by PPACA, a grandfathered health plan must preserve certain basic health coverage that was already in the Plan when that law was enacted. Being a grandfathered health plan means that your Plan may not include certain consumer protections (health and pharmaceutical coverages) of PPACA that apply to other (non-grandfathered) plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, the grandfathered plans must comply with certain other consumer protections in PPACA, for example, the elimination of lifetime limits on benefits. As a grandfathered plan, this Plan, self-funded by the Archdiocese of Galveston-Houston, does not provide medical and pharmaceutical coverage that contravenes with Catholic teachings. Questions regarding which protections (Medical and Pharmaceutical coverages) apply and which protections (Medical and Pharmaceutical coverages) do not apply to our grandfathered health plan status can be directed to the plan administrator, Charlie Pavlovsky, at 713-652-8261.

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2020 YOUR MEDICAL/Rx BENEFITS

YOUR PRESCRIPTION DRUG BENEFITS MANDATORY MAIL ORDER Do you take medicine every day for diabetes, asthma or another condition? These are called maintenance medications. Maintenance medications filled at a retail pharmacy that require more than two refills will be subject to mandatory mail order. You may fill your prescription at a retail pharmacy for the first two months, but the third prescription must go to OptumRx Home Delivery. Home delivery is a fast and convenient way to get the medications you need.

Save money — You will incur fewer copays when you order a 90-day supply, and there is no extra shipping charge for mail order prescriptions — standard shipping is always free.

Get more — You can get up to a 90-day supply of your medication instead of the 30-day supply you’d ordinarily receive from a retail pharmacy.

Save time — Refill your prescriptions just once every three months, with no trip to the pharmacy necessary. You can re-order online, by phone or by mail.

Don’t worry — Registered pharmacists check all orders for accuracy. Your medication is securely packed, then mailed quickly to you. If you have an emergency, you can call our pharmacists at any time.

Get started with OptumRx Home Delivery by visiting www.optumrx.com or call 1-855-524-0381.

STEP THERAPY PROGRAM The Step Therapy Program encourages safe and cost-effective medication use. The program is designed to keep members safe and save money when possible. To receive coverage for certain medications, you may need to first try a proven, generic equivalent medication before using a more costly treatment, if needed. For a complete list of drugs covered by your plan, as well as a list of Step Therapy drugs, visit www.optumrx.com.

GENERIC DRUGS Both prescription and over-the-counter generic drugs can be less costly than brand name drugs. You can save on your out-of-pocket costs by choosing generic medications. Brand and generic drugs are regulated by the FDA and are chemically and medically the same. However, generic drugs tend to cost significantly less than their brand name equivalent! Talk to your doctor to find out if generic drugs are right for you.

OPTUMRx MEMBER WEBSITE AND MOBILE APP The OptumRx member website and mobile app give you the tools you need to save time and money while staying healthy. When you register at www.optumrx.com and open an account, you gain access to the most convenient way to manage your prescriptions.

Simple — Easily refill a medication or transfer a retail prescription to home delivery.

Current — Access the most current drug coverage information as well as the nearest in-network retail pharmacy.

Personalized — Access a complete profile of your prescriptions via your Medicine Cabinet, which displays all of your recent and past prescriptions.

Save time & money — Compare potential cost savings and identify prescription drug options.

To register, visit www.optumrx.com or download the OptumRx Mobile App from the App Store or Google Play. Select the “Register Now” button to begin your registration. Make sure you have your OptumRx ID card ready.

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VIRTUAL VISITS

GET CARE WHEN & WHERE YOU NEED IT MDLive provides you and your covered dependents with access to

board-certified doctors anytime and anywhere it’s most

convenient for you—at home, work, or on the go. MDLive has the

nation’s largest telehealth network of doctors ready to provide

convenient, quality care by phone or secure video. Doctors can

diagnose a wide range of non-emergency medical issues and even

send prescribed medications to your pharmacy of choice. MDLive

physicians can treat the following:

On the Standard Plan: $25 copay per visit

On the Economy Plan: $35 copay per visit

Flu

Allergies

Cough

Sore throat

Fever

Headache

Nausea/ vomiting

Pink eye

Rash

Ear problems

UTI

To register, go to www.mdlive.com/bcbstx. Enter your first and

last name, date of birth and BCBSTX member ID number. Once

you have an account, you can browse doctor profiles, view

available appointment times and schedule an appointment

with the doctor of your choice.

ONLINE: www.mdlive.com/bcbstx

PHONE: 888-680-8646

MOBILE APP: www.mdlive.com/getapp

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2020 BCBSTX RESOURCES

BLUE ACCESS FOR MEMBERS Get information about your health benefits anytime, anywhere. Use your computer, phone or tablet to access the Blue Cross Blue Shield of Texas (BCBSTX) secure member website, Blue Access for Members. With Blue Access for members, you can:

PROVIDER FINDER Locate a doctor, hospital, facility or pharmacy in the Blue Choice PPO Network.

ID CARDS Request a new ID card—or print a temporary one.

WELLNESS TOOLS & RESOURCES Access handy tools like Well onTarget, which has fitness trackers, food diaries and more.

CLAIMS View or print Explanation of Benefits statements, and check the status or history of a claim.

MY COVERAGE See your benefits at a glance or in detail.

CUSTOMER SERVICE Use secure messaging to get in touch with helpful customer service representatives.

IT’S EASY TO GET STARTED

1. Go to www.bcbstx.com/member

2. Click Sign Up or Log In, then click Register Now.

3. Use the information on your BCBSTX ID card to complete your registration.

STAY CONNECTED WITH THE BCBSTX MOBILE APP Many of the services and resources available through Blue Access for

Members can also be found right in the palm of your hand. With the

BCBSTX Mobile App, you can access your important health plan

information wherever you are! Text* BCBSTXAPP to 33633 to get the

app, or download it directly from the App Store or Google Play.

*Message and data rates may apply. Terms and conditions and privacy policy at bcbstx.com/mobile/text-messaging.

24/7 NURSELINE Health happens—good or bad, 24 hours a day, 7 days a week. That is why BCBSTX has registered nurses waiting to talk

to you whenever you call the 24/7 Nurseline. Registered nurses are available to answer your health questions and try

to help you decide whether you should go to the emergency room or urgent care center or make an appointment with

your doctor. You can also call the 24/7 Nurseline whenever you or your covered family members need answers to

health questions about:

Plus when you call, you can access an audio library of more than 1,000 health topics—from allergies to surgeries—with

more than 500 topics available in Spanish. Call the 24/7 Nurseline anytime at 800-581-0393.

Asthma

Dizziness or severe headaches

Cuts or burns

Back pain

High fever

Sore throat

Diabetes

A baby’s nonstop crying

And much more!

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YOUR DENTAL BENEFITS

DENTAL BENEFITS

BCBSTX DENTAL PPO NETWORK IN-NETWORK & OUT-OF-NETWORK

Annual Deductible Individual / Family

$50 / $150

Annual Benefit Maximum $1,500 per individual

COVERED SERVICES

Preventive Services Exams, cleanings, fluoride treatments, sealants, bitewing x-rays

No charge; deductible waived

Basic Services Oral surgery, periodontics, endodontics, root canal

You pay 20% after deductible

Major Services Inlays, onlays, crowns, prosthodontics You pay 50% after deductible

ORTHODONTIC SERVICES

Eligibility Adults and dependent children up to age 19

Lifetime Orthodontic Deductible $50 per individual

Orthodontic Services & Treatment You pay 50% after orthodontic deductible

Lifetime Benefit Maximum $1,500 per individual

MORE REASONS TO SMILE Effective January 1, 2020, our Dental Plan will be administered by Blue Cross Blue Shield of Texas (BCBSTX). The BCBSTX Dental Network makes it easy to protect your health—and your smile—with the right dental care at the right price. Your Dental Plan gives you the ability to choose a dentist from one large network directory that is easily accessible and searchable online at www.bcbstx.com.

HOW YOUR PLAN WORKS With your Dental PPO Plan, you can visit any dentist you want, and you never need a referral. However, in-network dentists have agreed to offer certain services at a negotiated rate. By visiting an in-network dentist, you will generally pay less out-of-pocket. To see if your dentist is in-network, visit www.bcbstx.com or contact the Benefits Help Line at 855-664-8164.

OUT-OF-NETWORK CLAIMS If you choose an out-of-network dentist, your dentist may bill you for the difference between his or her normal fee and BCBSTX’s “recognized charge.” Additionally, you must file your own claim to be reimbursed for out-of-network services. You can find the claim form and instructions posted under the Forms section of the Archdiocese of Galveston-Houston Human Resources website.

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2020 YOUR VISION BENEFITS

SEE CLEARLY WITH VISION COVERAGE The Archdiocese of Galveston-Houston Vision Plan will be administered through VSP. Vision benefits are just as important as Medical and Dental coverage. Regular eye exams are important for overall health and can identify both vision and major medical conditions such as diabetes and high blood pressure. Early detection of eye diseases like glaucoma, cataracts and macular degeneration is also important, as these conditions can affect the way you see.

HOW YOUR PLAN WORKS With your Vision Plan, you and your covered dependents have access to quality vision care. Your plan covers yearly eye exams, glasses, and contact lenses. Although you can see any eye doctor you choose, you’ll save the most money if you choose an eye doctor from VSP’s extensive network of providers. Your Vision Plan also offers special pricing for LASIK and PRK correction procedures from contracted providers. To see if your eye doctor is in the VSP network, or to see a list of contracted LASIK and PRK correction providers, visit www.vsp.com or call 1-800-877-7195.

VISION BENEFITS

VSP VISION NETWORK IN-NETWORK OUT-OF-NETWORK

Copayments WellVision Exam Prescription Glasses Contact Lenses

$20 copay $20 copay $0 copay

N/A N/A N/A

Examination Covered 100% after copay Reimbursed up to $50

Lenses Single Vision Lined Bifocal Lined Trifocal

Covered 100% after copay Covered 100% after copay Covered 100% after copay

Reimbursed up to $50 Reimbursed up to $75

Reimbursed up to $100

Frames $150—$170 allowance* 20% savings on amount over allowance

Reimbursed up to $70

Elective Contact Lenses $150 allowance Applies to contacts and exam (fitting & evaluation)

Reimbursed up to $105

Benefit Frequency Examination Lenses OR Contact Lenses Frames

Once every 12 months Once every 12 months Once every 12 months

*$150 allowance for a wide selection of frames, $170 allowance for featured frame brands, $80 Costco frame allowance.

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LIFE AND AD&D BENEFITS

BASIC LIFE AND AD&D INSURANCE Life Insurance provides financial security for the people who depend on you. Basic Life and Accidental Death & Dismemberment (AD&D) Insurance, administered through The Standard, is provided for all benefit-eligible employees of the Archdiocese of Galveston-Houston at no cost to you. Should you pass away while employed by the Archdiocese of Galveston-Houston your beneficiaries will receive a benefit as described in the table below. AD&D benefits are paid in addition to any Life benefit if you die or become seriously injured or disabled as a result of an accident.

SUPPLEMENTAL LIFE INSURANCE In addition to the Basic Life and AD&D Insurance provided by the Archdiocese of Galveston-Houston, you can purchase Supplemental Life Insurance for yourself. If you purchase Supplemental Life Insurance for yourself, you are also eligible to purchase Supplemental Life Insurance for your eligible dependent child(ren). Effective January 1, 2016, Spouse Supplemental Life Insurance is no longer offered. However, those spouses who are currently covered under the Spousal Life benefit are grandfathered, and rates will match the Employee rates listed on page 3 of this guide. You can choose how much coverage you and your dependent child(ren) need; however, certain elections may require Evidence of Insurability (EOI).

EVIDENCE OF INSURABILITY REQUIREMENTS Any coverage amount requiring EOI will not become effective until approved by The Standard. EOI will be required for any increase in current coverage requested. For initial coverage, EOI is required if you (1) enroll more than 31 days after the date you are first eligible to enroll, or (2) were previously eligible for coverage but did not enroll. For more information, please refer to your policy or contact the Benefits Help Line at 855-664-8164.

BASIC LIFE/AD&D BENEFITS

EMPLOYEE BENEFIT BENEFIT DESCRIPTION

Lay & Religious Employees Benefit Amount Maximum Benefit Amount

1.5x your annual earnings

$50,000

Active Seminarians $5,000

Age Reduction Schedule Benefit reduces on January 1st following the date you attain age 65 and age 70

Benefit will reduce to 67% at age 65 and to 50% at age 70

SUPPLEMENTAL LIFE BENEFITS

EMPLOYEE BENEFIT BENEFIT DESCRIPTION

Lay & Religious Employees Benefit Amount Maximum Benefit Amount

Increments of $25,000

Lesser of $100,000 or 5x your annual earnings

Age Reduction Schedule Benefits reduce on the first of the month following the date of the change. Benefits will reduce to the noted percentage, rounded to the next higher multiple of $500, if not already a multiple of $500.

Benefit will reduce to 67% at age 65 and to 50% at age 70

DEPENDENT CHILD BENEFIT BENEFIT DESCRIPTION

Benefit Amount Live birth — age 26

$10,000

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2020

SHORT-TERM & LONG-TERM DISABILITY The Archdiocese of Galveston-Houston provides Disability Insurance through The Standard for all eligible, full-time employees at no cost to you. In the event of a covered disability, Short-Term Disability (STD) Insurance replaces a portion of your weekly salary, and Long-Term Disability (LTD) Insurance replaces a portion of your monthly salary.

A disability is caused by a sickness or injury (non-work related). Based on your condition, your doctor will determine how long you will be expected to be unable to work. In order to receive benefits, your doctor must submit a claim form to certify your disability. Remember: you may have sick days, vacation or PTO days you can use during the elimination period (i.e. the time you must wait before you can begin to receive benefits). Your health benefits will continue while on STD. Once an employee qualifies for LTD, health insurance and employment are terminated.

LEAVES OF ABSENCE If you need to take a leave of absence from work, you can rest assured that you have protection. The Standard will administer all leave requests for any of the following reasons:

Please contact The Standard 30 days prior to the last day you plan to work before taking your leave. If a sudden event results in an unscheduled leave, please call The Standard as soon as possible.

DISABILITY BENEFITS

SHORT-TERM DISABILITY (STD) BENEFIT DESCRIPTION

Weekly Benefit Percentage Maximum Weekly Benefit

60% of Pre-Disability Weekly Salary $1,000

Waiting Period 14-day elimination period

Maximum Benefit Duration 12 weeks

LONG-TERM DISABILITY (LTD) BENEFIT DESCRIPTION

Monthly Benefit Percentage Maximum Monthly Benefit

60% of Pre-Disability Monthly Salary $8,500

Waiting Period Later of 90 days or the end of the STD maximum benefit duration

Maximum Benefit Duration Until you are no longer considered disabled or you reach Social Security

Normal Retirement Age, whichever comes first

DISABILITY AND FMLA

Your own serious health condition;

Caring for an immediate family member with a serious health condition;

The birth of a son or daughter;

Time to bond with a newborn or newly placed (adoption or foster care) son or daughter;

For qualifying exigency when an immediate family member is a military member on covered active duty, or he/she has been notified of an impending call or order to covered active duty status; or

To care for a covered military service member with a serious injury or illness, to whom you are an immediate family member or next of kin.

NEED TO FILE A DISABILITY CLAIM OR REQUEST A LEAVE OF ABSENCE?

www.standard.com/absence 1-833-229-4173

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EMPLOYEE ASSISTANCE PROGRAM You, your dependents (including children up to age 26) and all household members can contact master’s-degreed clinicians 24/7 by phone, online, live chat, email and text. There’s even a mobile app for assistance on the go. Receive referrals to support groups, a network counselor, community resources or your health plan. If necessary, you’ll be connected to emergency services.

Your Employee Assistance Program (EAP) includes up to three (3) face-to-face counseling sessions per issue. Through the EAP, assistance is immediate, personal, and available when you need it. EAP services can help with:

To take advantage of the services available to you through your EAP, call 888-293-6948 (TTY 800-327-1833) or visit www.workhealthlife.com/Standard3 to explore a wealth of information online, including videos, guides, articles, webinars, resources, self-assessments and calculators. Morneau Shepell is the EAP vendor that The Standard utilizes for Archdiocese of Galveston-Houston members.

TRAVEL ASSISTANCE Things can happen on the road. Passports get stolen or lost. Unforeseen events or circumstances derail travel plans. Medical problems surface at the most inconvenient times. Travel Assistance can help you navigate these issues and more at any time of the day or night. Travel Assistance is available when you travel more than 100 miles from home or internationally for up to 180 days for business or leisure. It offers aid both before and during your trip, including:

United States, Canada, Puerto Rico, U.S. Virgin Islands and Bermuda: call 1-866-455-9188 Everywhere else: call +1-240-330-1380 www.standard.com/travel

ADDITIONAL SERVICES FROM THE STANDARD

Depression, grief, loss, and emotional well-being

Family and relationship issues

Life improvement and goal setting

Addictions and substance abuse

Stress or anxiety with work or family

Financial and legal concerns

Identity theft and fraud resolution

Online will preparation

Passport, visa, weather and currency exchange information, health hazards advice and inoculation requirements

Emergency ticket, credit card and passport replacement, funds transfer and missing baggage

24/7/365 phone access to registered nurses for health and medication information, symptom decision support, and help understanding treatment options

Emergency evacuation to the nearest adequate medical facility and medically necessary repatriation to the employee’s home, including repatriation of remains

Connection to medical care providers, interpreter services, a local attorney, consular office or bail bond services

Return travel companion if travel is disrupted due to emergency transportation services or return dependent children if left unattended due to prolonged hospitalization

Logistical arrangements for ground transportation, housing and/or evacuation in the event of political unrest and social instability; for more complex situation, assists with making arrangements with providers of specialized security services

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2020 ADDITIONAL SERVICES FROM THE STANDARD

THE LIFE SERVICES TOOLKIT Coverage under a group Life insurance policy from The Standard does more than help protect your family from financial hardship after a loss. The Standard offers a lineup of additional services that can make a difference now and in the future. Online tools and services can help you create a will, make advance funeral plans, and put your finances in order. After a loss, your beneficiary can consult experts by phone or in person, and obtain other helpful information online.

SERVICES TO HELP YOU NOW Estate Planning Assistance

Online tools, found in the Legal Forms section, walk you through the steps to prepare a will and create other documents such as living wills, powers of attorney and health care agent forms.

Financial Planning Consult online services to help you manage debt, calculate mortgage and loan payments, and take care of other financial matters with confidence.

Health and Wellness Timely articles about nutrition, stress management and wellness help employees and their families lead healthy lives.

Identity Theft Prevention Check the website for ways to thwart identity thieves and resolve issues if identity theft occurs.

Funeral Arrangements Use the website to calculate funeral costs, find funeral-related services and make decisions about funeral arrangements in advance.

SERVICES TO HELP YOUR BENEFICIARY Grief Support

Clinicians with master’s degrees are on call to provide confidential grief counseling sessions by phone or in person. Your beneficiaries are eligible for up to six (6) face-to-face sessions and unlimited phone contact.

Legal Services Obtain an estate planning package that consists of a simple will, a living will, a health care agent form and a durable power of attorney. Beneficiaries who choose to retain a participating attorney after an initial consultation receive a 25% discount on normal rates.

Financial Assistance Your beneficiaries will have unlimited phone access to financial counselors who can help with issues such as budgeting, credit and debt management and more.

Support Services During an emotional time, your beneficiaries can receive help planning a funeral or memorial service. Work-life advisors can guide them to resources to help manage household repairs and chores, find child care and elder care providers, or organize a move or relocation.

To access the Life Services Toolkit, please visit www.standard.com/mytoolkit (username=assurance) or call 800.378.5742.

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BENEFIT VENDOR PHONE / WEBSITE

HUMAN RESOURCES Archdiocese of

Galveston-Houston 713.652.8265

www.archgh.org

MEDICAL Blue Cross Blue Shield

of Texas (BCBSTX)

800.521.2227 www.bcbstx.com

Group Number: 274679

PRESCRIPTION DRUGS OptumRx 1.855.524.0381

www.optumrx.com

VIRTUAL VISITS MDLive 888.680.8646

www.mdlive.com/bcbstx

NURSELINE Blue Cross Blue Shield

of Texas (BCBSTX) 800.581.0393

Registered nurses available 24/7, 365 days a year

DENTAL Blue Cross Blue Shield

of Texas (BCBSTX)

800.521.2227 www.bcbstx.com

Group Number: 274852

VISION VSP 1.800.877.7195 www.vsp.com

Group Number: 12001362

LIFE AND AD&D The Standard 1.833.229.4173

www.standard.com Group Number: 756955

DISABILITY AND LEAVE MANAGEMENT

The Standard 1.833.229.4173

www.standard.com/absence Group Number: 756955

EMPLOYEE ASSISTANCE PROGRAM

The Standard (Morneau Shepell)

888.293.6948 TTY: 800.327.1833

www.workhealthlife.com/Standard3 Group Number: 756955

TRAVEL ASSISTANCE The Standard

www.standard.com/travel ops@gga-usa.com

USA, Canada, Puerto Rico, U.S. Virgin Islands, and Bermuda: 1.866.455.9188

Everywhere else: +1.240.330.1380 Group Number: D2STD

Activation Code: 181002

LIFE SERVICES TOOLKIT The Standard 800.378.5742

www.standard.com/mytoolkit Username: assurance

THE ARCHDIOCESE OF GALVESTON-HOUSTON BENEFITS HELP LINE

Need additional help with a claim or understanding your benefits? The Archdiocese of Galveston-Houston Benefits Help Line is available to help! A trained advocate can assist with any questions you and your dependents may have about your benefits.

Call 1-855-664-8164 or email agh_benefits@ajg.com

IMPORTANT CONTACT INFORMATION

This Benefits Guide is intended only to highlight your benefits and should not be relied upon to fully determine your coverage. If the information contained in this guide conflicts in any way with the Summary Plan Description

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

This benefit guide prepared by