Enrollment Information as of 11/1/2017 for:

Employee Name

HEALTH

COVERAGE

Health Plan:

Health Coverage:

Premium Status:

POS Plan

Emp., Spouse & Child(ren)

After Tax

DENTAL

COVERAGE

Coverage:

Premium Status:

Individual Coverage

After Tax Human Resources

Annual Benefits Enrollment VISION

INSURANCE

Vision Plan:

Vision Coverage:

Premium Status

Enhanced Plan

Individual Coverage

After Tax

October 27, 2017

SECTION

125/FSA

Health Care: Dependent Care

Not Participating Not Participating

Name

Address

City, State Zip

LIFE

INSURANCE

Optional Life:

Dependent Life:

4x salary ($500,000)

$20,000

DISABILITY

INSURANCE Optional STD:

Optional LTD: Not Enrolled

Not Enrolled

AD&D Coverage: Individual, $300,000

UA Announces Health, Dental & Vision Open Enrollment 11/1/2017-11/30/2017 NO LATE ENROLLEMENTS ACCEPTED – all changes must be completed by 11/30/2017

During Open Enrollment, you may:

Enroll in Flexible Spending Accounts (Health Care Reimbursement & Dependent Care Reimbursement). Annual enrollment required.

Enroll in a Health Savings Account (only if you enroll in the Health Savings Plan).

Enroll in or cancel health, dental and vision coverage. No annual re-enrollment required.

Change your health election among the Classic Plan, Health Savings Plan & the Premier Plan.

Add or delete dependents from health, dental or vision.

Change your vision election between Basic & Enhanced.

Change the status of health, dental & vision premiums between after-tax and pre-tax.

Enroll in Identity Theft or Legal Insurance.

All Open Enrollment changes are effective 1/1/2018.

How do I enroll or make changes?

Enrollments and changes to Flexible Spending and Health, Dental and Vision Insurance can be done on line via webBASIS.

Go to webBASIS.uark.edu & log in using your UARK ID & password.

If you will be covering dependents go to My Benefits, then Spouse/Dependents (for Benefits) to view your current dependents and add new dependents.

Go to My Benefits, then Annual Benefits Enrollment to make your enrollment changes.

Remember, you can only enroll in an HSA if you enroll in the Health Savings Plan

You must Validate and Save before your

transaction is finalized.

Send Dependent Documentation & the Dependent Verification Form to HR, fax 479-575-6971 or email to hrbenf@uark.edu.

Forms to make Open Enrollment changes are also available from HR’s website, http://hr.uark.edu (go to Open Enrollment under HR News 2017) and from Human Resources, 222 ADMN. Do not complete paper forms if you make your changes on webBASIS.

Contact HR at 479-575-5351 or hrbenf@uark.edu for questions.

Summary of Changes Effective 1/1/2018

Health Plan Changes:

Two new health plans, Health Savings Plan and Premier Plan added. See pages 2 & 7 for details & page 6 for premiums.

Classic Plan retained with no premium increase.

Point of Service (POS) Plan ends 12/31/2017.

POS participants will transfer to the Classic Plan unless Health Savings Plan or Premier Plan elected.

Changes to the Classic Plan:

Specialist & Urgent Care copays

increase from $50 to $55.

Prescription copayments will be Tier 1 $15 (no change), Tier 2 $55 (from $50) and Tier 3 $90 (from $80),

Dental Coverage Changes:

Provider changes from Delta Dental to

Arkansas Blue Cross and Blue Shield.

No change to coverage & premiums.

Orthodontic coverage for children up

to age 18 added.

See page 6 for premiums and page 9

for coverage information.

Vision Insurance:

No change to coverage or premiums.

See page 6 for premiums and page 9

for coverage information.

New SmartCare Option for Medical

Provides Medical Coverage participants with costs savings. See page 3.

Health Savings Account (HSA):

New Health Savings Account (Health Savings Plan Participants only). See page 3 & 4 for details.

2017 FSA participants enrolling in an HSA must use their health care FSA by 12/31/2017 – no carryover to 2018.

FSA Options Change:

Annual Enrollment required.

Up to $500 but not less than $50 of unused 2017 Healthcare FSA will carryover to 2018 (unless enrolled in HSA)

2017 Dependent Care FSA Grace Period. See page 4.

Cannot participate in 2018 Health Care FSA if enrolled in HSA.

See page 3 & 4 for additional information.

Life, Disability & AD&D Changes:

Premium Increase - Optional Life, Dependent Life & Optional Long Term Disability Insurance. See Page 6.

No Open Enrollment for Optional Life, Dependent Life or Optional Short Term Disability insurance.

Open Enrollment for Optional Long Term Disability (LTD) Insurance. See page 6.

Voluntary Products:

New Legal Assistance – Legal Shield

New Identity Theft - ID Watchdog

See page 5 for more info. 1

CHANGES TO UA MEDICAL PLANS EFFECTIVE JANUARY 1, 2018

Effective 1/1/2018, the University of Arkansas will offer three medical plans to benefits-eligible employees. All three plans offer the same

nationwide network of network providers and facilities and cover the same medial services and facilities. MedImpact will continue to be the

pharmacy provider for all three plans. The three plans are:

The Health Savings Plan (HSP) – this plan has the lowest monthly premiums but has the highest out-of-pocket expenses and includes a

Health Savings Account (see pages 3 & 4). See premiums page 6 and Medical Plan Comparison page 7.

Preventive care covered at 100% per Affordable Care Act provisions.

All other covered services, including prescriptions, will apply to the $2,700 (individual) or $5,400 (family) deductible.

Once you have satisfied your deductible, you will owe a 10% coinsurance until you hit your out of pocket maximum, $6,650

(individual) and $13,300 (family).

For the first year, the UA will contribute $420 (individual coverage) or $840 (family coverage) to a Health Savings Account (HSA).

Employees are encouraged to take all or part of their premiums savings and make voluntary contributions to the Health Savings

Account. Employees enrolled in the Health Savings Plan can only participate in the HSA and cannot participate in the Healthcare

Flexible Spending Account (FSA).

Employees who completed the Wellness Incentive requirements (completed the Health Assessment, including the Tobacco Pledge,

and completed the biometric screening) 7/1/2017-9/30/2017 will receive an additional $90 employer contribution to the HSA.

The Health Savings Plan will pay for services provided by out-of-network providers at reduced coverage. See page 3.

.The Classic Plan (CLC) - this plan has mid-range premiums and continues to work the same way that it currently does. CLC participants are

eligible for a Healthcare Flexible Spending Account (see pages 3 & 4). See premiums page 6 and Medical Plan Comparison page 7.

Preventive care covered at 100% per Affordable Care Act provisions.

$35 copay for PCPs and $55 copay for specialists. Prescription drug copays are $15 (Tier 1), $55 (Tier 2) & $90 (Tier 3).

Most other covered services will apply to $1,250 (individual) or $2,500 (family) deductible.

Once you have satisfied your deductible, you will owe a 25% coinsurance until you hit your out of pocket maximum, $5,250

(individual) or $10,500 (family).

Employees who participate in the Classic Plan are not eligible to participate in an HSA but can participate in an FSA.

Classic Plan participants who completed the Wellness Incentive requirements (completed the Health Assessment, including the

Tobacco Pledge, and completed the biometric screening) 7/1/2017-9/30/2017 will receive $1,400 discount in their 2018 out of pocket

maximums.

The Classic Plan will not pay for services provided by out-of-network providers unless approved in advance by UMR. See page 3.

Point of Service participants who do not elect the Health Savings Plan or the Premier plan will be transitioned to the Classic Plan with

no action on the participant’s part required.

The Premier Plan – this plan has the highest premiums but the lowest out of pocket expenses. It works the same as the Classic Plan but has

enhanced benefits.

Preventive care covered at 100% per Affordable Care Act provisions.

$25 copay for PCPs and $45 copay for specialists. Prescription drug copays are $10 (Tier 1), $50 (Tier 2) & $80 (Tier 3).

Outpatient labs and outpatient diagnostic testing are covered at 100%. Inpatient hospitalization will have a $300 copay and then will

be covered at 100%. Most other covered services will apply to the $650 (individual) or $1,300 (family) deductible.

Once you have satisfied your deductible, you will owe a 20% coinsurance until you hit your out of pocket maximum, $3,000

(individual) or $6,000 (family).

Employees who participate in the Premier Plan are not eligible to participate in an HSA but can participate in an FSA.

Premier Plan participants who completed the Wellness Incentive requirements (completed the Health Assessment, including the

Tobacco Pledge, and completed the biometric screening) 7/1/2017-9/30/2017 will receive a $500 discount in their 2018 out of pocket

maximums.

The Premier Plan will pay for services provided by out-of-network providers at reduced coverage. See page 3.

Making a Decision – Which Plan is Best For You?

Consider carefully when looking at the three plans to determine which plan will work best for you and your family. Compare premiums

and potential out of pocket costs. Look at your family’s general state of health and consider any medical expenses you anticipate for

2018 (example new babies, scheduled surgeries, prescriptions you are taking).

If you expect high medical costs for 2018, you may want to consider either the Classic Plan or the Premier Plan, since your day-to-day

out-of-pocket expenses will be lower with these options. If you are healthy and rarely see the doctor (and expect that to continue in

2018) you may want to consider the Health Savings Plan. Remember, once you’ve made your election, you cannot change it until the

next Open Enrollment

For additional information and for copies of Open Enrollment materials distributed, see HR’s website at https://hr.uark.edu/ (see “Open

Enrollment” under HR News 2017). The “Open Enrollment Decision Guide” mailed to medial plan participants’ home addresses by the

UA System Office has some good examples that can help you in your decision process. 2

Out of Network Medical Benefits The Health Savings Plan (HSP) and Premier Plan offer

coverage for out-of-network providers but your out-of-

pocket expenses will be higher. When you obtain health

care though a non-UA-UMR provider, your benefits

payments for covered services will be based on the

Maximum Allowable Payment for out-of-network services,

as determined by UMR. Charges in excess of the

Maximum Allowable Payments do not count toward

meeting the deductible or meeting the limitation on your

coinsurance maximum. Non-UA-UMR providers may bill

you for amounts in excess of the Maximum Allowable

Payment.

Annual Limited Out-of-Network Benefits:

SmartCare – UAMS & Pat Walker Health Center

Starting January 1, 2018, UA medical plan participants may save on health

care costs through the SmartCare program by visiting the Pat Walker Health

Center or a provider at a University of Arkansas for Medical Sciences (UAMS)

facility. The Pat Walker Health Center can only see employees and cannot

treat your dependents. Employees and their covered dependents can receive

the SmartCare benefits at UAMS facilities. You don’t have to specifically sign

up for SmartCare: you will receive the SmartCare benefits when you visit a

SmartCare facility for your care. UMR will automatically apply these

adjustments:

Health Savings Plan SmartCare Benefits Savings

Out of pocket maximum reduced by $500 (individual) & $1,000 (family)

After deductible is met, 5% reduction in coinsurance

Classic Plan SmartCare Benefits Savings

Office visit Copays: reduced by $15

Deductibles: reduced by $500 (individual) & $1,000 (family)

After deductible is met, 5% reduction in coinsurance

Inpatient Hospital admission copay reduced by $150

Outpatient surgery & mental health partial hospitalization/intensive day

treatment copayment waived

Premier Plan SmartCare Benefits Savings

Office visit Copays: reduced by $15

Deductibles: reduced by $500 (individual) & $1,000 (family)

After deductible is met, 5% reduction in coinsurance

Inpatient Hospital admission copay reduced by $150

Contact the Pat Walker Health Center at 479-575-4451 to access their providers. Contact the UAMS SmartCare concierge for assistance in making appointments or help with UAMS billing questions at (501) 686-8749 or email smartcare@uams.edu. Or online at https://hr.uams.edu/beneftis/smartcare/.

Deductible

Coinsurance

Out-of-Pocket Max

HSP

$2,700 Individual $5,400 Family

50%

$9,700 Individual $19,400 Family

Premier Plan

$2,000 Individual $4,000 Family

50%

$9,000 Individual $18,000 Family

Out-of-network deductibles and out-of-pocket maximums are separate from the in-network deductibles and OOP maximums. Out-of-network services are not covered under the Classic Plan. As always, participants in the Classic Plan, as well as the Health Savings Plan and the Premier Plan, can file an appeal to request authorization to see an out-of-network provide and to have the services covered as in-network. Request for authorization to see an out-of-network provider at in-network rates must be submitted and approved prior to services.

FLEXIBLE SPENDING ACCOUNTS AND HEALTH SAVINGS ACCOUNTS

There are now two options for employees to elect to have tax-exempt dollars to be deducted from their pay checks to cover unreimbursed medical, dental and vision expenses – a Health Care Flexible Spending Account (FSA) and a Health Savings Account (HSA). Employees who participate in the Classic Plan, Premier Plan or who don’t participate in UA health coverage at all are eligible to participate in a Healthcare Flexible Spending Account. Only employees who participate in the Health Savings Plan can participate in a Health Savings Account.

If you elect to enroll in the Health Savings Plan, you will be enrolled in a Health Savings Account through Optum Bank, Inc. Effective 1/1/2018 all employer and any voluntary employee HSA contributions will be made only to Optum HSAs. Additionally, you will need to understand the following if you elect to participate in an HSA:

You or your spouse cannot have a Healthcare Flexible Spending Account or Health Reimbursement Account (not available at the UA

but may be from your spouse’s employer) in the same year that you have a Health Savings Account.

If you are participating in a Healthcare Flexible Spending Account in 2017 and plan to switch to the Health Savings Plan in 2018, you

will need to use up your 2017 Healthcare FSA by 12/31/2017.

If you don’t spend all of your 2017 Healthcare FSA by 12/31/2017, you will have the option of waiving the automatic rollover (and

forfeiting the excess funds) so that you can have an HSA in 2018.

You and your covered family members can’t have any additional medical insurance coverage other than the UA Health Savings Plan.

You can’t be eligible for or enrolled in Medicare, covered by TRICARE, or have received Veterans Administration health benefits in

the three months previous to enrollment in an HSA.

You can’t be claimed as a dependent by someone else and be enrolled in an HSA. You may want to consult a tax advisor to discuss

your unique circumstances; the UA cannot give tax advice.

It is your responsibility to determine whether you are eligible to make contributions to an HSA; and to determine whether

contributions to the HSA have exceeded the maximum annual contribution limit. You will be liable for any tax penalties if you exceed

this limit.

3

What’s the difference between an FSA and an HSA?

FSA HSA

2018 Contribution Limits $2,600 tax-exempt, per person

Elect contribution amount during Open

Enrollment, no changes after open enrollment

except for a qualifying event

$3,450 tax-exempt – individual

$6,900 tax-exempt – family

(includes University Contributions)

Is there a “catch-up”

contribution?

No $1,000 additional catch-up allowed if you are 55 or

older

Can I contribute on my own? No, can only contribute through payroll

deduction.

Yes, you can contribute with after tax dollars directly

to Optum. Personal contributions and employer

contributions apply to the plan limits.

Who can participate? Classic Plan Participants

Premier Plan Participants

Employees not covered by any UA Medical

Coverage Plan

Employees who participate in the Health Savings

Plan only. Since there will be an employer

contribution in 2018, an HSA account will be opened

for all Health Savings Plan participants.

Plan Year Rollover Any amount over $50 and up to $500.

Amounts in excess of $500 will be forfeited.

Any amount

Is annual enrollment required? Yes Yes

Account Ownership Account is owned by The University. If you

leave UA employment, you can only use it up

through your termination date. Can elect to

continue through COBRA; once COBRA ends

any remaining account balances are forfeited.

You own the account. You can take it with you if you

leave UA employment or retire.

Access to funds Full yearly contribution available at the

beginning of the plan year.

Only funds already deposited into the account.

Employer contributions are posted twice a year, in

January and in September,

Account Growth Your contributions Your contributions

UA contributions

Transfers

Interest

Investment income

Reimbursement File eligible claims for the plan year by March

31 of the following year.

Access to HSA funds to pay for services incurred on

January 1, 2018, or later.

Can I use it for things other than

health care?

No Yes. Withdrawals when you are under age 65 will be

subject to a 20% penalty tax and income taxes. If

you are over age 65, the withdrawal is subject to

income taxes but not the penalty.

Eligible Expenses Copays or deductibles, dental care, vision care, qualifying prescriptions, certain medical equipment.

For a full list of qualified medical expenses, visit IRS.gov.

DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS (FSAs) & PREMIUM CONVERSION

All benefits-eligible employees, including those participating in an HSA, can participate in a Dependent Care FSA.

Dependent Care Account - Minimum $120; Maximum $5,000 if you are married and file a joint tax return or $2,500 if

married and file separate tax returns. Eligible expenses include daycare or elder care expenses for a child under age 13 or

an elderly person or a person with disabilities as long as they are claimed as a dependent for federal tax purposes. Expenses

must be work related and both spouses must be employed. Do not use the Dependent Care Account for unreimbursed health,

dental or vision expense for your spouse or children; use the Healthcare Account for those expenses. Annual enrollment is

required.

Premium Conversion – You can pay your health, dental & vision insurance premiums with tax-exempt dollars. Do not

include your UA insurance premiums in your FSA election. No annual re-election for premium conversion required.

4

Spouse and Dependent Documentation Required

All employees enrolling dependents in health, dental or vision coverage at any time who are not currently covered, including during Open Enrollment, are required to provide copies of the documentation below. Send fully legible photocopies only, not originals, along with the Dependent Documentation Form. Send the Dependent Documentation to 479-575-6971 (Fax) or email to hrbenf@uark.edu. Get the Dependent Documentation Form from the Open Enrollment section of HR’s website, https://hr.uark.edu (go to Open Enrollment under HR News 2017).

Proof for Legal Spouses

Marriage License that is government-issued and signed by the county clerk, state registrar or other assigned government official. Must

carry the seal of that office documenting the license has been recorded.

Proof for Dependent Child under age 26

Biological Child: Government-issued Birth Certificate identifying you as the parent.

Newborn Child less than 31 days old: Hospital issued Birth Certificate can be accepted. Must include baby’s name and date of birth,

parent’s names and be signed by the doctor or other hospital official.

Step-Child: government-issued Birth Certificate identifying your spouse as a parent AND a government-issued Marriage License showing

that you are married to the parent.

Adopted Child: court document showing adoption placement, petition for adoption or final adoption certificate; date of birth must be

included.

Legal Ward/Guardian Child/Foster Child under age 18: court or agency documentation AND a government issued Birth Certificate.

Medical Support Court Order: court documentation ordering you to provide insurance for your biological child.

Adult Disabled Child: government-issued Birth Certificate identifying you as the parent AND medical certification of disability prior to age

26. If the adult disabled child is your step-child, a government-issued Marriage License showing you are married to the parent is also

required.

Additional Information

UA Couples (at any UA System campus) need to coordinate coverage. You cannot be covered as both an employee and as the

spouse/child of an employee. Also, children can only be covered on one UA parent’s plan.

Social Security Numbers are required for dependents covered on the health coverage plan.

SBC Mailing – UMR will mail the Uniform Summary of Benefits Coverage documents for all health plans to all benefits-eligible employees.

These documents are in a government required format for the purpose of comparing our plan with others.

Expecting a baby? – Contact UMR in your first trimester & complete the Maternity Management program to save $300 on the delivery bill.

Be sure to add your newborn to your insurance coverage within 30 days of birth.

Enroll in Disease Management – Participate in the Disease Management and coaching programs offered through UMR and Onlife. Enroll

and the University plan provides for $0 cost for certain medications for diabetes and hypertension. Call UMR at 866-575-2540 for details

and assistance.

Tuition Discount – Remember, employees hired after May 1, 2017, must be employed in a 100% appointed, benefits-eligible,

position for one complete fall or spring semester to be eligible for the discount.

GROUP VOLUNTARY PRODUCTS

The UA added two new voluntary products effective 7/1/2017 – Identity Theft Protection through ID Watchdog and Legal Protection through LegalShield. Enroll and pay your premiums directly through the carriers. Enroll at any time.

Identity Theft Protection – ID Watchdog With the basic program you get Basic Identity Monitoring, Advanced Identity Monitoring, Internet Black Market Surveillance, Email & SMS Notifications, Full-service Indentity Restoration, Credit Reporting Monitoring, National Provider Identifier Alerts, & Credit Report & Score from one Bureau. The Platinum Program includes all Basic Program features plus a Credit Report and Score through three Bureaus. Contact ID Watchdog at or 1-866-513-1518. See HR”s website at https://hr.uark.edu/benefits/identify-theft.php for links to ID Watchdogs website and other information.

Legal Protection – LegalShield Through LegalShield you can receive unlimited personal advice from a lawyer without the worry of expensive hourly rates. Covered legal assistance includes: write letters or make phone calls on your behalf, will preparation, overcharge services, warranties, contract and document review (up to 15 pages), loan assistance, mortgages, insurance claims, collection agencies, international travel, contractors for storm damage, teenage drivers, assistance for college age children, IRS audit assistance, trial defense in covered civil actions, & uncontested divorce. Contact LegalShield at 1-870-295-0417. See HR’s website at https://hr.uark.edu/benefits/legal-protection.php for additional information.

RETIREMENT PARTICIPATION

All employees, regardless whether they are benefits-eligible or not, can participate in the University of Arkansas 403(b)/457(b) Retirement Plan. However only benefits-eligible employees are eligible for the employer matching contribution and will have to contribute the required employee contribution (currently 2%). Employees can participate in TIAA and/or Fidelity Investments. Employees who participate in APERS or ATRS can also make voluntary, unmatched, contributions to the University of Arkansas 403(b)/457(b) Retirement Plan.

Benefits-eligible employees who participate in the University of Arkansas Retirement Plan will receive a 5% employer contribution if they contribute anywhere from 2% to 5%. The University will match any contributions you make greater than 5% up to a maximum matching employer contribution of 10%. Any amount you contribute in excess of 10% will be unmatched by the University. You can contribute up to the IRS limits. For 2017 those limits are $18,000 to the 403(b) plan and $18,000 to the 457(b) plan. Employees age 50 and older can contribute an additional $6,000 each to the 403(b) plan and the 457(b) plan.

You can change your contributions at any time via webBASIS. Go to webBASIS.uark.edu and login using your UARK ID and password. Go to “My Benefits” and “Retirement Elections” to make your changes.

5

MONTHLY HEALTH COVERAGE PREMIUMS EFFECTIVE JANUARY 1, 2018

Classic Plan Health Savings Plan Premier Plan

Salary Tiers 75%-100% Appt 50%-74% Appt** 75%-100% Appt 50%-74% Appt** 75%-100% Appt 50%-74% Appt**

Below $28,000 Employee Only Emp/Spouse Emp/Child(ren) Family

12 Mon $68.05

$153.15 $120.12 $205.30

9 Mon* $90.73

$204.20 $160.16 $273.73

12 Mon $116.24 $261.55 $205.15 $350.65

9 Mon* $154.98 $348.74 $273.53 $467.53

12 Mon $37.81 $85.63 $64.96

$112.70

9 Mon* $50.41

$114.17 $86.61

$150.27

12 Mon $86.00

$194.04 $149.99 $258.05

9 Mon* $114.67 $258.72 $199.99 $344.07

12 Mon $136.51 $398.44 $308.80 $534.44

9 Mon* $182.01 $531.25 $411.73 $712.59

12 Mon $224.00 $576.56 $459.33 $786.00

9 Mon* $298.66 $768.75 $612.45

$1,048.00

$28,000-$38,999 Employee Only Emp/Spouse Emp/Child(ren) Family

12 Mon $68.05

$163.11 $127.93 $218.66

9 Mon* $90.73

$217.47 $170.57 $291.54

12 Mon $116.24 $278.56 $218.48 $373.45

9 Mon* $154.98 $371.41 $291.31 $497.93

12 Mon $37.81 $95.59 $72.77

$126.06

9 Mon* $50.41

$127.45 $97.03

$168.08

12 Mon $86.00

$211.05 $163.32 $280.85

9 Mon* $114.67 $281.39 $217.76 $374.46

12 Mon $136.51 $426.94 $324.44 $560.92

9 Mon* $182.01 $569.25 $432.59 $747.89

12 Mon $224.00 $597.94 $471.06 $805.86

9 Mon* $298.66 $797.25 $628.09

$1,074.48

$39,000-$54,999 Employee Only Emp/Spouse Emp/Child(ren) Family

12 Mon $74.86

$172.29 $135.14 $230.97

9 Mon* $99.81

$229.72 $180.18 $307.96

12 Mon $127.86 $294.24 $230.79 $394.49

9 Mon* $170.48 $392.33 $307.72 $525.98

12 Mon $44.62

$104.77 $79.98

$138.37

9 Mon* $59.49

$139.69 $106.64 $184.49

12 Mon $97.62

$226.73 $175.63 $301.89

9 Mon* $130.16 $302.30 $234.18 $402.52

12 Mon $143.32 $445.94 $343.99 $587.40

9 Mon* $191.09 $594.59 $458.65 $783.20

12 Mon $229.10 $612.19 $485.73 $825.72

9 Mon* $305.47 $816.25 $647.64

$1,100.96

$55,000-$99,999 Employee Only Emp/Spouse Emp/Child(ren) Family

12 Mon $80.98

$182.24 $142.94 $244.32

9 Mon* $107.97 $242.99 $190.59 $325.76

12 Mon $138.32 $311.25 $244.12 $417.27

9 Mon* $184.43 $415.00 $325.50 $556.36

12 Mon $50.74

$114.72 $87.78

$151.72

9 Mon* $67.65

$152.96 $117.04 $202.29

12 Mon $108.08 $243.74 $188.96 $324.67

9 Mon* $144.11 $324.99 $251.94 $432.90

12 Mon $149.44 $464.94 $363.54 $627.12

9 Mon* $199.25 $619.92 $484.72 $836.16

12 Mon $233.69 $626.44 $500.39 $855.51

9 Mon* $311.59 $835.25 $667.19

$1,140.68

$100,000-$149,999 Employee Only Emp/Spouse Emp/Child(ren) Family

12 Mon $82.34

$196.02 $153.37 $262.80

9 Mon* $109.78 $261.36 $204.49 $350.40

12 Mon $140.65 $334.79 $262.59 $448.84

9 Mon* $187.53 $446.39 $350.12 $598.45

12 Mon $52.10

$128.50 $98.21

$170.20

9 Mon* $69.47

$171.33 $130.95 $226.93

12 Mon $110.41 $267.28 $207.43 $356.24

9 Mon* $147.21 $356.37 $276.58 $474.99

12 Mon $150.80 $483.94 $379.18 $660.22

9 Mon* $201.07 $645.25 $505.57 $880.29

12 Mon $234.71 $640.69 $512.12 $880.33

9 Mon* $312.95 $854.25 $682.83

$1,173.78

$150,000& above Employee Only Emp/Spouse Emp/Child(ren) Family

12 Mon $83.70

$206.75 $162.16 $277.17

9 Mon* $111.60 $275.67 $216.22 $369.55

12 Mon $142.97 $353.10 $276.95 $473.38

9 Mon* $190.63 $470.80 $369.26 $631.18

12 Mon $53.46

$139.23 $107.00 $184.57

9 Mon* $71.28

$185.64 $142.67 $246.09

12 Mon $112.73 $285.59 $221.79 $380.79

9 Mon* $150.31 $380.78 $295.72 $507.72

12 Mon $152.16 $512.44 $402.64 $693.32

9 Mon* $202.88 $683.25 $536.85 $924.43

12 Mon $235.73 $662.06 $529.71 $905.16

9 Mon* $314.31 $882.75 $706.29

$1,206.88

Coverage Tiers DENTAL INSURANCE MONTHLY PREMIUMS VISION INSURANCE MONTHLY PREMIUMS

All Groups UAF, SYS, CJI, ARAS Division of Agriculture

75%-100% Appt 50%-74% Appt 75%-100% Appt 50%-74% Appt Basic Plan Enhanced Plan

Employee Only Emp/Spouse Emp/Child(ren) Family

12 Mon $16.00 $33.00 $27.85 $44.85

9 Mon* $21.33 $44.00 $37.13 $59.80

12 Mon $21.44 $44.22 $37.32 $60.10

9 Mon* $28.59 $58.96 $49.76 $80.13

12 Mon $15.53 $32.04 $27.04 $43.54

9 Mon* $20.71 $42.72 $36.05 $58.05

12 Mon $20.82 $42.93 $36.23 $58.35

9 Mon* $27.76 $57.25 $48.31 $77.80

12 Mon $5.76

$11.43. $11.19 $17.01

9 Mon* $7.68

$15.24 $14.92 $22.68

12 Mon $11.62 $22.97 $22.52 $34.22

9 Mon* $15.49 $30.63 $30.03 $45.63

Optional Long Term Disability

Basic LTD (employer paid) is increasing from $0.180 to $0.196

per $100.

Optional LTD (employee paid) is increasing from $0.47 per

$100 to $0.512 per $100.

You can cover salary in excess of $20,000 (maximum covered

salary $100,000) for Long Term Disability benefits. Take

advantage of this Open Enrollment period to enroll in coverage.

Complete the Group Benefits Change form to enroll and return

it to Human Resources no later than 11/30/2017. Find the

Open Enrollment forms from HR’s website at http://hr.uark.edu/

(go to Open Enrollment under HR QuickFind).

Dependent Life Insurance – Monthly Premiums

Current premiums are $2.71 ($10,000), $4.07 ($15,000) & $5.42 ($20,000) based on 12 month premiums.

Spouse covered for $10,000, $15,000 or $20,000. Eligible dependent children covered at 50% of spouse’s coverage

Coverage: $10,000 $15,000 $20,000

12 Month $2.85 $4.27 $5.69

9 Month* $3.80 $5.69 $7.59

Basic Life Insurance Premiums (employer paid) are increasing from $0.13 to $0.155 per $1,000. Coverage is 1 times salary not to exceed $50,000.

Optional Life Insurance – Monthly Premiums

Optional Life Premiums Increasing by $0.002 to $0.08 per band.

Employees can purchase Optional Life Insurance in increments of 1, 2, 3 or 4 times their annual salaries not to exceed $500,000. Premiums based on age & salary.

Your Current Age: Less than 30 30 but < 35 35 but < 40 40 but < 45 45 but < 50 50 but < 55 55 but < 60 60 but < 65 65 but < 70 70 & older

12 Month $0.042 $0.059 $0.067 $0.084 $0.126 $0.193 $0.361 $0.554 $1.067 $1.722

9 Month* $0.056 $0.079 $0.089 $0.112 $0.168 $0.257 $0.481 $0.739 $1.423 $2.296

Monthly Prem (12-mo): 1. Annual salary ÷ 12

(not to exceed $100K) 2. Subtract $1,666.67 3. Divide by 100 4. Multiply by $0.512

Monthly Prem (9-mo*): 1. Annual salary ÷ 9

(not to exceed $100K) 2. Subtract $1,666.67 3. Divide by 100 4. Multiply by $0.512

If you sign up during Open Enrollment, your plan will be subject to a 12-month pre-existing condition exclusion period. Pre-existing means that you had symptoms, took medications, had treatment, or were diagnosed during the six month period immediately prior to your 1/1/2018 effective date of coverage.

To calculate your monthly premium: 1. Multiply your annual salary by 1, 2, 3, or 4 (based on your coverage election).

Round to next $1,000. 2. Divide by $1,000 3. Multiply by Age Rate above.

*9-Month Premiums. Faculty on a 9-month appointment and staff members paying benefits over 9 months pay an additional premium September through May to prepay for the following June, July, and August. These 9-month premiums are calculated assuming that the premiums will begin in September and will remain unchanged for a 12-month period (through the following August). Faculty/staff paying with 9-month premiums enrolling in coverage or making changes to their premiums October or later will have to pay an extra premium through the following May to assure that sufficient premiums will be collected to pre-pay for the following summer.

**Part-time employees (50%-74% appointed) health premiums will be in the salary tier equal to their equivalent 100% appointed salary. For example, a 50% employee making $20,000 a year will be the salary tier for $40,000 annual salary. 6

Effective: January 1, 2018

UNIVERSITY OF ARKANSAS Medical Plans Comparison - UMR

This is not a legal document. Complete benefits descriptions and exclusions are contained in the Summary Plan Description which is available through your campus HR Office.

CLASSIC PLAN HEALTH

SAVINGS PLAN* PREMIER PLAN*

INDIVIDUAL MEDICAL DEDUCTIBLE (a) $1,250 $2,700 $650

FAMILY MEDICAL DEDUCTIBLE (a) $2,500 $5,400 $1,300

COINSURANCE (b) 25% 10% 20%

MEDICAL OUT OF POCKET MAXIMUM Individual (c) $4,000+Deductible = $5,250 $6,650 $2,350+Deductible = $3,000 Family (c)

$8,000+Deductible=$10,500

$1,400/$2,800 wellness OOP credit

$13,300

$90 wellness HSA credit

$4,700+Deductible=$6,000

$500/$1,000 wellness OOP credit

PREVENTIVE CARE SERVICES (l) Well Baby/Child Visit (f) Immunizations Mammograms(first yearly mammogram) Colorectal Cancer Screening Nutritional Counseling* Physical Exams PCP or OB/GYN Specialist

Paid in Full Paid in Full Paid in Full Paid in Full Paid in Full

Paid in Full Paid in Full

Paid in Full Paid in Full Paid in Full Paid in Full Paid in Full

Paid in Full Paid in Full

Paid in Full Paid in Full Paid in Full Paid in Full Paid in Full

Paid in Full Paid in Full

PHYSICIAN SERVICES IN OFFICE (d) PCP or OB/GYN Office Visit Specialist Office Visit Diagnostic Lab Testing Surgical Services Advanced Imaging Services (CT, PET, MRI, & Nuclear Medicine) Prior Authorization Required

$35 Co-pay $55 Co-pay Coinsurance

Deductible + Coinsurance $100 Copayment

Deductible + Coinsurance

All Services other than ACA-

Preventive applies to deductible and coinsurance

Deductible + Coinsurance

$25 Co-pay $45 Co-pay

Covered at 100% Deductible + Coinsurance Deductible + Coinsurance

PHYSICIAN SERVICES NOT IN OFFICE Inpatient Medical Care Diagnostic Testing Surgical Services

Deductible + Coinsurance Deductible + Coinsurance Deductible + Coinsurance

Deductible + Coinsurance

Covered at 100% Deductible + Coinsurance

PHYSICIAN MATERNITY SERVICES (g) Maternity/Obstetrical Care OB/GYN

No deductible or coinsurance for pre-natal & physician delivery services

No deductible or coinsurance for pre-natal & physician delivery

services

OUTPATIENT FACILITY SERVICES Diagnostic Testing Surgical Services

ER Copay tiered by visit ( Co-payment waived if admitted)

Urgent Care Center

Deductible + Coinsurance

$150 Co-pay + Deductible + Coinsurance

$150 1st visit, $200 2nd visit $250 after 2nd visit

$55 Co-pay

Deductible + Coinsurance Deductible + Coinsurance

$150 1st visit, $200 2nd visit

$250 3rd visit $50 Co-pay

INPATIENT SERVICES (g) (h) Semi-Private Room & Board, Intensive Care

Room & Board, Ancillary Charges, & Maternity Inpatient Charges

$300 Co-pay + Deductible + Coinsurance (h)

$300 Co-pay

OTHER SERVICES Ambulance (Co-pay waived if admitted) Home Health (40 visits per year max)

Speech Therapy , PT, OT, Chiropractic (30 visits Combined / approval required for additional visits)

Durable Medical Hospice TMJ

$100 Co-pay

Deductible + Coinsurance $35 Office Visit Co-pay,

Deductible + Coinsurance on All Therapy and Chiropractic

Deductible + Coinsurance Deductible + Coinsurance

$200 copay + $1,000 Deduct + Coinsurance

$100 Co-pay

Deductible + Coinsurance $25 Office Visit Co-pay,

Deductible + Coinsurance on All therapy and Chiropractic

Deductible + Coinsurance Deductible + Coinsurance

$200 copay + $1,000 Deduct + Coinsurance

MENTAL HEALTH/SUBSTANCE ABUSE Inpatient Services (h) Outpatient Intensive Day Treatment Outpatient Services in office

$300 Co-pay + Ded + Coins $150 Copayment +

Ded + Coins $35 Co-pay

Deductible + Coinsurance Deductible + Coinsurance

$25 Co-pay

ROUTINE VISION EXAMS (j) One exam per calendar year

$35 Co-pay

$25 Co-pay

PRESCRIPTION DRUGS (k) $1600 OOP Max individual $3200 OOP Max family Separate from Medical OOP Max

$15 Tier 1; $55 Tier 2;

$90 Tier 3 (k)

Deductible + Coinsurance

10 Tier 1; $50 Tier 2;

$80 Tier 3 (k

See Next Page

7

*Out-of-network benefits are available. If services are received out-of-network, a higher out-of-network annual deductible, higher coinsurance

percentage and higher out-of-pocket maximums apply. In-network deductibles do not apply to out-of-network deductibles and visa versa. For more information about out-of-network coverage, or to get a copy of the complete terms of coverage, visit www.umr.com or contact UMR at 1-888-438-6105.

FOOTNOTES:

(a) Deductible means a fixed dollar amount that you must incur each calendar year before the health plan begins to pay for covered medical services. The

calendar year deductible applies to all Covered Services except for Preventive Care Services and for those services in the Classic and Premier Plans where a Co-payment applies in, unless otherwise noted. In-network deductibles do not apply to out-of-network deductibles and visa versa. Two individual deductibles = the family deductible.

(b) Coinsurance means a fixed percentage of charges you must pay toward the cost of covered medical services. Coinsurance applies to all Covered Services except those for which a Co-payment applies unless otherwise noted.

(c) Medical Out of Pocket Maximum is the maximum combined deductible, coinsurance and copayments you will pay in any calendar year. It does not include

costs for services not covered by the plan such as exclusions, limitations and pharmacy copayments. In the Classic and Premier Plans the maximum OOP for prescriptions drugs is a separate OOP from medical expenses. In the Health Savings Plan the medical OOP and pharmacy OOP are combined. Family OOP max requires two individual family member meet the individual OOP max.

(d) Co-Payment means a fixed dollar amount that you must pay each time you receive a particular medical service. You pay a co-payment when you obtain

health care directly from your Network Primary Care Physician or a Network Specialist. Certain services rendered in the Network Primary Care Physician or Network Specialist’s office are not subject to the deductible. Services rendered in the Network Primary Care Physician or Network Specialist’s office that are subject to deductible, coinsurance and additional copayments include advanced imaging such as MRI, CT Scans, PET Scans and Nuclear Medicine (imaging studies using medical radioisotopes), Temporomandibular Joint Disorder (TMJ) treatment and all therapy including chiropractic.

(e) When you obtain health care through a Non-UMR Provider, your benefit payments for covered services will be based on the Maximum Allowable Payment

for out-of-network services, as determined by UMR. Charges in excess of the Maximum Allowable Payments do not count toward meeting the deductible or meeting the limitation on your Out of Pocket maximum. Non-UMR Providers may bill the patient for amounts in excess of the Maximum Allowable Payment.

(f) Well baby/child visits from an In-Network provider are covered in full from birth until the day the child attains age 19. (g) In the Classic Plan maternity inpatient charges are subject to co-payment and coinsurance. With any of the medical plans it is your responsibility to

notify Human Resources within 31 days of the birth or adoption of your child in order to obtain coverage for your newborn. (h) In the Classic and Premier Plans the maximum combined Inpatient co-payment per calendar year is $1,200 per person (no more than one co-payment per

30 calendar days). (i) In the Classic and Premier Plans the TMJ deductible is separate from the other In-Network or Out-of-Network deductibles. The TMJ deductible is in addition

to any In-Network or Out-of-Network deductible and requires pre-authorization. (j) Vision Exams: Ophthalmologist or Optometrist in-network and out-of-network benefits are the same. (k) In the Classic and Premier Plans, co-payments at non-participating pharmacies will be $20.00 for Tier 1, $60.00 for Tier 2, and $95.00 for Tier 3. If a new

enrollee has to get a prescription prior to receiving his/her pharmacy card, he/she will have to pay for the prescription in full, apply for reimbursement, and will be reimbursed less the $20.00, $60.00, or $95.00 co-payments. Alternatively, if the enrollment process has been completed and benefits are in effect, a temporary prescription drug ID card can be printed by going to www.medimpact.com, registering and clicking on ‘member ID card’. A complete summary of prescription drug benefits is also on the above web-address. Excluded or non-covered medication or devices do not apply to the OOP maximum.

(l) Preventive care services and cancer screenings will follow the U.S. Preventive Task Force Recommendations. See the health plan Summary Plan

Description for details on coverage. The following procedures for all plans will require pre-authorization before the services are rendered:

1. Any admission to Inpatient Facilities or Partial Hospitalization Units 2. Any referral by your PCP to an Out-of-Network Provider 3. Pre-Natal/Maternity Care. Authorization includes physician care and one ultra sound. Additional ultrasounds require pre-authorization. UAMS offers a

$500 waiver of out-of-pocket expenses for deliveries at its hospital. 4. Home Health Care and Home Infusion Services 5. Transplant Services (including the evaluation to determine if you are a candidate for transplant by a transplant program) 6. All Advanced Imaging (CT, MRI, Thallium Stress Test, PET. Go to www.UMR.com for a complete listing) regardless of place of service. 7. MRI of the Breast

Note: Certain other services have special Pre-authorization including surgical treatment of Temporomandibular Joint Dysfunction (TMJ), Accidental Injury to Teeth.

The Smoking Cessation Program: smoking cessation program provides free PCP visits and $0 copay for certain nicotine addiction drugs. The Diabetes Management Initiative and the Healthy Heart Program provide the opportunity for $0 copayments on certain medications. For more information on all programs call UMR 888-438-6105. *Nutritional Counseling and Weight Management Services: One annual visit with a dietitian and up to three additional visits in conjunction with health coaching for those who have a BMI of 27 and above. Prior authorization is required and continued approval contingent upon program compliance. Metabolic weight loss programs are reimbursable up to $1000/ life time for individuals with a BMI of 30 and above who participate in coaching. Prior authorization is required. For more information call UMR 888-438-6105.

8

Dental Coverage Arkansas BlueCross BlueShield

a) Deductible: $50 individual/$100 family. See below for services subject to deductible

b) Annual Maximum Payment: $1,500 Per Person Per Calendar Year c) Benefit Period: Calendar year (January 1 – December 31)

Schedule of Benefits Subject to Deductible In-Network Out-of-Network

Coverage A – Diagnostic and Preventive Services

● Exams & Cleanings (twice a year) ●·Bitewing and periapical X-rays as required ● Full-mouth X-rays once in any three (3) year period ● Fluoride treatments once per benefit period for children to age nineteen (19) ● Sealants (once per permanent tooth) for children to age nineteen (19)

No 100% 90%

Coverage B – Basic Restorative Services

● Fillings (amalgam & composite/resin) ● Simple & Surgical Extractions. ● Oral surgery ● Root Canals

Yes 80% 72%

Coverage C – Major Restorative Services

● Crowns & bridges ● Prosthodontics ● Endosteal implants

Yes 50% 45%

Coverage D – Orthodontics (for dependent children to age 18)

● Up to $2,000 life-time limit No 50% 40%

Carryover Benefit Rider – must have received at least one covered service during the calendar year to qualify.

● Carryover Benefit: $375 – carryover benefit maximum $1,500 ● Claims Threshold: Less than $750

Provider Network – To find an in-network dentist, visit uasdental.blueadvantagearkansas.com and select “Find a Dentist.” You can search

for a dentist by city, ZIP code, distance, doctor name or specialty. Payments to non-Blue Cross/Blue Shield providers will be paid as out-of-network and payment will be based on the BCBS Maximum Plan Allowance (MPA) and not billed charges. Non-BCBS providers can balance bill for amounts excess of the MPA.

This is not a legal document. Complete benefits descriptions and exclusions are contained in the Summary Plan Description, available from Human Resources at http://hr.uark.edu.

SUPERIOR VISION 1-800-507-3800 www.superiorvison.com

You may choose between two plans: Basic Plan and Enhanced Plan

Basic Plan Enhanced Plan

Exam $10 Exam $10

Copayments Materials¹ $20 Materials¹ $20

Contact Lens Fitting $25 Contact Lens Fitting $25

Exam 1 per calendar year Exam 1 per calendar year Frames 1 per 2 calendar years Frames 1 per calendar year

Services/Frequency Contact Lens Fitting 1 per calendar year Contact Lens Fitting 1 per calendar year Lenses 1 pair per calendar year Lenses 1 pair per calendar year Contact Lens 1 allowance per calendar year Contact Lens 1 allowance per calendar year

Benefits In-Network Out-of-Network In-Network Out-of-Network Exam (MD) Covered in full Up to $42 Covered in full Up to $42 Exam (OD) Covered in full Up to $36 Covered in full Up to $36 Frames $125 retail allowance Up to $70 $150 retail allowance Up to $84 Contact Lens Fitting (standard²) Covered in full Not Covered Covered in full Not Covered Contact Lens Fitting (specialty ²) $50 retail allowance Not Covered $50 retail allowance Not Covered

Lenses (standard) per pair

Single Vision Covered in full Up to $28 Covered in full Up to $28 Bifocal Covered in full Up to $42 Covered in full Up to $42 Trifocal Covered in full Up to $56 Covered in full Up to $56 Progressive See Descripton³ Not Covered Covered in full⁴ Not Covered Scratch coating See discount features Not Covered Covered in full Not Covered UV coating See discount features Not Covered Covered in full Not Covered

Contact Lenses³ $120 retail allowance Up to $100 $150 retail allowance Up to $100 Co-payments apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursement. ¹Materials co-pay applies to lenses and frames only, not contact lenses. ²See your benefits materials for definitions of standard and specialty contact lens fittings. ³Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus copay. ⁴If premium progressive lenses are selected, members receive an allowance based on the provider’s charge for standard progressive lenses. ³Contact lenses are in lieu of eyeglass lenses and frames benefit.

Discount Features: Look for providers in the Provider Directory who accept discounts, as some do not; please verify their services and discounts (range from 10% to 30%) prior to service as they may vary. The following options have out-of-pocket maximums (discounts and maximums may vary by lens type – check with provider): Scratch coat-$13, Ultraviolet coat-$15, tints (solid or gradient)-$25 & anti-reflective coat-$50.

Refractive Surgery: Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks who offer members a discount. These discounts range from 15%-50%, and are the best possible discounts available to Superior Vision. 9

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of August 10, 2017. Contact your State for more information on eligibility –

ARKANSAS – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

To see if any other states have added a premium assistance program since August 10, 2017, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

10 OMB Control Number 1210-0137 (expires 12/31/2019)