2023-FMOLHS_New_Hire_Ready_Text_Only.docx

Information Resources Your 2023 Total Rewards Just as our team members are more than job descriptions and titles, our rewards program is more than just compensation and benefits. Total Rewards is our commitment to provide value to you and your family throughout your career at Franciscan Missionaries...

Information Resources Your 2023 Total Rewards Just as our team members are more than job descriptions and titles, our rewards program is more than just compensation and benefits. Total Rewards is our commitment to provide value to you and your family throughout your career at Franciscan Missionaries of Our Lady Health System. It combines six distinct areas that you can use to meet your individual and family needs: My Purpose, My Compensation, My Benefits, My Personal Growth & Development, My Recognition, and My Health & Well-Being. When all of these components are tied together, they create a Total Rewards package that is unique to our organization. This guide will help you understand more about the rewards available to you as a team member of FMOLHS. Benefit Education Our goal is to make benefits easy to understand so you can make the most of them. We have an interactive online learning experience available on our Total Rewards page. In this interactive learning experience, you can pick and choose the topics you want to dive deeper into. Check out all of the education resources available by visiting the page today. » Click here for the Total Rewards page » Click here for 2023 Interactive Benefit Education Video or scan the QR code at right to directly access the benefit education video » Click here to review the FMOLHS EPO and PPO Network » Click here to learn about FMOLHS Network Navigation Resources to help you help find a provider in our network. Have Questions? Need assistance with your Benefit Enrollment? The FMOLHS askHR Team is available by phone or email. » Phone: 833-482-7547 » Email: [email protected] Note In addition to these resources, we are committed to keeping you informed. Stay up to date on the latest communication and updates through: Oracle Employee Self Service, your FMOLHS email, fmolhs.org/TotalRewards and TeamTalk. Your 2023 Enrollment Options Your enrollment options will be displayed in Oracle Employee Self-Service in the following order: NEW ENROLLEE FUTURE ENROLLEE BENEFIT PLAN FMOLHS HEALTH PLAN HEALTH SAVINGS ACCOUNT (HSA) MEDICAL FLEXIBLE SPENDING ACCOUNT (FSA) LIMITED MEDICAL FLEXIBLE SPENDING ACCOUNT (LUFSA) FMOLHS DENTAL PLAN VISION PLAN Team members who are within their 1st 30 calendar days of eligibility may enroll through Oracle Employee Self-Service. Enroll through Oracle Employee Self-Service annually during the Open Enrollment period. LINCOLN VOLUNTARY EMPLOYEE LIFE LINCOLN VOLUNTARY SPOUSE LIFE LINCOLN VOLUNTARY DEPENDENT LIFE Team members who are within their 1st 30 calendar days of eligibility may enroll through Oracle Employee Self-Service. For those outside of their 1st 30 calendar days of eligibility, enrollment in coverage is not available. LONG TERM DISABILITY Team members who are within their 1st 30 calendar days of eligibility may enroll through Oracle Employee Self-Service. Team members who previously waived coverage must complete evidence of insurability online during the Open Enrollment period at MyLincolnPortal.com for eligibility review. LINCOLN VOLUNTARY ACCIDENT LINCOLN VOLUNTARY CRITICAL ILLNESS Team members who are within their 1st 30 calendar days of eligibility may enroll through Oracle Employee Self-Service. Enroll through Oracle Employee Self-Service annually during the Open Enrollment period. COMPANY-PROVIDED GROUP LIFE INSURANCE GROUP BASIC LIFE (COMPANY-PAID) Company-provided Basic Life Insurance coverage. Team members do not need to enroll. Team members do need to designate a beneficiary in Oracle Employee Self Service. Eligible Team members are automatically enrolled in the Basic Life Insurance. Team members do need to designate a beneficiary in Oracle Employee Self Service. 403(b) AND 457(b) RETIREMENT ENROLLMENT PROCESS 403(b) AND 457(b) RETIREMENT PLANS Eligible Team members enroll at LincolnFinancial.com/FMOLHS Eligible Team members enroll at LincolnFinancial.com/FMOLHS You can verify your enrollment and print a copy of your elections in Oracle Employee Self Service by clicking on Me/Benefits/My Benefits. Note Most benefits are effective on the first day of the month following 30 days of employment. Long Term Disability benefits are effective first of the month following 6 months of employment. (New Hire date: March 5; benefits are effective on October 1.) Important Information Enrollment for the 2023 Plan Year Complete your benefit enrollment and submit complete dependent verification documentation within 30 calendar days of your new hire/new eligibility date (e.g. for a new hire date of May 1, enrollment and documentation deadline is May 30). If you meet the income guidelines, apply for the health plan premium reduction, Just Premium, within 30 calendar days of your eligibility date (see page 10 for details). Member Cards Team Members who enroll in the following benefits will receive member identification cards: » Medical Cards – FMOLHS Health Plan through Blue Cross Blue Shield (BCBS) » Dental Cards – Delta Dental » Vision Cards – UNUM » Medical Flexible Spending Account (FSA)/Health Savings Account (HSA) – Payflex Human Resources Contact Reach out using the method that works best for you: » Submit an Oracle Service Request by clicking on Help Desk/HR Service Requests.* » Email [email protected] » Call 833-4UaskHR (833-482-7547) *This is the fastest method for getting an answer to your question. Note If you (and/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 page 58 for more information concerning Medicare Part D coverage. Important Information Be Healthy. Be Happy. Register for My Health Toolkit to help you get started. You will have anywhere, anytime access to your benefits information, insurance cards, claims and covered local providers. Download the My Health Toolkit mobile app. It’s free at: www.MyHealthToolkitLA.com/links/FMOLHS. Get Started Today Why wait? It’s easy to sign up. In just a few clicks, you will have everything you need at your fingertips. 1. Go to www.MyHealthToolkitLA.com/links/FMOLHS and select Register Now. 2. Enter the number on your membership card and your date of birth. If you don’t have your membership card, you can enter your social security number. 3. Choose a username and password. 4. Enter your email address and choose to go paperless, if you would like. Your Membership Card Your Blue Cross Blue Shield membership card contains important information that helps providers apply your benefits correctly. Keep it with you at all times by downloading your digital ID card to keep on your smart phone. It is all about convenience. Your digital ID card has the same information that your plastic card will have. In 2023, your membership card will now include your deductible and out of pocket maximums. You will be able to: » View your card on your smartphone, tablet or computer » Email the card to a spouse, child, doctor’s office or pharmacy » Print the card from a smartphone, tablet or computer and use the print out just like a plastic card Accessing your Digital ID Card To access your digital ID card through the My Health Toolkit app you will need to follow these instructions: » Log in to My Health Toolkit. » From your mobile device, select Insurance Card. » From a computer select Insurance Card and then View Your Card. Note Sign Up for My Health Toolkit at: www.MyHealthToolkitLA.com/links/FMOLHS Enrollment All eligible team members must enroll online through Oracle Employee Self Service. Things to Consider Before you enroll, it is a good opportunity for you to assess your benefit needs. » Does your spouse have benefits coverage available through another employer? » Did you get married, divorced or have a baby recently? If so, do you need to add any dependent(s) or add your beneficiary designation? » Did any of your children reach his or her 26th birthday this year? If so, they are not eligible for benefits. Your Eligible Dependents for Core Benefits Enrollment Dependents eligible for coverage in the FMOLHS Benefit Plans include: » Your legal spouse. » Your dependent children up to age 26 (includes stepchildren, legally-adopted children or children placed with you for adoption, foster children and grandchildren for whom you have legal custody). » Your dependent child, regardless of age, provided he or she is incapable of self-support due to a mental or physical disability, is fully dependent on you for support as indicated on your federal tax return, and is approved by your Health Plan to continue coverage past age 26. » Please note that verification of eligibility will be required once dependents are enrolled. See page 8 for dependent verification requirements. Note All eligible Team Members must enroll within 30 calendar days of new hire/new eligibility date. Qualifying Life Events Include: Enrollment changes based upon a qualifying life event must occur within 30 calendar days of that event.* (For Example: If you get married on March 1st, you must enroll no later than March 30th.) » Change in your FTE status from part-time to full-time or full-time to part-time that results in a significant increase or decrease in your premiums (medical or dental) » Change in your legal marital status (marriage and divorce) » Change in the number of your dependents (for example, through birth or adoption, or if a child is no longer an eligible dependent) » Change in your spouse’s employment status (resulting in a loss or gain of coverage) » Change in your employment resulting in a gain or loss of coverage » Entitlement to Medicare or Medicaid* *If you become eligible for or lose coverage under Medicaid or a state child health plan, you must enroll or terminate coverage within 60 days. Dependent Verification ACCEPTED/REQUIRED VERIFICATION DOCUMENTS DEPENDENT TYPE NATURAL CHILD* Birth Certificate; for newborns, birth letter from hospital STEP CHILD* (Requires current spouse & child verification documents) Birth Certificate AND verification of current marriage between Team Member and natural parent (see spouse verification requirements below) ADOPTED CHILD/CHILD PLACED FOR ADOPTION* Adoption Certificate/placement letter from court or adoption agency for pending adoptions FOSTER CHILD* Proof of Legal Custody, such as a court order GRANDCHILD* (Requires 2 documents) Proof of Legal Custody, such as a court order AND copy of current tax return that identifies grandchild as a taxable dependent SPOUSE (Requires 2 documents) Marriage Certificate; AND current or previous year tax return face sheet OR proof of current joint ownership (such as a joint mortgage, joint rental agreement, joint bank account, joint auto insurance etc.) *Less than age 26 regardless of marital or student status Dependent verification documents for any newly enrolled or previously unverified dependents must be received within 30 calendar days of new hire/new eligibility date in order to maintain dependent coverage. FMOLHS reserves the right to audit dependent verification documents at any time. Note Upload Dependent Verification Documents in Oracle Employee Self Service under Benefits/My Documents. How to Enroll in Oracle Employee Self Service 1. Understand Your Choices! The Team Member Guide to Benefits Enrollment is available by clicking on My Benefits on our Total Rewards page. 2. Review Your Personal Information 3. Enroll Online from Work or Home https://eqtm.login.us2.oraclecloud.com 4. Log in with Your Username and Password a. Click the Me tab b. Click the Benefits tile » Note: Before starting your enrollment, be sure to review My Benefit Resources Card for your benefit options and important notices c. Click Start Enrollment button 5. Add Your Dependents and Beneficiary(s) a. Be sure to complete all required fields for each dependent and beneficiary b. Upload dependent verification documents to Oracle Employee Self Service under Benefits/My Documents. 6. Review Your Dependent Child’s Eligibility for Coverage a. Core Benefits (Health, Dental, Vision) – To age 26 regardless of marital or student status. b. Voluntary Life Benefits – Unmarried dependent children to age 21; to age 25 if a full time student. c. Voluntary Accident and Critical Illness Benefits – To age 26 regardless of marital status or student status. 7. Save and Print Your Elections! If your benefit elections are properly completed and saved, you will get a confirmation message on the screen that states, "Your benefit elections were saved.." If you do not receive a confirmation message, your elections were not properly completed. You must complete the election process again within 30 days of your new hire/new eligibility date. Go to My Benefits card to view and print a copy of your elections. You must have a copy of your 2023 benefit elections to report a problem with your enrollment. 2023 Premium Reduction Opportunities – EPO and PPO Medical Plans Team members are required to complete an annual application to determine eligibility for “Just Premium”. “Just Premium” aligns with our Mission and expands the offer of medical plan premium reductions to team members who apply and qualify for financial assistance based on total household income. Based upon your total household income (adjusted gross income), the number of dependents you claim on your 2021 Federal Income Tax Return, your FTE status (only available to full-time team members), and your hourly rate, you and your family may be eligible for the Just Premium reduction. DEPENDENTS LISTED ON TAX RETURN MAXIMUM HOUSEHOLD INCOME 0 to 1 $34,373 2 $35,482 3 $41,026 4 or more $46,570 Current Maximum Hourly Rate $32.00 Approved team members will receive higher FMOLHS medical plan subsidies to improve affordability and access to coverage. Team Members may select from the EPO or PPO Plans for themselves and their eligible dependents. Please submit a completed application and tax return within 30 calendar days of your new hire/new eligibility date. To apply for Just Premium: » Select My Benefits on our Total Rewards and then click on the Just Premium Application link. » Print and complete the application and attach a copy of the first two pages of your 2021 Federal Individual Income Tax Return. If you are married, filing jointly, submit one tax return. If you are married, filing single or head of household, you will be required to submit the first two pages of both your tax return and your spouse’s return. » Return application/tax return(s) to [email protected] or fax 225-765-9307 within 30 calendar days of your new hire/new eligibility date. Note Individuals who did not file a 2021 Income Tax Return will not be eligible for the 2023 Just Premium. My Health Benefits Blue Cross Blue Shield www.MyHealthToolkitLA.com/links/fmolhs • 833-468-3594 Health coverage is one of the most important benefits FMOLHS can provide. Health benefits provide significant value through support for and protection against potentially large financial expenses, as well as covering preventive care. FMOLHS is committed to keeping team members healthy and productive by offering comprehensive health care plans. The option you choose will be in place for all of 2023, unless you have a qualifying life event. Health benefits will be administered by Blue Cross Blue Shield. How Do I Find a Provider? FMOLHS has a customized provider directory for its Plan members. To see the current list of the FMOLHS EPO Network or PPO Tier 1 or Tier 2 Network providers online, visit www.MyHealthToolkitLA.com/links/fmolhs. If you do not have access to the website, please call Blue Cross Blue Shield Customer Service at 833-468-3594 for assistance. Navigate Our Provider Network the Easy Way STEP 1 FINDING AN IN-NETWORK PROVIDER We understand the importance of finding a healthcare provider who can best meet the needs of you and your family. We also understand how daunting it might be to scroll through a list of doctors in search of the best fit. That’s why we offer team members a resource to help navigate our FMOLHS customized network. They are called Network Guides, and they are available in most locations by phone 24/7 for team members in both Louisiana and Mississippi. Whether it be our EPO network or our PPO Tier 1 or Tier 2 network, our Network Guides can help you: • Find a provider in network • Check if a provider you are already seeing is in network prior to enrollment • Assist with scheduling an appointment with network-based primary care physicians • Check availability of a specialty service within our network Call (855) 875-6265 to connect with a Network Guide today. You will be prompted to select a guide for either our Louisiana or Mississippi network. We offer a variety of ways to connect and access care with an FMOLHS primary care provider. Your PCP is responsible for providing comprehensive care, for having knowledge of your overall medical history, and in assisting you with navigating certain health risks and your healthcare journey. If you need services that are not available within our EPO or PPO Tier 1 or Tier 2 network, Network Exceptions are available. To receive an exception, you must complete the Network Exception form on the Total Rewards My Benefits page and have it signed by your provider. Signed and completed forms must be submitted to BCBS of South Carolina before services are rendered to be considered. BCBS SC will notify you of their decision on your request. Submit all completed requests in writing via fax to (803) 264-0259, by email to FMOLHSEXCEPTION@ BCBSSC.COM or by mail to: Blue Cross Blue Shield of South Carolina Attn: Network Waiver, AX-630 PO Box 100300 Columbia, SC 29202 NOTE: The network exception MUST be requested and approved before services are rendered. If the request is made after services are rendered, it will not be considered unless otherwise required by law. Road Map to Care Think of your Primary Care Physician (PCP) as your go-to for your health care needs. Your PCP plays an important role in your healthcare journey. Ultimately, building a relationship with your PCP and going to them regularly for illnesses, yearly checkups and screenings can lead to better health outcomes and a higher level of satisfaction with care. In need of a Primary Care Physician? Our Network Guides can help you find a provider. Call now at 855-875-6265. First Stop Primary Care Physician (PCP) Having one doctor who knows your overall health history and can better guide you as you navigate certain health risks leads to better patient experience. There are several ways you can connect and receive care from your in-network PCP, through in-person visits to convenient virtual visits like video or virtual extended hours. See our network navigator page to learn more about each care opportunity available in your area. Second Stop If it's the weekend or it’s later in the evening, Virtual Extended Hours and Urgent Care are good options to consider. Third Stop There are several medical conditions that are considered emergencies because treatment is only available in a hospital setting. Which Plan Is Right for Me — the EPO Plan, PPO Plan or HDHSA Plan? Choosing the most cost-effective health plan is more than just signing up for the one with the lowest paycheck deduction. EPO Plan The EPO Plan provides access to a narrow network of healthcare providers that are either a part of our health system or considered our preferred partners. This means that the plan will allow for eligible medical services as long as you visit a healthcare provider — doctor, hospital or other place offering health care services — within our narrow EPO network. With this plan, the cost shared by you will be lower, whether that is through premiums, copays, deductibles or your out-of-pocket-maximum limit for the year. The plan offers a $250 individual and $500 family deductible and a $0 copay for PCP office visits. Upon enrolling in the EPO Plan, you will gain access to providers who offer high quality care and who are more clinically integrated with our organization’s electronic medical record system, allowing for more comprehensive care. In addition, you can designate a primary care provider (PCP) that can act as your personal health advocate and coordinate your healthcare. It’s important to know that coverage for medical services outside of the EPO network will only be allowed in the event a medical service is needed that is not available within the network. In an emergency, however, eligible services will be covered. This plan may be a better option for those who would like lower deductibles and copays at time of service as well as overall reduced out-of-pocket expense. PPO Plan The PPO health plan design has higher deductibles, coinsurance and copays than the EPO Plan, and continues to offer out-of-network coverage for most services. The pharmacy design copays remain the same including the specialty copays — $100 if filled at RxONE and $150 if filled by Express Scripts. If you reside outside of Louisiana or Mississippi, you are eligible for out-of-area coverage at the Tier 2 coverage level if you see a BCBS provider in your home state. The out-of-area coverage is based solely upon the employed team member’s address outside of Louisiana or Mississippi. The PPO has higher monthly premiums, but offers out-of- network coverage if needed. This plan choice is beneficial for those individuals who need out-of-area coverage or need a broader network coverage including out-of-network coverage. HDHSA Plan The HDHSA Plan design has higher deductibles and out-of-pocket maximums along with FMOLHS funding. FMOLHS will provide $750 individual and $1500 family contribution to your HSA account to help with out-of-pocket medical expenses. The deductibles for the HDHSA Plan are $1,750 individual and $3,500 family. If you can take on more financial risk, perhaps you might consider the HDHSA Plan. With a High Deductible Health Plan and a Health Savings Account (HSA), you can save additional pre-tax dollars to pay for medical expenses. You decide how to spend your dollars. Unused HSA dollars roll over from year-to- year. (There are restrictions and limitations to enrollment in the HSA.) Choosing the health plan that is right for you is important. You want to make sure you’re covered for the year ahead, while ensuring you choose the most effective option based on your personal health needs. CONSIDER THE EPO PLAN CONSIDER THE PPO PLAN CONSIDER THE HDHSA PLAN MY HEALTHCARE NEEDS I HAVE A CHRONIC DISEASE, SEE SPECIALIST PHYSICIANS, AND/ OR TAKE SEVERAL BRAND PRESCRIPTION MEDICATIONS. I AM VERY HEALTHY, HAVE NO PLANNED MEDICAL PROCEDURES, TAKE ONE GENERIC PRESCRIPTION MEDICATION AND ONLY HAVE ROUTINE PREVENTIVE CARE. I HAVE A SURGERY SCHEDULED AND CAN USE TIER 1 PROVIDERS. I AM PREGNANT OR PLAN TO BECOME PREGNANT. I HAVE SAVED DOLLARS TO PAY TOWARD MY DEDUCTIBLE AND CAN AFFORD TO PAY THE CO-INSURANCE COSTS OF MY MEDICAL CARE. I HAVE YOUNG CHILDREN WHO ARE OFTEN SICK OR INJURED. I AM LOOKING FOR A HIGH DEDUCTIBLE PLAN THAT ALLOWS ME TO PAY FOR HEALTHCARE EXPENSES WITH DOLLARS I SAVE ONCE I RETIRE. I SEE A PROVIDER THAT IS IN TIER 3 OF THE PPO NETWORK AND WOULD LIKE TO CONTINUE TO SEE THIS PROVIDER EVEN THOUGH MY OUT OF POCKET EXPENSE IS HIGHER. I WORK REMOTELY IN A STATE OTHER THAN LA OR MS AND NEED TO ACCESS CARE FOR MYSELF AND MY FAMILY How Will I Be Billed for a Physician Office Visit? If you are enrolled in the EPO Plan and choose a provider in the EPO network, your primary care visit will be a $0 copay. There is no coverage outside of the EPO network. If you are enrolled in the PPO Plan, your office visit copay pays for your share of the cost of the office visit. When you have additional services, those services are subject to deductible and coinsurance. All services under the HDHSA Plan are subject to deductible and coinsurance. The chart below gives examples of how services would process under the EPO and PPO Plan. IF YOU HAVE: YOU WILL PAY UNDER EPO PLAN: YOU WILL PAY UNDER PPO PLAN: PCP Office Visit No Cost Copay Specialty Office Visit Copay Copay Injections Included with Applicable Office Visit Copay* Deductible & Coinsurance X-rays Included with Applicable Office Visit Copay* Deductible & Coinsurance Lab work Included with Applicable Office Visit Copay* Deductible & Coinsurance *For some services, coinsurance and deductible may apply. How Will I Be Billed for Medical Services? The chart below gives examples of medical services that require the attention of a physician who may send a separate bill for payment. IF YOU HAVE: YOU WILL ALSO RECEIVE A BILL FROM: X-rays The radiologist Certain lab tests The pathologist Surgery The anesthesiologist & surgeon Visit by your personal physician Your personal physician EKG Cardiologist Please note for the PPO Plan: If you have a procedure performed at an FMOLHS facility, your provider may or may not be a FMOLHS Network Tier 1 provider. If the provider is not a FMOLHS Network Tier 1 provider, but is an in-network provider, you will receive a separate bill from the provider for the services performed and the provider will be paid at the Tier 2 benefit level. For example: if you have elected the PPO Plan (80% FMOLHS Network Tier 1 / 70% Preferred Provider Network Tier 2) you would be responsible for 30% of the in-network anesthesiologist’s bill after you have met your deductible. How Do I View My Medical Claims Online? To register for Blue Cross Blue Shield Online Services, after you receive your new medical ID card visit www.MyHealthToolkitLA.com/links/FMOLHS. You will need your medical ID card to register. » Select Register Now » Select Register » Follow the steps given to register www.MyHealthToolKitLA.com/links/FMOLHS allows you to: » View medical claims » View or print explanations of benefits » View, request or print an ID card » Find a network provider What If a Medical Service or a Claim Is Denied? What Are My Appeal Rights? When a claim for benefits or service denial occurs under the FMOLHS Health Plan, the member receives an explanation of benefits (EOB) or service denial letter explaining the reason for the denial. The member has the right to file an appeal to request a review of the denial. The appeal should include policy holder name, health plan ID number, patient name, details regarding the claim/service being appealed (such as a claim number), and date and provider of service. For full details, please see the Grievances and Appeals Process in the FMOLHS Health Plan Document posted on your facility intranet. You must file an appeal within 180 days after you have been notified of the denial of benefits. Send requests for review of a denial of benefits by mail to: Blue Cross Blue Shield Columbia Service Center Attention: Appeals Coordinator AX-830 P.O. Box 100121 Columbia, SC 29202-3121 Health Plan Summaries The charts below give a summary of the 2023 Health Plans for FMOLHS. All covered services are subject to medical necessity as determined by the Plan. All out-of-network services are subject to reasonable and customary (R&C) limitations. EPO Plan The Plan will pay the designated percentage of covered charges if the provider is in the EPO network until out-of-pocket amounts are reached, at which time the Plan will pay 100% of the remainder of covered charges for the rest of the calendar year unless stated otherwise. The following charges do not apply toward the out-of-pocket maximum and are never paid at 100%: deductible(s), cost containment penalties, and above usual and customary charges. There is no out-of-network coverage under the EPO Plan unless otherwise required by law. EPO PLAN FMOLHS EPO NETWORK OUT-OF-NETWORK ANNUAL DEDUCTIBLE EMPLOYEE ONLY $250 No Coverage EMPLOYEE WITH DEPENDENTS $500 No Coverage MAXIMUM OUT-OF-POCKET (INCLUDES DEDUCTIBLE) EMPLOYEE ONLY $2,000 No Coverage EMPLOYEE WITH DEPENDENTS $4,000 No Coverage OFFICE VISIT PRIMARY CARE PHYSICIAN (PCP) $0 copay No Coverage SPECIALIST $35 copay No Coverage EMERGENCY ROOM/URGENT CARE EMERGENCY ROOM $250 copay $250 copay URGENT CARE $60 copay No Coverage OTHER COPAYS OUTPATIENT SURGERY $250 copay No Coverage INPATIENT $200 copay per day (4 day/$800 max) No Coverage PHYSICIAN SERVICES INPATIENT VISITS Included in Inpatient copay No Coverage OUTPATIENT Included in Office Visit copay, Outpatient Surgery copay, or 100% coverage after deductible (depending on place of service) No Coverage HOSPITAL SERVICES ROOM AND BOARD Included in Inpatient copay No Coverage INTENSIVE CARE UNIT Included in Inpatient copay No Coverage OUTPATIENT SURGERY Included in outpatient surgery copay No Coverage SKILLED NURSING FACILITY $200 copay per day (4 day/$800 max) No Coverage BARIATRIC SURGERY Plan Coverage for Bariatric surgery is available only to a Full-Time or Part-Time Active employee who is a Class A Participant who remains in that status on the date of service and satisfies the requirements in Exhibit C and employee’s covered spouse and dependent who satisfies the requirements in Exhibit C. $3,000 copay; Surgery must be performed at a MBSAQIP Accredited FMOLHS facility No Coverage ORGAN TRANSPLANT Blue Distinction Centers coverage only. 90% coverage after deductible when performed at Blue Distinction Center facility No Coverage OTHER SERVICES ALLERGY TESTING 90% coverage after deductible or included in office visit copay, depending on place of service No Coverage ALLERGY SERUM AND INJECTIONS 90% coverage after deductible or included in office visit copay, depending on place of service No Coverage OTHER INJECTIONS 90% coverage after deductible or included in office visit copay, depending on place of service EPO PLAN (CONTINUED) FMOLHS EPO NETWORK OUT-OF-NETWORK OTHER SERVICES DIAGNOSTICS 90% coverage after deductible or included in office visit copay, depending on place of service No Coverage LABORATORY 90% coverage after deductible or included in office visit copay, depending on place of service No Coverage CHEMOTHERAPY 90% coverage after deductible or included in office visit copay, depending on place of service No Coverage HOME HEALTH CARE 90% coverage after deductible; limited to 50 visits per calendar year No Coverage HOSPICE CARE 90% coverage after deductible No Coverage AMBULANCE SERVICE 90% coverage after deductible No Coverage OCCUPATIONAL THERAPY PHYSICAL THERAPY SPEECH THERAPY 90% coverage after deductible; maximum of 120 visits per year (and maximum of 20 visits per week) combined Occupational, Physical, and Speech Therapy No Coverage APPLIED BEHAVIOR ANALYSIS (ABA) 90% coverage after deductible maximum of 20 hours per week annually No Coverage SPECIFIC GENETIC TESTING (MUST SATISFY MEDICALLY NECESSARY CRITERIA) 90% coverage after deductible drawn/ordered by FMOLHS Geneticist No Coverage SMOKING CESSATION AIDS Smoking cessation is available through the prescription benefit program. 100% coverage of screening for tobacco use and two tobacco cessation attempts per year which includes four tobacco cessation counseling sessions of at least 10 minutes each without prior authorization and 90 day supply of Smoking Cessation Aids when prescribed by a health care provider without prior authorization No Coverage DURABLE MEDICAL EQUIPMENT (DME) 90% coverage after deductible No Coverage INSULIN PUMP 90% coverage after deductible; limited to 1 per 5 years No Coverage ORTHOTICS AND PROSTHETICS 90% coverage after deductible No Coverage GENERIC DIABETES PRESCRIPTION MEDICATIONS AND SUPPLIES 100% coverage of Generic Diabetes Prescription Medications and Preferred Supplies through the pharmacy benefit. No coverage MENTAL HEALTH AND SUBSTANCE ABUSE INPATIENT INCLUDING PARTIAL HOSPITALIZATION (PHP), INTENSIVE OUTPATIENT PROGRAM (IOP), AND RESIDENTIAL $200 copay per day (4 day/$800 max) No Coverage OFFICE VISIT $0 Copay No Coverage OTHER OUTPATIENT SERVICES 90% coverage after deductible or included in office visit copay, depending on place of service No Coverage PREGNANCY CARE AND DELIVERY LABOR & DELIVERY AND ASSOCIATED CHARGES $200 copay per day (4 day/$800 max) No Coverage MATERNAL/FETAL ULTRASOUND 90% coverage after deductible or included in office visit copay, depending on place of service and other than included in prenatal care No Coverage IN NETWORK BREAST PUMP AND LACTATION COUNSELING THROUGH HEALTHY LIVES 100% coverage No Coverage PRE-NATAL CARE One-time $50 copay applies for coverage of routine OB visits, initial routine labs and one ultrasound per term pregnancy. No Coverage PREVENTIVE CARE ROUTINE WELL ADULT CARE Generally limited to approved preventive or wellness services, which could include the following annual screenings depending on your age, gender, and health status: Lipid (Cholesterol), HGB A1C (Diabetes), Bone Marrow Density Test, Mammogram, Pap Test, Fecal Occult Blood Test, Colonoscopy, Depression Screening, Obesity Screening and Counseling. *Please call the Claims Administrator to confirm coverage 100% coverage Limited to one routine physical examination annually and approved wellness screenings annually No Coverage ADULT IMMUNIZATIONS Immunizations are subject to current CDC Recommendations which include age limitations 100% coverage No Coverage ROUTINE WELL CHILD CARE Unlimited routine office visits through age two (2); annually ages three (3) up. Includes: office visits, routine physical examination and immunizations in accordance with CDC Guidelines and preventive care in accordance with federal guidelines. 100% coverage No Coverage *FMOLHS follows federal guidelines for coverage of preventive/wellness screenings. PPO Plan The Plan will pay the designated percentage of covered charges until out-of-pocket amounts are reached, at which time the Plan will pay 100% of the remainder of covered charges for the rest of the calendar year unless stated otherwise. The following charges do not apply toward the out-of-pocket maximum and are never paid at 100%: deductible(s), cost containment penalties, and above usual and customary charges. PPO PLAN FMOLHS NETWORK (TIER 1) PREFERRED PROVIDER NETWORK (TIER 2) NON-PREFERRED PROVIDER (TIER 3) OUT-OF-NETWORK ANNUAL DEDUCTIBLE EMPLOYEE ONLY $800 $800 $3,000 $5,000 EMPLOYEE WITH DEPENDENTS $1,600 $1,600 $6,000 $10,000 MAXIMUM OUT-OF-POCKET (INCLUDES DEDUCTIBLE) EMPLOYEE ONLY $3,000 $4,000 $6,000 $10,000 EMPLOYEE WITH DEPENDENTS $6,000 $8,000 $12,000 $20,000 Out of Area Coverage. A subscriber (team member) who is enrolled in the PPO Plan and whose home address is in a state other than Louisiana or Mississippi may (i) access care at Tier 2 network coverage with a BCBS PPO network provider in their home state for themselves and their enrolled dependents or (ii) access providers in the FMOLHS Louisiana and Mississippi networks at Tier 1 or Tier 2 coverage. Any other network access would follow the Tier 3 or Out-of-Network coverage. The Out of Area Coverage is based solely on the subscriber’s (team member’s) home address. A dependent’s address does not entitle the dependent to Out of Area Coverage. OFFICE VISIT PCP/MEDICAL HOME $5 copay office visit only, all other services subject to deductible and coinsurance $30 copay office visit only, all other services subject to deductible and coinsurance 60% coverage after deductible 40% coverage after deductible SPECIALIST $45 copay office visit only, all other services subject to deductible and coinsurance $70 copay office visit only, all other services subject to deductible and coinsurance EMERGENCY ROOM/URGENT CARE EMERGENCY ROOM 80% coverage after deductible URGENT CARE $75 copay $75 copay 60% coverage after deductible 40% coverage PHYSICIAN SERVICES INPATIENT VISITS 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible OUTPATIENT 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible HOSPITAL SERVICES ROOM AND BOARD 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible INTENSIVE CARE UNIT 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible SURGERY 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible SKILLED NURSING FACILITY 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible BARIATRIC SURGERY Plan Coverage for Bariatric surgery is available only to a Full-Time or Part-Time Active employee who is a Class A Participant who remains in that status on the date of service and satisfies the requirements in Exhibit C and employee’s covered spouse and dependent who satisfies the requirements in Exhibit C $3,000 copay; Surgery must be performed at a MBSAQIP Accredited FMOLHS facility No coverage No coverage No coverage ORGAN TRANSPLANT Blue Distinction Centers coverage only. 80% coverage after deductible when performed at Blue Distinction Center facility No coverage OTHER SERVICES ALLERGY TESTING 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible ALLERGY SERUM AND INJECTIONS 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible OTHER INJECTIONS 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible DIAGNOSTICS 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible LABORATORY 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible CHEMOTHERAPY 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible HOME HEALTH CARE 80% coverage after deductible; maximum of 50 visits per calendar year 70% coverage after deductible; maximum of 50 visits per calendar year 60% coverage after deductible; maximum of 50 visits per calendar year No coverage HOSPICE CARE 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible AMBULANCE SERVICE 80% coverage after deductible PPO PLAN (CONTINUED) FMOLHS NETWORK (TIER 1) PREFERRED PROVIDER NETWORK (TIER 2) NON-PREFERRED PROVIDER (TIER 3) OUT-OF-NETWORK OTHER SERVICES OCCUPATIONAL THERAPY PHYSICAL THERAPY SPEECH THERAPY 80% coverage after deductible; 70% coverage after deductible 60% coverage after deductible No coverage Maximum of 120 visits per year (and maximum of 20 visits per week) combined with Occupational, Physical, and Speech Therapy APPLIED BEHAVIOR ANALYSIS (ABA) 80% coverage after deductible; max 20 hours per week annually 70% coverage after deductible; max 20 hours per week annually 60% coverage after deductible; max 20 hours per week annually No coverage SPECIFIC GENETIC TESTING (MUST SATISFY MEDICALLY NECESSARY CRITERIA) 80%; drawn/ordered by FMOLHS Geneticist No coverage No coverage No coverage SMOKING CESSATION AID Smoking cessation is available through the prescription benefit program 100% coverage of screening for tobacco use and two tobacco cessation attempts per year which includes four tobacco cessation counseling sessions of at least 10 minutes each without prior authorization and 90 day supply of Smoking Cessation Aids when prescribed by a health care provider without prior authorization No coverage DURABLE MEDICAL EQUIPMENT (DME) 80% coverage after deductible; 70% coverage after deductible 60% coverage after deductible No coverage INSULIN PUMP 80% coverage after deductible; limited to 1 per 5 years 70% coverage after deductible; limited to 1 per 5 years 60% coverage after deductible; limited to 1 per 5 years No coverage ORTHOTICS AND PROSTHETICS 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible GENERIC DIABETES PRESCRIPTION MEDICATIONS AND PREFERRED SUPPLIES 100% coverage of Generic Diabetes Prescription Medications and Preferred Supplies through the pharmacy benefit No coverage No coverage MENTAL/NERVOUS AND SUBSTANCE ABUSE INPATIENT Including Partial Hospitalization (PHP), Intensive Outpatient Program (IOP) and Residential 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible OFFICE VISIT ONLY $5 copay $30 copay 60% coverage after deductible 40% coverage after deductible OTHER OUTPATIENT SERVICES 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible PREGNANCY CARE AND DELIVERY LABOR & DELIVERY AND ASSOCIATED CHARGES 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible MATERNAL/FETAL ULTRASOUND 80% coverage after deductible; other than included in pre-natal care 70% coverage after deductible; other than included in pre-natal care 60% coverage after deductible; other than included in pre-natal care 40% coverage after deductible IN NETWORK BREAST PUMP AND LACTATION COUNSELING THROUGH HEALTHY LIVES 100% coverage 100% coverage 100% coverage No coverage PRE-NATAL CARE One time $50 copay applies to routine OB visits, initial routine labs and one ultrasound per term pregnancy. 40% coverage after deductible PREVENTATIVE CARE ROUTINE WELL ADULT CARE Generally limited to approved preventive or wellness services, which could include the following annual screenings depending on your age, gender, and health status: Lipid (Cholesterol), HGB A1C (Diabetes), Bone Marrow Density Test, Mammogram, Pap Test, Fecal Occult Blood Test, Colonoscopy, Depression Screening, Obesity Screening and Counseling.* Please call the Claims Administrator to confirm coverage 100% coverage Limited to one routine physical examination annually and approved wellness screenings annually. 100% coverage Limited to one routine physical examination annually and approved wellness screenings annually. 100% coverage Limited to one routine physical examination annually and approved wellness screenings annually. 40% coverage after deductible; Limited to one routine physical examination annually and approved wellness screenings annually. ADULT IMMUNIZATIONS Immunizations are subject to current CDC Recommendations which include age limitations 100% coverage 100% coverage 100% coverage 40% coverage after deductible ROUTINE WELL CHILD CARE Unlimited routine office visits through age two (2); annually ages three (3) up. Includes: office visits, routine physical examination and immunizations in accordance with CDC Guidelines and preventive care in accordance with federal guidelines. 100% coverage 100% coverage 100% coverage 40% coverage after deductible *FMOLHS follows federal guidelines for coverage of preventive wellness screenings. HDHSA HDHSA Plan – A high deductible health plan with a tax-free health savings account (HSA). You determine how much you’ll contribute to the account, when to use the money to pay for qualified medical, prescription, dental and vision services, and when to reimburse yourself. HSAs allow you to save and roll over money if you do not spend it in the calendar year. The money in this account is portable, even if you change plans or jobs. Company HSA contributions will be pro-rated based on enrollment date. You cannot open an HSA if: » You have other health coverage that helps you pay for health care expenses before your deductible is met. » You or your spouse has a flexible spending account (FSA) or health reimbursement arrangement (HRA). (You are allowed to participate in a Limited Use FSA, which would only cover Dental and Vision expenses.) » You also have Medicare or TRICARE. » Someone else can claim you as a dependent. » You have used Veterans Affairs hospital or medical services in the three months prior to opening your HSA, unless it was for a disability related to your military service. HIGH DEDUCTIBLE HSA PLAN FMOLHS NETWORK (TIER 1) PREFERRED PROVIDER NETWORK (TIER 2) NON-PREFERRED PROVIDER (TIER 3) OUT-OF-NETWORK HSA ANNUAL CONTRIBUTIONS EMPLOYEE ONLY $750 EMPLOYEE WITH DEPENDENTS $1,500 ANNUAL DEDUCTIBLE (AGGREGATED) EMPLOYEE ONLY $1,750 $1,750 $3,500 $4,000 EMPLOYEE WITH DEPENDENTS $3,500 $3,500 $7,000 $8,000 MAXIMUM OUT-OF-POCKET (INCLUDES DEDUCTIBLE) (EMBEDDED OOP) EMPLOYEE ONLY $3,500 $4,000 $7,000 $10,500 EMPLOYEE WITH DEPENDENTS $7,000 $8,000 $14,000 $21,000 The Out of Area coverage is not available under the High Deductible HSA Plan. OFFICE VISIT CHARGE ONLY PRIMARY CARE PHYSICIAN (PCP) 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible SPECIALIST 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible EMERGENCY ROOM/URGENT CARE EMERGENCY ROOM 80% coverage after deductible 80% coverage after deductible 80% coverage after deductible 80% coverage after deductible URGENT CARE 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible PHYSICIAN SERVICES INPATIENT VISITS 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible OUTPATIENT 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible HOSPITAL SERVICES ROOM AND BOARD 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible INTENSIVE CARE UNIT 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible SURGERY 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible SKILLED NURSING FACILITY 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible HDHSA PLAN (CONTINUED) FMOLHS NETWORK (TIER 1) PREFERRED PROVIDER NETWORK (TIER 2) NON-PREFERRED PROVIDER (TIER 3) OUT-OF-NETWORK HOSPITAL SERVICES BARIATRIC SURGERY Plan Coverage for Bariatric surgery is available only to a Full-Time or Part-Time Active employee who is a Class A Participant who remains in that status on the date of service and satisfies the requirements in Exhibit C and employee’s covered spouse and dependent who satisfies the requirements in Exhibit C $3,000 copay; Surgery must be performed at a MBSAQIP Accredited FMOLHS facility No coverage No coverage No coverage ORGAN TRANSPLANT Blue Distinction Centers coverage only 80% coverage after deductible when performed at Blue Distinction Center facility No coverage OTHER SERVICES ALLERGY TESTING 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible ALLERGY SERUM AND INJECTIONS 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible OTHER INJECTIONS 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible DIAGNOSTICS 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible LABORATORY 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible CHEMOTHERAPY 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible HOME HEALTH CARE 80% coverage after deductible; maximum of 50 visits per calendar year 70% coverage after deductible; maximum of 50 visits per calendar year 60% coverage after deductible; maximum of 50 visits per calendar year No coverage HOSPICE CARE 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible AMBULANCE SERVICE 80% coverage after deductible OCCUPATIONAL THERAPY PHYSICAL THERAPY SPEECH THERAPY 80% coverage after deductible; 70% coverage after deductible 60% coverage after deductible No coverage Maximum of 120 visits per year (and maximum of 20 visits per week) combined with Occupational, Physical, and Speech Therapy APPLIED BEHAVIOR ANALYSIS (ABA) 80% coverage after deductible; max 20 hours per week annually 70% coverage after deductible; max 20 hours per week annually 60% coverage after deductible; max 20 hours per week annually No coverage SPECIFIC GENETIC TESTING (MUST SATISFY MEDICALLY NECESSARY CRITERIA) 80%; drawn/ordered by FMOLHS Geneticist No coverage No coverage No coverage SMOKING CESSATION AID Smoking cessation is available through the prescription benefit program 100% coverage of screening for tobacco use and two tobacco cessation attempts per year which includes four tobacco cessation counseling sessions of at least 10 minutes each without prior authorization and 90 day supply of Smoking Cessation Aids when prescribed by a health care provider without prior authorization No coverage DURABLE MEDICAL EQUIPMENT (DME) 80% coverage after deductible; 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible INSULIN PUMP 80% coverage after deductible; limited to 1 per 5 years 70% coverage after deductible; limited to 1 per 5 years 60% coverage after deductible; limited to 1 per 5 years No coverage ORTHOTICS AND PROSTHETICS 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible GENERIC DIABETES PRESCRIPTION MEDICATIONS AND PREFERRED SUPPLIES Employee must satisfy deductible 100% coverage of Generic Diabetes Prescription Medications and Preferred Supplies through the pharmacy benefit No coverage No coverage MENTAL/NERVOUS AND SUBSTANCE ABUSE INPATIENT Including Partial Hospitalization (PHP), Intensive Outpatient Program (IOP) and Residential 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible OFFICE VISIT ONLY 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible OTHER OUTPATIENT SERVICES 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible PREGNANCY CARE AND DELIVERY LABOR & DELIVERY AND ASSOCIATED CHARGES 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible MATERNAL/FETAL ULTRASOUND 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible HDHSA PLAN (CONTINUED) FMOLHS NETWORK (TIER 1) PREFERRED PROVIDER NETWORK (TIER 2) NON-PREFERRED PROVIDER (TIER 3) OUT-OF-NETWORK PREGNANCY CARE AND DELIVERY IN-NETWORK BREAST PUMP AND LACTATION COUNSELING THROUGH HEALTHY LIVES 100% coverage 100% coverage 100% coverage No coverage PRE-NATAL CARE 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible PREVENTATIVE CARE ROUTINE WELL ADULT CARE Generally limited to approved preventive or wellness services, which could include the following annual screenings depending on your age, gender, and health status: Lipid (Cholesterol), HGB A1C (Diabetes), Bone Marrow Density Test, Mammogram, Pap Test, Fecal Occult Blood Test, Colonoscopy, Depression Screening, Obesity Screening and Counseling. *Please call the Claims Administrator to confirm coverage 100% coverage Limited to one routine physical examination annually and approved wellness screenings annually. 100% coverage Limited to one routine physical examination annually and approved wellness screenings annually. 100% coverage Limited to one routine physical examination annually and approved wellness screenings annually. 40% coverage after deductible; Limited to one routine physical examination annually and approved wellness screenings annually. ADULT IMMUNIZATIONS Immunizations are subject to current CDC Recommendations which include age limitations 100% coverage 100% coverage 100% coverage 40% coverage after deductible ROUTINE WELL CHILD CARE Unlimited routine office visits through age two (2); annually ages three (3) up. Includes: office visits, routine physical examination and immunizations in accordance with CDC Guidelines and preventive care in accordance with federal guidelines. 100% coverage 100% coverage 100% coverage 40% coverage after deductible *FMOLHS follows federal guidelines for coverage of preventive wellness screenings. Note When you enroll in the HSA plan, PayFlex will provide you with a debit card that includes the FMOLHS annual contribution to help pay for eligible expenses. Health Plan Premiums (Bi-weekly Team Member Contributions – 26 Contributions) HEALTH PLAN PREMIUMS (BI-WEEKLY TEAM MEMBER CONTRIBUTIONS – 26 CONTRIBUTIONS) TEAM MEMBER ONLY TEAM MEMBER & SPOUSE TEAM MEMBER + CHILD(REN) FAMILY EPO PLAN JUST PREMIUM $21.89 $95.40 $43.27 $118.85 STANDARD PREMIUM $50.52 $163.16 $100.17 $214.65 PART-TIME PREMIUM $50.56 $274.74 $184.36 $356.20 TEAM MEMBER ONLY TEAM MEMBER & SPOUSE TEAM MEMBER + CHILD(REN) FAMILY PPO PLAN JUST PREMIUM $48.23 $180.39 $90.93 $228.96 STANDARD PREMIUM $100.54 $257.67 $180.75 $337.88 PART-TIME PREMIUM $146.51 $365.53 $271.72 $490.74 TEAM MEMBER ONLY TEAM MEMBER & SPOUSE TEAM MEMBER + CHILD(REN) FAMILY HDHSA PLAN JUST PREMIUM N/A N/A N/A N/A STANDARD PREMIUM $82.00 $222.74 $191.00 $308.00 PART-TIME PREMIUM $119.50 $315.97 $287.12 $405.50 My Pharmacy Benefits Express Scripts (ESI) • www.express-scripts.com • 877-816-8717 Prescription Drug Coverage for Medical Plans Your prescription drug program will be coordinated through Express Scripts (ESI). Your cost is determined by the tier assigned to the prescription drug product. All prescription drug products on the prescription drug list (Express Scripts' National Preferred Formulary) are assigned as Generic, Preferred, Non-Preferred and Specialty. You may contact ESI for information on your benefit coverage and search for network pharmacies by logging on to www.express-scripts.com or calling ESI Customer Care at 877-816-8717. Why Do My Prescriptions Cost So Much? In recent years, drug costs have increased, outpacing inflation by nearly four times annually. Rising drug costs are one of the single largest causes of the ballooning cost of health care. Although rising drug costs are inevitable, there are many ways you, the patient, with the help of your physician, can minimize your prescription drug costs while maintaining the same quality of health. You share the cost of your medications with your employer. Your share of the cost is called a copay or coinsurance. Some plans offer lower copays for less costly drugs. For example, they charge one copay for a Generic drug, a higher copay for a Preferred drug, and an even higher copay for a Non-Preferred drug. Coinsurance is a percent of the drug’s cost. When you pay a percentage, your cost may be high for many reasons: » The cost of the drug may be high. Let’s assume your coinsurance is 20%. In this case, a $250 drug will be more costly than a $25 drug. » Your drug may not be on the Preferred Drug List, so you pay at a higher tier. » You may be buying a more expensive brand-name drug when there is a generic equivalent available for less money. How Can I Minimize My Medication Costs? » Consider Mail Order for your maintenance medications. You receive a 3-month supply for only two copays if you fill your prescription at RxONE. Example: EPO PLAN ANNUAL COST PRESCRIPTION GENERIC – IN-HOUSE $10 per month $120 GENERIC – MAIL ORDER $20 per 3 months $80 YOUR ANNUAL SAVINGS N/A $40 » You can explore the benefits available to you before enrolling by visiting https://www.express-scripts.com/fmolhs. Here you can review plan options, find prices on medications under the plan, and explore an overview of the benefits offered. » Print a copy of the Express Scripts National Preferred formulary and bring it with you when you visit your physician. Log on to www.express-scripts.com, and click on Register. Once you complete the registration you will have access to your account information, benefits and formulary list. » Let your physician know that you would like to try generics first, if that is an appropriate option for you. » Ask your provider if there are Over-the-Counter (OTC) products available to obtain the same results as prescription medications. Often these OTC products will be less expensive than your copay and will provide the same relief. » Get a $5 discount when you fill your prescription at an in-house pharmacy. Get an additional $5 discount when your prescription is written by the Franciscan Clinic and filled at the in-house pharmacy. Refer to page 27 for a listing of the in-house pharmacy locations/services. EPO PRESCRIPTION PLAN COST IN-HOUSE NETWORK RETAIL PHARMACY (30-DAY SUPPLY) GENERIC DRUG $10 copay $15 copay GENERIC DIABETIC PRESCRIPTION MEDICATIONS AND SUPPLIES $0 copay $0 copay PREFERRED DRUG $35 copay $70 copay NON-PREFERRED DRUG $70 copay $110 copay SPECIALTY DRUG Filled by RxONE – $100 copay Filled by Express Scripts – $150 copay MAIL ORDER PHARMACY (90-DAY SUPPLY — RXONE OR EXPRESS SCRIPTS) GENERIC DRUG PREFERRED DRUG NON-PREFERRED DRUG 2x in-house copay* 3x network copay* BRAND-NAME DRUGS WHEN GENERIC IS AVAILABLE The brand copayment, plus the difference between the retail cost of the brand-name drug and of the generic drug. Note: The difference will not be applied to the out-of-pocket maximum. IMMUNIZATIONS According to CDC Immunization Schedules; Subject to age limitations *Mail order copays do not apply to mail order Specialty Prescriptions. PPO PRESCRIPTION PLAN COST IN-HOUSE NETWORK RETAIL PHARMACY (30-DAY SUPPLY) GENERIC DRUG $10 copay $15 copay GENERIC DIABETIC PRESCRIPTION MEDICATIONS AND SUPPLIES $0 copay $0 copay PREFERRED DRUG $45 copay $70 copay NON-PREFERRED DRUG $70 copay $110 copay SPECIALTY DRUG Filled by RxONE – $100 copay Filled by Express Scripts – $150 copay MAIL ORDER PHARMACY (90-DAY SUPPLY – RXONE OR EXPRESS SCRIPTS) GENERIC DRUG PREFERRED DRUG NON-PREFERRED DRUG 2x In-house copay* 3x Network copay* BRAND-NAME DRUGS WHEN GENERIC IS AVAILABLE The brand copayment, plus the difference between the retail cost of the brand-name drug and of the generic drug. Note: The difference will not be applied to the out-of-pocket maximum. IMMUNIZATIONS According to CDC Immunization Schedules; Subject to age limitations *Mail order copays do not apply to mail order Specialty Prescriptions. HDHSA PRESCRIPTION PLAN COST IN-HOUSE NETWORK RETAIL PHARMACY (30-DAY SUPPLY) GENERIC DRUG 20% after deductible 20% after deductible GENERIC DIABETIC PRESCRIPTION MEDICATIONS AND SUPPLIES 20% after deductible 20% after deductible PREFERRED DRUG 20% after deductible 20% after deductible NON-PREFERRED DRUG 20% after deductible 20% after deductible SPECIALTY DRUG (RXONE OR EXPRESS SCRIPTS) 20% after deductible 20% after deductible MAIL ORDER PHARMACY (90-DAY SUPPLY — RXONE OR EXPRESS SCRIPTS) GENERIC DRUG PREFERRED DRUG NON-PREFERRED DRUG 20% after deductible BRAND-NAME DRUGS WHEN GENERIC IS AVAILABLE The brand copayment, plus the difference between the retail cost of the brand-name drug and of the generic drug. Note: The difference will not be applied to the out-of-pocket maximum. IMMUNIZATIONS According to CDC Immunization Schedules; Subject to age limitations *Mail order copays do not apply to mail order Specialty Prescriptions. Preauthorization Requirement List Note: The following services, supplies and care must be preauthorized or reimbursement from the Plan may be