2023 FMOLHS Benefit Guide PDF

My Benefits 2023 Team Member Guide to Benefit Enrollment Open Enrollment | November 1 – 15 Enroll through Oracle I nformation 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. To...

My Benefits 2023 Team Member Guide to Benefit Enrollment Open Enrollment | November 1 – 15 Enroll through Oracle I nformation 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 booklet 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. This year we will have an interactive online learning experience available on our Total Rewards Open Enrollment 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 Open Enrollment page today. » Click here for the Total Rewards Open Enrollment page » Click here for 2023 Open Enrollment 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 will be available by phone or email for extended hours during Open Enrollment. » Phone: 833-482-7547 » Email: [email protected] Note DATES AVAILABLE HOURS November 1 – November 4 7am – 7pm November 5 8am – 12pm November 7 – November 11 7am – 7pm November 12 8am – 12pm November 14 – November 15 7am – 7pm In addition to these resources, we are committed to keeping you informed during the open enrollment period. Stay up to date on the latest communication and updates through: Oracle Employee Self Service, your FMOLHS email, fmolhs.org/TotalRewards and TeamTalk. 2 Your 2023 Enrollment Options Your enrollment options will be displayed in Oracle Employee Self‑Service in the following order: CURRENT ENROLLEE NEW ENROLLEE Your 2022 election terminates on December 31, 2022. You must re‑enroll in or waive coverage for 2023 through Oracle Employee Self‑Service. Team members who are within their first 30 days of eligibility may enroll through Oracle Employee Self‑Service. LINCOLN VOLUNTARY EMPLOYEE LIFE Team members currently enrolled may add $10,000 or $20,000 coverage. If you terminate coverage, you will not have an opportunity to re-enroll. Team members who are within their first 30 days of eligibility may enroll through Oracle Employee Self‑Service. LINCOLN VOLUNTARY SPOUSE LIFE LINCOLN VOLUNTARY DEPENDENT LIFE You will have an opportunity to review and maintain coverage through Oracle Employee Self‑Service. If you terminate coverage, you will not have an opportunity to re-enroll. Team members who are within their first 30 days of eligibility may enroll through Oracle Employee Self‑Service. LINCOLN VOLUNTARY CRITICAL ILLNESS LINCOLN VOLUNTARY ACCIDENT Your 2022 election terminates on December 31, 2022. You must re‑enroll in or waive coverage for 2023 through Oracle Employee Self‑Service. Team members who are within their first 30 days of eligibility may enroll through Oracle Employee Self‑Service. You will have an opportunity to review and maintain coverage through Oracle Employee Self‑Service. If you terminate coverage in a Grandfathered Plan, you will not have an opportunity to re‑enroll. Not available after 12/31/2014. You will no longer be able to pay for the premium via payroll deduction. If you desire to continue this GF Critical Illness Plan instead of enrolling in the New Lincoln Voluntary Critical Illness Plan, please contact Lincoln at 855-818-2883 for more information on how to pay the premium. N/A BENEFIT PLAN FMOLHS HEALTH PLAN HEALTH SAVINGS ACCOUNT MEDICAL FLEXIBLE SPENDING ACCOUNT MEDICAL LIMITED USE FLEXIBLE SPENDING ACCOUNT FMOLHS DENTAL PLAN VISION PLAN GRANDFATHERED (GF) PLANS GF GROUP LIFE PLANS GF LINCOLN CRITICAL ILLNESS PLAN THESE BENEFITS CONTINUE IN 2023 AS CURRENTLY ELECTED LONG TERM DISABILITY Your LTD elections will continue unless you terminate the coverage. Team members do not need to re‑enroll. Team members who previously waived coverage must complete evidence of insurability online at MyLincolnPortal.com by November 15, 2022 for eligibility review. Team members who are within their first 30 days of eligibility may enroll through Oracle Employee Self‑Service. GROUP BASIC LIFE (COMPANY‑PROVIDED) Company‑provided Basic Life Insurance coverage continues. Team members do not need to re‑enroll. Eligible Team members are automatically enrolled in the Basic Life Insurance. 403(b) AND 457(b) RETIREMENT ENROLLMENT PROCESS 403(b) AND 457(b) RETIREMENT PLANS Enroll through Lincoln Financial at LincolnFinancial.com/FMOLHS Eligible Team members enroll at LincolnFinancial.com/FMOLHS New in 2023 Enhanced Benefits and Reduced Premiums 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 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 61 for more information concerning Medicare Part D coverage. 3 Table of Contents 5 Important Information Open Enrollment 7 2023 Total Rewards Highlights November 1, 2022 – November 15, 2022 13 My Health Benefits 9 Enrollment 14 Navigating Our Network 27 My Pharmacy Benefits 30 Preauthorization Requirement List 34 My Health and Well-Being 37 39 41 43 45 47 My Dental Benefits My Vision Benefits My Health Savings Accounts – HSA My Flexible Spending Account – FSA My Life Insurance My Retirement Benefits 50 My Disability Insurance 55 My EAP 51 My Voluntary Benefits 57 My Discounts 61 Required Notices 66 Important Contacts In this guide we use the term “Company” to refer to FMOLHS. This guide is intended to describe the eligibility requirements, enrollment procedures, and coverage effective dates for the benefits program offered by the Company. It is not a legal plan document and does not imply a guarantee of employment or a continuation of benefits. This guide is not intended to answer all of your questions, but to provide you with a tool to answer most of your questions. Full details of the plans are contained in the Plan Documents, which are available on your facility intranet and govern each plan’s operation. Whenever an interpretation of a plan benefit is necessary, the actual plan documents will be used. 4 I mportant Information Enrollment for the 2023 Plan Year All team members are required to enroll or re‑enroll in the core benefits (Health, Dental, Vision, Medical FSA) and some voluntary benefits, whether you intend to make plan changes or not. Current core benefits will terminate on December 31, 2022, for any team members who do not re‑enroll by November 15, 2022. Member Cards » Medical Cards – Team members who currently participate in the Health Plan should maintain their current ID cards. If you would like a new card, you can access and print your digital ID card online. New cards will only be issued for new enrollees or changes in enrollment. » Dental Cards – Team members who currently participate in the Dental Plan should maintain their current ID cards. New cards will only be issued for new enrollees or change in enrollment. » Vision Cards – Team members who currently participate in the Vision Plan should maintain their current ID cards. New cards will only be issued for new enrollees or changes in enrollment. » Debit Cards – All team members who currently participate in the Medical Flexible Spending Account (FSA) or Health Savings Account (HSA) should maintain their current debit cards. 2023 elections will be funded on the current card by January 6, 2023. 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 Enrollment Dates for the 2023 Plan Year: Tuesday, November 1, 2022 through Tuesday, November 15, 2022. 5 I mportant 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. 6 Note Sign Up for My Health Toolkit at: www.MyHealthToolkitLA.com/links/FMOLHS 2023 Total Rewards Highlights Just as our team members are more than just our job descriptions and titles, our Total Rewards program is more than just compensation and benefits. Each year we evaluate all of our offerings and adjust and develop them with you in mind. These new programs and savings opportunities incorporate the feedback you’ve shared through past surveys and listening sessions on what’s important to you for benefit coverage, health, recognition and more. Increased Access to Providers in Our Network Growing Our Network FMOLHS has invested time in growing our primary care and specialty network to provide you with convenient access to care. We’ve added more providers, extended hours and offer virtual visits. All of our FMOLHS employed providers are in the EPO network and considered Tier 1 in our PPO network. Virtual Extended Hours Available in Louisiana As a team member, you receive priority when seeking care from our providers. Virtual Extended Hours offers video visits outside of normal hours of operation to address problems that don’t require a full physical exam. Team members are able to stay within our FMOLHS Provider network and receive convenient access to care, in the comfort of their home, for free under our EPO plan or for only $5 under our PPO plan. Appointments are available for all ages in Louisiana. We are working to expand this care opportunity to Mississippi. Schedule an appointment today using the MyChart app. We’re working on other ways to expand access to our providers including on-demand and other virtual care options. More information will be shared about new offerings throughout 2023 on our TeamTalk app. Healthcare Cost Saving Opportunities Health Plan Premiums It is a priority to make quality healthcare affordable for our team members. FMOLHS covers a substantial share of the premium price of plans so that the increase in price to team members is minimal each year. Medication Copay Savings and Personal Service Available through RxONE RxONE is our FMOLHS-owned, in-house pharmacy where you will receive reduced copays for prescriptions including mail order/90-day prescriptions and specialty medications. In addition to discounts, RxONE offers team members personal service through their in-store or curbside delivery options, faster fill times, immunizations, and ease of access to our pharmacists. Select an RxONE location as your pharmacy of choice and start taking advantage of these savings and personalized service options for your medications. See page 29 for a listing of RxONE locations. Reduced Health Premium Available Through Our Just Premium Program We recognize that health insurance can be a significant expense, which is why we offer a discounted premium opportunity called Just Premium. Team members must apply to be considered for the program, which is based on total household income. To apply, complete this application and submit your 2021 Federal Income Tax Return by November 15. The application along with more information is available on our Total Rewards website on the Open Enrollment page or by contacting askHR at [email protected]. New and Enhanced Programs Enhanced Accident and Critical Illness Benefit Effective on January 1, 2023, our Accident and Critical Illness benefit coverage, which is administered by Lincoln Financial, will offer numerous enhancements to our current plans, including more options and reduced rates. 7 Below is an overview of the key changes: Accident: » Accident coverage now extends to accidental injuries that occur on or off the job. » Enhanced benefits such as Motor Vehicle Injury benefit of $100, Health Assessment Benefit $50, and Additional 25% for Child Sports Injury. In addition, benefit amounts have increased in most categories such as fractures, dislocations, emergency care, and surgical care. » Team Member premiums have been significantly reduced, making this benefit more affordable for enhanced coverage. Critical Illness: » Rates have been reduced and team member coverage has increased to $10,000 or $20,000. » Age based rates will now be based on your attained age instead of the age at which you purchased coverage. This means your rate will change as you age, similar to your voluntary life coverage. » The plan now covers occupationally acquired illnesses, for example, HIV, Hepatitis, TB, MRSA and Tetanus. » Child coverage is enhanced to include a number of childhood critical conditions including diabetes. » Now new participants can participate in an ongoing annual open enrollment, allowing them to add coverage WITHOUT evidence of insurability or good health. » If you are currently enrolled in a Grandfathered Critical Illness Plan or the current 2022 Critical Illness Plan, you have the option of porting these plans and making your premium contributions directly to Lincoln. Contact Lincoln at 855-818-2883 for more details. FMOLHS Pharmacy Benefits Website Through Express Scripts Express Scripts is our pharmacy benefit manager. Just like your medical plan covers visits to your doctor, your Express Scripts prescription plan covers the medication your doctor prescribes. Team members can explore the benefits available to them 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. 8 More Visits Added to the Employee Assistance Program Your well-being is our top priority, which is why we partner with New Directions to offer an Employee Assistance Program (EAP). In 2023, you will now have access to six visits with a counselor per presenting issue to connect with when and how you need it. In addition to counseling, New Directions provides a wealth of resources including confidential access to the programs and services needed for overall health and well-being on their website. Expanding our Bariatric Surgery Benefit We’re expanding our Bariatric Surgery Benefit offering to include coverage of revisional surgeries. In 2023, team members enrolled in a FMOLHS Health Plan are eligible for covered revisional surgeries if specific criteria is satisfied. Team members can contact askHR ([email protected]) for more details. In addition, 2023 Bariatric Surgery Program Criteria will be available soon on our Total Rewards website under My Benefits page. My Recognition Program Available Now No need to wait for 2023 for this new program. In August, we launched our new My Recognition Program that includes real-time acknowledgment for special celebratory milestones such as your birthday, your work anniversary and more. It features both pointsbased recognition rewards as well as personalized acknowledgment for special celebrations with flexible ways to redeem the points you earn based on what’s most important to you. Learn more about this program here. Access your Total Rewards Anywhere, Anytime You can dive deeper into all of our benefit options and Total Rewards offerings anywhere, anytime by visiting our Total Rewards website. FMOLHS.org/TotalRewards is accessible at work, home or on the go. Visit our site today to learn more about all of the opportunities, perks and benefits available to you. E  nrollment All eligible team members must enroll online through Oracle Employee Self Service by November 15, 2022. Things to Consider Before you enroll, it is a good opportunity for you to re‑assess your benefit decisions and determine if you need to make changes. The elections that you make are effective on January 1, 2023. » 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 or remove any dependent(s) or update your beneficiary designation? » Did any of your covered children reach his or her 26th birthday this year? If so, they are no longer 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 if your dependents have not already been verified. See page 10 for dependent verification requirements. Qualifying Life Events Include: Outside of Open Enrollment, 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. 9 Dependent Verification ACCEPTED/REQUIRED VERIFICATION DOCUMENTS DEPENDENT TYPE NATURAL CHILD* STEP CHILD* (Requires current spouse & child verification documents) ADOPTED CHILD/CHILD PLACED FOR ADOPTION* FOSTER CHILD* Birth Certificate; for newborns, birth letter from hospital Birth Certificate AND verification of current marriage between Team Member and natural parent (see spouse verification requirements below) Adoption Certificate/placement letter from court or adoption agency for pending adoptions 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 by November 15, 2022 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. 10 How to Enroll in Oracle Employee Self Service 1. Understand Your Choices! The Benefits Guide is available on our Total Rewards website on the Open Enrollment page. 2. Review Your Personal Information 3. E  nroll Online from Work or Home https://eqtm.login.us2.oraclecloud.com 4. L  og 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. U  pdate or 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. R  eview 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 before November 15, 2022. 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. 11 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) and the number of dependents you claim on your 2021 Federal Individual Income Tax Return; 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. To ensure that you receive a decision on eligibility for the Just Premium prior to your Health Plan enrollment, please submit complete application and tax return by October 31, 2022. Applications that are submitted by November 15th will still be reviewed, but you may not know the status of your eligibility until after you have enrolled in benefits. We are unable to allow changes to benefit elections after November 15, 2022, regardless of your Just Premium eligibility. 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 by November 15, 2022. Note Individuals who did not file a 2021 Income Tax Return will not be eligible for the 2023 Just Premium. 12 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. 13 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. STEP 2 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 • Assist with scheduling an appointment with network-based primary care physicians • • Check if a provider you are already seeing is in network prior to enrollment 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. NOTE: Always verify a provider’s network status by calling Blue Cross Blue Shield at (833) 468-3594 or by logging on to MyHealthToolkitLA. com/links/fmolhs. You will have access to the EPO and PPO Tier 1 and Tier 2 networks at this site. If the provider address listed on the directory is not the address where care will be delivered, the provider may not be in network. Contact BCBS to confirm. ACCESSING CARE IN OUR 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. In-Person Visits Video Visits Meet face to face with your provider for wellness checks or appointments that need full evaluations. STEP 3 Same great care from your own provider from the comfort of your home. Avoid urgent care or ER fees and meet virtually with a FMOLHS primary care provider in our network after hours for free with the EPO plan or for $5 with the PPO Plan. Available in Louisiana only. We’re working to expand this care opportunity to Mississippi. All appointment types are available to schedule through MyChart for all ages. ACCESSING CARE OUTSIDE OUR NETWORK 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. 14 Virtual Extended Hours Submit all completed requests in writing via fax to (803) 264-0259, by email to FMOLHSEXCEPTION@ [email protected] 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. 15 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 narrow 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-ofnetwork 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-toyear. (There are restrictions and limitations to enrollment in the HSA.) 16 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. 17 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 18 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 EMPLOYEE ONLY $250 No Coverage EMPLOYEE WITH DEPENDENTS $500 No Coverage EMPLOYEE ONLY $2,000 No Coverage EMPLOYEE WITH DEPENDENTS $4,000 No Coverage PRIMARY CARE PHYSICIAN (PCP) $0 copay No Coverage SPECIALIST $35 copay No Coverage ANNUAL DEDUCTIBLE MAXIMUM OUT‑OF‑POCKET (INCLUDES DEDUCTIBLE) OFFICE VISIT EMERGENCY ROOM/URGENT CARE EMERGENCY ROOM $250 copay $250 copay URGENT CARE $60 copay No Coverage OUTPATIENT SURGERY $250 copay No Coverage $200 copay per day (4 day/$800 max) No Coverage Included in Inpatient copay No Coverage Included in Office Visit copay, Outpatient Surgery copay, or 100% coverage after deductible (depending on place of service) No Coverage 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 $3,000 copay; Surgery must be performed at a MBSAQIP Accredited FMOLHS facility No Coverage 90% coverage after deductible when performed at Blue Distinction Center facility No Coverage OTHER COPAYS INPATIENT PHYSICIAN SERVICES INPATIENT VISITS OUTPATIENT 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. ORGAN TRANSPLANT Blue Distinction Centers coverage only. OTHER SERVICES ALLERGY TESTING ALLERGY SERUM AND INJECTIONS OTHER INJECTIONS 90% coverage after deductible or included in office visit copay, depending on place of service 90% coverage after deductible or included in office visit copay, depending on place of service 90% coverage after deductible or included in office visit copay, depending on place of service No Coverage No Coverage 19 EPO PLAN (CONTINUED) FMOLHS EPO NETWORK OUT-OF-NETWORK 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 90% coverage after deductible; limited to 50 visits per calendar year No Coverage 90% coverage after deductible No Coverage OTHER SERVICES HOME HEALTH CARE HOSPICE CARE AMBULANCE SERVICE OCCUPATIONAL THERAPY PHYSICAL THERAPY SPEECH THERAPY 90% coverage after deductible No Coverage 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 90% coverage after deductible maximum of 20 hours per week annually No Coverage 90% coverage after deductible drawn/ordered by FMOLHS Geneticist No Coverage 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 90% coverage after deductible No Coverage 90% coverage after deductible; limited to 1 per 5 years No Coverage 90% coverage after deductible No Coverage 100% coverage of Generic Diabetes Prescription Medications and Preferred Supplies through the pharmacy benefit. No coverage APPLIED BEHAVIOR ANALYSIS (ABA) SPECIFIC GENETIC TESTING (MUST SATISFY MEDICALLY NECESSARY CRITERIA) SMOKING CESSATION AIDS Smoking cessation is available through the prescription benefit program. DURABLE MEDICAL EQUIPMENT (DME) INSULIN PUMP ORTHOTICS AND PROSTHETICS GENERIC DIABETES PRESCRIPTION MEDICATIONS AND SUPPLIES MENTAL HEALTH AND SUBSTANCE ABUSE INPATIENT INCLUDING PARTIAL HOSPITALIZATION (PHP), INTENSIVE OUTPATIENT PROGRAM (IOP), AND RESIDENTIAL OFFICE VISIT OTHER OUTPATIENT SERVICES $200 copay per day (4 day/$800 max) No Coverage $0 Copay No Coverage 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 MATERNAL/FETAL ULTRASOUND IN NETWORK BREAST PUMP AND LACTATION COUNSELING THROUGH HEALTHY LIVES PRE-NATAL CARE $200 copay per day (4 day/$800 max) No Coverage 90% coverage after deductible or included in office visit copay, depending on place of service and other than included in prenatal care No Coverage 100% coverage No Coverage One‑time $50 copay applies for coverage of routine OB visits, initial routine labs and one ultrasound per term pregnancy. No Coverage 100% coverage Limited to one routine physical examination annually and approved wellness screenings annually 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 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. 20 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. FMOLHS NETWORK (TIER 1) PPO PLAN PREFERRED PROVIDER NETWORK (TIER 2) NON-PREFERRED PROVIDER (TIER 3) $800 $800 $3,000 $5,000 $1,600 $1,600 $6,000 $10,000 OUT-OF-NETWORK ANNUAL DEDUCTIBLE EMPLOYEE ONLY EMPLOYEE WITH DEPENDENTS 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 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 60% coverage after deductible 40% coverage after deductible EMERGENCY ROOM/URGENT CARE EMERGENCY ROOM URGENT CARE 80% coverage after deductible $75 copay $75 copay 60% coverage after deductible 40% coverage 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 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 $3,000 copay; Surgery must be performed at a MBSAQIP Accredited FMOLHS facility No coverage No coverage No coverage PHYSICIAN SERVICES 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 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 21 PPO PLAN (CONTINUED) FMOLHS NETWORK (TIER 1) PREFERRED PROVIDER NETWORK (TIER 2) NON-PREFERRED PROVIDER (TIER 3) 80% coverage after deductible; 70% coverage after deductible 60% coverage after deductible OUT-OF-NETWORK OTHER SERVICES OCCUPATIONAL THERAPY PHYSICAL THERAPY SPEECH THERAPY APPLIED BEHAVIOR ANALYSIS (ABA) SPECIFIC GENETIC TESTING (MUST SATISFY MEDICALLY NECESSARY CRITERIA) SMOKING CESSATION AID Smoking cessation is available through the prescription benefit program Maximum of 120 visits per year (and maximum of 20 visits per week) combined with Occupational, Physical, and Speech Therapy 80% coverage after deductible; max 20 hours per week annually 80%; drawn/ordered by FMOLHS Geneticist 70% coverage after deductible; 60% coverage after deductible; max 20 hours per week annually max 20 hours per week annually No coverage No coverage 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 No coverage No coverage 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 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible No coverage No coverage 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible $5 copay $30 copay 60% coverage after deductible 40% coverage after deductible 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible 80% coverage after deductible 70% coverage after deductible 60% coverage after deductible 40% coverage after deductible 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 100% coverage 100% coverage 100% coverage No coverage ORTHOTICS AND PROSTHETICS GENERIC DIABETES PRESCRIPTION MEDICATIONS AND PREFERRED SUPPLIES 100% coverage of Generic Diabetes Prescription Medications and Preferred Supplies through the pharmacy benefit MENTAL/NERVOUS AND SUBSTANCE ABUSE INPATIENT Including Partial Hospitalization (PHP), Intensive Outpatient Program (IOP) and Residential 80% coverage after deductible OFFICE VISIT ONLY OTHER OUTPATIENT SERVICES PREGNANCY CARE AND DELIVERY LABOR & DELIVERY AND ASSOCIATED CHARGES MATERNAL/FETAL ULTRASOUND IN NETWORK BREAST PUMP AND LACTATION COUNSELING THROUGH HEALTHY LIVES 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. 100% coverage 100% coverage 100% coverage 40% coverage after deductible 100% coverage 100% coverage 100% coverage 40% coverage after deductible ADULT IMMUNIZATIONS Immunizations are subject to current CDC Recommendations which include age limitations 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. *FMOLHS follows federal guidelines for coverage of preventive wellness screenings. 22 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 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 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 PHYSICIAN SERVICES HOSPITAL SERVICES 23 HDHSA PLAN (CONTINUED) FMOLHS NETWORK (TIER 1) PREFERRED PROVIDER NETWORK (TIER 2) NON‑PREFERRED PROVIDER (TIER 3) OUT‑OF‑NETWORK $3,000 copay; Surgery must be performed at a MBSAQIP Accredited FMOLHS facility No coverage No coverage No coverage 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 80% coverage after deductible when performed at Blue Distinction Center facility ORGAN TRANSPLANT Blue Distinction Centers coverage only 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