Geisinger Open Enrollment Information & Application

Southern Columbia Area School District 2020-2021 Benefits Open Enrollment

TABLE OF CONTENTS 1. Geisinger Plan Highlight Sheet 2. Geisinger Medical Enrollment Form 3. In-Network Hospital Listing 4. Geisinger Urgent Care Facilities 5. Geisinger Provider Search Instructions 6. Geisinger Online Member Registration 7. Rx Mail Order Form 8. SCSD HSA Payroll Contribution Authorization Form 9. Vision Highlight Sheet 10. Highmark Vision Enrollment Form 11. SCSD Benefit Waiver Form 12. HealthiestYou Telemedicine Enrollment 13. SCSD Wellness Physical Completion Form 14. Geisinger Healthy Rewards Flyer 15. Geisinger Healthy Rewards Reimbursement Form 16. GHP Local Discounts

Geisinger Choice PPO Premium Quotation for Southern Columbia Area School District HDHP Direct Access – PPO

BENEFIT PLAN INCLUDES:

In-Network Out-of-Network Deductible Applies $4000/$8000 Deductible PCP OV 0% after Deductible 20% Coinsurance Specialist OV 0% after Deductible $5500/$11000 Coinsurance Max. Rehab (PT/OT/ST) 0% after Deductible 0% Emergency Room Copayment after deductible Drug Plan Generic 20% - $25 max Drug Plan Brand / Non-Preferred 25% - $50 max / 30% - $50 max $0 Prescription Drug Copayment after deductible 2.0 X Drug Copayment/90-day supply - Mail Order Drugs (Includes Contraceptives, Diabetes Supplies & Mail Order) Manipulative Treatment Services 0% after deductible Autism Inpatient Mental Health/Serious Mental Illness/Mental Health Parity 0% after Deductible $2000 Single / $4000 Family Deductible 0% Coinsurance $6450 / $12900 Maximum Out of Pocket

RATES: Effective date: 7/1/2020

Employee $675.30 Employee/Spouse $1610.59 Employee/Child $941.36 Employee/Children $1342.48 Family $1834.78

PREDICATIONS:

Minimum of 10 contracts required for groups with 16+ eligible employees; minimum of 2 contracts required for groups 2-15 eligible employees.

Domestic Partners and their children are not eligible for COBRA coverage.

Employees must be legally employed, work required number of hours, and be paid in accordance with minimum wage laws.

The Group shall contribute a minimum of 50% of the single premium toward each tier for each benefit option.

Non-Medicare Retiree (Pre-65) coverage is not available to groups with 50 or less employees. (See Non-Medicare Retiree Policy for additional information.)

The Premium Variance of plan offering cannot have a difference greater than 20% from the lowest deductible Single Rate to highest deductible Single Rate.

GEISINGER HEALTH PLAN GEISINGER QUALITY OPTIONS, INC. 100 North Academy Avenue GROUP SUBSCRIBER APPLICATION 100 North Academy Avenue Danville, PA 17822 Danville, PA 17822

GENERAL ADMINISTRATIVE INFORMATION (for completion by Employer)

1. Group number: 10118622 2. Division number: ______5. Effective Date of Change: ______(MM/DD/YY) 6. This Application is being submitted as a result of: (Check one) a.  Group Open Enrollment Period b.  Employee New Hire c.  Change due to Qualifying Event (If you checked this box, please specify type of event and complete Question #7) (i) Specify type of event:______

7. Is the Subscriber or Subscriber’s eligible Dependent(s) electing continuation coverage under COBRA and/or Mini-COBRA? (Check one)  Yes  No  Not Applicable 8. Plan selection: (check one)  PPO HSA $2,000/$4,000  PPO Retiree $1,000/$2,000

APPLICANT INFORMATION (Please Print Clearly)

5. LEGAL NAME (LAST) 6. (MAIDEN NAME) 7. (FIRST) 8. (M.I.) 9. GENDER  FEMALE  MALE 10. ADDRESS (NUMBER) (STREET) (APT. NO.) 11. CITY 12. STATE 13. ZIP CODE 14. COUNTY

15. HOME PHONE NUMBER 16. CELL PHONE NUMBER PREFERRED CONTACT METHOD:  EMAIL  PHONE  MAIL 17. EMAIL ADDRESS: (The email address you provide on this application helps Geisinger Health Plan and Geisinger Quality Options, Inc. (collectively tthe “Health Plan) to conduct business and provide you the best service possible. It is used to facilitate activities such as enrollment, customer identiﬁ cation and billing. The email address you provide is stored in a secure database and will not be sold to any entity outside of the Health Plan. It may be used for promotional or research purposes. You will be given an opportunity to opt-out of these communications whenever the Health Plan sends them). 18. SOCIAL SECURITY NUMBER 19. DATE OF BIRTH 20. MARITAL STATUS MONTH DAY YEAR  MARRIED  SINGLE  DIVORCED/SEPARATED  WIDOWED 21. EMPLOYER (NAME, CITY, AND PHONE NUMBER) 22. DATE OF EMPLOYMENT 23. GEISINGER MEDICAL RECORD # (if any)

24. While enrolled in Geisinger Health Plan or Geisinger Quality Options, Inc. (collectively the “Health Plan”) will you also be covered by Medicare? Yes  No  If “Yes”, please provide: Your Medicare Number: ______(Check one)  Part A  Part B 25. While enrolled in the Health Plan will any Dependent(s) listed on this form also be covered by Medicare? (Check one) Yes  No  If “Yes”, please provide the following information:

Dependent(s) Name Medicare Number Part A Part B (check as applicable)

26. While enrolled in the Health Plan will you or any Dependent(s) listed on this form also be covered by other health insurance? Yes  No  If “Yes”, please complete the following information: A. Name of Insurance Company: ______E. I.D. or Social Security No.: ______B. Subscriber Name: ______F. Group Name (Employer): ______C. Check one:  Family Plan  Self Only G. Group Number ______D. Effective Date of Coverage: ______(Month) (Day) (Year)

M-152-308-F Dev. 11/16pb (1 of 3) SPOUSE/DEPENDENT INFORMATION LIST LAST NAME IF DIFFERENT SOCIAL PRIMARY CARE PRIMARY CARE LOCATION LEGAL NAME FROM APPLICANT SECURITY NO. RELATIONSHIP DATE OF BIRTH PHYSICIAN NAME PHYSICIAN NUMBER (TOWN) FIRST M.I. LAST  HUSBAND

MAIDEN NAME  WIFE

FIRST M.I. LAST  SON  DAUGHTER  OTHER* FIRST M.I. LAST  SON  DAUGHTER  OTHER* FIRST M.I. LAST  SON  DAUGHTER  OTHER* FIRST M.I. LAST  SON  DAUGHTER  OTHER* *In the space below, brieﬂ y describe the type of “Other” legal relationship between the Dependent(s) and yourself. NOTE: Documentation obligating the applicant or the applicant’s spouse, if applicable, to provide health care coverage to Dependent(s) will be required. All Dependents must meet eligibility criteria. Dependent(s) Name Gender Description of Legal Relationship  Female  Male  Female  Male  Female  Male  Female  Male PLEASE NOTE: If any of your Dependent(s), for which you are applying, do not live at the address listed in Section B, please indicate name(s), current address(es) and reason(s) why your Dependent(s) do not live at such address, in the space provided below. If your Dependent(s) live with a custodial parent, please provide name of custodial parent.

NOTICE OF SPECIAL ENROLLMENT RIGHTS If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption. To request special enrollment or obtain more information, contact our Customer Service Team at (1-800-447-4000). DECLINATION OF ENROLLMENT  I declare that I have coverage under another group health plan or have other health insurance coverage and, therefore decline enrollment for myself and any family dependents. ______Signature of Applicant Date Signed Signature of Employer Date Signed FRAUD STATEMENT Any person who knowingly and with intent to defraud any insurance company or other person fi les an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. DECLARATIONS I hereby apply to the Health Plan for the coverage now being offered for myself and the dependent(s), if any, as shown above. I understand that this application is subject to acceptance by the Health Plan, and that if a Subscription Certifi cate is issued, services will be available subject to the exclusions, limitations and other conditions of the Subscription Certifi cate and/or Rider(s), if applicable. In the event it is determined that one (1) or more of my dependent(s) is/are ineligible for enrollment in the Health Plan pursuant to the Subscription Certifi cate, I authorize the Health Plan to process this application, omitting the names of such ineligible dependent(s). I further understand that rates for the Subscription Certifi cate and/ or Rider(s), if applicable, issued to me are subject to change by the Health Plan, in accordance with terms of the agreement with my employer, and upon thirty (30) days’ prior notice to my employer acting on my behalf. I authorize my employer to make periodic deductions from my salary or wages of the amount, if any, I am required to contribute toward the rates for the coverage provided under my Subscription Certifi cate and/or Rider(s). The information recorded above is true and correct to the best of my knowledge and belief. I understand that the intentional misrepresentation of any material fact by me on this application could constitute grounds for the cancellation of any Subscription Certifi cate and/or Rider(s), if applicable, issued by the Health Plan in consideration of this application, upon notice and in accordance with applicable law. I represent that I have read this document or it has been read to me, including the sections titled, “Notice of Special Enrollment Rights,” “Fraud Statement” and “Declarations”. ______Signature of Applicant Date Signed Signature of Employer Date Signed M-152-308-F Dev. 11/16pb (2 of 3) Discrimination is against the law Geisinger Health Plan and Geisinger Quality Options, Inc. If you believe that the Health Plan has failed to provide these (collectively referred to as the “Health Plan”) comply with services or discriminated in another way on the basis of race, applicable federal civil rights laws and do not discriminate on color, national origin, age, disability, sex, gender identity, or the basis of race, color, national origin, age, disability, sex, sexual orientation, you can file a grievance with: gender identity, or sexual orientation. The Health Plan does Civil Rights Grievance Coordinator not exclude people or treat them differently because of race, Geisinger Health Plan Appeals Department color, national origin, age, disability, sex, gender identity, or 100 North Academy Avenue, Danville, PA 17822-3220 sexual orientation. Phone: 866-577-7733, TTY: 711 The Health Plan: Fax: 570-271-7225 • Provides free aids and services to people with disabilities [email protected] to communicate effectively with us, such as: You can file a grievance in person or by mail, fax, or email. If • Qualified sign language interpreters you need help filing a grievance, the Civil Rights Grievance Coordinator is available to help you. • Written information in other formats (large print, audio, accessible electronic formats, other formats) You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil • Provides free language services to people whose primary Rights electronically through the Office for Civil Rights language is not English, such as: Complaint Portal, available at https://ocrportal.hhs.gov/ocr/ • Qualified interpreters portal/lobby.jsf, or by mail or phone at: • Information written in other languages U.S. Department of Health and Human Services If you need these services, call the Health Plan at 200 Independence Avenue SW., Room 509F 800-447-4000 or TTY: 711. HHH Building, Washington, DC 20201 Phone: 800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 800-447-4000 or TTY: 711. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 800-447-4000 (TTY: 711). 㲐シ烉⤪㝄ぐἧ䓐䷩橼ᷕ㔯炻ぐ⎗ẍ⃵屣䌚⼿婆妨㎜≑㚵⊁ˤ婳农暣ġ800-447-4000㸦TTY㸸711㸧ˤ CHÚ Ý: Nũu bįn nói Tiũng Viŭt, có các dƌch vǖ hƲ trƹ ngôn ngǜ miŬn phí dành cho bįn. Gƭi sƯ 800-447-4000 (TTY: 711).ġ ˵́˼̀˳́˼˸͸˸̴̷̷̶̷̵̧̺̱̪̫̪̹̱̻̭̹̼̺̺̳͈̰̳̭̈́̈́͹̷̵̷̸̶̸̴̶̴̸̷̧̧̧̻̪̬̺̻̼̩̭̺̻̭̼̺̼̫̱̭̹̭̪̬̈́̈́Ͷ˻̷̶̪̱̻̭800-447-4000 ̴̸̧̻̭̭̻̲ͥ͸711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 800-447-4000 (TTY: 711). 㨰㢌aGG䚐ạ㛨⪰G㇠㟝䚌㐐⏈Gᷱ㟤SG㛬㛨G㫴㠄G㉐⽸㏘⪰Gⱨ⨀⦐G㢨㟝䚌㐘G㍌G㢼㏩⏼␘UG800-447-4000 (TTY: 711) ⶼ㡰⦐G㤸䞈䚨G㨰㐡㐐㝘U ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 800-447-4000 (TTY: 711). .711ϢϜΒϟ΍ϭϢμϟ΍ϒΗΎϫϢϗέ 800-447-4000ϢϗήΑϞμΗ΍ϥΎΠϤϟΎΑϚϟήϓ΍ϮΘΗΔϳϮϐϠϟ΍ΓΪϋΎδϤϟ΍ΕΎϣΪΧϥΈϓˬΔϐϠϟ΍ήϛΫ΍ΙΪΤΘΗΖϨϛ΍Ϋ·ΔυϮΤϠϣ ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 800-447-4000 (ATS : 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 800-447-4000 (TTY: 711).

ɅIWk h: KsS\p ȤK^hSjZs_Shesk , SsiW:ɃƣD[hck h deh] dpahBS\h^h \hN° ;X_ƞV Jp. YsWD^s 800-447-4000 (TTY: 711). HJ393͸=SǲS[X]ƣgXck`_`_[cZe͹]_ǲSckcZ_bkicdNŕkPSk`ƗNd^SY`_]_QiYŤkiZ_gSYͶMNRkg_Ɲ`_R^e]Sb800-447-4000 (TTY: 711). 3G3AFLBA͸FXg`N[S>bSiƧ[3iXciS^͹VS^cŢfXcŢR`_e[ang ki disponib gratis pou ou. Rele 800-447-4000 (TTY: 711). ƅŞŻȽŅŚɉ ȒŞȋơǯřēƴŚéřǯžŻ ŴƤȓîŷƄ, ȒơƑĐșřȇŻȓŧŚéŴƤȒīŻŶǯřóǯŅĕśȉƉóǽƷĆŹřơșƇŞȥŞșȒƄǶƴŚ éɇĆȄ ƄŏȄƄơȽŬŐ 800-447-4000 (TTY: 711)ɇ ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 800-447-4000 (TTY: 711). HPM 50 alb: Nondiscrimination dev. 9.12.16 M-152-308-F Dev. 11/16pb (3 of 3) Y0032_16242_2 File and Use 9/2/16 Participating hospitals All-Access network

Adams Clinton St. Luke’s Hospital - Sacred Heart Gettysburg Hospital Bucktail Medical Center Campus Allegheny UPMC Susquehanna Lock Haven Luzerne Allegheny General Hospital Geisinger Wyoming Valley Medical Columbia Center Allegheny Valley Hospital Berwick Hospital Center Wilkes-Barre General Hospital UPMC Children’s Hospital of Pittsburgh Geisinger Bloomsburg Hospital Lycoming Western Pennsylvania Hospital Cumberland Geisinger Jersey Shore Hospital Geisinger Holy Spirit Hospital Western Pennsylvania Hospital-Forbes UPMC Susquehanna Muncy Regional Campus UPMC Carlisle Williamsport Regional Medical Center Berks Dauphin St. Joseph Medical Center Penn State Milton S Hershey Medical Mifflin Center Geisinger Lewistown Hospital Surgical Institute of Reading Delaware Monroe Blair Riddle Memorial Hospital Lehigh Valley Hospital - Pocono Conemaugh Nason Medical Hospital Elk St. Luke’s Hospital - Monroe Campus Tyrone Hospital Penn Highlands Elk Montgomery UPMC Altoona Fayette Abington Lansdale Hospital Uniontown Hospital Bradford Abington Memorial Hospital Guthrie Towanda Memorial Hospital Fulton Fulton County Medical Center Bryn Mawr Hospital Robert Packer Hospital Huntingdon Lankenau Hospital Troy Community Hospital Penn Highlands Huntingdon Memorial Hospital Montour Bucks Geisinger Medical Center Jefferson Health Northeast - Bucks Jefferson Campus Penn Highlands Brookville Northampton Lehigh Valley Hospital - Muhlenberg St. Luke's Quakertown Hospital Lackawanna Geisinger Community Medical Center St. Luke’s Hospital - Anderson Campus Cambria Conemaugh Memorial Medical Center Moses Taylor Hospital St. Luke’s Hospital - Bethlehem Conemaugh Memorial Medical Center - Regional Hospital of Scranton Steward Easton Hospital, Inc. Lee Campus Lancaster Northumberland Conemaugh Miners Medical Center Ephrata Community Hospital Geisinger Shamokin Area Community Hospital Carbon Lancaster General Hospital St. Luke’s Hospital - Gnaden Huetten UPMC Susquehanna Sunbury Campus Lancaster General Women & Babies Hospital Philadelphia St. Luke’s Hospital - Palmerton Campus Children’s Hospital of Philadelphia UPMC Lititz Centre Fox Chase Cancer Center Mount Nittany Medical Center Lebanon Good Samaritan Hospital Hospital of the University of Pennsylvania Chester Paoli Hospital Lehigh Jeanes Hospital Lehigh Valley Health Network - Tilghman Clearfield Jefferson Health Northeast - Frankford Penn Highlands Clearfield Hospital Lehigh Valley Hospital Campus

Penn Highlands DuBois St. Luke's Hospital - Allentown Campus Jefferson Health Northeast - Torresdale Campus Pennsylvania Hospital Out-of-state Steuben participating hospitals Corning Hospital Presbyterian Medical Center of the District of Columbia UPHS Sibley Memorial Hospital Ira Davenport Memorial Hospital Temple University Hospital Delaware Sullivan Thomas Jefferson University Hospital New Castle Catskill Regional Medical Center Alfred I duPont Hospital for Children Thomas Jefferson University Hospital - Catskill Regional Medical Center - Grover Methodist Campus Maryland Hermann Baltimore Wills Eye Hospital Mt. Washington Pediatric Hospital Potter UM Rehabilitation & Orthopaedic Institute Charles Cole Memorial Hospital Baltimore City Schuylkill Johns Hopkins Bayview Medical Center Geisinger St. Luke’s Hospital Johns Hopkins Hospital Lehigh Valley Hospital - Schuylkill East Norwegian St. UMMC Midtown Campus Lehigh Valley Hospital - University of Maryland Medical Center Schuylkill South Jackson St. Howard St. Luke’s Miners Memorial Hospital Howard County General Hospital Somerset Montgomery Chan Soon-Shiong Medical Center at Suburban Hospital Windber Washington Conemaugh Meyersdale Medical Center Meritus Medical Center How do I find my provider online? Somerset Hospital New Jersey 1. Go to geisingerhealthplan.com/ Atlantic Susquehanna AtlantiCare Regional Medical Center - providersearch. Barnes-Kasson Hospital City Campus 2. Enter your location. Endless Mountains Health Systems AtlantiCare Regional Medical Center - Mainland Campus Tioga 3. Select your plan. Soldiers + Sailors Memorial Hospital Burlington Virtua Memorial Hospital of Burlington Union County 4. Select a category to search from our Evangelical Community Hospital entire library of applicable providers, Virtua West Jersey Hospital Marlton Washington or narrow your search by searching for Canonsburg Hospital Camden doctors, specialties, locations or types Virtua West Jersey Hospital Voorhees of places. Wayne Wayne Memorial Hospital Warren St. Luke’s Warren Hospital Wyoming Tyler Memorial Hospital New York Chemung York Arnot Ogden Medical Center OSS Orthopaedic Hospital LLC St. Joseph’s Hospital UPMC Hanover Orange UPMC Memorial Bon Secours Community Hospital York Hospital Orange Regional Medical Center St. Anthony Community Hospital Rockland Good Samaritan Hospital

Your primary care physician (PCP) should be your first contact when you’re sick or in need of medical treatment. Many offices offer extended hours for your convenience; however, when your PCP isn’t readily available and you need immediate attention, you now have options in addition to the emergency room.

Convenient care and urgent care facilities that are contracted with Geisinger Health Plan (GHP) can be a cost-effective way to receive medical treatment. Copays for convenient or urgent care facilities are significantly lower than an emergency room copay, and no appointments are necessary. These facilities provide shorter waiting times and treatment after normal working hours. To find a participating facility near you, visit GeisingerHealthPlan.com/find. Remember, the facility must be listed on the online search for services to be covered.*

There are key differences between convenient care facilities and urgent care facilities. Remember to check your member ID card to confirm your PCP copay amount.

Convenient care facilities Urgent care facilities • Requires PCP copay. • Requires PCP copay. • Usually located inside a retail or grocery • Usually located in free-standing facilities. store. Some are also located at physician • Staffed by physician assistants and certified offices. registered nurse practitioners. • Staffed by physician assistants and certified • Treats patients of all ages.** registered nurse practitioners. A physician is • Lab and X-ray services are available. Can assigned to each facility but may not always treat more serious conditions such as sprains, be on site. strains, lacerations, back pain, fractures, and • Treats patients of all ages.** minor surgeries.

• Lab or X-ray services may not be available. *Visiting a convenient care or urgent care facility outside of GHP’s network could result in additional costs. Treats minor illnesses or conditions such as **Some facilities do not treat patients 12 months and younger. colds, the flu, or minor infections.

Geisinger Health Plan may refer collectively to Geisinger Health Plan, Geisinger Quality Options, Inc., and Geisinger Indemnity Insurance Company, unless otherwise noted.

Geisinger Health Plan, Geisinger Quality Options, Inc., and Geisinger Indemnity Insurance Company comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 800-447-4000 (TTY: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 800-447-4000 (TTY: 711)。 Urgent care sites • CHOP Urgent Care Bucks County, Chalfont, Delaware 215-997-5730 • CHOP Urgent Care Brandywine Valley, Glen Mills, Adams • MedExpress Urgent Care - Quakertown, 267-425-8500 • Wellspan Urgent Care, Gettysburg, 717-339-2875 Quakertown, 215-538-6127 • Main Line Health Urgent Care at Broomall, Broomall, • St. Luke’s Care Now - Quakertown, Quakertown, 484-565-1293 Allegheny 215-538-4930 • Main Line Health Urgent Care in Concordville, • Concentra Urgent Care, Pittsburgh, 412-621-5430 Glen Mills, 484-565-1293 • Concentra Urgent Care, Pittsburgh, 412-784-1678 Butler • MedExpress Urgent Care - Brookhaven, • Concentra Urgent Care, Pittsburgh, 412-391-1137 • MedExpress Urgent Care - Butler, Butler, Brookhaven, 610-876-3072 • Concentra Urgent Care, Pittsburgh, 412-429-9675 724-283-3627 • Nemours duPont Pediatrics Urgent Care, Glen Mills, • MedExpress Urgent Care - Allison Park, Allison • MedExpress Urgent Care - Mars, Mars, 484-800-8630 Park, 412-486-3027 724-778-3627 • MedExpress Urgent Care - Brentwood, Pittsburgh, Erie 412-884-0327 Cambria • Concentra Urgent Care, Erie, 866-944-6046 • MedExpress Urgent Care - Bridgeville, Bridgeville, • MedExpress Urgent Care - Johnstown, • MedExpress Urgent Care - Millcreek Twp, 412-221-5475 Johnstown, 814-266-1138 Erie, 814-866-1443 • MedExpress Urgent Care - Monroeville Mosside • MedWELL, Ebensburg, 814-472-7336 Blvd, Monroeville, 412-372-5649 • MedWELL, Johnstown, 814-269-5200 Fayette • MedExpress Urgent Care - Moon Twp, Coraopolis, • MedExpress Urgent Care - Dunbar Twp, 412-299-3627 Carbon Connellsville, 724-626-1347 • MedExpress Urgent Care - Mt. Lebanon, Pittsburgh, • St. Luke’s Care Now - Jim Thorpe, Jim Thorpe, • MedExpress Urgent Care - Uniontown, 412-531-1585 570-325-2400 Uniontown, 724-439-3627 • MedExpress Urgent Care - OHara Twp, Pittsburgh, • St. Luke’s Care Now - Lehighton, Lehighton, 412-782-3278 570-645-1000 Franklin • MedExpress Urgent Care - Pleasant Hills, Pleasant • MedExpress Urgent Care - Chambersburg, Hills, 412-653-5556 Centre Chambersburg, 717-267-2273 • MedExpress Urgent Care - Robinson Twp, McKees • Geisinger Careworks Walk-In Clinic - State College, Rocks, 412-787-3508 State College, 814-238-1279 Greene • MedExpress Urgent Care - Ross Twp, Pittsburgh, • MedExpress Urgent Care - State College, • MedExpress Urgent Care - Waynesburg, 304-985-6329 State College, 814-238-1066 Waynesburg, 724-852-6391 • MedExpress Urgent Care - Scott Twp, Pittsburgh, 412-343-3627 Chester Huntingdon • MedExpress Urgent Care - Shadyside, Pittsburgh, • LGHP/Penn Medicine Urgent Care Parkesburg, • Penn Highlands Medical Services Convenient Care, 412-687-3627 Parkesburg, 610-857-6639 Huntingdon, 814-643-8750 • MedExpress Urgent Care - Tarentum, Tarentum, • Main Line Health Care at Exton Sq Mall, Exton, 724-224-2770 484-421-1669 Indiana • MedExpress Urgent Care - Wexford, Wexford, • MedExpress Urgent Care - Indiana, Indiana, 724-934-3627 Clearfield 724-349-4362 • MedExpress Urgent Care - Wilkins Twp Penn Hwy, • MedExpress Urgent Care - DuBois, DuBois, Pittsburgh, 412-825-3627 814-371-6164 Lackawanna • Geisinger Careworks Walk-In Clinic - Scranton, Beaver Columbia Scranton, 570-207-4054 • MedExpress Urgent Care - Center Twp, Monaca, • Geisinger Careworks Walk-In Clinic - Berwick, • Lake Scranton Urgent Care LLC, Scranton, 724-495-3278 Berwick, 570-802-5590 570-800-5926 • MedExpress Urgent Care - Chippewa, Beaver Falls, • Geisinger Careworks Walk-In Clinic - Bloomsburg, • Medicus Urgent Care, Scranton, 570-207-2612 724-891-3278 Bloomsburg, 570-416-1890 Lancaster Berks Crawford • Concentra Urgent Care, Lancaster, 717-391-3087 • Concentra Urgent Care, Reading, • MedExpress Urgent Care - Meadville, Meadville, • LGHP/Penn Medicine Urgent Care - Duke Street, 610-921-5811 814-333-3627 Lancaster, 717-544-6111 • Concentra Urgent Care, Reading, 866-944-6046 • LGHP/Penn Medicine Urgent Care - Kissel Hill, Lititz, • SJRHN-Muhlenberg, Reading, 610-208-8800 Cumberland 717-627-7687 • St. Joseph Health Network at Maidencreek, • Concentra Urgent Care, Carlisle, 866-944-6046 • LGHP/Penn Medicine Urgent Care - Norlanco, Blandon, 610-208-4650 • Concentra Urgent Care, Mechanicsburg, Elizabethtown, 717-544-6350 • St. Joseph Health Network at Strausstown Urgent 717-795-1819 • LGHP/Penn Medicine Urgent Care - Ephrata, Care, Strausstown, 610-488-9790 • Geisinger Holy Spirit Urgent Care, Camp Hill, Ephrata, 717-721-4585 • St. Luke’s Care Now - Hamburg, Hamburg, 717-763-3730 • LGHP/Penn Medicine Urgent Care - Rohrerstown, 610-628-7201 • Geisinger Holy Spirit Urgent Care, Carlisle, Lancaster, 717-544-0150 717-218-3990 • MedExpress Urgent Care - Lancaster, Lancaster, Blair 717-299-3627 • MedExpress Urgent Care - Altoona, Altoona, Dauphin • WellSpan Urgent Care, Ephrata, 717-738-5275 814-946-3801 • Aspire Urgent Care and Family Medicine, • WellSpan Urgent Care, Lititz, 717-466-2445 Harrisburg, 717-901-3440 Bucks • Concentra Urgent Care, Harrisburg, Lawrence • Aria AllMed Urgent Care Family Medicine, 717-558-6708 • MedExpress Urgent Care - Neshannock Twp, Bensalem, 215-638-0666 • MedExpress Urgent Care - Hershey, New Castle, 724-656-4320 Hershey, 717-533-4935 Lebanon Montour York • LGHP/Penn Medicine Urgent Care Lebanon, • Geisinger Careworks Walk-In Clinic - Danville, • Concentra Urgent Care, York, 717-764-1008 Lebanon, 717-675-1788 Danville, 570-284-4575 • MedExpress Urgent Care - Hanover, Hanover, • MedExpress Urgent Care - Lebanon, Lebanon, 717-633-3647 717-272-7469 Northampton • MedExpress Urgent Care - York, York, • St. Luke’s Care Now - Bethlehem, Bethlehem, 717-845-2273 Lehigh 484-526-3218 • WellSpan Urgent Care, Hanover, 717-646-4201 • St. Luke’s Care Now - West End, Allentown, • St. Luke’s Care Now - Wind Gap, Wind Gap, • WellSpan Urgent Care, Manchester, 717-356-4370 484-426-2501 484-526-7850 • WellSpan Urgent Care, Shrewsbury, 717-812-2400 • WellSpan Urgent Care, York, 717-851-1566 Luzerne Philadelphia • WellSpan Urgent Care, York, 717-356-4240 • Concentra Urgent Care, Wilkes-Barre, • Aria AllMed - Grant Ave, Philadelphia, • WellSpan Urgent Care, York, 717-356-4460 570-822-8831 215-934-3471 • Geisinger Careworks Walk-In Clinic - Kingston, • Concentra Urgent Care, Philadelphia, Convenient clinic sites Kingston, 570-714-5810 215-537-4755 Adams • Geisinger Careworks Walk-In Clinic - Mountain Top, • Concentra Urgent Care, Philadelphia, • UPMC Pinnacle Express Care, New Oxford, Mountain Top, 570-474-5847 215-677-0930 717-624-1337 • Geisinger Careworks Walk-In Clinic - Pittston, • Concentra Urgent Care, Philadelphia, Pittston, 570-602-5610 215-365-7510 Clinton • GWVMC at GSWB Pediatric Urgent Care, • Geisinger Careworks Walk-In Clinic - McElhattan, Wilkes-Barre, 570-808-8831 Schuylkill Lock Haven, 570-263-4042 • GWVMC at GSWB Urgent Care, Wilkes-Barre, • MedExpress Urgent Care - St. Clair, St. Clair, 570-808-3181 570-429-1012 Lackawanna • GWVMC Urgent Care Center, Wilkes-Barre, • St. Luke’s Care Now - West Penn, New Ringgold, • Commonwealth Health Priority Care, Peckville, 570-808-6023 570-645-1520 570-307-7600 • MedExpress Urgent Care - Edwardsville, Kingston, • Geisinger Careworks Walk-In Clinic - Weis Market, 570-283-0791 Snyder Clarks Summit, 570-587-2290 • MedExpress Urgent Care - Wilkes-Barre, • MedExpress Urgent Care - Selinsgrove, Wilkes-Barre, 570-825-2046 Selinsgrove, 570-743-7821 Luzerne • Ultracare Urgent and Family Care, Kingston, • Geisinger Careworks Walk-In Clinic - Kistler, 570-714-3333 Somerset Wilkes Barre, 570-208-6281 • MedExpress Urgent Care - Somerset Twp, • Geisinger Careworks Walk-In Clinic - West Hazleton, Lycoming Somerset, 814-443-4740 West Hazleton, 570-501-3760 • Geisinger Careworks Walk-In Clinic - Williamsport, • Geisinger Careworks Walk-In Clinic - Wilkes Barre, Williamsport, 570-601-2200 Union Wilkes Barre, 570-808-5135 • MedExpress Urgent Care - Williamsport, • Urgent Care of Evangelical, Lewisburg, Williamsport, 570-323-4072 570-523-3006 Mifflin • Geisinger Careworks Walk-In Clinic - Lewistown, Mercer Washington Burnham, 717-242-0196 • MedExpress Urgent Care - Hermitage, • MedExpress Urgent Care - Peters Twp, Hermitage, 724-347-2083 Canonsburg, 724-941-3273 Philadelphia • MedExpress Urgent Care - Washington, • Aria FastCare Shoprite Morrell Site, Philadelphia, Monroe Washington, 724-225-3627 215-632-2636 • DSP Health System, East Stroudsburg, 570-420-1955 Wayne Schuylkill • Pocono Urgent Care, Stroudsburg, • Lake Region Urgent Care, Honesdale, • Geisinger Careworks Walk-In Clinic, Pottsville, 570-872-9955 570-390-4545 570-624-4495 • Pocono Urgent Care, East Stroudsburg, 570-872-9615 Westmoreland Snyder • MedExpress Urgent Care - Belle Vernon, • Geisinger Careworks Walk-In Clinic, Montgomery Belle Vernon, 724-929-3278 Shamokin Dam, 570-884-3726 • CHOP Urgent Care Haverford, Bryn Mawr, • MedExpress Urgent Care - Greensburg, 610-658-0999 Greensburg, 724-836-3027 Wyoming • CHOP Urgent Care King of Prussia, King of Prussia, • MedExpress Urgent Care - Jeannette, • Geisinger Careworks After-Hours, 610-337-3232 Jeannette, 724-527-3428 Tunkhannock, 570-996-2790 • Concentra Urgent Care, Plymouth Meeting, • MedExpress Urgent Care - Latrobe, Latrobe, 610-275-3884 724-537-5064 York • Jefferson Urgent Care - Flourtown, • MedExpress Urgent Care - Mount Pleasant, • UPMC Pinnacle Express Care, Hanover, Flourtown, 215-836-1354 Mount Pleasant, 724-547-3627 717-637-0470 • Jefferson Urgent Care - Willow Grove, • MedExpress Urgent Care - Murrysville, • UPMC Pinnacle Express Care, Spring Grove, Willow Grove, 267-537-3300 Murrysville, 724-325-3027 717-225-9869 • St. Luke’s Care Now - Upper Perkiomen, Pennsburg, • MedExpress Urgent Care - N Huntington, Irwin, 267-424-8005 724-863-4362

Questions? Please call the number on the back of your member ID card. The list above includes urgent and convenient care sites in the Geisinger Health Plan service area and was updated on May 15, 2020. For a complete and up-to-date list of participating facilities, visit our website at GeisingerHealthPlan.com/find. Search Geisinger Health Plan

HPM50 kf Urgent Care flier Rev 5/2020 GEISINGER HEALTH PLAN

How to search for providers online

How do I find my provider online?

1. Go to GeisingerHealthPlan.com/ProviderSearch.

2. Enter your location. For this example, we used Elysburg, PA.

3. Select your plan. For this example, we chose Geisinger PPO from the employer group plans. 4. You’re ready to find a provider! Select a category to search from our entire library of applicable providers, or narrow your search by searching for doctors, specialties, locations or types of places. For this example, we searched for primary care doctors.

5. You will be shown a list of providers near you.

Geisinger Health Plan may refer collectively to health care coverage sponsors Geisinger Health Plan, Geisinger Quality Options, Inc., and Geisinger Indemnity Insurance Company, unless otherwise noted. Geisinger Health Plan is part of Geisinger, an integrated health care delivery and coverage organization. HPM50 ab Souther Columbia provider search flier Rev. 6/20 Member information is just a click away Get the most from your benefits and play an active role in your health with the powerful tools available at GeisingerHealthPlan.com/signin. Once registered, you can view account information, send secure messages as well as update your preferences. You can also find the following information regarding your account:

Plan and benefits Claims Health and wellness • Plan, benefits and costs • Medical claims for your • Wellness assessment • Member ID cards account • Free wellness programs • Family and dependents • Behavioral health and • Health plan history pharmacy claims • Forms

Pharmacy and prescriptions Find a provider, drug or location • Pharmacy claims and benefits • Find a doctor or hospital • Pharmacy locations and medications • Change your primary care provider • Geisinger CareSite Mail Order Pharmacy enrollment and refill

To register for our website, have your member ID card available and visit GeisingerHealthPlan.com/register.

Geisinger Health Plan may refer collectively to Geisinger Health Plan, Geisinger Quality Options, Inc., and Geisinger Indemnity Insurance Company, unless otherwise noted.

Never worry about your Rx refills again

Did you know Geisinger Health Plan (GHP) offers a secure and convenient program to deliver prescription medications right to your home? Our mail order prescription drug service located in Elysburg, Pa., specializes in providing 90-day supplies of medications you take on a regular basis. So you can focus on better care for yourself and less on running out to pick up refills.

Save up to 50% Take fewer trips to Sign-up for no-hassle, on Rx copays* the pharmacy automatic refills

Get free shipping Request a signature Track your order with real- with no membership for added security time shipment information fees

Talk one-on-one with Receive your a pharmacist over the medications in phone unmarked packagings

*Nearly all GHP members with prescription drug coverage will have lower copay amounts for their mail-order medications. Savings rates depend on your particular health plan. Call us at 800-988-4861 to learn more. Get started in 3 easy steps. Enrollment takes less than 5 minutes. 1. Ask your provider to e-prescribe your eligible prescriptions to Geisinger Mail-Order Pharmacy. We can help you transfer your existing prescriptions from other pharmacies.

2. Call the Geisinger pharmacy team at 844-878-5562 to set up your account. Be sure to have your insurance and payment information handy. And so you have peace of mind, we use a variety of tools to keep your information safe.

3. Your medications will arrive within seven business days in unmarked, confidential packaging. Standard shipping is free, and you can track your order from beginning to end.

Never be without your medications. Refills Renewals

EZ Refill by phone: 844-878-5562 When your refills run out, we make renewals EZ Refill online: geisinger.org/refill easy. To renew your medications, call our pharmacy team at 844-878-5562. Set up automatic refills so you have one less thing to remember. We’ll call your doctor and take care of the rest!

Questions?

Call us at 844-878-5562 (TTY: 711) 6:30 a.m. – 7 p.m., Monday – Friday

Mail order benefit does not include all medications. Benefits and costs will vary depending onour y specific coverage or if you’re enrolled in a cost assistance program. Please contact the customer service team with any questions on your benefits.

Geisinger Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 800-447-4000 (TTY: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 800-447-4000 (TTY : 711) HPM50 ab Mail order flier Rev. 6/2020

HSA Payroll Deduction Contribution Authorization Form

Only complete this form if you will be contributing to your HSA through payroll deduction effective after July 1, 2020.

Contribution Criteria You may deduct your HSA contribution on a pre-tax basis through payroll deduction. Contributions to your health savings account are based on the calendar year, January through December. You need to determine how much to deduct from each paycheck based on the number of pay periods remaining in the year at the time you begin your contribution.

Your total 2020 annual contribution must NOT exceed the amount allowable by law $3,550 single/$7,100 family. When considering your contribution amount be sure to keep in mind SCSD employer contribution of $1,000 single/$2,000 family (these amounts assume you complete the wellness initiatives to earn the extra $250 single/$500 family. Please consult with your tax advisor to review your specific circumstances and determine your allowable HSA contribution. If you exceed your allowable annual contribution, you may be subject to IRS tax penalty. Your total 2021 annual contribution must NOT exceed the amount allowable by law $3,600 single/$7,200 family. When considering your contribution amount be sure to keep in mind SCSD employer contribution of $1,000 single/$2,000 family (these amounts assume you complete the wellness initiatives to earn the extra $250 single/$500 family. Please consult with your tax advisor to review your specific circumstances and determine your allowable HSA contribution. If you exceed your allowable annual contribution, you may be subject to IRS tax penalty.

Authorization

I authorize Southern Columbia School District (SCSD) to deduct $ per pay beginning (Date) and to deposit my contributions into my health savings account (HSA).

26 pays starting July 3, 2020 20 pays starting August 28, 2020

I qualify for an additional $1,000 pre-taxed contribution because I am or will be 55 years of age this calendar year. My birth year is .

Please check what coverage you elected in the HSA plan: HSA Single Coverage HSA Two-Person Coverage HSA Family Coverage

Signature Print Name & Date Southern Columbia School District Client 068191; Group 02869703 Effective 7/1/2020 – 6/30/2021 In-Network Benefits – Non-Voluntary Fashion Focus V Frequency – Once Every: Eye Examination (including dilation when professionally indicated) 12 months Spectacle Lenses 12 months Frame 12 months Contact Lens Evaluation, Fitting & Follow-Up Care 12 months Contact Lenses (in lieu of eyeglass lenses) 12 months Copayments Eye Examination $0 Spectacle Lenses $0 Contact Lens Evaluation, Fitting & Follow-Up Care $0 Eyeglass Benefit - Frame Average Retail Value Non-Collection Frame Allowance (Retail): Up to $130 Up to $60 Davis Vision Frame Collection/1 (in lieu of Allowance): - Fashion level Up to $125 Included - Designer level Up to $175 $20 copayment - Premier level Up to $225 $40 copayment Eyeglass Benefit - Spectacle Lenses Average Retail Value Member Charges Clear plastic single-vision, lined bifocal, trifocal or lenticular $60-$120 Included lenses (any Rx) Oversize Lenses $20 Included Tinting of Plastic Lenses $20 $11 Scratch-Resistant Coating $25-$40 Included Scratch Protection Plan Single Vision $60-$120 $20 Scratch Protection Plan Multifocal $60-$120 $40 Polycarbonate Lenses/2 $60-$75 $0 or $30 Ultraviolet Coating $25-$30 $12 Standard Anti-Reflective (AR) Coating $50-$70 $35 Premium AR Coating $65-$90 $48 Ultra AR Coating $100-$125 $60 Standard Progressive Lenses $150-$195 $50 Premium Progressives (Varilux®, etc.) $195-$225 $90 Ultra Progressive Lenses $225-$300 $140 Intermediate-Vision Lenses $150-$175 $30 High-Index Lenses $90-$150 $55 Polarized Lenses $95-$110 $75 Plastic Photosensitive Lenses $95-$150 $65 Contact Lens Benefit (in lieu of eyeglasses) - Evaluation, Fitting & Follow-Up Care – Standard Lens Types Included - Evaluation, Fitting & Follow-Up Care – Specialty Lens Types Included Contact Lenses (in lieu of Allowance): Materials - Standard daily wear contact lenses Included - Disposable/Planned Replacement Up to $75 - Specialty (i.e.; Gas Permeable) Up to $75 Medically Necessary Contact Lenses (with prior approval) - Materials, Evaluation, Fitting & Follow-Up Care Included Out-of-Network Reimbursement Schedule: up to Eye Examination: $32 Single Vision Lenses: $25 Trifocal Lenses: $46 Elective Contact Lenses: $48-75 Frame: $30 Bifocal/Progressive Lenses: $36 Lenticular Lenses: $72 Medically Necessary CL: $225 Contact Lens Evaluation & Fitting - Daily Wear: $20 Contact Lens Evaluation & Fitting – Extended Wear: $30 1/Collection is available at most participating independent provider offices. Collection is subject to change. Collection is inclusive of select torics and multifocals. 2/Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions +/- 6.00 diopters or greater. One-year eyeglass breakage warranty included Network providers—The Davis Vision provider network is will receive an allowance toward the cost of lenses from being used through a contractual arrangement between the retailer’s supply. With prior approval, medically Davis Vision and Highmark. Davis Vision is an independent necessary contact lenses will be covered in full at all network provider locations. company that manages a network of licensed vision providers in both private practice and retail locations. Low vision services—You and your covered Network providers are reviewed and credentialed to ensure dependents are entitled to a comprehensive low vision that standards for quality and service are maintained. evaluation once every five years and low vision aids up to the plan maximum. Up to four follow-up visits will be Network retail locations—In order to provide you with the covered during the five-year period. greatest amount of flexibility and convenience, the network includes a number of retail establishments. Benefits at the Exclusions—This vision program excludes coverage for retail locations may vary slightly from other locations, as certain items and services, including: medical treatment noted in this benefit description. However, your value is of eye disease or injury; vision therapy; special lens comparable. designs or coatings other than those previously described; replacement of lost or stolen eyewear; non- Locating a network provider—To find a network provider, prescription (Plano) lenses; and services not performed go to www.highmarkblueshield.com and click on “Find a by licensed personnel. Doctor or Rx.” Click on “Find an Eyecare Provider”. Enter your zip code and mile radius then click on “Search” to see VALUE-ADDED FEATURES the most current listing of providers that will accept your Replacement contact lens program—Highmark offers a vision plan. contact lens replacement program to members. This mail order program exclusively allows you to enjoy the Receiving services from a network provider: guaranteed lowest prices on contact lens replacement  Call the network provider of your choice and schedule materials. Call 1-855-589-7911 or visit an appointment. www.davisvisioncontacts.com with a current prescription.  Identify yourself as a Highmark member, or eligible Every order comes with a complimentary starter kit. dependent, in a vision plan administered by Davis Vision. Laser Vision Correction —Highmark members enjoy  Provide the office with your identification (ID) number lower prices on LASIK procedures than other carriers, along (located on your Highmark ID card), and the name and with flexible financing options – up to 12 months interest birth date of the covered dependent receiving services. free. These savings are up to 40%-50% off the national average price of traditional LASIK and are available at over It’s that easy! The provider’s office will verify your eligibility 1,000 locations across our nationwide network of laser for services. No claim forms are required! vision correction providers. Laser vision correction services are administered by QualSight, LLC. Terms and conditions Frame benefit—You may choose from 'The Collection' in are subject to change. Locate a participating provider by most independent network provider offices or a program calling 1-855-502-2020. allowance will be applied toward a network provider's own frames. Many Collection frames are covered in full or Hearing Aid Discounts-Our members have access to have a nominal copayment which helps you select high- exclusive discounts from Your Hearing Network to get quality frames, while minimizing out-of-pocket expenses. started on the way to better hearing. Members receive a Network retail providers typically do not display the free hearing exam, and discounts of up to 40% off Collection. You will instead be given a program allowance premium hearing aids. Each order includes: toward your frame purchase. If the chosen frame exceeds  A Trial period - 60 day money back guarantee the allowance, you will be responsible for any remaining  1 year of follow-up care balance.  A 4-year service warranty, including 1 year of loss and damage  A 4-year supply of batteries (included with each hearing aid purchase) Contact lenses benefit—Contact lenses may be selected in lieu of eyeglass lenses. A program Call 1 (888) 809-0044 for more information, or to schedule allowance will be applied toward contact lenses from the your consultation with a local hearing aid professional. provider's own supply. At a network retail location, you

Call Member Service Monday through Friday, 8:00 am to 5:00 pm, Eastern Standard Time (EST) at 1-800-223-4795 (TTY users call 1-800-523-2847) to find a network provider, ask benefit questions, verify eligibility or request an out-of-network provider reimbursement form.

For information prior to enrolling, call 1-800-223-4795.

ENROLLMENT/WAIVER FORM 57411 COMPLETE THIS APPLICATION IN ITS ENTIRETY IN BLUE OR BLACK INK. DO NOT USE PENCIL OR HIGHLIGHTER.

I EMPLOYEE/CONTRACT HOLDER INFORMATION (Must be completed for both enrollees and waivers) Effective Date Employer/Group Name Group Number Payroll Location

First Name MI Last Name Social Security Number (If no SS#, write N/A)

Address

City State Zip County Home/Cell Phone

Marital Status (Please check one) : Enrollment Status qActive Employee q COBRA Continuant Start Date / / q Single/Widowed q Married q Rehired Employee q HIPAA Life Event q Divorced (Please attach a copy of COBRA Election Notice or HIPAA Certificate to support eligibility.) Full-Time Hire (or Rehire) Date (Month/Day/Year) Hours Worked Per Week Job Title / /

Gender Date of Birth (Month/Day/Year) Age Product Selection q Male q Female / / q Vision Full Name of Physician of Record (POR) Group Practice

II DEPENDENT INFORMATION (If enrolling more than four dependents, please attach a separate sheet.)

SPOUSE First Name MI Last Name

Social Security Number (If no SS#, write N/A) Gender Date of Birth (Month/Day/Year) Age q Male q Female / / Product Selection: q Vision

Note: If spouse’s last name differs from the contract holder above, please attach a copy of your marriage certificate.

DEPENDENT CHILD First Name MI Last Name Relationship to You? q Child q Step-child q Adopted* q Other* Social Security Number (If no SS#, write N/A) Gender Date of Birth (Month/Day/Year) Age q Male q Female / / Product Selection: Dependent Status if Age 26 or Older q Vision q Disabled q Act 4** Is Child an Established Patient? q Yes q No

*If enrolling an adopted child or a child that has been legally placed in your care, please attach a copy of the custodial/legal papers to support dependent eligibility. **If your employer offers Act 4 adult dependent coverage, complete and attach an Act 4 Dependent Verification Form.

57411 MEMEW-257-N ENR-257 (R10-16) DEPENDENT CHILD First Name MI Last Name Relationship to You? q Child q Step-child q Adopted* q Other* Social Security Number (If no SS#, write N/A) Gender Date of Birth (Month/Day/Year) Age q Male q Female / / Product Selection: Dependent Status if Age 26 or Older q Vision q Disabled q Act 4** Is Child an Established Patient? q Yes q No

*If enrolling an adopted child or a child that has been legally placed in your care, please attach a copy of the custodial/legal papers to support dependent

Special Enrollment Rights:

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may in the future be able to enroll yourself and your dependents in this plan, provided that you request enrollment within 31 days after you and your dependent’s other coverage ends, or not later than 60 days if the other plan coverage was through Medicaid or a state Children’s Health Insurance Program (CHIP). In addition, if you have a new eligible dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your eligible dependents, provided that you request enrollment within 30 days after the marriage, birth, adoption or placement for adoption. To request special enrollment or obtain more information, contact your employer or call the toll-free Highmark Member Service number: 1-800-241-5704 (TTY/TDD: Dial 711).

V IMPORTANT: AUTHORIZED SIGNATURE REQUIRED I understand that this form enrolls those eligible persons listed above in the Products as described in the agreement between Highmark and my employer. I authorize any payroll deductions required for the coverage and recognize that I must formally enroll my dependents on this form or they will not be covered. To the best of my knowledge and belief, the information provided on this application is true and correct.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

I acknowledge and agree that any personally identifiable health information about me or my enrolled dependents (“Protected Health Information”) is protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other privacy laws, and that, in accordance with those laws, Highmark may use and disclose Protected Health Information for payment, treatment and health care operations as described in its Notice of Privacy Practices. I understand that a copy of the Highmark Notice of Privacy Practices is available on the Highmark Web site, or from the Highmark Privacy Office.

Print Employee/Contract Holder Name Print Employer/Group Name

Employee/Contract Holder Signature Date WAIVER OF INSURANCE COVERAGE

A. APPLICANT INFORMATION (Please Print): Employee Name:

Date of Birth: SS #:

Employer Name: Hire Date:

B. OTHER INSURANCE INFORMATION: I elect to waive health care coverage offered by my employer. I currently:

 Do not have health coverage under any health plan.  Do have health coverage through (please complete the following information):

CONTRACT HOLDER NAME

NAME OF HEALTH CARE PLAN/INSURER

GROUP NUMBER SUBSCRIBER ID NUMBER

RELATIONSHIP OF CONTRACT HOLDER TO YOU

 I decline coverage for the following individuals. Please check ( ) types of coverage being waived for each individual. COVERAGE WAIVED

LAST FIRST NAME NAME MI MEDICAL DRUG VISION EMPLOYEE

SPOUSE

DEPENDENT

C. VALIDATION/AUTHORIZATION STATEMENT:

 I hereby certify that I have been given the opportunity to participate in the group health insurance plan offered by my employer. I understand that in the event that I decide to apply for this coverage at a later date, not related to a lifestyle change, I and/or any other eligible dependents may be subject to certain waiting periods.

Employee Signature Date

6202 C 5/03 How to register and get started with HealthiestYou! …………………………………………………………………………………………………………………………………………………

Step 1 Step 2

Search and download Select “First time here? Register “HealthiestYou” or “HY” in Now”. Then tell us how you are the app store or Google Play! provided with the benefit. Available on your iPhone or Android devices! (You may also access member.healthiestyou.com)

Step 3 Step 4

Enter the Primary Member's A list of names associated with the account will appear. Select your Information: name. - Last Name - Dependents under 18 will appear - D.O.B. on the primary member’s profile. - Zip Code - Dependents over 18 will need to register their own account with a separate email.

Step 5 Step 6

Enter in a valid email address Enter in the best number to reach and password. you. Our doctors will use this number to contact you. Password must meet the listed requirements. Select your preferred language. Click “I Accept Terms & Conditions.” Click Finish.

………………………………………………………………………………………………………………………………………………… Download the App Today! member.healthiestyou.com 866-703-1259 2020-2021 Physical Certification Form

I (NAME) certify that I was seen by my physician on (DATE) _to obtain an annual physical.

PHYSICIAN’S STAMP - REQUIRED Must include Physician’s Name and Office Location Employee Signature

Physician's Signature

Please return to Lori Levan no later than June 30, 2021

School District Use Only:

Confirm Wellness Profile has been completed: ___Yes or ___No

Deposit Wellness Dollars into employee HSA Account:

Date Deposited Amount Get rewarded for making healthy choices

Need motivation to exercise? Already work out regularly? Healthy Rewards is a reimbursement program that helps members pay for fitness activities.

How does Healthy Rewards work? Annual reimbursement up to $100/single and $200/family • Members (policyholder only) must complete the online wellness assessment to be eligible. • Activities considered include: • Fitness center memberships • Gymnastics • Exercise classes • Sports camps • Race fees • Sports fees • School athletic fees • K arate and more! • Swimming lessons

How do I get it? Healthy Rewards is available to members who have a Geisinger HMO, Geisinger PPO or Geisinger Funding Alternative (GFA) plan through their employer.** For more information visit GeisingerHealthPlan.com: • Log in as a member. • Once logged in, under the “Health and Wellness” tab at the top, click on “Healthy Rewards Reimbursement”. • Take the wellness assessment. • Download and mail the reimbursement form, along with receipts, per the instructions listed on the form.

**Healthy Rewards is not available for Geisinger Gold, GHP Family, GHP Kids, individual Marketplace plans or ACA-compliant plans for small groups. Self- funded members may be able to participate if their employer has opted into Healthy Rewards. This benefit highlight is intended as an information source. Please consult with your benefits manager to confirm that you are eligible to participate. Reimbursement is subject to approval by Geisinger Health Plan. The policyholder is the only member required to take a wellness assessment, but each member must fill out the Health Rewards Reimbursement Form. Get a health snapshot with Wellness Online One of the first steps toward a healthier you is getting a snapshot of your current health. Wellness Online can help you do that! Our wellness assessment will give you a health score, risk for specific conditions and includes recommendations on ways you can improve your health. You can access and update your wellness assessment at anytime. Wellness Online also includes other beneficial tools you can use to keep track of your eating and exercise habits. Our goal is to keep you and your family healthy. What will you need? It’s a good idea to have your health history, medical and lifestyle information, to get the best results. Remember, there is no cost to you.

Other Wellness Online benefits: Track and analyze your personal health, nutrition and fitness data through the “My Diet and Nutrition” and “My Exercise” tabs. • Enroll in wellness workshops on various topics including weight, stress, diabetes, quitting tobacco and more. You can complete these at your own pace and manage them through the “My Wellness Activities” tab. • Access an online meal planner based on your own dietary and caloric needs. • Search for recipes, build your own shopping list and more (under the “My Diet and Nutrition” tab). • Use our wellness tools to track and graph your blood pressure, blood glucose, cholesterol and heart rate.

Accessing Wellness Online and the wellness assessment Visit GeisingerHealthPlan.com** • Log in as a member (registration required) • Hover over the “Health and Wellness” tab at the top, click on “Wellness Online” • To access or update your wellness assessment, hover over the “Health and Wellness” tab at the top, click on the “Wellness Assessment”

Geisinger Health Plan may refer collectively to Geisinger Health Plan, Geisinger Quality Options, Inc., and Geisinger Indemnity Insurance Company, unless otherwise noted.

**If you are part of an employer wellness program with access to Wellness Online, but not a member, log in at wellness.geisinger.org. Members log in at geisingerhealthplan. com. If you are unable to access this information, please contact your employer or our wellness team at 866-415-7138. Geisinger Health Plan, Geisinger Quality Options, Inc., and Geisinger Indemnity Insurance Company comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 800-447-4000 (TTY: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 800-447-4000 (TTY: 711)。 HPM50 ab Healthy Rewards Wellness Online Rev. 11/2019 Healthy Rewards Reimbursement Request Form

Please submit one Reimbursement Request Form Per Member. Complete this form to request your reimbursement of up to $100/single or $200/family per benefit period for completing a health risk assessment (HRA) and for participating in qualified activities (if you are requesting reimbursement for activities completed by family members, you must submit a separate reimbursement form for each member). Please complete the information requested below and return this form(s), along with a valid receipt to the address listed at the bottom of this form.

______Subscriber Last Name First Name Date of Birth Phone Number ______Street Address City State Zip

Step 1-Complete Activity for Reimbursement information and include a receipt. Reminder, a separate form must be completed for each family member. Please check one or more qualified activities and include the name and ID number of the member for whom reimbursement is being requested. You must include a valid receipt showing the amounts paid for the activity(ies) indicated. The receipt must be for amounts paid within the current benefit period. The receipt should include the name and address of the business or organization along with the amount paid. Canceled checks with the activity listed in the memo line are also considered to be valid receipts. Reimbursement is issued for amounts paid only. Contracts for services and rate sheets are not considered valid receipts. Member Name:______Member ID:______Date of Birth:______

Activity for Date Amount Activity for Date Amount Activity for Date Amount Reimbursement Paid Paid Reimbursement Paid Paid Reimbursement Paid Paid Fitness Center Membership Football Lacrosse Exercise Classes (aerobics, Basketball Cycling yoga, etc) Weight Management School Athletic Activity Fees Baseball/Softball Program (registration/ (registration related) (including Little League) member fees) Hockey Volleyball Tennis

Karate, Tae Kwon Do, etc. Cheerleading Lessons (golf, dance, etc) Swimming Lessons /Team Registration/Race/ Sports Camps/Leagues Fees Tournament Fees /Clubs Total Reimbursement Gymnastics Soccer $ Amount Requested Examples of activities that do not qualify for reimbursement are: uniforms, athletic clothes, shoes and equipment, exercise and sporting equipment, personal training, fitness DVDs, hunting and fishing equipment or fees, miniature golf, amusement parks, food and supplements in general and associated with weight management programs, admission to sporting events, bowling, recreational activities to include greens fees, driving range fees, ski lift tickets, ice skating, roller skating, rock climbing, skate/bike parks, community and private pools, indoor trampoline facilities.

Activity Certification: I certify that the information above is correct to the best of my knowledge. I am claiming reimbursement for eligible activities incurred during the applicable benefit period for eligible members.

Subscriber’s signature: ______Date: ______

Continued, next page (Healthy Rewards Reimbursement Request form, Page 2)

Step 2-Verify Completion of your Health Risk Assessment Completion of an HRA is required by the subscriber prior to reimbursement being issued. Log onto the secure member section of thehealthplan.com and follow the instructions provided for completing your HRA. Please be sure to sign the statement below verifying that your HRA has been completed.

HRA Certification I certify that I have completed the HRA available via thehealthplan.com on the date indicated below during my current benefit period or during my prior benefit period in conjunction with an organized wellness program. Note: The subscriber only needs to complete one HRA per benefit period. If you have already completed an HRA during this benefit period, please re-sign on the line below and include the original date that you completed your HRA. Subscriber’s Signature: ______Date of HRA: ______

Reimbursement is subject to approval by Geisinger Health Plan.* Your receipts may be reviewed retroactively for validation purposes. If, upon review, your receipt is determined to be invalid, or we have no record of your HRA completion, we reserve the right to reconsider prior reimbursement payments. Please allow 4-6 weeks from receipt for reimbursements. If you have any questions regarding your reimbursement, please contact us at the telephone number on the back of your member identification card.

Mail completed form with receipts to: Geisinger Health Plan* PO Box 8200 Danville, PA 17821-8200

*Geisinger Choice is offered through Geisinger Quality Options, Inc., an affiliate of Geisinger Health Plan.

HPCS 01 pmt:HRRF Rev. 4/20/2012

#M-151-997-F A healthier you starts close to home Did you know that you can save on select local services? You can get discounts on everyday health-related items, as well as tools to help you stay fit. Save money on products and services including: • Fitness centers and YMCAs • Massage therapy • Amusement park admissions • Acupuncture • Special events • Nutrition services • Vision services • Wearable fitness devices • Chiropractic care

Find more information online All details about how to take advantage of these discounts can be found at GeisingerHealthPlan.com. Log in (registration required), go to the “Health and Wellness” drop-down menu and click “Local discounts.”

Geisinger Health Plan may refer collectively to Geisinger Health Plan, Geisinger Quality Options, Inc., and Geisinger Indemnity Insurance Company, unless otherwise noted. Geisinger Health Plan, Geisinger Quality Options, Inc., and Geisinger Indemnity Insurance Company comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 800-447-4000 (TTY: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 800-447-4000 (TTY: 711)。

HPM50 ab Local discounts program flier Rev. 12/2019