1 EMPLOYEE BENEFITS GUIDE Effective Dates | January 1, 2020 – December 31, 2020 2 Table of Contents Medical Benefits Anthem BlueCross BlueShield Medical Plan Comparison 4 Find a Participating Provider/Verifying Provider Participation 6 Anthem BlueCross BlueShield Estimate Your Cost 7 Anthem BlueCross BlueShield Mobile App 7 Anthem BlueCross BlueShield Condition Care, NurseLine & Future Moms 9 Anthem BlueCross BlueShield LiveHealth Online 10 Dental Benefits Anthem 12 Vision Benefits Anthem 16 Health Savings Account HSA Participant Information 23 Supplemental Voluntary Benefits Short Term Disability 33 Accident Insurance 36 Critical Illness 40 Hospital Indemnity 48 Permanent Life & Long Term Care Rider 50 Other LMG Supplemental Benefits Life & Long Term Disability 54 401(k) Retirement Benefits 55 Pre-Paid Legal 58 Identity Theft Protections 59 Employee Assistance Program 60 Travel Assistance Program 61 Mode Notices 63 Key Contacts 79 Key Contacts 80 3 Medical Benefits Anthem BlueCross BlueShield Medical Plan Comparison 4 Option 2 | HealthKeepers Value Advantage Summary of Service Option 1 | Lumenos HSA GHSA 269 25/500 OA POS Network In Network Out-of-Network In Network Out-of-Network Individual | $1,500 Individual | $1,500 Individual | $500 Individual | $750 Annual Deductible Family | $3,000 Family | $3,000 Family | $1,000 Family | $1,500 Annual Out-of-Pocket Individual | $3,575 Individual | $6,000 Individual | $4,500 Individual | $5,500 Maximum Family | $7,150 Family | $12,000 Family | $9,000 Family | $11,000 Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Co-Insurance 10% 30% 10% 30% PCP PCP PCP PCP 10% after deductible 30% after deductible $20 Co-Payment 30% after deductible Office Visits Specialist Specialist Specialist Specialist 10% after deductible 30% after deductible $40 Co-Payment 30% after deductible Maternity Services 10% after deductible 30% after deductible No Charge 30% after deductible Office Visits Durable Medical 10% after deductible 30% after deductible 10% after deductible 30% after deductible Equipment Emergency Room Emergency Room Emergency Room Emergency Room Emergency & 10% after deductible Paid as in-network $100 Co-Payment Paid as in-network Urgent Care Urgent Care Urgent Care Urgent Care Urgent Care 10% after deductible 30% after deductible $40 Co-Payment 30% after deductible Preventive Services No Charge 30% after deductible No Charge 30% after deductible Outpatient Services Outpatient Services Outpatient Services Outpatient Services 10% after deductible 30% after deductible 10% after deductible 30% after deductible Hospital Services Inpatient Services Inpatient Services Inpatient Services Inpatient Services 10% after deductible 30% after deductible 10% after deductible 30% after deductible Physical, Occupational or Physical, Occupational or Physical, Occupational or Physical, Occupational or Speech Therapy Speech Therapy Speech Therapy Speech Therapy 10% after deductible 30% after deductible $40 Co-Payment 30% after deductible Chiropractic Services Chiropractic Services Chiropractic Services Chiropractic Services 10% after deductible 30% after deductible $40 Co-Payment 30% after deductible Therapy Services Inpatient Mental Illness Inpatient Mental Illness Inpatient Mental Illness Inpatient Mental Illness and Substance Abuse and Substance Abuse and Substance Abuse and Substance Abuse 10% after deductible 30% after deductible 10% after deductible 30% after deductible Outpatient Mental Illkness and Outpatient Mental Illkness and Outpatient Mental Illkness and Outpatient Mental Illkness and Substance Abuse Substance Abuse Substance Abuse Substance Abuse 10% after deductible 30% after deductible No Charge 30% after deductible Prescription Drugs *After Deductible Tier 1 – Tier 2 $10 – $25 – $45 – $65 $10 – $25 – $45 – $65 Tier 3 - Tier 4 5 Summary of Service Option 3 | HealthKeepers 10 POS Network In Network Out-of-Network Individual | None Individual | $300 Annual Deductible Family | None Family | $600 Annual Out-of-Pocket Individual | $1,000 Individual | $2,000 Maximum Family | $2,000 Family | $4,000 Lifetime Maximum Unlimited Unlimited Co-Insurance 10% 30% PCP PCP $10 Co-Payment 30% after deductible Office Visits Specialist Specialist $20 Co-Payment 30% after deductible Maternity Services No Charge 30% after deductible (Office Visits) Durable Medical 10% after deductible 30% after deductible Equipment Emergency Room Emergency Room Emergency & $100 Co-Payment Paid as in-network Urgent Care Urgent Care Urgent Care $20 Co-Payment 30% after deductible Preventive Services No Charge 30% after deductible Outpatient Services Outpatient Services 10% after deductible 30% after deductible Hospital Services Inpatient Services Inpatient Services 10% after deductible 30% after deductible Physical, Occupational or Physical, Occupational or Speech Therapy Speech Therapy $20 Co-Payment 30% after deductible Chiropractic Services Chiropractic Services $20 Co-Payment 30% after deductible Therapy Services Inpatient Mental Illness Inpatient Mental Illness and Substance Abuse and Substance Abuse 10% after deductible 30% after deductible Outpatient Mental Illkness and Outpatient Mental Illkness and Substance Abuse Substance Abuse No Charge 30% after deductible Prescription Drugs Tier 1 – Tier 2 $10 – $25 – $45 – $65 Tier 3 - Tier 4 6 Finding a Participating Provider/Verifying Provider Participation There are several networks listed under the major insurance carriers so it important that you are referring to the correct one when searching for new providers or attempting to verify participation of existing ones. FOR MEDICAL CALL: OA 25/500 and OA POS 10: 800-421-1880 Lumenos HSA: 800-451-1527 Visit Website www.Anthem.com Identify Your Plan to Find Your Network Your Plan Your Anthem Network Lumenos HSA GHSA 269 PPO HealthKeepers Value Advantage 25/500 OA POS HealthKeepers HMO / POS HealthKeepers 10 POS HealthKeepers HMO / POS FOR DENTAL CALL: Anthem Dental Complete 866-956-8607 FOR VISION CALL: Blue View Vision 866-723-0515 7 Compare quality and costs at hospitals and other facilities on anthem.com Did you know that different facilities may charge different amounts for the same service? Estimate your share of the costs before you get your care. Higher prices don’t always mean better care. Compare facilities based on their quality measures for certain procedures — length of stay, patient experience, complications and more. Just log on to anthem.com and click on Estimate Your Costs. } Simply search or browse for the procedure you are looking for and the tool will help guide you. } You can easily compare facilities in your area. Estimate Your Costs is just one of the many tools we have to help you manage your health care, simply and conveniently. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado and Nevada: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affi liates administer non-HMO benefi ts underwritten by HALIC and HMO benefi ts underwritten by HMO Missouri, Inc. RIT and certain affi liates only provide administrative services for self-funded plans and do not underwrite benefi ts. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 11916ANMENABS Rev. 12/13 8 Access your network of doctors and manage your benefits in a way that’s convenient for you. Get our mobile app or view the same information from your tablet and computer. 1. Forget your ID card? We have an app for that. You’ll get access to an electronic version of your ID card when you download our app to your smartphone. You also can: Find a doctor or urgent care center and get driving directions there. Refi ll a prescription, locate a network pharmacy, compare drug costs, switch to home delivery, and more. Get cost estimates and provider ratings for the procedures you need. 2. Don’t like to download? No problem. Download the Anthem app If you have an Apple or Android device, you can: You can view our mobile website using the 1. Go to the Apple Store or Google Play. web browser on your smartphone. You’ll get 2. Search for Anthem Blue Cross and many of the same features we offer on our Blue Shield. mobile app. 3. Select the app and start the free download. 3. Prefer the traditional website experience? Access the full anthem.com website from To log in and use our