Employee Benefit News

ABC Company
2010 - 2011 Plan
have previously waived coverage, you may elect to enroll in coverage during open enrollment).

n recent years, the cost of quality healthcare has risen considerably. Factors that impact these increases include everything from new treatments and improved technology, to unhealthy lifestyles and an aging population. But as health plan premiums continue to rise, we want to maintain a commitment to you and your family by offering an excellent benefit package. Therefore, effective: March 1, 2010 ABC Company is pleased to give you the opportunity to participate in the following medical plan option : Priority Health HMO 80/20% Hospital Plan

Enroll eligible enrolled.

dependents

previously

not

Some things to remember You and your eligible dependents must each enroll in the same plan. You must complete the ABC Company Enrollment/Waiver Form if you would like to participate in the medical plan. You must complete the ABC Company Enrollment/Waiver Form if you wish to waive any coverage. The medical plan you select is the plan in which you will remain until the next open enrollment period with an effective date of March 1, 2011.

During the open enrollment period you may: Enroll in the medical plan of your choice (if you

The Priority Health HMO

he Priority Health HMO plan offers many benefits for minimum co-payments, but in order to receive these benefits you must select, and receive services from a Primary Care Physician (PCP) from the approved list of health care providers of the Priority Health HMO network. Priority Health has contracted with many local physicians, hospitals and other health care providers to provide health care services to those covered under the plan. The network of physicians includes PCPs such as family practitioners, internists, obstetricians/gynecologists, pediatricians, and specialty care physicians. At enrollment, you and your family members each select a PCP in the network who will perform, arrange or authorize medical treatment. Most services are covered as long as your primary care physician authorizes that medical care. Any services that have not been authorized by your PCP will not be covered. If you wish to change your PCP, simply contact Member Services at 800.446.5674 for direction.

The Priority Health HMO plan benefits include:

$1,000 individual / $2,000 family plan year deductible $20 office visit co-payment $35 specialist office visit co-payment $15 generic / $50 brand formulary / $80 brand non- formulary prescription drug co-payments $100 co-payment for emergency room treatment $50 co-payment for Urgent Care Center visits Hospitalizations and surgeries covered at 80% after deductible $150 co-payment for Advanced Imaging services (max 10 co-pays per year) Diagnostic x-ray and lab covered at 80% (office visit co-payment may apply)

If the out-of-pocket maximum is reached during a contract year, Priority Health will pay 100% of covered hospital expenses incurred by that person for the rest of the contract year. If the family maximum is reached during a contract year, Priority Health will pay 100% of covered hospital expenses for you and all of your covered dependents for the rest of that contract year.

800.446.5674

Prescription Medication Co-Payments

hen you use your Priority Health HMO prescription drug card at the pharmacy, you receive up to a 30-day supply of medication for a co-payment of $15 for generic drugs and $50 for brand formulary drugs, and $80 for brand non-formulary drugs including prescription contraceptives. Contraceptive devices administered or supplied in the physicians office are covered

at 50%. A 90-day supply of maintenance medication is available through mail order for a $30 generic, $100 brand formulary, and $160 brand nonformulary co-payment per prescription. For more information in the mail order program go to www.priorityhealth.com or call Member Services at 800.446.5674.

Priority Health Pharmacy Tools

Priority Health pharmacy tools are available at www.priorityhealth.com. This site provides resources and information about your prescription benefits.

PRIORITY HEALTH 800.446.5674 www.priorityhealth.com

Injectable Drugs
Certain classes of injectable drugs shown on the Priority Health approved drug list are only available from specialty pharmacies. These drug classes include: Arthritis drugs ( Enbrel and Humira); Growth hormone drugs (such Norditropin); Hepatitis C drugs (such as Pegasys); Multiple sclerosis drugs (such Betaseron, Copaxone, and Rebif); and Psoriasis drugs (such as Enbrel) as and chronic disease. They send by mail or hand-deliver medications directly to your home. They provide patient education, monitoring and the supplies you need. They also offer greater discounts and are more costeffective for injectable drugs. Your doctor has information on how to order your injectable drug and have it delivered to you, along with any supplies needed, such as needles and swabs. If you have any questions, go to the Frequently Asked Questions page online at www.priorityhealth.com or call Customer Service at 800.446.5674.

as

Specialty pharmacies are pharmacies that specifically focus on injectable medications

Transition Fill
If you are new to Priority Health and are experiencing problems filling your prescription, you may qualify for a transition fill. This is available to new members whose prescriptions are not covered or require prior authorization. Your pharmacist will give you a one-time, 30day transition supply of your drug. You pay your regular drug co-pay and then you then have 30 days to work with your doctor to request prior 2 authorization for your medication to justify why you need that particular medication or switch to a medication that is covered by your plan that your doctor agrees will work for you. After your transition fill, you must make arrangements for prior authorization or for your physician to prescribe a new medication before your next refill, or you will be responsible for the full cost of the medication.

The Advantages of Generic Medications

nderstanding the advantages of generic medications as compared with more expensive brand name medications can help you effectively lower your prescription drug premiums. Generic medications contain the same active ingredients and deliver the same therapeutic effects as their brand name counterparts. The big difference between generics and brand name drugs is price. Generic drug costs are between 40% to 60% less than brand name drug prices. Plus, with generic medication there is no compromise on quality. The Food and Drug Administration holds generic drug manufacturers to the same stringent standards as brand name manufacturers. Under the Priority Health HMO plan, you automatically receive the generic equivalent unless:

There is no generic equivalent available. The doctor writes dispense as written, (or checks the DAW box) on the members prescription, and the drug is approved by the health plan. The member specifically requests the brand name drug and is willing to pay the difference between the brand name drug and the generic drug in addition to the copayment.

Be sure to check with your doctor to see if a generic medication is right for you before switching.

Brand Name vs. Generic Drug Costs

he price of generic drugs averages 30 to 80 percent less than the cost of brand name drugs. These drugs represent some of the most prescribed brand name drugs that have available generic equivalents. Strengths of the drugs shown vary upon most common strength dispensed for patients. Cost for generic drugs based upon Maximum Allowable Cost. Brand name cost based on Average Wholesale Price. Brand Name/Strength Allegra 180 mg Coumadin 5 mg Darvocet-N 100 100mg/650mg Glucotrol XL 10mg Inderol LA 80 mg Prilosec 20 mg Toprol XL 25 mg Xanax 0.5 mg Zocor 40 mg Brand Name Cost $88.56 $61.10 $153.55 $67.77 $53.96 $145.00 $30.06 $138.25 $149.35 Generic Cost $37.80 $11.69 $13.52 $21.00 $34.20 $21.00 $19.61 $4.50 $10.20 Generic Name Fexofenodine Hcl Warfarin Sodium Propoxyphene/Acetaminophen Glipizide Propranol Hcl Omeprazole Metoprolol Succinate Alprazolam Simvastatin Generic Savings $50.76 $49.41 $140.03 $46.77 $19.76 $124.00 $10.45 $133.75 $139.15

Generic medicines account for 69% of all prescriptions dispensed in the United States, yet only 16% of all dollars spent on prescriptions. (source: IMS Health)

Medical Benefits Summary

ITEM Plan Year Deductible Individual Family Coinsurance Individual Family Maximum Out-of-Pocket Individual Family Lifetime Maximum Benefit HOSPITAL SERVICES Pre-Certification Room and Board In-Patient Consultations EMERGENCY CARE Emergency Room Urgent Care Ambulance Services SURGICAL SERVICES In-Patient Surgery Out-Patient Surgery Voluntary Sterilization DIAGNOSTIC SERVICES Advanced Diagnostic Imaging* Laboratory / Pathology Testing Diagnostic Tests / X-Ray PHYSICIAN SERVICES Doctor Office Visits Specialist Office Visits PREVENTIVE SERVICES Routine Physical Exam Routine GYN Exam Pap Smear Screening Well Child Care Immunizations MAMMOGRAPHY Routine Mammogram Screening MATERNITY CARE Pre & Post Natal Care Delivery and Nursery Care PRIORITY HMO $1,000 $2,000 80% of first $7,500 80% of first $15,000 $2,500 $5,000 $5,000,000 Required of member/physician$250 penalty 80% after deductible 80% after deductible 100% after $100 co-pay 100% after $50 co-pay 100% after $100 co-pay 80% after deductible 80% after deductible 80% after deductible $150 co-pay per test/max of 10 co-pays per year* 80% after deductible 80% after deductible 100% after $20 co-pay 100% after $35 co-pay 100% - office visit co-pay may apply 100% - office visit co-pay may apply 100% - office visit co-pay may apply 100% - office visit co-pay may apply 100% - office visit co-pay may apply 100% - office visit co-pay may apply 100% after $20 co-pay 80% after deductible

Medical Benefits Summary

ITEM ALTERNATIVES TO HOSPITAL CARE Skilled Nursing Care Hospice Care Home Health Care MENTAL & NERVOUS In-Patient Care Out-Patient Care SUBSTANCE ABUSE In-Patient Care Out-Patient Care OTHER SERVICES Allergy Testing and Therapy Chiropractic Care Durable Medical Equipment and Prosthetics & Orthotics Outpatient Physical, Speech and Occupational Therapy 80% after deductible up to state mandated amount 80% after deductible up to state mandated amount, combined with inpatient maximum 100% injections and serum, $35 co-pay for testing $20 co-pay, max 30 visits per year, combined with Physical, Speech and Occupational Therapies 50% after deductible - prior approval required over $1,000 $20 co-pay, max 30 visits per year, combined with Chiropractic Care PRIORITY HMO 80% after deductible up to 45 days per year 80% after deductible up to 45 days per year 100% after deductible 80% after deductible up to 20 days 100% after $20 co-pay per visit up to 20 visits

Specific elective surgeries and Physician Fees only covered at 50% of the first $2,000 procedures including but not limited to: after deductible, for each surgery or treatment, then Bariatric or Rhinoplasty surgery, certain 100% thereafter. Prior approval required. Skin Disorders, Scar and Varicose Vein treatments, and Sleep Apnea Please see Certificate for complete details and limitations
(Other conditions included)

Prescription Drugs

$15 generic / $50 brand formulary / $80 brand nonformulary co-payments contraceptives included

*Note: Advanced Diagnostic Testing includes, but is not limited to the following: CT, CTA, MRI, MRA, Nuclear Cardiology Studies, and PET.

Priority Health Member Services Call 800.446.5674 or Visit www.priorityhealth.com

This brief description of the benefits and options that are available for this plan year provides a general overview of the benefits. Actual provisions contained in the insurance contracts and plan documents will be relied upon solely, in administration and interpretations of the plans.

When Are Emergencies Covered?

ne of the most frequently asked questions is, When are emergencies covered under the plan? To avoid unnecessary expenses, you need to know what qualifies as an emergency, and the benefits available for emergency services. Covered services for emergencies include two categories:
Accidental Injury Medical Emergency

burns; swallowing of poison; overdoses of medication; frostbite; allergic reactions caused by bee stings or insect bites; and attempted suicide. A medical emergency is an internal condition that threatens life or bodily functions, or one that could result in serious bodily harm unless treated promptly. Examples of a medical emergency include, but are not limited to: severe chest pain; severe bleeding (not a result of an injury); convulsions; and loss of consciousness.

An accidental injury is any injury caused by an external action, object or chemical agent. Examples of accidental injuries include, but are not limited to: sprains or cuts requiring prompt treatment by a physician; inhalation of smoke and

What Will My Health Plan Cover in the ER?

our health plan will pay for the treatment of serious symptoms only when the condition (or its symptoms) occurs suddenly and unexpectedly and the physician agrees when the patient arrived in the emergency room, a threat to life and bodily functions appeared to exist. Treatment must be given within 72 hours of the onset of the condition to be deemed an emergency. Services not covered in the Emergency Room include the following: Routine medical care given in a hospital emergency room. Routine means care normally provided in a physicians office for conditions such as a common cold, headache, back pain, or slight fever. Treatment of chronic (long lasting) conditions requiring repeated visits to the hospital, unless there is a sudden life threatening change in the condition, or symptoms the attending physician agrees appeared life threatening. Follow up visits after treatment for the original emergency.

The guidelines ensure you are covered in an emergency, but minimize health care costs by authorizing payment for treatment only in emergency situations. When an emergency room claim has been denied, and you feel it was an emergency situation, you should request a copy of the emergency room report or ask the hospital to resubmit the claim with the emergency room notes. The claim will be reviewed by a medical professional to see if the signs and symptoms met the criteria of an emergency at the time of treatment. An alternative to the Emergency Room is an Urgent Care Facility. An urgent care facility is a medical facility separate from a hospital, where ambulatory patients can be treated on a walk-in basis without an appointment, and receive immediate, non-routine, urgent care. This does not include primary care physicians or specialists. Urgent Care is for those times when your condition is not serious enough to be an emergency but you need urgent medical attention. Your copayment is lower in an urgent care facility than in the emergency room.

Physicians and hospitals use insurance guidelines to determine what services qualify as medical emergencies.

Eligibility and Waiving Coverage

Eligible dependents include your spouse and unmarried children. Children are eligible until the end of the year in which they reach age 19. Coverage may be extended, by way of a family continuance, to the date which a dependent turns age 25 if they are: unmarried and a full time student. Children over 19 who are physically or mentally handicapped may also be eligible for coverage. Contact Human Resources if you have a special circumstance. Human Resources will advise you of your waiting period and effective date of coverage. Keep in mind you must enroll your eligible dependents (new baby, spouse) within 30 days of their eligibility. If you fail to do so, they will not be eligible until the companys next open enrollment period. When enrolling in the medical plan, complete the change of enrollment /change of status form for the plan and then turn it into Human Resources. If you are covered under another group health plan, you may waive medical coverage. Keep in mind if you choose to waive coverage, you may not be able to get back into the plan until the next open enrollment unless specific circumstances apply. Important Note: If you waive medical coverage because you have coverage under your spouses plan and you lose that coverage involuntarily (e.g. spouses loss of employment, divorce, etc.), you may enroll in your employers plan within 30 days from the date of the loss of coverage. Please see Human Resources for more specific information.

Definitions
Plan Year Deductible - amount you pay each plan year (March 1st through February 28th) before your insurance company will pay for approved benefits. Coinsurance - a percentage amount you pay for a covered service (e.g. 20%, 50%). Co-payment - a fixed amount you must pay for a covered service (e.g. $20). Deductible - is the portion of the claim that is not covered by the insurance provider, on certain services. Maximum Out of Pocket - The maximum amount you pay each year for approved benefits. MOPD2x Mail Order Prescription Drug plan allows you to purchase a 90-day supply of medication for two times your prescription co-payment. HMO - Health Maintenance Organization - a plan where you choose one primary care physician (PCP) within the plan network to coordinate all of your health care needs. Services provided by non-network providers are not covered. Participating Providers Physicians, hospitals, labs, etc. that have agreed to accept Priority Health approved amounts, plus co-payments, and/or coinsurance, as payment in full for services rendered. 7

Delta Dental
ABC Companys 2010-2011 dental benefits are provided through the Delta Dental PPO plan. The PPO plan provides a valuable dental benefits program while giving subscribers the freedom to choose the provider that is right for them. A national network with more than 61,000 PPO dentists is available with the PPO plan. While you will save more out-of-pocket money with the Delta PPO plan, this dental plan also allows access to Delta Dental Premier Network dentists. Because this is a passive PPO plan, enrollees may go to any licensed dentist anywhere, but they will save money by choosing a Delta Dental PPO dentist. Delta Dental PPO dentists agree to accept our fee determination as full payment for covered services. This guaranteed acceptance of payment reduces group claims costs while protecting enrollees from balance-billing problems. The Maximum Payment is $1,000 per person total per benefit year on all services. There is a $75 deductible per person total per benefit year. This deductible does not apply to Diagnostic and Preventive Services, Emergency Palliative Treatment, and Brush Biopsy. Employees who are eligible for dental benefits can be covered on the first day of the month following 180 days of employment . There is a 12-month waiting period for certain services. Periodontic Services, Endodontic Services, Other Oral Surgery, Other Basic Services, Major Restorative Services, and Prosthodontic Services will not be covered until after a person is enrolled in the dental plan for 12 consecutive months. 8 Delta Dental provides members with resources to make managing your dental benefits easy. Go to www.deltadentalmi.com and click on the Enrollees tab. You will be directed to a page where you may access provider directories, download claim forms, and research dental related topics, such as Oral Health and Wellness. From the Enrollees page you may also access the Consumer Toolkit. The Consumer Toolkit enables you to review benefit and claims information online. For your convenience, it is also possible to print Delta Dental Identification Cards via the Consumer Toolkit. The card will also serve as an identification card for any eligible dependents. Simply click on the Consumer Toolkit link from the Enrollee page or go to www.ConsumerToolkit.com. Follow the onscreen instructions. The Summary of Dental Plan Benefits on the following page should be read in conjunction with your Delta Dental Certificate. In the event you seek treatment from a dentist that does not participate in the Delta Dental PPO program, you may be responsible for more than the percentage indicated above. To see if your dentist participates, or to find a Delta Dental PPO dentist, please call 800.482.8915 or go to www.deltadentalmi.com and click on the Enrollee tab.

Delta Dental PPO Plan Outline

ITEM
Your out-of-pocket cost depend upon which provider you choose. Annual Deductible Coinsurance Class I Benefits Class II Benefits Class III Benefits Annual Maximum (Types I-III) 0% 20% after deductible 50% after deductible $1,000 20% 40% after deductible 50% after deductible

DELTA DENTAL PPO PLAN

Visit a Delta PPO Dentist you pay: $75 per person
(waived on Class I Services)

Visit a Premier or NonParticipating Dentist and you pay: $75 per person
(waived on Class I Services)

EXAMPLES OF DENTAL BENEFITS / SERVICES

Oral Examinations (2 per year) Class I Benefits (Deductible Does Not Apply) Cleanings (2 per year) Fluoride Treatment (to age 19) Emergency Palliative Treatment X-Rays (Bitewing 1 per year) Simple Extractions Class II Benefits (Deductible Applies) Endodontics Periodontal Cleanings Bridge & Denture Repair Minor Restorative Services Class III Benefits (Deductible Applies) Bridges and Crowns Implants Dentures

Delta Dental Customer Service 800.524.0149 www.deltadentalmi.com

Womens Health and Cancer Rights Act

The Womens Health and Cancer Right Act (WHCRA) of 1998 was a part of the omnibus appropriations bill passed by Congress and signed into law on October 21, 1998. This law applies to group health plans, health insurance companies and HMOs, if the plans or coverage provide medical and surgical benefits for a mastectomy. Under WHCRA, mastectomy benefits must include coverage for: Reconstruction of the breast upon which the mastectomy has been performed, Surgery and reconstruction of the other breast to produce a symmetrical or balanced appearance, Prostheses (or breast implant), and Physical complications at all stages mastectomy, including lymphedema. of same basis as for any other illness or injury under the medical plan. Mastectomy benefits may have yearly deductibles and coinsurance like those established for other benefits under the plan or coverage. The WHCRA will not allow: Plans and insurance issuers to deny patients eligibility or continued eligibility to enroll or renew coverage under the plan to avoid the requirements of WHCRA. Plans and insurance issuers to provide incentives to, or penalize doctors to cause them to provide care in a manner not supportive with WHCRA.

Coverage for reconstructive breast surgery may not be denied or reduced on the grounds that it is cosmetic in nature or that it otherwise does not meet the coverage definition of medically necessary. Benefits must be provided on the

WHCRA is administered by the U.S. Departments of Labor and Health and Human Services. More information is available from the Department of Labors website, at www.dol.gov/ebsa.

Coverage for reconstructive breast surgery may not be denied or reduced on the grounds that it is cosmetic in nature or that it otherwise does not meet the coverage definition of medically necessary. Benefits must be provided on the same basis as for any other illness or injury under the medical plan.

Newborns & Mothers Health Protection Act

The Newborns Act
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

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ABC Company Enrollment and Waiver Form

NAME: ADDRESS: CITY: HOME PHONE: STATE: DOB: ZIP: SSN:

2010-2011 Plan Year

Please put a check next to the coverage you wish to enroll in: Weekly Medical Post-tax Contributions Coverage
PRIORITY HEALTH HMO DELTA DENTAL ( )

Employee Only
______ ______

2 Person
_____ _____

Family
______ ______

I wish to waive my Medical insurance benefit coverage altogether.

Please note: If you become Medicare eligible (age 65), you must contact Human Resources for appropriate rates. These rates are not reflected above.

Please select one of the following: ( ( ( ) ) ) I wish to enroll in the plans indicated above and have my deductions taken on a Pre-Tax basis. I wish to enroll in the plans indicated above and have my deductions taken on a Post-Tax basis. I wish to waive all benefits at this time. Attached is a copy of my current health insurance.

I understand that: If I waive my right to elect insurance coverage, I may not be able to re-elect coverage until our group open enrollment period, unless I experience a loss of coverage through another source. I am required to maintain my election until next open enrollment, unless I experience a Qualifying Event. The above amounts will be deducted from each paycheck I receive to cover the cost of my insurance. I will be removed immediately from the insurance if eligibility (hours) are not maintained. This election will automatically terminate if the plan is terminated, discontinued, or if I cease to receive compensation from the company equal to, or greater than the amount of my elected reduction. By reducing my compensation on a Pre-Tax basis, my Social Security benefits may be reduced. I will be notified of any subsequent change in the required contribution.

This agreement is subject to the terms and conditions of the ABC Company Benefit Plan.

Employee Signature Company Representative

Date Date

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