20240916AVU to Staff 6 - Attachment D.pdf

2024 AVISTA BENEFITS GUIDE
NON-BARGAINING
Benefits Effective:
January 1 – December 31, 2024

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Avista is committed to your overall health and well-being, and we’re
pleased to offer you a benefits package that provides valuable health and
financial protection for you and your family.
Use this guide to:
• Review your benefit choices
• Understand how the plans work
• Select the benefits that are best for you (and your family)
Learn more: Go to avistabenefits.com to learn more about your Avista benefits and programs.
WHAT’S INSIDE
WHAT’S INSIDE ............................................... 2
WHO’S ELIGIBLE .............................................. 3
HOW TO ENROLL OR MAKE CHANGES ............. 3
WHEN TO ENROLL ........................................... 4
WHEN COVERAGE ENDS .................................. 5
CONTACT INFORMATION ................................ 6
MEDICAL AND PRESCRIPTION
DRUG COVERAGE ............................................ 8
DENTAL INSURANCE ...................................... 15
VISION INSURANCE ....................................... 16
SAVINGS AND SPENDING ACCOUNTS ............ 17
SUPPLEMENTAL MEDICAL INSURANCE .......... 22
LIFE AND ACCIDENT INSURANCE ................... 25
PRE-PAID LEGAL ............................................ 27
IDENTITY THEFT PROTECTION ....................... 27
PET INSURANCE ............................................ 27
LONG-TERM CARE INSURANCE ...................... 28
WELLNESS INCENTIVE FROM AVISTA ............. 29
EMPLOYEE ASSISTANCE PROGRAM (EAP) ...... 29
ADOPTION ASSISTANCE ................................. 29
TUITION ASSISTANCE ..................................... 31
JURY DUTY BENEFIT ....................................... 32
ONE LEAVE (PTO) ........................................... 33
HOLIDAYS ...................................................... 35
FMLA: THE FEDERAL FAMILY AND
MEDICAL LEAVE ACT ...................................... 36
PARENTAL LEAVE ........................................... 37
WORKERS’ COMPENSATION .......................... 37
DISABILITY BENEFITS ..................................... 39
RETIREMENT BENEFITS .................................. 41
LEGAL NOTICES .............................................. 44
SUMMARY OF BENEFITS AND COVERAGE. ..... 60

Notice: Every effort has been made to describe the provisions of the Benefit Plans with accuracy and clarity. This
summary and the summaries of the plans that make up the Benefit Plans will give you a good overview of how the
Benefit Plans work. Because it is only a summary, however, it omits much of the detail found in the Benefit Plan
document itself. Should any discrepancy exist between the Benefit Plan and this summary or the summaries of the plans
that make up the Benefit Plans, the official Benefit Plan is the controlling document and is binding upon all parties. The
Benefit Plans are available to any Benefit Plan participant for review at Avista Corporation in the Avista Benefits
Department during regular business hours.
This summary and the summaries of the plans that make up the Benefit Plans are important documents, and you should
keep them in a safe place for future reference. If the Benefit Plans are changed in any way that affects your eligibility or
benefits, you will be given an explanation of the changes.
If you would like a copy of any of the Summary Plan Descriptions (SPD) for any of the benefit plans outlined in this Benefit
Summary Booklet, please contact the Avista Benefits Department in writing detailing which SPD you would like to receive.
Written requests can be emailed or mailed to Avista Benefits Department, PO Box 3237 MSC-39, Avista Corp., Spokane,
WA 99202.
More detailed Benefit Information can be found online at: avistabenefits.com.

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WHO’S ELIGIBLE
Employees
All active regular full-time or part-time employees who are scheduled to work 20 or more hours
per week are eligible to participate in Avista’s benefits program.
You may also cover your eligible dependents under Avista’s medical, prescription, dental, vision,
voluntary accident and critical illness insurance, optional life insurance, AD&D benefits, and
long-term care insurance.
Temporary employees who are expected to work at least 6 months are only eligible for Avista’s
medical, prescription, dental, vision, 2nd.MD, Health Advocate, voluntary accident and critical
illness insurance, optional life insurance, AD&D benefits, Employee Assistance Program (EAP),
One Leave (PTO) after 90 days of service, company holidays (eligible after six months), personal
holidays, pre-paid legal, identity theft protection, pet insurance, 401(k), and long-term care
benefits.
Dependents
Your eligible dependents include:
• Legal spouse (same or opposite sex)
• Your child(ren) and your covered spouse’s child(ren) up to age 26
• Disabled children who became disabled on or before age 26
HOW TO ENROLL OR MAKE CHANGES
Visit the UltiPro Enrollment site to enroll. The site will guide you through the benefits
enrollment process every step of the way.
Be sure that all of your dependent information is accurate and complete. If you are enrolling
new dependents, you will need their Social Security numbers and dates of birth. Also, please
send a copy of your marriage certificate and birth certificate(s) for your newly covered
dependents to [e-mail] within 2 weeks.
If you have any questions or would like to discuss alternate methods for submitting sensitive
information, please email the Benefits team. The team is available Monday through Friday, 8
a.m. to 5 p.m. PT, excluding holidays.
Automatic Enrollment
Eligible employees are automatically enrolled in the following Avista benefits:
• Employee Assistance Program
• Short Term Disability*
• Long Term Disability*
• Base Life Insurance*

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• Investment Plan – 401(k)
WHEN TO ENROLL
Upon Hire
You have 31 days from your date of hire to enroll in most Avista health and other insurance
benefits. If you do not take action, you will not have coverage. Your next opportunity to enroll in
benefits will be during our annual Open Enrollment unless you experience a qualifying life event,
such as a birth or a marriage, as described in “Mid-Year Changes” below.
Your Avista benefits coverage becomes effective on the first day of the month following your
hire date.
During Open Enrollment
Open Enrollment is your annual opportunity to enroll for benefits or make changes to your
existing benefits. Generally, benefits you elect during Open Enrollment will be effective January
1 through December 31 of the following year unless you experience a qualifying life event that
permits you to change your coverage or makes you ineligible for coverage.
Mid-Year Changes
If you experience a status change that affects your eligibility for benefits or an IRS-qualified life
event during the year, you may enroll for coverage in new plans and make changes to existing
coverage within 30 days of the event. Go to the enrollment site to start the process.
Your benefit elections or changes must be consistent with the event. Documentation of the
event may be required.
Qualifying Life Events
Examples of qualifying life events, per IRS guidelines, include but are not limited to:
• Marriage
• Divorce
• Birth, adoption of a child, or becoming a court-appointed legal guardian
• Death of a dependent
• Loss of dependent eligibility for coverage
• Loss of coverage due to a change in employment status
• Experiencing a significant change in cost or coverage (this doesn’t apply to the Health Care
FSA)

*Temporary employees are not eligible for this benefit.

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When Mid-Year Coverage Changes Begin
Changes you make generally will be effective on the first day of the month following or
coinciding with a qualified life event, except for:
• The birth of a baby or adoption: Coverage begins on the date of birth or date the child is
put in custody for adoption.
• Removing dependents from coverage: Coverage ends for your dropped dependent on the
last day of the month.
• Death: Coverage ends the day after the event date.
• Divorce: Coverage ends on the last day of the month.
WHEN COVERAGE ENDS
Your Avista medical, dental, and vision coverage ends on the last day of the month in which you
terminate your employment.
These benefits end on your date of termination: life insurance, AD&D insurance, disability
coverage, Health Savings Account (HSA) and Health Reimbursement Arrangement (HRA)
contributions, Flexible Spending Account (FSA) contributions, accident insurance, critical illness
insurance, home and auto insurance, pet insurance, identity theft protection, pre-paid legal
coverage, and long-term care insurance.

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CONTACT INFORMATION
Use this information to contact a carrier or plan administrator directly.
Benefit Carrier Group
Number Phone Website/Email
Medical Premera
Blue Cross
1023252 800.722.1471 premera.com
Second Opinions 2nd.MD N/A 866.841.2575 2nd.md/avista
Health Care Support Health Advocate Avista 866.695.8622 Healthadvocate.com
[e-mail]
Dental Delta Dental of Washington
00652 800.554.1907 deltadentalwa.com
Vision Premera
Blue Cross 1023252 800.722.1471 premera.com
Health Savings
Account (HSA)
Rehn &
Associates
Your
SSN 509.534.0600 cdh.rehnonline.com
Flexible Spending
Account (FSA)
Rehn &
Associates
Your
SSN
509.534.0600 cdh.rehnonline.com
Health
Reimbursement
Arrangement
(HRA) – Wellness
Program
Rehn &
Associates
Your
SSN
509.534.0600 cdh.rehnonline.com
Life and AD&D
Insurance
Unum 917826 800.445.0402 www.unum.com/claims
Long Term
Disability (LTD)
Unum 917825 800.858.6843 www.unum.com/claims
Accident and
Critical Illness
Insurance
Aflac 25785 800.433.3036 aflacgroupinsurance.com
Pre-paid Legal LegalEASE N/A 800.248.9000 legaleaseplan.com/avista
Identity Theft Protection Aura N/A 833.552.2123 www.aura.com
[e-mail]
Pet Insurance Trupanion 855.235.3134 trupanion.qualtrics.com

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Benefit Carrier Group
Number Phone Website/Email
Employee
Assistance
Program (EAP)
SupportLinc 888.881.5462 supportlinc.com
401(k) Plan Vanguard 092094 800.523.1188 vanguard.com
Long-Term Care
Insurance
ACSIA
Partners LLC
02699V 833.888.0982 avista.yourcare360.com/enrollment
FMLA (Family
and Medical
Leave Act)
Avista Clinic N/A 509.495.4660 [e-mail]

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MEDICAL AND PRESCRIPTION DRUG COVERAGE
Your health is everything. Avista provides valuable medical benefits through Premera Blue Cross
that help you and your family stay healthy and pay for care if you get sick or injured.
Avista offers you two medical plan options:
• Premera Blue Cross High Deductible Health Plan (HDHP)
• Premera Blue Cross PPO Medical Plan
When you enroll in an Avista medical plan, you receive:
• Comprehensive, affordable coverage for a wide range of health care services. Tip: If you need extra protection from large or unexpected medical expenses, you may also
choose to enroll in supplemental medical coverage described below.
• Free in-network preventive care, with services such as annual physicals, recommended
immunizations, and routine cancer screenings covered at 100%. See more covered
preventive services at healthcare.gov.
• Prescription drug coverage.
• Financial protection through annual out-of-pocket maximums that limit the amount you will
pay each year.
Avista pays the majority of the cost of your health care benefits, keeping your portion of the
premium at a minimum. However, you are responsible for sharing the cost of coverage through
contributions, copays, coinsurance, and deductibles.
Premera Blue Cross High Deductible Health Plan (HDHP)
The Premera Blue Cross HDHP pairs low premium, high-deductible coverage with a tax-free
Health Savings Account (HSA) that helps you save money and plan ahead for future medical
expenses. This combination gives you more control over your money and rewards you for
making healthy, cost-conscious choices.
As an added bonus, Avista currently contributes to the HSA — $700 for employee-only coverage
or $1,500 for employee + 1 coverage. With the Premera Blue Cross HDHP, you can see any
provider you wish, but you will pay less when you stay in network. Visit premera.com to find an
in-network provider near you.
How the Premera Blue Cross HDHP Works
• Preventive care: You pay nothing for in-network preventive care — it is covered in full.
• Deductible: You pay 100% of your medical and prescription costs until you meet the annual
deductible.*
• Coinsurance: After meeting the deductible, you and the plan share the cost of covered
medical care and prescriptions, with the plan paying the majority.
• Out-of-Pocket Maximum: You are protected by an annual limit on costs — the plan pays
100% of any further covered expenses for the rest of the year.**

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• Prescriptions: There are different tiers of prescription drugs which have different
percentages of cost payment after the deductible. Speak with your doctor about the most
effective and cost efficient prescription options.
* The family deductible is cumulative for all family members. The family deductible can be met
by a combination of family members; however, no single individual within the family will be
subject to more than $3,200 for in-network care.
** The family out-of-pocket maximum is cumulative for all family members. The family out-of-
pocket maximum can be met by a combination of family members; however, no single
individual within the family will be subject to more than $6,400 for in-network care.
Keep in Mind
• The Premera Blue Cross HDHP costs you less from your paycheck, so you may have extra
money available to put in your HSA.
• You can only spend HSA money that has actually been deposited into your account. If you
do not have enough money in your HSA when you need it, you can pay another way and
reimburse yourself later so you take full advantage of your HSA’s tax savings.
• You never forfeit any money left in your HSA — it rolls over year after year. If you know
about future expenses or want to save for your health care costs in retirement, set aside a
little extra each paycheck so your balance can grow over time.
• You can change your HSA contribution amount throughout the year as needed to keep up
with any changes in your situation.
• Maximum contribution limit — for the 2024 calendar year, the maximum HSA contribution
amount is $4,150 for individual coverage and $8,300 for family coverage. These amounts
include the employer contributions. If you are age 55 or older, you may contribute an extra
$1,000 to your HSA.
* Contributions are not subject to federal tax. Exceptions include CA and NJ, where you will pay
state tax on HSA contributions, and NH and TN where state taxes apply to tax dividend and
interest earnings after a certain dollar amount. Consult with your tax advisor to understand
the potential tax consequences of enrolling in an HSA. Money in an HSA can be withdrawn
tax-free as long as it is used to pay for qualified health-related expenses. If money is used for
ineligible expenses, you will pay ordinary income tax on the amount withdrawn, plus a 20%
penalty tax if you withdraw the money before age 65.
2024 Employee Contributions: Premera Blue Cross HDHP (Monthly)
Premera Blue Cross High Deductible Health Plan
Employee Only $0.00
Employee + Spouse $0.00
Employee + Child(ren) $0.00
Employee + Family $0.00

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Premera Blue Cross PPO Medical Plan
The Premera Blue Cross PPO Medical Plan offers slightly lower out-of-pocket costs in exchange
for higher premiums. With this plan, your costs are more predictable, but you will likely still have
out-of-pocket expenses. You can see any provider you wish, but you will pay less when you stay
in network. Visit premera.com to find an in-network provider near you.
How the Premera Blue Cross PPO Medical Plan Works
• Preventive care: You pay nothing for in-network preventive care — it is covered in full.
• Deductible: You pay 100% of your medical and prescription costs until you meet the annual
deductible.
• Copay or coinsurance: After meeting the deductible, you and the plan share the cost of
covered medical care and prescriptions, with the plan paying the majority. After meeting the
deductible, if applicable, you pay a copay for many services when you use in-network
providers. For other services, like hospital stays, or when you use out-of-network providers,
you pay a percentage of the cost.
• Out-of-pocket maximum: You are protected by an annual limit on costs — the plan pays
100% of any further covered expenses for the rest of the year.
• Prescriptions: There are different tiers of prescription drugs which have different copays
after the deductible. Speak with your doctor about the most effective and cost efficient
prescription options. Prescriptions must be filled at a pharmacy that participates in the
plan’s network. Otherwise, they will not be covered.
2024 Employee Contributions: Premera Blue Cross PPO Medical Plan (Monthly)
Premera Blue Cross PPO Medical Plan
Employee Only $83.52
Employee + Spouse $155.94
Employee + Child(ren) $134.08
Employee + Family $205.66

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Medical Plan Summary
Premera Blue Cross HDHP Premera Blue Cross PPO Medical
In-Network Out-of-Network In-Network Out-of-Network
HSA-eligible Yes

No

Avista contribution to
HSA
$700 individual/
$1,500 Employee + 1
None
Annual deductible (individual/family) $1,600 / $3,200 $3,200 / $6,400 $300 / $900 $400 / $1,200
Annual out-of-pocket
maximum
(individual/family)
$3,200 / $6,400 Unlimited $1,500 / $4,500 $3,000 / $9,000
Medical care: Your costs
Preventive care Covered at 100%; no deductible
Not covered Covered at 100%; no deductible
Not covered
Office visit (primary
care)
You pay 20%
after deductible
You pay 50%
after deductible
You pay $20
copay; no
deductible
You pay $20
copay, then 40%
after deductible
Office visit (specialist) You pay 20%
after deductible
You pay 50%
after deductible
You pay $20
copay; no
deductible
You pay $20
copay, then 40%
after deductible
Telemedicine visit You pay 20% after deductible N/A You pay $20 copay; no deductible
N/A
Urgent care You pay 20%
after deductible
You pay 50%
after deductible
You pay $20
copay; no
deductible
You pay $20
copay, then 40%
after deductible
Emergency room You pay 20% after deductible You pay 20% after deductible
Hospital stay You pay 20% after deductible
You pay 50% after deductible
You pay 20% after deductible
You pay 40% after deductible
Mental health office visit You pay 20% after deductible
You pay 50% after deductible
You pay $20 copay; no deductible
You pay $20 copay, then 40% after
deductible
Fertility Testing,
Diagnosis and
Treatment
You pay
20% after
deductible*
You pay
50% after
deductible*
You pay
20% after
deductible*
You pay
40% after
deductible*
* This benefit includes testing, invitro fertilization and artificial insemination. Limit: $2,000 per calendar year; $6,000 lifetime maximum.

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Premera Blue Cross HDHP Premera Blue Cross PPO Medical
In-Network Out-of-Network In-Network Out-of-Network
Physical, Occupational,
Speech and Massage
Therapy, and Chronic
Pain

You pay
20% after
deductible (up
to 30 days/year
for inpatient
and 45
visits/year for
outpatient)
You pay
50% after
deductible (up
to 30 days/year
for inpatient
and 45
visits/year for
outpatient)
Inpatient: You
pay 20% after
deductible (up
to 15 days/year)
Outpatient:
You pay
$20 copay; no
deductible (up
to 45
visits/year)
Inpatient: You
pay 40% after
deductible (up
to 15 days/year)
Outpatient:
You pay
$20 copay, then
40% after
deductible (up
to 45
visits/year)
Chiropractor You pay
20% after
deductible
You pay
50% after
deductible
You pay
$20 copay; no
deductible
You pay
$20 copay, then
40% after
deductible
Acupuncture You pay 20% after deductible
You pay 50% after deductible
You pay $20 copay; no deductible (up to 12 visits/year)
You pay $20 copay, then 40% after deductible (up to 12 visits/year)
Prescriptions: Your costs
30-day supply (retail pharmacy)
Generic You pay 20% after deductible
You pay 50% after deductible
You pay $5 copay Not covered
Preferred Brand You pay
20% after
deductible
You pay
50% after
deductible
You pay
$20 copay
Not covered
Non-Preferred Brand You pay
20% after
deductible
You pay
50% after
deductible
You pay
$40 copay
Not covered
90-day supply (mail order)
Generic You pay
20% after
deductible
Not covered You pay
$5 copay
Not covered
Preferred Brand You pay
20% after
deductible
Not covered You pay
$20 copay
Not covered
Non-Preferred Brand You pay 20% after deductible
Not covered You pay $40 copay Not covered
* Plan pays up to $2,000 per year, up to $6,000 per lifetime. Plan pays $3,000 per individual total.
per year. Plan pays up to

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Virtual Care
With virtual care visits, Avista’s Premera Blue Cross members can see a doctor via computer or
mobile device and get answers 24/7, 365 days a year. Virtual care provides fast, convenient
diagnosis and treatment for many common conditions through a video consult on your
smartphone or computer.
Virtual care visits are available to you and your dependents who are enrolled in one of Avista’s
Premera Blue Cross medical plans.
Our virtual care partners:
• Doctor On Demand and 98point6 for general medicine, dermatology, and mental health
care.
• Talkspace for private messaging and live video conference with a licensed therapist for
behavioral health.
• Workit Health and Boulder Care for substance abuse treatment.
• Physera for outpatient rehabilitation/physical therapy.
Livongo
Livongo combines technology with coaching to help you live a better and healthier life. When
you enroll, you will receive all of the following, at no cost to you:
• A glucose meter with a touch screen monitoring device that uses cellular technology to
automatically upload your glucose levels and provide you with real-time results.
• Unlimited test strips.
• Lancing device, lancets, and carrying case.
• Personalized feedback and tips with each reading.
• 24/7 access to certified diabetes coaches who can help you set goals and adopt healthy
habits — they will also reach out to you if your reading is out of range, to lend support when
you need it most.
Right Price Program
This program ensures your pharmacy automatically applies prescription discount codes and
coupons available for generic medications. This guarantees you pay the lowest price available.
SaveonSP
This program is available to those enrolled in the PPO Plan who take specialty medication.
Through SaveonSP, you can get 100% of your qualified specialty copay covered by taking
advantage of manufacturer-funded assistance. If you qualify for the program, SaveonSP will
reach out to you directly through the mail or the phone.
You must enroll in SaveonSP to participate.

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Split Fill Program
For certain specialty prescriptions, you may initially receive two 15-day fills of your prescription.
If your prescription is par of this program, you will be contacted by Accredo, the specialty
medication vendor. They will also reach out on day 8 of your prescription to check in and
coordinate sending the second 15-day fill.
2nd.MD
When you enroll for medical coverage through Avista, you will have access to 2nd.MD. This
service provides confidential second opinions and medical advice from some of the country’s
premier physicians to help you receive the most appropriate care for your situation. They can
also help you find the best doctor to help treat your particular illness or injury. This benefit is
100 percent confidential and offered at no charge to enrolled employees and dependents.
For more information, go to the 2nd.MD website or call 866.841.2575.
Health Advocate
You and your eligible family members, including parents and parents-in-law, have access to
Health Advocate, a leading national health advocacy and assistance company. Health Advocate
is available to those enrolled in an Avista medical plan.
Health Advocate provides many important services to help you and your family members
resolve health care-related issues, balance your life and work, and make healthy lifestyle
changes.
You have access to personal health advocates who can assist you and your eligible dependents
with the following services:
• Finding a doctor or hospital
• Resolving billing and claim issues
• Getting a second opinion for a diagnosis and expediting appointments
• Understanding conditions, test results, prescriptions, and treatment options
• Finding eldercare and support services
• Understanding Medicare
• And more…
For more information, go to Health Advocate, call 866.695.8622 or email
mailto:[e-mail].

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DENTAL INSURANCE
Healthy teeth and gums are important to your overall wellness. Avista offers coverage through
Delta Dental of Washington to help you maintain a healthy smile through regular preventive
care and fix any dental problems that may arise.
Key features at a glance:
• Free in-network preventive and diagnostic care to help keep your teeth healthy.
• Affordable coverage that helps you manage the cost of dental treatment.
• Wide network of providers that have agreed to negotiated rates, which helps you save
money — visit the Delta Dental of Washington website to find an in-network provider near
you.
2024 Employee Contributions: Dental (Monthly)
Delta Dental of Washington
Employee Only $4.40
Employee + Spouse $8.82
Employee + Child(ren) $11.90
Employee + Family $16.30
Dental Plan Summary
Delta Dental PPO
Dentist
Delta Dental
Premier Dentist
Non-Participating
Dentist
Annual Maximum per Person $2,000 $2,000 $2,000
Deductible: (Waived on Class I,
Orthodontia and Accidents) Individual/ Family
$25 / $75 $25 / $75 $25 / $75
Class 1 – Diagnostic &
Preventive
(Exams, Cleaning, Fluoride, X-
Rays, Sealants)
100%; no
deductible
100%; no
deductible
100%; no
deductible
Class II – Restorative
(Fillings, Endodontics,
Periodontics, Oral Surgery)
90% after
deductible
80% after
deductible
80% after
deductible
Class III – Major (Dentures, Partial Dentures, Implants, Bridges, Crowns)
50% after deductible 50% after deductible 50% after deductible
Orthodontia – Adults and
Dependent Children
Lifetime Maximum per Person
50% after
deductible
$1,000
50% after
deductible
$1,000
50% after
deductible
$1,000

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* If you use an out-of-network provider, you are responsible for any charges above the
usual, customary, and reasonable (UCR) limits.
VISION INSURANCE
To help you keep life in focus, vision coverage through Premera Blue Cross provides benefits for
eye exams, frames, and lenses.
Key features at a glance:
• Eye exam and prescription glasses covered every year, with only a small copay charged to
you.
• Coverage for eyeglasses or contacts, so you can choose the method of vision correction you
prefer.
• Wide network of providers to use for vision services — visit the Premera website to find an
in-network vision care provider near you.
2024 Employee Contributions: Vision (Monthly)
Premera Blue Cross
Employee Only $0.50
Employee + Spouse $0.92
Employee + Child(ren) $0.80
Employee + Family $1.22
Vision Plan Summary
In-Network Out-of-Network
Routine Vision Exam (once every
calendar year)
$20 copay $20 copay, then
40% coinsurance
Vision Hardware $150 per calendar year $150 per calendar year

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SAVINGS AND SPENDING ACCOUNTS
Avista’s tax-advantaged accounts are administered by Rehn & Associates.
Note: You must enroll in these accounts each Open Enrollment if you want to contribute the
next year, even if you already participate.
Health Savings Account (HSA)
With the Premera Blue Cross High Deductible Health Plan (HDHP), you are eligible to open and
contribute money to a Health Savings Account (HSA) through Rehn & Associates. The HSA is a
tax-free savings account that you own. You can use it to pay for eligible health expenses
anytime, even in retirement.
The HSA has a triple-tax advantage that trumps even a 401(k) or Roth IRA. And, Avista may
contribute to your account, too!
Benefits of an HSA
Put Money in Tax-Free*
• You contribute to your HSA through
pre-tax payroll deductions.
• If you need to, you can change your
contribution amount anytime.

Get Company Contributions
• Avista will contribute $700 if you have
employee-only medical plan coverage,
or $1,500 for those with employee + 1
coverage.
• Once you complete wellness initiatives,
Avista contributes up to an additional
$400.
Pay for Care Tax-Free**
• Pay for eligible medical, dental, and vision expenses for you and your family
using your HSA debit card (provided
sufficient funds are in your account).
• Track your spending, check your
balance, reimburse yourself, and more
on the Rehn & Associates website.
Grow Money for the Future — Tax-Free
• All the money in your HSA is yours to keep, year after year.
• You can build up savings through tax-
free interest and even invest your money once it reaches a minimum
balance, which gives you the potential
for tax-free earnings growth and a way to plan ahead.
* Contributions are not subject to federal tax. However, HSA contributions are currently
subject to state tax in CA and NJ, and both HSA and FSA contributions are subject to state
tax in NJ. Consult with your tax advisor to understand the potential tax consequences of
enrolling in an HSA and/or FSA.
** Money in an HSA can be withdrawn tax-free as long as it is used to pay for qualified
health-related expenses. If money is used for ineligible expenses, you will pay ordinary
income tax on the amount withdrawn, plus a 20% penalty tax if you withdraw the money
before age 65.

18
2024 Contribution Limits
Keep in mind, the maximum amount you and Avista can contribute to your HSA is determined
by annual limits that the IRS sets. In 2024, the total contribution limits are:
• $4,150 if you have employee-only medical plan coverage, or
• $8,300 if you cover dependents.
If you are age 55 or older, you can contribute an additional $1,000 above these limits.
Who Is Eligible for an HSA?
If you or your spouse have a health FSA or an HRA that pays or reimburses qualified medical
expenses, you are not eligible to contribute to an HSA. To establish and contribute to an HSA,
you:
• Must be enrolled in the Premera Blue Cross HDHP or another qualified high-deductible
medical plan.
• Cannot be enrolled in any other medical coverage, including a spouse’s plan or Medicare.
• Cannot be claimed as a dependent on someone else’s tax return.

If you elect to contribute to an HSA and have an existing HRA, the HRA will be converted into a
Limited Purpose HRA that can only be used for dental and vision expenses.
You should review IRS rules for making HSA contributions if you will turn age 65 during the year.
For more information, see IRS Publication 969.
Health Care FSA*
A Health Care FSA is available to employees who enroll in the Premera Blue Cross PPO or do not
elect medical coverage. You can contribute up to IRS limits each year through pre-tax payroll
deductions to help cover eligible medical, dental, and vision expenses. For 2024 contribution
limits, please visit avistabenefits.com.
• Choose your contribution amount when you enroll. You can only change it during the year if
your personal situation changes, so estimate carefully. See page 4 for information about
making mid-year changes.
• Contribute — Your annual contribution will be divided into equal payroll deductions, but the
entire amount is available to you from the beginning of the plan year.
• Spend — Log in to the Rehn & Associates website to request reimbursement for payments
you have made.
• Use it up — Unused money does not carry over at the end of each year. Use it or lose it! Be
sure to use it up. A “grace period” of 2 ½ months, as defined by IRS Notice 2005-42 has been
added to the end of the plan year, which currently ends on December 31 of each year. This
means that instead of the regular 12 month period during the plan year (January 1 through
December 31) to incur claims, you may now incur claims for 14 ½ months.

*Temporary employees are not eligible for this benefit.

19
Dependent Care FSA*
A Dependent Care FSA is available to all employees. You can contribute up to $5,000 if you are
married and filing jointly or up to $2,500 if you are single or married and filing separately.
Contributions are made through pre-tax payroll deductions to help cover your eligible
dependent care expenses, including child care for children up to age 13 and care for dependent
elders.
• Choose your contribution amount when you enroll. You can only change it during the year if
your personal situation changes, so estimate carefully. See page 4 for information about
making mid-year changes.
• Contribute — Your annual contribution will be divided into equal deductions from each
paycheck. You can only use money that has been deposited into your account.
• Spend — Log in to the Rehn & Associates website to request reimbursement for payments
you have made.
• Use it up — Unused money does not carry over at the end of each year. Use it or lose it! Be
sure to use it up.
Making Mid-Year Changes
You can change your Dependent Care FSA contribution if you experience a significant change in
cost or coverage (this doesn’t apply to the Health Care FSA). Examples include:
• A large increase or decrease to your day care provider’s monthly fees.
• A mid-year change to your spouse’s coverage that affects your dependent care.
Any mid-year changes must be consistent with the qualifying event. If your provider’s charges go
up, then it could be consistent to increase your Dependent Care FSA contributions — but not
consistent to reduce the amount you put in.
See page 4 for more information about making mid-year changes.
*Temporary employees are not eligible for this benefit.
Health Reimbursement Arrangement (HRA)
With the Premera Blue Cross PPO, Avista will contribute up to $400 to an HRA in your name
when you complete the Healthy Directions Initiative program, as described on page 29.
You can use the money to help cover your health care costs and your eligible family members.
The HRA is administered by Rehn & Associates.
HRA Features
• It is free money. Completely funded by Avista, without employee contributions.
• Works like a bank account. Avista contributes up to $400 to an account that can be used to
pay for your eligible health care expenses. Submit claims online after you spend money on:
- Deductibles
- Coinsurance
- Prescription drugs
- Out-of-pocket expenses such as copays
- And more

20
• Unused money carries over at the end of each year. If you leave the company, your HRA
dollars remain in your account. You can submit expenses until your balance is $0 – with no
required time limit.
• Can be paired with a Health Care FSA. You can set aside your own pre-tax money in an FSA
to help cover health expenses in addition to your HRA amount.
Compare the Accounts
HSA Health Care FSA Dependent Care FSA HRA
Available
with …
Premera Blue
Cross HDHP
Premera Blue
Cross PPO
(Also available if
you waive
medical
coverage)
Your
employment at
Avista
Premera Blue
Cross PPO
Receive company contribution
Yes No No Yes, when you complete the Healthy Directions Initiative program
Change your
contribution
amount anytime
Yes No No No
Access your
entire annual
contribution amount as
needed
No Yes No No
Access only funds that have been deposited
Yes No Yes Yes
Use account
money for…
All eligible
medical, dental,
and vision care
expenses for you
and your
qualified
dependents
All eligible
medical, dental,
and vision care
expenses for you
and your
qualified
dependents
Eligible
dependent care
expenses,
including child
care for children
up to age 13 and
care for
dependent
elders
Eligible medical,
dental, and
vision care
expenses not
covered by
insurance, for
you and your
qualified
dependents

21

HSA Health Care FSA Dependent Care FSA HRA
“Use it or lose
it” at year-end
No 2 ½ month grace
period to use
your balance in
the next plan
year – unused
amounts will be
forfeited
Yes No
Money is always yours to keep Yes No No Yes

22
SUPPLEMENTAL MEDICAL INSURANCE
Even with comprehensive coverage from your primary medical plan, you will still have some out-
of-pocket expenses if you get critically ill or are seriously injured. Supplemental medical
insurance offers additional protection to help you cover costs that arise in these situations.
• Accident Insurance: Helps protect you from unexpected financial stress if you or a covered
family member has an accident.
• Critical Illness Insurance: Provides financial support to help you when a serious illness
strikes.
Supplemental medical insurance plans are administered by Aflac.
Key Features at a Glance
Supplemental medical plans provide:
• Cash benefits that you can use to pay expenses not covered by your primary medical
coverage.
• Flexibility to spend your benefit payment on whatever costs you’re facing, including medical
bills, transportation costs, child care fees, and daily living expenses.
• Financial protection against the high costs often associated with accidental injuries or a
serious illness.
• An inexpensive way to supplement a high-deductible health plan, giving you a cost-
effective package of coverage that may minimize your overall medical expenses.

Keep in mind
On their own, supplemental medical insurance plans don’t provide comprehensive medical
coverage for your day-to-day health care needs. Rather, they’re intended to supplement
the coverage provided by your primary medical plan.

23
Accident Insurance
Accident insurance supplements your primary medical plan by providing cash benefits in cases
of covered accidental injuries. You can use this money to help pay for medical expenses not paid
by your medical plan (such as your deductible or coinsurance) or for anything else (such as
everyday living expenses).
You receive a cash benefit up to a specific amount for:
• Ambulance
• Emergency treatment
• Hospital admission
• Intensive care
• Medical expenses
• Travel expenses to distant treatment centers
• Everyday living expenses, like rent or mortgage, utility bills, groceries, and more
Benefits and Coverage
Coverage is available for you, your spouse, and dependent children. There are two coverage
options:
• High option
• Low option
The plan has limitations and exclusions that may affect benefits payable.
For details, go to avistabenefits.com and visit the Supplemental Medical section.
You can also contact Aflac for more information: 800.433.3036.
2024 Employee Contributions: Accident Insurance (Monthly)
Aflac
High Option Low Option
Employee Only $12.86 $7.01
Employee + Spouse $21.87 $11.88
Employee + Child(ren) $31.03 $17.16
Employee + Family $40.04 $22.03

24
Critical Illness Insurance
Critical Illness coverage protects against the financial impact of certain illnesses, such as a heart
attack, cancer, or stroke. If you experience a covered illness, you receive a lump-sum benefit
payment to help cover out-of-pocket expenses for your treatment that are not covered by your
medical plan.
You also can use the money to take care of other expenses, such as:
• Specialized treatment costs
• Transportation to a distant medical facility
• Living expenses like rent, mortgage, utility bills, and more
Benefits are paid directly to you, unless assigned to someone else.
Benefits and Coverage
Coverage is available for you, your spouse, and dependent children. There are two coverage
options:
• High option – provides up to a $30,000 benefit**
• Low option – provides up to a $15,000 benefit**
** Note: Coverage for spouses and dependent children is 50% of the employee coverage amount.
The plan has limitations and exclusions that may affect benefits payable.
For details, go to avistabenefits.com and visit the Supplemental Medical section.
You can also contact Aflac for more information: 800.433.3036.
2024 Employee Contributions: Critical Illness Insurance (Monthly)
Benefit Amount $15,000 — Aflac Benefit Amount $30,000 — Aflac
Age
Employee (or
employee plus
children**)
Spouse (or
employee plus
spouse)**
Employee (or
employee plus
children**)
Spouse (or
employee plus
spouse)**
18-25 $4.12 $2.56 $7.22 $4.12
26-30 $5.61 $3.31 $10.20 $5.61
31-35 $5.47 $3.24 $9.93 $5.47
36-40 $8.14 $4.58 $15.27 $8.14
41-45 $9.88 $5.44 $18.74 $9.88
46-50 $11.84 $6.43 $22.67 $11.84
51-55 $18.44 $9.72 $35.86 $18.44
56-60 $18.22 $9.61 $35.43 $18.22
61-65 $37.27 $19.14 $73.52 $37.27
66+ $65.60 $33.31 $130.19 $65.60
** Note: Coverage for spouses and dependent children is 50% of the employee coverage amount.

-

25
LIFE AND ACCIDENT INSURANCE
To help protect the financial well-being of your loved ones, Avista provides basic life insurance
— at no cost to you — along with the opportunity to purchase optional coverage.
Be sure to name a beneficiary
It is important to designate a beneficiary to receive the benefit paid by a life insurance policy.
As personal circumstances change, take the time to keep that information up to date. Visit
the enrollment site to add or change a beneficiary.
Base Life Insurance*
Avista provides Basic, Term Life insurance to assist your family in the event of your death. These
benefits are fully paid by the company and coverage is automatic — you do not need to enroll.
Group Term Life Insurance Coverage
• Employees hired on or after July 1, 1997 regardless of age: 1x annual base pay rounded to
the nearest $1,000, to a maximum of $50,000.
• Employees hired prior to July 1, 1997 and at least 40 years of age, but not yet 60 years of age as of July 1, 1997: 1x annual base pay rounded to the nearest $1,000, but not to exceed
$75,000.

*Temporary employees are not eligible for this benefit.
Optional Life Insurance
If you want more financial protection beyond the basic coverage that Avista provides, you can
buy optional life insurance for yourself. You pay the full cost of this coverage, which is provided
through Unum. You must purchase coverage for yourself in order to purchase it for your
dependents.
For You For Your Spouse For Your Child(ren)
Coverage amounts available
1 to 5 times your basic annual earnings, up to $500,000
$10,000 increments, up to $100,000 or 50% of your coverage (whichever is less)
$2,000; $5,000; or
$10,000
Guarantee issue
amounts
An amount equal to or
less than 2 times your
basic annual earnings
An amount equal to or
less than $50,000
Not required
Guarantee Issue Amounts
If you elect optional life insurance when you are first eligible, you will need to complete a
Statement of Health, also known as Evidence of Insurability (EOI), only for amounts above the guarantee issue amounts. Any future increases in coverage will require EOI.

26
If you (and/or your dependents) do not elect coverage when first eligible but elect at a later
date — or if you increase your coverage amount — you will be required to provide EOI.
2024 Employee Contributions: Optional Life Insurance (Monthly)
Age Monthly Rate for Each $1,000 of Coverage
Employee Spouse
< 30 $0.07 $0.06
30-34 $0.09 $0.08
35-39 $0.11 $0.10
40-44 $0.15 $0.13
45-49 $0.21 $0.18
50-54 $0.38 $0.33
55-59 $0.66 $0.58
60-64 $0.85 $0.75
65-69 $1.36 $1.27
70+ $2.06 $2.06
Child(ren) Coverage
$0.10
AD&D Insurance
AD&D insurance provides coverage if you die or are injured as the result of an accident.
You may choose to purchase additional accident protection for you and your eligible family
members. You pay the full cost of this coverage, which is provided through Unum. You must
purchase coverage for yourself in order to purchase it for your dependents.
Employee Family Spouse Only Child(ren) Only
Coverage
amounts available
$25,000
increments, up to $250,000 or 10x your base annual earnings (whichever is less)
Spouse: 40% of
employee’s coverage amount Child(ren): 10% of employee’s coverage amount
60% of
employee’s coverage amount
20% of
employee’s coverage amount
Guarantee
issue amounts
Not required Not required Not required Not required

2024 Employee Contributions: AD&D Insurance (Monthly)
Employee Family
$0.031 for each $1,000 of coverage $0.041 for each $1,000 of coverage

L J
L 1 J

27
PRE-PAID LEGAL
Pre-paid Legal offers economical access to attorneys for legal services such as will preparation,
estate planning, and family law.
• Give yourself, your spouse, your dependent children, and parents access to a nationwide
network of attorneys.
• Legal advice is a phone call away, and representatives will help you find an attorney in your
area.
For more information, visit the LegalEASE website or call 800.248.9000. You can enroll in Pre-
Paid Legal as a new hire or during Open Enrollment.
2024 Employee Contributions: Pre-Paid Legal (Monthly)
Family
$16.74
IDENTITY THEFT PROTECTION
Protect the identity of everyone in your household. Services from Identity Guard include
monitoring your identity, detecting fraud, and restoring your identity in the event of theft.
• Get peace of mind by protecting yourself against the damage of identity theft.
• Certified privacy advocates act on your behalf to resolve identity theft issues.
For more information, visit Identity Guard or call 855.443.7748. You can enroll in Identity Theft
Protection as a new hire or during Open Enrollment.
2024 Employee Contributions: Identity Theft Protection (Monthly)
Employee Family
$11.00 $19.00

PET INSURANCE
Trupanion pet insurance helps you cover the costs of veterinary care.
• Protect against the financial impact of veterinary care while using any veterinarian in the US, Canada, Puerto Rico, and Australia.
• You are eligible to receive special, lower monthly premium rates through this program.
• The plan covers 90% of eligible veterinary costs for the diagnosis and treatment of any new injury or illness.

28
For more information, visit the Trupanion website or call 855.235.3134. You can enroll in Pet
Insurance on the Trupanion enrollment website as a new hire or during Open Enrollment.
2024 Employee Contributions: Pet Insurance (Monthly)
Your Pet’s Age Dog ($250 deductible) Cat ($250 deductible)
8 weeks–2 years $35.37 $16.69
3–5 years $42.49 $17.05
6–7 years $53.76 $22.59
8–10 years $73.80 $26.97
11+ years $82.66 $51.67

LONG-TERM CARE INSURANCE
Long-term care insurance pays benefits when a covered person can’t perform everyday activities, such as bathing, dressing, or eating. This type of care is generally not covered by health insurance, Medicare, or Medicaid.
Long-term care insurance helps cover your future cost of care.
• Many adults require care and assistance at some point — whether it’s because of a serious accident, age-related illness, or disabling health condition.
• The younger you are when you purchase long-term care insurance, the lower your cost of coverage will be.
Benefits and Coverage
You can purchase long-term care insurance for you and your spouse/partner. You pay the full cost of this coverage, which is provided through ACSIA Partners LLC in partnership with LifeSecure Insurance Company.
• Enroll any time with a full medical questionnaire.
• New employees may apply within 90 days of their date of hire with a streamlined medical questionnaire.
Qualifying for care and how much you pay for coverage are based on your current health
situation, age, and other factors.
For more information, visit the ACSIA Partners website or call 833-888-0982.
2024 Employee Contributions: Long-Term Care Insurance (Monthly)
Premium depends on your current health situation, age, and other factors — contact ACSIA
Partners for a quote.

29
WELLNESS INCENTIVE FROM AVISTA
Receive up to $400 from Avista when you complete the Healthy Directions Initiative program.
With the Premera Blue Cross HDHP, Avista contributes the money to your Health Savings
Account (HSA).
With the Premera Blue Cross PPO, Avista contributes the money to an employer-funded Health
Reimbursement Arrangement (HRA) in your name. You can use the money to help cover the
costs of health care.
In order to qualify for this benefit, eligible employees must meet all the following conditions:
• Employee must have successfully completed the requirements of the Healthy Directions
Initiative program.
• Employee must be a member of an Avista Self-Insured Premera Blue Cross medical plan at
the time the incentive is actually paid.
• Employee must be employed by the company and still considered to be in an active
employment status at the time the incentive is actually paid.
EMPLOYEE ASSISTANCE PROGRAM (EAP)
The EAP, provided by SupportLinc, is a free, confidential benefit to help you and your household
members live well, at home and at work. The EAP offers:
• Confidential support for a variety of issues, including work/life balance, family and
relationships, depression and stress management, alcohol/substance abuse, and more.
• Eight counseling sessions (in-person, virtually, or via phone) for you and your eligible
dependents or household members at no cost to you.
• A 30 minute phone or in-person consultation to help answer basic legal questions and
simplify the process of obtaining legal help.
• A telephonic consultation with a qualified financial consultant to assist with a variety of
financial concerns.
• Online tools, resources, and learning modules dedicated to health and wellness information.
• Online personal empowerment videos.
ADOPTION ASSISTANCE*
If you decide to adopt a child, Avista is here to support you. Through the Adoption Assistance Program, you can receive reimbursement for up to $2,000 per adopted child in qualified
Reach out for assistance today
Call 888.881.5462 or visit the SupportLinc website. The EAP is available 24/7/365. I I

30
adoption-related expenses. You must provide the employer with reasonable substantiation that
payments or reimbursements made under the plan constitute “qualified” adoption expenses.
“Qualified” adoption expenses are reasonable and necessary adoption fees, court costs,
attorney fees, traveling expenses (including amounts spent for meals and lodging) while away
from home, and other expenses directly-related to, and whose principal purpose is for, the legal
adoption of an eligible child.
Qualifying adoption expenses do not include expenses:
• That violate state or federal law,
• For carrying out any surrogate parenting arrangement,
• For the adoption of your spouse’s child,
• Paid using funds received from any federal, state, or local program,
• Allowed as a credit or deduction under any other federal income tax rule, or
• Paid or reimbursed by your employer or otherwise (except that amounts paid or reimbursed
under an adoption assistance program may be qualifying expenses for the exclusion).
An “eligible child” is defined as any individual who, at the time a qualified adoption expense is
paid or incurred, is under the age of 18 or is physically or mentally incapable of caring for
himself or herself.
Learn about the IRS adoption credit and employer-provided adoption assistance programs.
Tax Considerations
Because the determination of how to take maximum advantage of the tax credit versus the
employer exclusion can be complicated, it is strongly advised that you seek consultation with a
tax advisor even before submitting expenses for employer reimbursement under this plan.
You will need to decide to what extent you want to submit expenses for employer
reimbursement versus using the tax credit. Generally the tax credit is more favorable because,
unlike an employer reimbursement, it is not subject to FICA tax. However, most employees with
adoption expenses will probably want to submit at least some expenses for employer
reimbursement after taking maximum advantage of the tax credit. Again, it is strongly advised
that you seek consultation with a tax advisor even before submitting expenses for employer
reimbursement under this plan.

*Temporary employees are not eligible for this benefit.

31
TUITION ASSISTANCE*
Avista Corp. will provide financial assistance to employees for approved courses when these can
be shown to reasonably add to the employee's improved performance and effectiveness in
present or foreseeable future jobs within the Company.
Tuition assistance of up to $5,250 in any calendar year is available for the cost of tuition and
books. Tuition, the required class related fees billed by the institution, and books are
reimbursed at 100%. Supplies, software, equipment, parking, or other non-tuition fees are not
covered costs. Any financial assistance in the form of a grant, fellowship, scholarship, or similar
assistance from any public or private source will be deducted from the total reimbursable
amount. Any course required to complete an undergraduate or graduate level program is
covered.
Regular, full-time or regularly scheduled part-time employees are eligible for tuition assistance
if:
• The course is taken for credit and offered by an approved and accredited college, university,
or academic institution.
• The course is necessary to satisfy a requirement for an undergraduate or graduate degree
program (courses taken for a certificate program, that do not provide a grade and credit, are
not reimbursable).
• The employee provides verification of satisfactory course completion.
Tuition is granted based on the following schedule:
• Employee receives tuition reimbursement for classes completed with a grade of C (2.0) or
better. Grades below a C, or courses dropped, will not receive financial support. Certificate
programs and classes taken as pass/fail (no credit toward a degree) are not eligible for
tuition reimbursement.
• Employees who voluntarily terminate their employment before completing the course(s)
will not receive reimbursement.
• By signing the tuition assistance application, the employee agrees to these terms.
To apply, complete the Tuition Aid Application and ask for your supervisor’s approval. After you
finish your course or degree program, submit your application, receipts for reimbursement, and
grades to [e-mail].

*Temporary employees are not eligible for this benefit.

32
JURY DUTY BENEFIT*
To encourage civic duty, you may serve on jury duty and receive pay from Avista for the time
served based upon your scheduled work hours. You will be expected to work your regular duties
for days or partial days while not on duty.
For example: A part-time employee scheduled to work 20 hours per week, would receive 20
hours of "jury duty" pay as long as they were serving during their regular scheduled work hours.
Employees are NOT allowed to receive more pay than their scheduled work hours. That means if
you normally work 4 hours per day, but serve 8 hours on the jury, you will receive 4 hours of
"jury duty" pay from the company.
Note: Employees are not required to "pay back" the company any daily stipend allowance
provided by the court.

*Temporary employees are not eligible for this benefit.

33
ONE LEAVE (PTO)
The One Leave Program is a benefit that allows you to accrue a “bank” of hours based on years
of service. Use your One Leave hours for vacation, personal business, family illness,
doctor/dental visits, funerals, or recovery from sickness or accident.
The maximum number of “banked” One Leave hours is 750 hours.
• Temporary employees hired for a minimum of 6 months will accrue One Leave starting on
their date of hire. They can start using One Leave hours at their 90-day anniversary.
• Employees who are exempt from overtime may take One Leave in four-hour increments.
• Non-exempt employees may take partial or full days of One Leave.
Transfer Hours to Cash
At the end of each year, eligible employees will have a window to elect to transfer a portion of
next year’s One Leave hours to cash. Hours will be paid bi-weekly throughout the next year. You
can elect up to your annual accrual rate:
One Leave Donation Plan
To support employees who are exhausting paid leave options due to illness, or a medical
emergency of an eligible family member, you can donate One Leave hours to them. Just use the
One Leave Donations Giving Form.
A few highlights include:
The ability to donate to a general One Leave pool. This pool supports employees when
donations are insufficient or confidentiality is necessary.
One Leave donations can be submitted at any time, but to be received this year they must be
submitted by December 1.
Year-end donations are a perfect opportunity for employees who are above the 750 hour year-
end maximum One Leave balance to transfer that value to the general One Leave pool.
If you're interested in learning more about the One Leave Donation Program, it's accessible on
The Avenue in the HR Department by selecting 'forms.'
Leaving Avista
When you retire from Avista, your One Leave balance will be credited to your individual HRA
account.
If you stop working for Avista before retirement, your One Leave balance will be paid to you as
cash.

34
How You Accrue One Leave Hours
This table shows a snapshot of how you accrue One Leave hours over time.
Completed Years
of Service
Estimated Accrual
Per Year (Days)
Estimated Accrual
Per Pay Period(80 Hours)
Accrual Rate Per
Hour Worked
During the 1st year 18.00 5.5392 .06924
During the 2nd year 18.69 5.7600 .07200
During the 3rd year 19.38 5.9696 .07462
During the 4th year 20.07 6.1800 .07725
During the 5th year 20.76 6.3896 .07987
During the 6th year 21.45 6.6000 .08250
During the 7th year 22.14 6.8200 .08525
During the 8th year 22.83 7.0296 .08787
During the 9th year 23.52 7.2400 .09050
During the 10th year 24.21 7.4496 .09312
During the 11th year 24.90 7.6696 .09587
During the 12th year 25.59 7.8800 .09850
During the 13th year 26.28 8.0896 .10112
During the 14th year 26.97 8.3000 .10375
During the 15th year 27.66 8.5096 .10637
During the 16th year 28.35 8.7296 .10912
During the 17th year 29.04 8.9400 .11175
During the 18th year 29.73 9.1496 .11437
During the 19th year 30.42 9.3600 .11700
During the 20th year 31.11 9.5800 .11975
During the 21st year 31.80 9.7896 .12237
During the 22nd year 32.49 10.0000 .12500
During the 23rd year 33.18 10.2096 .12762
During the 24th year 33.87 10.4296 .13037
During the 25th year 34.56 10.6400 .13300
During the 26th year 35.25 10.8496 .13562
During the 27th year 35.94 11.0600 .13825
During the 28th year 36.63 11.2800 .14100
During the 29th year 37.32 11.4896 .14362
During the 30th year 38.00 11.6960 .14620
Thereafter 38.00 11.6960 .14620

35
HOLIDAYS
Avista regularly observes the following holidays each year:
Holiday When Observed
New Year’s Day January 1
Martin Luther King Jr. Day Third Monday in January
Memorial Day Last Monday in May
Independence Day July 4
Labor Day First Monday in September
Thanksgiving Day Fourth Thursday in November
Day After Thanksgiving Day Friday after Thanksgiving
Christmas Day December 25
Three Personal Holidays
Personal Holidays are in addition to the standard company Holidays and your One Leave accrual.
You determine when your holiday will land — using the Personal Holiday in full day increments. Just like One Leave, check with your manager before taking the leave.
Just like any Holiday, the day does not carry over to the next year. These Personal Holidays are
available each January and must be used within the calendar year.

36
FMLA: THE FEDERAL FAMILY AND MEDICAL LEAVE ACT
Note: FMLA provides job protected leave that is non-paid.
Any employee absence, with the exception of scheduled vacation, that exceeds or is anticipated
to exceed five (5) days must be reported to the Occupational Health Nurse regardless of the
reason for leave.
FMLA Leave Entitlement
Effective August 5, 1993, the FMLA was enacted to allow employees to balance the demands
of the workplace with the needs of family. The Act provides for up to twelve (12) weeks of
unpaid, job-protected leave per twelve (12) month period to eligible employees the following
reasons:
• The birth of a child or placement of a child for adoption or foster care;
• To bond with a child (leave must be taken within one year of the child’s birth or placement);
• To care for the employee’s spouse, child, or parent who has a qualifying serious health condition;
• For the employee’s own qualifying serious health condition that makes the employee unable to perform the employee’s job;
• For qualifying exigencies related to the foreign deployment of a military member who is the employee’s spouse, child, or parent.
An eligible employee who is a covered service member’s spouse, child, parent, or next of kin may also take up to 26 weeks of FMLA leave in a single 12-month period to care for the service
member with a serious injury or illness.
Note: Dependent upon the triggering event, FMLA leave may be paid or unpaid.
Employees do not have to share a medical diagnosis, but must provide enough information to the employer so it can determine if the leave qualifies for FMLA protection. Sufficient information could include informing an employer that the employee is or will be unable to perform his or her job functions, that a family member cannot perform daily activities, or that
hospitalization or continuing medical treatment is necessary. Employees must inform the employer if the need for leave is for a reason for which FMLA leave was previously taken or certified.
Employers can require a certification or periodic recertification supporting the need for leave. If the employer determines that the certification is incomplete, it must provide a written notice indicating what additional information is required.
EMPLOYER RESPONSIBILITIES
This act is administered by the U.S. Department of Labor Wage and Hour Division. Once an employer becomes aware that an employee’s need for leave is for a reason that may qualify under the FMLA, the employer must notify the employee if they are eligible for FMLA leave and,

37
if eligible, must also provide a notice of rights and responsibilities under the FMLA. If the
employee is not eligible, the employer must provide a reason for ineligibility.
For a more in-depth definition of qualifying events and specific paid benefits, and to obtain a
copy of the FMLA notice, please contact the Occupational Health Nurse or our Benefits
Department at [e-mail].
PARENTAL LEAVE*
Parental Leave consists of three weeks of paid leave for new parents, which can be taken
consecutively or intermittently. It replaces 100% of your wages. Employees are eligible for three
weeks of paid parental leave when used within 12 months of the birth or adoption of their child.
Please note:
• Parental Leave may be used consecutively or intermittently, but in no less than 8-hour
increments.
• Parental Leave runs concurrent with FMLA.
• Parental Leave benefits cannot be used concurrently with workers’ compensation time-loss
benefits or with Avista provided leave benefits (such as Short Term Disability, One Leave,
and holiday pay).
Eligibility
You are eligible for Parental Leave if you are:
• A regular or full-time employee.
• A regularly scheduled (20+ hours) part-time employee.
• An employee with a minimum 1 year of service.
• Employees classified as casual, students, or temporary are not eligible.

*Temporary employees are not eligible for this benefit.
WORKERS’ COMPENSATION
Benefits paid for medical expenses and lost wages due to an "on the job" injury or illness.
If injured on the job, a claim must be filed within one year of the event that caused the injury.
An occupational illness claim must be filed within one year of the date of diagnosis, and a causal
relationship must exist between the development of the illness and the nature of the work.

38
Worker’s Compensation benefits for medical treatment and temporary total disability are paid
in accordance with Washington State’s Industrial Insurance Laws (RCW’s) as directed by the
Washington Administrative Codes (WAC’s). An employee who is unable to work due to an
occupational illness or injury may concurrently qualify for FMLA leave.
• Employees must report an occupational injury to their supervisor as soon as possible.
• An "Employee Injury Accident Report" must be completed and sent to Occupational Health within two (2) days.
• If the injury requires immediate medical attention, a Workers’ Compensation Claim form must be completed. Contact the Occupational Health Nurse if you need a claim form or assistance completing the report. This must be done as soon as possible to insure benefits are paid in a timely manner.
The Occupational Health Nurse will coordinate paperwork for FMLA leave and provide payroll
with appropriate time-loss information. If you have questions or would like more detail on a
specific disability benefit, please contact our Benefits Department at [e-mail].
Worker's Compensation benefits begin immediately after an industrial accident or injury.
Benefit Level (subject to limitations and maximums)
The employee will receive an amount from the Company which, when combined with
temporary Workers’ Compensation benefits will equal 100 % of their regular pay as long as they
receive temporary disability payments under Workers’ Compensation (not to exceed the weeks
shown in the following schedule according to years of service). After this time the employee will
receive Workers’ Compensation benefits according to the state schedule (at least 60%) as long
as they continue to be off work due to an industrial injury.
Years of Company Service
Industrial Accident Maximum Weeks Supplemented by Avista Weeks Paid at 100% of Salary
0.5 (6 mos.) 1
1 2
2 4
3 6
4 8
5 10
6 12
7 14
8 16
9 18
10+ 20

39
DISABILITY BENEFITS*
Disability insurance, provided through Avista or Unum, replaces a portion of your income in the
event of illness or injury. Your disability benefits will help you continue paying your bills and
meeting your financial obligations.
Short Term Disability (STD)*
The Short Term Disability (STD) plan is designed to provide you with income if you are unable to
work due to a non-occupational injury or illness.
Who pays for the benefit Avista
Administrator Your Avista Benefits Administrator
Elimination period Benefits begin after 5 consecutive days of disability (on the
sixth day)
Amount of the benefit 60% to 100% of your salary, based on your years of service.
Maximum benefit period Up to 26 weeks

Years of Service
Years of Service Weeks Paid at 100% of Salary Weeks Paid at 60% of Salary
.5 (6 months) 1 0
1 2 24
2 4 22
3 6 20
4 8 18
5 10 16
6 12 14
7 14 12
8 16 10
9 18 8
10+ 20 6

*Temporary employees are not eligible for this benefit.
l

40
Long Term Disability (LTD)*
The Long Term Disability (LTD) plan is designed to provide you income if you are unable to work
for a period longer than 26 weeks due to injury or illness.
Who pays for the benefit Avista
Administrator Unum
Elimination period Benefits begin after 26 weeks of continuous disability
Amount of the benefit 60% of your pre-disability earnings until you qualify as eligible
for retirement benefits
50% of your pre-disability earnings when you are eligible for
retirement but do not take retirement (when you reach age 55
and have at least 15 years of service with Avista)
Maximum benefit period Employees with 1 to 10 years of service: 1 year of benefits for each completed year of service
Employees with 10 or more years of service: until they reach the limiting age as defined by the Plan
Benefits continue for eligible employees until they retire or reach their Normal Retirement Age, whichever comes first
Taxation of benefit Any benefits you receive will be taxable to you

*Temporary employees are not eligible for this benefit.

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RETIREMENT BENEFITS
Avista offers benefits and tools to help you save for the future.
Investment Plan — 401(k)
Taking steps to ensure your current and future financial security is an important part of your
overall well-being. The Avista Corp Investment Plan – 401(k) helps you prepare for retirement by
offering an easy, tax-advantaged way to save for your future financial needs.
Key Features at a Glance
• Current tax savings. You will pay less in income taxes when you make pre-tax contributions.
• Roth after tax contributions. Contributions to a Roth account are on an after-tax basis.
Therefore, distributions from your Roth account — plus any earnings — will be tax-free if
you meet certain conditions.
• Tax-deferred investment growth. With 401(k) contributions, your money has the potential
to grow faster.
• Wide range of investment choices. Choose how you want to invest your money.
• Convenient payroll deductions. The 401(k) makes it easy to save for your future.
• Matching contribution from Avista. The company will match up to 6% of your contributions
(both pre-tax and Roth, and regardless of whether you were automatically enrolled in the
Plan) during the plan year. The formula is based on your hire date and employee group, as
described below. The company match is deposited into the Traditional 401(k) even for Roth
contributions.
Eligibility and Enrollment
Eligible employees are enrolled in the plan automatically at a paycheck deduction rate of 6% of
your eligible gross pay. (Employees hired on or after April 1, 2022 are automatically enrolled in
the plan at a paycheck deduction rate of 6% of your eligible gross pay.)
Your contributions will be invested in an age-appropriate target date fund. You can opt out,
contribute a different amount, or change your investment fund at any time by visiting Vanguard
or calling 800.523.1188.
Contributions
Your payroll deduction rate automatically increases each January:
• If you were hired prior to January 1, 2018, your deduction automatically increases by
1% until you reach 6%.
• If you were hired on or after January 1, 2018, your deduction automatically increases
by 1% until you reach 15%.
You may contribute between 1% and 75% of your eligible pay to your plan account, up to annual
IRS limits. In 2024, the IRS limits allow you to contribute up to:
• $23,000 if you are under age 50.
• $30,500 if you are age 50 or older this year (which includes an additional $7,500 in
catch-up contributions, made as a separate dollar amount election).

42

Try to contribute at least 6% to take full advantage of the match — otherwise, you are leaving
free money on the table. Log in to Vanguard to increase your contribution rate.
Matching Contributions
The company will match up to 6% of your contributions (both pre-tax and Roth, and regardless
of whether you were automatically enrolled in the Plan) during the plan year. There are
different company matching contribution formulas that apply, depending on when you are hired
or rehired and your employee group. The company match will be deposited into the Traditional
401(k) even for Roth contributions.
Avista’s matching contributions become 100% vested after your one-year employment
anniversary.
Non-Union and Local 659 Employees
hired prior to January 1, 2006
through December 31, 2010
Non-Union and Local 659 Employees
hired on or after January 1, 2011
Your company matching contribution is $0.75
for every $1 of contribution you make to the
Plan up to a maximum of 6% of pay.
Effective January 1, 2011 your company
matching contribution is $1 for every $1 of
contribution you make to the Plan up to a
maximum of 6% of pay.
Company contributions become 100% vested
after a participant has reached their one-year
employment anniversary.
Company contributions become 100% vested
after a participant has reached their one-year
employment anniversary.
You can contribute the lesser of 75% of your pay or up to the IRS limit. You can contribute the lesser of 75% of your pay or up to the IRS limit.
Company Non-Elective Contribution
The company will make a non-elective contribution to the Plan on your behalf if you are eligible
to receive such contributions.
Contribution amounts:
• Employees under age 40 receive a 3% contribution
• Employees age 40-49 receive a 4% contribution
• Employees age 50 and older receive a 5% contribution
Your contribution will begin on your very first paycheck. It will be placed automatically in the
Target Date Retirement Funds until you elect otherwise. You can go to Vanguard at any time to
change how this contribution is invested.
Note: This Non-Elective Contribution will be invested in the same funds that you elect for your 401(k). You will be vested in the plan after three years of service.
Note: Available for new employees hired on or after January 1, 2014.
l i

43
Name a Beneficiary
It is important to designate a beneficiary to receive the value of your 401(k) account in the event
you die before beginning to receive your benefit. As personal circumstances change, be sure to
keep that information up to date. Visit Vanguard to add or change a beneficiary.
Withdrawals and Loans
The money in your account is intended as a long-term investment to help you prepare for your
financial needs in retirement. However, under certain circumstances, you may be able to access
money from your account before reaching retirement age.
There are rules around withdrawals and loans. For more information, visit Vanguard or
call 800.523.1188.
Pension*
The Retirement Plan is a valuable benefit that can help you enjoy a more financially secure
retirement. Best of all, it is entirely company paid. The plan is a defined benefit plan fully funded
by Avista — you do not make any contributions.
Please note:
• The 1.5 Pension Plan is for non-bargaining employees hired prior to January 1, 2006.
• The 1.2 Pension Plan is for non-bargaining employees hired between January 1, 2006 and
December 31, 2013.
• Non-bargaining employees hired on or after January 1, 2014 are not eligible for the Pension
plans.
• Non-bargaining employees hired on or after January 1, 2014 are eligible for the non-elective
company contribution within the 401(k) Plan, in addition to any company match towards
your contributions.
Key Features at a Glance
• Automatic enrollment. You are automatically enrolled in the pension plan upon eligibility.
• No contributions required by you. All pension contributions are made by Avista.
• Choice of benefit payment options. You can choose the option that best matches your
retirement income needs.
Eligibility and Vesting
You become eligible to participate in the plan after completing 12 consecutive months of
service, working at least 1,000 hours during that time, and while employed by a participating
employer.
After five years of service, you become fully vested in your pension benefit. This means you have
a permanent right to receive your pension benefit when your employment ends.
How Your Benefit Is Determined
Your benefit provides a source of monthly income upon retirement from the company. The
amount is based on when you retire and which form of benefit you choose.

*Temporary employees are not eligible for this benefit.

44
LEGAL NOTICES
Federal laws require that Avista provide you with certain notices that inform you about your
rights regarding eligibility, enrollment, and coverage under group health plans. The following
notices explain these rights; please read them carefully and keep them where you can find
them.
These notices are for your information only and do not require action from you.
Medicare Creditable Coverage Notice
If you have Medicare, or will become eligible for Medicare in the next 12 months, a federal
law gives you more choices about your prescription drug coverage. See “Important Notice
From Avista about Creditable Prescription Drug Coverage and Medicare” on page 49 for
details.
Newborns’ and Mothers’ Health Protection Act (NMHPA or
“Newborns’ Act”) Notice
Federal law protects the benefit rights of mothers and newborns related to any hospital stay in
connection with childbirth. In general, group health plans and health insurance issuers may not:
• Restrict benefits for the length of hospital stay 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).
• Require that a provider obtain authorization from the plan or the insurance issuer for
prescribing a length of stay of up to 48 hours (or 96 hours).
For details on any state maternity laws that may apply to your medical plan, please refer to the
benefits material for the medical plan in which you are enrolled.
Women’s Health and Cancer Rights Act of 1998
If you have had or are going to have a mastectomy, you may be entitled to certain benefits
under the Women’s Health and Cancer Rights Act (WHCRA) of 1998. For individuals receiving
mastectomy-related benefits, coverage will be provided in a manner determined in consultation
with the attending physician and the patient, for:
• All stages of reconstruction of the breast on which the mastectomy was performed.
• Surgery and reconstruction of the other breast to produce a symmetrical appearance.
• Prostheses.
• Treatment of physical complications of the mastectomy, including lymphedemas.
These benefits will be provided subject to the same deductibles and coinsurance applicable to
other medical and surgical benefits provided under your group health plan coverage. Therefore,
if applicable, our health plan deductibles, coinsurance, and copayments will apply.

45
If you would like more information on WHCRA benefits, please contact our Benefits Department
at [e-mail].
Notice of Special Enrollment Rights for Health Plan Coverage
If you decline enrollment in an Avista health plan for you or your dependents (including your
spouse) because of other health insurance or group health plan coverage, you or your
dependents may be able to enroll in an Avista health plan without waiting for the next open
enrollment period provided that you request enrollment within 30 days after your other
coverage ends. 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 eligible dependents,
provided that you request enrollment within 30 days after the marriage, birth, adoption, or
placement for adoption.
Avista will also allow a special enrollment opportunity if you or your eligible dependents either:
• Lose Medicaid or Children’s Health Insurance Program (CHIP) coverage because you are no
longer eligible, or
• Become eligible for a state’s premium assistance program under Medicaid or CHIP.
For these enrollment opportunities, you will have 60 days — instead of 30 — from the date of
the Medicaid/CHIP eligibility change to request enrollment in the group health plan. Note that
this new 60-day extension doesn’t apply to enrollment opportunities other than due to the
Medicaid/CHIP eligibility change.
Note: If your dependent becomes eligible for special enrollment rights, you may add the
dependent to your current coverage or change to another health plan.
Premium Assistance Under Medicaid and the Children’s Health
Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage
from your employer, your state may have a premium assistance program that can help pay for
coverage using funds from their Medicaid or CHIP programs. If you or your children aren’t
eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs, but
you may be able to buy individual insurance coverage through the Health Insurance
Marketplace. For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed
below, you can contact your state Medicaid or CHIP office to find out if premium assistance is
available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or
any of your dependents might be eligible for either of these programs, you can contact your
state Medicaid or CHIP office or dial (877) KIDS NOW or visit www.insurekidsnow.gov to find out
how to apply. If you qualify, ask your state if it has a program that might help you pay the
premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as
under your employer plan, your employer must permit you to enroll in your employer plan if
you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must
request coverage within 60 days of being determined eligible for premium assistance. If you

46
have questions about enrolling in your employer plan, you can contact the Department of Labor
at www.askebsa.dol.gov or call (866) 444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance with paying your
employer health plan premiums. The following list of states is current as of July 31, 2023. You
should contact your state for further information on eligibility.

ALABAMA – Medicaid Website: http://myalhipp.com/
Phone: [phone]
ALASKA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: [phone] Email: [e-mail] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
ARKANSAS – Medicaid Website: http://myarhipp.com/
Phone: (855) MyARHIPP (855-692-7447)
CALIFORNIA – Medicaid Website: http://dhcs.ca.gov/hipp
Phone: [phone]
Fax: [phone]
Email: [e-mail]
COLORADO – Health First
Colorado (Colorado’s
Medicaid Program) &
Child Health Plan Plus
(CHP+)
Health First Colorado Website: https://www.healthfirstcolorado.com/
Health First Colorado Member Contact Center: 800-221-3943/ State Relay 711
CHP+: https://hcpf.colorado.gov/child-health-plan-plus CHP+ Customer Service: 800-359-1991/ State Relay 711
Health Insurance Buy-In Program (HIBI): https://www.mychohibi.com/ HIBI Customer Service: 855-692-6442
FLORIDA – Medicaid Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/index.html
Phone: [phone]
GEORGIA – Medicaid Website: https://medicaid.georgia.gov/health-insurance-premium-payment-program-
hipp
Phone: [phone], , press 1
CHIPRA Website: https://medicaid.georgia.gov/programs/third-party-
liability/childrens-healthinsurance-program-reauthorization-act-2009-chipra Phone: [phone], Press 2
INDIANA – Medicaid Healthy Indiana Plan for low-income adults 19-64
Website: http://www.in.gov/fssa/hip/ Phone: [phone]
All other Medicaid
Website: http://www.indianamedicaid.com Phone: [phone]

47
IOWA – Medicaid and
CHIP (Hawki)
Medicaid Website: https://dhs.iowa.gov/ime/membersMedicaid
Medicaid Phone: [phone]
Hawki Website: http://dhs.iowa.gov/Hawki
Hawki Phone: [phone]
HIPP Website: https://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp
HIPP Phone: [phone]
KANSAS – Medicaid Website: https://www.kancare.ks.gov/
Phone: [phone]
HIPP Phone: [phone]
KENTUCKY – Medicaid Kentucky Integrated Health Insurance Premium Payment (KI-HIPP) Program Website:
https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx
Phone: [phone]
Email: [e-mail]
KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx
Phone: [phone]
Kentucky Medicaid Website: https://chfs.ky.gov/agencies/dms
LOUISIANA – Medicaid Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp
Phone: [phone] (Medicaid hotline) or [phone] (LaHIPP)
MAINE – Medicaid Enrollment Website:
https://www.mymaineconnection.gov/benefits/s/?language=en_US Phone: [phone]
TTY: Maine relay 711
Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-forms
Phone: [phone] TTY: Maine Relay 711
MASSACHUSETTS –
Medicaid and CHIP
Website: https://www.mass.gov/masshealth/pa
Phone: [phone] TTY: 711
Email: [e-mail]
MINNESOTA – Medicaid Website: https://mn.gov/dhs/people-we-serve/children-and-families/health-
care/health-care-programs/programs-and-services/other-insurance.jsp
Phone: [phone]
MISSOURI – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
Phone: [phone]
MONTANA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP
Phone: [phone]
Email: [e-mail]
NEBRASKA – Medicaid Website: http://www.ACCESSNebraska.ne.gov
Phone: [phone]
Lincoln: [phone]
Omaha: [phone]
NEVADA – Medicaid Website: http://dhcfp.nv.gov/
Phone: [phone]
NEW HAMPSHIRE –
Medicaid
Website: https://www.dhhs.nh.gov/programs-services/medicaid/health-insurance-
premium-program
Phone: [phone]

48
Toll-free Number for the HIPP Program: [phone], ext. 5218
NEW JERSEY – Medicaid
and CHIP
Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/
Medicaid Phone: [phone]
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: [phone]
NEW YORK – Medicaid Website: https://www.health.ny.gov/health_care/medicaid/
Phone: [phone]
NORTH CAROLINA –
Medicaid
Website: https://medicaid.ncdhhs.gov/
Phone: [phone]
NORTH DAKOTA –
Medicaid
Website: https://www.hhs.nd.gov/healthcare
Phone: [phone]
OKLAHOMA – Medicaid
and CHIP
Website: http://www.insureoklahoma.org
Phone: [phone]
OREGON – Medicaid Websites: http://healthcare.oregon.gov/Pages/index.aspx
Phone: [phone]
PENNSYLVANIA – Medicaid & CHIP
Website: https://www.dhs.pa.gov/Services/Assistance/Pages/HIPP-Program.aspx
Phone: [phone]
RHODE ISLAND –
Medicaid and CHIP
Website: http://www.eohhs.ri.gov/
Phone: [phone], or [phone] (Direct RIte Share Line)
SOUTH CAROLINA –
Medicaid
Website: https://www.scdhhs.gov
Phone: [phone]
SOUTH DAKOTA -
Medicaid
Website: http://dss.sd.gov
Phone: [phone]
TEXAS – Medicaid Website: https://www.hhs.texas.gov/services/financial/health-insurance-premium-
payment-hipp-program
Phone: [phone]
UTAH – Medicaid and
CHIP
Medicaid Website: https://medicaid.utah.gov/
CHIP Website: http://health.utah.gov/chip
Phone: [phone]
VERMONT– Medicaid Website: https://dvha.vermont.gov/members/medicaid/hipp-program
Phone: [phone]
VIRGINIA – Medicaid and
CHIP
Medicaid Website: https://coverva.dmas.virginia.gov/learn/premium-
assistance/famis-select
https://coverva.dmas.virginia.gov/learn/premium-assistance/health-insurance-
premium-payment-hipp-programs
Phone: [phone]
WASHINGTON – Medicaid Website: https://www.hca.wa.gov/
Phone: [phone]
WEST VIRGINIA –
Medicaid
Website: https://dhhr.wv.gov/bms/
http://mywvhipp.com/

49
Medicaid Phone: [phone]
CHIP toll-free phone: 855-MyWVHIPP (855-699-8447)
WISCONSIN – Medicaid
and CHIP
Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm
Phone: [phone]
WYOMING – Medicaid Website: https://health.wyo.gov/healthcarefin/medicaid/programs-and-eligibility/
Phone: [phone]

To see if any more states have added a premium assistance program since July 31, 2023, or for
more information on special enrollment rights, you can contact either:
U.S. Department of Labor
Employee Benefits Security Administration
www.dol.gov/agencies/ebsa
(866) 444-EBSA (3272)
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
www.cms.hhs.gov
[phone], Menu Option 4, Ext. 61565
Important Notice from Avista about Creditable Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. The purpose of this notice is to advise you that the prescription drug coverage offered by Avista’s Premera Blue Cross medical plans, which are expected to pay out, on average, at least as much as the standard Medicare prescription drug coverage will pay in 2024. This is known as “creditable coverage.”
Why this is important. If you or your covered dependent(s) are enrolled in any prescription drug coverage during the 2024 plan year listed in this notice and are or become covered by Medicare, you may decide to enroll in a Medicare prescription drug plan later and not be subject to a late enrollment penalty — as long as you had creditable coverage within 63 days of your Medicare prescription drug plan enrollment. You should keep this notice with your important records.
If you or your family members aren’t currently covered by Medicare and won’t become covered by Medicare in the next 12 months, this notice doesn’t apply to you.
Please read the below notice carefully. It has information about prescription drug coverage with Avista and prescription drug coverage available for people with Medicare. It also tells you where to find more information to help you make decisions about your prescription drug coverage.
Notice of Creditable Coverage
You may have heard about Medicare’s prescription drug coverage (called Part D) and wondered how it would affect you. Prescription drug coverage is available to everyone with Medicare through Medicare prescription drug plans. All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare. Some plans also offer more coverage for a higher monthly premium.
Individuals can enroll in a Medicare prescription drug plan when they first become eligible, and each year from October 15 through December 7. Individuals leaving employer/union coverage may be eligible for a Medicare Special Enrollment Period.

50
If you are covered by the prescription drug coverage offered by one of the Avista’s medical
plans, you will be interested to know that coverage is, on average, at least as good as standard
Medicare prescription drug coverage for 2024. This is called “creditable coverage.” Coverage
under one of these plans will help you avoid a late Part D enrollment penalty if you are or
become eligible for Medicare and later decide to enroll in a Medicare prescription drug plan.
If you decide to enroll in a Medicare prescription drug plan and you are an active employee or
family member of an active employee, you may also continue your employer coverage. In this
case, the employer plan will continue to pay primary or secondary as it had before you enrolled
in a Medicare prescription drug plan. If you waive or drop coverage through Avista, Medicare
will be your only payer. You can re-enroll in the employer plan at annual enrollment or if you
have a special enrollment event for the Avista plan, assuming you remain eligible.
You should know that if you waive or leave coverage with Avista and you go 63 days or longer
without creditable prescription drug coverage (once your applicable Medicare enrollment
period ends), your monthly Part D premium will go up at least 1% per month for every month
that you did not have creditable coverage. For example, if you go 19 months without coverage,
your Medicare prescription drug plan premium will always be at least 19% higher than what
most other people pay. You will have to pay this higher premium as long as you have Medicare
prescription drug coverage. In addition, you may have to wait until the following October to
enroll in Part D.
You may receive this notice at other times in the future — such as before the next period in
which you can enroll in Medicare prescription drug coverage, if this coverage changes, or upon
your request.
For More Information About Your Options Under Medicare Prescription Drug Coverage
More detailed information about Medicare plans that offer prescription drug coverage is in the
Medicare & You handbook. Medicare participants will get a copy of the handbook in the mail
every year from Medicare. You may also be contacted directly by Medicare prescription drug
plans. Here’s how to get more information about Medicare prescription drug plans:
• Visit www.medicare.gov for personalized help.
• Contact your State Health Insurance Assistance Program; find contact numbers for your
state online at www.shiptacenter.org.
• Call (800) MEDICARE [phone]). TTY users should call [phone].
For people with limited income and resources, extra help paying for a Medicare prescription
drug plan is available. Information about this extra help is available from the Social Security
Administration (SSA). For more information about this extra help, visit SSA online at
www.socialsecurity.gov or call [phone] (TTY [phone]).
Remember:
Keep this notice. If you enroll in a Medicare prescription drug plan after your applicable
Medicare enrollment period ends, you may need to provide a copy of this notice when you
join a Part D plan to show that you are not required to pay a higher Part D premium
amount.

51
For more information about this notice or your prescription drug coverage, please contact our
Benefits Department at [e-mail].
Health Insurance Portability and Accountability Act (HIPAA)
The privacy rules under the Health Insurance Portability and Accountability Act (HIPAA) require
Avista to periodically send a reminder to participants about the availability of the plan’s Privacy
Notice and how to obtain that notice. The Privacy Notice explains participants’ rights and the
plan’s legal duties with respect to protected health information (PHI) and how the plan may use
and disclose PHI.
To obtain a copy of the Privacy Notice, please contact our Benefits Department at
[e-mail].
New Health Insurance Marketplace Coverage Options and Your
Health Coverage
PART A: General Information
To assist you as you evaluate options for you and your family, this notice provides some basic
information about the new Marketplace and employment based health coverage offered by
your employer.
What Is the Health Insurance Marketplace?
The Marketplace is designed to help you find health insurance that meets your needs and fits
your budget. The Marketplace offers "one-stop shopping" to find and compare private health
insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly
premium right away.
Can I Save Money on My Health Insurance Premiums in the Marketplace?
You may qualify to save money and lower your monthly premium, but only if your employer
does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on
your premium that you're eligible for depends on your household income.
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
Yes. If you have an offer of health coverage from your employer that meets certain standards,
you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your
employer's health plan. However, you may be eligible for a tax credit that lowers your monthly
premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you
at all or does not offer coverage that meets certain standards. If the cost of a plan from your
employer that would cover you (and not any other members of your family) is more than 9.83%
of your household income for the year, or if the coverage your employer provides does not
meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax
credit.
Note: If you purchase a health plan through the Marketplace instead of accepting health
coverage offered by your employer, then you may lose the employer contribution (if any) to the
employer-offered coverage. Also, this employer contribution as well as your employee
contribution to employer-offered coverage is often excluded from income for Federal and State

52
income tax purposes. Your payments for coverage through the Marketplace are made on an
after-tax basis.
How Can I Get More Information?
For more information about your coverage offered by your employer, please check your
summary plan description or contact our Benefits Department.
The Marketplace can help you evaluate your coverage options, including your eligibility for
coverage through the Marketplace and its cost. Please visit HealthCare.gov for more
information, including an online application for health insurance coverage and contact
information for a Health Insurance Marketplace in your area.
PART B: Information About Health Coverage Offered by Your Employer
This section contains information about any health coverage offered by your employer. If you
decide to complete an application for coverage in the Marketplace, you will be asked to provide
this information. This information is numbered to correspond to the Marketplace application.
3. Employer Name:
Avista Corp
4. Employer Identification Number (EIN):
91-1153956
5. Employer address: 1411 E Mission Ave 6. Employer phone number: [phone]
7. City
Spokane
8. State:
WA
9. Zip code:
99202
10. Who can we contact about employee health coverage at this job?
Avista Benefits Department
11. Phone number (if different from above) N/A 12. Email address: [e-mail]

Here is some basic information about health coverage offered by this employer:
As your employer, we offer a health plan to:
• All employees. Eligible employees are: all active regular full-time or part-time employees
who are scheduled to work 20 or more hours per week and temporary employees who are
expected to work at least 6 months.
With respect to dependents:
• We do offer coverage. Eligible dependents are:
- Legal spouse (same or opposite sex)
- Your child(ren) and your covered spouse’s child(ren) up to age 26
- Disabled children who became disabled on or before age 26

** Even if your employer intends your coverage to be affordable, you may still be eligible for a
premium discount through the Marketplace. The Marketplace will use your household
income, along with other factors, to determine whether you may be eligible for a premium
discount. If, for example, your wages vary from week to week (perhaps you are an hourly
employee or you work on a commission basis), if you are newly employed mid-year, or if
you have other income losses, you may still qualify for a premium discount.

53
If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through
the process. This is the employer information you'll enter when you visit HealthCare.gov to find
out if you can get a tax credit to lower your monthly premiums.
Notice Regarding Wellness Program
The Healthy Directions Initiative program provides a voluntary wellness program available to all
employees. The program is administered according to federal rules permitting employer-
sponsored wellness programs that seek to improve employee health or prevent disease,
including the Americans with Disabilities Act of 1990, the Genetic Information
Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as
applicable, among others.

If you choose to participate in the wellness program you will be asked to complete a voluntary
health risk assessment or "HRA" that asks a series of questions about your health-related
activities and behaviors and whether you have or had certain medical conditions (e.g., cancer,
diabetes, or heart disease). You will also be asked to complete a biometric screening, which will
include a blood test for glucose, A1c, and cholesterol levels. You are not required to complete
the HRA or to participate in the blood test or other medical examinations.

However, employees who choose to participate in the Healthy Directions Initiative program will
receive an incentive of $400 for completing the Healthy Directions Initiative program. Although
you are not required to complete wellness activities, only employees who do so will receive the
incentive.

Information gathered from your wellness program participation will be used to provide you with
information to help you understand your current health and potential risks, and may also be
used to offer you services through the wellness program. You also are encouraged to share your
results or concerns with your own doctor.
Protections from Disclosure of Medical Information
We are required by law to maintain the privacy and security of your personally identifiable
health information. Although the Healthy Directions Initiative program and Avista may use
aggregate information it collects to design a program based on identified health risks in the
workplace, the wellness program will never disclose any of your personal information either
publicly or to the employer, except as necessary to respond to a request from you for a
reasonable accommodation needed to participate in the wellness program, or as expressly
permitted by law. Medical information that personally identifies you that is provided in
connection with the wellness program will not be provided to your supervisors or managers and
may never be used to make decisions regarding your employment.

Your health information will not be sold, exchanged, transferred, or otherwise disclosed except
to the extent permitted by law to carry out specific activities related to the wellness program,
and you will not be asked or required to waive the confidentiality of your health information as
a condition of participating in the wellness program or receiving an incentive. Anyone who
receives your information for purposes of providing you services as part of the wellness program
will abide by the same confidentiality requirements.

54
In addition, all medical information obtained through the wellness program will be maintained
separate from your personnel records, information stored electronically will be encrypted, and
no information you provide as part of the wellness program will be used in making any
employment decision. Appropriate precautions will be taken to avoid any data breach, and in
the event a data breach occurs involving information you provide in connection with the
wellness program, we will notify you immediately.

You may not be discriminated against in employment because of the medical information you
provide as part of participating in the wellness program, nor may you be subjected to retaliation
if you choose not to participate.

If you have questions or concerns regarding this notice, or about protections against
discrimination and retaliation, please contact the Benefits team.
Continuation Coverage Rights Under COBRA
You’re getting this notice because you recently gained coverage under a group health plan (the
Plan). This notice has important information about your right to COBRA continuation coverage,
which is a temporary extension of coverage under the Plan. This notice explains COBRA
continuation coverage, when it may become available to you and your family, and what you
need to do to protect your right to get it. When you become eligible for COBRA, you may also
become eligible for other coverage options that may cost less than COBRA continuation
coverage.

The right to COBRA continuation coverage was created by a federal law, the Consolidated
Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become
available to you and other members of your family when group health coverage would
otherwise end. For more information about your rights and obligations under the Plan and
under federal law, you should review the Plan’s Summary Plan Description or contact the Plan
Administrator.

You may have other options available to you when you lose group health coverage. For
example, you may be eligible to buy an individual plan through the Health Insurance
Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs
on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a
30-day special enrollment period for another group health plan for which you are eligible (such
as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.
What is COBRA continuation coverage?
COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end
because of a life event. This is also called a “qualifying event.” Specific qualifying events are
listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered
to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children
could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying
event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage [choose
and enter appropriate information: must pay or aren’t required to pay] for COBRA continuation
coverage.

55
If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the
Plan because of the following qualifying events:
• Your hours of employment are reduced, or
• Your employment ends for any reason other than your gross misconduct.

If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your
coverage under the Plan because of the following qualifying events:
• Your spouse dies;
• Your spouse’s hours of employment are reduced;
• Your spouse’s employment ends for any reason other than his or her gross misconduct;
• Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or
• You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan
because of the following qualifying events:
• The parent-employee dies;
• The parent-employee’s hours of employment are reduced;
• The parent-employee’s employment ends for any reason other than his or her gross
misconduct;
• The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);
• The parents become divorced or legally separated; or
• The child stops being eligible for coverage under the Plan as a “dependent child.”
When is COBRA continuation coverage available?
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan
Administrator has been notified that a qualifying event has occurred. The employer must notify
the Plan Administrator of the following qualifying events:
• The end of employment or reduction of hours of employment;
• Death of the employee;
• The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).
For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the
Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to the Benefits team.
How is COBRA continuation coverage provided?
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA
continuation coverage will be offered to each of the qualified beneficiaries. Each qualified
beneficiary will have an independent right to elect COBRA continuation coverage. Covered
employees may elect COBRA continuation coverage on behalf of their spouses, and parents may
elect COBRA continuation coverage on behalf of their children.

COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18
months due to employment termination or reduction of hours of work. Certain qualifying

56
events, or a second qualifying event during the initial period of coverage, may permit a
beneficiary to receive a maximum of 36 months of coverage.

There are also ways in which this 18-month period of COBRA continuation coverage can be
extended:
Disability extension of 18-month period of COBRA continuation coverage
If you or anyone in your family covered under the Plan is determined by Social Security to be
disabled and you notify the Plan Administrator in a timely fashion, you and your entire family
may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a
maximum of 29 months. The disability would have to have started at some time before the 60th
day of COBRA continuation coverage and must last at least until the end of the 18-month period
of COBRA continuation coverage.

Second qualifying event extension of 18-month period of continuation coverage
If your family experiences another qualifying event during the 18 months of COBRA continuation
coverage, the spouse and dependent children in your family can get up to 18 additional months
of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified
about the second qualifying event. This extension may be available to the spouse and any
dependent children getting COBRA continuation coverage if the employee or former employee
dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or
legally separated; or if the dependent child stops being eligible under the Plan as a dependent
child. This extension is only available if the second qualifying event would have caused the
spouse or dependent child to lose coverage under the Plan had the first qualifying event not
occurred.
Are there other coverage options besides COBRA Continuation Coverage?
Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options
for you and your family through the Health Insurance Marketplace, Medicare, Medicaid,
Children’s Health Insurance Program (CHIP), or other group health plan coverage options (such
as a spouse’s plan) through what is called a “special enrollment period.” Some of these options
may cost less than COBRA continuation coverage. You can learn more about many of these
options at www.healthcare.gov.

57
Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends?
In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are
still employed, after the Medicare initial enrollment period, you have an 8-month special
enrollment period1 to sign up for Medicare Part A or B, beginning on the earlier of
• The month after your employment ends; or
• The month after group health plan coverage based on current employment ends.

If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to
pay a Part B late enrollment penalty and you may have a gap in coverage if you decide you want
Part B later. If you elect COBRA continuation coverage and later enroll in Medicare Part A or B
before the COBRA continuation coverage ends, the Plan may terminate your continuation
coverage. However, if Medicare Part A or B is effective on or before the date of the COBRA
election, COBRA coverage may not be discontinued on account of Medicare entitlement, even if
you enroll in the other part of Medicare after the date of the election of COBRA coverage.
If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally
pay first (primary payer) and COBRA continuation coverage will pay second. Certain plans may
pay as if secondary to Medicare, even if you are not enrolled in Medicare.
For more information visit https://www.medicare.gov/medicare-and-you. If you have questions
Questions concerning your Plan or your COBRA continuation coverage rights should be
addressed to the contact or contacts identified below. For more information about your rights
under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient
Protection and Affordable Care Act, and other laws affecting group health plans, contact the
nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security
Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers
of Regional and District EBSA Offices are available through EBSA’s website.) For more
information about the Marketplace, visit www.HealthCare.gov.
Keep your Plan informed of address changes
To protect your family’s rights, let the Plan Administrator know about any changes in the
addresses of family members. You should also keep a copy, for your records, of any notices you
send to the Plan Administrator.
Plan contact information
For more information about COBRA coverage, please contact our Benefits Department at
[e-mail].

1 https://www.medicare.gov/sign-up-change-plans/how-do-i-get-parts-a-b/part-a-part-b-sign-up-periods.

58
No Surprises Act Notice
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing. What is “balance billing” (sometimes called “surprise billing”)? When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. “Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit. “Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. You are protected from balance billing for: Emergency services If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services. Certain services at an in-network hospital or ambulatory surgical center When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

59
When balance billing isn’t allowed, you also have the following protections:
• You are only responsible for paying your share of the cost (like the copayments,
coinsurance, and deductibles that you would pay if the provider or facility was in-network).
Your health plan will pay out-of-network providers and facilities directly.
• Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance
(prior authorization).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an
in-network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward
your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact U.S. Department of Health and
Human Services beginning January 1, 2022 at 1-800-985-3059. Visit No Surprises Act | CMS for
more information about your rights.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2024 - 12/31/2024
Avista Corporation: Your Future HSA Agg NGF
Coverage for: Individual or Family | Plan Type: PPO
1 of 6
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-800-722-1471 (TTY: 711) or visit us
at www.premera.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other
underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call 1-800-722-1471 (TTY: 711) to request a copy.
Important Questions Answers Why This Matters:
What is the overall
deductible?
Calendar year aggregate
deductible. In-network: $1,600
Individual / $3,200 Family. Out-of-
network: $3,200 Individual / $6,400
Family.
Generally, you must pay all of the costs from providers up to the deductible amount before this
plan begins to pay. If you have other family members on the policy, the overall family deductible
must be met before the plan begins to pay.
Are there services
covered before you meet
your deductible?
Yes. Does not apply to Preventive
care and services listed below as
"No charge"
This plan covers some items and services even if you haven’t yet met the deductible amount.
But a copayment or coinsurance may apply. For example, this plan covers certain preventive
services without cost-sharing and before you meet your deductible. See a list of covered
preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other
deductibles for specific
services?
No. You don’t have to meet deductibles for specific services.
What is the out-of-pocket
limit for this plan?
In-network: $3,200 Individual,
$6,400 Family, Out-of-network: Not
applicable.
The out-of-pocket limit is the most you could pay in a year for covered services. If you have
other family members in this plan, the overall family out-of-pocket limit must be met.
What is not included in
the out-of-pocket limit?
Premium, balance-billed charges,
and health care this plan doesn't
cover.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Will you pay less if you
use a network provider?
Yes. See www.premera.com or call
1-800-722-1471 for a list of network
providers.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network.
You will pay the most if you use an out-of-network provider, and you might receive a bill from a
provider for the difference between the provider’s charge and what your plan pays (balance
billing). Be aware your network provider might use an out-of-network provider for some services
(such as lab work). Check with your provider before you get services.
Do you need a referral to
see a specialist? No. You can see the specialist you choose without a referral.

2 of 6
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common
Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important
Information Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
If you visit a health
care provider’s office
or clinic
Primary care visit to treat an
injury or illness 20% coinsurance 50% coinsurance None
Specialist visit 20% coinsurance 50% coinsurance None
Preventive care/screening/
immunization No charge Not covered
You may have to pay for services that aren’t
preventive. Ask your provider if the services
you need are preventive. Then check what
your plan will pay for.
If you have a test
Diagnostic test (x-ray, blood
work) 20% coinsurance 50% coinsurance None
Imaging (CT/PET scans, MRIs) 20% coinsurance 50% coinsurance
Prior authorization recommended for some
outpatient imaging tests. Penalty for out-of-
network: no penalty.
If you need drugs to
treat your illness or
condition

More information about
prescription drug
coverage is available at
https://www.premera.co
m/documents/052148_2
024.pdf
Generic drugs 20% coinsurance 20% coinsurance (retail),
not covered (mail)
Covers up to a 90 day supply (retail and mail).
No charge for specific preventive drugs. Prior
authorization recommended for some drugs.
Preferred brand drugs 20% coinsurance 20% coinsurance (retail),
not covered (mail)
Covers up to a 90 day supply (retail and mail).
Prior authorization recommended for some
drugs.
Non-preferred brand drugs 20% coinsurance 20% coinsurance (retail),
not covered (mail)
Covers up to a 90 day supply (retail and mail).
Prior authorization recommended for some
drugs.
Specialty drugs 20% coinsurance Not covered
Covers up to a 30 day supply. Only covered at
specific contracted specialty pharmacies. Prior
authorization recommended for some drugs.
Initial fill on certain specialty drugs are
dispensed in two 15 day increments. Please
see www.premera.com/documents/062915.pdf
for a list of these drugs.
If you have outpatient
surgery
Facility fee (e.g., ambulatory
surgery center) 20% coinsurance 50% coinsurance
Prior authorization recommended for some
services. Penalty for out-of-network: no
penalty.
Physician/surgeon fees 20% coinsurance 50% coinsurance None
3 of 6
Common
Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important
Information Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
If you need immediate
medical attention
Emergency room care 20% coinsurance 20% coinsurance None
Emergency medical
transportation 20% coinsurance 20% coinsurance None
Urgent care 20% coinsurance
Hospital-based: 20%
coinsurance
Freestanding center: 50%
coinsurance
None
If you have a hospital
stay
Facility fee (e.g., hospital room) 20% coinsurance 50% coinsurance
Prior authorization recommended for all
planned inpatient stays. Penalty for out-of-
network: no penalty.
Physician/surgeon fees 20% coinsurance 50% coinsurance None
If you need mental
health, behavioral
health, or substance
abuse services
Outpatient services 20% coinsurance 50% coinsurance None
Inpatient services 20% coinsurance 50% coinsurance
Prior authorization recommended for all
planned inpatient stays. Penalty for out-of-
network: no penalty.
If you are pregnant
Office visits 20% coinsurance 50% coinsurance
Cost sharing does not apply for preventive
services. Depending on the type of services, a
coinsurance may apply. Maternity care may
include tests and services described
elsewhere in the SBC (such as, ultrasound).
Childbirth/delivery professional
services 20% coinsurance 50% coinsurance
Cost sharing does not apply for preventive
services. Depending on the type of services, a
coinsurance may apply. Maternity care may
include tests and services described
elsewhere in the SBC (such as, ultrasound).
Childbirth/delivery facility
services 20% coinsurance 50% coinsurance
Cost sharing does not apply for preventive
services. Depending on the type of services, a
coinsurance may apply. Maternity care may
include tests and services described
elsewhere in the SBC (such as, ultrasound).
4 of 6
Common
Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important
Information Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
If you need help
recovering or have
other special health
needs
Home health care 20% coinsurance 50% coinsurance Limited to 130 visits per calendar year.
Rehabilitation services 20% coinsurance 50% coinsurance
Limited to 45 outpatient visits per calendar
year, limited to 30 inpatient days per calendar
year. Includes physical therapy, speech
therapy, and occupational therapy.
Prior authorization recommended for all
planned inpatient stays. Penalty for out-of-
network: no penalty.
Habilitation services 20% coinsurance 50% coinsurance
Limited to 45 outpatient visits per calendar
year, limited to 30 inpatient days per calendar
year. Includes physical therapy, speech
therapy, and occupational therapy.
Prior authorization recommended for all
planned inpatient stays. Penalty for out-of-
network: no penalty.
Skilled nursing care 20% coinsurance 50% coinsurance
Limited to 60 days per calendar year. Prior
authorization recommended for all planned
inpatient stays. Penalty for out-of-network: no
penalty.
Durable medical equipment 20% coinsurance 50% coinsurance
Prior authorization recommended to buy some
medical equipment. Penalty for out-of-network:
no penalty.
Hospice services 20% coinsurance 50% coinsurance
Limited to 240 respite hours, limited to 10
inpatient days - 6 month overall lifetime benefit
limit, except when approved otherwise.
If your child needs
dental or eye care
Children’s eye exam Not covered Not covered None
Children’s glasses Not covered Not covered None
Children’s dental check-up Not covered Not covered None

5 of 6
Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Bariatric surgery
• Cosmetic surgery
• Dental care (Adult)
• Hearing aids
• Long-term care
• Private-duty nursing
• Routine eye care (Adult)
• Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Acupuncture
• Chiropractic care or other spinal manipulations
• Foot care
• Infertility treatment
• Non-emergency care when traveling outside the
U.S.

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is: for ERISA plans, contact the Department of Labor’s Employee Benefit’s Security Administration at 1-866-444-EBSA (3272) or
www.dol.gov/ebsa/healthreform. For governmental plans, contact the Department of Health and Human Services, Center for Consumer Information and Insurance
Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. For church plans and all other plans, call 1-800-562-6900 for the state insurance department, or the
insurer at 1-800-722-1471 or TTY 711. Other coverage options may be available to you too, including buying individual insurance coverage through the Health
Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also
provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,
contact: your plan at 1-800-722-1471 or TTY 711, or the state insurance department at 1-800-562-6900, or Department of Labor’s Employee Benefits Security
Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.

Does this plan provide Minimum Essential Coverage? Yes.
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet the Minimum Value Standards? Yes.
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-800-722-1471.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-722-1471.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-800-722-1471.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-722-1471.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

6 of 6
Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association. WA 20097 | 1023252
Peg is Having a Baby
(9 months of in-network pre-natal care and a
hospital delivery)

Mia’s Simple Fracture
(in-network emergency room visit and follow up
care)

Managing Joe’s type 2 Diabetes
(a year of routine in-network care of a well-
controlled condition)

◼ The plan’s overall deductible $1,600
◼ Specialist coinsurance 20%
◼ Hospital (facility) coinsurance 20%
◼ Other coinsurance 20%

This EXAMPLE event includes services like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)

Total Example Cost $12,700

In this example, Peg would pay:
Cost Sharing
Deductibles $1,600
Copayments $0
Coinsurance $1,400
What isn’t covered
Limits or exclusions $60
The total Peg would pay is $3,060

◼ The plan’s overall deductible $1,600
◼ Specialist coinsurance 20%
◼ Hospital (facility) coinsurance 20%
◼ Other coinsurance 20%

This EXAMPLE event includes services like:
Primary care physician office visits (including
disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)

Total Example Cost $5,600

In this example, Joe would pay:
Cost Sharing
Deductibles $1,600
Copayments $0
Coinsurance $800
What isn’t covered
Limits or exclusions $20
The total Joe would pay is $2,420

◼ The plan’s overall deductible $1,600
◼ Specialist coinsurance 20%
◼ Hospital (facility) coinsurance 20%
◼ Other coinsurance 20%

This EXAMPLE event includes services like:
Emergency room care (including medical
supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)

Total Example Cost $2,800

In this example, Mia would pay:
Cost Sharing
Deductibles $1,600
Copayments $0
Coinsurance $200
What isn’t covered
Limits or exclusions $0
The total Mia would pay is $1,800
About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Discrimination is Against the Law
Premera Blue Cross (Premera) complies 1Mth applicable Federal and Washington state civil rights laws and does not discriminate on the
basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. Premera does not exclude people or treat
them differently because of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. Premera provides free
aids and services to people 1Mth disabilities to communicate effectively 1Mth us, such as qualified sign language interpreters and witten
information in other formats (large print, audio, accessible electronic formats, other formats). Premera provides free language services to
people whose primary language is not English, such as qualified interpreters and information witten in other languages. If you need these
services, contact the Civil Rights Coordinator. If you believe that Premera has failed to provide these services or discriminated in another
way on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation, you can file a grievance 1Mth
Civil Rights Coordinator-Complaints and Appeals, PO Box 91102, Seattle, WA 98111, Toll free 855-332-4535, Fax [phone],
TTY 711, Email [e-mail]. You can file a grievance in person or by mail, fax, or email. If you need help
filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint \/11th the US Department
of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at
https//ocrportal.hhs.gov/ocr/portalAobby.jsf, or by mail or phone at US Department of Health and Human Services, 200 Independence
Ave SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at
http//www.hhs.gov/ocr/office/filelindex.html. You can also file a civil rights complaint 1Mth the Washington State Office of the Insurance
Commissioner, electronically through the Office of the Insurance Commissioner Complaint Portal available at
https//wwwinsurance.wa.gov/file-complaint-or-check-your-complaint-status or by phone at 800-562-6900, 360-586-0241 (TDD).
Complaint forms are available at https//fortress.wa.gov/oic/onlineservices/cc/pub/complaintinformation.aspx.
Language Assistance
ATENCION si habla espafiol, tiene a su disposici6n servicios gratuitos de asistencia lingUistica. Llame al 800-722-1471 (TTY 711).
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'?9.I: ei;:;07~ Ai~olllll:: a5i', 2:107 Al~ Al~I:":~ 'f-li.5'. Ol~ol-:.!,;:, :?)gLICI. 800-722-1471(TTY711) \J:i~.5'. /'.l:Zloi '?~Al2.
BHv1MAHv1E EcnH Bbl roBOpHTe Ha pyccKOM H3bIKe, rn BaM AOCTynHbl 6ecnnaTHble ycnyrn nepeBOAa. 3BOHHT8 800-722-1471 (rnnernHn 711).
PAUNAWA Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ngtulong sa iMka nang walang bayad. Tumawag sa 800-722-1471 (TTY 711).
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XIYYEEFFANNAA Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 800-722-1471 (TTY 711 ) .
. (711 :f-;llJ ,....,i1 w..'1..i r'.J) 800-722-1471 r'Y. J...,:31 .u4-Jl: c!ll _)lfo ',;pl ,.iroWI C:.,l.,.l;,, u!J ,WI _fool C:.,.l,u; wis loj ::lJoeL,
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ACHTU NG Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche H ilfsdienstleistungen zur VerfUgung. Rufnummer 800-722-1471 (TTY 711 ).
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ATANSYON Si w pale Kreyol Ayisyen, gen sevis ed pou lang ki disponib gratis pou au. Rele 800-722-1471 (TTY 711).
ATTENTION • Si vous parlez frangais, des services d'aide linguistique vous sont proposes gratuitement Appelez le 800-722-1471 (ATS • 711 ).
UWAGA Jezeli m6wisz po polsku, mozesz skorzystac z bezp!atnej pomocy j~zykowej. Zadzwon pod nu mer 800-722-1471 (TTY 711).
ATEN CAO Se fala portugues, enoontram-se disponiveis servigos linguisticos, gratis Ligue para 800-722-1471 (TTY 711).
A TTEN ZI ONE In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti Chiamare ii numero 800-722-1471 (TTY 711 ).
,O,p, U'w 800-722-1471 (TTY 711) I.; ,,i.';,1.; cs" r"l..fa w c,1_;; u~I.) W.Jy,,>; c,ll.;j w~ ,.l;JS cs"}:£, cr)J ul:j "'! .fal :...,.ji
037378 (07-01-2021)
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2024 - 12/31/204
Avista Corporation : Your Choice (Copay) NGF
Coverage for: Individual or Family | Plan Type: PPO
1 of 6
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-800-722-1471 (TTY: 711) or visit us
at www.premera.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other
underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call 1-800-722-1471 (TTY: 711) to request a copy.
Important Questions Answers Why This Matters:
What is the overall
deductible?
In-network: $300 Individual / $900
Family. Out-of-network: $400 Individual
/ $1,200 Family.
Generally, you must pay all of the costs from providers up to the deductible amount before
this plan begins to pay. If you have other family members on the plan, each family member
must meet their own individual deductible until the total amount of deductible expenses paid
by all family members meets the overall family deductible.
Are there services covered
before you meet your
deductible?
Yes. Does not apply to Preventive care,
copayments, prescription drugs and
services listed below as "No charge"
This plan covers some items and services even if you haven’t yet met the deductible
amount. But a copayment or coinsurance may apply. For example, this plan covers certain
preventive services without cost-sharing and before you meet your deductible. See a list of
covered preventive services at https://www.healthcare.gov/coverage/preventive-care-
benefits/.
Are there other deductibles
for specific services? No. You don’t have to meet deductibles for specific services.
What is the out-of-pocket
limit for this plan?
In-network: $1,500 Individual / $4,500
Family, Out-of-network: $3,000
Individual / $9,000 Family.
Pharmacy: Calendar year aggregate out-
of-pocket maximum: In-network: $4,000,
Out-of-network not applicable.
The out-of-pocket limit is the most you could pay in a year for covered services. If you have
other family members in this plan, they have to meet their own out-of-pocket limits until the
overall family out-of-pocket limit has been met.
What is not included in
the out-of-pocket limit?
Premium, balance-billed charges, out-of-
network Office visit copayments, and
health care this plan doesn't cover.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Will you pay less if you use
a network provider?
Yes. See www.premera.com or call 1-
800-722-1471 for a list of network
providers.
This plan uses a provider network. You will pay less if you use a provider in the plan’s
network. You will pay the most if you use an out-of-network provider, and you might receive
a bill from a provider for the difference between the provider’s charge and what your plan
pays (balance billing). Be aware your network provider might use an out-of-network provider
for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to
see a specialist? No. You can see the specialist you choose without a referral.

2 of 6
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common
Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other
Important Information Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
If you visit a health
care provider’s office
or clinic
Primary care visit to treat
an injury or illness $20 copay/visit $20 copay/visit + 40%
coinsurance None
Specialist visit $20 copay/visit $20 copay/visit + 40%
coinsurance None
Preventive care/screening/
immunization No charge Not covered
You may have to pay for services that aren’t
preventive. Ask your provider if the services
you need are preventive. Then check what
your plan will pay for.
If you have a test
Diagnostic test (x-ray,
blood work) $20 copay/visit $20 copay/visit + 40%
coinsurance None
Imaging (CT/PET scans,
MRIs) 20% coinsurance 40% coinsurance
Prior authorization recommended for some
outpatient imaging tests. Penalty for out-of-
network: no penalty.
If you need drugs to
treat your illness or
condition

More information about
prescription drug
coverage is available at
https://www.premera.co
m/documents/055090_2
024.pdf
Generic drugs $5 copay/prescription

$5 copay/prescription +
40% coinsurance (retail),
not covered (mail)
Covers up to a 30 day supply (retail), covers
up to a 90 day supply (mail). No charge for
specific preventive drugs. Prior authorization
recommended for some drugs.
Preferred brand drugs $20 copay/prescription

$20 copay/prescription +
40% coinsurance (retail),
not covered (mail)
Covers up to a 30 day supply (retail), covers
up to a 90 day supply (mail). Prior
authorization recommended for some drugs.
Non-preferred brand drugs $40 copay/prescription

$40 copay/prescription +
40% coinsurance (retail),
not covered (mail)
Covers up to a 30 day supply (retail), covers
up to a 90 day supply (mail). Prior
authorization recommended for some drugs.
Specialty drugs
Generic: $5 copay/prescription
Pref. Brand: $20
copay/prescription
Non-Pref. Brand: $40
copay/prescription
Not covered
Covers up to a 30 day supply. Only covered
at specific contracted specialty pharmacies.
Prior authorization recommended for some
drugs. SaveonSP affects your copayment for
certain drugs. See
www.premera.com/saveonsp for more
information. Initial fill on certain specialty
drugs are dispensed in two 15 day
increments. Please
see www.premera.com/documents/062915.p
df for a list of these drugs.
3 of 6
Common
Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other
Important Information Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
If you have outpatient
surgery
Facility fee (e.g.,
ambulatory surgery center)
Hospital based: 20%
coinsurance
ASC/Office: $20 copay/visit
Hospital based:40%
coinsurance
ASC/Office: $20 copay/visit
+ 40% coinsurance
Prior authorization recommended for some
services. Penalty for out-of-network: no
penalty.
Physician/surgeon fees $20 copay/visit 40% coinsurance None
If you need immediate
medical attention
Emergency room care 20% coinsurance 20% coinsurance Emergency room copay waived if admitted
to hospital.
Emergency medical
transportation 20% coinsurance 20% coinsurance None
Urgent care
Hospital-based: 20%
coinsurance
Freestanding center: $20
copay/visit
Hospital-based: 20%
coinsurance
Freestanding center: $20
copay/visit + 40%
coinsurance
None
If you have a hospital
stay
Facility fee (e.g., hospital
room) 20% coinsurance 40% coinsurance
Prior authorization recommended for all
planned inpatient stays. Penalty for out-of-
network: no penalty.
Physician/surgeon fees $20 copay/visit 40% coinsurance None
If you need mental
health, behavioral
health, or substance
abuse services
Outpatient services Office Visit: $20 copay/visit
Facility: No charge
Office Visit: $20 copay/visit
+ 40% coinsurance
Facility: No charge
None
Inpatient services 20% coinsurance 40% coinsurance
Prior authorization recommended for all
planned inpatient stays. Penalty for out-of-
network: no penalty.
If you are pregnant
Office visits 20% coinsurance 40% coinsurance Cost sharing does not apply for preventive
services. Depending on the type of services,
a coinsurance may apply. Maternity care
may include tests and services described
elsewhere in the SBC (such as, ultrasound).
Childbirth/delivery
professional services 20% coinsurance 40% coinsurance
Childbirth/delivery facility
services 20% coinsurance 40% coinsurance
4 of 6
Common
Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other
Important Information Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
If you need help
recovering or have
other special health
needs
Home health care No charge 20% coinsurance
(deductible does not apply) Limited to 130 visits per calendar year.
Rehabilitation services Outpatient: $20 copay/visit
Inpatient: 20% coinsurance
Outpatient: $20 copay/visit
+ 40% coinsurance
Inpatient: 40% coinsurance
Limited to 45 outpatient visits per calendar
year, limited to 30 inpatient days per
calendar year. Includes physical therapy,
speech therapy, massage therapy and
occupational therapy. Neurodevelopmental
therapy limited to 24 outpatient visits per
calendar year.
Prior authorization recommended for all
planned inpatient stays. Penalty for out-of-
network: no penalty.
Habilitation services Outpatient: $20 copay/visit
Inpatient: 20% coinsurance
Outpatient: $20 copay/visit
+ 40% coinsurance
Inpatient: 40% coinsurance
Limited to 45 outpatient visits per calendar
year, limited to 30 inpatient days per
calendar year. Includes physical therapy,
speech therapy, and occupational therapy.
Neurodevelopmental therapy limited to 24
outpatient visits per calendar year.
Prior authorization recommended for all
planned inpatient stays. Penalty for out-of-
network: no penalty.
Skilled nursing care 20% coinsurance

40% coinsurance

Prior authorization recommended for all
planned inpatient stays. Penalty for out-of-
network: no penalty.
Durable medical
equipment 20% coinsurance 40% coinsurance
Prior authorization recommended to buy
some medical equipment. Penalty for out-of-
network: no penalty.
Hospice services No charge 20% coinsurance
(deductible does not apply)
Limited to 240 respite hours - 6 month
overall lifetime benefit limit, except when
approved otherwise.
If your child needs
dental or eye care
Children’s eye exam Not covered Not covered None
Children’s glasses Not covered Not covered None
Children’s dental check-up Not covered Not covered None

5 of 6
Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Bariatric surgery
• Cosmetic surgery
• Dental care (Adult)
• Long-term care
• Routine eye care (Adult)
• Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Acupuncture
• Chiropractic care or other spinal manipulations
• Foot care
• Hearing aids
• Infertility treatment
• Non-emergency care when traveling outside the
U.S.
• Private-duty nursing

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is: for ERISA plans, contact the Department of Labor’s Employee Benefit’s Security Administration at 1-866-444-EBSA (3272) or
www.dol.gov/ebsa/healthreform. For governmental plans, contact the Department of Health and Human Services, Center for Consumer Information and Insurance
Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. For church plans and all other plans, call 1-800-562-6900 for the state insurance department, or the
insurer at 1-800-722-1471 or TTY 711. Other coverage options may be available to you too, including buying individual insurance coverage through the Health
Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also
provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,
contact: your plan at 1-800-722-1471 or TTY 711, or the state insurance department at 1-800-562-6900, or Department of Labor’s Employee Benefits Security
Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.

Does this plan provide Minimum Essential Coverage? Yes.
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet the Minimum Value Standards? Yes.
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-800-722-1471.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-722-1471.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-800-722-1471.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-722-1471.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

6 of 6
Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association. WA 20097 | 1023252
Peg is Having a Baby
(9 months of in-network pre-natal care and a
hospital delivery)

Mia’s Simple Fracture
(in-network emergency room visit and follow up
care)

Managing Joe’s type 2 Diabetes
(a year of routine in-network care of a well-
controlled condition)

◼ The plan’s overall deductible $300
◼ Specialist copay $20
◼ Hospital (facility) coinsurance 20%
◼ Other coinsurance 20%

This EXAMPLE event includes services like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)

Total Example Cost $12,700

In this example, Peg would pay:
Cost Sharing
Deductibles $300
Copayments $300
Coinsurance $900
What isn’t covered
Limits or exclusions $60
The total Peg would pay is $1,560

◼ The plan’s overall deductible $300
◼ Specialist copay $20
◼ Hospital (facility) coinsurance 20%
◼ Other coinsurance 20%

This EXAMPLE event includes services like:
Primary care physician office visits (including
disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)

Total Example Cost $5,600

In this example, Joe would pay:
Cost Sharing
Deductibles $30
Copayments $1,100
Coinsurance $0
What isn’t covered
Limits or exclusions $20
The total Joe would pay is $1,150

◼ The plan’s overall deductible $300
◼ Specialist copay $20
◼ Hospital (facility) coinsurance 20%
◼ Other coinsurance 20%

This EXAMPLE event includes services like:
Emergency room care (including medical
supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)

Total Example Cost $2,800

In this example, Mia would pay:
Cost Sharing
Deductibles $300
Copayments $200
Coinsurance $300
What isn’t covered
Limits or exclusions $0
The total Mia would pay is $800
About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Discrimination is Against the Law
Premera Blue Cross (Premera) complies 1Mth applicable Federal and Washington state civil rights laws and does not discriminate on the
basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. Premera does not exclude people or treat
them differently because of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. Premera provides free
aids and services to people 1Mth disabilities to communicate effectively 1Mth us, such as qualified sign language interpreters and witten
information in other formats (large print, audio, accessible electronic formats, other formats). Premera provides free language services to
people whose primary language is not English, such as qualified interpreters and information witten in other languages. If you need these
services, contact the Civil Rights Coordinator. If you believe that Premera has failed to provide these services or discriminated in another
way on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation, you can file a grievance 1Mth
Civil Rights Coordinator-Complaints and Appeals, PO Box 91102, Seattle, WA 98111, Toll free 855-332-4535, Fax [phone],
TTY 711, Email [e-mail]. You can file a grievance in person or by mail, fax, or email. If you need help
filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint \/11th the US Department
of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at
https//ocrportal.hhs.gov/ocr/portalAobby.jsf, or by mail or phone at US Department of Health and Human Services, 200 Independence
Ave SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at
http//www.hhs.gov/ocr/office/filelindex.html. You can also file a civil rights complaint 1Mth the Washington State Office of the Insurance
Commissioner, electronically through the Office of the Insurance Commissioner Complaint Portal available at
https//wwwinsurance.wa.gov/file-complaint-or-check-your-complaint-status or by phone at 800-562-6900, 360-586-0241 (TDD).
Complaint forms are available at https//fortress.wa.gov/oic/onlineservices/cc/pub/complaintinformation.aspx.
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037378 (07-01-2021)