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HomeMy WebLinkAbout20250224GSW to Staff 17 Attachment 3.pdf NW Natural Water of ID Last Years Benefit Offerings compared to this Years Benefit Offierings December 2023 December 2024 (New) Employee Cigna Base Plan Regence HSA Plan Per Paycheck $2,000 / $6,000 $2,500 / $5,000 Employee $70.90 $85.41 Employee + Spouse $141.75 $170.76 Employee + Child(ren) $131.14 $157.98 Employee + Family $202.00 $243.35 Employee Cigna Buy-Up Plan Regence Classic Plan Per Paycheck $500 / $1,000 $500 / $1,000 Employee $78.61 $104.87 Employee + Spouse $157.23 $209.66 Employee + Child(ren) $145.45 $193.97 Employee + Family $224.06 $298.78 Employee Cigna Regence Per Paycheck Dental Plan Dental Plan Employee $3.49 $4.74 Employee + Spouse $7.16 $9.72 Employee + Child(ren) $7.96 $10.80 Employee + Family $12.41 $16.85 Employee MetLife Reliance Per Paycheck Vision Plan Vision Plan Employee $0.75 $0.76 Employee + Spouse $1 .50 $1.52 Employee + Child(ren) $1 .65 $1.68 Employee + Family $2.39 $2.44 GSW-W-24-01 IPUC Staff PR 17 Attachment 3 Page 1 of 94 NW Natural Water of Idaho Employee Open Enrollment Guide Plan Year: 2021 — 2022 T PAYCHEX"' Payroll I Benefits ( HR I Insurance The Power of Simplicity UNW-W-24-01 UC Staff PR 17 Attachment 3 Page 2 of 94 2021 — 2022 Benefits Enrollment Guide NW Natural Water of Idaho recognizes the importance of being able to provide our employees and their families with quality benefits as part of their overall compensation package. Therefore, NW Natural Water of Idaho, has developed a comprehensive benefits package that delivers quality and value while satisfying the diverse needs of our workforce. This summary highlights the benefit options offered by NW Natural Water of Idaho for the 2021 —2022 benefit year. MOpen Enrollment For newly hired employees or for those who become newly eligible during the plan year, you must enroll no later than 30 days after your eligibility date or the date of your change in eligibility status. All other eligible employees must enroll during open enrollment, which this year is from 05/01/2021 — 05/31/2021. al Eligibility If you are an employee working at least 30 hours a week, you are eligible for the benefits outlined in this guide. Eligible employees may elect to cover their spouse or children to age 26. Benefits are effective on the first of the month following your Full Time Date of Hire. Qualifying Event Employee contributions for medical, dental, and vision benefits are payroll deducted on a pre-tax basis under IRC Section 12S. Outside of open enrollment you are not permitted to make changes to your benefit elections unless you experience a qualifying event defined as: marriage, divorce or legal separation, birth or adoption of a child, a change in your or your spouse's employment or insurance status, a dependent ceasing to meet eligibility requirements, or a change in residence that affects coverage. If you experience a qualifying event, HR must notify the insurance company within 30 days of the qualifying event or you will not be able to make changes to your current election until the next open enrollment period. Please contact HR as soon as possible upon a qualifying event. MYCHOU Payroll I Benefits I HR I Insurance Please Note:This is a brief summary, actual policy provisions govern all benefits and costs. The Power of Simplicity GSW-W-24-01 IPUC Staff PR 17 Attachment 3 Page 3 of 94 BalanceCare BalanueCatu Member Guide BalanceCare is a comprehensive.time-saving resource paid for by your employer that will help you better understand and maximize your healthcare benefits. Our wide-ranging health advocacy services help manage and resolve benefit plan questions for you and your family at no cost to you. Services Our licensed Care Guides are available to provide How does BalanceCare work? benefit information and assistance navigating When you need help with a benefit plan issue, your health plant Care Guides provide healthcare simply call BalanceCare at 1.877.598.8617. claims and appeals management healthcare billing You will have immediate access to your own assistance, prescription information and costs,as benefit Care Guide. well as provider research. Who is eligible? BalanceCare can assist with services such as: BalanceCare is available to you and your eligible family members including spouses,parents,and • Claims Assistance dependent children. Call us if you have any • Benefit Coverage Verification questions concerning membership eligibility. • ID Cards • Prescription Drug Coverage Questions When is BalanceCare available? • Appeals You and your eligible family members have • HSA Questions immediate access to confidential support. • Health Benefit Education twenty-four hours a day,seven days a week. • Provider Research Is my privacy protected? Contact BalanceCare at Yes-with absolute confidentiality. BalanceCare follows government laws to ensure 1.877.598.8617 that your medical and personal information is protected.Your employer does not have access to your confidential information. �AV/'•YCV` rr�■vr�r� Payroll I Benefits I HR I Insurance The Power of Simplicity GSW-W-24-01 IPUC Staff PR 17 Attachment 3 Page 4 of 94 NW Natural Water of Idaho 2021 - 2022 Medical Pricing Guide (26 PP) Platinum 500 Employee Contribution Per Monthly Premium S Employer Monthly Contribution°° Pay Period Number of Pay (Employee Annual Periods Per Premium-#of Pay Insurance Plan Coverage Level Total Single Single Dependent Year Periods; Platinum 500 Employee Only $ 798.44 $ 798.44 80.00% 0.00% 26 $ 73.70 Platinum 500 Employee+Spouse $1,596.88 $ 798.44 80.00% 80.00% 26 $ 147.40 Platinum 500 Employee+Child(ren) $1,517.04 $ 798.44 80.00% 80.00% "_1 $ 140.03 Platinum 500 Employee+Family $2,315.48 $ 798.44 80.00% 80.00% 26 $ 213.74 Gold 500 Employee Contribution Per Monthly Premium S Employer Monthly Contribution Pay Period Number of Pay (Employee Annual Periods Per Premium-#of Pay Insurance Plan Coveracie Level Total Single Single Dependent Year Periods', Gold 500 Employee Only $ 710.88 S 7%88 80.00% 0. o% 26 $ 65.62 Gold 500 Employee+Spouse $1,421.76 $ 710.88 80.00% 80.00% 26 $ 131.24 Gold 500 Employee+Child(ren) $1,350.67 $ 710.88 80.00% 80.00% H $ 124.68 Gold 500 Employee+Family $2,061.55 $ 710.88 80.00% 80.00% 26 $ 190.30 Gold 1500 Employee Contribution Per Monthly Premium S Employer Monthly Contribution'° Pay Period Number of Pay Employee Annual Periods Per Premium-#of Pay Insurance Plan Coveracie Level Total Single Single Dependent Year Periods, Gold 1500 Employee Only $ 620.48 S 620.48 80.00% 0.00% 26 $ 57.28 Gold 1500 Employee+Spouse $1,240.96 $ 620.48 80.00% 80.00% 26 $ 114.55 Gold 1500 Employee+Child(ren) $1,178.91 S 620.48 80.00% 80.00% 26 $ 108.82 Gold 1500 Employee+Family $1,799.39 $ 620.48 80.00% 80.00% _ $ 166.10 PAYCHEX The Power of Simplicity GSW-W-24-01 IPUC Staff PR 17 Attachment 3 Page 5 of 94 NW Natural Water of Idaho 2021 - 2022 Employee Pricing Dental & Vision Employee Contribution Per Monthly Premium$ Employer Monthly Contribution 4a Pay Period Employee annual Number of Pay Premium+#of Pay Insurance Type Coverage Level Total Single Single Dependent Periods Per Year Periods) Sunlife Dental Employee Only $ 42-52 5 42 52 80-00% 80-00% 26 $ 3.92 Sunlife Dental Employee+ Spouse $ 85.03 S 42 52 80.00% 80-00% 26 $ 7.85 Sunlife Dental Employee+Child(ren) $ 98.42 S 42 52 80.00% 80.00% 26 $ 9.08 Sunlife Dental Employee+Family $ 143-86 S 42 52 80.00% 80-00% 26 $ 13.28 Employee Contribution Per Monthly Premium$ Employer Monthly Contribution% Pay Period Employee annual Number of Pay Premium+#of Pay Insurance Type Coverage Level Total Single Single Dependent Periods Per Yearl Periods) Sunlife Core Vision Employee Only $ 1-07 $ 1-07 100-00% 100-00% 26 $ Sunlife Core Vision Employee+ Spouse $ 2.14 S 1 07 100.00% 100.00% 26 $ Sunlife Core Vision Employee+Child(ren) $ 2-36 5 1 07 100.00% 100 00% 26 $ Sunlife Core Vision Employee+Family $ 3-43 5 1-07 100-00% 100-00% 26 $ Employer Monthly Contribution Employee Contribution Per Monthly Premium$ $ Pay Period Number of Pay Periods Per Emplcyee 4nnual Premium-# Insurance T Coverage Level Total Single Single Dependent Year cf Pay Pericds. SunLife Buy Up Vision Employee Only $ 9.17 S 9.17 $ 1.07 S - 26 $ 3.74 SunLife Buy Up Vision Employee+Spouse $ 18.34 S 9.17 $ 1.07 $ 1.07 26 $ 7.48 SunLife Buy Up Vision Employee+Child(ren) $ 20.26 S 9.17 $ 1.071 $ 1.29 26 $ 8.26 SunLife Buy Up Vision Employee+Family $ 29.28 S 9.17 $ 1.071 $ 2.36 26 $ 11.93 PAYCHEX Varrvu i tloncfas 4 t1R;insurance The Power of Simplicity GSW-W-24-01 IPUC Staff PR 17 Attachment 3 Page 6 of 94 Summary of Benefits and Coverage: What this Plan Covers &What You Pay For Covered Services Coverage Period: [When enrolled, coverage period will show here] Regence BlueShield of Idaho, Inc.: Regence Gold 500 Coverage for: Individual and Eligible Family I Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health Ilan. The SBC shows you how you and the Ilan would share the cost for covered health care services. NOTE: Information about the cost of this Ilan (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, go to https://regence.com/go/2021/booklet/ID/Gold500 Preferred or call 1 (888) 367-2117. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copavment, deductible, provide r, or other underlined terms see the Glossary. You can view the Glossary at healthcare.gov/sbc-glossary or call 1 (888) 367- 2117 to request a copy. Important In-network: $500 individual/$1,000 family per Generally, you must pay all of the costs from providers up to the deductible amount What is the overall calendar year. before this Ilan begins to pay. If you have other family members on the Ilan, each deductible? Out-of-network: $5,000 individual/$10,000 family member must meet their own individual deductible until the total amount of family per calendar year. deductible expenses paid by all family members meets the overall family deductible. This Ilan covers some items and services even if you haven't yet met the Are there services covered Yes. Certain preventive care and those deductible amount. But a copavment or coinsurance may apply. For example, before you meet your services listed below as "deductible does not this Ilan covers certain preventive services without cost sharing and before you deductible? apply"or as "No charge." meet your deductible. See a list of covered preventive services at healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles No. You don't have to meet deductibles for specific services. for specific services? In-network: $8,550 individual/$17,100 family The out-of-pocket limit is the most you could pay in a year for covered services. If you What is the out-of-pocket per calendar year. have other family members in this Ilan, they have to meet their own out-of-pocket limits limit for this Ilan? Out-of-network: $10,000 individual/$20,000 until the overall family out-of-pocket limit has been met. family per calendar year. What is not included in the Pediatric vision services, premiums, balance- out-of-pocket limit? billing charges, and health care this Ilan Even though you pay these expenses, they don't count toward the out-of-pocket limit. doesn't cover. This Ilan uses a provider network. You will pay less if you use a provider in the Ip an's Yes. See https://regence.com/go/ID/Preferred network. You will pay the most if you use an out-of-network provider, and you might Will you pay less if you use or call 1 (888) 367-2117 for a list of network receive a bill from a provider for the difference between theprovider's charge and what a network provider? your Ilan pays (balance billing). Be aware, your network provider might use an out-of- roviders. network provider for some services (such as lab work). Check with your provide r before you get services. Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist? GSW-W-24-01 Page 1 of 7 [WheaF&fhMdf N VotipaicibvmWill show here] Page 71 1 SGLD5SD ®, All c1 p went and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Services You May What You Will Pay ------Un!I tEltils-risi E I 1:11unt C,P t,11 1:1: :1111,i 11: IIn-Network Provider • • . . ut-of-Network Provider Event Need (You will pay the least) (You will pay the most) Information $30 copaV/office visit, deductible does not apply; Primary care visit to $20 copav/retail clinic ° treat an injury or illness visit, deductible does not 50% coinsurance apply; Copayment applies to each in-network office visit only. If you visit a health 30% coinsurance for all All other services are covered at the coinsurance care provider's office other services specified, after deductible. or clinic $50 copav/office visit, deductible does not apply; Specialist visit 50% coinsurance 30% coinsurance for all other services Preventive You may have to pay for services that aren't care/screening/ No charge 50% coinsurance preventive. Ask your provide r if the services needed immunization are preventive. Then check what your Ilan will pay for. 30% coinsurance, deductible does not apply Deductible does not apply to in-network outpatient Diagnostic test(x-ray, for outpatient services; 50% coinsurance services only. All other services are covered at the If you have a test blood work) 30/°° coinsurance for coinsurance specified, after deductible. inpatient services Imaging (CT/PET scans, 30% coinsurance 50% coinsurance None MRIs) If you need drugs to $10 copaV/preferred retail prescription No coverage for prescription drugs not on the Drug treat your illness or Preferred generic drugs $20 copaV/ preferred mail order prescription List. condition &generic drugs $35 copaV/retail prescription Deductible does not apply. More information about $70 copav/ mail order prescription 90-day supply/retail prescription (your cost share is prescription drug Preferred brand drugs $50 copay/retail prescription per 30-day supply) coverage is available at $100 copay/mail order prescription 90-day supply/mail order prescription https://regence.com/go/ Brand d 50% coinsurance/retail prescription 30-day supply/specialty drug retail prescription 2021/ID/6tier rugs 45% coinsurance/mail order prescription Specialty dru s are not availaW'irc *ail order. Page 8 of 94 page 2 of 7 In-NetworkCommon Medical Services You May What You Will Pay Limitations, Exceptions, & Other Important • • • Out-of-Network Pr• • • Event Need (You will • .y the least) (You will pay the most) Cost shares for preferred brand insulin will not exceed $100/30-day supply retail prescription or$200/90- day supply mail order prescription. 20% coinsurance/ No charge for certain preventive drugs[, women's Preferred specialty preferred retail prescription 50% coinsurance/ retail contraceptives] and immunizations at a participating drugs &specialty drugs 50% coinsurance/ retail prescription pharmacy. prescription The first fill of specialty drugs for hemophilia may be provided by a retail pharmacy; additional refills must be provided by a specialty pharmacy or a specialty pharmacy designated as a hemophilia treatment center. 20% coinsurance for Facility fee (e.g., ambulatory surgery centers; ambulatory surgery 50% coinsurance center) 30% coinsurance for all If you have outpatient other facilities None surgery 20% coinsurance for ambulatory surgery center Physician/surgeon fees physicians; 50% coinsurance 30% coinsurance for all other physicians Copavment applies to facility charge for each visit (waived if admitted), whether or not the in-network Emergency room care $350 copay/visit $350 copay/visit deductible has been met. In-network deductible applies to in-network and out-of- network services. If you need immediate Emergency medical 30% coinsurance 30% coinsurance In-network deductible applies to in-network and out-of- medical attention transportation network services. $50 copay/office visit, deductible does not apply; Copavment applies to each in-network office visit only. Urgent care 50% coinsurance All other services are covered at the coinsurance 30% coinsurance for all specified, after deductible. other services Gsw-w-24-01 Page 9 of 94 Page 3 of 7 In-NetworkCommon Medical Services You May What You Will Pay Limitations, Exceptions, & Other Important • • • Out-of-Network Pr• • • Event Need (You will • .y the least) (You will pay the most) If you have a hospital Facility fee (e.g., 30% coinsurance 50% coinsurance $5,000/day for inpatient non-emergency admission in hospital room) non-participating facilities stay Physician/surgeon fees 30% coinsurance 50% coinsurance None $30 copay/office visit, If you need mental deductible does not apply; ° Copavment applies to each in-network health, behavioral Outpatient services 50% coinsurance office/psychotherapy visit only. All other services are health, or substance 30% coinsurance for all covered at the coinsurance specified, after deductible. abuse services other services Inpatient services 30% coinsurance 50% coinsurance $5,000/day for inpatient non-emergency admission in non-participating facilities Office visits 30% coinsurance 50% coinsurance Cost sharing does not apply for preventive services. Childbirth/delivery ° ° Depending on the type of services, a copayment, professional services 30% coinsurance 50% coinsurance coinsurance or deductible may apply. Maternity care If you are pregnant may include tests and services described elsewhere in Childbirth/delivery 30/°° coinsurance 50/°° coinsurance the SBC (i.e. ultrasound). facility services $5,000/day for inpatient non-emergency admission in non-participating facilities Home health care 30% coinsurance 50% coinsurance None $30 copay/outpatient visit, 20 outpatient visits each for rehabilitation and deductible does not apply; Rehabilitation services 50% coinsurance habilitation services/year 30% coinsurance for Copavment applies to each in-network outpatient visit inpatient services only. All inpatient services are covered at the If you need help coinsurance specified, after deductible. deductible recovering or have copay/outpatient visit, Includes physical therapy, occupational therapy and other special health deductible does not apply; ° speech therapy. Habilitation services 50% coinsurance needs 30% coinsurance for $5,000/day for inpatient non-emergency admission in inpatient services non-participating facilities Skilled nursing care 30% coinsurance 50% coinsurance 30 inpatient days/year Durable medical equipment 30% coinsurance 50% coinsurance None Hospice services 30% coinsurance 50% coinsurance None If your child needs Children's eye exam No charge for VSP doctor 50% coinsurance, 1 routine eye examination/year for individuals under dental or eye care y g deductible does not apply age 19 GSw-w-24-01 tie staff PR 17 Attachment 3 Page 10 of 94 page 4 of 7 You In-NetworkCommon Medical Services You May What Event Need • • • Out-of-Network Pr• • • (You will • .y the least) (You will pay the most) 50% coinsurance, 1 pair of lenses/year Children's lasses No charge*for VSP doctor 1 set of frames/year g g deductible does not apply Glasses limited to individuals under age 19. *Frames limited to Otis & Piper Eyewear Collection. 2 cleanings*/year 2 preventive oral examinations/year Coverage limited to individuals under age 19. Children's dental check- No charge No charge *Coverage may include another cleaning, refer to your up Ilan for further information. Coverage includes basic and major dental services for individuals under age 19, refer to your plan for further information. Excluded Services &Other Covered Services: Services Your Plan Generally Does NOT Cover(Check your policy or Ilan document for more information and a list of any other excluded services.) • Abortion, except when performed to preserve the • Dental care (Adult) • Routine eye care (Adult) life of the enrolled female individual • Infertility treatment • Routine foot care, except for diabetic patients • Bariatric surgery • Long-term care • Weight loss programs • Cosmetic surgery, except congenital anomalies • Private-duty nursing Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your Ilan document.) • Acupuncture • Hearing aids Non-emergency care when traveling outside the • Chiropractic care, spinal manipulations only 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: the U.S. Department of Labor, Employee Benefits Security Administration at 1 (866) 444-3272 or dol.gov/ebsa/healthreform, or the U.S. Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at 1 (877)267-2323 ext. 61565 or cciio.cros.gov or your state insurance department. You may also contact the plan at 1 (888) 367-2117. 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 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 Ilan 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 Ilan. For more information about your rights, this notice, or assistance, contact the Ilan at 1 (888) 367-2117 or visit regence.com or the U.S. Department of Labor, Employee Benefits Security Administration at 1 (866)444-3272 or dol.gov/ebsa/healthreform. You may also contact the Idaho Department of Insurance by calling 1 (208) 334-4250 or the toll-free message line at 1 (800) 721-3272; by writing to the Idaho Department of Insurance, GSW-W-24-01 IPUC Staff PR 17 Attachment 3 Page 11 of 94 Page 5 of 7 Consumer Affairs, 700 W State Street, 3rd Floor; P.O. Box 83720, Boise, ID 83720-0043; through the Internet at: doi/Idaho.gov; or by E-mail at: consumeraffairs@doi.idaho.gov. 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 fora plan through the Marketplace. Language Access Services: Spanish (Espanol): Para obtener asistencia en Espanol, Ilame al 1 (888) 367-2117. To see examples of how this Ilan might cover costs for a sample medical situation, see the next section. GSW-W-24-01 IPUC Staff PR 17 Attachment 3 Page 12 of 94 page 6 of 7 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this Ilan 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 Ilan. 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. Peg is Having a Baby Managing Joe's Type 2 Diabetes Mia's Simple Fracture (9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up hospital delivery) I controlled condition) I care) I ■The Ip an's overall deductible $500 ■The Ip an's overall deductible $500 ■The Ip an's overall deductible $500 ■Specialist copayment $50 ■Specialist copayment $50 ■Specialist copayment $50 ■Hospital (facility) coinsurance 30% ■ Hospital (facility) coinsurance 30% ■ Hospital (facility) coinsurance 30% ■Other coinsurance 30% ■Other coinsurance 30% ■Other coinsurance 30% This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies) Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches) Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy) Specialist visit (anesthesia) Durable medical equipment (glucose meter) Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $500 Deductibles $500 Deductibles $500 Copavments $11 Copavments $1,004 Copavments $705 Coinsurance $3,515 Coinsurance $113 Coinsurance $370 What isn't covered What isn't covered What isn't covered Limits or exclusions $61 Limits or exclusions $178 Limits or exclusions $0 The total Peg would pay is $4,087 The total Joe would pay is $1,795 The total Mia would pay is $1,575 The Ilan would be responsible for the other costs of these EXAMPLE covered services. GSW-W-24-01 IPUC Staff PR 17 Attachment 3 Page 13 of 94 Page 7 of 7 Summary of Benefits and Coverage: What this Plan Covers &What You Pay For Covered Services Coverage Period: [When enrolled, coverage period will show here] Regence BlueShield of Idaho, Inc.: Regence Gold 1500 Coverage for: Individual and Eligible Family I Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health Ilan. The SBC shows you how you and the Ilan would share the cost for covered health care services. NOTE: Information about the cost of this Ilan (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, go to https://regence.com/go/2021/booklet/ID/Go Id1500Preferred or call 1 (888) 367-2117. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copavment, deductible, provide r, or other underlined terms see the Glossary. You can view the Glossary at healthcare.gov/sbc-glossary or call 1 (888) 367- 2117 to request a copy. Important In-network: $1,500 individual/$3,000 family Generally, you must pay all of the costs from providers up to the deductible amount What is the overall per calendar year. before this Ilan begins to pay. If you have other family members on the Ilan, each deductible? Out-of-network: $5,000 individual/$10,000 family member must meet their own individual deductible until the total amount of family per calendar year. deductible expenses paid by all family members meets the overall family deductible. This Ilan covers some items and services even if you haven't yet met the Are there services covered Yes. Certain preventive care and those deductible amount. But a copavment or coinsurance may apply. For example, before you meet your services listed below as "deductible does not this Ilan covers certain preventive services without cost sharing and before you deductible? apply"or as "No charge." meet your deductible. See a list of covered preventive services at healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles No. You don't have to meet deductibles for specific services. for specific services? In-network: $7,350 individual/$14,700 family The out-of-pocket limit is the most you could pay in a year for covered services. If you What is the out-of-pocket per calendar year. have other family members in this Ilan, they have to meet their own out-of-pocket limits limit for this Ilan? Out-of-network: $10,000 individual/$20,000 until the overall family out-of-pocket limit has been met. family per calendar year. What is not included in the Pediatric vision services, premiums, balance- out-of-pocket limit? billing charges, and health care this Ilan Even though you pay these expenses, they don't count toward the out-of-pocket limit. doesn't cover. This Ilan uses a provider network. You will pay less if you use a provider in the Ip an's Yes. See https://regence.com/go/ID/Preferred network. You will pay the most if you use an out-of-network provider, and you might Will you pay less if you use or call 1 (888) 367-2117 for a list of network receive a bill from a provider for the difference between theprovider's charge and what a network provider? your plan pays (balance billing). Be aware, your network provider might use an out-of- roviders. network provider for some services (such as lab work). Check with your provide r before you get services. Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist? GSW-W-24-01 Page 1 of 7 [WhertWfhMdf M Votipaicibmelwill show here] Page 141l#TNSGLD15SD ®, All c1 p went and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Services You May What You Will Pay ------Un!I tEltils-risi E I 1:11unt C,P t,11 1:1: :1111,i 11: IIn-Network Provider • • . . ut-of-Network Provider Event Need (You will pay the least) (You will pay the most) Information $30 copaV/office visit, deductible does not apply; Primary care visit to $20 copav/retail clinic o treat an injury or illness visit, deductible does not 50% coinsurance apply; Copayment applies to each in-network office visit only. If you visit a health 30% coinsurance for all All other services are covered at the coinsurance care provider's office other services specified, after deductible. or clinic $50 copav/office visit, deductible does not apply; Specialist visit 50% coinsurance 30% coinsurance for all other services Preventive You may have to pay for services that aren't care/screening/ No charge 50% coinsurance preventive. Ask your provide r if the services needed immunization are preventive. Then check what your Ilan will pay for. 30% coinsurance, deductible does not apply Deductible does not apply to in-network outpatient Diagnostic test(x-ray, for outpatient services; 50% coinsurance services only. All other services are covered at the If you have a test blood work) 30/o o coinsurance for coinsurance specified, after deductible. inpatient services Imaging (CT/PET scans, 30% coinsurance 50% coinsurance None MRIs) If you need drugs to $10 copaV/preferred retail prescription No coverage for prescription drugs not on the Drug treat your illness or Preferred generic drugs $20 copaV/ preferred mail order prescription List. condition &generic drugs $35 copaV/retail prescription Deductible does not apply. More information about $70 copav/ mail order prescription 90-day supply/retail prescription (your cost share is prescription drug Preferred brand drugs $50 copay/retail prescription per 30-day supply) coverage is available at $100 copay/mail order prescription 90-day supply/mail order prescription https://regence.com/go/ Brand d 50% coinsurance/retail prescription 30-day supply/specialty drug retail prescription 2021/ID/6tier rugs 45% coinsurance/mail order prescription Specialty dru s are not availalS 'ffiirbWli�it order. Page 15 of 94 page 2 of 7 In-NetworkCommon Medical Services You May What You Will Pay Limitations, Exceptions, & Other Important • • • Out-of-Network Pr• • • Event Need (You will • .y the least) (You will pay the most) Cost shares for preferred brand insulin will not exceed $100/30-day supply retail prescription or$200/90- day supply mail order prescription. 20% coinsurance/ No charge for certain preventive drugs[, women's Preferred specialty preferred retail prescription 50% coinsurance/ retail contraceptives] and immunizations at a participating drugs &specialty drugs 50% coinsurance/ retail prescription pharmacy. prescription The first fill of specialty drugs for hemophilia may be provided by a retail pharmacy; additional refills must be provided by a specialty pharmacy or a specialty pharmacy designated as a hemophilia treatment center. 20% coinsurance for Facility fee (e.g., ambulatory surgery centers; ambulatory surgery 50% coinsurance center) 30% coinsurance for all If you have outpatient other facilities None surgery 20% coinsurance for ambulatory surgery center Physician/surgeon fees physicians; 50% coinsurance 30% coinsurance for all other physicians Copavment applies to facility charge for each visit (waived if admitted), whether or not the in-network Emergency room care $350 copay/visit $350 copay/visit deductible has been met. In-network deductible applies to in-network and out-of- network services. If you need immediate Emergency medical 30% coinsurance 30% coinsurance In-network deductible applies to in-network and out-of- medical attention transportation network services. $50 copay/office visit, deductible does not apply; Copavment applies to each in-network office visit only. Urgent care 50% coinsurance All other services are covered at the coinsurance 30% coinsurance for all specified, after deductible. other services Gsw-w-24-01 Page 16 of 94 Page 3 of 7 In-NetworkCommon Medical Services You May What You Will Pay Limitations, Exceptions, & Other Important • • • Out-of-Network Pr• • • Event Need (You will • .y the least) (You will pay the most) If you have a hospital Facility fee (e.g., 30% coinsurance 50% coinsurance $5,000/day for inpatient non-emergency admission in hospital room) non-participating facilities stay Physician/surgeon fees 30% coinsurance 50% coinsurance None $30 copay/office visit, If you need mental deductible does not apply; ° Copavment applies to each in-network health, behavioral Outpatient services 50% coinsurance office/psychotherapy visit only. All other services are health, or substance 30% coinsurance for all covered at the coinsurance specified, after deductible. abuse services other services Inpatient services 30% coinsurance 50% coinsurance $5,000/day for inpatient non-emergency admission in non-participating facilities Office visits 30% coinsurance 50% coinsurance Cost sharing does not apply for preventive services. Childbirth/delivery ° ° Depending on the type of services, a copayment, professional services 30% coinsurance 50% coinsurance coinsurance or deductible may apply. Maternity care If you are pregnant may include tests and services described elsewhere in Childbirth/delivery 30/°° coinsurance 50/°° coinsurance the SBC (i.e. ultrasound). facility services $5,000/day for inpatient non-emergency admission in non-participating facilities Home health care 30% coinsurance 50% coinsurance None $30 copay/outpatient visit, 20 outpatient visits each for rehabilitation and deductible does not apply; Rehabilitation services 50% coinsurance habilitation services/year 30% coinsurance for Copavment applies to each in-network outpatient visit inpatient services only. All inpatient services are covered at the If you need help coinsurance specified, after deductible. deductible recovering or have copay/outpatient visit, Includes physical therapy, occupational therapy and other special health deductible does not apply; ° speech therapy. Habilitation services 50% coinsurance needs 30% coinsurance for $5,000/day for inpatient non-emergency admission in inpatient services non-participating facilities Skilled nursing care 30% coinsurance 50% coinsurance 30 inpatient days/year Durable medical equipment 30% coinsurance 50% coinsurance None Hospice services 30% coinsurance 50% coinsurance None If your child needs Children's eye exam No charge for VSP doctor 50% coinsurance, 1 routine eye examination/year for individuals under dental or eye care y g deductible does not apply age 19 GSw-w-24-01 tie staff PR 17 Attachment 3 Page 17 of 94 Page 4 of 7 You In-NetworkCommon Medical Services You May What Event Need • • • Out-of-Network Pr• • • (You will • .y the least) (You will pay the most) 50% coinsurance, 1 pair of lenses/year Children's lasses No charge*for VSP doctor 1 set of frames/year g g deductible does not apply Glasses limited to individuals under age 19. *Frames limited to Otis & Piper Eyewear Collection. 2 cleanings*/year 2 preventive oral examinations/year Coverage limited to individuals under age 19. Children's dental check- No charge No charge *Coverage may include another cleaning, refer to your up Ilan for further information. Coverage includes basic and major dental services for individuals under age 19, refer to your plan for further information. Excluded Services &Other Covered Services: Services Your Plan Generally Does NOT Cover(Check your policy or Ilan document for more information and a list of any other excluded services.) • Abortion, except when performed to preserve the • Dental care (Adult) • Routine eye care (Adult) life of the enrolled female individual • Infertility treatment • Routine foot care, except for diabetic patients • Bariatric surgery • Long-term care • Weight loss programs • Cosmetic surgery, except congenital anomalies • Private-duty nursing Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your Ilan document.) • Acupuncture • Hearing aids Non-emergency care when traveling outside the • Chiropractic care, spinal manipulations only 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: the U.S. Department of Labor, Employee Benefits Security Administration at 1 (866) 444-3272 or dol.gov/ebsa/healthreform, or the U.S. Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at 1 (877)267-2323 ext. 61565 or cciio.cros.gov or your state insurance department. You may also contact the plan at 1 (888) 367-2117. 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 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 Ilan 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 Ilan. For more information about your rights, this notice, or assistance, contact the Ilan at 1 (888) 367-2117 or visit regence.com or the U.S. Department of Labor, Employee Benefits Security Administration at 1 (866)444-3272 or dol.gov/ebsa/healthreform. You may also contact the Idaho Department of Insurance by calling 1 (208) 334-4250 or the toll-free message line at 1 (800) 721-3272; by writing to the Idaho Department of Insurance, GSW-W-24-01 IPUC Staff PR 17 Attachment 3 Page 18 of 94 Page 5 of 7 Consumer Affairs, 700 W State Street, 3rd Floor; P.O. Box 83720, Boise, ID 83720-0043; through the Internet at: doi/Idaho.gov; or by E-mail at: consumeraffairs@doi.idaho.gov. 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 fora plan through the Marketplace. Language Access Services: Spanish (Espanol): Para obtener asistencia en Espanol, Ilame al 1 (888) 367-2117. To see examples of how this Ilan might cover costs for a sample medical situation, see the next section. GSW-W-24-01 IPUC Staff PR 17 Attachment 3 Page 19 of 94 Page 6 of 7 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this Ilan 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 Ilan. 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. Peg is Having a Baby Managing Joe's Type 2 Diabetes Mia's Simple Fracture (9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up hospital delivery) I controlled condition) I care) I ■The Ip an's overall deductible $1,500 ■The Ip an's overall deductible $1,500 ■The Ip an's overall deductible $1,500 ■Specialist copayment $50 ■Specialist copayment $50 ■Specialist copayment $50 ■Hospital (facility) coinsurance 30% ■ Hospital (facility) coinsurance 30% ■ Hospital (facility) coinsurance 30% ■Other coinsurance 30% ■Other coinsurance 30% ■Other coinsurance 30% This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies) Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches) Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy) Specialist visit (anesthesia) Durable medical equipment (glucose meter) Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $1,500 Deductibles $790 Deductibles $1,500 Copavments $11 Copavments $1,004 Copavments $705 Coinsurance $3,215 Coinsurance $26 Coinsurance $72 What isn't covered What isn't covered What isn't covered Limits or exclusions $61 Limits or exclusions $178 Limits or exclusions $0 The total Peg would pay is $4,787 The total Joe would pay is $1,998 The total Mia would pay is $2,277 The Ilan would be responsible for the other costs of these EXAMPLE covered services. GSW-W-24-01 IPUC Staff PR 17 Attachment 3 Page 20 of 94 Page 7 of 7 Summary of Benefits and Coverage: What this Plan Covers &What You Pay For Covered Services Coverage Period: When enrolled, coverage period will show here Regence BlueShield of Idaho, Inc.: Regence Platinum 500 Coverage for: Individual and Eligible Family I Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health Ilan. The SBC shows you how you and the Ilan would share the cost for covered health care services. NOTE: Information about the cost of this Ilan (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, go to https://regence.com/go/2021/booklet/ID/Platinum500Preferred or call 1 (888) 367-2117. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copavment, deductible, provide r, or other underlined terms see the Glossary. You can view the Glossary at healthcare.gov/sbc-glossary or call 1 (888) 367- 2117 to request a copy. Important In-network: $500 individual/$1,000 family per Generally, you must pay all of the costs from providers up to the deductible amount What is the overall calendar year. before this Ilan begins to pay. If you have other family members on the Ilan, each deductible? Out-of-network: $3,000 individual/$6,000 family member must meet their own individual deductible until the total amount of family per calendar year. deductible expenses paid by all family members meets the overall family deductible. This Ilan covers some items and services even if you haven't yet met the Are there services covered Yes. Certain preventive care and those deductible amount. But a copavment or coinsurance may apply. For example, before you meet your services listed below as "deductible does not this Ilan covers certain preventive services without cost sharing and before you deductible? apply"or as "No charge." meet your deductible. See a list of covered preventive services at healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles No. You don't have to meet deductibles for specific services. for specific services? In-network: $4,000 individual/$8,000 family The out-of-pocket limit is the most you could pay in a year for covered services. If you What is the out-of-pocket per calendar year. have other family members in this Ilan, they have to meet their own out-of-pocket limits limit for this Ilan? Out-of-network: $10,000 individual/$20,000 until the overall family out-of-pocket limit has been met. family per calendar year. What is not included in the Pediatric vision services, premiums, balance- out-of-pocket limit? billing charges, and health care this Ilan Even though you pay these expenses, they don't count toward the out-of-pocket limit. doesn't cover. This Ilan uses a provider network. You will pay less if you use a provider in the Ip an's Yes. See https://regence.com/go/ID/Preferred network. You will pay the most if you use an out-of-network provider, and you might Will you pay less if you use or call 1 (888) 367-2117 for a list of network receive a bill from a provider for the difference between theprovider's charge and what a network provider? your Ilan pays (balance billing). Be aware, your network provider might use an out-of- roviders. network provider for some services (such as lab work). Check with your provide r before you get services. Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist? GSW-W-24-01 Page 1 of 7 When W( tef,,ffle1grdiApaharmtWill show here Page 21 of1V0121 SPLASD ®, All c1 p went and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Services You May What You Will Pay • Important Event Need In-Network Provider • Information (You will pay the least) (You will pay the most) $20 copaV/office visit, deductible does not apply; Primary care visit to $20 copay/retail clinic o treat an injury or illness visit, deductible does not 50% coinsurance apply; Copayment applies to each in-network office visit only. If you visit a health 20% coinsurance for all All other services are covered at the coinsurance care provider's office other services specified, after deductible. or clinic $30 copay/office visit, deductible does not apply; Specialist visit 50% coinsurance 20% coinsurance for all other services Preventive You may have to pay for services that aren't care/screening/ No charge 50% coinsurance preventive. Ask your provide r if the services needed immunization are preventive. Then check what your Ilan will pay for. 20% coinsurance, deductible does not apply Deductible does not apply to in-network outpatient Diagnostic test(x-ray, for outpatient services; 50% coinsurance services only. All other services are covered at the If you have a test blood work) 20/o o coinsurance for coinsurance specified, after deductible. inpatient services Imaging (CT/PET scans, 20% coinsurance 50% coinsurance None MRIs) If you need drugs to $8 copaV/ preferred retail prescription No coverage for prescription drugs not on the Drug treat your illness or Preferred generic drugs $16 copaV/ preferred mail order prescription List. condition &generic drugs $35 copaV/retail prescription Deductible does not apply. More information about $70 co pay/ mail order prescription 90-day supply/retail prescription (your cost share is prescription drug Preferred brand drugs $30 copay/retail prescription per 30-day supply) coverage is available at $60 copaV/ mail order prescription 90-day supply/mail order prescription https://regence.com/go/ Brand d 50% coinsurance/retail prescription 30-day supply/specialty drug retail prescription 2021/ID/6tier rugs 45% coinsurance/mail order prescription Specialty dru s are not availal Fffiirc email order. Page 22 of 94 page 2 of 7 In-NetworkCommon Medical Services You May What You Will Pay Limitations, Exceptions, & Other Important • • • Out-of-Network Pr• • • Event Need (You will • .y the least) (You will pay the most) Cost shares for preferred brand insulin will not exceed $100/30-day supply retail prescription or$200/90- day supply mail order prescription. 20% coinsurance/ No charge for certain preventive drugs[, women's Preferred specialty preferred retail prescription 50% coinsurance/ retail contraceptives] and immunizations at a participating drugs &specialty drugs 50% coinsurance/ retail prescription pharmacy. prescription The first fill of specialty drugs for hemophilia may be provided by a retail pharmacy; additional refills must be provided by a specialty pharmacy or a specialty pharmacy designated as a hemophilia treatment center. 10% coinsurance for Facility fee (e.g., ambulatory surgery centers; ambulatory surgery 50% coinsurance center) 20% coinsurance for all If you have outpatient other facilities None surgery 10% coinsurance for ambulatory surgery center Physician/surgeon fees physicians; 50% coinsurance 20% coinsurance for all other physicians Copavment applies to facility charge for each visit (waived if admitted), whether or not the in-network Emergency room care $300 copay/visit $300 copay/visit deductible has been met. In-network deductible applies to in-network and out-of- network services. If you need immediate Emergency medical 20% coinsurance 20% coinsurance In-network deductible applies to in-network and out-of- medical attention transportation network services. $30 copay/office visit, deductible does not apply; Copavment applies to each in-network office visit only. Urgent care 50% coinsurance All other services are covered at the coinsurance 20% coinsurance for all specified, after deductible. other services Gsw-w-24-01 Page 23 of 94 page 3 of 7 In-NetworkCommon Medical Services You May What You Will Pay Limitations, Exceptions, & Other Important • • • Out-of-Network Pr• • • Event Need (You will • .y the least) (You will pay the most) If you have a hospital Facility fee (e.g., 20% coinsurance 50% coinsurance $5,000/day for inpatient non-emergency admission in hospital room) non-participating facilities stay Physician/surgeon fees 20% coinsurance 50% coinsurance None $20 copay/office visit, If you need mental deductible does not apply; ° Copavment applies to each in-network health, behavioral Outpatient services 50% coinsurance office/psychotherapy visit only. All other services are health, or substance 20% coinsurance for all covered at the coinsurance specified, after deductible. abuse services other services Inpatient services 20% coinsurance 50% coinsurance $5,000/day for inpatient non-emergency admission in non-participating facilities Office visits 20% coinsurance 50% coinsurance Cost sharing does not apply for preventive services. Childbirth/delivery ° ° Depending on the type of services, a copayment, professional services 20% coinsurance 50% coinsurance coinsurance or deductible may apply. Maternity care If you are pregnant may include tests and services described elsewhere in Childbirth/delivery 20/°° coinsurance 50/°° coinsurance the SBC (i.e. ultrasound). facility services $5,000/day for inpatient non-emergency admission in non-participating facilities Home health care 20% coinsurance 50% coinsurance None $20 copay/outpatient visit, 20 outpatient visits each for rehabilitation and deductible does not apply; Rehabilitation services 50% coinsurance habilitation services/year 20% coinsurance for Copavment applies to each in-network outpatient visit inpatient services only. All inpatient services are covered at the If you need help coinsurance specified, after deductible. deductible recovering or have copay/outpatient visit, Includes physical therapy, occupational therapy and other special health deductible does not apply; ° speech therapy. Habilitation services 50% coinsurance needs 20% coinsurance for $5,000/day for inpatient non-emergency admission in inpatient services non-participating facilities Skilled nursing care 20% coinsurance 50% coinsurance 30 inpatient days/year Durable medical equipment 20% coinsurance 50% coinsurance None Hospice services 20% coinsurance 50% coinsurance None If your child needs Children's eye exam No charge for VSP doctor 50% coinsurance, 1 routine eye examination/year for individuals under dental or eye care y g deductible does not apply age 19 Gsw-w-24-01 tie staff PR 17 Attachment 3 Page 24 of 94 page 4 of 7 You In-NetworkCommon Medical Services You May What Event Need • • • Out-of-Network Pr• • • (You will • .y the least) (You will pay the most) 50% coinsurance, 1 pair of lenses/year Children's lasses No charge*for VSP doctor 1 set of frames/year g g deductible does not apply Glasses limited to individuals under age 19. *Frames limited to Otis & Piper Eyewear Collection. 2 cleanings*/year 2 preventive oral examinations/year Coverage limited to individuals under age 19. Children's dental check- No charge No charge *Coverage may include another cleaning, refer to your up Ilan for further information. Coverage includes basic and major dental services for individuals under age 19, refer to your plan for further information. Excluded Services &Other Covered Services: Services Your Plan Generally Does NOT Cover(Check your policy or Ilan document for more information and a list of any other excluded services.) • Abortion, except when performed to preserve the • Dental care (Adult) • Routine eye care (Adult) life of the enrolled female individual • Infertility treatment • Routine foot care, except for diabetic patients • Bariatric surgery • Long-term care • Weight loss programs • Cosmetic surgery, except congenital anomalies • Private-duty nursing Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your Ilan document.) • Acupuncture • Hearing aids Non-emergency care when traveling outside the • Chiropractic care, spinal manipulations only 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: the U.S. Department of Labor, Employee Benefits Security Administration at 1 (866) 444-3272 or dol.gov/ebsa/healthreform, or the U.S. Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at 1 (877)267-2323 ext. 61565 or cciio.cros.gov or your state insurance department. You may also contact the plan at 1 (888) 367-2117. 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 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 Ilan 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 Ilan. For more information about your rights, this notice, or assistance, contact the Ilan at 1 (888) 367-2117 or visit regence.com or the U.S. Department of Labor, Employee Benefits Security Administration at 1 (866)444-3272 or dol.gov/ebsa/healthreform. You may also contact the Idaho Department of Insurance by calling 1 (208) 334-4250 or the toll-free message line at 1 (800) 721-3272; by writing to the Idaho Department of Insurance, GSW-W-24-01 IPUC Staff PR 17 Attachment 3 Page 25 of 94 page 5 of 7 Consumer Affairs, 700 W State Street, 3rd Floor; P.O. Box 83720, Boise, ID 83720-0043; through the Internet at: doi/Idaho.gov; or by E-mail at: consumeraffairs@doi.idaho.gov. 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 fora plan through the Marketplace. Language Access Services: Spanish (Espanol): Para obtener asistencia en Espanol, Ilame al 1 (888) 367-2117. To see examples of how this Ilan might cover costs for a sample medical situation, see the next section. GSW-W-24-01 IPUC Staff PR 17 Attachment 3 Page 26 of 94 page 6 of 7 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this Ilan 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 Ilan. 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. Peg is Having a Baby Managing Joe's Type 2 Diabetes Mia's Simple Fracture (9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up hospital delivery) I controlled condition) I care) I ■The Ip an's overall deductible $500 ■The Ip an's overall deductible $500 ■The Ip an's overall deductible $500 ■Specialist copayment $30 ■Specialist copayment $30 ■Specialist copayment $30 ■Hospital (facility) coinsurance 20% ■ Hospital (facility) coinsurance 20% ■ Hospital (facility) coinsurance 20% ■Other coinsurance 20% ■Other coinsurance 20% ■Other coinsurance 20% This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies) Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches) Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy) Specialist visit (anesthesia) Durable medical equipment (glucose meter) Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $500 Deductibles $500 Deductibles $500 Copavments $11 Copavments $656 Copavments $515 Coinsurance $2,343 Coinsurance $75 Coinsurance $246 What isn't covered What isn't covered What isn't covered Limits or exclusions $61 Limits or exclusions $178 Limits or exclusions $0 The total Peg would pay is $2,915 The total Joe would pay is $1,409 The total Mia would pay is $1,261 The Ilan would be responsible for the other costs of these EXAMPLE covered services. GSW-W-24-01 IPUC Staff PR 17 Attachment 3 Page 27 of 94 Page 7 of 7 Dentat Insurance PROTECTS YOUR SMILE. You can feel more confident with dental insurance that encourages routine cleanings and checkups. Dental insurance helps protect your teeth for a lifetime. PREVENTS OTHER HEALTH ISSUES. Just annual preventive care alone can help prevent other COMMONLY health issues such as heart disease and diabetes. Many COVERED plans cover preventive services at or near 100% to make it Exams and cleanings easy for you to use your dental benefits. LOWERS OUT-OF-POCKET EXPENSES. C X-rays Seeing an in-network dentist can reduce your fees C Fillings approximately 30% from their standard fees. Add the benefits of your coinsurance to that and things are looking OTooth extractions good for your wallet. C Adult and child braces Periodontal disease can lead to receding gums, Treatment of gum disease bone damage, loss of teeth, and can increase in people with type 2 diabetes can lower blood the risk of other health problems such as heart sugar over time.z disease and diabetes.' Sun Life Assurance Company of Canada 166MGWzW'242G4021 08:21:41 :00 -,qqq covered Good news! Your plan covers routine services like cleanings and exams at 100%. CALENDAR YEAR MAXIMUM IN-NETWORK OUT-OF-NETWORK Type II, III (Basic and Major Services) $2,000 per person $2,000 per person Type IV Ortho Service $1,500 lifetime child and $1,500 lifetime child and adult adult Type I Preventive Services do not count toward your Calendar Year maximum CALENDAR YEAR DEDUCTIBLE PROCEDUREIN-NETWORK OUT-OF-NETWORK Type I Preventive Services N/A N/A Type II, III (Basic and Major Services) $50 individuaV$150 family $50 individual/$150 family Type IV Ortho Services N/A N/A THE PLAN PAYS THE FOLLOWING PERCENTAGE FOR PROCEDURES PROCEDUREIN-NETWORK Type I Preventive Services 100% 100% Type II Basic Services 80% I 80% Type III Major Services 50% 50% Type IV Ortho Services 50% 50% SERVICES Type I Preventive Dental Services, including: limit Oral evaluations — 1 in any 6 month period Stainless steel crowns— only for children under age 19 Routine dental cleanings — 1 in any 6 month period Inlay, onlay, and crown restorations — 1 per tooth in (frequency combined with periodontal maintenance) any 10 year period Fluoride treatment — 1 in any 6 month period. Only for Surgical extractions of erupted teeth, impacted teeth, children under age 14 or exposed root Sealants — no more than 1 per tooth in any 36 month Biopsy (including brush biopsy) period, only for permanent molar teeth. Only for Endodontics (includes root canal therapy) — 1 per tooth children under age 14 in any 24 month period Bitewing x-rays — 1 in any 12 month period Complex oral surgery Intraoral complete series x-rays — 1 in any 60 month General anesthesia/IV sedation — medically required period Type IV Ortho Services, including: Genetic test for susceptibility to oral diseases No orthodontic treatment age limitation Type II Basic Dental Services, including: Waiting Periods New fillings For a complete description of services and waiting periods, Space maintainers — only for children under age 19 please review your certificate of insurance. If you were Minor gum disease (non-surgical periodontics) covered under your employer's prior plan the wait will be Scaling and root planing— 1 in any 24 month period waived for any type of service covered under the prior plan per area and this plan. Periodontal maintenance — 1 in any 3 consecutive No waiting period for preventive, basic or major months (frequency combined with routine dental services cleanings) No waiting period for orthodontic services Localized delivery of antimicrobial agents Major gum disease (surgical periodontics) Type III Major Dental Services, including: Dentures and bridges — subject to 10 year replacement GSW-W-24-01 :00 Frequently asked - • How does a PPO work? common questions when it's convenient for you. PPO stands for Participating Provider Organization. With a What value added benefits does my plan include? dental PPO plan, dental providers agree to participate in a dental network by offering discounted fees on most Your plan includes our Lifetime of Smiles® program, with dental procedures. When you visit a provider in the benefits many people prefer, such as up to four network, you could see lower out-of-pocket costs periodontal cleanings in a year5,6 and brush biopsies for because providers in the network agree to these pre- the early detection of oral cancer. negotiated discounted fees on eligible claims. Your plan also includes Preventive Max Waiver®which How do I find a dentist? allows covered dental expenses for preventive services to Simply visit www.sunlife.com/findadentist. Follow the not apply to the annual maximum. prompts to find a dentist in your area who participates in the PPO network. You do not need to select a dentist in advance. The PPO network for your plan is the Sun Life Dental Network' with 130,000+ unique dentists. Do I have to choose a dentist in the PPO network? No. You can visit any licensed dentist for services. However, you could see lower out-of-pockets costs when you visit a dentist in the network. Are my dependents eligible for coverage? Yes. Your plan offers coverage for your spouse3 and dependent children. An eligible child is defined as a child to age 26.4 What if I have already started dental work, like a root canal or braces, that requires several visits? Your coverage with us may handle these procedures differently than your prior plan. To ensure a smooth transition for work in progress, call our dental claims experts before your next visit at 800-442-7742. Do I have to file the claim? Many dentists will file claims for you. If a dentist will not file your claim, simply ask your dentist to complete a standard American Dental Association (ADA) claim form and mail it to: CONSIDER A Sun Life PRE-DETERMINATION P.O. Box 2940 Clinton, IA 52733 OF BENEFITS How can I get more information about my coverage They allow us to review your or find my dental ID card? provider's treatment plan to let After the effective date of your coverage, you can view you know before treatment is benefit information online at your convenience through started how much of the work your Sun Life account. To create an account go to should be covered by the plan, www.sunlife.com/account and register. You can also and how much you may need to access this information from our mobile app—Benefit cover. We recommend them for Tools, which is available for Apple and Android devices. Or you can call Sun Life's Dental Customer Service at 800- any dental treatment expected 442-7742. You can also call any time, day or night, to to exceed $300. access our automated system and get answers to 1.American Academy of Periodontology http://www.perio.org/consumer/love_the—gumsyouu%27re_with. (accessed on 06/06/19) 2.https://www.cdc.gov/diabetes/ndep/pdfs/150-Healthy-teeth-matter.pdf(accessed 06/06/19) 3. If permitted by the Employer's employee benefit plan and not prohibited by state law,the term"spouse"in this benefit includes any individual who is either recognized as a spouse,a registered domestic partner,or a partner in a civil union,or otherwise accorded the same rights as a spouse. 4. Please see your employer for more specific information. 5.Classification of services varies by plan design. 6.Total number of combined prophylaxis cleaning and periodontal maintenance procedures cannot exceed 4 in a 12 month period. Read the Important information section for more details including limitations and eXgJ9*0Rs24-01 :00 Dental plan provisions MENEM Benefit adjustments Benefits will be coordinated with any other dental coverage. Under the Alternative Treatment provision, benefits will be payable for the most economical services or supplies meeting broadly accepted standards of dental care. Late entrant If you or a dependent apply for dental insurance more than 31 days after you become eligible, you or your dependent are a late entrant. The benefits for the first 12 months for late entrants will be limited as follows: TIME INSURED CONTINUOUSLY UNDER THE POLICY BENEFITS PROVIDED FOR ONLY THESE SERVICES Less than 12 months Preventive and Basic Services At least 12 months Preventive, Basic, Major and Ortho Services We will not pay for treatments subject to the late entrant limitation, and started or completed during the late entrant limitation period. GSW-W-24-01 :•• Vision Insurance hibmwom AA PROTECTS YOUR EYES. You can help protect your eyesight by visiting an eye doctor regularly. Vision insurance includes an annual comprehensive eye exam with an eye care doctor. Taking care of your eyes today can lead to a better quality of life later. COMMONLY PREVENTS OTHER HEALTH ISSUES. COVERED Just annual preventive care alone can help detect signs of chronic health conditions such as high blood pressure and CAnnual exams diabetes. Early detection can be key before costly symptoms C Lenses arise.' n I LOWERS OUT-OF-POCKET EXPENSES. Frames Seeing an in-network eye care provider can reduce your CContact lenses expenses with savings on frames, lenses, contacts, eye exams and more. CLaser vision correction discount v•..7•vall ••wJv•%r••lv\.A- rr•.a • rr•*.•.a Roughly, 90% of diabetes- 59% of adults report related blindness can be experiencing symptoms of avoided by getting an digital eye strain, such as annual eye exam.2 blurred vision or headaches. Sun Life Assurance Company of Canada 1662028G&W5;WgI 421 08:21:38 TorI 800 Page covered All employees receive the following benefits: BENEFIT FREQUENCY IN-NETWORK BENEFIT OUT-OF-NETWORK BENEFIT Exam services WellVision exam' 1 per 12 months $10 for exam Up to $52 Routine retinal No more than a $39 N/A screening copay Glasses discount 20% off one complete pair of prescription and N/A (lenses and frames) non-prescription glasses, including sunglasses from any VSP doctor within 12 months of your last exam. Elective contact 15% off contact lens fitting and evaluation. N/A lenses discount Materials are not covered. Laser vision Once per eye per Average 15% off the N/A correction discount lifetime. regular price or 5% off the promotional price. Discounts only available from contracted facilities. Employees who enroll in the Buy-up Plan also receive the following benefits: BENEFIT FREQUENCY IN-NETWORK BENEFIT OUT-OF-NETWORK BENEFIT Lenses Single lined Up to $55 Bifocal lined Up to $75 Trifocal 1 per 12 months $25 (lenses and frame) Up to $95 Lenticular Up to $125 Necessary contacts Up to $210 Frames 1 per 24 months $130 for the frame of Up to $57 your choice and 20% off the amount over your allowance Elective contact lenses 1 per 12 months $60 for your contact lens Up to $105 exam (fitting and Contact lenses are in place evaluation) of lenses and frame. $130 for contact lenses Additional glasses and 30% off complete pairs of prescription and non- N/A sunglasses discount prescription glasses, including sunglasses for same- day purchases. 20% off all lens options for any other day. Discounts are unlimited for 12 months following exam. This chart outlines services for Plan 2. Administrative services for the vision insurance plan are provided by Vision Service Plan (VSP) GS W-W-24-01 iPUC Staff PR 17 Attachment 3 Page 33 of 94 Frequently -d questions egoism How do I use my vision benefit? Can I enroll as a late entrant? Once enrolled, simply tell your VSP doctor you're a If you elect coverage more than 31 days after your member and they will handle the rest. If you visit an eligibility date, your effective date will be delayed to in-network doctor for services and materials, you don't the next plan anniversary date. need an ID card or have forms to complete. Are my dependents eligible for coverage? How do I locate an in-network VSP doctor? Yes. Your plan offers coverage for your spouses and You will have access to the largest national network4 dependent children. An eligible child is defined as a of private-practice eye care doctors in the industry child to age 26.6 through Vision Service Plan (VSP). There are three ways to find an in-network doctor: How can I get more information about my 1. Visit vsp.com and select the Signature network. coverage? 2. Call VSP at 800-877-7195. After the effective date of your coverage, you can visit 3. Download our mobile app, Benefit Tools, and search www.sunlife.com/account to create a Sun Life account. for a doctor near you. Once you're logged in, you'll be able to see your plan details and more. Or you can call VSP Customer Service What happens if I use an out-of-network doctor? at 800-877-7195. You will be required to pay the full amount to the doctor at time of service. You can then submit a claim Can I use my benefits to buy glasses or contacts for reimbursement, which is a lesser benefit when online? compared to visiting a VSP doctor. Absolutely.Just visit www.eyeconic.com. Once you have linked your benefits you will be able to see how When will my coverage become effective? your coverage will be applied to different options that Your coverage starts on the effective date specified in you are reviewing. Eyeconic features a virtual try-on your group policy, provided you are actively at work on tool so you can see how the glasses will look on you that date. Otherwise, your coverage will become before you make your purchase. effective on the day you return to full-time duties. 1. https://vsp.com/eye-symptoms.htmi accessed 03/13/19. 2. https://www.vsp.com/diabetes.html accessed 03/13/19. 3.The Vision Council https://www.thevisioncouncit.org/content/digital-eye-strain accessed on 02/21/19. 4. Netminder as of December 2018. S. If permitted by the Employer's benefit plan and not prohibited by state law,the term"spouse"in this benefit includes any individual who is either recognized as a spouse,a registered domestic partner,or a partner in a civil union, or otherwise accorded the same rights as a spouse. 6. Please see your employer for more specific information. Read the Important information section for more details including limitations and exclusions. GSW-W-24-01 Page 34 of M Basic Life Insurance hibbMIM WWdA PROTECTS YOUR LOVED ONES. Life insurance provides your loved ones with money they can use for household expenses, tuition, mortgage payments and more. HELPS PAY YOUR FINAL EXPENSES. Your beneficiaries may use this money to pay for your burial or cremation, and pay any outstanding medical bills. PART OF YOUR BENEFIT PACKAGE. Your employer pays for your coverage, as an employee. You are responsible for paying all or a portion of the cost for coverage Even among people for your spouse and child(ren). who have life insurance, about 1 in 5 say they rForou * 1 times your Basic Annual Earnings, up to a maximum don't have enough. of$100,000. No medical questions asked. Benefits are reduced at age 65 and may reduce again in subsequent years as noted in your Certificate. Dependent $5,000 for your spouse and $2,000 for your child(ren), Coverage with no medical questions asked. Dependent coverage cannot exceed 50%of your coverage amount. A full benefit is payable for a dependent child who is 6 months to 19 or to 23 years old if a full-time student.A reduced benefit of $500 is payable for a child from 14 days to 6 months. (No benefit is payable for a child from birth to 14 days.) in order to be covered,the child must depend primarily on the employee for 50%or more of their support. *This coverage includes Accidental Death and Dismemberment insurance. Sun Life Assurance Company of Canada 7662028 SEQGSW- V224 M1 08:21:23 ff PR 17 Attachment Page 35 of Frequently • questions What is my AD&D benefit? We will pay your beneficiaries an Accidental Death insurance amount that matches your Basic Life insurance amount, if you die from a covered accident. Additional benefits are available for accidental injuries (i.e., dismemberment) such as loss of limbs, fingers or sight. Refer to your Certificate for a full list of covered accidental injuries. Do I need to answer any health questions to enroll? If you contribute to the cost of your insurance, you may need to complete health questions if you don't elect coverage when it's first available to you and you want to elect at a later date, or if you want to increase coverage. To answer health questions, please fill out our Evidence of Insurability application. Health questions must be approved by Sun Life before coverage takes effect. Please see your Certificate for details. Can I take my insurance with me if I leave my employer? Depending upon state variations and your employer's plan, you may have an option to continue group coverage when your employment terminates. Your employer can advise you about your options. Can I access my life insurance if I become terminally ill? You may apply to receive a portion of your life insurance to help cover medical and living expenses. This is called an "Accelerated Benefit" and there are some important things to know about it, including that it is not long-term-care insurance, it may be taxable and it may affect your eligibility for public assistance programs. It will also reduce the total amount of the life insurance payment we pay to your beneficiary(ies). What happens if I become Totally Disabled? If we determine that you are Totally Disabled and cannot work, your life insurance coverage may continue at no cost. You must meet certain requirements, as detailed in the Certificate. How does my beneficiary file a death claim? Your beneficiary(ies) and your employer will complete the appropriate claims forms and submit them to us. We will notify your beneficiaries when the decision is made and if we have any questions. If approved, beneficiaries may elect to receive a lump sum payment or to have the benefit paid into an account where the funds accumulate interest and can be withdrawn at any time. (State restrictions apply and options may vary by state.) If your AD&D claim for an accidental injury is approved, the benefit amount will be paid directly to you. 1. LIMRA, Facts about Life 2018. Read the Important information section for more details including limitations and exclusions. GSW-W-24-01 IPUC Staff PR 17 Attachment Page 36 of Voluntary Life MIA Insurance BENEFITS (You can purchase this coverage at a group rate. MORE PROTECTION For you* You can choose from $10,000 to $300,000—in FOR YOUR LOVED ONES. increments of$10,000 not to exceed 5 times your Basic The people you love and Annual Earnings. No medical questions asked up to the support could face financial Guaranteed Issue amount of $100,000. challenges without you. Benefits are reduced at age 65 and may reduce again in Life insurance provides your subsequent years as noted in your Certificate. loved ones with money they can use for household expenses, tuition, mortgage payments and more. For your If you elect coverage for yourself, you can choose from spouse $5,000 to $100,000—in increments of$5,000. No HELPS YOU CLOSE ANY medical questions asked up to the Guaranteed Issue COVERAGE GAPS. amount of $20,000. You may have life The amount you select for your spouse cannot exceed insurance today, either 50% of your coverage amount. Coverage ends when your on your own or through your spouse turns age 70. employer. Now is a good time to ask yourself if you need more coverage. For your If you elect coverage for yourself, you can choose $2,500 children) to $10,000—in $2,500 increments. No medical questions asked. The amount you select for your children) cannot exceed 50% of your coverage amount. Benefits may reduce as noted in your Certificate. Child(ren) must primarily depend on the employee for 50% or more of their support. A full benefit is payable for a dependent child who is 6 months to 19 or to 23 years old if a full-time student. A reduced benefit of$500 is payable for a child from 14 days to 6 months. (No benefit is payable for a child from birth to 14 days). *This coverage includes Accidental Death and Dismemberment insurance. Sun Life Assurance Company of Canada 1662028'$W0'QCr94129'/1021 08:21:35 IPUC Staff :00 Frequently • questions What is my AD&D benefit? We will pay your beneficiaries an Accidental Death insurance amount that matches your Voluntary Life, if you die from a covered accident. Additional benefits are available for accidental injuries (i.e., dismemberment) such as loss of limbs, fingers or sight. Refer to your Certificate for a full list of covered accidental injuries. Do I need to answer any health questions to enroll? Yes, if you request an amount higher than the Guaranteed Issue amount. You may need to complete health questions if you don't elect coverage when it's first available to you and you want to elect at a later date, or if you want to increase coverage. To answer health questions, please fill out our Evidence of Insurability application. Health questions must be approved by Sun Life before coverage takes effect. Please see your Certificate for details. Can I take my insurance with me if I leave my employer? Depending upon state variations and your employer's plan, you may have an option to continue group coverage when your employment terminates. Your employer can advise you about your options. Can I access my life insurance if I become terminally ill? You may apply to receive a portion of your life insurance to help cover medical and living expenses. This is called an "Accelerated Benefit" and there are some important things to know about it, including that it is not long-term-care insurance, it may be taxable and it may affect your eligibility for public assistance programs. It will also reduce the total amount of the life insurance payment we pay to your beneficiary(ies). What happens if I become Totally Disabled? If we determine that you are Totally Disabled and cannot work, your life insurance coverage may continue at no cost. You must meet certain requirements, as detailed in the Certificate. How does my beneficiary file a death claim? Your beneficiary(ies) and your employer will complete the appropriate claims forms and submit them to us. We will notify your beneficiaries when the decision is made and if we have any questions. If approved, beneficiaries may elect to receive a lump sum payment or to have the benefit paid into an account where the funds accumulate interest and can be withdrawn at any time. (State restrictions apply and options may vary by state.) If your AD&D claim for an accidental injury is approved, the benefit amount will be paid directly to you. 1. LIMRA, Facts about Life 2018. Read the Important information section for more details including limitations and exclusions. GSW-W-24-01 IPUC Staff PR 17 Attachmen Page OFF Employee - Coverage and bi-weekly cost for Employee Voluntary Life and AD&D. Rates are effective as of June 1, 2021. The chart below shows possible coverage amounts and their bi-weekly costs. Find your age bracket(as of the effective date of coverage)to see the cost for the coverage amount you choose. $10,000 0.89 0.89 0.89 1.00 1.29 1.97 2.82 4.37 6.62 9.41 19.56 41.94 81.82 155.74 $20,000 1.77 1.77 1.77 2.00 2.58 3.93 5.63 8.74 13.24 18.82 39.12 83.87 163.63 311.47 $30,000 2.66 2.66 2.66 3.00 3.86 5.90 8.45 13.11 19.86 28.23 58.68 125.81 245.45 467.21 $40,000 3.54 3.54 3.54 4.01 5.15 7.86 11.26 17.48 26.47 37.64 78.24 167.74 327.27 622.95 $50,000 4.43 4.43 4.43 5.01 6.44 9.83 14.08 21.85 33.09 47.05 97.80 209.68 409.08 778.68 $60,000 5.32 5.32 5.32 6.01 7.73 11.80 16.89 26.22 39.71 56.46 117.36 251.61 490.90 934.42 $70,000 6.20 6.20 6.20 7.01 9.01 13.76 19.71 30.60 46.33 65.88 136.92 293.55 572.72 1090.16 $80,000 7.09 7.09 7.09 8.01 10.30 15.73 22.52 34.97 52.95 75.29 156.48 335.48 654.54 1245.90 $90,000 7.98 7.98 7.98 9.01 11.59 17.70 25.34 39.34 59.57 84.70 176.04 377.42 736.35 1401.63 $100,000 8.86 8.86 8.86 10.02 12.88 19.66 28.15 43.71 66.18 94.11 195.60 419.35 818.17 1557.37 $110,000 9.75 9.75 9.75 11.02 14.16 21.63 30.97 48.08 72.80 103.52 215.16 461.29 899.99 1713.11 $120,000 10.63 10.63 10.63 12.02 15.45 23.59 33.78 52.45 79.42 112.93 234.72 503.22 981.80 1868.84 $130,000 11.52 11.52 11.52 13.02 16.74 25.56 36.60 56.82 86.04 122.34 254.28 545.16 1063.62 2024.58 $140,000 12.41 12.41 12.41 14.02 18.03 27.53 39.42 61.19 92.66 131.75 273.84 587.10 1145.44 2180.32 $150,000 13.29 13.29 13.29 15.02 19.32 29.49 42.23 65.56 99.28 141.16 293.40 629.03 1227.25 2336.05 $160,000 14.18 14.18 14.18 16.02 20.60 31.46 45.05 69.93 105.90 150.57 312.96 670.97 1309.07 2491.79 $170,000 15.06 15.06 15.06 17.03 21.89 33.42 47.86 74.30 112.51 159.98 332.52 712.90 1390.89 2647.53 $180,000 15.95 15.95 15.95 18.03 23.18 35.39 50.68 78.67 119.13 169.39 352.08 754.84 1472.70 2803.26 $190,000 16.84 16.84 16.84 19.03 24.47 37.36 53.49 83.04 125.75 178.80 371.64 796.77 1554.52 2959.00 $200,000 17.72 17.72 17.72 20.03 25.75 39.32 56.31 87.42 132.37 188.22 391.20 838.71 1636.34 3114.74 $210,000 18.61 18.61 18.61 21.03 27.04 41.29 59.12 91.79 138.99 197.63 410.76 880.64 1718.16 3270.48 $220,000 19.50 19.50 19.50 22.03 28.33 43.26 61.94 96.16 145.61 207.04 430.32 922.58 1799.97 3426.21 $230,000 20.38 20.38 20.38 23.04 29.62 45.22 64.75 100.53 152.22 216.45 449.88 964.51 1881.79 3581.95 $240,000 21.27 21.27 21.27 24.04 30.90 47.19 67.57 104.90 158.84 225.86 469.44 1006.45 1963.61 3737.69 $250,000 22.15 22.15 22.15 25.04 32.19 49.15 70.38 109.27 165.46 235.27 489.00 1048.38 2045.42 3893.42 $260,000 23.04 23.04 23.04 26.04 33.48 51.12 73.20 113.64 172.08 244.68 508.56 1090.32 2127.24 4049.16 $270,000 23.93 23.93 23.93 27.04 34.77 53.09 76.02 118.01 178.70 254.09 528.12 1132.26 2209.06 4204.90 $280,000 24.81 24.81 24.81 28.04 36.06 55.05 78.83 122.38 185.32 263.50 547.68 1174.19 2290.87 4360.63 $290,000 25.70 25.70 25.70 29.04 37.34 57.02 81.65 126.75 191.94 272.91 567.24 1216.13 2372.69 4516.37 $300,000 26.58 26.58 26.581 30.05 38.63 58.98 84.46J 131.12 198.55 282.32 586.80 1258.06 2454.51 4672.11 GSW-W-24-01 IPUC Staff Page 39 of 9 IF- P-9 0 Spouse - Coverage and bi-weekly cost for Spouse Voluntary Life. Rates are effective as of June 1, 2021. The chart below shows possible coverage amounts and their bi-weekly costs. Find your spouse's age bracket(as of the effective date of coverage)to see the cost for the coverage amount you choose. Spouse rates are based on the spouse's age. $5,000 0.19 0.19 0.19 0.27 0.42 0.67 0.96 1.50 2.30 3.63 $10,000 0.38 0.38 0.38 0.55 0.83 1.35 1.92 3.01 4.60 7.25 $15,000 0.57 0.57 0.57 0.82 1.25 2.02 2.87 4.51 6.90 10.88 $20,000 0.77 0.77 0.77 1.10 1.66 2.70 3.83 6.02 9.20 14.50 $25,000 0.96 0.96 0.96 1.37 2.08 3.37 4.79 7.52 11.50 18.13 $30,000 1.15 1.15 1.15 1.65 2.49 4.04 5.75 9.03 13.80 21.75 $35,000 1.34 1.34 1.34 1.92 2.91 4.72 6.70 10.53 16.11 25.38 $40,000 1.53 1.53 1.53 2.20 3.32 5.39 7.66 12.04 18.41 29.00 $45,000 1.72 1.72 1.72 2.47 3.74 6.06 8.62 13.54 20.71 32.63 $50,000 1.92 1.92 1.92 2.75 4.15 6.74 9.58 15.05 23.01 36.25 $55,000 2.11 2.11 2.11 3.02 4.57 7.41 10.53 16.55 25.31 39.88 $60,000 2.30 2.30 2.30 3.30 4.98 8.09 11.49 18.06 27.61 43.50 $65,000 2.49 2.49 2.49 3.57 5.40 8.76 12.45 19.56 29.91 47.13 $70,000 2.68 2.68 2.68 3.84 5.82 9.43 13.41 21.06 32.21 50.76 $75,000 2.87 2.87 2.87 4.12 6.23 10.11 14.37 22.57 34.51 54.38 $80,000 3.06 3.06 3.06 4.39 6.65 10.78 15.32 24.07 36.81 58.01 $85,000 3.26 3.26 3.26 4.67 7.06 11.46 16.28 25.58 39.11 61.63 $90,000 3.45 3.45 3.45 4.94 7.48 12.13 17.24 27.08 41.41 65.26 $95,000 3.64 3.64 3.64 5.22 7.89 12.80 18.20 28.59 43.71 68.88 $100,000 3.83 3.831 3.83 5.49 8.31 13.48 19.15 30.09 46.02 72.51 Child - Coverage and bi-weekly cost for Child Voluntary Life. Rates are effective as of June 1, 2021. The chart below shows possible coverage amounts and their bi-weekly costs. 7 $2,500 0.23 $5,000 0.46 $7,500 0.69 $10,000 0.92 GSW-W-24-01 IPUC Staff Page 40 of 9 Short-Term Disability Insurance PROTECTS YOUR INCOME WHEN YOU CAN'T WORK. If you're unable to work because of a covered disability, Short-Term Disability insurance replaces a portion of your income in addition to providing other services and benefits that help you return to work. PROVIDES YOU WITH A WEEKLY CHECK. COMMON After your claim is approved, you will receive a check for your benefits CAUSES OF that helps you pay everyday expenses like your mortgage or rent, DISABILITY childcare and groceries. Pregnancy PART OF YOUR BENEFIT PACKAGE. CInjuries This benefit is completely paid for by your employer. CJoint disorders Cl/ Back disorders PRr Weekly benefit You will receive a check for your benefits on a weekly basis. C Digestive after your It will replace 60% of your Total Weekly Earnings, up to claim is $1,385 each week. disorders approved When benefits Benefits begin as soon as 15 days from the date you are begin unable to work due to an injury and 15 days due to an ill- ness. Benefits may Up to 24 weeks, as long as you are still unable to work due be paid for to a covered disability. Additional plan This plan provides a benefit for covered disabilities resulting information from illness or injury that are not work-related. SHORT-TERM DISABILITY FA 1 in 4 workers More than three-quarters of will miss up to 3 months of workers are living paycheck to work due to disability during paycheck.z their career.' Sun Life Assurance Company of Canada ,,.GSW8-W1-a4�Q1021 0821:30 :00 Frequently - • questions How do I file a Short-Term Disability claim? other group disability plans; no-fault benefits, salary If you become disabled after the effective date of continuance or sick leave; and return-to-work coverage, check with your employer to make sure you earnings. For more information, contact your benefits are eligible for benefits. You can file a claim with us by administrator. downloading forms from our website. We'll ask you How is my benefit taxed? and your doctor to provide information about your If you or your employer pays for all or part of the cost medical condition and your expected recovery. of coverage on a pre-tax basis, all or part of your How do I qualify for benefits? benefit amount will be Form W-2 taxable income. In You'll start receiving disability payments if you satisfy these situations, FICA tax deductions may reduce the the Elimination Period (see "When benefits begin" in amount we will pay you. the table) and meet the policy's definition of disability. Generally, disability is defined as your inability to perform some or all of your job duties due to your injury, illness or pregnancy and may require that you have also had a certain percentage of earnings loss due to your disability. Please see your Certificate for details. What if I have a pre-existing condition? If you become disabled within 12 months of your insurance taking effect or 12 months following any increase in your amount of insurance, we will not pay any benefit for any pre-existing condition. A pre- existing condition includes anything you have sought treatment for in the 3 months prior to your insurance becoming effective. Treatment can include consultation, advice, care, services or a prescription for drugs or medicine. Can I work while I'm disabled? Your plan is designed to encourage and support your return to work. If you are able to work part-time, for example, you may receive part of your benefit while working. Will income from other sources affect my benefit? Your benefit may be reduced by Social Security benefits; disability benefits from retirement, government plans or state disability income such as California SDI; state paid family and medical leaves; The group disability insurance policies described in this advertisement provide disability income insurance only. 1. Realitycheckup.org, Council for Disability Awareness,2018 2."Living Paycheck to Paycheck is a Way of Life for Majority of U.S.Workers,"CareerBuilder.com,Aug.2017. Read the Important information section for more details including limitations and exclusions. GSW-W-24-01 :•• Long-Term Disability Insurance 1h W HELPS YOU KEEP YOUR LIFE ON TRACK. If you're unable to work because of a covered disability, Long-Term Disability insurances replaces a portion of your income. After your claim is approved, you will receive a monthly check for your benefits that helps you pay everyday expenses like your mortgage or rent, COMMON childcare and groceries. CAUSES OF W HELPS YOU RETURN TO WORK. DISABILITY If you are able, Sun Life has benefits and services, including guidance from vocational rehabilitation counselors, to help you return to work. Musculoskeletal conditions PART OF YOUR BENEFIT PACKAGE. Circulatory This benefit is completely paid for by your employer. O conditions O Cancer BENEFITS ONervous system Monthly You will receive a check for your benefits on a monthly disorders benefit after basis. It will replace 60% of your Total Monthly Earnings, up your claim is to $7,000 each month. OInjuries approved When benefits Benefits begin as soon as 180 days from the date of your begin disability. Benefits may Up to your Social Security Normal Retirement Age or be paid for longer, depending on your age at disability. Additional plan This plan provides a benefit for covered disabilities resulting information from illness or injury that occur on or off the job. - LONG-TERM DISABILITY FAST FACTS 34.6 months You may receive additional benefits if your covered disability The length of the average begins with a hospital stay of long-term disability claim.' 14 days or more. Sun Life Assurance Company of Canada SQ8W-W2ai&A108:21:27 :00 Frequently -d questions How do I file a Long-Term Disability claim? earnings. For more information, contact your benefits If you become disabled after the effective date of administrator. coverage, check with your employer to make sure you How is my benefit taxed? are eligible for benefits. You can file a claim with us by If you or your employer pays for all or part of the cost downloading forms from our website. We'll ask you of coverage on a pre-tax basis, all or part of your and your doctor to provide information about your benefit amount will be Form W-2 taxable income. In medical condition and your expected recovery. these situations, FICA tax deductions may reduce the How do I qualify for benefits? amount we will pay you. You'll start receiving disability payments if you satisfy the Elimination Period (see "When benefits begin" in the table) and meet the policy's definition of disability. Generally, disability is defined as your inability to perform some or all of your job duties due to your injury, illness or pregnancy and may require that you have also had a certain percentage of earnings loss due to your disability. Please see your Certificate for details. What if I have a pre-existing condition? If you become disabled within 12 months of your insurance taking effect or 12 months following any increase in your amount of insurance, we will not pay any benefit for any pre-existing condition. A pre- existing condition includes anything you have sought treatment for in the 6 months prior to your insurance becoming effective. Treatment can include consultation, advice, care, services or a prescription for drugs or medicine. Can I work while I'm disabled? Your plan is designed to encourage and support your return to work. If you are able to work part-time, for example, you may receive part of your benefit while working. Will income from other sources affect my benefit? Your benefit may be reduced by Social Security benefits; disability benefits from retirement, government plans or state disability income; other group disability plans; no-fault benefits, salary continuance or sick leave; and return-to-work The group disability insurance policies described in this advertisement provide disability income insurance only. 1."Chances of disability,"Council for Disability Awareness,disabilitycanhappen.org, last accessed April 2019. Read the Important information section for more details including limitations and exclusions. GSW-W-24-01 :00 Accident Insurance A 111bbbow AA HELPS YOUR FINANCES AFTER A MISHAP. When you, your spouse' or child has a covered accident, like a fall from a bicycle that requires medical attention, you can receive cash benefits to help cover the unexpected costs. HELPS COVER RELATED EXPENSES. While health plans may cover direct costs associated with an accident, you can use accident benefits to help cover related expenses like lost income, child care, deductibles and co-pays. You can purchase this coverage for you and PAYS CASH BENEFITS DIRECTLY TO YOU. your family. Child Accident Insurance can be used however you want, and it pays in coverage is available addition to any other coverage you may already have. Benefits to age 26. are payable directly to you. And get this — there are no health questions or pre-existing conditions limitations. What's more, all family members on your plan are eligible for a wellness-screening benefit, also paid directly to you once each year per covered person. ACCIDENT FAST FACTS Falls are the leading cause of This coverage pays injuries treated in benefits for accidents that emergency rooms every occur off the job. year,for people of all ages.z Sun Life Assurance Company of Canada 166202( c8Wc0V10,Q4DLft1 08:21:17 I :00 covered Once your coverage goes into effect, you can file a claim for covered accidents that occur after your insurance plan"s effective date. Unless otherwise specified, benefits are payable only once for each covered accident, as applicable. The full list of benefits is listed here. Choose the plan that best meets your needs and your budget. LOW PLAN GH PLAN DISLOCATIONS OPEN CLOSED OPEN CLOSE (SURGERY) (NO SURGERY) (SURGERY) (NO SURGER Hip $2,000 $1,000 $4,000 $2,000 Knee,ankle,or bones of the foot $1,000 $500 $2,000 $1,000 Elbow,wrist or Lower jaw $400 $200 $800 $400 Shoulder $500 $250 $1,000 $500 Collarbone or bones of the hand $800 $400 $1,600 $800 Finger(s)or toe(s) $100 $50 $200 $100 FRACTURES OPEN CLOSED OPEN CLOSED (SURGERY) (NO SURGERY) (SURGERY) (NO SURGERY) Hip or thigh $2,000 $1,000 $4,000 $2,000 Skull-depressed $3,000 $1,500 $6,000 $3,000 Skull-simple $1,500 $750 $3,000 $1,500 Vertebral processes, Bones of the face or Nose $350 $175 $700 $350 Leg $1,000 $500 $2,000 $1,000 Vertebrae,Sternum or Pelvis $800 $400 $1,600 $800 Upperjaw or upper arm $375 $190 $750 $375 Lowerjaw,Collarbone,Shoulder, Forearm, Hand,Wrist,Foot,Ankle, $325 $170 $650 $325 Kneecap, Elbow or Heel Rib, Finger,Toe or Coccyx $175 $90 $350 $175 Multiple ribs $500 $250 $1,000 $500 ADDITIONAL Eye Injury-surgical repair $125 $250 Eye Injury-object remove $125 $250 Gunshot wound $250 $500 Paralysis-paraplegia $12,500 $25,000 Paralysis-quadriplegia $25,000 $50,000 Coma $5,000 $10,000 Concussion $50 $100 BURNS 20-40 square centimeters $200 $500 $400 $1,000 41-65 square centimeters $400 $1,000 $800 $2,000 66-160 square centimeters $600 $3,000 $1,200 $6,000 161-225 square centimeters $800 $7,000 $1,600 $14,000 More than 225 square centimeters $1,000 $10,000 $2,000 $20,000 Skin graft 50%of the applicable Burn 50%of the applicable Burn Benefit Benefit LACERATIONS No sutures and treated by doctor $20 $35 Single laceration under 5 cm with sutures $35 $65 5-15 cm with sutures(total of all lacerations) $125 $250 Greater than 15 cm with sutures(total of all lacerations) $250 $500 GSW-W-24-01 R :•• MEDICAL SERVICES Diagnostic Exam -Arteriogram,Angiogram,CT, CAT,EKG, EEG,or MRI(1 $100 $200 time per benefit year) Diagnostic Exam -X-ray(1 time per covered accident) $25 $30 Accident Emergency Treatment,non-emergency room(once per $25 $50 covered accident) Physician's Follow-up Treatment office visit(per visit,up to 6 times per $25 $25 covered accident) Physical Therapy(per visit up to 10 visits per covered accident) $25 $25 Medical Devices $100 $125 Epidural Pain Management(up to 2 times per covered accident) $25 $50 Prescription drug $15 $25 Prosthesis(one) $250 $500 Prosthesis(two) $500 $1,000 Blood, Plasma,or Platelet Transfusion $100 $200 HOSPITAL Hospital Admission (once per benefit year) $500 $1,000 Hospital Confinement(per day up to 365 days per covered accident) $150 $250 Intensive Care Unit Admission(once per Benefit Year;payable instead of $750 $1,500 Hospital Admission benefit if Confined immediately to ICU) Intensive Care Unit Confinement(per day up to 14 days,payable in $300 $500 addition to any Hospital Confinement benefit) Ambulance(Ground) $100 $200 Ambulance(Air) $750 $1,500 Emergency Room Admission $100 $150 Family Lodging(per day up to 30 days per benefit year) $50 $100 Transportation(100 or more miles up to 3 times per covered accident) $250 $500 Rehabilitation Unit(per day up to 30 days per covered accident) $50 $100 SURGERY Miscellaneous Surgery requiring general anesthesia(not covered by any $150 $300 other benefit) Open Surgery $625 $1,250 Exploratory Surgery or Debridement $125 $250 Tendon/Ligament/Rotator Cuff Tear $300 $625 Torn Knee Cartilage $300 $625 Ruptured/Herniated Disc $300 $625 EMERGENCYDENTAL Emergency Dental extraction $30 $65 Emergency Dental crown $100 $200 WELLNESS A Wellness Screening Benefit $50 $50 (once per benefit year) LIFE • DISMEMBERMENT LOSSES* LOW PLAN Accidental Death $15,000 $25,000 Accidental Death Common Carrier(pays an additional benefit if accidental death occurs while traveling as a fare- $30,000 $100,000 paying passenger on a public conveyance) Catastrophic Loss: Both arms or both hands,both legs or both feet,one hand and one foot or one arm and one leg, $7,500 $15,000 or irrecoverable loss of sight of both eyes Loss of one hand,foot,leg,or arm $3,750 $7,500 Loss of sight of one eye or loss of one eye $3,750 $7,500 Two or more fingers or toes $750 $1,500 One finger or one toe 1 $375 $750 GSW-W-24-01 iPUC Staff PR :•• Sun Life One Sun Life Executive Park, Wellesley Hills, MA 02481 .. k- Sun Life Group Enrollment Form ❑ Sun Life Assurance Company of Canada One Sun Life Executive Park Wellesley Hills, MA 02481 Employer use (check one): ❑ New employee ❑ Change ❑ COBRA I1. General Information Employer Name Account/ Policy Number Location NW Natural Water Company LLC 932178 12. Employee Information Employee's Full Legal Name(First,M.I.,Last) ❑ Male Date of Birth ❑ Female Street Address City State Zip Code Occupation Eligibility Class(if applicable) Social Security Number Phone Number Date employed: ❑ Full-Time Date: ❑ Return from layoff Date: ❑ Part-Time Date: ❑ Rehire Current Active Employment Type Earnings $ #of hours ❑ Full-Time ❑ Part-Time ❑ Hourly ❑ Weekly ❑ Monthly ❑ Annually ❑ Other: 3. Dependent Information Please complete this entire section if you are selecting dependent coverage. No employee can be insured as a dependent when he/she is also insured as an employee for any benefit under the same policy. If more space is needed,please add additional pages. Relationship Full legal name(First,M.I.,Last) Gender Social Security Date of birth Student number Y/N Spouse Children 14. Benefit Elections You need to complete all sections of the enrollment form including electing or refusing insurance coverage below and sign it.This must be done either during the enrollment period or within 31 days of your eligibility date.Benefits completely paid by your employer ("non-contributory benefits")cannot be refused.Not all of the benefit options listed below will be necessarily available to you.Your employer will tell you which benefits are available and what your Maximum Guaranteed Issue amount is. Elect Refuse Coverage ❑ ❑ Vision: ❑ Buy Up ❑ Employee ❑ Employee+ Spouse GSW-W-24-01 ❑ Employee+ Child(ren) ❑ Employee+ Family IPUC Staff PR 17 Attachment 3 GVMPEM-5627(Rev 4/20) 14. Benefit Elections(continued) Elect Refuse Coverage ❑ ❑ Dependent Basic Life $ ❑ ❑ Employee Voluntary Life and Accidental Death&Dismemberment(AD&D) $ ❑ ❑ Spouse Voluntary Life $ ❑ ❑ Child Voluntary Life $ ❑ ❑ Accident: ❑ Low/Off Job ❑ High/Off job ❑ Employee ❑ Employee+Spouse ❑ Employee+Child(ren) ❑ Employee+ Family Employer provided benefits--Your employer pays the premiums for the Core Vision, Basic Life,Short-Term,and Long-Term Disability. You are able to elect the buy up dental plan by checking the applicable box above,in which you are responsible for the additional cost(see rate grid). ❑ Employee Dental ❑ Employee Vision ❑ Employee+Spouse Dental ❑ Employee+Spouse Vision ❑ Employee+Child(ren)Dental ❑ Employee+Child(ren)Vision ❑ Employee+Family Dental ❑ Employee+Family Vision Q Employee Basic Life and Accidental Death&Dismemberment Q Short-Term Disability(STD) (AD&D) Q Long-Term Disability(LTD) Were you covered under another dental plan within the last 31 days?...................................................... ❑ Yes ❑ No If"Yes,"provide the termination date: Reason for termination of coverage? 15. Beneficiary Designation Information Primary Beneficiary Designation On the lines below,list the individual(s)who should receive proceeds in the event of your death.You may specify as many individuals as you like,but the total proceeds must equal 100%.This is your primary beneficiary.Attach additional pages if necessary. If you do not name a beneficiary or if no beneficiary is alive at the time of your death,proceeds will be payable in accordance with your Group insurance policy.Designation applies to all coverages for which a beneficiary designation is required. Primary Beneficiary(ies) Percent share of proceeds* 1 Name(First,M.I.,Last) Relationship to employee Social Security number Address Phone number Date of birth 2 Name(First,M.I.,Last) Relationship to employee Social Security number Address Phone number Date of birth *Must equal 100% GSW-W-24-01 IPUC Staff PR 17 Attachment 3 Page dA of Ad GVMPEM-5627(Rev 4/20) Secondary Beneficiary Designation On the lines below,list the individual(s)who should receive the proceeds ONLY IF ALL of the individuals listed above are not living at the time of your death.This is your secondary(or contingent)beneficiary.The Secondary beneficiary is not paid if a primary beneficiary is alive at the time of your death.Attach additional pages if necessary. Secondary Beneficiary(ies) Percent share of proceeds* 1 Name(First,M.I.,Last) Relationship to employee Social Security number Address Phone number Date of birth 2 Name(First,M.I.,Last) Relationship to employee Social Security number Address Phone number Date of birth *Must equal 100% 16. Signature and authorization information I understand that: • 1 am requesting coverage under a Group Insurance policy offered by my employer. This coverage will end when my employment terminates,subject to any portability or continuation provisions available under the Group Insurance policy. • My employer will deduct all or part of the premium for contributory coverage from my pay. • If applying for coverage more than 31 days past my eligibility date, Evidence of Insurability may be required. • For Life,Short-Term Disability,and Long-Term Disability insurance,Evidence of Insurability may be required for amounts over my Guarantee Issue for this enrollment. • Increases to current Life benefits may require Evidence of Insurability. • If I decline coverage for myself or,if applicable,for my family now and want it at a later date, I/we will have to submit an Evidence of Insurability application, if required for the elected coverage(s),to be approved by Sun Life Assurance Company of Canada(Wellesley,MA). For Dental coverage, I understand that I will not be entitled to benefits until the expiration of any Late Entrant benefit waiting period specified in the certificate of insurance. • For Dental Insurance plans, I have the right to select any dental care provider of my choice. • The dental plan includes a pre-determination provision that will advise me in advance of the benefits I may be eligible for if the procedure is performed. • Coverages include benefit waiting periods, limitations,exclusions and a pre-existing conditions provision that may affect my entitlement to benefits. • If I am not actively at work due to injury, illness, layoff or leave of absence on the date that any initial or increased coverage is scheduled to start under the plan,such coverage will not start until the date I return to work. • When required by the coverage, if my spouse or any of my dependent children are confined due to an injury or illness,as required by the coverage,on the date that any initial or increased coverage is scheduled to start under the plan,such coverage will not start until the date they are no longer confined and are able to perform their normal activities. By signing below,I am representing that the information I have provided is true and correct to the best of my knowledge and belief. X Employee Signature Today's Date To the Employee:Make a copy of this form for your records before submitting it to your employer. To the Employer:This original enrollment form should remain at the employer's site.Family status,coverage,or beneficiary changes should be recorded on another copy of the Enrollment Form. GSW-W-24-01 IPUC Staff PR 17 Attachment 3 Puae 50 of Ad GVMPEM-5627(Rev 4/20) PAYCHOU Payroll I Benefits I HR I Insurance The Power of Simplicity IPUC Staff PR 17 NW Natural Water of Idaho Employee Open Enrollment Guide Plan Year: 2022 — 2023 r Li PAYCHEX"' Payroll I Benefits I HIR I Insurance The Power of Simplicity UNW-W-24-01 UC Staff PR 17 Attachment 3 M Page 52 of 94 2022 — 2023 Benefits Enrollment Guide NW Natural Water of Idaho recognizes the importance of being able to provide our employees and their families with quality benefits as part of their overall compensation package. Therefore, NW Natural Water of Idaho, has developed a comprehensive benefits package that delivers quality and value while satisfying the diverse needs of our workforce. This summary highlights the benefit options offered by NW Natural Water of Idaho for the 2022—2023 benefit year. MOpen Enrollment For newly hired employees or for those who become newly eligible during the plan year, you must enroll no later than 30 days after your eligibility date or the date of your change in eligibility status. All other eligible employees must enroll during open enrollment, which this year is from 07/01/2022 — 07/31/2022. al Eligibility If you are an employee working at least 30 hours a week, you are eligible for the benefits outlined in this guide. Eligible employees may elect to cover their spouse or children to age 26. Benefits are effective on the first of the month following your Full Time Date of Hire. Qualifying Event Employee contributions for medical, dental, and vision benefits are payroll deducted on a pre-tax basis under IRC Section 12S. Outside of open enrollment you are not permitted to make changes to your benefit elections unless you experience a qualifying event defined as: marriage, divorce or legal separation, birth or adoption of a child, a change in your or your spouse's employment or insurance status, a dependent ceasing to meet eligibility requirements, or a change in residence that affects coverage. If you experience a qualifying event, HR must notify the insurance company within 30 days of the qualifying event or you will not be able to make changes to your current election until the next open enrollment period. Please contact HR as soon as possible upon a qualifying event. MYCHOU Payroll I Benefits I HR I Insurance Please Note:This is a brief summary, actual policy provisions govern all benefits and costs. The Power of Simplicity GSW-W-24-01 IPUC Staff PR 17 Attachment 3 Page 53 of 94 BalanceCare ° Member Guide b BalanceCare is a comprehensive, time-saving resource paid for by your employer that will help you better understand and maximize your healthcare benefits. Our wide-ranging health advocacy services help manage and resolve benefit plan questions for you and your family at no cost to you. Services Our licensed Care Guides are available to provide How does BalanceCare work? benefit information and assistance navigating When you need help with a benefit plan issue, your health plan. Care Guides provide healthcare simply call BalanceCare at 1.877.598.8617. claims and appeals management, healthcare billing You will have immediate access to your own assistance, prescription information and costs, as benefit Care Guide. well as provider research. Who is eligible? BalanceCare can assist with services such as: BalanceCare is available to you and your eligible family members including spouses, parents, and • Claims Assistance dependent children. Call us if you have any • Benefit Coverage Verification questions concerning membership eligibility. • ID Cards • Prescription Drug Coverage Questions When is BalanceCare available? • Appeals You and your eligible family members have • HSA Questions immediate access to confidential support, • Health Benefit Education twenty-four hours a day, seven days a week. • Provider Research Is my privacy protected? Contact BalanceCare at Yes - with absolute confidentiality. BalanceCare follows government laws to ensure 1.877.598.8617 that your medical and personal information is protected.Your employer does not have access to your confidential information. GSW-W-24-01 chment3— age 54 of 94 BalanceCare • • - • • - • byeni C >se yyr 1• tee;, �� dK WO oat a•• •o�� � al�rd - � .� 3iACi+�� . r� l7ri� , IV � .Y t •AW .�..; Moo . EMPLOYEE ASSISTANCE PROGRAM Get help and support with life's challenges How well we deal with life's challenges is a key component to healthy living. That's why your employer and Regence offer you an Employee Assistance Program (EAP). Designed to provide support and assistance for a wide variety of issues, the EAP can help you and your family stay healthy. The EAP is available at no extra cost to you as an employee and to anyone living in your household or dependent on your income. The EAP offers access to many services at no cost to you and discounts on others: Confidential counseling: Up to four counseling sessions (face-to-face, on the phone or video chat) for issues relating to relationships, anxiety, work stress and other common challenges. 24-hour crisis help: Toll-free access during a crisis situation. Online consultations: Convenient access to online consultations with licensed counselors. Tess,Al chatbot: 24/7 chatbot for emotional support and check-ins to boost wellness. Peer support groups: Online support groups for addiction, depression, bipolar, parenting and anxiety. Regence GSW_W_24_03 IPUC Staff PR 17 Attachment 3 Page 55 of 94 Work/life services Identity theft recovery: Support in restoring your Online legal forms: Resources to help you create, identity and credit after an incident. save, print and revise online legal forms including wills, contracts, leases and many more. Legal help: A half-hour consultation at no additional cost to you, followed by a 25% discount on legal fees. Child care: Support and help locating local resources (Legal services are not provided for any employer- for parenting, school, adoption, college planning, related issues.) teenager challenges, summer camps, day care and other important issues for parents. Mediation: Consultations for personal, family, and non-work related issues, such as divorce, plus 25% Adult and elder care: Specialists to help find off professional mediator services. information on transportation, meals, exercise programs, activities, in-home care, daytime care, Financial help: Thirty consecutive days of phone housing and more. consultations for debt counseling, budgeting, college/ retirement planning and taxes at no additional cost, Personal Advantage: A life balance website that including 25% off certified public accountant services offers interactive resources for solving and for tax preparation. preventing a range of personal problems. The EAP includes access to online tools and resources To find out more about like webinars, monthly newsletters, assessments, self- your EAP, schedule a directed courses, stress tools and healthy recipes. counseling appointment, To access online resources, go to com or get a referral for services uprisehealth.com/members,then enter your call 1 (866) 750-1327 access code: REGSGEAP. or go to uprisehealth.Com/ Once you're signed in you can: members. • View your benefits • Go to Personal Advantage • Request counseling or other services Mobile ready Information and resources • are always at your fingertips. EAP services are delivered by Uprise Health,formerly Reliant Behavioral Health (RBH), an IBH Company. V Is an Independent BlueShield of Idaho 0 2021 Regence Blu Regence is an Independent Licensee of the Blue Cross ©2021 Regence BlueShield of Idaho and Blue Shield Association 1211 West Myrtle Street,Suite 200 1 Boise,ID 83702 Uprise Health is a separate company that provides employee and beneficiary assistance programs for Regence members. Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race,color,national origin, age,disability,or sex.ATENCION:si habla espanol,tiene a su disposicion servicios gratuitos de asistencia l06M7,N82#Iifie al 1-888-344-6347(TTY:711).; :�AM ''(tjfl V,N rp3z,2�7v),9E RATM q 4SWN °13 staff�PR,4 @&Rxinait-311). Page 56 of 94 NW Natural Water of Idaho 2022 - 2023 Medical Pricing Guide (26 PP) Platinum 500 Employee Contribution Per Monthly Premium$ Employer Monthly Contribution% Pay Period (Employee Annual Number of Pay Premium+#of Pay InsuranceType Coverage Level Total Single Single Dependent periods per Year. Periods) Platinum 500 Employee Only $ 752.57 $ 752-57 so 00% 0-00% 26 $ 69.47 Platinum 500 Employee+Spouse $ 1,505.14 $ 762.57 80.00% 80 00% 26 $ 138.94 Platinum 500 Employee+Child(ren) $ 1,429.88 $ 752.57 80.00% 80 00% 26 $ 131.99 Platinum 500 Employee+Family $ 2,182-45 $ 752.57 80 00% so 00% 26 $ 201.46 Gold 500 Employee Contribution Per Monthly Premium$ Employer Monthly Contribution% Pay Period (Employee Annual Number of Pay Premium-#of Pay Insurance Type Coverage Level Total Single Single Dependent periods Per Year. Periods) Gold 500 Employee Only $ 665.62 $ 665-62 80 00% 0-00% 26 $ 61.44 Gold 500 Employee+Spouse $ 1,33124 $ 665-62 80 00% 80 00% 26 $ 122.88 Gold 500 Employee+Child(ren) $ 1,264-68 $ 665-62 80 00% 80 00% 26 $ 116.74 Gold 500 Employee+Family $ 1,930.30 $ 665.62 80.00% 80 00% 26 $ 178.18 Gold 1500 Employee Contribution Per Monthly Premium$ Employer Monthly Contribution% Pay Period (Employee Annual Number of Pay Premium+#of Pay Insurance T Coverage Level Total Single Single Dependent periods Per Year Periods) Gold 1500 Employee Only $ 609.70 $ 609.70 80 00% 0.00% 26 $ 56.28 Gold 1500 Employee+Spouse $ 1,218-94 $ 609-70 80 00% 80 00% 26 $ 112.52 Gold 1500 Employee+Child(ren) $ 1,157.99 $ 609-70 80.00% 80.00% 26 $ 106.89 Gold 1500 Employee+Family $ 1,767.46 $ 609.70 80.00% 80.00% 26 $ 163.15 PAYCHOU HR ( Payroll I Benefits I Insurance The Power of Simplicity GSW-W-24-01 IPUC Staff PR 17 Attachment 3 Page 57 of 94 Regence Regence BlueShield of Idaho, Inc. Mail form to: PO Box 1106 Lewiston, ID 83501 Req�,R.,oShidd of dnhn is,, n rpPnc1Mt Fax to: 1-866-303-5117 bwn5cc�f Eu,Q .vonjBloQ V,Q10.A4w:iatiQn Email to: Regence_Membership@regence.com Coversheet for Idaho Enrollment Application (for groups 2-50) Please print in black ink. Incomplete or illegible information may result in delayed coverage. If an item is not applicable, write "N/A." GROUP ADMINISTRATOR: This section should be completed by the Group Administrator. Group Number Subgroup Class Group Name Applicant's Last Name First Name Middle Initial Eligibility Waiting Period Start Date SECTIONDOMESTIC Skip this section if you are not enrolling a domestic partner. If you selected"Other"for Marital Status on the Idaho Universal Group Application and indicated domestic partnership, has it been registered by a U.S. or comparable governmental entity? ❑ Yes ❑ No—If no, you must submit an Affidavit of Qualifying Domestic Partnership. SECTIONSELECTION Refer to your Group Administrator for plan options available to you. Dental Medical ❑ Dental Select your metal level: ❑ Platinum ❑ Gold ❑ Silver ❑ Bronze ❑ No Medical Select your network: ❑ Preferred ❑ Regence Accord ❑ St. Luke's Health Partners ❑ No Dental Enter your deductible amount: $ HSA(health savings account) health plans only: If your employer has partnered with HealthEquity for your HSA bank account, it will be created for you automatically. No further action is required from you; however, you have the following alternative options: ❑ Send my claims data to HealthEquity. I have read and agreed to the HSA Authorization Form. ❑ No, I don't want a HealthEquity HSA. SECTION • : ENROLLMENT You or your dependents may be entitled to COBRA due to loss of current coverage.Skip this section if you are not electing COBRA. Reasons for entitlement include loss of coverage due to:Termination of employment;Enrolled child no longer eligible; Medicare entitlement; Reduction of hours; Divorce or termination of Domestic Partnership; Death. ❑ COBRA Enrollment: Reason for Entitlement: Date of Event: FORM 52751D Page 1 of 1 (Eff.1/2022)v3 Regence BlueShield of Idaho: 1602 215t Avenue, Lewiston, Idaho 83501 GSW-W-24-01 IPUC Staff PR 17 Attachment 3 110122EERLXS 1�1111111111111E111El 11�1111111111E11111111III111111�1111E11111E1111111�1 *F9W5V160 N01220101 • TO BE COMPLETED BY GROUP ADMINISTRATOR 0 10 • - • Group Number Effective Date Subgroup Class IDAHO UNIVERSAL GROUP APPLICATION FOR ENROLLMENT OUTSIDE OF THE IDAHO EXCHANGE Please type or print legibly in black ink and complete all applicable sections. • EMPLOYER/EMPLOYMENT INFORMATION 1. Name of Employer 2. Phone Number(include area code) 3. Address 4. City 5. State 6. Zip Code 7. Occupation 8. Hours Worked per Week 9. Original Date of Hire 10. Fulltime Date of Hire (mm/dd/yyyy) (mm/dd/yyyy) • APPLICANT INFORMATION (Employee) 1. Legal First Name, Middle Name, Last Name (and suffix, if applicable) 2. Mailing Address (Street, Route, P.O. Box) 3. City 4. State 5. Zip Code 6. County 7. Preferred Daytime Phone Number 8. Email Address 9. Date of Birth (mm/dd/yyyy) (include area code) 10. Gender 11. Social Security Number 12. Marital Status 13. Type of Enrollment-Please contact your group ❑ Male (required) ❑ Single administrator for plans available to you. ❑ Female ❑ Married ❑ Health ❑ Dental ❑ Vision ❑ Other ❑ Waive Coverage—see section 3 If you wish to waive coverage for you and/or any dependents at this time,please complete Section 3— Waiver of Coverage.If you wish to enroll yourself and/or your dependents,please complete all sections except Section 3. • WAIVER OF COVERAGE (To be completed only if coverage is declined or refused by an eligible employee or dependents.) 1. I decline coverage for: Self(name) Dependent(name) Spouse(name) Dependent(name) Dependent(name) Dependent(name) 2. Reason for declining coverage (check all that apply): ❑ I and/or my dependents currently have other qualifying medical coverage with (name of carrier) through: ❑ My other employer ❑ My spouse's employer ❑ Individual policy ❑ Medicare ❑ Medicaid ❑ Tricare ❑ Indian Health Services OR ❑ Other reason for declining coverage(please explain): SIGNATURE TO WAIVE" I have decided to waive coverage as indicated above. I have been given the opportunity to apply for group coverage by the employer. Should I decide to apply for this coverage in the future, I realize and agree any coverage may be subject to additional probationary waiting periods. "Signature Date (sign only if waiving coverage) mm/dd/yyyy Notice of enrollment rights: If you are declining enrollment for you or your dependents(including your spouse)because of other health insurance coverage,you may in the future be able to enroll yourself or your dependents in this plan,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 dependents, provided that you request enrollment within 60 days after the marriage,birth,adoption or placement for adoption. GSW-W-24-01 • ' • • Electronic System ID IPUC Staff PR 17 Attachment 3 ID GRP APP 01-19 Page 19 of 94 ENROLLMENT INFORMATION (check all that apply) 1. Are you:❑ A new applicant ❑ Adding dependents ❑ Enrolling during your employer's open enrollment 2. If you are enrolling outside of your employer's open enrollment or adding dependents, please mark the appropriate reason below and provide the date of the event(mm/dd/yyyy) (documentation maybe required) ❑ Marriage ❑ Divorce ❑ Birth ❑ Adoption ❑ Involuntary loss of employer coverage' ❑ Involuntary loss of individual coverage' *Provide name of carrier ❑ Involuntary loss of Medicaid ❑ Court order(copy of court order required) ❑ Other 3. Current employment status: ❑ Actively at work ❑ Retiree ❑ COBRA participant ❑ Disability ❑ Other DEPENDENT INFORMATION (List all eligible dependents you wish to enroll,including any child who is under the age of 26;or who is medically certified as disabled and dependent on parent for support(copy of certification required). If you have more dependents to include,make a copy of this page and attach.) Relationship Does Dependent (spouse,child, live at the same Social Security Date of Birth Gender Type of Dependent's N ..(first,initial,last) stepchild,etc.) address as you? Number (mm/dd/yyyy) Enrollment Dependent 1 ❑Yes ❑Male ❑Health ❑No ❑Female ❑Dental ❑Vision Dependent 2 ❑Yes ❑Male ❑Health ❑No ❑Female ❑Dental ❑Vision Dependent 3 ❑Yes ❑Male ❑Health ❑No ❑Female ❑Dental []Vision Dependent 4 ❑Yes ❑Male ❑Health ❑No ❑Female Dental ❑Vision Dependent 5 ❑yes ❑Male ❑Health ❑No ❑Female ❑Dental ❑Vision Dependent 6 ❑Yes ❑Male ❑Health ❑No ❑Female ❑Dental ❑Vision OTHER COVERAGE INFORMATION (Please complete the section below if you have other coverage that will remain in effect. If you have more policies to include,make a copy of this page and attach.) If coverage is provided for a dependent from a previous marriage or relationship,please attach a copy of the court documentation that shows who is responsible for the dependent(s)'health care insurance so that the insurance carrier can determine whose coverage is primary. Other Policy 1. Other Insurance Carrier Information: Insurance Carrier Name, Policy Number, Phone Number 2. Policy Holder Name 3. Names of Covered Members 4. Types of Coverage 5. Coverage Start Date 6. Is this coverage terminating? 7. Coverage End Date (check all that apply) mm/dd/yyyy ❑ Yes(complete#7) mm/dd/yyyy ❑ Group ❑ Medical ❑ No ❑ Individual ❑ Dental ❑ Medicare ❑ Vision GSW-W-24-01 2 • ' Electronic System ID IPUC Staff PR 17 Attachment 3 ID GRP APP 01-19 Page 60 of 94 • OTHER INFORMATION 1.Are you or any of your dependents listed on this application currently disabled? ❑ No ❑Yes Name of disabled person Physician's name and phone Date of disability Physician's address Nature of disability 2. Are you or any dependent listed on this application covered on Medicare or have received Social Security Disability or Worker's Compensation payments or are now eligible to receive such payments? ❑ No ❑ Yes If yes,give person's name,type of Coverage,and reason for entitlement: 3. Has any person listed on this application used a tobacco product on average four or more times a week within no longer than the past six months(anyone age 18 or older)? ❑No ❑Yes If yes, list names below: • AFFIRMATION affirm the answers in this"Idaho Universal Group Application"are complete and correct. I am providing these answers as part of the application procedure required by this insurance carrier to enroll in its insurance coverage. I understand that the insurance carrier will rely on each answer in making its determination to extend coverage and to determine the type of coverage offered. I understand if I have made any misstatement or omission in this application,the insurance carrier may take any action available by law, including but not limited to, retroactive adjustment of premiums or claims. Further, I understand that any fraud or intentional misrepresentation of material fact on the part of the employer is cause for retroactive termination of coverage by the insurance carrier and/or other action available by law. I will promptly inform the insurance carrier in writing if anything happens before my coverage takes effect that makes an answer on this application incomplete or incorrect. Following receipt of a fully-executed application, coverage will be in force as of the effective date determined by the insurance carrier under applicable law. • STATEMENT OF UNDERSTANDING By signing this application, I represent that all my answers are complete and accurate and that I understand and agree to the following conditions: • No independent producer, agent or employee of the insurance carrier, or of my employer, can change any part of this application or waive the requirement that I answer all questions completely and accurately. • The insurance carrier may terminate or rescind an employer's group coverage for any intentional misrepresentation omission of fact by, concerning, or on behalf of any applicant by the employer that was or would have been material to the insurance carrier's acceptance of a risk, extension of coverage, provision of benefits or payment of any claim. • As proof of status of employment, I authorize my employer to release to the insurance carrier appropriate documents, including but not limited to W-2 Wage and Tax Statements and other wage and tax summaries or forms. • Coverage for me and any eligible persons named on this application will begin on the effective date pursuant to the terms of the plan/ contract. • I agree to abide by the terms of the group's master policy/member certificate,which sets forth all of the terms and conditions of my coverage. No agent or other person can change the terms of the master contract, any of its amendments, or this application, except with an amendment issued expressly for that purpose and signed by an authorized officer of the insurance carrier. • I have reviewed all answers given on this application and, regardless of whether an independent producer or other person has filled out the answers for me, I verify that the answers are true and complete. GSW-W-24-01 3 • ' Electronic System ID IPUC Staff PR 17 Attachment 3 ID GRP APP 01-19 • 1 ACKNOWLEDGMENT acknowledge and understand my health plan may request or disclose health information about me or my dependents(persons who are eligible for benefits coverage and are listed on the enrollment form)for the purpose of facilitating health care treatment, payment or for the purpose of business operations necessary to administer health care benefits; or as required by law. Health information requested or disclosed may be related to treatment or services performed by: • A physician, dentist, pharmacist or other physical or behavioral health care practitioner; • A clinic, hospital, long-term care or other medical facility; • Any other institution providing care,treatment, consultation, pharmaceuticals or supplies or; • An insurance carrier or group health plan. Health information requested or disclosed may include, but is not limited to: claims records, correspondence, medical records, billing statements, diagnostic imaging reports, laboratory reports, dental records, or hospital records(including nursing records and progress notes). This acknowledgment does not apply to obtaining information regarding psychotherapy notes.A separate authorization will be used for psychotherapy notes. Signature of Employee Date(mm/dd/yyyy) GSW-W-24-01 4 • ' • • Electronic System ID IPUC Staff PR 17 Attachment 3 ID GRP APP 01-19 NONDISCRIMINATION NOTICE Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Regence does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Regence: Provides free aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio, and accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages If you need these services listed above, You can also file a civil rights complaint with the please contact: U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Medicare Customer Service Office for Civil Rights Complaint Portal at 1-800-541-8981 (TTY: 711) https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: Customer Service for all other plans 1-888-344-6347 (TTY: 711) U.S. Department of Health and Human Services 200 Independence Avenue SW, If you believe that Regence has failed to Room 509F HHH Building provide these services or discriminated in Washington, DC 20201 another way on the basis of race, color, national origin, age, disability, or sex, you can 1-800-368-1019, 800-537-7697 (TDD). file a grievance with our civil rights coordinator below: Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Medicare Customer Service Civil Rights Coordinator MS: B32AG, PO Box 1827 Medford, OR 97501 1-866-749-0355, (TTY: 711) Fax: 1-888-309-8784 medicareappeals@regence.com Customer Service for all other plans Civil Rights Coordinator MS CS B32B, P.O. Box 1271 Portland, OR 97207-1271 1-888-344-6347, (TTY: 711) CS@regence.com GSW-W-24-01 01012017.04PF12LNoticeNDMARegence IPUC Staff PR 17 Attachment 3 Page 63 of 94 Language assistance ATENCION: si habla espafiol, tiene a su disposicion servicios gratuitos de asistencia lingiiistica. Llame al 1-888-344-6347 (TTY: 711). P1--n1m=n nU'U*S� ITH F9� �1 S;JhJ 1-888-344- _ 6347 (TTY: 711)1 Ea RMRA"o 'aR w 1-888-344-6347 (TTY: 711)o flefr: #37iff z?Rl�`t cr, 3T 9w f4a CHO t Neu ban not Tieng Viet, co cac dich vu ho H� 3 � 11-888-344- trg ngon ngfr mien phi danh cho ban. Goi so 1-888- 6347 (TTY: 711) '�4 311F-614I 344-6347 (TTY: 711). O , a �] Ao A ^ ACHTUNG: Wenn Sie Deutsch sprechen, stehen T L� --zc O 1 O T, 7L 1 A]���� TR� d1 o 4�� T I'll q�. 1-888- Ihnen kostenlose Sprachdienstleistungen zur 344-6347 (TTY: 711) �° �� }a}� -z�-Aj A]d Verfiigung. Rufnummer: 1-888-344-6347 (TTY: 711) Pa%1774- - 5�') ha7Ct�htrt ?+C?-90 hCq,4- PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari J47Ck+*° MR A S'OIIiP+4-HP) 4-` A [1a%h4-Aa)--ATC kang gumamit ng raga serbisyo ng tulong sa wika nang J?,ga).h. 1-888-344-6347 (pDba7+ A4*7;fa)-:- 711):: walang bayad. Tumawag sa 1-888-344-6347 (TTY: 711). YBAFA! SIKIAO BH p03MOBJIACTe yxpaiHcbKOIO MOBOIO, BH MO)KeTe 3BepHYTHCA go 6e3KOMTOBHOY BHHMAH14E: ECJIH BbI rOBOPHTe Ha pyCCKOM A316IKe, CJIY)K6H MOBHOY HigTpHMKH. Teiie4)OHYRTe 3a To BaM AOCTynHbl 6ecriJlaTHbie YCJIYFH riepeBoAa. HOmepoM 1-888-344-6347 (TeJIeTaHri: 711) 3BOHHTe 1-888-344-6347 (TeneTaHn: 711). ATTENTION : Si vous parlez franoais, des services d'aide linguistique vous sont proposes gratuitement. 711 i ' 1-888-344-6347 (fzfcar�: Appelez le 1-888-344-6347 (ATS : 711) 711 > " lR : El 2r III ;�- tL 6'A , �f ())-t-i a ATENTIE: Daca vorbiti limba romana, va stau la dispozitie servicii de asistenta lingvistica, gratuit. fJ�1, �`�`Gt - ° 1-888-344-6347 Sunati la 1-888-344-6347 (TTY: 711) (TTY:711 Z - �3 -C < tt c, L) ° MAANDO: To a waawi [Adamawa], e woodi ballooji- Dii baa ako ninizin: Dii saad bee yanilti'go Dine ma to ekkitaaki wolde caahu. Noddu 1-888-344-6347 Bizaad, saad bee aka'anida'awo'dee', t"' jiik'eh, ei (TTY: 711) na holo,koji' hodiilnih 1-888-344-6347 (TTY: 711.) FAKATOKANGA'I: Kapau `oku ke Lea- 1�15 1-888-344-6347 (TTY: 711) Fakatonga, ko e kau tokoni fakatonu lea `oku nau fai atu ha tokoni ta'etotongi, pea to ke lava `o ma'u ia. FUoglu: uinucaw m.)a')O ha'o telefonimai mai ki he fika 1-888-344-6347 (TTY: n�x�u�n�x�a�€�c�n9ci�u����,Fn€�uc3€i�, ccuuui.i�a�2�iui�u. 711) Fins 1-888-344-6347 (TTY: 711) OBAVJESTENJE: Ako govorite srpsko-hrvatski, Afaan dubbattan Oroomiffaa tiif, tajaajila gargaarsa usluge jezicke pomo6i dostupne su vam besplatno. afaanii tola ni jira. 1-888-344-6347 (TTY: 711)tiin Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa bilbilaa. ogte6enim govorom ili sluhom: 711) vy� 1-888-344-6347 (TTY: 711) ►� 1-888-344-6347 fit+�l .� li J1�s19,5 a yx]II o�l�.,011 "l,o�vls �ax]]I yS�l� - S i3l :abj�L (TTY: 01012017.04PF12LNoticeNDMARegence IPUC Staff PR 17 Attachment 3 Page 64 of 94 Regence Platinum 500 d Regence Preferred Regence BlueShield of Idaho, Inc. Regence BlueShield of Idaho is an Independent Effective January 1,2022 through December 31,2022 Licensee of the Blue Cross and Blue Shield Association Cost Share D• • Coinsurance The amount you pay after you meet your deductible 20% 50% Annual Medical Deductible The total deductible you pay per calendar year $500 Individual $3,000 Individual $1,000 Family $6,000 Family Annual Prescription Deductible The total deductible you pay per calendar year for prescription Shared with medical medications Annual Out-of-Pocket Maximum The combined total for your deductible(s),coinsurance and $4,000 Individual $10,000 Individual copays per calendar year $8,000 Family $20,000 Family Be aware that your actual costs for covered services provided by an Out-of-Network provider may exceed the Out-of-Pocket Maximum amount. In addition, Out-of-Network providers can bill you for the difference between the amount charged and our Allowed Amount and that amount does not count toward any Out-of-Pocket Maximum. Medical Benefits (unless stated otherwise,a deductible applies) • Primary Care Visits(for Illness or Injury) $20 copay per visit, 50% deductible waived Specialist Visits $30 copay per visit, 50% deductible waived Urgent Care Visits $30 copay per visit, 50% deductible waived Other Professional Services 20% 50% Preventive Care/Immunizations Covered in full 50% Preventive Care-Expanded Immunizations that do not meet age limits and frequency 20% 50% Immunizations guidelines according to,and as recommended by,the USPSTF, HRSA or by the CDC are covered. Radiology and Laboratory-Inpatient Mammography,prenatal testing,including radiology and lab for 20% 50% maternity,DNA probes of infections agents and genetic testing services Radiology and Laboratory-Outpatient Mammography,prenatal testing,including radiology and lab for 20%,deductible waived 50% maternity,laboratory work associated with initial evaluation of infertility and diagnostic laparoscopy,DNA probes of infections agents and genetic testing services Excludes treatment for infertility,including reversal of sterilization Complex Imaging-Outpatient CT/PET/SPECT scans,MRIs,MRAs,etc. 20% 50% Acupuncture 18 visits per calendar year $20 copay per visit, 50% deductible waived Ambulance Services Air and Ground:services provided to the nearest hospital equipped 20%,In-Network deductible applies to render the necessary treatment Ambulatory Surgical Center 10% 50% Blood Bank 20%,In-Network deductible applies Dental Hospitalization $5,000 per day for inpatient non-emergency admissions to 20% 50% out-of-network facilities Diabetic Education Covered in full 50% Dialysis-Initial Outpatient Treatment 120 days for hemodialysis,peritoneal dialysis and hemofiltration 20% 50% Period services GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221PLASD, 110112MMOSIDflI0422CCONINISD 110122ZPLASD Page 1 Medical Benefits (unless stated otherwise,a deductible applies) • . Dialysis-Supplemental Outpatient If our agreement with the provider expressly specifies that its Covered in full Treatment Period terms supersede the benefits(or this benefit)of your booklet,we pay 100% of the Allowed Amount. Otherwise,we pay 125% of the Medicare allowed amount at the time of service. You may be subject to pay the balance of billed charges(not applicable towards Out-of-Pocket Maximum)when seeing an Out-of-Network Provider if you are not enrolled in Medicare Part B. Durable Medical Equipment 20% 50% Emergency Room Facility&professional services $300 copay per visit,In-Network deductible applies Habilitative Services-Inpatient $5,000 per day for inpatient non-emergency admissions to 20% 50% out-of-network facilities Habilitative Services-Outpatient 20 visits per calendar year $20 copay per visit, 50% deductible waived Hearing Aids and Evaluation Limited to Member and spouse/domestic partner 20% 50% $500 per calendar year per Member for hearing aids Excludes hearing exams,assistive hearing technology systems, batteries or cords Hearing Loss Limited to dependent children up to age 26 20% 50% 1 hearing aid device per ear every 36 months 45 outpatient speech and language therapy visits within 12 months from the receipt of a hearing aid,bone conduction device or cochlear implant Home Health Care 20% 50% Hospice Care 20% 50% Hospital Care-Inpatient $5,000 per day for inpatient non-emergency admissions to 20% 50% out-of-network facilities Hospital Care-Outpatient 20% 50% Maternity Care $5,000 per day for inpatient non-emergency admissions to 20% 50% out-of-network facilities Medical Foods 20% 50% Mental Health/Substance Use Disorder- $5,000 per day for inpatient non-emergency admissions to 20% 50% Inpatient out-of-network facilities Applied Behavioral Analysis(ABA)for the treatment of autism spectrum disorders included Mental Health/Substance Use Disorder- ABA for the treatment of autism spectrum disorders included $20 copay per outpatient 50% Outpatient office/psychotherapy visit, deductible waived Newborn Care $5,000 per day for inpatient non-emergency admissions to 20% 50% out-of-network facilities Nutritional Counseling 3 visits per calendar year(diabetic counseling is subject to this 20% 50% limit) Orthotic Devices 20% 50% Palliative Care 30 visits per calendar year 20% 50% Prosthetic Devices 20% 50% Rehabilitation Services-Inpatient $5,000 per day for inpatient non-emergency admissions to 20% 50% out-of-network facilities Rehabilitation Services-Outpatient 20 visits per calendar year $20 copay per visit, 50% deductible waived GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221PLASD, 11012MM60,1110422CCONIVISD 110122ZPLASD Page 2 Medical Benefits (unless stated otherwise,a deductible applies) • . Repair of Teeth Injury to sound natural teeth 20% 50% Treatment must be provided within 12 months from the date of injury Retail Office Visits Visits to a walk-in clinic located within a retail operation $20 copay per visit, 50% deductible waived Skilled Nursing Facility 30 days per calendar year 20% 50% Spinal Manipulations 18 spinal manipulations per calendar year $20 copay per visit, 50% deductible waived Termination of Pregnancy 20% 50% Transplants Travel expenses for the patient and companion(s)are limited to 14 20% 50% days per transplant episode $5,000 per day for inpatient non-emergency admissions to Out-of-Network facilities Commercial lodging expenses are limited to$300 per night for the Member and companion(s)combined Meal expenses are limited to$80 per day per Member or per companion(s) Virtual Care-Store&Forward Asynchronous(not real-time)communications such as text or fax $10 copay per visit, 50% deductible waived Virtual Care-Telehealth Doctor visits via phone or video chat when not in a healthcare $10 copay per visit, 50% facility deductible waived Virtual Care-Telemedicine Doctor visits via phone or video chat when in a healthcare facility 20% 50% Pediatric Benefits-Dependents Under Age 19 (unless stated otherwise,a deductible applies) What You Pay Dental Care-Preventive Bitewing X-rays,Fluoride Treatment,Oral Exams-2 per calendar Covered in full year Cleanings-2 per calendar year with a 3'd covered with qualifying diagnosis Sealants-1 per permanent molar every 3 years Dental Care-Basic Emergency/Palliative Treatment-emergency pain relief, 20%,deductible waived restoration not allowed on same date of service Endodontics-such as root canal Fillings Oral Surgery-includes removal of teeth and surgical extractions Periodontal Maintenance-4 per calendar year(in lieu of preventive cleaning) Scaling and Root Planing-1 in a 2 year period per quadrant Dental Care-Major Crowns,Inlays,Onlays-1 per tooth every 7 years 50%,deductible waived Dental Implants-4 per lifetime Dentures(full or partial),Bridges(fixed partial denture)-1 every 5 years Vision Care-Exams 1 comprehensive routine eye exam per calendar year $0 copay,deductible 50%,deductible waived waived for VSP provider Vision Care-Contact Lenses Contacts may be selected once per calendar year in lieu of all $0 copay,deductible 50%,deductible waived other lens and frame benefits waived for VSP provider Evaluation and Fitting Exam-1 per year Vision Care-Frames 1 frame per calendar year $0 copay,deductible 50%,deductible waived waived for VSP provider Limited to Otis&Piper Eyewear Collection GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221PLASD, 11016$D,11t0422CCONMSD 110122ZPLASD Page 3 In-NetworkPediatric Benefits-Dependents Under Age 19 (unless stated otherwise,a deductible applies) What You Pay • Vision Care-Lenses 1 pair of glass or plastic lenses per calendar year $0 copay,deductible 50%,deductible waived Includes:Single vision,lined bifocal,lined trifocal or lenticular waived for VSP provider lenses;Polycarbonate lenses;Scratch and UV protection;Tints, photochromic Additional lens enhancements available at a discount from VSP providers Find your vision plan benefits or a VSP vision provider at regence.com or call 1 (844)299-3041 Prescription Medication Benefits (unless stated otherwise,a deductible applies) What You Pay Preferred Generic Deductible waived $8 retail prescription*/$16 mail order prescription 90-day supply for retail or mail order Generic Deductible waived $35 retail prescription*/$70 mail order prescription 90-day supply for retail or mail order Preferred Brand" Deductible waived $30 retail prescription*/$60 mail order prescription 90-day supply for retail or mail order Brand Deductible waived 50%retail prescription/45%mail order prescription 90-day supply for retail or mail order Preferred Specialty Deductible waived 20%participating pharmacy retail prescription/50% 30-day supply for retail nonparticipating pharmacy retail prescription Specialty Deductible waived 50%participating pharmacy retail prescription/50% 30-day supply for retail nonparticipating pharmacy retail prescription *1 copay per 30 day supply "Insulin Cost Share Cap:Retail:$100 cap on member cost share per 30 day supply,deductible waived,$300 cap on member cost share up to 90 day supply,deductible waived Mail:$100 cap on member cost share per 30 day supply,deductible waived;$200 cap on member cost share up to 90 day supply,deductible waived More information about prescription drug coverage is available at https://regence.com/go/20221ID16tier Other • Employee Assistance Program(EAP) 4 mental health counseling visits per issue Covered in full Not covered Frequently Asked Questions How is my privacy protected? Regence is committed to the confidentiality and security of your personal information. We maintain physical,administrative and technical safeguards to protect against unauthorized access,use,or disclosure of your personal information. You can view our full privacy practices online at regence.com. What if I need access to specialty care? You can receive care from any in-network provider without a referral. For some services,prior authorization may be required. Do I need a referral? General Exclusions Activity Therapy: The following activity therapy services are not covered:creative arts;play;dance;aroma;music;equine or other animal-assisted;recreational or similar therapy;and sensory movement groups. Adventure,Outdoor,or Wilderness Interventions and Camps: Outward Bound,outdoor youth or outdoor behavioral programs,or courses or camps that primarily utilize an outdoor or similar non-traditional setting to provide services that are primarily supportive in nature and rendered by individuals who are not Providers,are not covered,including,but not limited to interventions or camps focused on: ❑ building self-esteem or leadership skills; ❑ losing weight; ❑ managing diabetes; ❑ contending with cancer or a terminal diagnosis;or ❑ living with,controlling or overcoming: - blindness; - deafness/hardness of hearing; GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221PLASD, 11012MM60,1110422CCONMSD 110122ZPLASD Page 4 General Exclusions - a Mental Health Condition;or - a Substance Use Disorder. Services by Physicians or Practitioners in adventure,outdoor or wilderness settings may be covered if they are billed independently and would otherwise be a Covered Service in this Policy. Assisted Reproductive Technologies: Assisted reproductive technologies,regardless of underlying condition or circumstance,are not covered,including,but not limited to:cryogenic or other preservation,storage and thawing(or comparable preparation)of egg,sperm or embryo;in vitro fertilization;artificial insemination;embryo transfer;other artificial means of conception;or any associated surgery,medications,testing or supplies. Breast Reduction: Except when following a Medically Necessary mastectomy,to the extent required by law,breast reductions are not covered. For more information on breast reconstruction,see the Women's Health and Cancer Rights notice. Certain Therapy,Counseling and Training: Except as provided in the EAP Section,if applicable,the following therapies,counseling and training services are not covered:educational;vocational;social;image;self-esteem;milieu or marathon group therapy;premarital or marital counseling;and job skills or sensitivity training. Conditions Caused by Active Participation in a War or Insurrection: The treatment of any condition caused by or arising out of a Member's active participation in a war or insurrection. Conditions Incurred in or Aggravated During Performances in the Uniformed Services: The treatment of any Member's condition that the Secretary of Veterans Affairs determines to have been incurred in,or aggravated during,performance of service in the uniformed services of the United States. Cosmetic/Reconstructive Services and Supplies: Except for treatment of the following,cosmetic and/or reconstructive services and supplies are not covered: ❑ a Congenital Anomaly; ❑ to restore a physical bodily function lost as a result of Illness or Injury;or ❑ related to breast reconstruction following a Medically Necessary mastectomy,to the extent required by law. For more information on breast reconstruction,see the Women's Health and Cancer Rights notice. "Cosmetic"means services or supplies that are applied to normal structures of the body primarily to improve or change appearance. "Reconstructive"means services,procedures or surgery performed on abnormal structures of the body,caused by Congenital Anomalies,developmental abnormalities, trauma,infection,tumors or disease. It is performed to restore function,but,in the case of significant malformation,is also done to approximate a normal appearance. Counseling in the Absence of Illness: Except as required by law,counseling in the absence of Illness is not covered. Custodial Care: Except as provided in the Palliative Care benefit,non-skilled care and helping with activities of daily living is not covered. Dental Services: Except as provided in the Pediatric Dental Services or the Repair of Teeth benefits,Dental Services provided to prevent,diagnose or treat diseases or conditions of the teeth and adjacent supporting soft tissues are not covered,including treatment that restores the function of teeth. Elective Abortions:Elective abortions are not covered. "Elective abortion"means an abortion for any reason other than to preserve the life of the Member upon whom the abortion is performed. Coverage for non-elective abortions is provided in the Termination of Pregnancy benefit. Expenses Before Coverage Begins or After Coverage Ends: Services and supplies incurred before Your Effective Date under the Contract or after Your termination under the Contract. Family Counseling: Except when provided as part of the treatment for a child or adolescent with a covered diagnosis,family counseling is not covered. Fees,Taxes,Interest: Except as required by law,the following fees,taxes and interest are not covered:charges for shipping and handling,postage,interest or finance charges that a Provider might bill:excise,sales or other taxes;surcharges;tariffs;duties;assessments;or other similar charges whether made by federal,state or local government or by another entity. Government Programs:Except as required by state law(such as cases of medical emergency or coverage provided by Medicaid)or for facilities that contract with Us, benefits that are covered(or would be covered in the absence of this plan)by any federal,state or government program are not covered. Additionally,except as listed below,government facilities or government facilities outside the service area are not covered: ❑ facilities contracting with the local Blue Cross and/or Blue Shield plan;or ❑ as required by law for emergency services. Hypnotherapy and Hypnosis Services: Hypnotherapy and hypnosis services and associated expenses are not covered,including,but not limited to:treatment of painful physical conditions;Mental Health Conditions;Substance Use Disorders;or for anesthesia purposes. Illegal Activity: Services and supplies are not covered for treatment of an Illness,Injury or condition caused or sustained by a Member's voluntary participation in an activity where the Member is found guilty of an illegal activity in a criminal proceeding or is found liable for the activity in a civil proceeding. A guilty finding includes a plea of guilty or a no contest plea. If benefits already have been paid before the finding of guilt or liability is reached,We may recover the payment from the person We paid or anyone else who has benefited from it. Illegal Services,Substances and Supplies: Services,substances and supplies that are illegal as defined by state or federal law. Individualized Education Program(IEP): Services or supplies,including,but not limited to,supplementary aids and supports as provided in an IEP developed and adopted pursuant to the Individuals with Disabilities Education Act. Infertility: Except to the extent Covered Services are required to diagnose such condition,treatment of infertility is not covered,including,but not limited to:surgery, uterine transplants;fertility medications;and other medications associated with fertility treatment. Investigational Services: Except as provided in the Approved Clinical Trials benefit,Investigational services are not covered,including,but not limited to:services, supplies and accommodations provided in connection with Investigational treatments or procedures(Health Interventions);and any services or supplies provided by an Investigational protocol. Liposuction for the Treatment of Lipedema Motor Vehicle Coverage and Other Available Insurance: When motor vehicle coverage,other available insurance or contract is either issued to,or makes benefits available to a Member(whether or not the Member makes a claim with such coverage),expenses are not covered for services and supplies that are payable by any: ❑ automobile medical; ❑ personal injury protection(PIP); GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221PLASD, 110162DflI0422CC0NMSD 110122ZPLASD Page 5 General Exclusions ❑ automobile no-fault coverage(unless the automobile contract contains a coordination of benefits provision,in which case,Our Coordination of Benefits provision shall apply); ❑ underinsured or uninsured motorist coverage; ❑ homeowner's coverage; ❑ commercial premises coverage; ❑ excess coverage;or ❑ similar contract or insurance. Further,the Member is responsible for any cost-sharing required by the other insurance coverage,unless applicable state law requires otherwise. Once benefits in such contract or insurance are exhausted or considered to no longer be Injury-related by the no-fault provisions of the contract,benefits will be provided accordingly. Non-Direct Patient Care: Except as provided in the Virtual Care benefit,non-direct patient care services are not covered,including,but not limited to: ❑ appointments scheduled and not kept(missed appointments); ❑ charges for preparing or duplicating medical reports and chart notes; ❑ itemized bills or claim forms(even at Our request);and ❑ visits or consultations that are not in person(including telephone consultations and e-mail exchanges). Obesity or Weight Reduction/Control: Except as provided in the Nutritional Counseling benefit,as required by law or for reversals or revisions of surgery for obesity when required to correct a life-endangering condition,services or supplies that are intended to result in or relate to weight reduction(regardless of diagnosis or psychological conditions)are not covered,including,but not limited to: medical treatment; medications; ❑ surgical treatment(including treatment of complications,revisions and reversals);or ❑ programs. Orthognathic Surgery: Except for treatment of the following,orthognathic surgery is not covered:orthognathic surgery due to an Injury;sleep apnea(specifically, telegnathic surgery);developmental anomalies;or Congenital Anomaly. "Orthognathic surgery"means surgery to manipulate facial bones,including the jaw,in patients with facial bone abnormalities resulting from abnormal development performed to restore the proper anatomic and functional relationship of the facial bones. "Telegnathic surgery"means skeletal(maxillary,mandibular and hyoid)advancement to anatomically enlarge and physiologically stabilize the pharyngeal airway to treat obstructive sleep apnea. Over-the-Counter Contraceptives: Except as provided in the Prescription Medications Section or as required by law,over-the-counter contraceptive supplies are not covered. Personal Items: Items that are primarily for comfort,convenience,cosmetics,contentment,hygiene,environmental control,education or general physical fitness are not covered,including,but not limited to: ❑ telephones; ❑ televisions; ❑ air conditioners,air filters or humidifiers; ❑ whirlpools; ❑ heat lamps; ❑ light boxes; ❑ weightlifting equipment;and 11 therapy or service animals,including the cost of training and maintenance. Physical Exercise Programs and Equipment: Physical exercise programs or equipment are not covered(even if recommended or prescribed by Your Provider), including,but not limited to:hot tubs;or membership fees to spas,health clubs or other such facilities. Private-Duty Nursing: Private-duty nursing,including ongoing shift care in the home. Reversals of Sterilizations: Services and supplies related to reversals of sterilization. Routine Foot Care Routine Hearing Examinations Self-Help,Self-Care,Training or Instructional Programs: Except as provided in the Medical Benefits Section or for services provided without a separate charge in connection with Covered Services that train or educate a Member,self-help,non-medical self-care,and training or instructional programs are not covered,including,but not limited to: ❑ childbirth-related classes including infant care;and ❑ instructional programs that: - teach a person how to use Durable Medical Equipment; - teach a person how to care for a family member;or - provide a supportive environment focusing on the Member's long-term social needs when rendered by individuals who are not Providers. Services and Supplies Provided by a Member of Your Family: Services and supplies provided to You by a member of Your immediate family are not covered. "Immediate family"means: You and Your parents,parents'spouses or domestic partners,spouse or domestic partner,children,stepchildren,siblings and half-siblings; Your spouse's or domestic partner's parents,parents'spouses or domestic partners,siblings and half-siblings; Your child's or stepchild's spouse or domestic partner;and any other of Your relatives by blood or marriage who shares a residence with You. Services and Supplies That Are Not Medically Necessary: Services and supplies that are not Medically Necessary for the treatment of an Illness or Injury. GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221PLASD, 11012 MD,flf0422CCONMSD 110122ZPLASD Page 6 General Exclusions Services Required by an Employer or for Administrative or Qualification Purposes: Physical or mental examinations and associated services(laboratory or similar tests)required by an employer or primarily for administrative or qualification purposes are not covered. Administrative or qualification purposes include,but are not limited to: ❑ admission to or remaining in: - school;a camp;a sports team;the military;or any other institution. ❑ athletic training evaluation; ❑ legal proceedings(establishing paternity or custody); ❑ qualification for: - employment or return to work;marriage;insurance;occupational injury benefits;licensure;or certification. travel,immigration or emigration. Sexual Dysfunction: Except as provided in the Mental Health Services benefit,treatment,services and supplies(including medications)are not covered for or in connection with sexual dysfunction regardless of cause. Temporomandibular Joint(TMJ)Disorder Treatment: Services and supplies provided for TMJ disorder treatment. Third-Party Liability: Services and supplies for treatment of Illness,Injury or health condition for which a third-party is or may be responsible. Travel and Transportation Expenses: Except as provided in the Ambulance benefit or as otherwise provided in the Medical Benefits Section,travel and transportation expenses are not covered. Varicose Vein Treatment: Except for the following,treatment of varicose veins is not covered:when there is associated venous ulceration;or persistent or recurrent bleeding from ruptured veins. Vision Care: Except as provided in the Pediatric Vision Services Section,vision care services are not covered,including,but not limited to:routine eye examinations; vision hardware;visual therapy;training and eye exercises;vision orthoptics,surgical procedures to correct refractive errors/astigmatism;and reversals or revisions of surgical procedures which alter the refractive character of the eye. Wigs: Wigs or other hair replacements regardless of the reason for hair loss or absence. Work-Related Conditions: Except when a Member is exempt from state or federal workers'compensation law,expenses for services or supplies incurred as a result of any work-related Illness or Injury(even if the service or supply is not covered by workers'compensation benefits)are not covered. This includes any claims resolved as a result of a disputed claim settlement. If an Illness or Injury could be considered work-related,a Member will be required to file a claim for workers'compensation benefits before We will consider providing any coverage. Pediatric Dental Exclusions Adjustments: Adjustment of a denture or bridgework which is done within six months after insertion by the same Dentist who installed the denture or bridgework. Aesthetic Dental Procedures: Services and supplies provided in connection with dental procedures that are primarily aesthetic,including bleaching of teeth. Bone Grafts: Bone grafts done in connection with extractions,apicoectomies or non-covered/ineligible implants. Cone Beam Imaging/MR1 Procedures Cosmetic/Reconstructive Services and Supplies: Except for the following,cosmetic and/or reconstructive services and supplies are not covered:Dentally Appropriate services and supplies to treat a Congenital Anomaly;or to restore a physical bodily function lost as a result of Illness or Injury. "Cosmetic"means services or supplies that are applied to normal structures of the body primarily to improve or change appearance. "Reconstructive"means services,procedures or surgery performed on abnormal structures of the body,caused by Congenital Anomalies,developmental abnormalities, trauma,infection,tumors or disease. It is generally performed to restore function,but,in the case of significant malformation,is also done to approximate a normal appearance. Decay Prevention: Supplies and materials to prevent decay are not covered,including,but not limited to:toothpaste;fluoride gels;dental floss;and teeth whiteners. Duplicate Services: Services submitted by a Dentist which are for the same services performed on the same date for the same Member by another Dentist. Experimental or Investigational Services Fabrication of Athletic Mouth Guard Facility Expenses: Services and supplies related to facility expenses are not covered,including,but not limited to: ❑ those performed by a Dentist who is compensated by a facility for similar Covered Services performed for a Member;and costs or any additional fees that the Dentist or Hospital charges for treatment at the Hospital(inpatient or outpatient). Failure to Comply: Services and supplies resulting from Your failure to comply with professionally prescribed treatment. Gold-Foil Restorations Nitrous Oxide Oral Hygiene and Dietary Instructions Oral Sedation Orthodontic Dental Services: Except when Medically Necessary,orthodontic services and supplies are not covered,including,but not limited to: ❑ correction of malocclusion; ❑ craniomandibular orthopedic treatment; other orthodontic treatment; preventive orthodontic procedures; ❑ procedures for tooth movement,regardless of purpose;and ❑ repair of damaged orthodontic appliances. GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221PLASD, 1101TWUDfIf0422CC0NMSD 110122ZPLASD Page 7 Pediatric Dental Exclusions Plaque Control Programs Precision Attachments,Personalization,Precious Metal Bases and Other Specialized Techniques Provisional,Temporary and Duplicate Devices or Appliances Replacements: Replacement of any lost,stolen or broken dental appliance,including,but not limited to,dentures or retainers. Sealants: Except as provided for permanent molars,sealants are not covered. Separate Charges: Services and supplies that may be billed as separate charges(services that should be included in the billed procedure)are not covered,including, but not limited to: ❑ any supplies; ❑ local anesthesia;and sterilization(office infection control charges). Services and Supplies to Alter Vertical Dimension and/or Restore or Maintain the Occlusion: Services and supplies to alter vertical dimension and/or restore or maintain the occlusion are not covered,including,but not limited to: ❑ equilibration; periodontal splinting; full mouth rehabilitation;and ❑ restoration for misalignment of teeth. Services and Supplies Which the Member Would Have No Legal Obligation to Pay in the Absence of this Coverage Services and Treatment Not Prescribed By or Under the Direct Supervision of a Dentist Services Provided by Certain Entities: Services and treatment are not covered when received from a dental or medical department maintained by or on behalf of: an employer; ❑ mutual benefit association; ❑ labor union; ❑ trust; ❑ Veterans Administration Hospital;or similar person or group. Specialized Procedures and Techniques Temporomandibular Joint(TMJ)Disorder Treatment: Services and supplies provided in connection with TMJ disorder treatment. Topical Medicament Center Pediatric Vision Exclusions Certain Contact Lens Expenses artistically-painted or non-prescription contact lenses; contact lens modification,polishing or cleaning; ❑ refitting of contact lenses after the initial(90-day)fitting period; ❑ additional office visits associated with contact lens pathology;and ❑ contact lens insurance policies or service agreements. Corneal Refractive Therapy(CRT):Reversals or revisions of surgical procedures which alter the refractive character of the eye,including orthokeratology(a procedure using contact lenses to change the shape of the cornea in order to reduce myopia). Corrective Vision Treatment of an Experimental Nature Costs for Services and/or Supplies Exceeding Benefit Allowances Lens Enhancements:Except as provided in the Vision Hardware benefit,lens enhancements are not covered,including,but not limited to:anti-reflective coating;color coating;mirror coating;blended lenses;cosmetic lenses;laminated lenses;oversize lenses;or standard,premium and custom progressive multifocal lenses. Medical or Surgical Treatment of the Eyes: Medical or surgical treatment of the eyes,including reversals or revisions of surgical procedures of the eye. Orthoptics or Vision Training: Except as provided in the Low Vision benefits,orthoptics,vision training and any associated supplemental testing are not covered. Plano Lenses(Less Than a±.50 Diopter Power) Replacements:Replacement of any lost,stolen or broken lenses and/or frames. Two Pair of Glasses in Lieu of Bifocals GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221PLASD, ll012%EMD,fl10422CC0NMSD 110122ZPLASD Page 8 Prescription Medications Exclusions Biological Sera,Blood or Blood Plasma Bulk Powders: Except as included on Our Drug List and presented with a Prescription Order,bulk powders are not covered. Cosmetic Purposes: Prescription Medications used for cosmetic purposes,including,but not limited to: removal,inhibition or stimulation of hair growth;anti-aging; repair of sun-damaged skin;or reduction of redness associated with rosacea. Devices or Appliances:Except as provided in the Medical Benefits Section,devices or appliances of any type,even if they require a Prescription Order are not covered. Diagnostic Agents:Except as provided in the Medical Benefits Section,diagnostic agents used to aid in diagnosis rather than treatment are not covered. Foreign Prescription Medications:Except for the following,foreign Prescription Medications are not covered:Prescription Medications associated with an Emergency Medical Condition while You are traveling outside the United States;or Prescription Medications You purchase while residing outside the United States. These exceptions apply only to medications with an equivalent FDA-approved Prescription Medication that would be covered in this section if obtained in the United States. General Anesthetics: Except as provided in the Medical Benefits Section,general anesthetics are not covered. Medical Foods: Except as provided in the Medical Benefits Section,medical foods are not covered. Medications that are Not Considered Self-Administrable:Except as provided in the Medical Benefits Section or as specifically indicated in this Prescription Medications Section,medications that are not considered self-administrable are not covered. Nonprescription Medications:Except for the following,nonprescription medications that by law do not require a Prescription Order are not covered:medications included on Our Drug List,medications approved by the FDA,or a Prescription Order by a Physician or Practitioner. Nonprescription medications include,but are not limited to:over-the-counter medications;vitamins;minerals;food supplements;homeopathic medicines;nutritional supplements;and any medications listed as over-the-counter in standard drug references,regardless of state law prescription requirements,such as pseudoephedrine and cough syrup products. Prescription Medications Dispensed in a Facility:Prescription Medications dispensed to You while You are a patient in a Hospital,Skilled Nursing Facility,nursing home or other health care institution. Medications dispensed upon discharge should be processed by this benefit if obtained from a Pharmacy. Prescription Medications Found to be Less than Effective under Drug Efficacy Safety Implementation(DESI) Prescription Medications Not Approved by the FDA Prescription Medications Not Dispensed by a Pharmacy Pursuant to a Prescription Order Prescription Medications Not on the Drug List:Except as provided through the Drug List Exception Process,Prescription Medications that are not on the Drug List are not covered. Prescription Medications Not within a Provider's License:Prescription Medications prescribed by Providers who are not licensed to prescribe medications(or that particular medication)or who have a restricted professional practice license. Prescription Medications with Lower Cost Alternatives:Prescription Medications for which there are covered therapeutically equivalent(similar safety and efficacy) alternatives or over-the-counter(nonprescription)alternatives. Prescription Medications without Examination:Except as provided in the Virtual Care benefit,whether the Prescription Order is provided by mail,telephone,internet or some other means,Prescription Medications without a recent and relevant in-person examination by a Provider,are not covered. Additionally,this exclusion does not apply to a Provider or Pharmacist who may prescribe:an opioid antagonist to a Member who is at risk of experiencing an opiate-related overdose;or an epinephrine auto-injector to a Member who is at risk of experiencing anaphylaxis. An examination is"recent"if it occurred within 12 months of the date of the Prescription Order and is"relevant"if it involved the diagnosis,treatment or evaluation of the same or a related condition for which the Prescription Medication is being prescribed. Professional Charges for Administration of Any Medication Repackaged Medications,Institutional Packs and Clinic Packs This benefit summary provides a brief description of your plan benefits,limitations and/or exclusions under your plan and is not a guarantee of payment. Once enrolled, you can view your benefits booklet online at regence.com. PLEASE REFER TO YOUR BENEFITS BOOKLET OR SUMMARY PLAN DESCRIPTION FOR A COMPLETE LIST OF BENEFITS,THE LIMITATIONS AND/OR EXCLUSIONS THAT APPLY,AND A DEFINITION OF MEDICAL NECESSITY. Regence is providing this benefit summary for illustrative purposes only. Regence makes no warranties or representations regarding compliance with applicable federal,state,or local laws,or the accuracy of the benefit summary. This document is not the legally required Summary of Benefits and Coverage that an employer is required to provide to employees and members under Federal law,and the group must provide a legally compliant Summary of Benefits and Coverage to its employees and members. Regence BlueShield of Idaho,Inc.-Medical and Pediatric Dental 1 (888)367-2117-TTY:711 1 1211 West Myrtle Street,Suite 200,Boise,ID 83702 1 regence.com Vision Service Plan-Pediatric Vision Customer Service Provider and Benefit Inquiries 1 (844)299-3041 1 Membership Inquiries 1 (888)367-2117-TTY:711 1 PO Box 997100,Sacramento,CA 95899-7100 1 vsp.com GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221PLASD, 11012%(EMDfl10422CCONMSD 110122ZPLASD Page 9 Regence Gold 500 d Regence Preferred Regence BlueShield of Idaho, Inc. Regence BlueShield of Idaho is an Independent Effective January 1,2022 through December 31,2022 Licensee of the Blue Cross and Blue Shield Association Cost Share Details In-Network • Coinsurance The amount you pay after you meet your deductible 30% 50% Annual Medical Deductible The total deductible you pay per calendar year $500 Individual $5,000 Individual $1,000 Family $10,000 Family Annual Prescription Deductible The total deductible you pay per calendar year for prescription Shared with medical medications Annual Out-of-Pocket Maximum The combined total for your deductible(s),coinsurance and copays $7,000 Individual $10,000 Individual per calendar year $14,000 Family $20,000 Family Be aware that your actual costs for covered services provided by an Out-of-Network provider may exceed the Out-of-Pocket Maximum amount. In addition, Out-of-Network providers can bill you for the difference between the amount charged and our Allowed Amount and that amount does not count toward any Out-of-Pocket Maximum. Medical Benefits (unless stated otherwise,a deductible applies) • Primary Care Visits(for Illness or Injury) $30 copay per visit, 50% deductible waived Specialist Visits $50 copay per visit, 50% deductible waived Urgent Care Visits $50 copay per visit, 50% deductible waived Other Professional Services 30% 50% Preventive Care/Immunizations Covered in full 50% Preventive Care-Expanded Immunizations that do not meet age limits and frequency 30% 50% Immunizations guidelines according to,and as recommended by,the USPSTF, HRSA or by the CDC are covered. Radiology and Laboratory-Inpatient Mammography,prenatal testing,including radiology and lab for 30% 50% maternity,DNA probes of infections agents and genetic testing services Radiology and Laboratory-Outpatient Mammography,prenatal testing,including radiology and lab for 30% 50% maternity,laboratory work associated with initial evaluation of infertility and diagnostic laparoscopy,DNA probes of infections agents and genetic testing services Excludes treatment for infertility,including reversal of sterilization Complex Imaging-Outpatient CT/PET/SPECT scans,MRIs,MRAs,etc. 30% 50% Acupuncture 18 visits per calendar year $30 copay per visit, 50% deductible waived Ambulance Services Air and Ground:services provided to the nearest hospital equipped 30%,In-Network deductible applies to render the necessary treatment Ambulatory Surgical Center 20% 50% Blood Bank 30%,In-Network deductible applies Dental Hospitalization $5,000 per day for inpatient non-emergency admissions to 30% 50% out-of-network facilities Diabetic Education Covered in full 50% Dialysis-Initial Outpatient Treatment 120 days for hemodialysis,peritoneal dialysis and hemofiltration 30% 50% Period services GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221GLD5SD,1101 NDflI0422CC0NMSD 110122ZGLD5SD Page 1 Medical Benefits (unless stated otherwise,a deductible applies) • . Dialysis-Supplemental Outpatient If our agreement with the provider expressly specifies that its Covered in full Treatment Period terms supersede the benefits(or this benefit)of your booklet,we pay 100% of the Allowed Amount. Otherwise,we pay 125% of the Medicare allowed amount at the time of service. You may be subject to pay the balance of billed charges(not applicable towards Out-of-Pocket Maximum)when seeing an Out-of-Network Provider if you are not enrolled in Medicare Part B. Durable Medical Equipment 30% 50% Emergency Room Facility and professional services $350 copay per visit,In-Network deductible applies Habilitative Services-Inpatient $5,000 per day for inpatient non-emergency admissions to 30% 50% out-of-network facilities Habilitative Services-Outpatient 20 visits per calendar year $30 copay per visit, 50% deductible waived Hearing Aids and Evaluation Limited to Member and spouse/domestic partner 30% 50% $500 per calendar year per Member for hearing aids Excludes hearing exams,assistive hearing technology systems, batteries or cords Hearing Loss Limited to dependent children up to age 26 30% 50% 1 hearing aid device per ear every 36 months 45 outpatient speech and language therapy visits within 12 months from the receipt of a hearing aid,bone conduction device or cochlear implant Home Health Care 30% 50% Hospice Care 30% 50% Hospital Care-Inpatient $5,000 per day for inpatient non-emergency admissions to 30% 50% out-of-network facilities Hospital Care-Outpatient 30% 50% Maternity Care $5,000 per day for inpatient non-emergency admissions to 30% 50% out-of-network facilities Medical Foods 30% 50% Mental Health/Substance Use Disorder- $5,000 per day for inpatient non-emergency admissions to 30% 50% Inpatient out-of-network facilities Applied Behavioral Analysis(ABA)for the treatment of autism spectrum disorders included Mental Health/Substance Use Disorder- ABA for the treatment of autism spectrum disorders included $30 copay per outpatient 50% Outpatient office/psychotherapy visit, deductible waived Newborn Care $5,000 per day for inpatient non-emergency admissions to 30% 50% out-of-network facilities Nutritional Counseling 3 visits per calendar year(diabetic counseling is subject to this 30% 50% limit) Orthotic Devices 30% 50% Palliative Care 30 visits per calendar year 30% 50% Prosthetic Devices 30% 50% Rehabilitation Services-Inpatient $5,000 per day for inpatient non-emergency admissions to 30% 50% out-of-network facilities Rehabilitation Services-Outpatient 20 visits per calendar year $30 copay per visit, 50% deductible waived GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221GLD5SD,11012MMM,1110422CCONIVISID 110122ZGLD5SD Page 2 Medical Benefits (unless stated otherwise,a deductible applies) • Repair of Teeth Injury to sound natural teeth 30% 50% Treatment must be provided within 12 months from the date of injury Retail Office Visits Visits to a walk-in clinic located within a retail operation $20 copay per visit, 50% deductible waived Skilled Nursing Facility 30 days per calendar year 30% 50% Spinal Manipulations 18 spinal manipulations per calendar year $30 copay per visit, 50% deductible waived Termination of Pregnancy 30% 50% Transplants Travel expenses for the patient and companion(s)are limited to 14 30% 50% days per transplant episode $5,000 per day for inpatient non-emergency admissions to Out-of-Network facilities Commercial lodging expenses are limited to$300 per night for the Member and companion(s)combined Meal expenses are limited to$80 per day per Member or per companion(s) Virtual Care-Store and Forward Asynchronous(not real-time)communications such as text or fax $10 copay per visit, 50% deductible waived Virtual Care-Telehealth Doctor visits via phone or video chat when not in a healthcare $10 copay per visit, 50% facility deductible waived Virtual Care-Telemedicine Doctor visits via phone or video chat when in a healthcare facility 30% 50% Pediatric Benefits-Dependents Under Age 19 (unless stated otherwise,a deductible applies) What You Pay Dental Care-Preventive Bitewing X-rays,Fluoride Treatment,Oral Exams-2 per calendar Covered in full year Cleanings-2 per calendar year with a 3'd covered with qualifying diagnosis Sealants-1 per permanent molar every 3 years Dental Care-Basic Emergency/Palliative Treatment-emergency pain relief, 20%,deductible waived restoration not allowed on same date of service Endodontics-such as root canal Fillings Oral Surgery-includes removal of teeth and surgical extractions Periodontal Maintenance-4 per calendar year(in lieu of preventive cleaning) Scaling and Root Planing-1 in a 2 year period per quadrant Dental Care-Major Crowns,Inlays,Onlays-1 per tooth every 7 years 50%,deductible waived Dental Implants-4 per lifetime Dentures(full or partial),Bridges(fixed partial denture)-1 every 5 years Vision Care-Exams 1 comprehensive routine eye exam per calendar year $0 copay,deductible 50%,deductible waived waived for VSP provider Vision Care-Contact Lenses Contacts may be selected once per calendar year in lieu of all $0 copay,deductible 50%,deductible waived other lens and frame benefits waived for VSP provider Evaluation and Fitting Exam-1 per year Vision Care-Frames 1 frame per calendar year $0 copay,deductible 50%,deductible waived waived for VSP provider Limited to Otis&Piper Eyewear Collection GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221GLD5SD,lI01ZQWMD,11I0422CCONMSD 110122ZGLD5SD Page 3 In-NetworkPediatric Benefits-Dependents Under Age 19 (unless stated otherwise,a deductible applies) What You Pay • Vision Care-Lenses 1 pair of glass or plastic lenses per calendar year $0 copay,deductible 50%,deductible waived Includes:Single vision,lined bifocal,lined trifocal or lenticular waived for VSP provider lenses;Polycarbonate lenses;Scratch and UV protection;Tints, photochromic Additional lens enhancements available at a discount from VSP providers Find your vision plan benefits or a VSP vision provider at regence.com or call 1 (844)299-3041 Prescriptionstated otherwise, Preferred Generic Deductible waived $10 retail prescription*/$20 mail order prescription 90-day supply for retail or mail order Generic Deductible waived $35 retail prescription*/$70 mail order prescription 90-day supply for retail or mail order Preferred Brand" 90-day supply for retail or mail order $50 retail prescription*/$100 mail order prescription Brand 90-day supply for retail or mail order 50%retail prescription/45%mail order prescription Preferred Specialty 30-day supply for retail 20%participating pharmacy retail prescription/50% nonparticipating pharmacy retail prescription Specialty 30-day supply for retail 50%participating pharmacy retail prescription/50% nonparticipating pharmacy retail prescription *1 copay per 30 day supply "Insulin Cost Share Cap:Retail.$100 cap on member cost share per 30 day supply,deductible waived,$300 cap on member cost share up to 90 day supply,deductible waived Mail.$100 cap on member cost share per 30 day supply,deductible waived,-$200 cap on member cost share up to 90 day supply,deductible waived More information about prescription drug coverage is available at https://regence.com/go/20221ID16tier Other • Employee Assistance Program(EAP) 4 mental health counseling visits per issue Covered in full Not covered FrequentlyAsked Questions How is my privacy protected? Regence is committed to the confidentiality and security of your personal information. We maintain physical,administrative and technical safeguards to protect against unauthorized access,use,or disclosure of your personal information. You can view our full privacy practices online at regence.com. What if I need access to specialty care? You can receive care from any in-network provider without a referral. For some services,prior authorization may be required. Do I need a referral? ActivityGeneral Thera Exclusions The following activity therapy services are not covered:creative arts;play;dance;aroma;music;equine or other animal-assisted;recreational or Therapy: 9 tY PY P y q similar therapy;and sensory movement groups. Adventure,Outdoor,or Wilderness Interventions and Camps: Outward Bound,outdoor youth or outdoor behavioral programs,or courses or camps that primarily utilize an outdoor or similar non-traditional setting to provide services that are primarily supportive in nature and rendered by individuals who are not Providers,are not covered,including,but not limited to interventions or camps focused on: ❑ building self-esteem or leadership skills; ❑ losing weight; ❑ managing diabetes; ❑ contending with cancer or a terminal diagnosis;or ❑ living with,controlling or overcoming: - blindness; - deafness/hardness of hearing; - a Mental Health Condition;or - a Substance Use Disorder. GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221GLD5SD,1101 m$®,flI0422CCONMSD 110122ZGLD5SD Page 4 General Exclusions Services by Physicians or Practitioners in adventure,outdoor or wilderness settings may be covered if they are billed independently and would otherwise be a Covered Service in this Policy. Assisted Reproductive Technologies: Assisted reproductive technologies,regardless of underlying condition or circumstance,are not covered,including,but not limited to:cryogenic or other preservation,storage and thawing(or comparable preparation)of egg,sperm or embryo;in vitro fertilization;artificial insemination;embryo transfer;other artificial means of conception;or any associated surgery,medications,testing or supplies. Breast Reduction: Except when following a Medically Necessary mastectomy,to the extent required by law,breast reductions are not covered. For more information on breast reconstruction,see the Women's Health and Cancer Rights notice. Certain Therapy,Counseling and Training: Except as provided in the EAP Section,if applicable,the following therapies,counseling and training services are not covered:educational;vocational;social;image;self-esteem;milieu or marathon group therapy;premarital or marital counseling;and job skills or sensitivity training. Conditions Caused by Active Participation in a War or Insurrection: The treatment of any condition caused by or arising out of a Member's active participation in a war or insurrection. Conditions Incurred in or Aggravated During Performances in the Uniformed Services: The treatment of any Member's condition that the Secretary of Veterans Affairs determines to have been incurred in,or aggravated during,performance of service in the uniformed services of the United States. Cosmetic/Reconstructive Services and Supplies: Except for treatment of the following,cosmetic and/or reconstructive services and supplies are not covered: ❑ a Congenital Anomaly; ❑ to restore a physical bodily function lost as a result of Illness or Injury;or ❑ related to breast reconstruction following a Medically Necessary mastectomy,to the extent required by law. For more information on breast reconstruction,see the Women's Health and Cancer Rights notice. "Cosmetic"means services or supplies that are applied to normal structures of the body primarily to improve or change appearance. "Reconstructive"means services,procedures or surgery performed on abnormal structures of the body,caused by Congenital Anomalies,developmental abnormalities, trauma,infection,tumors or disease. It is performed to restore function,but,in the case of significant malformation,is also done to approximate a normal appearance. Counseling in the Absence of Illness: Except as required by law,counseling in the absence of Illness is not covered. Custodial Care: Except as provided in the Palliative Care benefit,non-skilled care and helping with activities of daily living is not covered. Dental Services: Except as provided in the Pediatric Dental Services or the Repair of Teeth benefits,Dental Services provided to prevent,diagnose or treat diseases or conditions of the teeth and adjacent supporting soft tissues are not covered,including treatment that restores the function of teeth. Elective Abortions:Elective abortions are not covered. "Elective abortion"means an abortion for any reason other than to preserve the life of the Member upon whom the abortion is performed. Coverage for non-elective abortions is provided in the Termination of Pregnancy benefit. Expenses Before Coverage Begins or After Coverage Ends: Services and supplies incurred before Your Effective Date under the Contract or after Your termination under the Contract. Family Counseling: Except when provided as part of the treatment for a child or adolescent with a covered diagnosis,family counseling is not covered. Fees,Taxes,Interest: Except as required by law,the following fees,taxes and interest are not covered:charges for shipping and handling,postage,interest or finance charges that a Provider might bill:excise,sales or other taxes;surcharges;tariffs;duties;assessments;or other similar charges whether made by federal,state or local government or by another entity. Government Programs:Except as required by state law(such as cases of medical emergency or coverage provided by Medicaid)or for facilities that contract with Us, benefits that are covered(or would be covered in the absence of this plan)by any federal,state or government program are not covered. Additionally,except as listed below,government facilities or government facilities outside the service area are not covered: ❑ facilities contracting with the local Blue Cross and/or Blue Shield plan;or ❑ as required by law for emergency services. Hypnotherapy and Hypnosis Services: Hypnotherapy and hypnosis services and associated expenses are not covered,including,but not limited to:treatment of painful physical conditions;Mental Health Conditions;Substance Use Disorders;or for anesthesia purposes. Illegal Activity: Services and supplies are not covered for treatment of an Illness,Injury or condition caused or sustained by a Member's voluntary participation in an activity where the Member is found guilty of an illegal activity in a criminal proceeding or is found liable for the activity in a civil proceeding. A guilty finding includes a plea of guilty or a no contest plea. If benefits already have been paid before the finding of guilt or liability is reached,We may recover the payment from the person We paid or anyone else who has benefited from it. Illegal Services,Substances and Supplies: Services,substances and supplies that are illegal as defined by state or federal law. Individualized Education Program(IEP): Services or supplies,including,but not limited to,supplementary aids and supports as provided in an IEP developed and adopted pursuant to the Individuals with Disabilities Education Act. Infertility: Except to the extent Covered Services are required to diagnose such condition,treatment of infertility is not covered,including,but not limited to:surgery, uterine transplants;fertility medications;and other medications associated with fertility treatment. Investigational Services: Except as provided in the Approved Clinical Trials benefit,Investigational services are not covered,including,but not limited to:services, supplies and accommodations provided in connection with Investigational treatments or procedures(Health Interventions);and any services or supplies provided by an Investigational protocol. Liposuction for the Treatment of Lipedema Motor Vehicle Coverage and Other Available Insurance: When motor vehicle coverage,other available insurance or contract is either issued to,or makes benefits available to a Member(whether or not the Member makes a claim with such coverage),expenses are not covered for services and supplies that are payable by any: ❑ automobile medical; ❑ personal injury protection(PIP); ❑ automobile no-fault coverage(unless the automobile contract contains a coordination of benefits provision,in which case,Our Coordination of Benefits provision shall apply); GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221GLD5SD,II01ZQKMD,11I0422CCONMSD 110122ZGLD5SD Page 5 General Exclusions ❑ underinsured or uninsured motorist coverage; ❑ homeowner's coverage; ❑ commercial premises coverage; ❑ excess coverage;or ❑ similar contract or insurance. Further,the Member is responsible for any cost-sharing required by the other insurance coverage,unless applicable state law requires otherwise. Once benefits in such contract or insurance are exhausted or considered to no longer be Injury-related by the no-fault provisions of the contract,benefits will be provided accordingly. Non-Direct Patient Care: Except as provided in the Virtual Care benefit,non-direct patient care services are not covered,including,but not limited to: ❑ appointments scheduled and not kept(missed appointments); ❑ charges for preparing or duplicating medical reports and chart notes; ❑ itemized bills or claim forms(even at Our request);and ❑ visits or consultations that are not in person(including telephone consultations and e-mail exchanges). Obesity or Weight Reduction/Control: Except as provided in the Nutritional Counseling benefit,as required by law or for reversals or revisions of surgery for obesity when required to correct a life-endangering condition,services or supplies that are intended to result in or relate to weight reduction(regardless of diagnosis or psychological conditions)are not covered,including,but not limited to: ❑ medical treatment; ❑ medications; ❑ surgical treatment(including treatment of complications,revisions and reversals);or ❑ programs. Orthognathic Surgery: Except for treatment of the following,orthognathic surgery is not covered:orthognathic surgery due to an Injury;sleep apnea(specifically, telegnathic surgery);developmental anomalies;or Congenital Anomaly. "Orthognathic surgery"means surgery to manipulate facial bones,including the jaw,in patients with facial bone abnormalities resulting from abnormal development performed to restore the proper anatomic and functional relationship of the facial bones. "Telegnathic surgery"means skeletal(maxillary,mandibular and hyoid)advancement to anatomically enlarge and physiologically stabilize the pharyngeal airway to treat obstructive sleep apnea. Over-the-Counter Contraceptives: Except as provided in the Prescription Medications Section or as required by law,over-the-counter contraceptive supplies are not covered. Personal Items: Items that are primarily for comfort,convenience,cosmetics,contentment,hygiene,environmental control,education or general physical fitness are not covered,including,but not limited to: ❑ telephones; ❑ televisions; ❑ air conditioners,air filters or humidifiers; ❑ whirlpools; ❑ heat lamps; ❑ light boxes; ❑ weightlifting equipment;and ❑ therapy or service animals,including the cost of training and maintenance. Physical Exercise Programs and Equipment: Physical exercise programs or equipment are not covered(even if recommended or prescribed by Your Provider), including,but not limited to:hot tubs;or membership fees to spas,health clubs or other such facilities. Private-Duty Nursing: Private-duty nursing,including ongoing shift care in the home. Reversals of Sterilizations: Services and supplies related to reversals of sterilization. Routine Foot Care Routine Hearing Examinations Self-Help,Self-Care,Training or Instructional Programs: Except as provided in the Medical Benefits Section or for services provided without a separate charge in connection with Covered Services that train or educate a Member,self-help,non-medical self-care,and training or instructional programs are not covered,including,but not limited to: ❑ childbirth-related classes including infant care;and ❑ instructional programs that: - teach a person how to use Durable Medical Equipment; - teach a person how to care for a family member;or - provide a supportive environment focusing on the Member's long-term social needs when rendered by individuals who are not Providers. Services and Supplies Provided by a Member of Your Family: Services and supplies provided to You by a member of Your immediate family are not covered. "Immediate family"means: ❑ You and Your parents,parents'spouses or domestic partners,spouse or domestic partner,children,stepchildren,siblings and half-siblings; ❑ Your spouse's or domestic partner's parents,parents'spouses or domestic partners,siblings and half-siblings; ❑ Your child's or stepchild's spouse or domestic partner;and ❑ any other of Your relatives by blood or marriage who shares a residence with You. Services and Supplies That Are Not Medically Necessary: Services and supplies that are not Medically Necessary for the treatment of an Illness or Injury. Services Required by an Employer or for Administrative or Qualification Purposes: Physical or mental examinations and associated services(laboratory or similar tests)required by an employer or primarily for administrative or qualification purposes are not covered. Administrative or qualification purposes include,but are not limited to: 11 admission to or remaining in: GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221GLD5SD,II01Z8KND,11I0422CCONMSD 110122ZGLD5SD Page 6 General Exclusions - school;a camp;a sports team;the military;or any other institution. ❑ athletic training evaluation; ❑ legal proceedings(establishing paternity or custody); ❑ qualification for: - employment or return to work;marriage;insurance;occupational injury benefits;licensure;or certification. ❑ travel,immigration or emigration. Sexual Dysfunction: Except as provided in the Mental Health Services benefit,treatment,services and supplies(including medications)are not covered for or in connection with sexual dysfunction regardless of cause. Temporomandibular Joint(TMJ)Disorder Treatment: Services and supplies provided for TMJ disorder treatment. Third-Party Liability: Services and supplies for treatment of Illness,Injury or health condition for which a third-party is or may be responsible. Travel and Transportation Expenses: Except as provided in the Ambulance benefit or as otherwise provided in the Medical Benefits Section,travel and transportation expenses are not covered. Varicose Vein Treatment: Except for the following,treatment of varicose veins is not covered:when there is associated venous ulceration;or persistent or recurrent bleeding from ruptured veins. Vision Care: Except as provided in the Pediatric Vision Services Section,vision care services are not covered,including,but not limited to:routine eye examinations; vision hardware;visual therapy;training and eye exercises;vision orthoptics,surgical procedures to correct refractive errors/astigmatism;and reversals or revisions of surgical procedures which alter the refractive character of the eye. Wigs: Wigs or other hair replacements regardless of the reason for hair loss or absence. Work-Related Conditions: Except when a Member is exempt from state or federal workers'compensation law,expenses for services or supplies incurred as a result of any work-related Illness or Injury(even if the service or supply is not covered by workers'compensation benefits)are not covered. This includes any claims resolved as a result of a disputed claim settlement. If an Illness or Injury could be considered work-related,a Member will be required to file a claim for workers'compensation benefits before We will consider providing any coverage. Pediatric Dental Exclusions Adjustments: Adjustment of a denture or bridgework which is done within six months after insertion by the same Dentist who installed the denture or bridgework. Aesthetic Dental Procedures: Services and supplies provided in connection with dental procedures that are primarily aesthetic,including bleaching of teeth. Bone Grafts: Bone grafts done in connection with extractions,apicoectomies or non-covered/ineligible implants. Cone Beam Imaging/MRI Procedures Cosmetic/Reconstructive Services and Supplies: Except for the following,cosmetic and/or reconstructive services and supplies are not covered:Dentally Appropriate services and supplies to treat a Congenital Anomaly;or to restore a physical bodily function lost as a result of Illness or Injury. "Cosmetic"means services or supplies that are applied to normal structures of the body primarily to improve or change appearance. "Reconstructive"means services,procedures or surgery performed on abnormal structures of the body,caused by Congenital Anomalies,developmental abnormalities, trauma,infection,tumors or disease. It is generally performed to restore function,but,in the case of significant malformation,is also done to approximate a normal appearance. Decay Prevention: Supplies and materials to prevent decay are not covered,including,but not limited to:toothpaste;fluoride gels;dental floss;and teeth whiteners. Duplicate Services: Services submitted by a Dentist which are for the same services performed on the same date for the same Member by another Dentist. Experimental or Investigational Services Fabrication of Athletic Mouth Guard Facility Expenses: Services and supplies related to facility expenses are not covered,including,but not limited to: ❑ those performed by a Dentist who is compensated by a facility for similar Covered Services performed for a Member;and costs or any additional fees that the Dentist or Hospital charges for treatment at the Hospital(inpatient or outpatient). Failure to Comply: Services and supplies resulting from Your failure to comply with professionally prescribed treatment. Gold-Foil Restorations Nitrous Oxide Oral Hygiene and Dietary Instructions Oral Sedation Orthodontic Dental Services: Except when Medically Necessary,orthodontic services and supplies are not covered,including,but not limited to: ❑ correction of malocclusion; ❑ craniomandibular orthopedic treatment; other orthodontic treatment; preventive orthodontic procedures; ❑ procedures for tooth movement,regardless of purpose;and ❑ repair of damaged orthodontic appliances. Plaque Control Programs Precision Attachments,Personalization,Precious Metal Bases and Other Specialized Techniques Provisional,Temporary and Duplicate Devices or Appliances GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221GLD5SD,1101I kEND,fl10422CCONMSD 110122ZGLD5SD Page 7 Pediatric Dental Exclusions Replacements: Replacement of any lost,stolen or broken dental appliance,including,but not limited to,dentures or retainers. Sealants: Except as provided for permanent molars,sealants are not covered. Separate Charges: Services and supplies that may be billed as separate charges(services that should be included in the billed procedure)are not covered,including, but not limited to: ❑ any supplies; ❑ local anesthesia;and ❑ sterilization(office infection control charges). Services and Supplies to Alter Vertical Dimension and/or Restore or Maintain the Occlusion: Services and supplies to alter vertical dimension and/or restore or maintain the occlusion are not covered,including,but not limited to: equilibration; ❑ periodontal splinting; ❑ full mouth rehabilitation;and ❑ restoration for misalignment of teeth. Services and Supplies Which the Member Would Have No Legal Obligation to Pay in the Absence of this Coverage Services and Treatment Not Prescribed By or Under the Direct Supervision of a Dentist Services Provided by Certain Entities: Services and treatment are not covered when received from a dental or medical department maintained by or on behalf of: an employer; ❑ mutual benefit association; ❑ labor union; ❑ trust; ❑ Veterans Administration Hospital;or ❑ similar person or group. Specialized Procedures and Techniques Temporomandibular Joint(TMJ)Disorder Treatment: Services and supplies provided in connection with TMJ disorder treatment. Topical Medicament Center Pediatric Vision Exclusions Certain Contact Lens Expenses ❑ artistically-painted or non-prescription contact lenses; ❑ contact lens modification,polishing or cleaning; ❑ refitting of contact lenses after the initial(90-day)fitting period; ❑ additional office visits associated with contact lens pathology;and contact lens insurance policies or service agreements. Corneal Refractive Therapy(CRT):Reversals or revisions of surgical procedures which alter the refractive character of the eye,including orthokeratology(a procedure using contact lenses to change the shape of the cornea in order to reduce myopia). Corrective Vision Treatment of an Experimental Nature Costs for Services and/or Supplies Exceeding Benefit Allowances Lens Enhancements:Except as provided in the Vision Hardware benefit,lens enhancements are not covered,including,but not limited to:anti-reflective coating;color coating;mirror coating;blended lenses;cosmetic lenses;laminated lenses;oversize lenses;or standard,premium and custom progressive multifocal lenses. Medical or Surgical Treatment of the Eyes: Medical or surgical treatment of the eyes,including reversals or revisions of surgical procedures of the eye. Orthoptics or Vision Training: Except as provided in the Low Vision benefits,orthoptics,vision training and any associated supplemental testing are not covered. Plano Lenses(Less Than a±.50 Diopter Power) Replacements:Replacement of any lost,stolen or broken lenses and/or frames. Two Pair of Glasses in Lieu of Bifocals Prescription Medications Exclusions Biological Sera,Blood or Blood Plasma Bulk Powders: Except as included on Our Drug List and presented with a Prescription Order,bulk powders are not covered. Cosmetic Purposes: Prescription Medications used for cosmetic purposes,including,but not limited to: removal,inhibition or stimulation of hair growth;anti-aging; repair of sun-damaged skin;or reduction of redness associated with rosacea. Devices or Appliances:Except as provided in the Medical Benefits Section,devices or appliances of any type,even if they require a Prescription Order are not covered. Diagnostic Agents:Except as provided in the Medical Benefits Section,diagnostic agents used to aid in diagnosis rather than treatment are not covered. Foreign Prescription Medications:Except for the following,foreign Prescription Medications are not covered:Prescription Medications associated with an Emergency Medical Condition while You are traveling outside the United States;or Prescription Medications You purchase while residing outside the United States. GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221GLD5SD,ll01k&WRDfIl0422CCONMSD 110122ZGLD5SD Page 8 Prescription Medications Exclusions These exceptions apply only to medications with an equivalent FDA-approved Prescription Medication that would be covered in this section if obtained in the United States. General Anesthetics: Except as provided in the Medical Benefits Section,general anesthetics are not covered. Medical Foods: Except as provided in the Medical Benefits Section,medical foods are not covered. Medications that are Not Considered Self-Administrable:Except as provided in the Medical Benefits Section or as specifically indicated in this Prescription Medications Section,medications that are not considered self-administrable are not covered. Nonprescription Medications:Except for the following,nonprescription medications that by law do not require a Prescription Order are not covered:medications included on Our Drug List,medications approved by the FDA,or a Prescription Order by a Physician or Practitioner. Nonprescription medications include,but are not limited to:over-the-counter medications;vitamins;minerals;food supplements;homeopathic medicines;nutritional supplements;and any medications listed as over-the-counter in standard drug references,regardless of state law prescription requirements,such as pseudoephedrine and cough syrup products. Prescription Medications Dispensed in a Facility:Prescription Medications dispensed to You while You are a patient in a Hospital,Skilled Nursing Facility,nursing home or other health care institution. Medications dispensed upon discharge should be processed by this benefit if obtained from a Pharmacy. Prescription Medications Found to be Less than Effective under Drug Efficacy Safety Implementation(DESI) Prescription Medications Not Approved by the FDA Prescription Medications Not Dispensed by a Pharmacy Pursuant to a Prescription Order Prescription Medications Not on the Drug List:Except as provided through the Drug List Exception Process,Prescription Medications that are not on the Drug List are not covered. Prescription Medications Not within a Provider's License:Prescription Medications prescribed by Providers who are not licensed to prescribe medications(or that particular medication)or who have a restricted professional practice license. Prescription Medications with Lower Cost Alternatives:Prescription Medications for which there are covered therapeutically equivalent(similar safety and efficacy) alternatives or over-the-counter(nonprescription)alternatives. Prescription Medications without Examination:Except as provided in the Virtual Care benefit,whether the Prescription Order is provided by mail,telephone,internet or some other means,Prescription Medications without a recent and relevant in-person examination by a Provider,are not covered. Additionally,this exclusion does not apply to a Provider or Pharmacist who may prescribe:an opioid antagonist to a Member who is at risk of experiencing an opiate-related overdose;or an epinephrine auto-injector to a Member who is at risk of experiencing anaphylaxis. An examination is"recent"if it occurred within 12 months of the date of the Prescription Order and is"relevant'if it involved the diagnosis,treatment or evaluation of the same or a related condition for which the Prescription Medication is being prescribed. Professional Charges for Administration of Any Medication Repackaged Medications,Institutional Packs and Clinic Packs This benefit summary provides a brief description of your plan benefits,limitations and/or exclusions under your plan and is not a guarantee of payment. Once enrolled, you can view your benefits booklet online at regence.com. PLEASE REFER TO YOUR BENEFITS BOOKLET OR SUMMARY PLAN DESCRIPTION FOR A COMPLETE LIST OF BENEFITS,THE LIMITATIONS AND/OR EXCLUSIONS THAT APPLY,AND A DEFINITION OF MEDICAL NECESSITY. Regence is providing this benefit summary for illustrative purposes only. Regence makes no warranties or representations regarding compliance with applicable federal,state,or local laws,or the accuracy of the benefit summary. This document is not the legally required Summary of Benefits and Coverage that an employer is required to provide to employees and members under Federal law,and the group must provide a legally compliant Summary of Benefits and Coverage to its employees and members. Regence BlueShield of Idaho,Inc.-Medical and Pediatric Dental 1 (888)367-2117-TTY:711 1 1211 West Myrtle Street,Suite 200,Boise,ID 83702 1 regence.com Vision Service Plan-Pediatric Vision Customer Service Provider and Benefit Inquiries 1 (844)299-3041 1 Membership Inquiries 1 (888)367-2117-TTY:711 1 PO Box 997100,Sacramento,CA 95899-7100 1 vsp.com GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221GLD5SD,1101k&WMDf1I0422CCONMSD 110122ZGLD5SD Page 9 Regence Gold 1500 d Regence Preferred Regence BlueShield of Idaho, Inc. Regence BlueShield of Idaho is an Independent Effective January 1,2022 through December 31,2022 Licensee of the Blue Cross and Blue Shield Association Cost Share Details In-Network • Coinsurance The amount you pay after you meet your deductible 30% 50% Annual Medical Deductible The total deductible you pay per calendar year $1,500 Individual $5,000 Individual $3,000 Family $10,000 Family Annual Prescription Deductible The total deductible you pay per calendar year for prescription Shared with medical medications Annual Out-of-Pocket Maximum The combined total for your deductible(s),coinsurance and $7,350 Individual $10,000 Individual copays per calendar year $14,700 Family $20,000 Family Be aware that your actual costs for covered services provided by an Out-of-Network provider may exceed the Out-of-Pocket Maximum amount. In addition, Out-of-Network providers can bill you for the difference between the amount charged and our Allowed Amount and that amount does not count toward any Out-of-Pocket Maximum. Medical Benefits (unless stated otherwise,a deductible applies) What You Pay Primary Care Visits(for Illness or Injury) $30 copay per visit, 50% deductible waived Specialist Visits $50 copay per visit, 50% deductible waived Urgent Care Visits $50 copay per visit, 50% deductible waived Other Professional Services 30% 50% Preventive Care/Immunizations Covered in full 50% Preventive Care-Expanded Immunizations that do not meet age limits and frequency 30% 50% Immunizations guidelines according to,and as recommended by,the USPSTF, HRSA or by the CDC are covered. Radiology and Laboratory-Inpatient Mammography,prenatal testing,including radiology and lab for 30% 50% maternity,DNA probes of infections agents and genetic testing services Radiology and Laboratory-Outpatient Mammography,prenatal testing,including radiology and lab for 30%,deductible waived 50% maternity,laboratory work associated with initial evaluation of infertility and diagnostic laparoscopy,DNA probes of infections agents and genetic testing services Excludes treatment for infertility,including reversal of sterilization Complex Imaging-Outpatient CT/PET/SPECT scans,MRIs,MRAs,etc. 30% 50% Acupuncture 18 visits per calendar year $30 copay per visit, 50% deductible waived Ambulance Services Air and Ground:services provided to the nearest hospital equipped 30%,In-Network deductible applies to render the necessary treatment Ambulatory Surgical Center 20% 50% Blood Bank 30%,In-Network deductible applies Dental Hospitalization $5,000 per day for inpatient non-emergency admissions to 30% 50% out-of-network facilities Diabetic Education Covered in full 50% Dialysis-Initial Outpatient Treatment 120 days for hemodialysis,peritoneal dialysis and hemofiltration 30% 50% Period services GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221GLD15SD,11012MMMID,1110422CCONIMSID 110122ZGLD15SD Page 1 Medical Benefits (unless stated otherwise,a deductible applies) • . Dialysis-Supplemental Outpatient If our agreement with the provider expressly specifies that its Covered in full Treatment Period terms supersede the benefits(or this benefit)of your booklet,we pay 100% of the Allowed Amount. Otherwise,we pay 125% of the Medicare allowed amount at the time of service. You may be subject to pay the balance of billed charges(not applicable towards Out-of-Pocket Maximum)when seeing an Out-of-Network Provider if you are not enrolled in Medicare Part B. Durable Medical Equipment 30% 50% Emergency Room Facility and professional services $350 copay per visit,In-Network deductible applies Habilitative Services-Inpatient $5,000 per day for inpatient non-emergency admissions to 30% 50% out-of-network facilities Habilitative Services-Outpatient 20 visits per calendar year $30 copay per visit, 50% deductible waived Hearing Aids and Evaluation Limited to Member and spouse/domestic partner 30% 50% $500 per calendar year per Member for hearing aids Excludes hearing exams,assistive hearing technology systems, batteries or cords Hearing Loss Limited to dependent children up to age 26 30% 50% 1 hearing aid device per ear every 36 months 45 outpatient speech and language therapy visits within 12 months from the receipt of a hearing aid,bone conduction device or cochlear implant Home Health Care 30% 50% Hospice Care 30% 50% Hospital Care-Inpatient $5,000 per day for inpatient non-emergency admissions to 30% 50% out-of-network facilities Hospital Care-Outpatient 30% 50% Maternity Care $5,000 per day for inpatient non-emergency admissions to 30% 50% out-of-network facilities Medical Foods 30% 50% Mental Health/Substance Use Disorder- $5,000 per day for inpatient non-emergency admissions to 30% 50% Inpatient out-of-network facilities Applied Behavioral Analysis(ABA)for the treatment of autism spectrum disorders included Mental Health/Substance Use Disorder- ABA for the treatment of autism spectrum disorders included $30 copay per outpatient 50% Outpatient office/psychotherapy visit, deductible waived Newborn Care $5,000 per day for inpatient non-emergency admissions to 30% 50% out-of-network facilities Nutritional Counseling 3 visits per calendar year(diabetic counseling is subject to this 30% 50% limit) Orthotic Devices 30% 50% Palliative Care 30 visits per calendar year 30% 50% Prosthetic Devices 30% 50% Rehabilitation Services-Inpatient $5,000 per day for inpatient non-emergency admissions to 30% 50% out-of-network facilities Rehabilitation Services-Outpatient 20 visits per calendar year $30 copay per visit, 50% deductible waived GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221GLD15SD,11012NWHID,1110422CCONIMSD 110122ZGLD15SD Page 2 Medical Benefits (unless stated otherwise,a deductible applies) • Repair of Teeth Injury to sound natural teeth 30% 50% Treatment must be provided within 12 months from the date of injury Retail Office Visits Visits to a walk-in clinic located within a retail operation $20 copay per visit, 50% deductible waived Skilled Nursing Facility 30 days per calendar year 30% 50% Spinal Manipulations 18 spinal manipulations per calendar year $30 copay per visit, 50% deductible waived Termination of Pregnancy 30% 50% Transplants Travel expenses for the patient and companion(s)are limited to 14 30% 50% days per transplant episode $5,000 per day for inpatient non-emergency admissions to Out-of-Network facilities Commercial lodging expenses are limited to$300 per night for the Member and companion(s)combined Meal expenses are limited to$80 per day per Member or per companion(s) Virtual Care-Store and Forward Asynchronous(not real-time)communications such as text or fax $10 copay per visit, 50% deductible waived Virtual Care-Telehealth Doctor visits via phone or video chat when not in a healthcare $10 copay per visit, 50% facility deductible waived Virtual Care-Telemedicine Doctor visits via phone or video chat when in a healthcare facility 30% 50% Pediatric Benefits-Dependents Under Age 19 (unless stated otherwise,a deductible applies) What You Pay Dental Care-Preventive Bitewing X-rays,Fluoride Treatment,Oral Exams-2 per calendar Covered in full year Cleanings-2 per calendar year with a 3'd covered with qualifying diagnosis Sealants-1 per permanent molar every 3 years Dental Care-Basic Emergency/Palliative Treatment-emergency pain relief, 20%,deductible waived restoration not allowed on same date of service Endodontics-such as root canal Fillings Oral Surgery-includes removal of teeth and surgical extractions Periodontal Maintenance-4 per calendar year(in lieu of preventive cleaning) Scaling and Root Planing-1 in a 2 year period per quadrant Dental Care-Major Crowns,Inlays,Onlays-1 per tooth every 7 years 50%,deductible waived Dental Implants-4 per lifetime Dentures(full or partial),Bridges(fixed partial denture)-1 every 5 years Vision Care-Exams 1 comprehensive routine eye exam per calendar year $0 copay,deductible 50%,deductible waived waived for VSP provider Vision Care-Contact Lenses Contacts may be selected once per calendar year in lieu of all $0 copay,deductible 50%,deductible waived other lens and frame benefits waived for VSP provider Evaluation and Fitting Exam-1 per year Vision Care-Frames 1 frame per calendar year $0 copay,deductible 50%,deductible waived waived for VSP provider Limited to Otis&Piper Eyewear Collection GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221GLD15SD,lI012NWaSD,11I0422CC0NIvlSD 110122ZGLD15SD Page 3 In-NetworkPediatric Benefits-Dependents Under Age 19 (unless stated otherwise,a deductible applies) What You Pay • Vision Care-Lenses 1 pair of glass or plastic lenses per calendar year $0 copay,deductible 50%,deductible waived Includes:Single vision,lined bifocal,lined trifocal or lenticular waived for VSP provider lenses;Polycarbonate lenses;Scratch and UV protection;Tints, photochromic Additional lens enhancements available at a discount from VSP providers Find your vision plan benefits or a VSP vision provider at regence.com or call 1 (844)299-3041 deductiblePrescription Medication Benefits (unless stated otherwise,a Preferred Generic Deductible waived $10 retail prescription*/$20 mail order prescription 90-day supply for retail or mail order Generic Deductible waived $35 retail prescription*/$70 mail order prescription 90-day supply for retail or mail order Preferred Brand' Deductible waived $50 retail prescription*/$100 mail order prescription 90-day supply for retail or mail order Brand Deductible waived 50%retail prescription/45%mail order prescription 90-day supply for retail or mail order Preferred Specialty Deductible waived 20%participating pharmacy retail prescription/50% 30-day supply for retail nonparticipating pharmacy retail prescription Specialty Deductible waived 50%participating pharmacy retail prescription/50% 30-day supply for retail nonparticipating pharmacy retail prescription *1 copay per 30 day supply "Insulin Cost Share Cap:Retail:$100 cap on member cost share per 30 day supply,deductible waived;$300 cap on member cost share up to 90 day supply,deductible waived Mail:$100 cap on member cost share per 30 day supply,deductible waived;$200 cap on member cost share up to 90 day supply,deductible waived More information about prescription drug coverage is available at https://regence.com/go/20221ID16tier Other • Employee Assistance Program(EAP) 4 mental health counseling visits per issue Covered in full Not covered Frequently Asked Questions How is my privacy protected? Regence is committed to the confidentiality and security of your personal information. We maintain physical,administrative and technical safeguards to protect against unauthorized access,use,or disclosure of your personal information. You can view our full privacy practices online at regence.com. What if I need access to specialty care? You can receive care from any in-network provider without a referral. For some services,prior authorization may be required. Do I need a referral? General Exclusions Activity Therapy: The following activity therapy services are not covered:creative arts;play;dance;aroma;music;equine or other animal-assisted;recreational or similar therapy;and sensory movement groups. Adventure,Outdoor,or Wilderness Interventions and Camps: Outward Bound,outdoor youth or outdoor behavioral programs,or courses or camps that primarily utilize an outdoor or similar non-traditional setting to provide services that are primarily supportive in nature and rendered by individuals who are not Providers,are not covered,including,but not limited to interventions or camps focused on: ❑ building self-esteem or leadership skills; ❑ losing weight; ❑ managing diabetes; ❑ contending with cancer or a terminal diagnosis;or ❑ living with,controlling or overcoming: - blindness; - deafness/hardness of hearing; GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221GLD15SD,1101 &6®,fl10422CCONMSD 110122ZGLD15SD Page 4 General Exclusions - a Mental Health Condition;or - a Substance Use Disorder. Services by Physicians or Practitioners in adventure,outdoor or wilderness settings may be covered if they are billed independently and would otherwise be a Covered Service in this Policy. Assisted Reproductive Technologies: Assisted reproductive technologies,regardless of underlying condition or circumstance,are not covered,including,but not limited to:cryogenic or other preservation,storage and thawing(or comparable preparation)of egg,sperm or embryo;in vitro fertilization;artificial insemination;embryo transfer;other artificial means of conception;or any associated surgery,medications,testing or supplies. Breast Reduction: Except when following a Medically Necessary mastectomy,to the extent required by law,breast reductions are not covered. For more information on breast reconstruction,see the Women's Health and Cancer Rights notice. Certain Therapy,Counseling and Training: Except as provided in the EAP Section,if applicable,the following therapies,counseling and training services are not covered:educational;vocational;social;image;self-esteem;milieu or marathon group therapy;premarital or marital counseling;and job skills or sensitivity training. Conditions Caused by Active Participation in a War or Insurrection: The treatment of any condition caused by or arising out of a Member's active participation in a war or insurrection. Conditions Incurred in or Aggravated During Performances in the Uniformed Services: The treatment of any Member's condition that the Secretary of Veterans Affairs determines to have been incurred in,or aggravated during,performance of service in the uniformed services of the United States. Cosmetic/Reconstructive Services and Supplies: Except for treatment of the following,cosmetic and/or reconstructive services and supplies are not covered: ❑ a Congenital Anomaly; ❑ to restore a physical bodily function lost as a result of Illness or Injury;or ❑ related to breast reconstruction following a Medically Necessary mastectomy,to the extent required by law. For more information on breast reconstruction,see the Women's Health and Cancer Rights notice. "Cosmetic"means services or supplies that are applied to normal structures of the body primarily to improve or change appearance. "Reconstructive"means services,procedures or surgery performed on abnormal structures of the body,caused by Congenital Anomalies,developmental abnormalities, trauma,infection,tumors or disease. It is performed to restore function,but,in the case of significant malformation,is also done to approximate a normal appearance. Counseling in the Absence of Illness: Except as required by law,counseling in the absence of Illness is not covered. Custodial Care: Except as provided in the Palliative Care benefit,non-skilled care and helping with activities of daily living is not covered. Dental Services: Except as provided in the Pediatric Dental Services or the Repair of Teeth benefits,Dental Services provided to prevent,diagnose or treat diseases or conditions of the teeth and adjacent supporting soft tissues are not covered,including treatment that restores the function of teeth. Elective Abortions:Elective abortions are not covered. "Elective abortion"means an abortion for any reason other than to preserve the life of the Member upon whom the abortion is performed. Coverage for non-elective abortions is provided in the Termination of Pregnancy benefit. Expenses Before Coverage Begins or After Coverage Ends: Services and supplies incurred before Your Effective Date under the Contract or after Your termination under the Contract. Family Counseling: Except when provided as part of the treatment for a child or adolescent with a covered diagnosis,family counseling is not covered. Fees,Taxes,Interest: Except as required by law,the following fees,taxes and interest are not covered:charges for shipping and handling,postage,interest or finance charges that a Provider might bill:excise,sales or other taxes;surcharges;tariffs;duties;assessments;or other similar charges whether made by federal,state or local government or by another entity. Government Programs:Except as required by state law(such as cases of medical emergency or coverage provided by Medicaid)or for facilities that contract with Us, benefits that are covered(or would be covered in the absence of this plan)by any federal,state or government program are not covered. Additionally,except as listed below,government facilities or government facilities outside the service area are not covered: ❑ facilities contracting with the local Blue Cross and/or Blue Shield plan;or ❑ as required by law for emergency services. Hypnotherapy and Hypnosis Services: Hypnotherapy and hypnosis services and associated expenses are not covered,including,but not limited to:treatment of painful physical conditions;Mental Health Conditions;Substance Use Disorders;or for anesthesia purposes. Illegal Activity: Services and supplies are not covered for treatment of an Illness,Injury or condition caused or sustained by a Member's voluntary participation in an activity where the Member is found guilty of an illegal activity in a criminal proceeding or is found liable for the activity in a civil proceeding. A guilty finding includes a plea of guilty or a no contest plea. If benefits already have been paid before the finding of guilt or liability is reached,We may recover the payment from the person We paid or anyone else who has benefited from it. Illegal Services,Substances and Supplies: Services,substances and supplies that are illegal as defined by state or federal law. Individualized Education Program(IEP): Services or supplies,including,but not limited to,supplementary aids and supports as provided in an IEP developed and adopted pursuant to the Individuals with Disabilities Education Act. Infertility: Except to the extent Covered Services are required to diagnose such condition,treatment of infertility is not covered,including,but not limited to:surgery, uterine transplants;fertility medications;and other medications associated with fertility treatment. Investigational Services: Except as provided in the Approved Clinical Trials benefit,Investigational services are not covered,including,but not limited to:services, supplies and accommodations provided in connection with Investigational treatments or procedures(Health Interventions);and any services or supplies provided by an Investigational protocol. Liposuction for the Treatment of Lipedema Motor Vehicle Coverage and Other Available Insurance: When motor vehicle coverage,other available insurance or contract is either issued to,or makes benefits available to a Member(whether or not the Member makes a claim with such coverage),expenses are not covered for services and supplies that are payable by any: ❑ automobile medical; ❑ personal injury protection(PIP); GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221GLD15SD,1101 ND,fl10422CC0NMSD 110122ZGLD15SD Page 5 General Exclusions ❑ automobile no-fault coverage(unless the automobile contract contains a coordination of benefits provision,in which case,Our Coordination of Benefits provision shall apply); ❑ underinsured or uninsured motorist coverage; ❑ homeowner's coverage; ❑ commercial premises coverage; ❑ excess coverage;or ❑ similar contract or insurance. Further,the Member is responsible for any cost-sharing required by the other insurance coverage,unless applicable state law requires otherwise. Once benefits in such contract or insurance are exhausted or considered to no longer be Injury-related by the no-fault provisions of the contract,benefits will be provided accordingly. Non-Direct Patient Care: Except as provided in the Virtual Care benefit,non-direct patient care services are not covered,including,but not limited to: ❑ appointments scheduled and not kept(missed appointments); ❑ charges for preparing or duplicating medical reports and chart notes; ❑ itemized bills or claim forms(even at Our request);and ❑ visits or consultations that are not in person(including telephone consultations and e-mail exchanges). Obesity or Weight Reduction/Control: Except as provided in the Nutritional Counseling benefit,as required by law or for reversals or revisions of surgery for obesity when required to correct a life-endangering condition,services or supplies that are intended to result in or relate to weight reduction(regardless of diagnosis or psychological conditions)are not covered,including,but not limited to: medical treatment; medications; ❑ surgical treatment(including treatment of complications,revisions and reversals);or ❑ programs. Orthognathic Surgery: Except for treatment of the following,orthognathic surgery is not covered:orthognathic surgery due to an Injury;sleep apnea(specifically, telegnathic surgery);developmental anomalies;or Congenital Anomaly. "Orthognathic surgery"means surgery to manipulate facial bones,including the jaw,in patients with facial bone abnormalities resulting from abnormal development performed to restore the proper anatomic and functional relationship of the facial bones. "Telegnathic surgery"means skeletal(maxillary,mandibular and hyoid)advancement to anatomically enlarge and physiologically stabilize the pharyngeal airway to treat obstructive sleep apnea. Over-the-Counter Contraceptives: Except as provided in the Prescription Medications Section or as required by law,over-the-counter contraceptive supplies are not covered. Personal Items: Items that are primarily for comfort,convenience,cosmetics,contentment,hygiene,environmental control,education or general physical fitness are not covered,including,but not limited to: ❑ telephones; ❑ televisions; ❑ air conditioners,air filters or humidifiers; ❑ whirlpools; ❑ heat lamps; ❑ light boxes; ❑ weightlifting equipment;and 11 therapy or service animals,including the cost of training and maintenance. Physical Exercise Programs and Equipment: Physical exercise programs or equipment are not covered(even if recommended or prescribed by Your Provider), including,but not limited to:hot tubs;or membership fees to spas,health clubs or other such facilities. Private-Duty Nursing: Private-duty nursing,including ongoing shift care in the home. Reversals of Sterilizations: Services and supplies related to reversals of sterilization. Routine Foot Care Routine Hearing Examinations Self-Help,Self-Care,Training or Instructional Programs: Except as provided in the Medical Benefits Section or for services provided without a separate charge in connection with Covered Services that train or educate a Member,self-help,non-medical self-care,and training or instructional programs are not covered,including,but not limited to: ❑ childbirth-related classes including infant care;and ❑ instructional programs that: - teach a person how to use Durable Medical Equipment; - teach a person how to care for a family member;or - provide a supportive environment focusing on the Member's long-term social needs when rendered by individuals who are not Providers. Services and Supplies Provided by a Member of Your Family: Services and supplies provided to You by a member of Your immediate family are not covered. "Immediate family"means: You and Your parents,parents'spouses or domestic partners,spouse or domestic partner,children,stepchildren,siblings and half-siblings; Your spouse's or domestic partner's parents,parents'spouses or domestic partners,siblings and half-siblings; Your child's or stepchild's spouse or domestic partner;and any other of Your relatives by blood or marriage who shares a residence with You. Services and Supplies That Are Not Medically Necessary: Services and supplies that are not Medically Necessary for the treatment of an Illness or Injury. GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221GLD15SD,1101OWND,flM422CCONMSD 110122ZGLD15SD Page 6 General Exclusions Services Required by an Employer or for Administrative or Qualification Purposes: Physical or mental examinations and associated services(laboratory or similar tests)required by an employer or primarily for administrative or qualification purposes are not covered. Administrative or qualification purposes include,but are not limited to: ❑ admission to or remaining in: - school;a camp;a sports team;the military;or any other institution. ❑ athletic training evaluation; ❑ legal proceedings(establishing paternity or custody); ❑ qualification for: - employment or return to work;marriage;insurance;occupational injury benefits;licensure;or certification. travel,immigration or emigration. Sexual Dysfunction: Except as provided in the Mental Health Services benefit,treatment,services and supplies(including medications)are not covered for or in connection with sexual dysfunction regardless of cause. Temporomandibular Joint(TMJ)Disorder Treatment: Services and supplies provided for TMJ disorder treatment. Third-Party Liability: Services and supplies for treatment of Illness,Injury or health condition for which a third-party is or may be responsible. Travel and Transportation Expenses: Except as provided in the Ambulance benefit or as otherwise provided in the Medical Benefits Section,travel and transportation expenses are not covered. Varicose Vein Treatment: Except for the following,treatment of varicose veins is not covered:when there is associated venous ulceration;or persistent or recurrent bleeding from ruptured veins. Vision Care: Except as provided in the Pediatric Vision Services Section,vision care services are not covered,including,but not limited to:routine eye examinations; vision hardware;visual therapy;training and eye exercises;vision orthoptics,surgical procedures to correct refractive errors/astigmatism;and reversals or revisions of surgical procedures which alter the refractive character of the eye. Wigs: Wigs or other hair replacements regardless of the reason for hair loss or absence. Work-Related Conditions: Except when a Member is exempt from state or federal workers'compensation law,expenses for services or supplies incurred as a result of any work-related Illness or Injury(even if the service or supply is not covered by workers'compensation benefits)are not covered. This includes any claims resolved as a result of a disputed claim settlement. If an Illness or Injury could be considered work-related,a Member will be required to file a claim for workers'compensation benefits before We will consider providing any coverage. Pediatric Dental Exclusions Adjustments: Adjustment of a denture or bridgework which is done within six months after insertion by the same Dentist who installed the denture or bridgework. Aesthetic Dental Procedures: Services and supplies provided in connection with dental procedures that are primarily aesthetic,including bleaching of teeth. Bone Grafts: Bone grafts done in connection with extractions,apicoectomies or non-covered/ineligible implants. Cone Beam Imaging/MR1 Procedures Cosmetic/Reconstructive Services and Supplies: Except for the following,cosmetic and/or reconstructive services and supplies are not covered:Dentally Appropriate services and supplies to treat a Congenital Anomaly;or to restore a physical bodily function lost as a result of Illness or Injury. "Cosmetic"means services or supplies that are applied to normal structures of the body primarily to improve or change appearance. "Reconstructive"means services,procedures or surgery performed on abnormal structures of the body,caused by Congenital Anomalies,developmental abnormalities, trauma,infection,tumors or disease. It is generally performed to restore function,but,in the case of significant malformation,is also done to approximate a normal appearance. Decay Prevention: Supplies and materials to prevent decay are not covered,including,but not limited to:toothpaste;fluoride gels;dental floss;and teeth whiteners. Duplicate Services: Services submitted by a Dentist which are for the same services performed on the same date for the same Member by another Dentist. Experimental or Investigational Services Fabrication of Athletic Mouth Guard Facility Expenses: Services and supplies related to facility expenses are not covered,including,but not limited to: ❑ those performed by a Dentist who is compensated by a facility for similar Covered Services performed for a Member;and costs or any additional fees that the Dentist or Hospital charges for treatment at the Hospital(inpatient or outpatient). Failure to Comply: Services and supplies resulting from Your failure to comply with professionally prescribed treatment. Gold-Foil Restorations Nitrous Oxide Oral Hygiene and Dietary Instructions Oral Sedation Orthodontic Dental Services: Except when Medically Necessary,orthodontic services and supplies are not covered,including,but not limited to: ❑ correction of malocclusion; ❑ craniomandibular orthopedic treatment; other orthodontic treatment; preventive orthodontic procedures; ❑ procedures for tooth movement,regardless of purpose;and ❑ repair of damaged orthodontic appliances. GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221GLD15SD,1101OWND,1110422CCONMSD 110122ZGLD15SD Page 7 Pediatric Dental Exclusions Plaque Control Programs Precision Attachments,Personalization,Precious Metal Bases and Other Specialized Techniques Provisional,Temporary and Duplicate Devices or Appliances Replacements: Replacement of any lost,stolen or broken dental appliance,including,but not limited to,dentures or retainers. Sealants: Except as provided for permanent molars,sealants are not covered. Separate Charges: Services and supplies that may be billed as separate charges(services that should be included in the billed procedure)are not covered,including, but not limited to: ❑ any supplies; ❑ local anesthesia;and sterilization(office infection control charges). Services and Supplies to Alter Vertical Dimension and/or Restore or Maintain the Occlusion: Services and supplies to alter vertical dimension and/or restore or maintain the occlusion are not covered,including,but not limited to: ❑ equilibration; periodontal splinting; full mouth rehabilitation;and ❑ restoration for misalignment of teeth. Services and Supplies Which the Member Would Have No Legal Obligation to Pay in the Absence of this Coverage Services and Treatment Not Prescribed By or Under the Direct Supervision of a Dentist Services Provided by Certain Entities: Services and treatment are not covered when received from a dental or medical department maintained by or on behalf of: an employer; ❑ mutual benefit association; ❑ labor union; ❑ trust; ❑ Veterans Administration Hospital;or similar person or group. Specialized Procedures and Techniques Temporomandibular Joint(TMJ)Disorder Treatment: Services and supplies provided in connection with TMJ disorder treatment. Topical Medicament Center Pediatric Vision Exclusions Certain Contact Lens Expenses artistically-painted or non-prescription contact lenses; contact lens modification,polishing or cleaning; ❑ refitting of contact lenses after the initial(90-day)fitting period; ❑ additional office visits associated with contact lens pathology;and ❑ contact lens insurance policies or service agreements. Corneal Refractive Therapy(CRT):Reversals or revisions of surgical procedures which alter the refractive character of the eye,including orthokeratology(a procedure using contact lenses to change the shape of the cornea in order to reduce myopia). Corrective Vision Treatment of an Experimental Nature Costs for Services and/or Supplies Exceeding Benefit Allowances Lens Enhancements:Except as provided in the Vision Hardware benefit,lens enhancements are not covered,including,but not limited to:anti-reflective coating;color coating;mirror coating;blended lenses;cosmetic lenses;laminated lenses;oversize lenses;or standard,premium and custom progressive multifocal lenses. Medical or Surgical Treatment of the Eyes: Medical or surgical treatment of the eyes,including reversals or revisions of surgical procedures of the eye. Orthoptics or Vision Training: Except as provided in the Low Vision benefits,orthoptics,vision training and any associated supplemental testing are not covered. Plano Lenses(Less Than a±.50 Diopter Power) Replacements:Replacement of any lost,stolen or broken lenses and/or frames. Two Pair of Glasses in Lieu of Bifocals GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221GLD15SD,ll012QKMDfIM422CC0NMSD 110122ZGLD15SD Page 8 Prescription Medications Exclusions Biological Sera,Blood or Blood Plasma Bulk Powders: Except as included on Our Drug List and presented with a Prescription Order,bulk powders are not covered. Cosmetic Purposes: Prescription Medications used for cosmetic purposes,including,but not limited to: removal,inhibition or stimulation of hair growth;anti-aging; repair of sun-damaged skin;or reduction of redness associated with rosacea. Devices or Appliances:Except as provided in the Medical Benefits Section,devices or appliances of any type,even if they require a Prescription Order are not covered. Diagnostic Agents:Except as provided in the Medical Benefits Section,diagnostic agents used to aid in diagnosis rather than treatment are not covered. Foreign Prescription Medications:Except for the following,foreign Prescription Medications are not covered:Prescription Medications associated with an Emergency Medical Condition while You are traveling outside the United States;or Prescription Medications You purchase while residing outside the United States. These exceptions apply only to medications with an equivalent FDA-approved Prescription Medication that would be covered in this section if obtained in the United States. General Anesthetics: Except as provided in the Medical Benefits Section,general anesthetics are not covered. Medical Foods: Except as provided in the Medical Benefits Section,medical foods are not covered. Medications that are Not Considered Self-Administrable:Except as provided in the Medical Benefits Section or as specifically indicated in this Prescription Medications Section,medications that are not considered self-administrable are not covered. Nonprescription Medications:Except for the following,nonprescription medications that by law do not require a Prescription Order are not covered:medications included on Our Drug List,medications approved by the FDA,or a Prescription Order by a Physician or Practitioner. Nonprescription medications include,but are not limited to:over-the-counter medications;vitamins;minerals;food supplements;homeopathic medicines;nutritional supplements;and any medications listed as over-the-counter in standard drug references,regardless of state law prescription requirements,such as pseudoephedrine and cough syrup products. Prescription Medications Dispensed in a Facility:Prescription Medications dispensed to You while You are a patient in a Hospital,Skilled Nursing Facility,nursing home or other health care institution. Medications dispensed upon discharge should be processed by this benefit if obtained from a Pharmacy. Prescription Medications Found to be Less than Effective under Drug Efficacy Safety Implementation(DESI) Prescription Medications Not Approved by the FDA Prescription Medications Not Dispensed by a Pharmacy Pursuant to a Prescription Order Prescription Medications Not on the Drug List:Except as provided through the Drug List Exception Process,Prescription Medications that are not on the Drug List are not covered. Prescription Medications Not within a Provider's License:Prescription Medications prescribed by Providers who are not licensed to prescribe medications(or that particular medication)or who have a restricted professional practice license. Prescription Medications with Lower Cost Alternatives:Prescription Medications for which there are covered therapeutically equivalent(similar safety and efficacy) alternatives or over-the-counter(nonprescription)alternatives. Prescription Medications without Examination:Except as provided in the Virtual Care benefit,whether the Prescription Order is provided by mail,telephone,internet or some other means,Prescription Medications without a recent and relevant in-person examination by a Provider,are not covered. Additionally,this exclusion does not apply to a Provider or Pharmacist who may prescribe:an opioid antagonist to a Member who is at risk of experiencing an opiate-related overdose;or an epinephrine auto-injector to a Member who is at risk of experiencing anaphylaxis. An examination is"recent"if it occurred within 12 months of the date of the Prescription Order and is"relevant"if it involved the diagnosis,treatment or evaluation of the same or a related condition for which the Prescription Medication is being prescribed. Professional Charges for Administration of Any Medication Repackaged Medications,Institutional Packs and Clinic Packs This benefit summary provides a brief description of your plan benefits,limitations and/or exclusions under your plan and is not a guarantee of payment. Once enrolled, you can view your benefits booklet online at regence.com. PLEASE REFER TO YOUR BENEFITS BOOKLET OR SUMMARY PLAN DESCRIPTION FOR A COMPLETE LIST OF BENEFITS,THE LIMITATIONS AND/OR EXCLUSIONS THAT APPLY,AND A DEFINITION OF MEDICAL NECESSITY. Regence is providing this benefit summary for illustrative purposes only. Regence makes no warranties or representations regarding compliance with applicable federal,state,or local laws,or the accuracy of the benefit summary. This document is not the legally required Summary of Benefits and Coverage that an employer is required to provide to employees and members under Federal law,and the group must provide a legally compliant Summary of Benefits and Coverage to its employees and members. Regence BlueShield of Idaho,Inc.-Medical and Pediatric Dental 1 (888)367-2117-TTY:711 1 1211 West Myrtle Street,Suite 200,Boise,ID 83702 1 regence.com Vision Service Plan-Pediatric Vision Customer Service Provider and Benefit Inquiries 1 (844)299-3041 1 Membership Inquiries 1 (888)367-2117-TTY:711 1 PO Box 997100,Sacramento,CA 95899-7100 1 vsp.com GSW-W-24-01 IPUC Staff PR 17 Attachment 3 1101221GLD15SD,1101OWS0,,1110422CCONMSD 110122ZGLD15SD Page 9 NONDISCRIMINATION NOTICE Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Regence does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Regence: Provides free aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio, and accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages If you need these services listed above, You can also file a civil rights complaint with the please contact: U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Medicare Customer Service Office for Civil Rights Complaint Portal at 1-800-541-8981 (TTY: 711) https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: Customer Service for all other plans 1-888-344-6347 (TTY: 711) U.S. Department of Health and Human Services 200 Independence Avenue SW, If you believe that Regence has failed to Room 509F HHH Building provide these services or discriminated in Washington, DC 20201 another way on the basis of race, color, national origin, age, disability, or sex, you can 1-800-368-1019, 800-537-7697 (TDD). file a grievance with our civil rights coordinator below: Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Medicare Customer Service Civil Rights Coordinator MS: B32AG, PO Box 1827 Medford, OR 97501 1-866-749-0355, (TTY: 711) Fax: 1-888-309-8784 medicareappeals@regence.com Customer Service for all other plans Civil Rights Coordinator MS CS B32B, P.O. Box 1271 Portland, OR 97207-1271 1-888-344-6347, (TTY: 711) CS@regence.com GSW-W-24-01 01012017.04PF12LNoticeNDMARegence IPUC Staff PR 17 Attachment 3 Page 92 of 94 Language assistance ATENCION: si habla espafiol, tiene a su disposicion servicios gratuitos de asistencia lingiiistica. Llame al 1-888-344-6347 (TTY: 711). P1--n1m=n nU'U*S� ITH F9� �1 S;JhJ 1-888-344- _ 6347 (TTY: 711)1 Ea RMRA"o 'aR w 1-888-344-6347 (TTY: 711)o flefr: #37iff z?Rl�`t cr, 3T 9w f4a CHO t Neu ban n6i Tieng Viet, c6 cac dich vu ho H� 3 � 11-888-344- trg ngon ngfr mien phi danh cho ban. Goi so 1-888- 6347 (TTY: 711) '�4 311F-614I 344-6347 (TTY: 711). O , a �] Ao A ^ ACHTUNG: Wenn Sie Deutsch sprechen, stehen T L� --zc O 1 O T, 7L 1 A]���� TR� d1 o 4�� T I'll q�. 1-888- Ihnen kostenlose Sprachdienstleistungen zur 344-6347 (TTY: 711) �° �� }a}� -z�-Aj A]d Verfiigung. Rufnummer: 1-888-344-6347 (TTY: 711) Pa%1774- - 5�') ha7Ct�htrt ?+C?-90 hCq,4- PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari J47Ck+*° MR A S'OIIiP+4-HP) 4-` A [1a%h4-Aa)--ATC kang gumamit ng raga serbisyo ng tulong sa wika nang J?,ga).h. 1-888-344-6347 (pDba7+ A4*7;fa)-:- 711):: walang bayad. Tumawag sa 1-888-344-6347 (TTY: 711). YBAFA! SIKIAO BH p03MOBJIACTe yxpaiHcbKOIO MOBOIO, BH MO)KeTe 3BepHYTHCA go 6e3KOMTOBHOY BHHMAH14E: ECJIH BbI rOBOPHTe Ha pyCCKOM A316IKe, CJIY)K6H MOBHOY HigTpHMKH. Teiie4)OHYRTe 3a To BaM AOCTynHbl 6ecriJlaTHbie YCJIYFH riepeBoAa. HOmepoM 1-888-344-6347 (TeJIeTaHri: 711) 3BOHHTe 1-888-344-6347 (TeneTaHn: 711). ATTENTION : Si vous parlez franoais, des services d'aide linguistique vous sont proposes gratuitement. 711 i ' 1-888-344-6347 (fzfcar�: Appelez le 1-888-344-6347 (ATS : 711) 711 > " lR : El 2r III ;�- tL 6'A , �f ())-t-i a ATENTIE: Daca vorbiti limba romana, va stau la dispozitie servicii de asistenta lingvistica, gratuit. fJ�1, �`�`Gt - ° 1-888-344-6347 Sunati la 1-888-344-6347 (TTY: 711) (TTY:711 Z - �3 -C < tt c, L) ° MAANDO: To a waawi [Adamawa], e woodi ballooji- Dii baa ak6 ninizin: Dii saad bee yanitti'go Dine ma to ekkitaaki wolde caahu. Noddu 1-888-344-6347 Bizaad, saad bee aka'anida'awo'dee', t"' jiik'eh, ei (TTY: 711) na h616,koji' hodiilnih 1-888-344-6347 (TTY: 711.) FAKATOKANGA'I: Kapau `oku ke Lea- 1�15 1-888-344-6347 (TTY: 711) Fakatonga, ko e kau tokoni fakatonu lea `oku nau fai atu ha tokoni ta'etotongi, pea to ke lava `o ma'u ia. FUoglu: uinucaw m.)a')O ha'o telefonimai mai ki he fika 1-888-344-6347 (TTY: n�x�u�n�x�a�€�c�n9ci�u����,Fn€�uc3€i�, ccuuui.i�a�2�iui�u. 711) Fins 1-888-344-6347 (TTY: 711) OBAVJESTENJE: Ako govorite srpsko-hrvatski, Afaan dubbattan Oroomiffaa tiif, tajaajila gargaarsa usluge jezicke pomo6i dostupne su vam besplatno. afaanii tola ni jira. 1-888-344-6347 (TTY: 711)tiin Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa bilbilaa. ogte6enim govorom ili sluhom: 711) vy� 1-888-344-6347 (TTY: 711) ►� 1-888-344-6347 fit+�l .� li J1�s19,5 a yx]II o�l�.,011 "l,o�vls �ax]]I yS�l� - S i3l :abj�L (TTY: 01012017.04PF12LNoticeNDMARegence IPUC Staff PR 17 Attachment 3 Page 93 of 94 PAYCHOU Payroll I Benefits I HR I Insurance The Power of Simplicity IPUC Staff PR 17