20040325Response of Avista to Staff Part XVII.pdf

PARr 1/7/
VISTA CORPORATION
RESPONSE TO REQUEST FOR INFORMATION
JURISDICTION:
CASE NO:
REQUESTER:
TYPE:
REQUEST NO.
Idaho
A VU-O4-0l / A VU-O4-
IPUC
Data Request
Staff - 152
DATE PREPARED:
WITNESS:
RESPONDER:
DEP ARTMENT:
TELEPHONE:
03/22/2004
Scott Morris
Mary Trudel
Human Resources
[phone]
REQUEST:
Please provide summaries of all benefit and retirement plans provided to any classification of
A vista employees to the extent not previously provided in Company response to Audit Request
No. 31.
RESPONSE:
See attached Employee Benefit Summaries for Union and Non-Union employees and the March
, 2003 Proxy Statement for other plans.
:~.~\\
'iI'JI'
Corp.
EMPLO YEE
BENEFIT
SUMMARY
(D ni 0 n Em ploy ees )
January 1 2004 - December 31 2004
LIFE INSURANCE
Group Life Insurance (Base Life)
.............. ............... ........... .................
MetLife Optional Life Insurance ..... ........... ...... .................. ....... ........... 3-
Accidental Death & Dismemberment (AD&D).,........................................ 5-
EMPLOYEE ASSISTANCE PROGRAMS
Employee Assistance Program.... ....... ............... ..... ........ ........... ........ .... 10-
Tuition Aid """""""""""""""""""""""""""............................... 12
Adoption
""""""""""""""""""""""""""""""""""""""""""'"
Jury Duty ........................................................................,.............. 14
MEDICAL INSURANCE
A VISTA-EBA Plans.......... ...... ......... ......... ..... ........ ............ ..... .......... 15-
Group Health................ ......... ....
""""'"
......... '" ... .......... ...... ............ 24-
Washington Dental Service................................................................. 29-41
Retiree MedicaL........................ .... .....
.... """ ...... ............ ...... ............
42-
COBRA.................................... ........ ...
"""""""""
... ......... ............. 48-
PAID TIME OFF
Holidays........................................ .... ..................... .....
...... .............
FMLA (Family Medical Leave Act)........................................................
Worker s Compensation...................................................................... 55
Short Term Disability (STD).. ..
.. .. .. .... ...... .. .... .. .. .. .. . .. .. .. .. .... .. .. .. ............
Long Term Disability (LTD)....
......... ........................... ... ............... .......
One Leave..............................................
"""""""""""""""""""
PRE-TAX PROGRAMS
Health Care Reimbursement Plan.....
........ ............ ........ ""'" .... ........
58-
60-
Dependent Care Reimbursement Plan.
................ ............ ...
....... ............. 63-
Premium Payment Plan.............................................. ........................
RETIREMENT & 401(k) INVESTMENT PLANS
InvestmentPlan - 401(k)..................................................................... 67-
RetirementBonus............................................................................. 71
Retirement Plan ............................................................................... 72-
HIPAA Privacy Notice................
"""""""""""""""""""""""""""
77-
A vista Corp.
Group Life Insurance (Basic Life Insurance)
ELIGIBILITY
You are eligible to participate in the Plan if you are a:
Regular or full-time employee, or
Regularly scheduled (20+ hours) part-time employee. (Casual or temporary employees are not eligible).
COST TO YOU
The Company pays the cost of the insurance in full.
COVERAGE FOR YOU
1. Employees not yet 40 years of age on 7/1/97:
.1 x annual base pay rounded to the nearest $1 000 but not to exceed $50 000.
2. Employees 40 years of age, but not yet 60 years of age on 7/1/97:
.1 x your annual base pay rounded to the nearest $1 000, but not to exceed $75 000.
1. Employees 60 years of age or older on 7/1/97:
.1 x your annual base pay rounded to the nearest $1 000 but not to exceed $250 000.
Note: Employees hired on and after 7/1/97 reJ!ardless of aJ!e.will have coverage of x annual base pay
rounded to the nearest $1 000, but not to exceed $50 000.
COVERAGE WHEN YOU RETIREE
1. Employees not yet 40 years of age on 7/1/97:
. $5 000
2. Employees 40 years of age, but not yet 60 years of age on 7/1/97:
1 x your annual pension to the nearest $100, but not to exceed $20 000.
Note:$20 000 currently exceeds the average annual pension to the nearest $100.
3. Employees 60 years of age or older on 7/1/97:
1 x your annual pension to the nearest $100.
Note:Employees hired on and after 7/1/97 will have NO company provided Life Insurance upon retirement.
IF YOU LEAVE THE COMPANY
Coverage ends.
A vista Corp.
MetLife Optional Life Insurance Protection Program
With Dependent Life Insurance Coverage
OPTIONAL LIFE
You may obtain between $10,000 and $300 000 of Optional Life insurance for yourself, available through the
convenience of payroll deduction, in flexible multiples of your annual salary (maximum benefit is 5 times annual
earnings). This coverage is available for you without medical evidence of insurability if you select one times annual
earnings up to a maximum of $300,000, provided enrollment takes place within 31 days of becoming eligible, and
you have not been hospitalized within 90 days of enrollment. The definition of "hospitalized" includes inpatient
hospital care, care in a hospice, intermediate or long-term care facility. This also includes outpatient hospital care for
receipt of chemotherapy, radiation therapy, or dialysis treatment.
Avista Corporation s Optional Life plan includes the following features:
Portability: Allows you to continue term coverage on your life should you leave A vista Corporation, or if you
are no longer part of an eligible class for the coverage. Competitive group rates apply, and you will be billed
directly by MetLife. Dependent term coverage on spouses and children is not portable.
Conversion: If your life insurance coverage terminates, you may convert your term coverage to a MetLife
individual permanent policy without evidence of insurability. Covered dependents may also convert.
Accelerated Benefits Option: Allows terminally ill participants diagnosed with less than six months to live to
receive up to 50% of their insurance proceeds while still living.
Total Control Account: Provides beneficiaries with immediate access to insurance proceeds. The account is
similar to a bank money market account and is fully guaranteed by MetLife.
Disability Provision: Should you become unable to work due to total and permanent disability, your term life
coverage may be continued until age 65.
DEPENDENT COVERAGE
Life insurance coverage is also available for your spouse without medical evidence of insurability if you select
amounts between $10,000 and $50 000 provided enrollment takes place within 31 days of the date he or she becomes
eligible, and your spouse has not been hospitalized within 90 days of enrollment.
Coverage on the life of your spouse is available in $10 000 increments, with a minimum benefit of $10 000 and a
maximum of $100 000, as long as the amount does not exceed the maximum allowable of 50% of the employee
amount, permitted by the State of Washington.
Coverage is also available in the amount of $2 000, $5 000, or $10 000 as long as the amount does not exceed the
maximum allowable of 50% of the employee amount, permitted by the State of Washington for your dependent
child(ren) age 15 days to 19 years (23 years if a full time student) provided that they have not been hospitalized in the
90 days prior to enrollment. A full Statement of Health is required if your child has been hospitalized in the 90 days
prior to enrollment.
COVERAGE IN RETIREMENT
Avista Corporation s Optional Life plan allows you to continue your current term coverage on your life and your
dependents when you retire. The group rates listed still apply, and your premium will be taken directly from your
Avista pension check. Retirees are not allowed to purchase new coverage or increase their current coverage levels.
ELIGIBILITY
To be eligible for these coverages, you must be actively at work on the effective date. The definition of actively at
work differs slightly for each coverage. "Actively at Work" means that you have worked at least 20 hours over the
last seven consecutive calendar days at your usual place of business, or away from your usual place of business at
your employer s request, doing all the substantial and material duties of your regular employment or occupation.
Your dependent must also be able to perform "nonnal activities." This means that the dependent is not confined at
home under the care of a physician due to sickness or injury and is not receiving or is entitled to receive any
disability income from any source due to their own sickness or injury.
EVIDENCE OF INSURABILITY
If you apply for optional life coverage amounts in excess of 1 times your basic annual earnings, or your dependents
apply for coverage amounts in excess of $50 000, or if any applicant has been hospitalized within 90 days of
enrollment, a full Statement of Health must be completed for each individual applicant and returned with your
enrollment form.
Employees will be allowed a coverage increase of one times pay up to the plan maximum subject to medical evidence
once per year on January 1.
If you decide to increase or enroll for coverage after the enrollment period has ended, all applicants will be required
to complete a Statement of Health form regardless of the coverage amount selected.
If your spouse is covered under your employer s current plan, your spouse can obtain coverage equal to the stated
amount without evidence of insurability or hospitalization requirements.
TO ENROLL
Contact Human Resources for a MetLife enrollment packet. Upon Metlife s review of your formes), additional
medical information may be required based on you and/or your dependent's health status , and coverage amount
elected. You will be advised when coverage is approved or if additional information is needed.
COST TO YOU
Rates (cost per $1 000 of coverage) are based on employee/spouse age. Premiums will increase or decrease
accordingly dependent on age, salary, and coverage levels. Premiums will automatically increase as employee or
souse s a e reaches increased a e brackets.
Less Than 30
30-
35-
40-44
45-49
50-
55-
60-
65-
70-
75 +
*Per $1 000/ month
$ .
.25
.46
1.04
1.65
Child(ren) Rate: Cost is $.12 per $1 000 of coverage and covers all eligible children, regardless of number.
Notices:
.:.
Please refer to the Benefit Plan for more detail and plan exclusions. Like most group policies, MetLife s group
policies contain certain exclusions, limitations, reductions and terms for keeping them in force.
A vista Corp.
Accidental Death & Dismemberment Insurance (AD&D)
OVERVIEW
The AD&D Program provides protection in the event of accidental death for both you and your family. In addition
the program provides benefits in the event of loss of limb, eyesight , speech or hearing.
ELIGIBILITY
You are eligible to participate in the Plan if you are a:
Regular or full-time employee, or
Regularly scheduled (20+ hours) part-time employee. (Casual or temporary employees are not eligible).
Your spouse under the age 70 and unmarried dependant children under the age of 19 are also eligible. Unmarried
children who are full time students and primarily dependant on you for support are also eligible to age 23.
WHEN AM I COVERED?
You are covered 24 hours a day. Anywhere in the world. On the job or at home. And these benefits are payable in
addition to any other insurance you have.
WHEN WILL MY COVERAGE BECOME EFFECTIVE?
If you are eligible you may enroll for coverage at any time during the year. Coverage will become effective on the
first of the month on or next following the date your enrollment form is received.
CAN I CHANGE MY COVERAGE AFTER I'VE ENROLLED?
Yes. To request a change in coverage, simply complete a new enrollment form. Forms are available in the Benefits
Section, Human Resources. The change will become effective on the first of the month on or next following the date
your enrollment is received.
WHO WILL BE THE BENEFICIARY?
Benefits for loss to your life will be paid directly to the beneficiary you have designated. If you have not designated
a beneficiary, the life benefit will be paid to your estate. Benefits for loss other than life will be paid to you. All
dependent benefits are paid to you.
BENEFITS FOR ACCIDENTAL DEATH AND DISMEMBERMENT
If an injury results in any of the following losses within 365 days after the accident, this plan will pay:
For Loss of:
Life
Both Hands or Both Feet or Sight of Both Eyes
One Hand and One Foot
Speech and Hearing
Either Hand or Foot and Sight of One Eye
Movement of Both Upper and Lower Limbs (Quadriplegia)
Movement of Both Upper and Lower Limbs of One Side of the Body
Either Hand or Foot
Sight of One Eye
Speech or Hearing
Thumb and Index Finger of Either Hand
Movement of Both Lower Limbs (Paraplegia)
Principal Sum
Principal Sum
Principal Sum
Principal Sum
Principal Sum
Principal Sum
One-Half of Principal Sum
One-Half of Principal Sum
One-Half of Principal Sum
One-Half of Principal Sum
One-Quarter of Principal Sum
Three-Quarters of Principal
The total limit of liability for anyone person for all losses due to the same accident will not be more than the
Principal Sum.
Loss means with regard to hands and feet, actual severance through or above wrist or ankle joints; sight, speech or
hearing, entire and irrecoverable loss thereof; thumb and index finger, actual severance through or above the
metacarpophalangeal joints; movement of limbs, complete and irreversible paralysis of such limbs.
Injury means a bodily injury resulting directly from an accident, and independent of all other causes. Loss resulting
from sickness or disease, or medical or surgical treatment of a sickness or disease, is not covered. The accident must
occur while you are covered under the policy.
$20 000 EDUCATION BENEFIT
(Pays up to $5 000 per year, for up to 4 years)
If your dependents are covered under the family plan and you die, and the Principal Sum is payable, the plan will pay
an Education Benefit to each student. The education benefit will be the lesser of 5% of your Principal Sum or the
maximum amount of $5 000.
To receive this benefit, a student must show proof that, on the date of your death he or she was a covered dependent
and:
a full-time post-high school student in a school for higher learning, or
a student in 12th grade and becomes a full-time post-high school student in a school for higher learning
within 365 days.
This benefit is payable every year in which the student meets the above definition for up to 4 years, provided the
dependent submits proof of his or her student status each year.
If an Education Benefit would be payable, but no person qualifies as a student, the plan will pay the minimum
amount of $1 500 according to the terms of the beneficiary section.
000 SPOUSE EDUCATION BENEFIT
If your dependents are covered under the family plan and the Principal Sum is payable because of your death, the
plan will pay your spouse an Education Benefit. This benefit will be the lesser of:
. 5% of your Principal Sum, or
the Expense Incurred for Occupational Training, or
the maximum amount of $5,000.
To qualify for this benefit, your spouse must enroll in an Occupational Training Program for the purpose of earning
an independent income. Enrollment must take place within one year of your death, and expenses must be incurred
within two years of your death.
If the Principal Sum is payable because of your death, and no covered spouse survives, the Plan will pay the
minimum amount of $1 500, according to the terms of the beneficiary section.
Expenses Incurred means actual tuition charged and cost of materials required for the Occupa~ional Training
Program. It does not include room and board.
Occupational Trainine: Proe:ram means any educational, professional, or trade, which prepares your spouse for an
occupation for which he or she would not otherwise be qualified.
$10 000 DAY CARE BENEFIT
(Pays up to $2 500 per year, for up to 4 years)
If your dependents are covered under the family plan and you die, and the Principal Sum is payable, the plan will pay
a Day Care Benefit on behalf of each eligible dependent. The Day Care Benefit will be the lesser of 2.5% of your
Principal Sum or the maximum amount of $2 500.
To receive this benefit, an eligible dependent must be under age 7 and:
be enrolled in a licensed Day Care Program, or
will be attending such a program in 365 days.
This benefit is payable every year for up to four years, provided the dependent child continues to be enrolled for Day
Care and is under age 7.
. If a Day Care Benefit would be payable, but no person qualifies as an eligible dependent, the plan will pay the
beneficiary s benefit of $1,250.
$10 000 SEAT BELT BENEFIT
If you or your dependents suffer a loss payable under the Accidental Death and Dismemberment Benefit, the plan
will pay an additional benefit of lO%of the applicable principal sum to the maximum amount of $10 000 if injury
occurred:
while a passenger in or the licensed operator of a registered automobile; and
while wearing a Seat Belt, as verified in the policy accident report.
This benefit does not cover loss if you are operating the automobile under the influence of any intoxicant, excitant
hallucinogen, narcotic or other drug, or similar substance as verified in the policy accident report.
Automobile means a four-wheeled, private passenger car, station wagon, van or jeep-style vehicle, which is not
being used as a Common Carrier.
Common Carrier means a vehicle operated by a business organized and licensed to transport passengers for hire
and operated by an employee of that business. The Policyholder s business does not qualify as a Common Carrier
under this contract.
CAN I CONVERT COVERAGE?
Yes. If your coverage terminates because you are no longer eligible, you may convert to a policy from ITT Hartford
and no evidence of insurability is required. You may only convert coverage if the policy is in force and you have
paid the premium. You must request conversion in writing to ill Hartford and pay the initial premium within 31
days of the date this conversion terminates. Dependent coverage can be converted if your dependents were covered
under this policy on the date your coverage ceased. The maximum benefit amount is $100,000.
SCHEDULE OF BENEFITS
Cost to You Per Month - You
Princi al Sum
$25 000
000
000
100 000
125,000
150 000
175 000
200 000
225 000
250 000
REDUCTION DUE TO AGE
Your Principal Sum automatically reduces on the premium due date on or next following the date you attain the age
indicated below:
Insured Person s Age
Age 70-
Age 75-
Age 80-
Age 85 or over
Percentage of Principal Sum
65%
45%
30%
15%
SCHEDULE OF BENEFIT OPTIONS
If both you and your spouse are employed by A vista Corp. and are eligible for this coverage, only one may purchase
the Family Plan. Please check with the Benefits Department for further details.
F AMIL Y PLAN:
In addition to your own coverage, family coverage provides the following insurance for your dependants:
1) If you have a spouse only, your spouse is insured for 60% of your Principal Sum.
2) If you have a spouse and children:
a. Your spouse is insured for 40% of your Principal Sum and
b. Each unmarried dependent child, under age 19, is insured for 10%of your Principal Sum (to age 23 if
eligible) .
3) If you have children only (no spouse), each unmarried dependant child, under age 19, is insured for 20%
of your Principal Sum (to age 23 if eligible).
ARE THERE ANY EXCLUSIONS?
Yes. Loss caused by any of the following events is not covered:
Intentionally self-inflicted injury, suicide or attempted suicide, whether sane or insane.
War or act of war, whether declared or not.
Injury sustained while in the armed forces of any country or international authority.
Injury sustained while riding on any aircraft, unless it s a civilian or public aircraft, or military transport
aircraft.
Injury sustained while riding on any aircraft as a pilot, crewmember, student pilot, flight instructor, or
exannner.
Injury sustained while riding on any aircraft owned, operated or leased by or for the policyholder or any
employer or organization whose eligible persons are covered under the policy.
Injury sustained while riding on any aircraft being used for or in connection with crop dusting or seeding
or spraying, fire fighting, exploration, pipe or power line inspection, any form of hunting, bird or fowl
herding, aerial photography, banner towing or any test or experimental purpose, unless previously
consented to in writing by the company.
CAN MY COVERAGE BE TERMINATED?
Yes. Coverage will terminate on the earliest of the following dates:
The date the policy is terminated
The premium due on or next following the date you are no longer an eligible person or fail to pay
prennum.
Coverage for eligible dependents terminates on the premium due date next following the earlier of:
The date you cease to be insured
The date your dependent is no longer eligible
The date your covered spouse reaches age 70.
Family coverage provides, in addition to the employee s coverage:
If you have spouse only, your spouse is insured for 50% of your Principal Sum.
A vista Corp.
APS Employee Assistance Program (EAP)
Overview
The APS Healthcare Employee Assistance Program (EAP) is a benefit available to A vista Corporation employees
their dependents, and household members. This EAP provides confidential, short-term counseling at no out-of-
pocket expense to you for up to eight (8) sessions. Your EAP encourages you to seek assistance before a concern or
issue becomes serious. APS therapists evaluate any concern affecting one s life, including alcohol and drug abuse
marital and family issues, financial difficulties, emotional concerns, and work stress.
Discussions and personal information are never shared with anyone, including your employer, without your direct
knowledge and written approval. Exceptions are made only in cases governed by law to prot~ct individuals threatened
by violence.
Employees and managers may make an appointment with a local, licensed, professional therapist by calling 533-6175
in Spokane or 800-999-1 077 outside the area, during regular business hours. Employees and family members who
need an immediate response for crisis counseling or after-hours assistance may call the APS toll-free, 24-hour Crisis
Line at 800-833-3031. You may also receive free legal and financial consultations by calling 800-999-1077.
Some common employee concerns:
Family
Drug Abuse
Alcohol Abuse
Mari tal/Rela tionshi p
APS Employee Assistance Legal Services
Work Related
Emotional
Financial
Because almost every life event can involve a legal question or problem, APS offers both free legal consultations and
discounted legal referrals. Complex legal language and the legal system may intimidate many people in general. APS
legal services will help calm many fears and anxieties associated with legal concerns by answering basic questions
and simplifying the process of obtaining legal help.
Sorne common legal concerns include:
Divorce
Wills
Child custody
Immigration
Estate planning
. Wage garnishment
Legal consultation
Guardianship
. Tenant's rights
Order for protection
Civil disputes
Criminal issues
Commercial concerns
Taxes
Litigation
Power of attorney
. Consumer s rights
Bankruptcy
Liens
Legal consultations may be the catalyst you need to create an action plan to resolve or alleviate your legal concern.
The legal consultations are provided at no cost to you , whether you speak with the attorney over the telephone or in
their office. When you call you will be directed to a lawyer in the city or community where the legal concern is
taking place. On average, the "lead lawyer" in the firm has over twenty years of experience.
Legal consultations are available during business hours, Monday through Friday. Legal consultations may also be
available during "off-hours" for emergencies. APS staff members are always available 24 hours every day if you
need information about legal services or simply wish to discuss any concerns that may accompany your legal issues.
Local legal referrals
It may be necessary to get a referral to meet with a lawyer in-person. Referrals will be made to a law firm in your
area. Referral lawyers have agreed to provide the initial half-hour consultation at no cost to you. If you decide to
retain the lawyer for further services, the lawyer will charge you at a special 25% reduced rate from their regular fees
because you were referred through APS. If for any reason you would like to use another lawyer, APS will provide
another referral resource.
APS Employee Assistance Financial Services
Family problems and daily living issues often include a financial component. For example, clients may be
concerned about the impending costs of an upcoming tax bill. Individuals struggling with a difficult domestic
situation may be worried about the financial impact of separation or divorce.
Clients who contact their Employee Assistance Program (EAP) with financial concerns can be connected to a
financial consultant who is able to discuss these concerns and provide suggestions regarding a course of action. This
telephonic consultation is provided free of charge to the employee or their dependent family members. The financial
consultant will review the client s past financial history, assess the current situation and problem solve with the client
to develop a resolution strategy. When appropriate, the EAP can provide a local community referral for a specific
concern.
Examples of areas in which the EAP can help include:
Taxes
Failure to file
Payment plans
Withholding questions
Tax preparation
Education
College funding
Alternatives to Bankruptcy
Credit counseling
Housing
Utility collections
Credit Problems
Credit card debt
Overextended
Negotiating with credit card companiesMortgage
Qualifying for a mortgage
Refinancing
Avoiding foreclosure
Budgeting & Cash Flow
Developing a budget
Retirement Planning
401 K Plans
lRAs & Stock Options
. What will I need?
Credit Restoration
Dealing with credit bureaus
If you have financial concerns, the EAP is there to help. APS Employee Assistance counselors are available 24 hours
per day to assist, no matter what the problem.
A vista Corp.
Tuition Aid Program
A VISTA Corp. will provide financial assistance to employees for approved courses when these can be shown to
reasonably add to the employee s improved performance and effectiveness in present or foreseeable future jobs
within the Company.
Tuition aid of up to $2 500 in any calendar year is available for the cost of tuition and books. Tuition and the
required class related fees billed by the institution are reimbursed at 100%, and books are covered at 50%.
Supplies, software, equipment, parking or other non-tuition fees are not covered costs. Any course required to
complete an undergraduate or masters level program is covered.
Regular; full-time or regularly scheduled part-time employees are eligible for tuition aid if:
the course is offered by an approved and accredited college, university, or academic institution
the course is necessary to satisfy a requirement for a degree program
the employee provides verification of satisfactory course completion
Tuition is granted based on the following schedule:
Employee receives tuition reimbursement for classes completed with a grade of C (2.0) or better. Grades
below a C, or courses dropped, will not receive financial support.
Employees who voluntarily terminate their employment before completing the course(s) will not receiv
reimbursement.
. By signing the tuition aid application , employee agrees to these terms.
PROCEDURE:
Complete the Tuition Aid Application and have your supervisor sign it to approve the course or degree
program.
Pay for your tuition and books and retain all receipts.
After completing the class(es) and receiving your grade(s) of a C (2.0) or better, submit the completed
application, copies of all recei?ts, and grade(s)to the Tuition Aid Coordinator in the Human Resources
Department at MSC-39.
Accounts payable will then notify you when your reimbursement is ready. Please allow up to three weeks for
reimbursement.
vista Corp.
Adoption Reimbursement Benefit
ELIGIBILITY
You are eligible to participate in the Plan if you are a:
Regular or full-time employee , or
Regularly scheduled (20+ hours) part-time employee. (Casual or temporary employees are not eligible).
HOW THE PLAN WORKS (Tax Free Benefit)
To support your decision to adopt a child under the age of 12, the Company will provide eligible employees 000
per adopted child to mitigate adoption expenses and possible time off without pay. The natural child of either parent
is excluded. Contact the benefits department for more information.
vista Corp.
Jury Duty
ELIGIBILITY
You are eligible to participate in the Plan if you are a:
+ Regular (Frr or prr) employee
How THE JURY DUTY BENEFIT WORKS
To encourage civic duty, you may serve on jury duty and receive full pay from the Company for the
time served. You will be expected to work at your regular duties for days or partial days while not on duty.
Employees are not required to "pay back" to the Company any daily stipend allowance provided by the
court.
vista Corp.
Key Definitions for Medical Plan Coverage
(A vista MSC-EBA Medical Plan)
ALLOWABLE CHARGE
The maximum allowable charge to which the Plan will apply its percentage of payment is the charge that the Plan has
negotiated with its preferred providers. For services or supplies for which there is no agreement between the Plan
and any providers, the Plan will apply its percentage of payment based on the usual, customary and reasonable charge
for the area in which the service or supply was rendered. When a Plan participant must use a Non-Preferred Provider
because of medical emergency, medical necessity or residence outside of the service area, the Plan will apply its
percentage of payment based on the usual, customary and reasonable charge for the area in which the service was
rendered.
CO-INSURANCE (out-of-pocket)
The 10% you pay toward a covered expense that is only covered at the 90% level. The out-of-pocket maximum is
$450 per calendar year per person.
CO-PAYMENT
The fixed $15 amount you pay toward a covered expense. (I.e. Dr. Office Visit co-pay)
The vision exam co-pay is $10.
DEDUCTIBLE
The $225 front-end amount you pay each year for certain services before the Plan pays benefits. Certain services are
subject to deductible.
LIFETIME MAXIMUM
The $1,000 000 total benefit limit offered to a Plan participant over the course of his or her lifetime.
LIMITATIONS AND MAXIMUMS
Specific limitations and maximums may apply for special services such as mental and nervous conditions, substance
abuse, chiropractic, well-baby care, hospice and home health care, special nursing care, rehabilitative therapy,
physical therapy and TMJ treatment.
OUT-OF-AREA EMERGENCY
Generally, an out-of-area emergency is one in which Preferred Providers are not geographically available (or within
30 miles) and the situation is life threatening.
OUT-OF-POCKET MAXIMUM
An out-of-pocket maximum limits the amount of co-insurance you must pay during the year. This out-of-pocket
maximum provision applies to all services and benefits subject to co-insurance except rehabilitation services and
therapy, mental health services, educational programs, special nursing care and services of a Non-Preferred Provider
unless treatment is for a medical emergency.
PREFERRED PROVIDER DIRECTORY
Directories for Preferred Providers under the Avista-EBA Plan are available in Human Resources.
Contact Premera Blue Cross at 1-800-572-0778 for more complete information.
PREFERRED PRO VID ERS
Are health care providers such as doctors, hospitals, and clinics that have signed special agreements with Medical
Service Corporation.
WHEN PREFERRED PROVIDERS ARE A AILABLE
If you live within a Preferred Provider service area, you must use doctors and facilities from the approved list in order
to obtain maximum benefits. If you receive service from a provider who is not on the list, some of your benefits will
be paid at a lower level, and some services not covered at all.
WHEN PREFERRED PROVIDERS ARE UNA AILABLE
If you live outside a Preferred Provider service area, you may use any physician or hospital and receive maximum
benefits. But if there are an adequate number of Preferred providers in your service area, you must use a preferred
Provider in order to receive maximum coverage under the plan.
EMERGENCY CARE
If emergency services are needed due to an accidental bodily injury or medical emergency and are provided by a non-
preferred provider because the services of a Preferred provider were not reasonably available, the Plan will pay the
amount it would have paid a Preferred provider. It will pay for these services by a non-preferred provider for a
period of 24 hours and such minimum additional time as is required for the patient to come under the care of a
Preferred Provider.
DEPENDENT STUDENTS ATTENDING A HIGHER EDUCATION CENTER
Dependent students attending an institution of higher education located 50 miles or more form a Preferred Provider
will be reimbursed for services of a non-preferred provider at 100% of the reasonable charge for the area in which the
service is received.
It is your responsibility to notify Premera Blue Cross with the name of the dependent student and the dates the
student will be out of the service area. Otherwise, claims will be paid as non-preferred provider services.
PREFERRED VS. USUAL, CUSTOMARY AND REASONABLE (UCR) CHARGES
This Plan talks about two types of charges: "Preferred" and "VCR." These are shortened terms for "preferred
allowable charges" and "usual , customary and reasonable charges." Preferred charges are discounted fees that
Preferred Providers have agreed to accept as their full charge. Where the plan has not arranged for a preferred
charge, the Plan bases its benefits on UCR charges. These are non-discounted fees that are accepted to be usual
customary and reasonable (VCR) for the geographic area in which the service is offered.
When you use a Preferred Provider, the Plan covers all or part of preferred charges. Because these charges are
prearranged, you should have no surprises in your bill.
Fees charged by providers who are not preferred are not limited in this way. These fees might also exceed what is
reasonable for the area. You should know that the Plan will not pay fees that exceed preferred or VCR charges. You
must pay the difference.
COVERAGE OUTSIDE PLAN SERVICE AREA
The plan will pay for the expense of treatment outside the Plan service area for illness or accidental injuries as
follows:
Nonemergency care: Coverage will be provided the same as for services and supplies received in the Plan service
areas from a provider that is not preferred.
Emergency care: Treatment of accidental bodily injury or medical emergency will be paid at the amount that would
ordinarily be paid for like services up to the VCR charge in that area.
MEDICAL INSURANCE OUTSIDE OF THE
The Department of State strongly urges Americans to consult with their medical insurance company prior to traveling
abroad to confirm whether their policy applies overseas and if it will cover emergency expenses such as a medical
evacuation. U.S. medical insurance plans (such as Avista s Premera Blue Cross and Group Health plans) seldom
cover health costs incurred outside the United States unless supplemental coverage is purchased. Further, U.
Medicare and Medicaid programs do not provide payment for medical services outside the United States. Many travel
agents and private companies offer insurance plans that will cover health care expenses incurred overseas, including
emergency services such as medical evacuations, but doctors and hospitals in some countries often do not accept U.
medical insurance, even if the policy applies overseas.
Many foreign doctors and hospitals require payment in cash prior to providing service, and medical evacuation to the
United States may cost well in excess of $50 000. Uninsured travelers who require medical care overseas often face
extreme difficulties. When consulting with your insurer prior to your trip, please ascertain whether payment will be
made to the overseas healthcare provider or if you will be reimbursed later for expenses that you incur. Some
insurance policies also include coverage for psychiatric treatment and for disposition of remains in the event of death.
Useful information on medical emergencies abroad, including overseas insurance programs, is provided in the
Department of State s Bureau of Consular Affairs brochure lvIedicallnformation for Americans Trovelin,? Abroad
available via the Bureau of Consular Affairs home page or autofax: [phone].
Contact Premera Blue Cross at 1-800-572-0778 for more information regarding coverage outside of
the
A vista Corp.
Medical Insurance: Avista-EBA Plan
ELIGIBILITY
You are eligible to participate in the Plan if you are a:
Regular or full-time employee, or
Regularly scheduled (20+ hours) part-time employee. (Casual employees are not eligible).
Regular Temporary Employee, scheduled for 20+ hours per week for a minimum of 6 months
COST TO YOU
EBA Emp
36.49
68.
62.
95.
328.43
620.
565.
857.
Total
364.
689.
628.
952.44
E only
E+Sp
E+Ch
E +All
HOW SELF -INSURED PLAN WORKS
The A vista-EBA PLAN is a self-insured plan that is a "Preferred Provider" plan, and includes coverage for medical
dental , prescription drugs, and vision care. Third-party administrators process and pay claims for the A vista-EBA
PLAN. Participants residing in the Preferred Provider service area must utilize physicians from the Preferred
Provider listing to receive maximum benefits. If you obtain service from a Provider who is not preferred, your
benefits will be paid at a lesser amount and some benefits will not be covered at all.
DEPENDENT ELIGIBILITY
Must be a lawful spouse or a dependent child.
Dependent child eligibility to aJ!e whether or not a student; must be dependent on subscriber for support.
It is the subscriber s responsibility to maintain accurate and timely dependent eligibility information. The
employee must inform the Benefits Department within 30 days of a qualifying event of a dependent no longer
being eligible. Coverage for that dependent will end on the last day of the month in which the qualifying event
occurs.
Contact Premera Blue Cross at 1-800-572-0778 for more complete information.
Premera Blue Cross
A VISTA MSC-EBA PLAN
Annual Deductible:$225 per person $675 per family
Coinsurance:90% (70% out of network)
Out-of-pocket Maximum:$450 per person $1350 per family
Lifetime Maximum Benefit:000 000
Minor Emergency or Urgent Care Facility:
Hospital emergency rooms are subject to deductible)
$15.
Physician Office Visits:$15.
Specialist Visits:$15.
Surgery Done In Office:$15.
Chiropractic:90% (Maximum $1 000 per year)
Immunizations:100% (Immunizations are subject to age limitations & other
plan limits; contact Premera Blue Cross for eligibility)
Diagnostic-Therapeutic Lab & X-ray:90%
MRI:90%
Physical Exam:
(One per calendar year)Covered in full to a maximum
of $500 per person, including lab and x-ray.
(Mammograms are not covered under the annual exam.
Mammograms are a separate charge covered at 90%)
Physical Therapy:90% (Maximum $1 000 per year)
Routine Newborn Well Nursery Care:100% of the allowable charge for the first 48 hours
Well Baby Care:
(Baby under the age of 1 year)
7 Visits covered at 100%
Mammograms:90%
Ambulance:90% (Subject to deductible)
Cardiac Rehabilitation:
(Subject to deductible)
90% up to $1 000 per year
Durable Medical Equipment:
(Limited to the rental price or initial acquisition price)
90% (Subject to deductible)
Hearing Aids:
(Employee only)
Paid at 100%, once every five years, limited to $1 000
Home Health Care:100% (Must be preauthorized; limited to the greater of 130
visits or $10 000 per year)
Infertility Services:90% (Maximum $2,000 per year; $6 000 per lifetime)
Orthotics:Subject to deductible and covered at 90% thereafter
Institutional Inpatient 90%. Must be pre-authorized with Premera Blue Cross.
($1 000 penalty applied if not pre-authorized)
Semi-Private Room:90%. Must be pre-authorized with Premera Blue Cross.
($1 000 penalty applied if not pre-authorized)
Miscellaneous Services and Supplies:90%. Must be pre-authorized with Premera Blue Cross.
($1 000 penalty applied if not pre-authorized)
Institutional Inpatient Private Room:90%. Must be pre-authorized with Premera Blue Cross.
($1 000 penalty applied if not pre-authorized)
(When Medically Necessary):
Institutional Outpatient Services:90% (Subject to deductible)
Mental & Nervous:Institutional: 12 days paid at 90%
Professional: 60 visits paid at 90%
Lifetime maximums:
180 visits for professional.
36 days for Institutional
(Not subject to out-of-pocket maximum; referral by a
physician or EAP counselor required)
Maternity Benefits:Covered as any other condition
(Enrolled Employees and spouses only)
Rehabilitation Services:90%
(Must be preauthorized; not subject to out-of-pocket
maximum) (Up to $5,000 + additional $15 000 for stroke or
spinal cord injury per occurrence)
Skilled Nursing Facility:90% (Subject to deductible)
Special Nursing Care:90% (Must be preauthorized; maximum $1 000 per year)
Sterilization:Covered as any other illness or injury.
Substance Abuse:500 outpatient per year, lifetime maximum $5,000
000 inpatient per year, lifetime maximum $18 000.
(Must be preauthorized; Referral by a physician or EAP
counselor required)
Prescriptions
Generic Prescriptions:(3D-day supply): $5.00 co-pay for Generic Drugs
Brand Name Prescriptions:(30-day supply) (When a generic drug is not available):
$20.00 co-pay for Non-Generic when Generic is not
available
Brand Name Prescriptions:(30-day supply) (When a generic drug~ available):
$40 co-pay for Non-Generic drugs when a generic lli
available
Birth Control Pills:Birth Control Pills are covered under the prescription
drug provision. ("Over -the-counter" birth control items are
not covered under the plan) Contact Premera Blue Cross
directly for more information regarding birth control.
Every Employee Should Take Advantage of the Home Delivery Pharmacy Service
With prescription costs increasing 20% - 25% annually, Avista encourages all employees to do their part in
keeping costs down by utilizing Generic drugs whenever possible and also to take advantage of the Home
Delivery Pharmacy Service (Mail Order Prescription Program).
This program is an expansion of your current prescription drug benefit program. It is ideal for people who take
prescription medication on an ongoing basis. Listed below are several advantages to this program that are
detailed in the enclosed Home Delivery Pharmacy Service materials:
Immediate Savings: When you order by mail you can get up to a 90-day supply for only one copayment.
Convenience: You save time by simply mailing your prescriptions to Merck-Medco. Merck-Medco will
send your prescription to your home via US mail, postage paid.
Contact Human Resources at ext. 4751 to obtain order forms and an informational brochure.
Vision Benefits
Routine Eye Exam:Paid at 100% after $10 co-pay. Once per calendar year.
Lenses:
Frames:
Contacts:$150 per year allowance for:
Lenses, Frames or Contacts once per calendar year.
CONTROLLING COSTS
Your medical plan offers several features to reduce unnecessary treatment, provide care at the proper level, and
protect your rights as a health care consumer. These features help you and A vista Corp. reduce waste and
increase the quality of our health care. Please read these provisions carefully. If you do not follow the guidelines
you may incur up to an additional $1 000 in charges for your care.
Voluntary Second Opinion Before Surgery. You may voluntarily obtain a second opinion for certain
elective non-emergency surgeries from a physician who is not affiliated with your first physician. If the second
opinion disagrees with the first opinion , you may seek a third opinion. These second and third opinions will be
covered at 100% when provided by a network physician. Regardless of the second or third opinion , you may
choose whether or not to have the elective surgery.
Mandatory Outpatient Surgery. There are many surgical procedures that must be performed on an
outpatient basis unless medical necessity requires the surgery to be performed on an inpatient basis. Please check
with your health plan s member services for a list of these procedures.
Preadmission Testing. Tests that can be done prior to inpatient admission should be completed in an
outpatient setting within seven days prior to admission. These tests will be subject to any applicable deductibles
and covered at 100% of the allowed charge when you receive these services from a Preferred Provider.
Hospital Admission Certification. This certification must be obtained for all inpatient admissions prior to
three days before admission for non-emergency situations and within 48 hours of admission for emergencies.
Concurrent Review. Inpatient stays will be reviewed concurrently to monitor standards for quality of care
medical management, length of stay, and medical necessity. In the event that it is determined that benefits will
not be provided, you and your attending physician will be notified of your medical plan s intent to cease benefits.
Services not covered
Certain services are not covered. The limitations below provide an overview of these exclusions, but it is not
exhaustive list of all exclusions. Please read these provisions carefully and contact your plan if you would like
more information.
1. Any condition for which the Veteran Administration or any of the armed services is responsible or provides
treatment, except as required by law.
2. Dental care or condition, whether resulting from disease or dental treatment, are not covered. Please see your
Dental SPD for details on your separate dental program.
3. Replaceable blood or blood products except for the administration and processing of blood.
4. Drawing and processing of autologous blood for transfusion.
5. Homeopathic care, acupuncture, shiatsu, biofeedback, alternative medicine or other forms of self-care or self-
help training and any related diagnostic testing.6. Orthopedic appliances prescribed primarily for use during participation in sports, recreation and similar
activities.7. Services and supplies to the extent that they are not medically necessary for treatment of an injury, illness or
physical disability; hospitalization for a condition for which patients are not usually hospitalized; any service
or benefit not listed as covered in the plan documents.
8. Experimental or investigational services, except as otherwise defined.
9. Medical, surgical or hospital services or supplies incident to the placement of nonhuman or manufactured
organs, and other organ transplants, except as specifically identified in the plan documents.
10. Conditions resulting from prior military service or declared or undeclared war.
11. Services received prior to the effective date of your coverage.
12. Thermography.
13. Services or supplies for which you are not legally liable.
14. Cosmetic surgery that is not for an eligible nonoccupational accidental bodily injury.
Women s Rights Regarding Cancer
The Women s Health and Cancer Rights Act of 1998 requires that our plan provide the following medical and
surgical benefits after mastectomies in a manner determined in consultation with the attending physician and the
patient, including:
reconstruction of the breast on which the mastectomy has been performed
surgery and reconstruction of the other breast to produce a symmetrical appearance
prostheses and physical complications of all stages of mastectomies, including lymphedemas (please follow
pre-certification procedures).
Newborns and Mothers Health Protection Act
Under federal law, our plan will not restrict benefits for any hospital length of stay in connection with childbirth
for the mother or newborn to less than 48 hours following a vaginal delivery, or less than 96 hours following a
delivery by cesarean section. Please follow the plan procedures for obtaining pre-certification for any hospital
stay.
Coordination of Benefits with Other Plans
You or an eligible dependent may be entitled to medical benefits under another group plan. If so, all benefits due
to you will be coordinated with the benefits from the other plan. This means that the total amount paid under all
plans can amount to as much as 100% of the allowable charges ... but no more than this amount. (Different rules
apply if you are eligible for Medicare. Contact Human Resources for further information.) The word "plan" for
this purpose means a plan providing coverage for hospital and medical care. This includes:
group, blanket or franchise insurance, or other prepaid group plans, and
federal or statutory plans.
If you have an expense that is covered by two plans, one plan will pay your claim first. This plan is called the
primary plan. The other plan - called the secondary plan - will then pay some or all the difference (if any)
between what the primary plan pays and the total allowable expenses.
Your A vista Corp. medical plan is primary for any expenses you incur. The plan that covers your spouse as an
employee is the primary plan for expenses that your spouse incurs. The A vista Corp. medical plan will be
secondary for your spouse in this instance.
If your children are covered as dependents by your plan and your spouse s plan, the primary plan is that of the
parent whose birthday occurs earlier in the year. If you are separated or divorced, the plan of the parent who has
custody of the child pays first unless the divorce decree indicates otherwise. If you remarry and you have
custody, your plan will be primary. . . followed by your spouse s plan and then your former spouse s plan.
If you are an active associate covered by this plan, and you become eligible for Medicare, your Avista Corp.
medical plan will remain primary. If your covered spouse becomes eligible for Medicare, primary coverage will
continue under your active plan unless your spouse is covered as an employee under another group health plan.
Once you retire and are age 65 or older, Medicare becomes primary, and if you are eligible for the Company
retiree medical coverage, the Company s supplemental plan becomes secondary. In a calendar year, this Medical
Plan will pay its regular benefits in full if it is primary, or a reduced amount of benefits if it is secondary.
If you are disabled and have been receiving Social Security disability benefits for 24 months , Medicare will
provide your primary coverage and the Company s supplemental medical plan will be the secondary provider of
coverage
A vista Corp.
Group Health Northwest
ELIGIBILITY
You are eligible to participate in the Plan if you are a:
Regular or full-time employee, or
Regularly scheduled (20+ hours) part-time employee. (Casual employees are not eligible).
Regular Temporary Employee, scheduled for 20+ hours per week for a minimum of 6 months
HOW THE GROUP HEALTH NORTHWEST PLAN WORKS
Group Health Northwest is a Health Maintenance Organization with 143 Family Practice Specialists available
and over 360 community specialists available upon referral by your Group Health personal physician. You
choose from GHNW Medical Centers , Rockwood Clinic, or numerous other community physician partners for
your care. A 24 hr consulting nurse is available for medical advice on holidays, weekends and after hours by
calling 324-6464 or 1-800-826-3620. Group Health emphasizes preventative care and early detection and
treatment of medical conditions.
COST TO YOU
Grou Health
E only
E +Spouse
E +Child(ren)
E +Family
27.
58.
52.
89.
248.
529.
473.47
802.
Total
276.
588.
526.
891.22
SUMMARY OF BENEFITS
This is a brief summary of benefits and limitations. TillS IS NOT A CONTRACT. For a more detailed
description of your benefits and exclusions, refer to your certificate of coverage or contact your employer or
benefits administrator.
Hospital Preauthorization Not required.
Annual Deductible No annual deductible.
Plan Coinsurance No plan coinsurance.
Lifetime Maximum No lifetime maximum.
Out-of Pocket Limit (Stop Loss)
Out of Pocket Expenses paid for covered services:
Inpatient services (except as otherwise noted)
Outpatient services (except as otherwise noted)
Emergency care services
Ambulance services
Limited to an aggregate maximum of $2 000
per Member and $4 000 per family per
calendar year.
Ambulance Service
Emergency (ground/air) ambulance transportation
Chemical Dependency Treatment
Inpatient and outpatient alcoholism and/or drug
abuse treatment authorized by GHC's Medical
Director, including counseling and treatment.
Devices, Equipment and Supplies
Including durable medical equipment, prosthetics
orthopedic appliances, oxygen, ostomy supplies
breast prostheses, glucose monitors and external
insulin pumps
Diagnostic Lab and X-ray
Emergency Care
Provided at GH or GH designated hospital
emergency departments
Provided at non-GH Facilities
Hearing Examinations/Aids
Home HealthIHospice
Hospital Inpatient Care
Hospital room and board
Inpatient surgery and anesthesia
Intensive and coronary care unit
Delivery and associated hospital care , including
home births for low risk pregnancies
Drugs while in hospital
Chemical dependency detoxification
Covered at 80%. Group Health Cooperative
(GHC)-initiated non-emergency transfers are
covered in full.
Limited to $11 285 any 24 consecutive
months. All services are subject to applicable
copayments.
Covered at 80% of charges if authorized in
advance by a GH provider as medically
- necessary, and listed as covered in GHC'
Durable Medical Equipment Formulary,
Orthopedic Appliance Formulary, or Prosthetic
Device Formulary.
Covered in full.
$75 copayment per emergency visit per
Member. Copayment is waived if Member
admitted directly from the Emergency
department.
Covered subject to a $125 deductible.
Deductible is not waived if Member is
admitted directly from the Emergency
department.
If you are admitted to a non-GH Facility, you
must notify GHC within 24 hours by calling
888-457 -9516 in order to be covered.
Hearing examinations covered subject to the
outpatient services copayment. Hearing aids
not covered.
Covered in full.
$100 copayment per day up to a maximum of
5 days per Member per calendar year.
Infertility Services (including Sterility)
General diagnostic services for sterility and
infertility
Specific diagnostic services, treatment, and
outpatient prescription drugs
Manipulative Therapy
Self-referrals for manipulative therapy of the spine
by GH designated providers. The medical necessity
for manipulative therapy must meet GHC protocol.
Mental Health Services
Outpatient mental health services such as
evaluation, crisis intervention, managed
psychotherapy, intermittent care, psychological
testing and consultation services when authorized
by GHC's Medical Director
Inpatient mental health services
Optical Care
Routine eye examinations and refractions
Eyeglass frames and lenses (any type), or contact
lenses, including exams associated with their fitting,
in lieu of standard eyeglass lenses and frames
Organ Transplants (Only kidney, simultaneous pancreas
and kidney, cornea, heart, single lung, double lung, heart-
lung, bone marrow and liver)
Covered subject to the outpatient services
copayment.
Covered at 50% of total charges. Diagnosis or
treatment of sexual dysfunction is not
covered.
Covered up to 10 visits per Member per
calendar year, subject to the applicable
outpatient services copayment.
Covered up to 20 visits per Member per
calendar year, subject to a $20 copayment per
individual/family/couple visit and $10
copayment per group visit. Copayments do
not apply to out-of-pocket limit.
Covered at 80% up to 12 days per calendar
year when referred in advance by GHc.
Coinsurance does not apply to out-of-pocket
limit.
One exam covered per Member in any
consecutive 12 month period, subject to the
outpatient services copayment.
One pair covered up to $150 per Member in
any consecutive 24 month period.
Covered up to a lifetime maximum of
$200 000 per Member, subject to applicable
copayments. Coverage for all transplants
including follow-up care, is excluded until the
Member has been continuously enrolled under
a GHC plan for 12 months.
Outpatient Prescription Drugs
Legend drugs (a drug which by law requires a
provider s prescription), including injectables, and
diabetic supplies including insulin syringes, lancets
urine testing reagents and blood glucose monitoring
reagents, when provided at GH Facilities
prescribed by GH providers and listed as covered in
the GHC drug formulary.
Allergy Serum
Contraceptive drugs and devices and their fitting
Outpatient Services
Office visits
Allergy testing
Radiation therapy, chemotherapy
Outpatient surgery
Podiatric Care
Pre-existing Conditions
Care, medication, or medical advice received for medical
conditions which existed within the three-month period
prior to the effective date of coverage.
Prenatal Care (prenatal and postpartum visits, including
prenatal testing for the detection of congenital disorders)
Preventive Care (most immunizations and vaccinations
and routine mammography screening)
Rehabilitation Services.
Inpatient physical, occupational and restorative
speech therapy services combined, including
services for neurodevelopmentally disabled children
age 6 and under are covered up to 60 days per
condition per calendar year.
Covered subject to a maximum $15
copayment for a supply of 30 days or less of
each prescription or refill. Some exclusions
apply. Copayment does not apply to out-of-
pocket limit.
Covered subject to twelve times the outpatient
prescription drug copayment. Copayment does
not apply to out-of-pocket limit.
Covered subject to the outpatient prescription
drug copayment (including birth control pills).
DepoProvera covered subject to the applicable
copayment. Copayment does not apply to out-
of-pocket limit.
$15 copayment per visit per Member.
Covered subject to the outpatient services
copayment when referred by a GH provider.
Routine foot care is excluded.
Covered in full.
Covered subject to the outpatient services
copayment.
Preventive care visits according to GHC'
well-child" and "well-adult" schedules
including routine mammography screening
when referred by a GH provider, covered
subject to the outpatient services copayment.
Most immunizations and vaccinations covered
in full.
Covered subject to the applicable hospital
inpatient care copayment.
Outpatient physical, occupational and restorative
speech therapy services combined , including
services for neurodevelopmentally disabled children
age 6 and under are covered up to 60 visits per
condition per calendar year.
Skilled Nursing Facility
Full-time skilled nursing care in a GH-approved
nursing facility
Sterilization Services (vasectomy, tubal ligation)
Temporomandibular Joint (TMJ) Services
Inpatient and outpatient TMJ services when
Medically Necessary and authorized by GHC
Lifetime Maximum Benefit
Tobacco Cessation
Approved pharmacy products covered for a 30-day
supply or less of each prescription or refill, when
prescribed by a GHP provider and obtained at a GH
Facility.
Well-Adult Care
Well-Child Care
Covered subject to the outpatient services
copayment.
Covered in full up to a maximum of sixty (60)
days per Member per calendar year.
Covered subject to the applicable copayment.
Procedures to reverse a sterilization are not
covered.
000 maximum per Member per calendar
year.
000 per Member.
Groups purchasing outpatient prescription
drug coverage, will be covered subject to the
lesser of GHC's charge or the outpatient
prescription drug copayment. Groups not
purchasing outpatient prescription drug
coverage may be subject to a charge.
See Preventive Care.
See Preventive Care.
Limitations: Coverage for growth hormone treatment is excluded until the Member has been continuously enrolled
under a GHC plan for 12 months. Coverage for cosmetic services is limited to breast reconstruction following
mastectomy, and reconstructive breast reduction on non-diseased breast. External breast prostheses following
mastectomy, limited to one per diseased breast every two years.
Exclusions: Services or programs not provided or authorized by GHC staff (except as specified); drugs not listed as
covered in the GHC Drug Formulary; travel medications; investigational or experimental procedures, drugs and devices;
dental care; arch supports including custom shoe modifications or inserts and their fittings except for therapeutic shoes,
modifications and shoe inserts for severe diabetic foot disease; convalescent or custodial care; cardiac rehabilitation
programs; services covered by first-party insurance; services covered by government and military programs; employment
license, immigration or insurance examinations or reports.
Unless otherwise noted as covered, the following services are also excluded: diagnostic testing of sterility,
infertility or sexual dysfunction; eyeglasses; contact lenses, including services associated with their fitting,
except following cataract surgery performed at GHC; drugs not requiring a prescription , including diabetic
supplies and contraceptive drugs and devices; hearing aids; equipment, appliances and supplies; skilled nursing
facility services; blood; work-related conditions (including self-employment, L&I and worker s compensation).
A vista Corp.
Dental Benefits
Washington Dental Service (Delta Dental)
SUMMARY OF BENEFITS
Reimbursement Levels for Allowable Benefits
*Class 1........................................................... ................. Constant 1000/0
Class II .............................................................................. Constant 800/0
Class III ............................................................................. Constant 500/0
* Annual Deductible per Person .........................................................$25
* Annual Deductible - Family Maximum ...........................................$75
Annual Program Maximum per Person.........................................000
*Lifetime Orthodontic Benefits per Person ................................ $1,000
The payment level for covered dental expenses arising as a direct result of an accidental bodily injury is 100%
up to the unused program maximum.
All covered employees and covered dependents are eligible for Class I, Class II, Class III, Orthodontic Benefits
and Dental Accident Benefits.
* Annual deductible is waived for Class I, Orthodontic Benefits and Dental Accident Benefits.
Welcome to the DeltaPremier dental plan, which is administered by Washington Dental Service, the state
largest and most experienced dental benefits carrier. Washington Dental Service is a member of the nationwide
Delta Dental Plans Association. With a Delta Dental plan from Washington Dental Service, you join
approximately 1.5 million people who have discovered the value of our coverage.
HOW TO USE YOUR PROGRAM
The best way to take full advantage of your dental plan is to understand its features. You can do this most easily
by reading this benefits booklet before you go to the dentist. The booklet is designed to give you a clear
understanding of how your dental insurance works and how to make it work for you. It also answers some
common questions and defines a few technical terms. If this booklet doesn t answer all of your questions, or if
you don t understand something, call a Washington Dental Service customer service representative at (206) 522-
2300 or [phone].
Choosin2 A Dentist
With Washington Dental Service, you may select any licensed dentist. Tell your dentist that you are covered by a
Washington Dental Service dental plan and give him or her your Social Security number, the program name and
the group number - which is 378.
Member dentists
If you select a dentist who is a member of Washington Dental Service, that dentist has agreed to provide
treatment for eligible persons covered by Washington Dental Service/Delta Dental programs according to the
provisions of his or her member dentist contract. You won t have to hassle with sending in claim forms.
Participating dentists complete claim forms and submit them directly to Washington Dental Service. They receive
payment directly from Washington Dental Service. You will not be charged for more than the approved fee or the
fee that the member dentist has filed with us. You may, however, be responsible for copayments (see Copayment
heading in this section) and for any elective care you choose to receive outside the covered benefits. To find out
whether your dentist is a member, ask him or her, check your plan s Directory of Dentists or go online to the
Washington Dental Service Web site at www.deitadentalwa.com and click on the "Find a Dentist" option.
Nonmember dentists
If you select a dentist who is not a member of Washington Dental Service, you are responsible for having your
dentist complete and sign a claim form. We accept any American Dental Association-approved claim form that
your dentist may provide. It is up to you to ensure that the claim is sent to Washington Dental Service. Since
Washington Dental Service does not have fees on file for nonmember dentists, the payment for services
performed by a nonmember is based upon actual charges or Washington Dental Service s allowable fees for
nonmember Dentists, whichever is less. The payment will be issued in both your name and that of your dentist
unless you specifically authorize that payment be made directly to your dentist.
Out-of-state dentists
If you receive treatment from a dentist outside Washington State, you are responsible for having the dentist
complete and sign a claim form. It is up to you to pay the dentist s bill and submit the claim to Washington
Dental Service. Payment will be based upon actual charges or Washington Dental Service s allowable fees for
out-of-state Dentists , whichever is less.
Claim Forms
American Dental Association-approved claim forms may be obtained from your dentist. Washington Dental
Service is not obligated to pay for treatment performed in the event that a claim form is submitted for payment
more than 6 months after the treatment is provided.
Predetermination of Benefits
If your dental care will be extensive, you may ask your dentist to complete and submit a request for an estimate
called a "predetermination of benefits." This will allow you to know in advance what procedures are covered
the amount Washington Dental Service will pay toward the treatment and your financial responsibility.
Benefit Period
Most dental benefits are calculated within a "benefit period " which is typically for one year. For this program,
the benefit period is the 12-month period beginning January 1 and ending December 31.
Reimbursement Levels.
Your dental plan offers three classes of covered treatment. Each class also specifies limitations and exclusions
(see the explanation of these terms elsewhere in this section). Here is the way the three levels work under your
plan:
The payment level for covered and allowable Class I (diagnostic and preventive) procedures is 100 percent.
The payment level for covered and allowable Class II (basic) procedures is 80 percent.
The payment level for covered and allowable Class ill (major) procedures is 50 percent.
The payment level for covered dental expenses arising as a direct result of an accidental bodily injury is 100
percent, up to the unused program maximum.
See "Benefits Covered by Your Program" for specific Class I, Class II and Class ill covered dental benefits under
this program.
Limitations and Exclusions
Dental plans typically include limitations and exclusions, meaning that the plans don t cover every aspect of
dental care. This can affect the type of procedures performed or the number of visits. These limitations are
detailed in this booklet under the sections called "Benefits Covered by Your Program" and "General Exclusions.
They warrant careful reading.
Copavments (Coinsurance)
A copayment policy is typical of most insurance plans. This means the insurance company (Washington Dental
Service) will pay a predetermined percentage of the cost of your treatment, and you are responsible for paying the
balance. What you pay is called the copayment. It is paid even after a deductible is reached.
Program Maximum
The program maximum is the maximum dollar amount a dental plan will pay toward the cost of dental care
within a specific benefit period. You are personally responsible for paying costs above the annual maximum.
For your program, the maximum amount payable by Washington Dental Service for Class I, II and ill covered
dental benefits (including dental accident benefits) per eligible person is $2 000 each benefit period. Charges for
dental procedures requiring multiple treatment dates are considered incurred on the date the services are
completed. Amounts paid for such procedures will be applied to the program maximum based on the incurred
date.
The lifetime maximum amount payable by WDS for Orthodontic Benefits is $1 000 per eligible person.
Pro2ram Deductible
Most dental plans have a specific dollar deductible. It works like your car insurance deductible. During a benefit
period, you may have to personally pay a portion of your dental bill before your insurance carrier Washington
Dental Service will contribute to your bill.
Your program has a $25 deductible per eligible person each benefit period. This means that from the first
payment or payments made for covered dental benefits, a deduction of $25 is made. Once each eligible person
has satisfied the deductible during the period, no further deduction will apply to that eligible person until the next
period. The maximum deductible per family each benefit period is $75. This means that the maximum amount
that will be deducted for a family, regardless of the number of eligible persons, will be $75. Once a family has
satisfied the maximum deductible amount during the period, no further deduction will apply to that family until
the next succeeding period. The deductible does not apply to Class I, Orthodontic Benefits or dental accident
benefits.
Employee Eli2ibility and Termination
Eligible employees are all full-time and part-time employees for yvhom employercontributions are made.
New employees are eligible on the first day of the month following completion of the waiting period established
by the employer.
You must complete an enrollment form. All of your eligible dependents must be listed on the enrollment form.
Coverage terminates at the end of the month in which you cease to be an eligible employee.
In the event of a suspension of compensation as a result of a strike, lockout, or other labor dispute, an eligible
employee may pay the applicable premium directly to the employer for a period not to exceed six months.
Payment of premiums must be made when due, or Washington Dental Service may terminate the coverage.
The Federal Family and Medical Leave Act ("FMLA") became effective August 5, 1993. The benefits under
your Washington Dental Service dental program may be continued provided you are eligible for FMLA and you
are on a leave of absence that meets the FMLA criteria. For further information, contact your employer.
The "Continuation of Coverage" legislation passed into federal law (PL 99-272 and as amended by PL 104-191)
requires that should certain qualifying events occur which would have previously terminated coverage, employee
coverage may continue for a period of time on a self-pay basis.
When you terminate for reasons other than gross misconduct, you may continue your dental benefits up to 18
months, or until you are covered under another group dental plan, by self-paying the required premium.
Contact your employer for further clarification and details of how they plan to implement this continuation of
coverage for eligible persons.
Dependent Eli2ibility and Termination
If dependent coverage is included in the program, eligible dependents are your lawful spouse and unmarried
children including biological children, stepchildren, foster children , and adopted children. Lawful spouse of
eligible retirees shall continue to be eligible up to age 65.
Children are covered from birth through age 23.
An unmarried child over the limiting age may continue to be an eligible dependent providing all of the following
conditions are met: 1) the child is incapable of self-support because of a physical handicap or developmental
disability that commenced prior to reaching the limiting age, 2) a physician s certificate is submitted to WDS
within 31 days following attainment of the limiting age, and 3) the child was an eligible dependent upon
attainment of the limiting age.
A new family member, with the exception of newborns and adopted children, must be enrolled on the first day of
the month following the date he or she qualifies as an eligible dependent. A newborn shall be covered from and
after the moment of birth, and an adopted child shall be covered from the date of placement for the purpose of
adoption, provided that if this program requires payment of an additional monthly premium for coverage of such
child, enrollment of the newborn or adopted child and payment to Washington Dental Service of all applicable
premiums is completed within 90 days after the date of birth or placement to assure coverage. If no additional
premium is required, Washington Dental Service requests completion of the enrollment process for the newborn
or adopted child within 90 days after the date of birth or placement, but coverage will be provided in any event.
To enroll a newborn or adopted child, an eligible employee parent must complete a new enrollment form
provided by Washington Dental Service. If an additional premium for coverage is required and enrollment and
payment is not completed for a newborn or adopted child within said 90 days, such child may be enrolled
coincident with any renewal or extension of the Contract.
A child will be considered an eligible dependent as an adopted child if the following conditions are met: 1) the
child has been placed with the eligible employee for the purpose of adoption under the laws of the state in which
the employee resides; and 2) the employee has assumed a legal obligation for total or partial support of the child
in anticipation of adoption. Notification of placement of a child for adoption and payment of any additional
required monthly premiums must be furnished to Washington Dental Service within 90 days from the date of
placement.
Dependent coverage terminates at the end of the month in which your coverage terminates, or the dependent
ceases to be an eligible dependent, whichever occurs first.
The "Continuation of Coverage" legislation passed into federal law (PL 99-272 and as amended by PL 104-191)
requires that should certain qualifying events occur which would have previously terminated coverage, dependent
coverage may continue for a period of time on a self-pay basis.
If a dependent no longer meets the eligibility requirements due to the death or divorce of the employee, or does
not meet the age requirement for children , coverage may continue up to 3 years, or until the dependent is covered
under another group dental plan , by self-paying the required premium.
Contact your employer for further clarification and details of how they plan to implement this continuation of
coverage for eligible persons.
COORDINATION OF BENEFITS
If an eligible person is entitled to benefits under two or more group dental plans, the amount payable under this
plan will be coordinated with any other plan. The amount paid by Washington Dental Service, together with
amounts from other group programs, will not exceed 100% of dental expenses incurred and the total amount
payable by Washington Dental Service will not exceed the amount that would have been paid for covered
benefits if no other program was involved.
The following rules establish the order of benefit payments:
a. The benefits of the plan that does not have a coordination of benefits (COB) provision will be primary (the
plan whose benefits are determined first).
b. The benefits of the plan that covers the person as an active employee will be determined before the benefits
of a plan that covers the person as a dependent.
c. If the person is a child whose parents are not separated or divorced:
The benefits of the plan covering the parent whose month and day of birth occurs earlier in the calendar year
will be determined before the benefits of the plan of the parent whose month and day of birth occurs later in
the calendar year. However, if one of the parents' plans does not have this "birthday rule , then the plan
covering the father is primary.
d. If the person is a child of parents who are separated or divorced, then the benefits are determined in the
following order:
(1) The plan of the parent with custody
(2) The plan of the new spouse of the parent with custody
(3) The plan of the parent without custody
(4) The plan of the new spouse of the parent without custody
However, if the court decrees financial responsibility for the child's health care, the plan of the parent with
the financial responsibility is the primary plan.
The plan covering the person as a retired or laid-off employee or dependent of such person will be
determined after the benefits of any other plan covering such person as an employee, other than a laid-off or
retired employee, or dependent of such person. This provision will not apply if neither plan has a provision
regarding laid-off or retired employees , which results in each plan determining its benefits after the other.
f. If the above order does not establish the primary plan, then the plan that has covered that person for the
longest period of time is the primary plan.
In the event Washington Dental Service makes payments in excess of the maximum amount, Washington Dental
Service shall have the right to recover the excess payments from the patient, the subscriber, the provider or the
other plan.
BENEFITS COVERED BY YOUR PROGRAM
The following are Class I, Class II, and Class ill covered dental benefits under this program that are subject to the
limitations and exclusions contained in this booklet. Such benefits (as defined) are available only when rendered
by a licensed dentist or other WDS-approved licensed professional when appropriate and necessary as
determined by the standards of generally accepted dental practice and Washington Dental Service.
The amounts payable by Washington Dental Service for Class I, II and ill covered dental benefits are described
under Reimbursement Levels in this booklet.
DIAGNOSTIC
Class I Services
Covered Dental Benefits
Routine examination.
Limitations
Exclusions
X-rays.
Emergency examination.
Examination by a specialist in an American Dental Association recognized specialty.
WDS - approved caries susceptibility tests.
Examination is covered twice in a benefit period.
Complete series (4 bitewing x-rays and up to 10 periapical x-rays) or panorex x-rays are
covered once in a 3-year period.
Supplementary bitewing x-rays are covered twice in a benefit period.
Diagnostic services and x-rays related to temporomandibular joints Uaw joints).
Consultations or elective second opinions.
Study models.
PREVENTIVE
Covered Dental Benefits
Prophylaxis (cleaning).
Fissure sealants.
Topical application of fluoride or preventative therapies.
Space maintainers when used to maintain space eruption of permanent teeth.
Limitations
Exclusions
RESTO RA TIVE
Prophylaxis is covered twice in a benefit period.
Topical application of fluoride or preventative therapies (but not both) is covered twice
in a Benefit Period.
Fissure sealants are available for children through age 14. If eruption of permanent
molars is delayed, sealants will be allowed if applied within 12 months of eruption with
documentation from the attending Dentist. Payment for application of sealants will be for
permanent maxillary (upper) or mandibular (lower) molars with incipient or no caries
(decay) on an intact occlusal surface. The application of fissure sealants is a covered
benefit only once in a 3-year period per tooth.
Plaque control program (oral hygiene instruction, dietary instruction and home fluoride
kits).
Cleaning of a prosthetic appliance.
Replacement of a space maintainer previously paid for by WDS.
***REFER ALSO TO GENERAL EXCLUSIONS***
Class II Services
Covered Dental Benefits
Limitations
Exclusions
Amalgam, composite or filled resin restorations (fillings) for treatment of carious lesions
(visible destruction of hard tooth structure resulting from the process of dental decay) or
fracture resulting in significant loss of tooth structure (missing cusp).
Stainless steel crowns.
Restorations on the same surface(s) of the same tooth are covered once in a 2-year
period.
If a composite or filled resin restoration is placed in a posterior tooth, an amalgam
allowance will be made for such procedure. The difference in cost is your responsibility.
Stainless steel crowns are covered once in a 2-year period.
Refer to Class III Limitations if teeth are restored with crowns, inlays or onlays.
Restorations necessary to correct vertical dimension or to alter the morphology (shape)
or occlusion.
Overhang removal, re-contouring or polishing of restoration.
ORAL SURGERY
Covered Dental Benefits
Limitations
Exclusions
PERIODONTICS
Removal of teeth and surgical extractions.
Preparation of the alveolar ridge and soft tissue of the mouth for insertion of dentures.
Treatment of pathological conditions and traumatic facial injuries.
General anesthesia/intravenous sedation.
General anesthesia/intravenous sedation is covered only when administered by a licensed
dentist or other WDS-approved licensed professional who meets the educational
credentialing and privileging guidelines established by the Dental Quality Assurance
Commission of the State of Washington in conjunction with certain covered oral surgery
procedures, as determined by WDS.
Iliac crest or rib grafts to alveolar ridges.
Ridge extension for insertion of dentures (vestibuloplasty).
Tooth transplants.
Covered Dental Benefits
Limitations
Surgical and nonsurgical procedures for treatment of the tissues supporting the teeth.
Services covered include examinations, periodontal maintenance, periodontal
scaling/root planing, periodontal surgery.
Limited adjustments to occlusion (8 teeth or less).
WDS-approved localized delivery of chemotherapeutic agents.
General anesthesia/intravenous sedation.
Refer to Class III Periodontics for benefits and limitations on complete occlusal
equilibration and occlusal guards (nightguards).
Examinations are covered twice in a benefit period.
Under certain conditions of oral health, periodontal maintenance and/or prophylaxis may
be covered up to a total of 4 times in a benefit period. Please note: These benefits are
available only under certain conditions of oral health. It is strongly recommended that
you have your dentist submit a predetermination of benefits to determine if the treatment
will be covered.
Periodontal scaling/root planing is covered once in a 3-year period.
Limited occlusal adjustments are covered once in a 12-month period.
Exclusions
Localized delivery of chemotherapeutic agents approved by WDS are a covered benefit
under certain conditions of oral health. Localized delivery of chemotherapeutic agents is
limited to two (2) teeth per quadrant and up to two (2) times (per tooth) in a benefit period.
Please note: These benefits are available only under certain conditions of oral health. It is
strongly recommended that you have your dentist submit a predetermination of benefits to
determine if the treatment will be covered.
Periodontal surgery (per site) is covered once in a 3-year period.
Soft tissue grafts (per site) are covered once in a 3-year period.
Periodontal surgery and localized delivery of chemotherapeutic agents must be preceded by
scaling and root planing a minimum of 6 weeks and a maximum of 6 months, or the patient
must have been in active supportive periodontal therapy, prior to such treatment.
General anesthesia/intravenous sedation is covered only when administered by a licensed
dentist or other WDS-approved licensed professional who meets the educational
credentialing and privileging guidelines established by the Dental Quality Assurance
Commission of the State of Washington in conjunction with certain covered periodontal
surgery procedures , as determined by WDS.
Periodontal splinting and/or crown and bridgework in conjunction with periodontal
splinting, crowns as part of periodontal therapy and periodontal appliances.
Gingival curettage.
Localized delivery of chemotherapeutic agents is not covered when used for the purpose of
maintaining non-covered dental procedures or implants.
ENDODONTICS
Covered Dental Benefits
Limitations
Exclusions
Procedures for pulpal and root canal treatment.
Services covered include pulp exposure treatment, pulpotomy and apicoectomy.
General anesthesia/intravenous sedation
Root canal treatment on the same tooth is covered only once in a 2-year period.
General anesthesia/intravenous sedation is covered only when administered by a licensed
dentist or other WDS-approved licensed professional who meets the educational
credentialing and privileging guidelines established by the Dental Quality Assurance
Commission of the State of Washington in conjunction with certain covered endodontic
surgery procedures, as determined by WDS.
Refer to Class III Limitations if the root canals are placed in conjunction with a
prosthetic appliance.
Bleaching of teeth.
GENERAL ANESTHESIA
Covered Dental Benefits
Limitations
PERIODONTICS
General anesthesia, when medically necessary, for children through age 6, or a physically or
developmentally disabled person, when in conjunction with Class I, II, ill and Orthodontic
covered dental procedures.
General anesthesia is covered only when administered by a licensed Dentist or other WDS-
approved Licensed Professional who meets the educational, credentialing and privileging
guidelines established by the Dental Quality Assurance Commission of the State of
Washington, when medically necessary, for children through age 6, or a physically or
developmentally disabled person, when in conjunction with covered dental procedures.
***REFER ALSO TO GENERAL EXCLUSIONS
Class III Services
Covered Dental Benefits
Limitations
Exclusions
Under certain conditions of oral health, services covered are occlusal guards
(nightguards) and complete occlusal equilibration. Please note: These benefits are
available only under certain conditions of oral health. It is strongly recommended that
you have your dentist submit a predetermination of benefits to determine if the treatment
will be covered.
Occlusal guards, including repairs, are covered once in a 3-year period.
Complete occlusal equilibration is covered once in a lifetime.
Periodontal splinting, crown and bridgework in conjunction with periodontal splinting,
crowns as part of periodontal therapy and periodontal appliances.
RESTORATIVE
Covered Dental Benefits
Crowns, inlays (only when used as an abutment for a fIXed bridge), onlays (whether they
are gold, porcelain, WDS-approved gold substitute castings (except processed resin) or
combinations thereof) for treatment of carious lesions (visible destruction of hard tooth
structure resulting from the process of dental decay) or fracture resulting in significant
loss of tooth structure (missing cusp), when teeth cannot reasonably be restored with
filling rnaterials such as amalgam or filled resins.
Crown buildups, subject to limitations and exclusions
Limitations
Exclusions
PROSTHODONTICS
Crowns or onlays on the same teeth are covered once in a 5-year period. Inlays are a
covered benefit on the same teeth once in a 5-year period only when used as an abutment
for a fixed bridge. If a tooth can be restored with a filling material such as amalgam or
filled resin, an allowance will be made for such a procedure toward the cost of any other
type of restoration that may be provided. WDS will allow the appropriate amount for an
amalgam or composite restoration toward the cost of processed filled resin or processed
composite restorations.
Crown buildups are a covered benefit when more than 50% of the natural tooth structure is
missing or there is less than 2mm of circumferential tooth structure remaining around the
gingival portion.
Crown buildups are not a covered benefit within two (2) years of a restoration on the same
tooth.
A crown used as an abutment to a partial denture for purposes of re-contouring, repositioning
or to provide additional retention is not covered unless the tooth is decayed to the extent that
a crown would be required to restore the tooth whether or not a partial denture is required.
Crowns used to repair micro-fractures of tooth structure when the tooth is asymptomatic
(displays no symptoms) or existing restorations with defective margins when no pathology
exists.
Crowns and/or onlays placed because of weakened cusps or existing large restorations
without overt pathology.
Crown buildups for the purpose of improving tooth form, filling in undercuts or reducing
bulk in castings are considered basing materials and are not a covered benefit.
Covered Dental Benefits
Limitations
Dentures, fixed bridges, removable partial dentures and the adjustment or repair of an
existing prosthetic device.
Surgical placement or removal of implants or attachments to implants.
Replacement of an existing prosthetic device is covered only once every 5 years and only
then if it is unserviceable and cannot be made serviceable.
Replacement of implants and superstructures is covered only after 5 years have elapsed
from any prior provision of the implant.
Full, immediate and overdentures - WDS will allow the appropriate amount for a full
immediate or overdenture toward the cost of any other procedure that may be provided
such as personalized restorations or specialized treatment.
Exclusions
Temporary/interim dentures - WDS will allow the amount of a reline toward the cost of an
interim partial or full denture. After placement of the permanent prosthesis, an initial reline
will be a benefit after 6 months.
Root canal treatment performed in conjunction with overdentures is limited to 2 teeth per
arch and is paid at the Class ill payment level.
Partial dentures - If a more elaborate or precision device is used to restore the case, WDS
will allow the cost of a cast chrome and acrylic partial denture toward the cost of any other
procedure that may be provided.
Denture adjustments and relines - Denture adjustments and relines done more than 6
months after the initial placement are covered. Subsequent relines or jump rebases (but not
both) will be covered once in a 12-month period.
Duplicate dentures.
Personalized dentures.
Cleaning of prosthetic appliances.
Crowns and copings in conjunction with overdentures
***REFER ALSO TO GENERAL EXCLUSIONS
ACCIDENTAL INJURY
Washington Dental Service will pay 100% of covered dental benefit expenses arising as a direct result of an
accidental bodily injury. However, payment for accidental injury claims will not exceed the unused program
maximum. The accidental bodily injury must have occurred while the patient was eligible. A bodily injury
does not include teeth broken or damaged during the act of chewing or biting on foreign objects. Coverage
includes necessary procedures for dental diagnosis and treatment rendered within 180 days following the date
of the accident.
ORTHODONTIC BENEFITS FOR ADULTS
AND ELIGIBLE CHILDREN
Orthodontic treatment is defined as the necessary procedures of treatment, performed by a licensed dentist
involving surgical or appliance therapy for movement of teeth and post-treatment retention.
Eligible persons include the employee, lawful spouse plus children through age 23.
The lifetime maximum amount payable by WDS for Orthodontic Benefits rendered to an eligible person shall
be $1 000. Not more that $500 of the maximum, or one-half ofWDS's total responsibility shall be payable
for treatment during the "construction phase." Subsequent payments ofWDS's responsibility shall be made
on a monthly basis, providing the employee is eligible and the dependent is in compliance with the age
limitation.
WDS will pay a constant 50% of the lesser of the Maximum Allowable Fees or the fees actually charged for
Orthodontic Benefits.
It is strongly suggested that orthodontic treatment be submitted to, and authorized by, WDS
prior to commencement of treatment.
Covered Dental Benefits
Treatment of malalignment of teeth and/or jaws.
Limitations - Payment is limited to:
Completion, or through age 23 , whichever occurs first
Termination of the treatment plan prior to completion of the case.
Termination of this program.
Exclusions
Charges for replacement or repair of an appliance.
Orthognathic Surgery
No benefits will be provided for services considered inappropriate and unnecessary, as
determined by WDS.
General Exclusions
Services for injuries or conditions that are compensable under Worker s Compensation or Employers
Liability laws, and services that are provided to the eligible person by any federal or state or provincial
government agency or provided without cost to the eligible person by any municipality, county, or other
political subdivision, other than medical assistance in this state, under medical assistance RCW 74.09.500, or
any other state, under 42 D., Section 1396a, section 1902 of the Social Security Act.
Dentistry for cosmetic reasons
Restorations or appliances necessary to correct vertical dimension or to restore the occlusion. Such
procedures include restoration of tooth structure lost from attrition, abrasion or erosion and restorations for
malalignment of teeth.
Application of desensitizing agents
Experimental services or supplies. Experimental services or supplies are those whose use and acceptance as
a course of dental treatment for a specific condition is still under investigation/observation. In determining
whether services are experimental, Washington Dental Service, in conjunction with the American Dental
Association, will consider if: (1) the services are in general use in the dental community in the state of
Washington; (2) the services are under continued scientific testing and research; (3) the services show a
demonstrable benefit for a particular dental condition; and (4) they are proven to be safe and effective. Any
individual whose claim is denied due to this experimental exclusion clause will be notified of the denial
within 20 working days of receipt of a fully documented request.
Any denial of benefits by Washington Dental Service on the grounds that a given procedure is deemed
experimental, may be appealed to Washington Dental Service. By law, Washington Dental Service must
respond to such appeal within 20 working days after receipt of all documentation reasonably required to
make a decision. The 20-day period may be extended only with written consent of the covered individual.
General anesthesia/intravenous (deep) sedation, except as specified by WDS for certain oral, periodontal, or
endodontic surgical procedures. General anesthesia except when medically necessary, for children through
age 6, or a physically or developmentally disabled person, when in conjunction with covered dental
procedures.
Analgesics such as nitrous oxide, conscious sedation, euphoric drugs, injections or prescription drugs
In the event an Eligible Person fails to obtain a required examination from a WDS-appointed consultant
dentist for certain treatments, no benefits shall be provided for such treatment
Hospitalization charges and any additional fees charged by the dentist for hospital treatment
Broken appointments
Patient management problems
Completing insurance forms
Habit breaking appliances
Washington Dental Service shall have the discretionary authority to determine whether services are covered
benefits in accordance with the general limitations and exclusions shown in the Contract, but it shall not
exercise this authority arbitrarily or capriciously or in violation of the provisions of the contract.
This program does not provide benefits for services or supplies to the extent that benefits are payable for
them under any motor vehicle medical , motor vehicle no-fault, uninsured motorist, underinsured motorist
personal injury protection (PIP), commercial liability, homeowner s policy, or other similar type of coverage.
All other services not specifically included in this program as covered dental benefits
MEDICAL COVERAGE IN RETIREMENT
(For Retirements After January 1 1992 and Retirees Under Age 65)
A vista Corp. offers medical benefits to retiring employees who have reached a minimum of age 55 and have
completed 15 years of service. Retirees under age 65 are provided the same medical benefits as active
employees.
The cost to you for coverage depends on the plan you choose and your family coverage category. The portion
A vista Corp. pays for your coverage varies based on the date of your retirement and your length of service.
The Company Contribution amount has been "capped" for retirees, so the retiree will responsible for all
premiums beyond the maximum Company contribution amounts.
The premiums for retirees under age 65 are listed below based on years of service:
20 + Years of Service
Retiree Company Total
RETIREE Under 6S Premium Premi urn Premi urn % of total Caps
Retiree only 109.$255.364.30.$255.
Retiree +Spouse 159.530.689.23.530.
Retiree +child(ren)183.445.628.29.445.
Retiree + Family 187.44 765.952.19.765.
years 0 serVIce
Retiree Company Total
RETIREE Under Premium Premi urn Premium % of total Caps
Retiree only 122.242.364.33.242.
Retiree +Spouse 185.503.50 689.26.503.50
Retiree +child(ren)205.422.628.32.422.
Retiree + Family 225.726.952.44 23.726.
years 0 serVIce
Retiree Company Total
RETIREE Under 6S Premium Premi urn Premium % of total Caps
Retiree only 135.42 229.50 364.37.229.50
Retiree +Spouse 212.477.689.30.477.
Retiree +child(ren)227.56 400.50 628.36.400.
Retiree + Family 263.688.952.27.688.50
17 years of service
Retiree Company Total
RETIREE Under 65 Premium Premium Premium % of total Caps
Retiree only 148.216.364.40.216.
Retiree +Spouse 238.450.689.34.450.50
Retiree +child(ren)249.378.628.39.378.
Retiree + Family 302.650.952.31.73 650.
years 0 serVIce
Retiree Company Total
RETIREE Under 65 Premium Premium Premi urn % of total Caps
Retiree only 160.204.364.44.204.
Retiree +Spouse 265.424.689.38.48 424.
Retiree +child(ren)272.06 356.628.43.356.
Retiree + Family 340.44 612.952.35.612.
15 Years of Service
Retiree Company Total
RETIREE Under 65 Premium Premium . Premium % of total Caps
Retiree only 173.$191.364.47.$191.25
Retiree +Spouse 291.76 397.50 689.42.397.50
Retiree +child(ren)294.333.628.46.333.
Retiree + Family 378.573.952.44 39.573.
MEDICAL COVERAGE IN RETIREMENT
(For Retirements After January 1 1992 and Retirees Over Age 65)
Once a retiree reaches age 65 he/she is provided with a Retiree Medical Medicare Supplemental Plan.
The cost to you for coverage depends on the plan you choose and your family coverage category. The portion
A vista Corp. pays for your coverage varies based on the date of your retirement and your length of service.
The Current Premiurn for Over age 65 retirees (with 20+ years of service) are listed below. The Company
Contribution amount has been "capped" for retirees, so the retiree will responsible for all premiums beyond the
maximum Company contribution amounts.
20 + Years of Service
Retiree Company Total
RETIREE Over 65 Premium Premium Premium Caps
Retiree over 65 25.226.56 251.73 255.
Retiree over 65 +Spouse Under 65 57.521.01 578.530.
Retiree over 65 +2 Under 65 96.765.861.765.
Retiree over 65 + Spouse Over 65 52.475.50 528.530.
RETIREE MEDICAL MEDICARE SUPPLEMENT PLAN FOR RETIREES/DEPENDENTS OVER AGE 65
(FOR RETIREMENTS ON OR AFTER JANUARY 1, 1992)
SUBSCRIBER:
Must be retired from active service
Have attained age 65 and have been covered immediately prior to the attainment of age 65 under one of the
medical coverage options offered by A vista Corp., and
Must be enrolled in Medicare Parts A and B.
DEPENDENT SPOUSE:
The lawful dependent spouse of the subscriber must have attained age 65, and
Have been covered by the subscriber immediately prior to the attainment of age 65 under one of the medical
coverage options offered by A vista Corp., and
Must be enrolled in Medicare Parts A and B.
DATE OF ELIGIBILITY:
The Subscriber and/or dependent spouse becomes eligible on the first day of the month coincident with
eligibility to enroll in Medicare.
LIFETIME MAXIMUMS, DEDUCTIBLES AND STOP LOSS PROVISIONS
Subject to the other terms and conditions of the Plan , the service and benefits indicated below will be paid for
conditions for which treatment is medically necessary
LIFETIME MAXIMUMS:
Two Hundred and Fifty thousand dollars ($250 000) for all covered conditions for each beneficiary.
INCLUDED IN THE MAXIMUM IS:
Six thousand dollars ($6 000) for inpatient services for treatment of chemical dependency
Two thousand dollars ($2 000) for inpatient mental health services
Two thousand dollars ($2 000) combined for outpatient mental health services and treatment of chemical
dependency.
DEDUCTIBLE:
. Seventy-five ($75) for each beneficiary each benefit year for Medicare Part B services.
Benefits under Medicare Part B shall apply only after the deductible has been satisfied. Benefits provided by this
Plan, except as otherwise specified, shall apply only for allowable medical expense within each benefit year.
STOP Loss PROVISION:
Medicare Part B Services
For each beneficiary for each benefit year, the Company will be responsible for payment of 80% of the
reasonable charge for Medicare Part B services after satisfaction of the deductible. The beneficiary will be
responsible for payment of the remaining percentage of the reasonable charge, up to a maximum out-of-
pocket expense for Medicare Part B services of Two Hundred Dollars ($200). The Company will then be
responsible for payment of 100% of the allowed charge for Medicare Part B services for the remainder of
that benefit year. Any amounts paid to satisfy the deductible or any amounts in excess of the allowed charge
will not be applied to the stop loss amount. Charges for services from non-participating providers are not
included in the stop loss provision.
BENEFITS PROVIDED
Subject to the other terms and conditions of this Plan, including Exclusions and Limitations, the Company
will provide benefits and service or will pay benefits and service as listed below , provided the condition for
which the beneficiary is beneficiary is being treated is eligible under Medicare.
MEDICARE PART A - HOSPITAL SERVICES
The Medicare Part A is deductible.
Medicare Part A coinsurance amount for 6151 through 90th day in any Medicare benefit period
Coverage of Medicare Part A eligible expenses incurred as daily hospital charges during the use of
Medicare s lifetime hospital inpatient reserve days
Upon exhaustion of all Medicare hospital inpatient coverage including the lifetime reserve days
coverage of one hundred percent (100%) of all Medicare Part A eligible expenses for hospitalization not
covered by Medicare subject to a lifetime maximum benefit of an additional thirty (30) days or up to the
Fifty Thousand Dollar ($50 000) lifetime maximum, whichever is less.
Coinsurance for post-hospital care in a skilled nursing facility as follows:
One hundred percent (100%) for the Twenty-first (2151) through one-hundredth (lOO ) day. The
one hundred first (10151) through one hundred thirtieth (BO ) day will be paid to a maximum of
Twelve Dollars ($12) per day after Medicare Payment.
The three (3) pint deductible for whole blood as applied under Medicare Parts A and B
Coinsurance for inpatient mental health services up to a lifetime maximum of Two Thousand Dollars
($2 000) when referred by a physician or an Employee Assistance Program (EAP) counselor.
(Professional services also apply to this lifetime maximum.
Coinsurance for inpatient chemical dependency treatment up to a lifetime maximum of Six Thousand
Dollars ($6 000) (Professional services also apply to this lifetime maximum.
Coinsurance for outpatient mental health services and outpatient chemical dependency treatment up to a
combined lifetime maximum of Two Thousand Dollars ($2 000). (Professional services also apply to
this lifetime maximum.
MEDICARE PART B - MEDICAL
After the deductible has been satisfied, the coinsurance (20%) of Medicare s allowed charge as determined
under the provisions of Medicare for:
Medical or surgical service rendered in the doctor s office , the hospital, or the member s home
Hospital outpatient services;
Inpatient mental health services up to a lifetime maximum of Two Thousand Dollars ($2 000) when
referred by a physician or an Employee Assistance Program (EAP) counselor. (Institutional services also
apply to this lifetime maximum.
Chemical dependency treatment up to a lifetime maximum of Six Thousand Dollars ($6 000)
(Institutional services also apply to this lifetime maximum.
Outpatient mental health services when referred by a physician or an Employee Assistance Program
(EAP) counselor and outpatient chemical dependency treatment up to a combined lifetime maximum of
Two Thousand Dollars ($2 000) (Institutional services also apply to this lifetime maximum.
Mammography screening benefits for screening or diagnostic mammography services , when rendered by
a provider.
PRESCRIPTION DRUGS:
Generic Prescriptions:(30-day supply): $5.00 co-pay for Generic Drugs
Brand Name Prescriptions:(30-day supply) (When a generic drug is not available):
$20.00 co-pay for Non-Generic when Generic is not
available
Brand Name Prescriptions:(30-day supply) (When a generic drug available):
$40 co-pay for Non-Generic drugs when a generic lli
available
Mail Order Prescriptions:(90-day supply): Same as Above
EXCLUSIONS AND LIMITATIONS
Expenses incurred for the following will not be covered:
Any illness, injury, or condition which is not eligible for coverage under Medicare, except as specifically
provided in this Plan; and
No benefits will be provided to the extent such benefits are available to any beneficiary hereunder for
any injury, condition, or illness under the terms of any automobile medical, personal injury protection
automobile no-fault, or similar contract or insurance, when such a contract or insurance is issued to or
provides benefits for any beneficiary under this Plan. Any benefits provided by the Company contrary to
this exclusion are provided solely to assist the beneficiary. By providing such benefits, the Company is
not waiving any right to reimbursement or to subrogation as provided in this plan.
Limitations as to particular conditions:
Benefits under this Plan for reconstructive breast surgery following a mastectomy, as a result of illness
injury or disease, and all stages of one reconstructive breast reduction on the nondiseased breast to make it
equal size with the diseased breast after reconstructive surgery on the diseased breast has been performed
will be paid the same as for any other eligible medical condition.
Benefits which are rendered in the service area by a non-participating provider, will be paid upon presentation of
the completely itemized bill to the Insurance Company or Third Party Administrator. The amount the Company
will be obligated to pay on behalf of the beneficiary shall not exceed the sum the Company would have paid if
the beneficiary had been under the care of a participating provider. .
This is only a brief summary of benefits. In the event a question or dispute
arises on coverage or service, the official contract of benefits would be the
ruling document.
Contact Premera Blue Cross at 1-800-572-0778 for more complete Plan
info rma ti 0 n.
Initial COBRA Notice
Federal law requires most employers sponsoring group health plans to offer employees and their families the
opportunity to elect a temporary extension of health coverage (called "continuation coverage" or "COBRA
coverage ) in certain instances when coverage under a group health plan would otherwise end. A group health
plan includes any major medical plan, dental plan, vision plan, health FSA , or other plan that we may maintain
and that provides medical care. For simplicity, any such group health plan is referred to in this Notice as the
Plan." You do not have to show that you are insurable to elect continuation coverage. However, you will have
to pay all of the premium for your continuation coverage. At the end of the maximum coverage period (described
below), you will be allowed to enroll in an individual conversion health plan if it is otherwise available under the
Plan, subject to the requirement to pay the premiums required by the individual conversion health plan.
This Notice provides a brief overview of your rights and obligations under current law. The Plan offers no
greater COBRA rights than what the COBRA statute requires, and this Notice should be construed accordingly.
Both you (the employee) and your spouse should read this summary
carefully and keep it with your records!
Qualifying Events
If you are an employee of the Employer and are covered by the Plan, you have the right to elect continuation
coverage if you lose coverage under the Plan because of anyone of the following two "qualifying events
1. Termination of your employment (for reasons other than gross misconduct).2. Reduction in the hours of your employment.
If you are the spouse of an employee covered by the Plan, you have the right to elect continuation coverage if you
lose coverage under the Plan because of any of the following four "qualifying events
1. The death of your spouse.
2. A termination of your spouse s employment (for reasons other than gross misconduct) or reduction in
your spouse s hours of employment with the Employer.
3. Divorce or legal separation from your spouse. (Also, if an employee eliminates coverage for his or her
spouse in anticipation of a divorce or legal separation, and a divorce or legal separation later occurs , then
the later divorce or legal separation will be considered a qualifying event even though the ex-spouse lost
coverage earlier. If the ex-spouse notifies the administrator within 60 days after the later divorce or legal
separation and can establish that the coverage was eliminated earlier in anticipation of the divorce or
legal separation, then COBRA coverage may be available for the period after the divorce or legal
separation.
4. Your spouse becomes entitled to Medicare benefits.
In the case of a dependent child of an employee covered by the Plan , the dependent child has the right to elect
continuation coverage if group health coverage under the Plan is lost because of any of the following five
qualifying events
1. The death of the employee-parent.
2. The termination of the employee-parent's employment (for reasons other than gross misconduct) or
reduction in the employee-parent's hours of employment with the Employer.
3. Parent s divorce or legal separation.
4. The employee-parent becomes entitled to Medicare benefits.
5. The dependent child ceases to be a "dependent child" under the Plan.
Your IMPORTANT Notice Obligations
If your spouse or dependent child loses coverage under the Plan because of divorce, legal separation or the
child's losing dependent status under the Plan, then you (the employee) or your spouse or dependent has the
responsibility to notify the Plan Administrator of the divorce, legal separation, or the child's losing dependent
status. You or your spouse or dependent must provide this notice no later than 60 days after the date coverage
terminates under the plan (see summary plan description for details regarding when plan coverage terminates).
you or your spouse or dependent childfails to provide this notice to the Plan Administrator during this 60-day
notice period, any spouse or dependent child who loses coverage will NOT be offered the option to elect
continuation coverage. Furthermore, if you or your spouse or dependent child fails to provide this notice to the
Plan Administrator, and if any claims are mistakenly paid for expenses incurred after the date coverage is
supposed to terminate upon the divorce, legal separation, or a child's losing dependent status, then you, your
spouse and dependent children will be required to reimburse the Plan for any claims so paid.
If the Plan Administrator is timely provided with notice of a divorce, legal separation, or a child's losing
dependent status that has caused a loss of coverage, then the Plan Administrator will notify the affected family
member of the right to elect continuation coverage (but only to the extent that the Plan Administrator has been
notified in writing of the affected family member s current mailing address---see the YOU MUST NOTIFY US
paragraph below).
The Plan Administrator will also notify you (the employee), your spouse and dependent children of the right to
elect continuation coverage after it receives notice of the following events that result in a loss of coverage: the
employee s termination of employment (other than for gross misconduct), reduction in hours, or death, or the
employee s becoming entitled to Medicare.
Election Procedures
You (the employee) and/or your spouse and dependent children must elect continuation coverage within 60 days
after Plan coverage ends, or, if later, 60 days after the Plan Administrator provides you or your family member
with notice of the right to elect continuation coverage. If you or your spouse and dependent children do not elect
continuation coverage within this 60-day election period, YOLt will lose your right to elect continuation coverage.
A COBRA election mailed to the Plan Administrator is considered to be made on the date of the mailing.
You (the employee) and/or your spouse and dependent children may elect continuation coverage for all
qualifying family members. You, your spouse and dependent children each have an independent right to elect
continuation coverage. Thus , a spouse or dependent child may elect continuation coverage even if the covered
employee does not (or is not deemed to) elect it.
You (the employee) and/or your spouse and dependent children may elect continuation coverage even if covered
under another employer-sponsored group health plan or entitled to Medicare.
Type of Coverage
Ordinarily, the continuation coverage that is offered will be the same coverage that you, your spouse or
dependent children had on the day before the qualifying event. Therefore, an employee, spouse or dependent
child who is not covered under the Plan on the day before the qualifying event generally is not entitled to
COBRA coverage except, for example, when there is no coverage because it was eliminated in anticipation of a
qualifying event such as divorce. If the coverage is modified for similarly situated employees or their spouses or
dependent children, then COBRA coverage will be modified in the same way.
If the Employer maintains more than one group health plan (or offers a choice of separate benefit packages under
a single plan), you (or your spouse or dependent children) may elect COBRA coverage under one or more of
those plans (or separate benefit packages) in which you have coverage. For example, if you are covered under
three separate Employer plans (e.g. a medical plan , a dental plan, and a vision plan), you could elect COBRA
coverage under the medical plan and decline coverage under either or both of the dental plan and vision plans.
But if the Employer maintains one consolidated group health plan (for example, one that provides medical
dental, and vision benefits under a single plan), you must elect or decline COBRA coverage for the plan as a
whole.
If the Employer maintains a health flexible spending arrangement (health FSA) under which you are reimbursed
for medical expenses, you (or your spouse or dependent children) may elect to continue the health FSA coverage
under COBRA, but only if there is a positive account balance (i., year-to-date contributions exceed year-to-date
claims) on the day before the qualifying event (taking into account all claims submitted by that date). COBRA
coverage under the health FSA will continue only for the remainder of the Plan year in which the qualifying
event occurred. If there is a negative account balance (i., year-to-date contributions are less than year-to-date
claims), then no qualified beneficiary may elect COBRA coverage under the health FSA.
COBRA Premiums That You Must Pay
The premium payments for the "initial premium months" must be paid for you (the employee) and for any spouse
or dependent child by the 45th day after electing continuation coverage. The initial premium months are the
months that end on or before the 45th day after the election of continuation coverage is made.
Once continuation coverage is elected, the right to continue coverage is subject to timely payment of the required
COBRA premiums. Coverage will not be effective for any initial premium month until that month's premium is
paid within the 45-day period after the election of continuation coverage is made.
All other premiums are due on the 151 of the month for which the premium is paid, subject to a 30-day grace
period. A premium payment that is mailed is considered to be made on the date it is sent. If you don t make the
full premium payment by the due date or within the 30-day grace period, then COBRA coverage will be canceled
retroactively to the 1 5t of the month, with no possibility of reinstatement.
Maximum Coverage Periods
The maximum duration for COBRA coverage is described below. COBRA coverage terminates before the
maximum coverage period in certain situations described later under the heading "Termination of COBRA
Coverage Before the END of the Maximum Coverage Period.
36 Months. If you (the spouse or dependent child) lose group health coverage because of the employee s death
divorce , legal separation, or the employee s becoming entitled to Medicare, or because you lose your status as a
dependent child under the Plan, then the maximum coverage period (for spouse and dependent child) is three
years from the date of the qualifying event.
18 Months. If you (the employee, spouse or dependent child) lose group health coverage because of the
employee s termination of employment (other than for gross misconduct) or reduction in hours, then the
maximum continuation coverage period (for the employee, spouse and dependent child) is 18 months from the
date of termination or reduction in hours. There are three exceptions:
If an employee or family member is disabled at any time during the first 60 days after the date of termination
of employment or reduction in hours, then the continuation coverage period for all qualified beneficiaries
under the qualifying event is 29 months from the date of termination or reduction in hours. The Social
Security Administration must formally determine under Title II (Old Age, Survivors, and Disability
Insurance) or Title XVI (Supplemental Security Income) of the Social Security Act that the disability exists
and when it began. For the 29-month continuation coverage period to apply, notice of the determination of
disability under the Social Security Act must be provided to the Plan Administrator within both the 18-month
coverage period and 60 days after the date of the determination.
If a second qualifying event that gives rise to a 36-month maximum coverage period for the spouse or
dependent child (for example, the employee dies or becomes divorced) occurs within the 18-month or 29-
month coverage period, then the maximum coverage period (for a spouse or dependent child) becomes three
years from the date of the initial termination or reduction in hours. For the 36-month maximum coverage
period to apply, notice of the second qualifying event must be provided to the Plan Administrator within 60
days after the date of the event. If no notice is given within the required 60-day period, no extension of
COBRA coverage will occur.
If the qualifying event occurs within the 18 months after the employee becomes entitled to Medicare, then the
maximum coverage period (for the spouse and dependent child) ends three years from the date the employee
became entitled to Medicare.
Shorter Maximum for Health FSAs. The maximum COBRA period for a health flexible spending
arrangement (health FSA) maintained by the Employer (if there is a positive account balance as of the date of the
qualifying event, as explained above) ends on the last day of the Plan year in which the qualifying event
occurred. If there is a negative account balance as of the date of the qualifying event, no COBRA coverage will
be offered.
Children Born to or Placed for Adoption With the Covered Employee During COBRA Period
A child born to, adopted by or placed for adoption with a covered employee during a period of continuation
coverage is considered to be a qualified beneficiary provided that, if the covered employee is a qualified
beneficiary, the covered employee has elected continuation coverage for himself or herself. The child's COBRA
coverage begins when the child is enrolled in the Plan, whether through special enrollment or open enrollment
and it lasts for as long as COBRA coverage lasts for other family members of the employee. To be enrolled in
the Plan, the child must satisfy the otherwise applicable Plan eligibility requirements (for example, regarding
age).
Open Enrollment Rights and HIPAA Special Enrollment Rights
Qualified beneficiaries who have elected COBRA will be gi ven the same opportunity available to similarly
situated active employees to change their coverage options or to add or eliminate coverage for dependents at open
enrollment. In addition, HIPAA's special enrollment rights will apply to those who have elected COBRA.
HIPAA, a federal law, gives a person already on COBRA certain rights to add coverage for dependents if such
person acquires a new dependent (through marriage, birth, adoption , or placement for adoption), or if an eligible
dependent declines coverage because of other coverage and later loses such coverage due to certain qualifying
reasons. Except for certain children described above under "Children Born to or Placed for Adoption With the
Covered Employee During COBRA Period " dependents who are enrolled in a special enrollment period or open
enrollment period do not become qualified beneficiaries---their coverage will end at the same time that coverage
ends for the person who elected COBRA and later added them as dependents.
Alternate Recipients Under QMCSOs
A child of yours (the employee s) who is receiving benefits under the Plan pursuant to a Qualified Medical Child
Support Order (QMCSO) received by the Plan Administrator during your (the employee s) period of employment
with the employer is entitled to the same rights under COBRA as a dependent child of yours, regardless of
whether that child would otherwise be considered your dependent.
Termination of COBRA Coverage Before the End of Maximum Coverage Period
Continuation coverage of the employee, spouse and/or dependent child will automatically terminate (before the
end of the maximum coverage period) when anyone of the following six events occur:
1. The Employer no longer provides group health coverage to any of its employees.
2. The premium for the qualified beneficiary s COBRA coverage is not timely paid.
3. After electing COBRA, you (the employee, spouse or dependent child) become covered under another
group health plan (as an employee or otherwise) that has no exclusion or limitation with respect to any
preexisting condition that you have. If the other plan has applicable exclusions or limitations, then your
COBRA coverage will terminate after the exclusion or limitation no longer applies (for example, after a
12-month preexisting condition waiting period expires). This rule applies only to the qualified
beneficiary who becomes covered by another group health plan. (Note that under HIPAA, an exclusion
or limitation of the other group health plan might not apply at all to the qualified beneficiary, depending
on the length of his or her credible health plan coverage prior to enrolling in the other group health plan.4. After electing COBRA coverage, you (the employee, spouse or dependent child) become entitled to
Medicare benefits. This will apply only to the person who becomes entitled to Medicare.
5. You (the employee, spouse or dependent child) became entitled to a 29-monthmaximum coverage period
due to disability of a qualified beneficiary, but then there is a final determination under Title II or XVI of
the Social Security Act that the qualified beneficiary is no longer disabled (however, continuation
coverage will not end until the month that begins more than 30 days after the determination).6. Occurrence of any event (e., submission of fraudulent benefit claims) that permits termination of
coverage for cause with respect to covered employees or their spouses or dependent childr~n who have
coverage under the Plan for a reason other than the COBRA coverage requirements of federal law.
You Must Notify Us About Address Changes , Marital Status Changes, Dependent Status Changes and Disability
Status Changes
If you or your spouse s address changes, you must promptly notify the Plan Administrator in writing (the Plan
Administrator needs up-to-date addresses in order to mail important COBRA notices and other information).
Also, if your marital status changes or if a dependent ceases to be a dependent eligible for coverage under the
Plan terms, you or your spouse or dependent must prornptly notify the Plan Administrator in writing (such
notification is necessary to protect COBRA rights for your spouse and dependent children). In addition, you
must notify us if a disabled employee or family member is determined to be no longer disabled.
Plan Administrator
The Employer is the Plan Administrator. All notices and other communications regarding the Plan and regarding
COBRA must be directed to the following individual who is acting on behalf of the Plan Administrator: (Keith
Rust, Benefits Administrator, telephone [phone]. Mailing address is: Keith Rust, Benefits Administrator
Avista Corp., 1411 E. Mission Ave., Spokane, W A 99220.
For More Information
If you, your spouse or dependent children have any questions about this notice or COBRA, please contact the
Plan Administrator. Also, please contact the Plan Administrator if you wish to receive the most recent copy of
the Plan s Summary Plan Description , which contains important information about Plan benefits, eligibility,
exclusions and limitations.
vista Corp.
Holidays
Holidays shall be as follows: New Year s Day, Memorial Day, Fourth of July, Labor Day, Thanksgiving Day
and the following day, and Christmas day.
Employees may elect to declare Veterans Day and/or President s Day as a holiday by providing two weeks
notice to their immediate supervisor. These days will be charged against the employee s One Leave account
except for the employees subject to 24-hour shift provisions.
Employees subject to 24 hour shift provisions may choose one (1) day of One Leave per calendar year as a
personal holiday, provided he/she gives at least two (2) weeks advance notice. Once scheduled, this holiday
will not be changed except where an employee and Supervisor mutually agree to a change.
When a holiday falls on Saturday, Friday shall be observed. When a holiday falls on Sunday, Monday shall
be observed.
Temporary employees are not eligible for holiday pay until they have completed six (6) months of continuous
serVIce.
Holiday pay for an employee who is temporarily upgraded or dual rated shall be based on the rate of pay for
the higher classification, provided he/she works the regularly scheduled work day preceding and the regularly
scheduled work day following the holiday at the higher classification.
The following rules shall apply to the Fourth of July Holiday: When mutually agreed by the Company and
the Union and when the work permits, employees working out of temporary headquarters (i.e. employees
temporarily assigned outside the 25-mile radius from permanent headquarters) may observe the holiday as
follows: When the holiday falls on Sunday, Monday, or Tuesday; Mondays shall be observed. When the
holiday falls on Wednesday, Thursday, Friday, or Saturday; Friday shall be observed.
Any eligible employee not required to work on a holiday shall be allowed his regular day s pay for the
holiday.
Holidays that fall on Saturday or Sunday will be observed on that Saturday or Sunday for employees who
are scheduled to work in a 24 hour day, seven (7) days a week, shift work operation. Any eligible
employee required to work on a holiday on regular shift schedule work shall be allowed his/her regular
day s pay for the holiday and paid, in addition, at the rate of time and one-half (1 V2) for the time worked.
Any eligible employee required to work on a holiday other than on regular shift schedule work shall be
allowed his/her regular day s pay for the holiday and paid, in addition, at the douple time rate for the time
worked.
A vista Corp.
FMLA (The Federal Family and Medical Leave Act)
OVERVIEW
Any employee absence, with the exception of scheduled vacation, that exceeds or is anticipated to exceed
five (5) days must be reported to the Occupational Health Nurse regardless of the reason for leave.
FMLA-THE FEDERAL FAMILY AND MEDICAL LEAVE ACT: Effective as of August 5th, 1993 , the FMLA
was enacted to allow employees to balance the demands of the workplace with the needs of family. The Act
provides for up to twelve weeks of job-protected leave per 12 month period to eligible employees for the birth of
a child, or for the serious illness of the employee or a family member. This act is administered by the
Department of Labor s (DOL) Employment Standards Administration (ESA). It is the responsibility of the
employer to notify an employee of his rights of eligibility for FMLA leave and clearly document when leave is
granted.
Job-protected FMLA leave is triggered by one of the following events:
Birth of the Employee s child or placement for adoption or Foster Care of a child with the employee.
The employee is needed to care for an immediate family member (spouse, child, or parent) who has a
serious health condition.
The employee has a serious health condition arise.
These triggering events have specific , detailed descriptions under the law and require the "Certification of
Physician or Practitioner . Dependant upon the triggering event, FMLA leave may be paid or unpaid.
Avista Corp. requires the employee to use all paid leave benefits (STD/One Leave) first, as part of his/her
FMLA, before taking unpaid leave. For a more in-depth definition of qualifying events and specific paid
benefits, please contact the Occupational Health Nurse or your Human Resources Business Partner.
If you have questions or would like more detail on a specific disability benefit, please contact Rita Gregovich, COHN/CM at extension 4712.
vista Corp.
Worker s Compensation
You are eligible to participate in the Plan if
you are an:
Avista Corp. Employee
Refer to your Union Contract
HOWWORKER'SCOMPENSAriON'YORKS'
~:\,.-, "" '. '. '
Article 9 Short Term/Long Term Disability &
Workers Compensation
Sec. 9 In case of any injury which is
covered by State Industrial Insurance Acts
the employee will receive an amount from
the Company which, when combined with
temporary Workers' Compensation benefits
will equal 80% of his/her regular pay. Such
payments will continue as long as he/she
receives temporary disability payments
under Workers' Compensation but not to
exceed the weeks show in the following
schedule according to years of service.
Refer to your Union Contract
Years of Service
0 - 9
10+
Wks. Pd. at 80% of
Salar
104
Years of Service
Contract
Wks. Pd. at a % of
Salar
Contract
mEW Local #77 Union
Based on your time with Avista Corp. you receive 80% of pay for the weeks listed.
Other Unions
Please refer to your union contract.
Please contact Rita Gregovich , RN, COHN/CM at extenSion 4712.
A vista Corp.
STD (Short Term Disability)
STD
Short-Term Disability: The company s non-occupational temporary disability benefit plan may provide for up to
twenty-six (26) weeks of disability compensation for eligible employees following a waiting period and
certification from the employee s physician. To qualify for STD, you must be a regularly scheduled employee
working twenty (20) or more hours per week and have at least six months of service with the company. The
number of weeks of STD benefit and the level of benefit pay for which the employee is entitled is based upon
years of service. Once the employee returns to work from STD leave with no further utilization of benefits for
six (6) months, his/her STD benefits bank is fully restored.
1. The waiting period consists of consecutive. re eularlv scheduled workdavs (or 40 consecutive
hours).STD will begin on the sixth consecutive day of absence due to the employee s own serious
health condition. Occurrences of illness or injury lasting less than the waiting period may be covered by
the One Leave Plan.
2. For an elective, planned absence from work for treatment of a health condition, the employee must
notify the supervisor and the Occupational Health Nurse in advance of the leave of absence.
3. For an unexpected illness or injury, the employee or his/her supervisor must notify the Occupational
Health Nurse as soon as it is anticipated that STD will be activated.
4. If payroll receives an employee s time sheet for wage benefits under STD that has not been
authorized by the Occupational Health Nurse Case Manager, STD will not be paid. It is the
responsibility of the employe~ and his/her supervisor to notify the Occupational Health Nurse
soon as it is apparent the employee s absence will exceed the 5-day waiting period. The
Occupational Health Nurse Case Manager will determine the employee s STD benefits eligibility
based of length of service and applicable medical information. Once eligibility criteria are
satisfied, a written notice is provided to payroll authorizing payment of wages under STD.
Amount of Benefit
Amount of benefit depends on years of service at the time of the disability. Years of service determine the
number of weeks at 100% or 60% of base pay up to 26 weeks in combination.
.5 (6 mos.
10 +
If you have questions or would like more detail on a specific disability benefit, please contact Rita Gregovich
, COHN/CM at extension 4712.
vista Corp.
Long Term Disability
ELIGIBILITY
Regular employees working 1000 or more hours per year and who have completed 12 months of
service are eligible for the Company s Long Term Disability Plan. Employees with one to ten (1-10)
years of service are eligible for one (1) year of benefit for each year of service. Employees with ten
(10) or more years of service are eligible for payment of benefits as defined by the Plan. Employees
will continue to accrue retirement service and be eligible to participate in the Company s Medical
and Group Life Plans.
OVERVIEW
The Long Term Disability Plan provides benefits after twenty-six (26) weeks of continuous disability that
when combined with Worker s Compensation benefits, if applicable, provides 60% of the employee
straight time earnings at the time of disability. If the employee qualifies for Social Security disability the
benefit is 70%.
Benefit Level: Eligible employees will receive LTD benefits at 60% (70% if you are eligible for Social
Security Benefits) until they qualify as eligible for retirement benefits under A vista s Defined Benefit
Pension (DBP) plan, at which time their LTD benefit will be at 50% (60% if you are eligible for Social
Security Benefits) of their straight time earnings. The 50% (60%) L TD benefit will continue for eligible
employees until they retire under the A vista DBP or until they reach Normal Retirement Age (65), whichever
comes first.
While on Long Term Disability, One Leave will not accrue.
vista Corp.
One Leave Program
ELIGIBILITY
. One Leave shall be accrued based on the employee s Anniversary date. Regular full time employees shall
have available a One Leave allowance according to the following schedule:
During the 1 st Year
During the 2nd Year
During the 3rd Year
During the 4th Year
During the 5th Year
During the 6th Year
During the ih Year
During the 8th Year
During the 9th Year
During the 10th Year
During the 11 th Year
During the 1 ih Year
During the 13th Year
During the 14th Year
During the 15th Year
During the 16th Year
During the 17th Year
During the 18 th Year
During the 19th Year
During the 20th Year
During the 21 st Year
During the 22nd Year
During the 23rd Year.
During the 24th Year
During the 25th Year
During the 26th Year
During the 27th Year
During the 28th Year
During the 29th Year
During the 30th Year
Thereafter
18.
18.
19.
20.
20.
21.45
22.
22.
23.
24.
24.
25.
26.
26.
27.
28.
29.
29.
30.42
31.11
31.80
32.49
33.
33.
34.
35.
35.
36.
37.
38.
38.00 days or
6.39
7.45
9.58
10.
10.
10.43
10.
10.
11.06
11.28
11.49
11.70
11.70 hrs per pay period
06924
07200
07462
07725
07987
08250
08525
08787
09050
09312
09587
09850
10112
10375
10637
10912
.11175
11437
11700
11975
12237
12500
12762
13037
13300
.13562
13825
14100
14362
14620
.14620
Maximum Cap effective is 750 hours
vista Corp.
One Leave Program
The One Leave Program is a benefit that allows employees to accrue a "bank" of hours, based on years of service, to use for
vacation, personal business, family illness, doctor/dental visits, funerals or recovery from sickness or accident. An employee
may also sell the time back to the Company for cash in accordance with the One Leave Cash-Out rules.
One Leave pay will be computed at the straight time rate of pay applicable to the employee s regular classification as of the
time One Leave is taken.
One Leave schedule shall be so arranged as to cause a minimum of disturbance to the Company s operations. The One Leave
schedule, once arranged, shall not be changed except for valid reasons.
Temporary full time employees shall accrue One Leave, but shall be eligible to take One Leave only if
continuously employed for six (6) months or longer.
Maximum One Leave Accrual
One Leave may be accumulated to a maximum of 750 hours. The One Leave plan shall be administered as a
debit/credit system, and will be accrued in "accordance with the One Leave Accrual Schedule (shown above).
Except as noted above, under "Temporary full time employees , One Leave will be immediately available for
use.
One Leave Cash-Out
Employees may cash out available One Leave hours at 100% of their regular rate of pay at the time of
termination (including retirement). Employees may cash out accrued One Leave hours down to forty (40) hours
during the calendar year in an amount not to exceed their annual accrual rate as of the first pay period of January
each year. Employees may cash out up to 120 hours at 100% of their regular rate of pay and may cash out the
remainder of their annual accrual at 80% of their regular rate of pay. Cash-outs are not paid at higher dual-rate
wage rates. One Leave cashed out will be paid only on the employee s biweekly paycheck.
Additional One Leave Information
Additional One Leave above two (2) calendar weeks per year will be taken outside the period mid-
May through mid-September and at a time convenient to the Company. When additional One Leave
will not inconvenience Company operations or deprive another employee of the opportunity for One
Leave during this period, this restriction may be suspended by the Company.
When a holiday occurs while an employee is on One Leave it will not be considered a One Leave
day.
While on One Leave, One Leave will accrue.
While on a Leave of Absence, One Leave will not accrue.
To be eligible for One Leave due to sickness or emergency, an employee shall notify his supervisor
as early as possible before he/she is scheduled for work. One Leave for these purposes can be taken
in increments of one half-hour.
. An employee hospitalized during his/her One Leave shall promptly notify his/her supervisor.
A vista Corp.
Health Care Reimbursement Plan (HCR)
ELIGIBILITY
You are eligible to participate in the Plan if you are a:
Regular (Frr or prr) employee
Medical Care Expense Reimbursement Benefits
Under the Medical Care Reimbursement component, you purchase a specific level of Medical Care
Reimbursement benefits, paying for coverage through the Salary Reduction Agreement with Avista Corp, in lieu
of a corresponding amount of current pay, which means that the premiums you pay will be with pre-tax funds. In
return, you may be reimbursed from the Plan for certain eligible Medical Expenses. This arrangement helps you
because the level of coverage you elect is non-taxable, thereby saving you social security and income taxes on the
amount of the premiums you pay.
Medical Care Expense Reimbursement Account
If you elect benefits under this portion of the Plan, a Medical Expense Reimbursement Account will be set up in
your name to keep a record of the reimbursements you are entitled to, as well as the premiums you have paid for
such benefits during the Plan Year. Your Medical Care Reimbursement Account is merely a record keeping
account; it is not funded (all reimbursements are paid from the general assets of Avista Corp).
What annual benefits are available under the Medical Care Reimbursement component, and how much
will they cost?
You may choose any amount of Plan Year reimbursement you desire, subject to a maximum reimbursement
amount of $5 000 per year and a minimum of $lO/month or $ 120/year. You will be required to pay the annual
premium equal to the coverage level you have chosen.
How is my Medical Care Expense Reimbursement benefit paid for?
When you complete the Salary Reduction Agreement, you specify the amount of Medical Care Reimbursement
you wish to pay with your salary reduction. Thereafter, you must pay a premium for such coverage by having an
equal portion of the annual premium deducted from each paycheck. The full amount of the coverage you have
elected will be available to reimburse you for certain Medical Expenses at any time during the Plan Year, so long
as you continue to pay the premiums.
What amounts will be available for Medical Care Expense Reimbursement at any particular time during
the Plan Year?
Provided that you have continued to pay the periodic premiums due for this benefit, then the full annual amount
of coverage that you have elected will be available at any time during the Plan Year, although reduced by the
amount of prior reimbursements received during the Year.
How do I receive reimbursement under the Plan?
If you elect to participate in this Plan, then you will have to take certain steps to be reimbursed for your Medical
Expenses. When you incur an expense that is eligible for payment, you must submit a claim to the Plan
contract administrator, A. W. Rehn & Associates, Inc. on a claim form that will be supplied to you. You must
include written statement(s) from an independent third party(ies) stating that the medical expense(s) have been
incurred, and the amount of such expense(s) along with the claim form. In addition, you must include an
Explanation of Benefits (EOB) Form(s) from any primary medical and/or dental insurance carrieres) indicating
the amount(s) that you are obligated to pay. Claims should be submitted to:
W. Rehn & Associates, Inc.
O. Box 5433
Spokane, W A 99205
[phone]
Claims are paid on a weekly basis through the contract administrator. Remember, though, you cannot be
reimbursed for any total expenses above the annual reimbursement amount you have elected.
You have 90 days from the end of the Plan Year in which to submit a claim for reimbursement for Medical
Expenses incurred during the previous Plan Year. You will be notified in writing if any claim for benefits is
denied.
Please note that it is not necessary for you to have actually paid the bill for a Medical Expense - only for you to
have incurred the expense and that it is not being paid for or reimbursed from any other source.
What is a "Medical Expense
A "Medical Expense" generally means an item for which you could have claimed a Medical Expense deduction
on an itemized federal income tax return (see IRS Publication 502) for which you have not otherwise been
reimbursed from insurance or from some other source. Medical Expenses are limited to generally recognized
health care expenses , which are defined to mean (a) expenses incurred for diagnosis, cure, mitigation, treatment
or prevention of disease or for the purpose of affecting any structure or function of the body, and (b) for
transportation primarily for and essential to such medical and dental care. They include, for example, expenses
you, your spouse or eligible dependents have incurred for:
Medicine, drugs, birth control pills and vaccines that your doctor prescribed.
Over the counter drugs and pregnancy kits;
Medical doctors, dentists, eye doctors, optometrists, chiropractors, osteopaths, podiatrists
psychiatrists, psychologists, physical therapists, acupuncturists, chiropodists, Christian Science
practitioners and naturopaths.
Medical examination, x-ray and laboratory service.
Nursing care services.
Hospital care (including meals and lodging), clinic costs and lab fees.
Medical treatment at a center for drug and alcohol addiction.
Medical aids such as hearing aids (including batteries), dentures, eyeglasses, contact lenses
braces; artificial limbs, orthopedic shoes, elastic hose as medically prescribed, crutches
wheelchairs, guide dogs and the cost of maintaining them.
Ambulance service and other travel costs to get medical care. If you use your own car, you can
claim what you spent for gas and oil to go to and from the place you received the care; or you can
claim $.14 a mile. Add parking and tolls to the amounts you claim under either method.
Expenses for weight loss programs or treatments for a specific medical condition. Meal
replacements, dietary supplements and vitamins are excluded.
Stop smoking programs (but not non prescription drugs to aid in smoking cessation)
Automobile modifications (hand controls, special equipment, mechanical lifts)
Eye surgery to correct vision
Vasectomy
However, the following items are not Medical Expenses, even if they meet the criteria of IRS Publication 502:
EXCLUSIONS
Health insurance premiums that you or your spouse pay for coverage under another health plan;
Basic cost of Medicare Insurance, life insurance or income protection policies;
Long-term care services;
Cosmetic surgery or other similar procedures , unless the surgery or procedure is necessary to
ameliorate a deformity arising from, or directly related to, a congenital abnormality, a personal
injury resulting from an accident or trauma, or disfiguring disease. "Cosmetic surgery" means
any procedure or drug which is directed at improving the patient s appearance and does not
meaningfully promote the proper function of the body or prevent or treat illness or disease; .
The salary expense of a nurse to care for a healthy newborn at home;
Household and domestic help (even though recommended by a qualified physician due to an
employee s or dependent's inability to perform physical housework);
Custodial care;
Health club dues, or fitness programs;
Social activities, such as dance lessons (even though recommended by a qualified physician for
general health improvement;
Bottled water;
Maternity clothes;
Diaper service or diapers;
Cosmetics, toiletries, toothpaste, etc.
Vitamins, food supplements or special foods, even if prescribed;
Marijuana and other controlled substances , even if prescribed; and
Travel your doctor tells you to take for rest or change.
ORTHODONTIC TREATMENT
Expenses for orthodontic treatment can only be reimbursed for the expenses incurred during the Plan Year. The
Plan will reimburse up to one third of the entire cost of the orthodontic treatment when the braces are installed
and amortize the remaining amount of the cost over the treatment period.
When must the expenses be incurred?
Medical Expenses must have been incurred during the Plan Year. You may not be reimbursed for any expenses
arising before the Plan became effective, before your Salary Reduction Agreement became effective, for any
expenses incurred after the close of the Plan Year, or after a separation from service (except for ContinuationCoverage).
What if the Medical Expenses I incur during the Plan Year are less than the annual amount I have elected
for Medical Care Reimbursement?
You will not be entitled to receive any direct or indirect payment of any amount that represents the difference
between the actual medical expenses you have incurred and the annual coverage level you have elected and paid
for. Any unused annual coverage benefit not used shall be forfeited and used to offset administrative expenses
and future costs.
A vista Corp.
Dependent Care Reimbursement Plan (DCR)
ELIGIBILITY
You are eligible to participate in the Plan if you are a:
. Regular (Frr or prr) employee
Dependent Care Expense Reimbursement Benefits
Under the Dependent Care Expense Reimbursement (DCR) component, you provide a source of pre-tax funds to
reimburse yourself for your Eligible Dependent Care Expenses by entering into a Salary Reduction Agreement
with A vista Corp under which you agree to a salary reduction to fund Dependent Care Expenses in lieu of a
corresponding amount of your regular pay. This arrangement helps you because the coverage you elect is non-
taxable, thereby saving you social security and income taxes on the amount of salary conversion.
Dependent Care Expense Reimbursement Account
If you elect benefits under this portion of the Plan, a Dependent Care Expense Reimbursement Account will be
set up in your name to keep a record of the reimbursements you are entitled to. Your Dependent Care
Reimbursement Account is merely a record keeping account; it is not funded (all reimbursements are paid out of
the general assets of A vista Corp).
What is the maximum Dependent Care Reimbursement benefit I may elect?
This amount can not exceed the maximum amount specified in Section 129 of the Internal Revenue Code. The
maximum amount is currently $5 000 per Plan Year if you:
are married and file ajoint return;
are married, but you furnish more than one-half the cost of maintaining those dependents for
whom you are eligible to receive tax-free reimbursements under the DCR, your spouse maintains
a separate residence for the last six months of the calendar year, and you file a separate tax
return; or
are single or are the head of the household for tax purposes.
If you are married and reside with your spouse, but you file a separate federal income tax return, then the
maximum DCR benefit you may elect is $2 500.
How is my Dependent Care Expense benefit funded?
When you complete the Salary Reduction Agreement, you specify the amount of DCR benefits for which you
wish to pay with your salary reduction. Thereafter, your Dependent Care Reimbursement Account will be
credited with the portion of your gross income that you have elected to forego through salary reduction. These
portions will be credited as of each pay period. The amount that is available for reimbursement at any particular
time will be whatever has been credited to your Dependent Care Reimbursement Account, less any
reimbursements already paid.
What is a "Dependent Care Expense" for which I can claim a reimbursement?
You may be reimbursed for work-related expenses incurred on behalf of any individual in your family who is
under the age of 13, who resides with you and whom you could claim as a dependent on your federal income tax
return; any other dependent who is mentally or physically incapable of self-care; or your spouse, if the spouse is
likewise physically or mentally incapacitated.
Generally, these expenses must meet all of the following conditions for them to be eligible Dependent Care
Expenses:
1. the expenses are incurred for services rendered after the date of your election to receive Dependent
Care Expense Reimbursement, and during the calendar year to which it applies:
2. each individual for whom you incur the expenses is:
(a) a dependent under age 13 whom you are entitled to a personal tax exemption as a dependent;
(b) a spouse or other tax dependent who is physically or mentally incapable of caring for himself or
herself;3. the expenses are incurred for the care of a dependent (as described above), or for related household
services , and are incurred to enable you to be gainfully employed;
4. if the expenses are incurred for services outside your household and such expenses are incurred for
the care of a spouse or other tax dependent age 13 or older who is incapable of self-care, such
individual regularly spends at least eight hours per day in your home;
5. if the expenses are incurred for services provided by a dependent care center (i., a facility that
provides care for more than six individuals not residing at the facility), the center complies with all
applicable state and local laws and regulations;
6. the expenses are not paid or payable to a child of yours who is under age 19 at the end of the year in
which the expenses are incurred or an individual for whom you or your spouse is entitled to a
personal tax exemption as a dependent; and7. this reimbursement (when aggregated with all other Dependent Care Reimbursements during the
same year) may not exceed the least of the following limits:
(a) $5,000;
(b) $2 500, if you are married but you and your spouse file separate tax returns;
(c) your taxable compensation (after your Salary Reduction under this Plan); and
(d) if you are married, your spouse s actual or deemed Earned Income.
For purposes of (d) above, your spouse will be deemed to have Earned Income of $200 ($400 if you have two or
more dependents described in paragraph 2 above), for each month in which your spouse is (i) physically or
mentally incapable of self-care, or (ii) a full-time student at an educational institution.
You are encouraged to consult your personal tax advisor or IRS Publication 17 "Your Federal Income Tax" for
further guidance as to what is or is not an Eligible Expense, if you have any doubts.
How do I receive a Dependent Care Expense Reimbursement under the Plan?
If you have elected to participate in this portion of the Plan, you will have to take certain steps in order to be
reimbursed for your Dependent Care Expenses. When you incur an expense that is eligible for payment, you
must submit a claim to the contract administrator, A. W. Rehn & Associates, Inc. on a claim form that will be
supplied to you. Your claim must include a statement from the dependent care provider showing the dates the
expenses were incurred, the name of the dependent cared for,. the cost of the care and the provider s taxpayer
identification number. If there are enough credits in your Dependent Care Expense Reimbursement Account, you
will be reimbursed for your eligible expenses. Please read the claims instructions with which you have been
furnished and sent claims to:
A.W. Rehn & Associates , Inc.
O. Box 5433
Spokane, W A 99205
[phone]
If a claim is for an amount that is more than your current Dependent Care Reimbursement Account balance, then
the excess part of the claim will be carried over into the next payment cycle, to be paid out as your balance
becomes adequate. Remember, though, that you can not be reimbursed for any total expenses above the available
annual credits to your Dependent Care Reimbursement Account. You may not be reimbursed for any expenses
that arise before your Salary Reduction Agreement becomes effective, or for any expense incurred after the close
of the Plan Year.
Please note that it is not necessary for you to have actually paid an amount due for Dependent Care Expenses -
only for you to have incurred the expense, and that it is not being paid for or reimbursed from any other source.
You will have 90 days after the end of the Plan Year in which to submit a claim for reimbursement for Dependent
Care Expenses incurred during the previous Plan Year. You will be notified in writing if any claim for benefits is
denied.
What if the Dependent Care Expenses I incur during the Plan Year are less than the annual amount .
coverage I have elected for Dependent Care Expense Reimbursement?
You will not be entitled to receive any direct or indirect payment of any amount that represents the difference
between the actual Dependent Care Expenses you have incurred and the annual coverage level you have elected
and paid for. Any unused annual coverage benefit not used shall be forfeited and used to offset administrative
expenses and future costs.
Will I be taxed on the DCR benefits I receive?
You will not normally be taxed on your DCR benefits, up to the limits set out in Q-29 of this summary.
However, to qualify for tax-free treatment, you will be required to file IRS Form 2441 or a similar form with your
annual income tax return to list the names and taxpayer identification numbers of any persons who provided you
with dependent care services during the calendar year for which you have claimed tax-free reimbursement.
If I participate in the DCR, will I still be able to claim the household and dependent care credit on my
federal income tax return?
You may not claim any other tax benefit for the tax-free amounts received by you under this Plan, although the
balance of your Dependent Care Expenses may be eligible for the dependent care credit.
What is the household and dependent care credit?
The household and dependent care credit is an allowance for a percentage of your annual dependent care
expenses as a credit against your federal income tax liability under the U.S. Tax Code. In determining what the
tax credit would be, you may take into account only $3 000 such expenses for one dependent, or $6 000 for two
or more dependents. Depending on your adjusted gross income, the percentage could be as much as 35% of your
qualifying expenses (to a maximum credit amount of $1 050 for one dependent or $2 100 for two or more
dependents), to a minimum of 20% of such expenses (producing a maximum credit of $600 for one dependent or
200 for two or more dependents). The maximum 35% rate must be reduced by 1 % (but not below 20%) for
each $2 000 portion (or any fraction of $2 000) of your adjusted gross income over $15 000.
When would I be better off to include the reimbursements in my income and claim the credit, rather than
to treat the reimbursements as tax-free?
Generally, if you are in one of the lower income tax brackets, you might come out ahead by including the DCR
benefits in income and by claiming the credits for dependent care and earned income. On the other hand, it will
generally be better to treat DCR benefits as tax-free the more income taxes you are required to pay. Because the
actual determination of the preferable method for treating benefit payments depends on a number factors such as
one s tax filing status (e.g. married, single, head of household), number of dependents, etc., each Participant will
have to determine his or her tax position individually in order to make the decision between taxable and tax-free
benefits. Use IRS Form 2441 to help you.
A vista Corp.
Premium Payment Plan
ELIGIBILITY
You are eligible to participate in the Plan if you are a:
. Regular (Fff or Pff) employee
How THE PREMIUM PAYMENT PLAN WORKS
The Premium Payment Plan allows you to pay the premiums for some of your Company benefits
with pre-tax dollars. This results in tax savings. You may use the Plan to pay premiums for:
~ MSC-EBA Medical Plans
~ WDS Dental Plans
Group Health Medical Plan
~ AD&D (Accidental Death & Dismemberment Insurance)
You will automatically be enrolled in the Premium Payment Plan if you participate in any of these plans.
If you do not want these premiums to be paid on a pre-tax basis for any year, you must complete and
submit a written request to that effect no later than December 31 of the preceding year.
EXAMPLE OF TAX BENEFIT
Suppose you earn $24 000 a year and have a federal income tax rate of 20%. Suppose, also, that you pay
$300 a year in premiums for EBA coverage for you and your family, and $103 a year in premiums for
$100 000 of family AD&D coverage. You would save "$111 a year in taxes by using the Premium
Payment Plan. Here s how the savings are calculated:
With POP Without POP
Annual gross income $24 000 $24 000
EBA premium (pre-tax)300
AD&D premium (pre-tax)103
Adjusted gross income $23 597 $24 000
Federal income tax (20%)720 800
Social Security Tax 805 836
EBA premium (after tax)300
AD&D premium (after tax)103
Take-home pay $17,072 $16 961
Tax savings $111
(This example is intended to illustrate the effect that the Plan has on an employee s take-home pay. The
tax assumptions used here will most likely be slightly different than your own situation.
A vista Corp.
401(k) Plan Investment Options
Artisan International Fund
A vista Corp. Stock Fund
Dodge & Cox Stock Fund
Julius Baer Int'l Equity A
Sentinal Small Company A
Sterling Small Cap Value Fund
Vanguard PRIMECAP Fund
Vanguard 500 Index Fund
Vanguard Retirement Savings Trust Fund
Vanguard Small-Cap Value Index Fund
Vanguard Total Bond Fund
Vanguard Value Index Fund
Vanguard We11ington Fund
Vanguard Brokerage Option
Contact Vanguard at 1-800-523-1188 for more complete plan information. Or go to
their website at Vanguard.com
A vista Corp.
Investment Plan - 401(k)
ELIGIBILITY
Eligible on the enrollment date that immediately follows your employment date. (You must have at least
one complete payclose in order to be recognized by Vanguard as an eligible participant.Students &
leased employees are not eligible.
PARTICIPANT DEFERRAL PERCENTAGE CHANGES
Changes are allowed monthly. The transaction deadline is the 20th of the month. The effective date is
the first day of the month following the transaction. Deductions are taken out of each paycheck and can
be in whole percentage increments between 1 % and 25%.
FUND TRANSFER & FUTURE INVESTMENT DIRECTION CHANGES
Changes are allowed daily. Transfers and investment changes made before 1 p.m. Pacific time will be
effective the next day. Investment elections are effective for the first payclose following the transaction.
Exchanges in the A vista Stock Fund must be made before lOam Pacific Time.
CONFIRMATIONS
Confirmations are provided for each transaction completed. Confirmations are mailed directly to
participant's home. Participants can also request an immediate FAX confirmation.
QUARTERLY FEES
Participants are responsible for investment management fees for the funds they invest. Also, record
keeping, trustee and custodian, consulting, legal and counting fees are paid from the trust and allocated
to participant accounts based on investment balances.
DISTRIBUTIONS
Distributions are processed daily. Proceeds are distributed within 45 days of the end of the month
processed.
IF You LEAVE THE COMPANY
Termination Distributions: Allowed for retirement, death or termination of employment.
In-Service Distributions: Allowed at age 59 Y2 and upon disability.
All Distributions: Participants are allowed to choose how their Avista Common Stock is distributed.
Participants may choose either stock certificates or cash.
Retiree Distributions: Retired participants may elect monthly installment payments from their account
over a period not to exceed 15 years. An annual fee of $100 per year will be assessed to the Retiree.
Changes in the monthly amount are allowed annually.
A vista Corp.
Investment Plan - 401(k)
COMPANY STOCK DIVERSIFICATION
Participants at least age 50 and older, with 5 years in the plan can diversify.up to 50% of their year-end
Company ESOP match balance.
Diversification Prior to age 50: Participants may elect to diversify up to 100% of their Non-ESOP
Company match account at anytime.
Retiree Diversification: Retirees may diversify 100% of the Company match portion of their account at
any time.
LOANS
Loan Set Up Fee: Loan set-up fee of $100
Initiating A Loan: Loans are modeled and set up through Vanguard Participant Services 1-800-523-
1188.
Types of loans: You can request a 5-year general loan for any reason. The 10-year loan must be for the
purchase of your primary residence only. Th~ purchase agreement will be required as documentation for
the primary residence loan.
Process Dates: Loans are processed after the loan is requested from Vanguard Participant Services 1-
800-523-1188.
Withdrawal from the participant account, for the loan proceeds, is made on a prorated basis from all
funds.
Number of Loan(s) Allowed: Two outstanding loans at a time, but no more than one home loan.
Therefore, either two general OR one general and one home loan are allowed at anyone time.
Repayment of Loan(s): Maximum payback on general loans is 5 years. Maximum payback for the
primary residence loan is 10 years (Documentation is required).
Repayment to the account is made in the same investments as most current payroll investment election.
Payment Set Up: All loan payments made via payroll 1 pension deduction. Cash payment not accepted
except for lump sum payoff.
Minimum / Maximum: You can borrow a Minimum of $1 000; Maximum of the lesser of 50% of
account balance or $50,000 reduced by your highest outstanding loan balance during the 12 - month
period ending on the date of the loan. Loan proceeds are withdrawn only from the Non Company match
accounts.
Interest Rate: Interest rate of Prime + 1 % at the time of the loan request.
If You Leave the Company: If you terminate employment with the Company, other than Retirement
you have 60 days following termination to repay the loan in full. If you default, the outstanding balance
is considered a taxable distribution subject to both income tax and a 10% penalty tax.
RETIREE LOAN(S)
Retirees are eligible for loans. At no time will a loan be granted in which the monthly payment exceeds
net pension benefits.
Vesting: The balance of participant contributions & earnings are 100% vested at all times. Employer
contributions are vested after the participant's one-year employment anniversary.
vista Corp.
Retirement Bonus
How THE RETIREMENT BONUS WORKS
In recognition of years of service to the Company, a Retirement Bonus will be paid to employees retiring
from active service (with a minimum of 15 years) as defined under provisions of the Retirement Plan for
Employees of A vista Corp.
Completed
Years of Days Pay
Service
30+
IS-year minimum: 1 day for each year or partial year of service.
A vista Corp.
Retirement Plan
OVERVIEW
The Retirement Plan provides you with a continuing source of monthly income upon retirement from the
Company. This benefit is funded entirely by the Company.
ELIGIBILITY
After completion of one year of service and a minimum of 1000 hours an eligible employee becomes a
Member of the Plan if they are employed by a Participating Employer.
VESTING
Vesting is a form of ownership or right to receive a pension benefit. Vesting Service is time, which is
counted toward earning a vested pension benefit. Benefits are vested after five years of service.
NORMAL RETIREMENT FORMULA
Normal Retirement Date is the first day of the month coincident with or next following your 65th
birthday or the fifth anniversary of your employment date, whichever is later. When you retire on or
after your Normal Retirement Date, you are entitled to an unreduced pension benefit calculated using the
Normal Retirement Formula described below. If you have at least 15 years of Vesting Service you may
retire with a reduced benefit as early as age 55, or retire as early as age 62 and receive an unreduced
benefit. See "Early Retirement" section for more detail.
Formula: The Plan formula averages your highest consecutive 36 months of base pay during the last
ten-year period worked. This is called your "Year Final Average Pay
1.5 % of 3- Year Final Average Pay for each year of Benefit Service.
The amount resulting from this calculation is called your "accrued benefit"
Example Calculation: If you have 20 years of Benefit Service and 3- Year Final Average Pay of
$25 000, your benefit will be $7 500 per year or $625.00 per month calculated as follows:
1.5% x 20 years = 30%
30% x $25 000 = $7 500
500 + 12 months = $625.
This benefit, called a Life Annuity, is paid in equal monthly installments for as long as you live.
A vista Corp.
Retirement Plan
EARL y RETIREMENT
Retirement from ACTIVE Service:If you are actively employed by the Company and you are at least
age 55 you can elect to retire if you have at least 15 years of service. Since monthly benefits will be
paid over a longer period of time, they will be reduced by a percentage according to your age when
payments begin.
Early Retirement Reduction
Factors (ERRF):
A(!e at Retirement of Normal Retirement Benefit
Pavable
72%
76%
80%
84%
88%
92%
96%
100%
100%
100%
100%
Early Retirement Reduction Factors
Adjustment: For each year of Benefit Service in excess of 15 , the reduction for early retirement is
decreased by 1%.
For example, with 27 years of Benefit Service, you can retire as early as age 59 with afull, unreduced
pension!
27 years - 15 years = 12
age 59 ERRF = 88%
12 + 88% = 100% of Normal Retirement Benefit
Example Calculation: Suppose you choose to retire at age 55 and elect to receive your benefits
immediately. Your Final Average Pay is $35 000 and you have 16 years of Benefit Service. Your
annual pension (Life Annuity) will be $6 132 or $511 per month.
1.5% x 16 years = 24%
24% x $35,000 = $8 400
16 years - 15 years = 1 (which equals 1 %)
age 55 ERRF = 72%
1 + 72% = 73% of Normal Retirement Benefit
$8,400 x 73% = $6 132
132 + 12 months = $511
vista Corp.
Retirement Plan
BENEFITS FOR VESTED TERMINEES
Vested employees who leave the Company before qualifying for early or normal retirement receive
benefits according to the following table. To be eligible for pension benefits, which begin prior to age
65 you, must have completed at least 15 years of Vesting Service. The Early Retirement Reduction
Factor - Adjustment of 1 % for every year over 15 years also applies to Vested Terminees.
ERRF for Vested Terminees:A.ee Benefit Bef!ins % of Normal Retirement Benefit
Pavable
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
FORMS OF BENEFITS
In addition to choosing whether to retire early or on your Normal Retirement Date, you may choose the
form in which your pension is paid. If you are married at the time of retirement your choices are:
Life Annuity, or
Social Security Level Income Benefit, or
Lump Sum Cash Out
If you are single, your choices are:
Life Annuity Benefit, or
. Ten-year Certain and Life Benefit, or
Social Security Level Income Benefit, or
Lump Sum Cash Out
Life Annuity Benefit: The Life Annuity Benefit is paid to you for as long as you live. Eligible
dependents receive survivor benefits. You will automatically receive your pension in this form unless
you elect otherwise. The Life Annuity Benefit is reduced if you retire early based upon the ERRF
described previously.
Social Security Level Income Benefit: This form of benefit is available to you if you retire before age
62. Under this option, your pension payments would be higher before age 62, and then reduced to reflect
the amount received from Social Security. The intent of this option is to provide you with a somewhat
level income before and after Social Security benefits begin.
If you are married and choose this option, the reduction shall apply to only your benefit; it will have no
effect on survivor benefits.
vista Corp.
Retirement Plan
Ten- Year Certain and Life: If you are single, but want to provide coverage for an ineligible dependent
or other beneficiary, you may elect the Ten- Year Certain and Life Annuity. This option provides a
reduced lifetime pension for you, but it assures that a total of at least 120 equal monthly payments will
be made to either you or your beneficiary. If you die before receiving 120 payments, the remaining
payments are made to your beneficiary. However, if you die after receiving 120 monthly payments, no
benefits will be payable to your beneficiary.
The following table shows what your reduced Ten-Year Certain and Life Annuity would be as a
percentage of the Life Annuity Benefit you would be entitled to receive at a given retirement age:
Af"e
65 or older
Reduced Benefzt as a % of Life Annuitv
Benefzt
98%
97%
96%
95%
94%
93%
92%
91%
90%
89%
88%
If you retire early and choose the Ten-Year Certain and Life Annuity, your monthly benefit is further
reduced. In the previous example, you retired with 16 years service at age 55 and received a reduced
Lifetime Annuity Benefit of $511 per month. If you chose the Ten- Year Certain and Life Annuity, the
monthly benefit would be $$500.78. The table above shows that the Ten- Year Certain and Life Annuity
at age 55 is 98% of the benefit you would otherwise be entitled to receive. Therefore, 98% of $511 is
$500.78.
Lump-Sum Cash Payment: The Plan permits you the option of electing a single lump sum cash
payment distribution in lieu of the normal form of annuity benefit. This single lump sum cash payment
would be the actuarial equivalent of your benefit otherwise payable in annuity form. If you are married
your spouse must consent to this election. A lump sum election means you receive a single payment
from the Plan and no other benefit payable to you or a survivor upon your death.
Benefit Less Than $5 000: If the present value of your accrued benefit is less than $5 000 at the time of
your termination from the Company, the Plan will distribute the actuarial equivalent of your benefit in a
single lump sum cash payment.
A vista Corp.
Retirement Plan
SURVIVOR BENEFITS
If you choose either the Life Annuity Benefit or the Social Security Level Income Benefit, your eligible
surviving dependents will receive a survivor benefit after you die.
To be eligible for benefits, your spouse must have been married to you at the time benefits commenced
and have been your spouse for at least 12 months at the time of your death. After your death, 66 2/3 % of
your pension will be paid to your Eligible Surviving Spouse until he or she reaches age 60. After age 60
50% of your pension will be paid for his or her life.
Example: Suppose your Life Annuity Benefit is calculated to be 500 a month. If your Eligible Spouse
survives you, the survivor s monthly pension would be $1000 until he or she reaches age 60. After age
60 the survivor pension would be $750 for his or her life.
The example above assumes that you are not more than five years older than your spouse is. Benefit
percentages are reduced two percent for each full year that you are more than five years older than your
spouse IS.
Example: If you are Ih years older than your Eligible Spouse, the benefit payable if he or she survives
you would be 64 2/3% of your benefit until your spouse reaches age and 48% after age 60 for life. If
your pension was 500 per month, the survivors monthly benefit would be $970 until age 60 and $720
thereafter.
If you have no Eligible Spouse when you die , but do have Eligible Children, 66 2/3% of your pension
will be shared equally amount your children until they reach age 19.
Pre-Retirement Survivor Income Death Benefit: If you die after becoming fully vested in the Plan
but before you begin receiving benefits , your Eligible Surviving Spouse or Eligible Dependent Children
will receive pension payments. The date upon which benefits begin depends on whether you die before
or after becoming eligible for early retirement.
After Eligibility for Early Retirement
If you die after becoming eligible for early retirement, your eligible survivor(s) is/are entitled to receive a
pension benefit starting the first day of the month following your death.
Before Eligibility for Early Retirement
If you die before becoming eligible for early retirement, your eligible survivor(s) islare entitled to the
same survivor benefit that would have been paid had you terminated rather than died. The survivor
benefit will commence on the earliest date you could have received a pension benefit.
A vista Corp.
HIP AA Privacy Notice
THIS NOTICE DESCRIBES How MEDICAL INFORMATION ABOUT You MAyBE USED AND DISCLOSED AND
How You CAN GET ACCESS To THIS INFORMATION. PLEASE REvIEW IT CAREFULLY.
This notice is required by a federal law called the Health Information Portability and Accountability Act of 1996
(HJPAA). Under HJPAA, Avista must take steps to protect the privacy of your "protected health information
(PHI.) PHI includes information that we have created or received regarding your health or payment for your
health. It includes both your medical records and personal information such as your name, social security
number, address , and phone number.
UNDER FEDERAL LAW, WE ARE REQUIRED TO:
Protect the privacy of your PHI. All of our employees are required to maintain the confidentiality of PHI and
receive appropriate privacy training.
Provide you with this Notice of Privacy Practices explaining our duties and practices regarding your PHI.
Follow the practices and procedures set forth in the Notice.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION BY A VISTA THAT DO NOT REQUIRE
YOUR AUTHORIZATION
Avista uses and discloses PHI in a number of ways connected to payment for your care and health care
operations. Some examples of how we may use or disclose your PHI without your authorization are listed
below:
1. Payment Functions We may use or disclose health information about you to determine eligibility for
plan benefits, obtain premiums, facilitate payment for the treatment and services you receive from health
care providers, determine plan responsibility for benefits , and to coordinate benefits. For example
payment functions may include reviewing the medical necessity of health care services, determining
whether a particular treatment is experimental or investigational, or determining whether a treatment is
covered under your plan.
2. Health Care Operations. We may use and disclose health information about you to carry out necessary
insurance-related activities. For example, such activities may include underwriting, premium rating and
other activities relating to plan coverage; conducting quality assessment and improvement activities;
submitting claims for stop-loss coverage; conducting or arranging for medical review, legal services
audit services, and fraud and abuse detection programs; and business planning, management and general
administration.
3. Public Health. As required by law, we may disclose your health information to public health authorities
for purposes related to: preventing or controlling disease, injury or disability; reporting child abuse or
neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with
products and reactions to medications; and reporting disease or infection exposure.
4. ReQuired by Law. As required by law, we may use and disclose your health information.
5. Health Oversie:ht Activities. We may disclose your health information to health agencies during the
course of audits, investigations, inspections , licensure and other proceedings related to oversight of the
health care system.
6. Judicial and Administrative ProceediO!~s. We may disclose your health information in the course of
any administrative or judicial proceeding.
7. Law Enforcement.We may disclose your health information to a law enforcement official for purposes
such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a
court order or subpoena and other law enforcement purposes.
8. Coroners, Medical Examiners and Funeral Directors We may disclose your health information to
coroners, medical examiners and funeral directors. For example, this may be necessary to identify a
deceased person or determine the cause of death.
9. Organ and Tissue Donation. We may disclose your health information to organizations involved in
procuring, banking or transplanting organs and tissues, as necessary.
10. Public Safety We may disclose your health information to appropriate persons in order to prevent or
lessen a serious and imminent threat to the health or safety of a particular person or the general public.
11. National Security. We may disclose your health information for military, national security, and
government benefits purposes.
12. Worker s Compensation. We may disclose your health information as necessary to comply with
worker s compensation or similar laws.
13. Education We may contact you to give you information about health-related benefits and services that
may be of interest to you.
14. Disclosures to Plan Sponsors We may disclose your health information to the sponsor of your group
health plan, for purposes of administering benefits under the plan.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION BY A VISTA THAT REQUIRE US TO
OBTAIN YOUR AUTHORIZATION
Except as described in this Notice of Privacy Practices, we will not use or disclose your health information
without written authorization from you. If you do authorize us to use or disclose your health information for
another purpose, you may revoke your authorization in writing at any time. If you revoke your authorization, we
will no longer be able to use or disclose health information about you for the reasons covered by your written
authorization , though we will be unable to take back any disclosures we have already made with your permission.
Statement of Your Health Information Rights
1. Right to Request Restrictions. You have the right to request restrictions on certain uses and disclosures
of your health information. A vista is not required to agree to the restrictions that you request. If you
would like to make a request for restrictions, you must submit your request in writing to the Privacy
Administrator - MSC-39, Avista Corp, 1411 E. Mission Ave., Spokane, W A 99202.
2. Right to Request Confidential Communications You have the right to receive your health
information through a reasonable alternative means or at an alternative location. To request confidential
communications, you must submit your request in writing to the Privacy Administrator - MSC-39, Avista
Corp, 1411 E. Mission Ave., Spokane, W A 99202. We are not required to agree to your request.
3. Right to Inspect and COpy. You have the right to inspect and copy health information about you that
may be used to make decisions about your plan benefits. To inspect and copy such information, you
must submit your request in writing to the Privacy Administrator - MSC-39, Avista Corp, 1411 E.
Mission Ave., Spokane, W A 99202. If you request a copy of the information , we may charge you a
reasonable fee to cover expenses associated with your request.
4. Right to Request Amendment. You have a right to request that A vista amend your health information
that you believe is incorrect or incomplete. We are not required to change your health information and if
your request is denied, we will provide you with information about our denial and how you can disagree
with the denial. To request an amendment, you must make you request in writing to the Privacy
Administrator - MSC-39, Avista Corp, 1411 E. Mission Ave., Spokane, WA 99202. You must also
provide a reason for your request.
S. Right to Accounting of Disclosures. You have the right to receive a list or "accounting of disclosures
of your health information made by us, except that we do not have to account for disclosures made for
purposes of payment functions or health care operations, or made to you. To request this accounting of
disclosures, you must submit your request in writing to the Privacy Administrator - MSC-, Avista
Corp, 1411 E. Mission Ave. Spokane, W A 99202. Your request should specify a time period of up to
six years and may not include dates before April 14, 2003. A vista will provide one list per 12-month
period free of charge; we may charge you for additional lists.
6. Right to Paper COpy. You have a right to receive a paper copy of this Notice of Privacy Practices at
any time. To obtain a paper copy of this Notice, send your written request to the Privacy Administrator -
MSC- 39, A vista Corp, 1411 E. Mission Ave., Spokane, W A 99202. You may also obtain a copy of this
Notice at our HR website, http://avanet/departments/hr/.
CHANGES TO THIS NOTICE OF PRIVACY PRACTICES
Avista reserves the right to amend this Notice of Privacy Practices at any time in the future and to make the new
Notice provisions effective for all health information that it maintains. We will promptly revise our Notice and
distribute it to you whenever we make material changes to the Notice. Until such time, A vista is required by law
to comply with the current version of this Notice.
COMPLAINTS
Complaints about this Notice of Privacy Practices or about how we handle your health information should be
directed to the Privacy Administrator - MSC-, Avista Corp, 1411 E. Mission Ave. Spokane, WA 99202.
A vista will not retaliate against you in any way for filing a complaint. All complaints to A vista must be
submitted in writing. If you believe your privacy rights have been violated, you may file a complaint with the
Secretary of the Department of Health and Human Services.
CONTACT INFORMATION FOR QUESTIONS
Questions about this Notice of Privacy Practices or about how we handle your health information should be
directed to Keith Rust - Benefits Administrator, Avista Corp, 1411 E. Mission Ave. Spokane, WA 99202.(509)
495-4751.
EFFECTIVE DATE OF THIS NOTICE: APRIL 2003
Notice
Every effort has been made to describe the provisions of the Benefits PlaI;1S with accuracy and
clarity. This summary and the summaries of the plans that make up the Benefits Plans will give
you a good overview of how the Benefits Plan works. Because it is only a summary, however, it
omits much of the detail found in the Benefits Plan document itself. Should any discrepancy exist
between the Benefits Plan and this summary or the summaries of the plans that make up the
Benefits Plan, the official Benefits Plan is the controlling document and is binding upon all
parties. The Benefits Plan is available to any Benefits Plan participant for review at A vista
Corporation in the Human Resources office during regular business hours.
This summary and the summaries of the plans that make up the Benefits Plan are important
documents, and you should keep them in a safe place for future reference. You can access
Benefits Plan summaries on-line at http://avanet. If the Benefits Plan is changed in any way that
affects your eligibility or benefits, you will be given an explanation of the changes.
~'iI'STA.
Corp.
EMPLO YEE
BENEFIT
SUMMARY
(Non-Union)
January 1 , 2004 December 31 , 2004
LIFE INSURANCE
Group Life Insurance (Base Life) ......................................................... 2
MetLife Optional Life Insurance """"""""""""""""""""""""""".... 3-
Accidental Death & Dismemberment (AD&D).. ................. ...... .......... ....... 5-
EMPLOYEE ASSISTANCE PROGRAMS
Employee Assistance Program.... ....... ................................................... 10-
Tuition Aid ......................................................""""""""""""""'" 12
Adoption ....................................................................................... 13
Jury Duty ......................................................"""""""""""""""'" 14
MEDICAL INSURANCE
A VISTA-EBA Plans........
.............. """""""""""""""""""""""'"
15-
Group Health.................................................................................... 24-
Washington Dental Service.................................................................29-
Retiree MedicaL...... .... ............ ...... ...... .....
......... ....... ... ... .............. ....
42-
COBRA........................................................."""""""""""""""'" 48-
P AID TIME OFF
Holidays.........................................................................................
FMLA (Family Medical Leave Act).. .. ..
. . .. . .. . . . . .. . .. . . .. .. . .. .. .. . .. . .. .. . .. . . .. ..
.... 54
Worker s Compensation...........................................""""""""""""'" 55
Short Term Disability (STD).................................................................
Long Term Disability (LTD)................................................................. 57
One Leave.............................................. ........................................58-
PRE-TAX PROGRAMS
Health Care Reimbursement Plan................................... ...................... 60-
Dependent Care Reimbursement Plan.... ......... .................. ....... ............. 63-
Premium Payment Plan ......................................................................
RETIREMENT & 401(k) INVESTMENT PLANS
Investment Plan - 401(k)...........
....................................... ........
........... 68-
Retirement Bonus.
. .. . . . . . . . . . . . . . .. .... .. . .. . .. .... .. .. . . . . . . . . .. . .. . . .. . .. .. .. . .. . ... .. .. ...
Retirement Plan ............................................................,.................. 72-
HIPAAPrivacyNotice........................................................................77-
A vista Corp.
Group Life Insurance (Basic Life Insurance)
ELIGIBILITY
You are eligible to participate in the Plan if you are a:
Regular or full-time employee, or
Regularly scheduled (20+ hours) part-time employee. (Casual or temporary employees are not eligible).
COST TO YOU
The Company pays the cost of the insurance in full.
COVERAGE FOR YOU
1. Employees not yet 40 years of age on 7/1/97:
. 1 x annual base pay rounded to the nearest $1 000 but not to exceed $50 000.
2. Employees 40 years of age, but not yet 60 years of age on 7/1/97:
. 1 x your annual base pay rounded to the nearest $1 000 but not to exceed $75 000.
J . Employees 60 years of age or older on 7/1/97:
. 1 x your annual base pay rounded to the nearest $1 000 but not to exceed $250 000.
Note: Employees hired on and after 7/1/97 ref;?ardless of af;?e,will have coverage of x annual base pay
rounded to the nearest $1 000, but not to exceed $50 000.
COVERAGE WHEN YOU RETIREE
1. Employees not yet 40 years of age on 7/1/97:
. $5 000
2. Employees 40 years of age, but not yet 60 years of age on 7/1/97:
1 x your annual pension to the nearest $100, but not to exceed $20 000.
Note: $20 000 currently exceeds the average annual pension to the nearest $100.
3. Employees 60 years of age or older on 7/1/97:
1 x your annual pension to the nearest $100.
Note: Employees hired on and after 7/1/97 will have NO company provided Life Insurance upon retirement.
IF YOU LEAVE THE COMPANY
Coverage ends.
A vista Corp.
MetLife Optional Life Insurance Protection Program
With Dependent Life Insurance Coverage
OPTIONAL LIFE
You may obtain between $10,000 and $300 000 of Optional Life insurance for yourself, available through the
convenience of payroll deduction, in flexible multiples of your annual salary (maximum benefit is 5 times annual
eamings). This coverage is available for you without medical evidence of insurability if you select one times annual
earnings up to a maximum of $300,000, provided enrollment takes place within 31 days of becoming eligible, and
you have not been hospitalized within 90 days of enrollment. The definition of "hospitalized" includes inpatient
hospital care, care in a hospice, intermediate or long-term care facility. This also includes outpatient hospital care for
receipt of chemotherapy, radiation therapy, or dialysis treatment.
A vista Corporation s Optional Life plan includes the following features:
Portability: Allows you to continue telm coverage on your life should you leave A vista Corporation, or if you
are no longer part of an eligible class for the coverage. Competitive group rates apply, and you will be billed
directly by MetLife. Dependent term coverage on spouses and children is not portable.
Conversion: If your life insurance coverage terminates, you may convert your term coverage to a MetLife
individual permanent policy without evidence of insurability. Covered dependents may also convert.
Accelerated Benefits Option: Allows terminally ill participants diagnosed with less than six months to live to
receive up to 50% of their insurance proceeds while still living.
Total Control Account: Provides beneficiaries with immediate access to insurance proceeds. The account is
similar to a bank money market account and is fully guaranteed by MetLife.
Disability Provision: Should you become unable to work due to total and permanent disability, your term life
coverage may be continued until age 65.
DEPENDENT COVERAGE
Life insurance coverage is also available for your spouse without medical evidence of insurability if you select
amounts between $10 000 and $50 000 provided enrollment takes place within 31 days ofthe date he or she becomes
eligible, and your spouse has not been hospitalized within 90 days of enrollment.
Coverage on the life of your spouse is available in $10 000 increments, with a minimum benefit of $10 000 and a
maximum of $ 100 000, as long as the amount does not exceed the maximum allowable of 50% of the employee
amount, permitted by the State of Washington.
Coverage is also available in the amount of $2 000, $5 000, or $10 000 as long as the amount does not exceed the
maximum allowable of 50% of the employee amount, permitted by the State of Washington for your dependent
child(ren) age 15 days to 19 years (23 years if a full time student) provided that they have not been hospitalized in the
90 days prior to enrollment. A full Statement of Health is required if your child has been hospitalized in the 90 days
prior to enrollment.
COVERAGE IN RETIREMENT
A vista Corporation s Optional Life plan allows you to continue your current term coverage on your life and your
dependents when you retire. The group rates listed still apply, and your premium will be taken directly from your
A vista pension check. Retirees are not allowed to purchase new coverage or increase their current coverage levels.
ELIGIBILITY
To be eligible for these coverages, you must be actively at work on the effective date. The definition of actively at
work differs slightly for each coverage. "Actively at Work" means that you have worked at least 20 hours over the
last seven consecutive calendar days at your usual place of business, or away from your usual place of business at
your employer s request, doing all the substantial and material duties of your regular employment or occupation.
Your dependent must also be able to perform "normal activities." This means that the dependent is not confined at
home under the care of a physician due to sickness or injury and is not receiving or is entitled to receive any
disability income from any source due to their own sickness or injury.
EVIDENCE OF INSURABILITY
If you apply for optional life coverage amounts in excess of 1 times your basic annual eal11ings, or your dependents
apply for coverage amounts in excess of $50,000, or if any applicant has been hospitalized within 90 days of
enrollment, a full Statement of Health must be completed for each individual applicant and retul11ed with your
enrollment form.
Employees will be allowed a coverage increase of one times pay up to the plan maximum subject to medical evidence
once per year on January 1.
If you decide to increase or enroll for coverage after the enrollment period has ended, all applicants will be required
to complete a Statement of Health form regardless of the coverage amount selected.
If your spouse is covered under your employer s current plan, your spouse can obtain coverage equal to the stated
amount without evidence of insurability or hospitalization requirements.
TO ENROLL
Contact Human Resources for a MetLife enrollment packet. Upon Metlife s review of your formes), additional
medical information may be required based on you and/or your dependent's health status , and coverage amount
elected. You will be advised when coverage is approved or if additional information is needed.
COST TO YOU
Rates (cost per $1 000 of coverage) are based on employee/spouse age. Premiums will increase or decrease
accordingly dependent on age, salary, and coverage levels. Premiums will automatically increase as employee or
souse s acre reaches increased acre brackets.
Less Than 30
30-
35-
40-
45-
50-
55-
60-
65-
70-
75 +
*Per $1 000/ month
$ .
.46
1.04
1.65
Child(ren) Rate: Cost is $.12 per $1 000 of coverage and covers all eligible children , regardless of number.
Notices:
.:.
Please refer to the Benefit Plan for more detail and plan exclusions. Like most group policies, MetLife s group
policies contain certain exclusions, limitations, reductions and ten11S for keeping them in force.
A vista Corp.
Accidental Death & Dismemberment Insurance (AD&D)
OVERVIEW
The AD&D Program provides protection in the event of accidental death for both you and your family. In addition
the program provides benefits in the event of loss of limb, eyesight, speech or hearing.
ELIGIBILITY
You are eligible to participate in the Plan if you are a:
Regular or full-time employee, or
Regularly scheduled (20+ hours) part-time employee. (Casual or temporary employees are not eligible).
Your spouse under the age 70 and unmarried dependant children under the age of 19 are also eligible. Unmarried
children who are full time students and primarily dependant on you for support are also eligible to age 23.
WHEN AM I COVERED?
You are covered 24 hours a"day. Anywhere in the world. On the job or at home. And these benefits are payable in
addition to any other insurance you have.
WHEN WILL MY COVERAGE BECOME EFFECTIVE?
If you are eligible you may enroll for coverage at any time during the year. Coverage will become effective on the
first of the month on or next following the date your enrollment form is received.
CAN I CHANGE MY COVERAGE AFTER I'VE ENROLLED?
Yes. To request a change in coverage , simply complete a new enrollment form. Forms are available in the Benefits
Section , Human Resources. The change will become effective on the first of the month on or next following the date
your enrollment is received.
WHO WILL BE THE BENEFICIARY?
Benefits for loss to your life will be paid directly to the beneficiary you have designated. If you have not designated
a beneficiary, the life benefit will be paid to your estate. Benefits for loss other than life will be paid to you. All
dependent benefits are paid to you.
BENEFITS FOR ACCIDENTAL DEATH AND DISMEMBERMENT
If an injury results in any of the following losses within 365 days after the accident, this plan will pay:
For Loss of:
Life
Both Hands or Both Feet or Sight of Both Eyes
One Hand and One Foot
Speech and Hearing
Either Hand or Foot and Sight of One Eye
Movement of Both Upper and Lower Limbs (Quadriplegia)
Movement of Both Upper and Lower Limbs of One Side of the Body
Either Hand or Foot
Sight of One Eye
Speech or Hearing
Thumb and Index Finger of Either Hand
Movement of Both Lower Limbs (Paraplegia)
Principal Sum
Principal Sum
Principal Sum
Principal Sum
Principal Sum
Principal Sum
One-Half of Principal Sum
One-Half of Principal Sum
One-Half of Principal Sum
One-Half of Principal Sum
One-Quarter of Principal Sum
Three-Quarters of Principal
The total limit of liability for anyone person for all losses due to the same accident will not be more than the
Principal Sum.
Loss means with regard to hands and feet, actual severance through or above wrist or ankle joints; sight, speech or
hearing, entire and irrecoverable loss thereof; thumb and index finger, actual severance through or above the
metacarpophalangeal joints; movement of limbs, complete and irreversible paralysis of such limbs.
Iniurv means a bodily injury resulting directly from an accident, and independent of all other causes. Loss resulting
from sickness or disease, or medical or surgical treatment of a sickness or disease, is not covered. The accident must
occur while you are covered under the policy.
$20 000 EDUCATION BENEFIT
(Pays up to $5 000 per year, for up to 4 years)
If your dependents are covered under the fanrily plan and you die, and the Principal Sum is payable, the plan will pay
an Education Benefit to each student. The education benefit will be the lesser of 5% of your Principal Sum or the
maximum amount of $5 000.
To receive this benefit, a student must show proof that, on the date of your death he or she was a covered dependent
and:
a full-time post-high school student in a school for higher learning, or
a student in 12th grade and becomes a full-time post-high school student in a school for higher learning
within 365 days.
This benefit is payable every year in which the student meets the above definition for up to 4 years, provided the
dependent submits proof of his or her student status each year.
If an Education Benefit would be payable, but no person qualifies as a student, the plan will pay the minimum
amount of $1,500 according to the terms of the beneficiary section.
000 SPOUSE EDUCATION BENEFIT
If your dependents are covered under the family plan and the Principal Sum is payable because of your death, the
plan will pay your spouse an Education Benefit. This benefit will be the lesser of:
. 5% of your Principal Sum, or
the Expense Incurred for Occupational Training, or
the maximum amount of $5 000.
To qualify for this benefit, your spouse must enroll in an Occupational Training Program for the purpose of earning
an independent income. Enrollment must take place within one year of your death, and expenses must be incurred
within two years of your death.
If the Principal Sum is payable because of your death, and no covered spouse survives, the Plan will pay the
minimum amount of $1 500, according to the terms of the beneficiary section.
Expenses Incurred means actual tuition charged and cost of materials required for the Occupational Training
Program. It does not include room and board.
Occupational Training Program means any educational, professional , or trade, which prepares your spouse for an
occupation for which he or she would not otherwise be qualified.
$10 000 DA Y CARE BENEFIT
(Pays up to $2 500 per year, for up to 4 years)
If your dependents are covered under the family plan and you die, and the Principal Sum is payable, the plan will pay
a Day Care Benefit on behalf of each eligible dependent. The Day Care Benefit will be the lesser of 2.5% of your
Principal Sum or the maximum amount of $2 500.
To receive this benefit, an eligible dependent must be under age 7 and:
be enrolled in a licensed Day Care Program, or
will be attending such a program in 365 days.
This benefit is payable every year for up to four years, provided the dependent child continues to be enrolled for Day
Care and is under age 7.
If a Day Care Benefit would be payable, but no person qualifies as an eligible dependent, the plan will pay the
beneficiary s benefit of $1,250.
$10 000 SEAT BELT BENEFIT
If you or your dependents suffer a loss payable under the Accidental Death and Dismemberment Benefit, the plan
will pay an additional benefit of 10%of the applicable principal sum to the maximum amount of $10 000 if injury
occurred:
while a passenger in or the licensed operator of a registered automobile; and
while wearing a Seat Belt, as verified in the policy accident report.
This benefit does not cover loss if you are operating the automobile under the influence of any intoxicant, excitant
hallucinogen, narcotic or other drug, or similar substance as verified in the policy accident report.
Automobile means a four-wheeled, private passenger car, station wagon, van or jeep-style vehicle, which is not
being used as a Common Carrier.
Common Carrier means a vehicle operated by a business organized and licensed to transport passengers for hire
and operated by an employee of that business. The Policyholder s business does not qualify as a Common Carrier
under this contract.
CAN I CONVERT COVERAGE?
Yes. If your coverage terminates because you are no longer eligible, you may convert to a policy from ITT Hartford
and no evidence of insurability is required. You may only convert coverage if the policy is in force and you have
paid the premium. You must request conversion in writing to ITT Hartford and pay the initial premium within 31
days of the date this conversion terminates. Dependent coverage can be converted if your dependents were covered
under this policy on the date your coverage ceased. The maximum benefit amount is $100,000.
SCHEDULE OF BENEFITS
Cost to You Per Month - You
Princi al Sum
$25 000
000
000
100 000
125 000
150 000
175 000
200 000
225 000
250 000
REDUCTION DUE TO AGE
Your Princi pal Sum automatically reduces on the premium due date on or nex t fo 11 owing the date you attain the age
indicated below:
Insured Person s Age
Age 70-
Age 75-
Age 80-
Age 85 or over
Percentage of Principal Sum
65%
45%
30%
15%
SCHEDULE OF BENEFIT OPTIONS
If both you and your spouse are employed by A vista Corp. and are eligible for this coverage, only one may purchase
the Family Plan. Please check with the Benefits Department for further details.
F AMIL Y PLAN:
In addition to your own coverage, family coverage provides the following insurance for your dependants:
1) If you have a spouse only, your spouse is insured for 60% of your Principal Sum.
2) If you have a spouse and children:
a. Your spouse is insured for 40% of your Principal Sum and
b. Each unmarried dependent child, under age 19, is insured for lO%of your Principal Sum (to age 23 if
eligible).
3) If you have children only (no spouse), each unmarried dependant child , under age 19, is insured for 20%
of your Principal Sum (to age 23 if eligible).
ARE THERE ANY EXCLUSIONS?
Yes. Loss caused by any of the following events is not covered:
Intentionally self-inflicted injury, suicide or attempted suicide , whether sane or insane.
War or act of war, whether declared or not.
Injury sustained while in the armed forces of any country or international authority.
Injury sustained while riding on any aircraft, unless it's a civilian or public aircraft , or military transport
aircraft.
Injury sustained while riding on any aircraft as a pilot, crewmember, student pilot, flight instructor, or
examIner.
Injury sustained while riding on any aircraft owned, operated or leased by or for the policyholder or any
employer or organization whose eligible persons are covered under the policy.
Injury sustained while riding on any aircraft being used for or in connection with crop dusting or seeding
or spraying, fire fighting, exploration , pipe or power line inspection, any form of hunting, bird or fowl
herding, aerial photography, banner towing or any test or experimental purpose, unless previously
consented to in writing by the company.
CAN MY COVERAGE BE TERMINATED?
Yes. Coverage will terminate on the earliest of the following dates:
The date the policy is terminated
The premium due on or next following the date you are no longer an eligible person or fail to pay
premIUm.
Coverage for eligible dependents terminates on the premium due date next following the earlier of:
The date you cease to be insured
The date your dependent is no longer eligible
The date your covered spouse reaches age 70.
Family coverage provides, in addition to the employee s coverage:
If you have spouse only, your spouse is insured for 50% of your Principal Sum.
A vista Corp.
APS Employee Assistance Program (EAP)
Overview
The APS Healthcare Employee Assistance Program (EAP) is a benefit available to A vista Corporation employees,
their dependents, and household members. This EAP provides confidential, short-term counseling at no out-of-
pocket expense to you for up to eight (8) sessions. Your EAP encourages you to seek assistance before a concern or
issue becomes serious. APS therapists evaluate any concern affecting one s life, including alcohol and drug abuse
marital and family issues, financial difficulties, emotional concerns, and work stress.
Discussions and personal information are never shared with anyone, including your employer, without your direct
knowledge and written approval. Exceptions are made only in cases governed by law to protect individuals threatened
by violence.
Employees and managers may make an appointment with a local, licensed, professional therapist by calling 533-6175
in Spokane or 800-999-1077 outside the area, during regular business hours. Employees and family members who
need an immediate response for crisis counseJing or after-hours assistance may call the APS toll-free, 24-hour Crisis
Line at 800-833-3031. You may also receive free legal and financial consultations by calling 800-999-1077.
Some common employee concerns:
Family
Drug Abuse
Alcohol Abuse
MaritallRelati onshi p
Work Related
Emotional
Financial
APS Employee Assistance Legal Services
Because almost every life event can involve a legal question or problem, APS offers both free legal consultations and
discounted legal referrals. Complex legal language and the legal system may intimidate many people in general. APS
legal services will help calm many fears and anxieties associated with legal concerns by answering basic questions
and simplifying the process of obtaining legal help.
Some common legal concerns include:
Divorce Guardianship Taxes
Wills Tenant's rights Litigation
Child custody Order for protection Power of attorney
Immigration Civil disputes Consumer s rights
Estate planning Criminal issues Bankruptcy
Wage garnishment Commercial concerns Liens
Legal consultation
Legal consultations may be the catalyst you need to create an action plan to resolve or alleviate your legal concern.
The legal consultations are provided at no cost to you , whether you speak with the attorney over the telephone or in
their office. When you call you will be directed to a lawyer in the city or community where the legal concern is
taking place. On average, the "lead lawyer" in the firm has over twenty years of experience.
Legal consultations are available during business hours, Monday through Friday. Legal consultations may also be
available during "off-hours" for emergencies. APS staff members are always available 24 hours every day if you
need information about legal services or simply wish to discuss any concerns that may accompany your legal issues.
Local legal referrals
It may be necessary to get a referral to meet with a lawyer in-person. Referrals will be made to a law firm in your
area. Referral lawyers have agreed to provide the initial half-hour consultation at no cost to you. If you decide to
retain the lawyer for further services, the lawyer will charge you at a special 25% reduced rate from their regular fees
because you were referred through APS. If for any reason you would like to use another lawyer, APS will provide
another referral resource.
APS Employee Assistance Financial Services
Family problems and daily living issues often include a financial component. For example, clients may be
concerned about the impending costs of an upcoming tax bill. Individuals struggling with a difficult domestic
situation may be worried about the financial impact of separation or divorce.
Clients who contact their Employee Assistance Program (EAP) with financial concerns can be connected to a
financial consultant who is able to discuss these concerns and provide suggestions regarding a course of action. This
telephonic consultation is provided free of charge to the employee or their dependent family members. The financial
consultant will review the client's past financial history, assess the current situation and problem solve with the client
to develop a resolution strategy. When appropriate, the EAP can provide a local community referral for a specific
concern .
Examples of areas in which the EAP can help include:
Taxes
Failure to file
Payment plans
Withholding questions
Tax preparation
Education
College funding
Alternatives to Bankruptcy
Credit counseling
Mortgage
Qualifying for a mortgage
Refinancing
. A voiding foreclosure
Credit Problems
Credit card debt
Overextended
Negotiating with credit card companies
Housing
Utility collections
Budgeting & Cash Flow
Developing a budget
Retirement Planning
401 K Plans
lRAs & Stock Options
What will I need?
Credit Restoration
Dealing with credit bureaus
If you have financial concerns, the EAP is there to help. APS Employee Assistance counselors are available 24 hours
per day to assist, no matter what the problem.
A vista Corp.
Tuition Aid Program
A VISTA Corp. will provide financial assistance to employees for approved courses when these can be shown to
reasonably add to the employee s improved performance and effectiveness in present or foreseeable future jobs
within the Company.
Tuition aid of up to $2 500 in any calendar year is available for the cost of tuition and books. Tuition and the
required class related fees billed by the institution are reimbursed at 100%, and books are covered at 50%.
Supplies, software, equipment, parking or other non-tuition fees are not covered costs. Any course required to
complete an undergraduate or masters level program is covered.
Regular, full-time or regularly scheduled part-time employees are eligible for tuition aid if:
the course is offered by an approved and accredited college, university, or academic institution
the course is necessary to satisfy a requirement for a degree program
the employee provides verification of satisfactory course completion
Tuition is granted based on the following schedule:
Employee receives tuition reimbursement for classes completed with a grade of C (2.0) or better. Grades
below a C, or courses dropped, will not receive financial support.
Employees who voluntarily terminate their employment before completing the course(s) will not recei"
reimbursement.
By signing the tuition aid application, employee agrees to these tell11S.
PROCEDURE:
Complete the Tuition Aid Application and have your supervisor sign it to approve the course or degree
program.
Pay for your tuition and books and retain all receipts.
After completing the c1ass(es) and receiving your grade(s) of a C (2.0) or better, submit the completed
application, copies of all receipts, and grade(s)to the Tuition Aid Coordinator in the Human Resources
Department at MSC-39.
Accounts payable will then notify you when your reimbursement is ready. Please allow up to three weeks for
reimbursement.
vista Corp.
Adoption Reimbursement Benefit
ELIGIBILITY
You are eligible to participate in the Plan if you are a:
Regular or full-time employee, or
Regularly scheduled (20+ hours) part-time employee. (Casual or temporary employees are not eligible).
HOW THE PLAN WORKS (Tax Free Benefit)
To support your decision to adopt a child under the age of 12, the Company will provide eligible employees 000
per adopted child to mitigate adoption expenses and possible time off without pay. The natural child of either parent
is excluded. Contact the benefits department for more information.
vista Corp.
Jury Duty
ELIGIBILITY
You are eligible to participate in the Plan if you are a:
. Regular (FfT or PfT) employee
How THE JURY DUTY BENEFIT WORKS
To encourage civic duty, you may serve on jury duty and receive full pay from the Company for the
time served. You will be expected to work at your regular duties for days or partial days while not on duty.
Employees are not required to "pay back" to the Company any daily stipend allowance provided by the
court.
vista Corp.
Key Definitions for Medical Plan Coverage
(A vista MSC- EBA Medical Plan)
ALLOWABLE CHARGE
The maximum allowable charge to which the Plan will apply its percentage of payment is the charge that the Plan has
negotiated with its prefelTed providers. For services or supplies for which there is no agreement between the Plan
and any providers , the Plan will apply its percentage of payment based on the usual, customary and reasonable charge
for the area in which the service or supply was rendered. When a Plan participant must use a Non-Prefened Provider
because of medical emergency, medical necessity or residence outside of the service area, the Plan will apply its
percentage of payment based on the usual, customary and reasonable charge for the area in which the service was
rendered.
CO-INSURANCE (out-of-pocket)
The 10% vou pay toward a covered expense that is only covered at the 90% level. The out-of-pocket maximum is
$450 per calendar year per person.
CO-PAYMENT
The fixed $15 amount you pay toward a covered expense. (I.e. Dr. Office Visit co-pay)
The vision exam co-pay is $10.
DEDUCTIBLE
The $225 front-end amount you pay each year for certain services before the Plan pays benefits. Ce11ain services are
subject to deductible.
LIFETIME MAXIMUM
The $1 000 000 total benefit limit offered to a Plan partjcipant over the course of his or her lifetime.
LIMITATIONS AND MAXIMUMS
Specific limitations and maximums may apply for special services such as mental and nervous conditions, substance
abuse, chiropractic, well-baby care, hospice and home health care, special nursing care, rehabilitative therapy,
physical therapy and TMJ treatment.
OUT-OF-AREA EMERGENCY
Generally, an out-of-area emergency is one in which Preferred Providers are not geographically available (or within
30 miles) and the situation is life threatening.
OUT-OF-POCKET MAXIMUM
An out-of-pocket maximum limits the amount of co-insurance you must pay during the year. This out-of-pocket
maximum provision applies to all services and benefits subject to co-insurance except rehabilitation services and
therapy, mental health services, educational programs , special nursing care and services of a Non-Prefened Provider
unless treatment is for a medical emergency.
PREFERRED PROVIDER DIRECTORY
Directories for PrefelTed Providers under the Avista-EBA Plan are available in Human Resources.
Contact Premera Blue Cross at 1-800-572-0778 for more complete information.
PREFERRED PRO VID ERS
Are health care providers such as doctors , hospitals, and clinics that have signed special agreements with Medical
Service Corporation.
WHEN PREFERRED PROVIDERS ARE A V AILABLE
If you live within a Preferred Provider service area, you must use doctors and facilities from the approved list in order
to obtain maximum benefits. If you receive service from a provider who is not on the list, some of your benefits wil1
be paid at a lower level, and some services not covered at all.
WHEN PREFERRED PROVIDERS ARE UNAVAILABLE
If you live outside a Preferred Provider service area, you may use any physician or hospital and receive maximum
benefits. But if there are an adequate number of Preferred providers .in your service area, you must use a preferred
Provider in order to receive maximum coverage under the plan.
EMERGENCY CARE
If emergency services are needed due to an accidental bodily injury or medical emergency and are provided by a non-
preferred provider because the services of a Preferred provider were not reasonably available, the Plan will pay the
amount it would have paid a Preferred provider. It will pay for these services by a non-preferred provider for a
period of 24 hours and such minimum additional time as is required for the patient to come under the care of a
Preferred Provider.
DEPENDENT STUDENTS ATTENDING A HIGHER EDUCATION CENTER
Dependent students attending an institution of higher education located 50 miles or more form a Preferred Provider
will be reimbursed for services of a non-preferred provider at 100% of the reasonable charge for the area in which theservice is received.
It is your responsibility to notify PREMERA BLUE CROSS with the name of the dependent student and the dates the
student will be out of the service area. Otherwise, claims will be paid as non-prefened provider services.
PREFERRED VS. USUAL, CUSTOMARY AND REASONABLE (UCR) CHARGES
This Plan talks about two types of charges: "Prefened" and "UCR." These are shortened terms for "preferred
allowable charges" and "usual, customary and reasonable charges." Preferred charges are discounted fees that
Preferred Providers have agreed to accept as their full charge. Where the plan has not arranged for a preferred
charge, the Plan bases its benefits on VCR charges. These are non-discounted fees that are accepted to be usual
customary and reasonable (UCR) for the geographic area in which the service is offered.
When you use a Preferred Provider, the Plan covers all or part of prefened charges. Because these charges are
preananged, you should have no surprises in your bill.
Fees charged by providers who are not preferred are not limited in this way. These fees might also exceed what
reasonable for the area. You should know that the Plan will not pay fees that exceed preferred or VCR charges. Yau
must pay the difference.
COVERAGE OUTSIDE PLAN SERVICE AREA
The plan will pay for the expense of treatment outside the Plan service area for illness or accidental injuries as
follows:
Nonemergency care: Coverage will be provided the same as for services and supplies received in the Plan service
areas from a provider that is not preferred.
Emergency care: Treatment of accidental bodily injury or medical emergency will be paid at the amount that would
ordinarily be paid for like services up to the VCR charge in that area.
MEDICAL INSURANCE OUTSIDE OF THE U.
The Department of State strongly urges Americans to consult with their medical insurance company prior to traveling
abroad to confirm whether their policy applies overseas and if it will cover emergency expenses such as a medical
evacuation. U.S. medical insurance plans (such as Avista s PREMERA BLUE CROSS and Group health plans)
seldom cover health costs incurred outside the United States unless supplemental coverage is purchased. Further,
S. Medicare and Medicaid programs do not provide payment for medical services outside the United States. Many
travel agents and private companies offer insurance plans that will cover health care expenses incurred overseas
including emergency services such as medical evacuations, but doctors and hospitals in some countries often do not
accept u.S. medical insurance, even if the policy applies overseas.
Many foreign doctors and hospitals require payment in cash prior to providing service, and medical evacuation to the
United States may cost well in excess of $50 000. Uninsured travelers who require medical care overseas often face
extreme difficulties. When consulting with your insurer prior to your trip, please ascertain whether payment will be
made to the overseas healthcare provider or if you will be reimbursed later for expenses that you incur. Some
insurance policies also include coverage for psychiatric treatment and for disposition of remains in the event of death.
Useful information on medical emergencies abroad, including overseas insurance programs, is provided in the
Department of State s Bureau of Consular Affairs brochure Medical Information for Americans Travelinrz Abroad
available via the Bureau of Consular Affairs home page or autofax: [phone].
Contact Premera Blue Cross at 1-800-572~O778 for more information regarding coverage outside of
the U.
A vista Corp.
Medical Insurance: A vista-EBA Plan
ELIGIBILITY
You are eligible to participate in the Plan if you are a:
Regular or full-time employee, or
Regularly scheduled (20+ hours) part-time employee. (Casual employees are not eligible).
Regular Temporary Employee, scheduled for 20+ hours per week for a minimum of 6 months
COST TO YOU
EBA
36.49
68.
62.
95.
328.43
620.
565.
857.
Total
364.
689.
628.
952.44
E only
E+Sp
E+Ch
E +All
HOW SELF-INSURED PLAN WORKS
The Avista-EBA PLAN is a self-insured plan that is a "Preferred Provider" plan, and includes coverage for medical
dental, prescription drugs, and vision care. Third-party administrators process and pay claims for the A vista-EBA
PLAN. Participants residing in the Preferred Provider service area must utilize physicians from the Preferred
Provider listing to receive maximum benefits. If you obtain service from a Provider who is not preferred, your
benefits will be paid at a lesser amount and some benefits will not be covered at all.
DEPENDENT ELIGIBILITY
Must be a lawful spouse or a dependent child.
Dependent child eligibility to aee whether or not a student; must be dependent on subscriber for support.
It is the subscriber s responsibility to maintain accurate and timely dependent eligibility information. The
employee must inform the Benefits Department within 30 days of a qualifying event of a dependent no longer
being eligible. Coverage for that dependent will end on the last day of the month in which the qualifying event
occurs.
Contact Premera Blue Cross at 1-800-572-0778 for more complete information.
Premera Blue Cross
VISTA MSC-EBA PLAN
Annual Deductible:$225 per person / $675 per family
Coinsurance:90%(70% out of network)
Out-of-pocket Maximum:$450 per person / $1350 per family
Lifetime Maximum Benefit:000 000
Minor Emergency or Urgent Care Facility:
Hospital emergency rooms are subject to deductible)
$15.
Physician Office Visits:$15.
Specialist Visits:$15.
Surgery Done In Office:$15.
Chiropractic:90% (Maximum $1,000 per year)
Immunizations:100% (Immunizations are subject to age limitations & other
plan limits; contact Premera Blue Cross for eligibility)
Diagnostic-Therapeutic Lab & X-ray:90%
MRI:90%
Physical Exam:
(One per calendar year)Covered in full to a maximum
of $500 per person, including lab and x-ray.
(Mammograms are not covered under the annual exam.
Mammograms are a separate charge covered at 90%)
Physical Therapy:90% (Maximum $1,000 per year)
Routine Newborn Well Nursery Care:100% of the allowable charge for the first 48 hours
Well Baby Care:
(Baby under the age of 1 year)
7 Visits covered at 100%
Mammograms:90%
Ambulance:90% (Subject to deductible)
Cardiac Rehabilitation Outpatient Therapy:90% up to $1,000 per year
Durable Medical Equipment:
(Limited to the rental price or initial acquisition price)
90% (Subject to deductible)
Hearing Aids:
(Employee only)
Paid at 100%, once every five years, limited to $1 000
Home Health Care:100% (Must be preauthorized; limited to the greater of 130
visits or $10,000 per year)
Infertility Services:90% (Maximum $2 000 per year; $6,000 per lifetime)
Orthotics:Subject to deductible and covered at 90% thereafter
Institutional Inpatient 90%. Must be pre-authorized with Premera Blue Cross.
($1 000 penalty applied if not pre-authorized)
Semi-Private Room:90%. Must be pre-authorized with Premera Blue Cross.
($1,000 penalty applied if not pre-authorized)
Miscellaneous Services and Supplies:90%. Must be pre-authorized with Premera Blue Cross.
($1 000 penalty applied if not pre-authorized)
Institutional Inpatient Private Room:90%. Must be pre-authorized with Premera Blue Cross.
($1 000 penalty applied if not pre-authorized)
(When Medical1y Necessary):
Institutional Outpatient Services:90% (Subject to deductible)
Mental & Nervous:Institutional: 12 days paid at 90%
Professional: 60 visits paid at 90%
Lifetime maximums:
180 visits for professional.
36 days for Institutional
(Not subject to out-of-pocket maximum; referral by a
physician or EAP counselor required)
Maternity Benefits:Covered as any other condition
(Enrolled Employees and spouses only)
Rehabilitation Services:90%
(Must be preauthorized; not subject to out-of-pocket
maximum) (Up to $5,000 + additional $15 000 for stroke or
spinal cord injury per occurrence)
Skilled Nursing Facility:90% (Subject to deductible)
Special Nursing Care:90% (Must be preauthorized; maximum $1,000 per year)
Sterilization:Covered as any other illness or injury.
Chemical Dependency treatment:Inpatient professional and institutional services
(including ancillaries)-provided at 90% to a combined
max of $9,000 per year. Lifetime Maximum $18 000.
Outpatient professional and institutional services
(including ancillaries)-provided at 90% to a combined
maximum of $2 500 per year. Lifetime maximum
000.
Prescriptions
Generic Prescriptions:(30-day supply): $5.00 co-pay for Generic Drugs
Brand Name Prescriptions:(30-day supply) (When a generic drug is not available):
$20.00 co-pay for Non-Generic when Generic is not
available
Brand Name Prescriptions:(30-day supply) (When a generic drug~ available):
$40 co-pay for Non-Generic drugs when a generic lli
available
Birth Control Pills:Birth Control Pills are covered under the prescription
drug provision. ("Over -the-counter" birth control items are
not covered under the plan) Contact Premera Blue Cross
directly for more information regarding birth control.
Every Employee Should Take Advantage of the Home Delivery Pharmacy Service
With prescription costs increasing 20% - 25% annually, A vista encourages all employees to do their part in
keeping costs down by utilizing Generic drugs whenever possible and also to take advantage of the Home
Delivery Pharmacy Service (Mail Order Prescription Program).
This program is an expansion of your current prescription drug benefit program. It is ideal for people who take
prescription medication on an ongoing basis. Listed below are several advantages to this program that are
detailed in the enclosed Home Delivery Pharmacy Service materials:
Immediate Savings: When you order by mail you can get up to a 90-day supply for only one copayment.
Convenience: You save time by simply mailing your prescriptions to Merck-Medco. Merck-Medco will
send your prescription to your home via US mail, postage paid.
Contact Human Resources at ext. 4751 to obtain order forms and an informational brochure.
Vision Benefits
Routine Eye Exam:Paid at 100% after $10 co-pay. Once per calendar year.
Lenses:
Frames:
Contacts:$150 per year allowar..ce for:
Lenses, Frames or Contacts once per calendar year.
CONTROLLING COSTS
Your medical plan offers several features to reduce unnecessary treatment, provide care at the proper level, and
protect your rights as a health care consumer. These features help you and A vista Corp. reduce waste and
increase the quality of our health care. Please read these provisions carefully. If you do not follow the guidelines
you may incur up to an additional $1 000 in charges for your care.
Voluntary Second Opinion Before Surgery. You may voluntarily obtain a second opinion for certain
elective non-emergency surgeries from a physician who is not affiliated with your first physician. If the second
opinion disagrees with the first opinion, you may seek a third opinion. These second and third opinions will be
covered at 100% when provided by a network physician. Regardless of the second or third opinion, you may
choose whether or not to have the elective surgery.
Mandatory Outpatient Surgery. There are many surgical procedures that must be performed on an
outpatient basis unless medical necessity requires the surgery to be performed on an inpatient basis. Please check
with your health plan s member services for a list of these procedures.
Preadmission Testing. Tests that can be done prior to inpatient admission should be completed in an
outpatient setting within seven days prior to admission. These tests will be subject to any applicable deductibles
and covered at 100% of the allowed charge when you receive these services from a Preferred Provider.
Hospital Admission Certification. This certification must be obtained for all inpatient admissions prior to
three days before admission for non-emergency situations and within 48 hours of admission for emergencies.
Concurrent Review. Inpatient stays will be reviewed concurrently to monitor standards for quality of care
medical management, length of stay, and medical necessity. In the event that it is determined that benefits will
not be provided, you and your attending physician will be notified of your medical plan s intent to cease benefits.
Services not covered
Certain services are not covered. The limitations below provide an overview of these exclusions, but it is not
exhaustive list of all exclusions. Please read these provisions carefully and contact your plan if you would like
more information.
1. Any condition for which the Veteran Administration or any of the armed services is responsible or provides
treatment, except as required by law.
2. Dental care or condition, whether resulting from disease or dental treatment, are not covered. Please see your
Dental SPD for details on your separate dental program.
3. Replaceable blood or blood products except for the administration and processing of blood.
4. Drawing and processing of autologous blood for transfusion.
5. Homeopathic care, acupuncture, shiatsu, biofeedback, alternative medicine or other forms of self-care or self-
help training and any related diagnostic testing.6. Orthopedic appliances prescribed primarily for use during participation in sports, recreation and similar
activities.7. Services and supplies to the extent that they are not medically necessary for treatment of an injury, illness or
physical disability; hospitalization for a condition for which patients are not usually hospitalized; any service
or benefit not listed as covered in the plan documents.
8. Experimental or investigational services, except as otherwise defined.
9. Medical, surgical or hospital services or supplies incident to the placement of nonhuman or manufactured
organs, and other organ transplants, except as specifically identified in the plan documents.
10. Conditions resulting from prior military service or declared or undeclared war.
11. Services received prior to the effective date of your coverage.
12. Thermography.
13. Services or supplies for which you are not legally liable.
14. Cosmetic surgery that is not for an eligible nonoccupational accidental bodily injury.
Women s Rights Regarding Cancer
The Women s Health and Cancer Rights Act of 1998 requires that our plan provide the following medical and
surgical benefits after mastectomies in a manner determined in consultation with the attending physician and the
patient, including:
reconstruction of the breast on which the mastectomy has been performed
surgery and reconstruction of the other breast to produce a symmetrical appearance
prostheses and physical complications of all stages of mastectomies, including lymph edemas (please follow
pre-certification procedures).
Newborns and Mothers Health Protection Act
Under federal law, our plan will not restrict benefits for any hospital length of stay in connection with childbirth
for the mother or newborn to less than 48 hours following a vaginal delivery, or less than 96 hours following a
delivery by cesarean section. Please follow the plan procedures for obtaining pre-certification for any hospital
stay.
Coordination of Benefits with Other Plans
You or an eligible dependent may be entitled to medical benefits under another group plan. If so, all benefits due
to you will be coordinated with the benefits from the other plan. This means that the total amount paid under all
plans can amount to as much as 100% of the allowable charges ... but no more than this amount. (Different rules
apply if you are eligible for Medicare. Contact Human Resources for further information.) The word "plan" for
this purpose means a plan providing coverage for hospital and medical care. This includes:
group, blanket or franchise insurance, or other prepaid group plans, and
Federal or statutory plans.
If you have an expense that is covered by two plans, one plan will pay your claim first. This plan is called the
primary plan. The other plan - called the secondary plan - will then pay some or all the difference (if any)
between what the primary plan pays and the total allowable expenses.
Your A vista Corp. medical plan is primary for any expenses you incur. The plan that covers your spouse as an
employee is the primary plan for expenses that your spouse incurs. The A vista Corp. medical plan will be
secondary for your spouse in this instance.
If your children are covered as dependents by your plan and your spouse s plan, the primary plan is that of the
parent whose birthday occurs earlier in the year. If you are separated or divorced, the plan of the parent who has
custody of the child pays first unless the divorce decree indicates otherwise. If you remarry and you have
custody, your plan will be primary. . . followed by your spouse s plan and then your former spouse s plan.
If you are an active associate covered by this plan , and you become eligible for Medicare, your A vista Corp.
medical plan will remain primary. If your covered spouse becomes eligible for Medicare, primary coverage will
continue under your active plan unless your spouse is covered as an employee under another group health plan.
Once you retire and are age 65 or older, Medicare becomes primary, and if you are eligible for the Company
retiree medical coverage , the Company s supplemental plan becomes secondary. In a calendar year, this Medical
Plan will pay its regular benefits in full if it is primary, or a reduced amount of benefits if it is secondary.
If you are disabled and have been receiving Social Security disability benefits for 24 months, Medicare will
provide your primary coverage and the Company s supplemental medical plan will be the secondary provider of
coverage
A vista Corp.
Group Health Northwest
ELI G IBILITY
You are eligible to participate in the Plan if you are a:
Regular or full-time employee, or
Regularly scheduled (20+ hours) part-time employee. (Casual employees are not eligible).
Regular Temporary Employee, scheduled for 20+ hours per week for a minimum of 6 months
HOW THE GROUP HEALTH NORTHWEST PLAN WORKS
Group Health Northwest is a Health Maintenance Organization with 143 Family Practice Specialists available
and over 360 community specialists available upon referral by your Group Health personal physician. You
choose from GHNW Medical Centers, Rockwood Clinic, or numerous other community physician partners for
your care. A 24 hr consulting nurse is available for medicaJ advice on holidays, weekends and after hours by
calling 324-6464 or 1-800-826-3620. Group Health emphasizes preventative care and early detection and
treatment of medical conditions.
COST TO YOU
Grou Health
E only
E +Spouse
E +Child(ren)
E +Family
27.
58.
52.
89.
248.
529.
473.47
802.
Total
276.
588.
526.
891.
SUMMARY OF BENEFITS
This is a brief summary of benefits and limitations. THIS IS NOT A CONTRACT. For a more detailed
description of your benefits and exclusions , refer to your certificate of coverage or contact your employer or
benefits administrator.
Hospital Preauthorization Not required.
Annual Deductible No annual deductible.
Plan Coinsurance No plan coinsurance.
Lifetime Maximum No lifetime maximum.
Out-of Pocket Limit (Stop Loss)
Out of Pocket Expenses paid for covered services:
Inpatient services (except as otherwise noted)
Outpatient services (except as otherwise noted)
Emergency care services
Ambulance services
Limited to an aggregate maximum of $2 000
per Member and $4 000 per family per
calendar year.
Ambulance Service
Emergency (ground/air) ambulance transportation
Chemical Dependency Treatment
Inpatient and outpatient alcoholism and/or drug
abuse treatment authorized by GHC' s Medical
Director, including counseling and treatment.
Devices, Equipment and Supplies
Including durable medical equipment, prosthetics
orthopedic appliances, oxygen, ostomy supplies
breast prostheses, glucose monitors and external
insulin pumps
Diagnostic Lab and X-ray
Emergency Care
Provided at GH or GH designated hospital
emergency departments
Provided at non-GH Facilities
Hearing Examinations/Aids
Home Health/Hospice
Hospital Inpatient Care
Hospital room and board
Inpatient surgery and anesthesia
Intensive and coronary care unit
Delivery and associated hospital care, including
home births for low risk pregnancies
Drugs while in hospital
Chemical dependency detoxification
Covered at 80%. Group Health Cooperative
(GHC)-initiated non-emergency transfers are
covered in full.
Limited to $11 285 any 24 consecutive
months. All services are subject to applicable
copayments.
Covered at 80% of charges if authorized in
advance by a GH provider as medically
necessary, and listed as covered in GHC'
Durable Medical Equipment Formulary,
Orthopedic Appliance Formulary, or Prosthetic
Device Formulary.
Covered in full.
$75 copayment per emergency visit per
Member. Copayment is waived if Member is
admitted directly from the Emergency
department.
Covered subject to a $125 deductible.
Deductible is riot waived if Member is
admitted directly from the Emergency
department.
If you are admitted to a non-GH Facility, you
must notify GHC within 24 hours by calling
888-457-9516 in order to be covered.
Hearing examinations covered subject to the
outpatient services copayment. Hearing aids
not covered.
Covered in full.
$100 copayment per day up to a maximum of
5 days per Member per calendar year.
Infertility Services (including Sterility)
General diagnostic services for sterility and
infertility
Specific diagnostic services, treatment, and
outpatient prescription drugs
Manipulative Therapy
Self-referrals for manipulative therapy of the spine
by GH designated providers. The medical necessity
for manipulative therapy must meet GHC protocol.
Mental Health Services
Outpatient mental health services such as
evaluation, crisis intervention , managed
psychotherapy, intermittent care, psychological
testing and consultation services when authorized
by GHC's Medical Director
Inpatient mental health services
Optical Care
Routine eye examinations and refractions
Eyeglass frames and lenses (any type), or contact
lenses, including exams associated with their fitting,
in lieu of standard eyeglass lenses and frames
Organ Transplants (Only kidney, simultaneous pancreas
and kidney, cornea, heart, single lung, double lung, heart-
lung, bone marrow and liver)
Covered subject to the outpatient services
copayment.
Covered at 50% of total charges. Diagnosis or
treatment of sexual dysfunction is not
covered.
Covered up to 10 visits per Member per
calendar year, subject to the applicable
outpatient services copayment.
Covered up to 20 visits per Member per
calendar year, subject to a $20 copayment per
individual/family/couple visit and $10
copayment per group visit. Copayments do
not apply to out-of-pocket limit.
Covered at 80% up to 12 days per calendar
year when referred in advance by GHC.
Coinsurance does not apply to out-of-pocket
limit.
One exam covered per Member in any
consecutive 12 month period, subject to the
outpatient services copayment.
One pair covered up to $150 per Member in
any consecutive 24 month period.
Covered up to a lifetime maximum of
$200 000 per Member, subject to applicable
copayments. Coverage for all transplants
including follow-up care, is excluded until the
Member has been continuously enrolled under
a GHC plan for 12 months.
Outpatient Prescription Drugs
Legend drugs (a drug which by law requires a
provider s prescription), including injectables , and
diabetic supplies including insulin syringes, lancets,
urine testing reagents and blood glucose monitoring
reagents, when provided at GH Facilities,
prescribed by GH providers and listed as covered in
the GHC drug formulary.
Allergy Serum
Contraceptive drugs and devices and their fitting
Outpatient Services
Office visits
Allergy testing
Radiation therapy, chemotherapy
Outpatient surgery
Podiatric Care
Pre-existing Conditions
Care, medication, or medical advice received for medical
conditions which existed within the three-month period
prior to the effective date of coverage.
Prenatal Care (prenatal and postpartum visits, including
prenatal testing for the detection of congenital disorders)
Preventive Care (most immunizations and vaccinations
and routine mammography screening)
Rehabilitation Services
Inpatient physical, occupational and restorative
speech therapy services combined, including
services for neurodevelopmentally disabled children
age 6 and under are covered up to 60 days per
condition per calendar year.
Covered subject to a maximum $15
copayment for a supply of 30 days or less of
each prescription or refill. Some exclusions
apply. Copayment does not apply to out-of-
pocket limit.
Covered subject to twelve times the outpatient
prescription drug copayment. Copayment does
not apply to out-of-pocket limit.
Covered subject to the outpatient prescription
drug copayment (including birth control pills).
DepoProvera covered subject to the applicable
copayment. Copayment does not apply to out-
of-pocket limit.
$15 copayment per visit per Member.
Covered subject to the outpatient services
copayment when referred by a GH provider.
Routine foot care is excluded.
Covered in full.
Covered subject to the outpatient services
copayment.
Preventive care visits according to GHC's
well-child" and "well-adult" schedules
including routine mammography screening
when referred by a GH provider, covered
subject to the outpatient services copayment.
Most immunizations and vaccinations covered
in full.
Covered subject to the applicable hospital
inpatient care copayment.
Outpatient physical, occupational and restorative
speech therapy services combined, including
services for neurodevelopmentally disabled children
age 6 and under are covered up to 60 visits per
condition per calendar year.
Covered subject to the outpatient services
copayment.
Skilled Nursing Facility
Full-time skilled nursing care in a GH-approved
nursing facility
Covered in full up to a maximum of sixty (60)
days per Member per calendar year.
Sterilization Services (vasectomy, tubal ligation)Covered subject to the applicable copayment.
Procedures to reverse a sterilization are not
covered.
Temporomandibular Joint (TMJ) Services
Inpatient and outpatient TMJ services when
Medically Necessary and authorized by GHC
000 maximum per Member per calendar
year.
Lifetime Maximum Benefit 000 per Member.
Tobacco Cessation
Approved pharmacy products covered for a 30-day
supply or less of each prescription or refill, when
prescribed by a GHP provider and obtained at a GH
Facility.
Groups purchasing outpatient prescription
drug coverage, will be covered subject to the
lesser of GHC' s charge or the outpatient
prescription drug copayment. Groups not
purchasing outpatient prescription drug
coverage may be subject to a charge.
Well-Adult Care See Preventive Care.
Well-Child Care See Preventive Care.
Limitations: Coverage for growth honnone treatment is excluded until the Member has been continuously enrolled
under a GHC plan for 12 months. Coverage for cosmetic services is limited to breast reconstruction following
mastectomy, and reconstructive breast reduction on non-diseased breast. External breast prostheses following
mastectomy, limited to one per diseased breast every two years.
Exclusions: Services or programs not provided or authorized by GHC staff (except as specified); drugs not listed as
covered in the GHC Drug Formulary; travel medications; investigational or experimental procedures, drugs and devices;
dental care; arch supports including custom shoe modifications or inserts and their fittings except for therapeutic shoes
modifications and shoe inserts for severe diabetic foot disease; convalescent or custodial care; cardiac rehabilitation
programs; services covered by first-party insurance; services covered by government and military programs; employment
license, immigration or insurance examinations or reports.
Unless otherwise noted as covered, the following services are also excluded: diagnostic testing of sterility,
infertility or sexual dysfunction; eyeglasses; contact lenses, including services associated with their fitting,
except following cataract surgery performed at GHC; drugs not requiring a prescription, including diabetic
supplies and contraceptive drugs and devices; hearing aids; equipment, appliances and supplies; skil1ed nursing
facility services; blood; work-related conditions (including self-empJoyment, L&I and worker s compensation).
A vista Corp.
Dental Benefits
Washington Dental Service (Delta Dental)
SUMMARY OF BENEFITS
Reimbursement Levels for Allowable Benefits
*Class I............................................................................ Constant 1000/0
Class II
"""""""""""""""""""""""""""""""""""""""
Constant 800/0
Class III ............................................................................. Constant 500/0
* Annual Deductible per Person .........................................................$25
* Annual Deductible - Family Maximum
"""""""""""""""""""" ...
$75
Annual Program Maximum per Person.........................................000
*Lifetime Orthodontic Benefits per Person ................................ $1 000
The payment level for covered dental expenses arising as a direct result of an accidental bodily injury is 100%
up to the unused program maximum.
All covered employees and covered dependents are eligible for Class I, Class II, Class III, Orthodontic Benefits
and Dental Accident Benefits.
* Annual deductible is waived for Class I, Orthodontic Benefits and Dental Accident Benefits.
Welcome to the DeltaPremier dental plan, which is administered by Washington Dental Service, the state
largest and most experienced dental benefits carrier. Washington Dental Service is a member of the nationwide
Delta Dental Plans Association. With a Delta Dental plan from Washington Dental Service, you join
approximately 1.5 million people who have discovered the value of our coverage.
HOW TO USE YOUR PROGRAM
The best way to take full advantage of your dental plan is to understand its features. You can do this most easily
by reading this benefits booklet before you go to the dentist. The booklet is designed to give you a clear
understanding of how your dental insurance works and how to make it work for you. It also answers some
common questions and defines a few technical terms. If this booklet doesn t answer all of your questions, or if
you don t understand something, call a Washington Dental Service customer service representative at (206) 522-
2300 or [phone].
Choosing A Dentist
With Washington Dental Service, you may select any licensed dentist. Tell your dentist that you are covered by a
Washington Dental Service dental plan and give him or her your Social Security number, the program name and
the group number which is 378.
Member dentists
If you select a dentist who is a member of Washington Dental Service, that dentist has agreed to provide
treatment for eligible persons covered by Washington Dental Service/Delta Dental programs according to the
provisions of his or her member dentist contract. You won t have to hassle with sending in claim forms.
Participating dentists complete claim forms and submit them directly to Washington Dental Service. They receive
payment directly from Washington Dental Service. You will not be charged for more than the approved fee or the
fee that the member dentist has filed with us. You may, however, be responsible for copayments (see Copayment
heading in this section) and for any elective care you choose to receive outside the covered benefits. To find out
whether your dentist is a member, ask him or her, check your plan s Directory of Dentists or go online to the
Washington Dental Service Web site at www.deltadentalwa.com and click on the "Find a Dentist" option.
Nonmember dentists
If you select a dentist who is not a member of Washington Dental Service, you are responsible for having your
dentist complete and sign a claim form. We accept any American Dental Association-approved claim form that
your dentist may provide. It is up to you to ensure that the claim is sent to Washington Dental Service. Since
Washington Dental Service does not have fees on file for nonmember dentists, the payment for services
performed by a nonmember is based upon actual charges or Washington Dental Service s allowable fees for
nonmember Dentists, whichever is less. The payment will be issued in both your name and that of your dentist
unless you specifically authorize that payment be made directly to your dentist.
Out-or-state dentists
If you receive treatment from a dentist outside Washington State, you are responsible for having the dentist
complete and sign a claim form. It is up to you to pay the dentist s bill and submit the claim to Washington
Dental Service. Payment will be based upon actual charges or Washington Dental Service s allowable fees for
out-of-state Dentists, whichever is less.
Claim Forms
American Dental Association-approved claim forms may be obtained from your dentist. Washington Dental
Service is not obligated to pay for treatment performed in the event that a claim form is submitted for payment
more than 6 months after the treatment is provided.
Predetermination of Benefits
If your dental care will be extensive, you may ask your dentist to complete and submit a request for an estimate
called a "predetermination of benefits." This will allow you to know in advance what procedures are covered
the amount Washington Dental Service will pay toward the treatment and your financial responsibility.
Benefit Period
Most dental benefits are calculated within a "benefit period " which is typically for one year. For this program
the benefit period is the 12-month period beginning January 1 and ending December 31.
Reimbursement Levels.
Your dental plan offers three classes of covered treatment. Each class also specifies limitations and exclusions
(see the explanation of these terms elsewhere in this section). Here is the way the three levels work under your
plan:
The payment level for covered and allowable Class I (diagnostic and preventive) procedures is 100 percent.
The payment level for covered and allowable Class II (basic) procedures is 80 percent.
The payment level for covered and allowable Class III (major) procedures is 50 percent.
The payment level for covered dental expenses arising as a direct result of an accidental bodily injury is 100
percent, up to the unused program maximum.
See "Benefits Covered by Your Program" for specific Class I, Class II and Class III covered dental benefits under
this program.
Limitations and Exclusions
Dental plans typically include limitations and exclusions, meaning that the plans don t cover every aspect of
dental care. This can affect the type of procedures performed or the number of visits. These limitations are
detailed in this booklet under the sections called "Benefits Covered by Your Program" and "General Exclusions.
They warrant careful reading.
Copavments (Coinsurance)
A copayment policy is typical of most insurance plans. This means the insurance company (Washington Dental
Service) will pay a predetermined percentage of the cost of your treatment, and you are responsible for paying the
balance. What you pay is called the copayment. It is paid even after a deductible is reached.
Program Maximum
The program maximum is the maximum dollar amount a dental plan will pay toward the cost of dental care
within a specific benefit period. You are personally responsible for paying costs above the annual maximum.
For your program, the maximum amount payable by Washington Dental Service for Class I, II and III covered
dental benefits (including dental accident benefits) per eligible person is $2 000 each benefit period. Charges for
dental procedures requiring multiple treatment dates are considered incurred on the date the services are
completed. Amounts paid for such procedures will be applied to the program maximum based on the incurred
date.
The lifetime maximum amount payable by WDS for Orthodontic Benefits is $1,000 per eligible person.
Program Deductible
Most dental plans have a specific dollar deductible. It works like your car insurance deductible. During a benefit
period, you may have to personally pay a portion of your dental bill before your insurance carrier Washington
Dental Service will contribute to your bill.
Your program has a $25 deductible per eligible person each benefit period. This means that from the first
payment or payments made for covered dental benefits, a deduction of $25 is made. Once each eligible person
has satisfied the deductible during the period, no further deduction will apply to that eligible person until the next
period. The maximum deductible per family each benefit period is $75. This means that the maximum amount
that will be deducted for a family, regardless of the number of eligible persons, will be $75. Once a family has
satisfied the maximum deductible amount during the period, no further deduction will apply to that family until
the next succeeding period. The deductible does not apply to Class I, Orthodontic Benefits or dental accident
benefits.
Employee Eligibility and Termination
Eligible employees are all full-time and part-time employees for whom employer contributions are made.
New employees are eligible on the first day of the month following completion of the waiting period established
by the employer.
You must complete an enrollment form. All of your eligible dependents must be listed on the enrollment form.
Coverage terminates at the end of the month in which you cease to be an eligible employee.
In the event of a suspension of compensation as a result of a strike, lockout, or other labor dispute, an eligible
employee may pay the applicable premium directly to the employer for a period not to exceed six months.
Payment of premiums must be made when due, or Washington Dental Service may terminate the coverage.
The Federal Family and Medical Leave Act ("FMLA") became effective August 5, 1993. The benefits under
your Washington Dental Service dental program may be continued provided you are eligible for FMLA and you
are on a leave of absence that meets the FMLA criteria. For further information, contact your employer.
The "Continuation of Coverage" legislation passed into federal law (PL 99-272 and as amended by PL 104-191)
requires that should certain qualifying events occur which would have previously terminated coverage, employee
coverage may continue for a period of time on a self-pay basis.
When you terminate for reasons other than gross misconduct, you may continue your dental benefits up to 18
months, or until you are covered under another group dental plan, by self-paying the required premium.
Contact your employer for further clarification and details of how they plan to implement this continuation of
coverage for eligible persons.
Dependent Eligibility and Termination
If-dependent coverage is included in the program, eligible dependents are your lawful spouse and unmarried
children including biological children, stepchildren, foster children, and adopted children. Lawful spouse of
eligible retirees shall continue to be eligible up to age 65.
Children are covered from birth through age 23.
An unmarried child over the limiting age may continue to be an eligible dependent providing all of the following
conditions are met: 1) the child is incapable of self-support because of a physical handicap or developmental
disability that commenced prior to reaching the limiting age, 2) a physician s certificate is submitted to WDS
within 31 days following attainment of the limiting age, and 3) the child was an eligible dependent upon
attainment of the limiting age.
A new family member, with the exception of newborns and adopted children, must be enrolled on the first day of
the month following the date he or she qualifies as an eligible dependent. A newborn shall be covered from and
after the moment of birth, and an adopted child shall be covered from the date of placement for the purpose of
adoption , provided that if this program requires payment of an additional monthly premium for coverage of such
child, enrollment of the newborn or adopted child and payment to Washington Dental Service of all applicable
premiums is completed within 90 days after the date of birth or placement to assure coverage. If no additional
premium is required, Washington Dental Service requests completion of the enrollment process for the newborn
or adopted child within 90 days after the date of birth or placement, but coverage will be provided in any event.
To enroll a newborn or adopted child, an eligible employee parent must complete a new enrollment form
provided by Washington Dental Service. If an additional premium for coverage is required and enrollment and
payment is not completed for a newborn or adopted child within said 90 days, such child may be enrolled
coincident with any renewal or extension of the Contract.
A child will be considered an eligible dependent as an adopted child if the following conditions are met: 1) the
child has been placed with the eligible employee for the purpose of adoption under the laws of the state in which
the employee resides; and 2) the employee has assumed a legal obligation for total or partial support of the child
in anticipation of adoption. Notification of placement of a child for adoption and payment of any additional
required monthly premiums must be furnished to Washington Dental Service within 90 days from the date of
placement.
Dependent coverage terminates at the end of the month in which your coverage terminates, or the dependent
ceases to be an eligible dependent, whichever occurs first.
The "Continuation of Coverage" legislation passed into federal law (PL 99-272 and as amended by PL 104-191)
requires that should certain qualifying events occur which would have previously terminated coverage, dependent
coverage may continue for a period of time on a self-pay basis.
If a dependent no longer meets the eligibility requirements due to the death or divorce of the employee, or does
not meet the age requirement for children, coverage may continue up to 3 years, or until the dependent is covered
under another group dental plan, by self-paying the required premium.
Contact your employer for further clarification and details of how they plan to implement this continuation of
coverage for eligible persons.
COORDINATION OF BENEFITS
If an eligible person is entitled to benefits under two or more group dental plans , the amount payable under this
plan will be coordinated with any other plan. The amount paid by Washington Dental Service, together with
amounts from other group programs, will not exceed 100% of dental expenses incurred and the total amount
payable by Washington Dental Service will not exceed the amount that would have been paid for covered
benefits if no other program was involved.
The following rules establish the order of benefit payments:
a. The benefits of the plan that does not have a coordination of benefits (COB) provision will be primary (the
plan whose benefits are determined first).
b. The benefits of the plan that covers the person as an active employee will be determined before the benefits
of a plan that covers the person as a dependent.
c. If the person is a child whose parents are not separated or divorced:
The benefits of the plan covering the parent whose month and day of birth occurs earlier in the calendar year
will be determined before the benefits of the plan of the parent whose month and day of birth occurs later in
the calendar year. However, if one of the parents' plans does not have this "birthday rule , then the plan
covering the father is primary.
d. If the person is a child of parents who are separated or divorced , then the benefits are determined in the
following order:
(1) The plan of the parent with custody
(2) The plan of the new spouse of the parent with custody
(3) The plan of the parent without custody
(4) The plan of the new spouse of the parent without custody
However, if the court decrees financial responsibility for the child's health care, the plan of the parent with
the financial responsibility is the primary plan.
The plan covering the person as a retired or laid-off employee or dependent of such person will be
determined after the benefits of any other plan covering such person as an employee, other than a laid-off or
retired employee, or dependent of such person. This provision will not apply if neither plan has a provision
regarding laid-off or retired employees, which results in each plan determining its benefits after the other.
f. If the above order does not establish the primary plan, then the plan that has covered that person for the
longest period of time is the primary plan.
In the event Washington Dental Service makes payments in excess of the maximum amount, Washington Dental
Service shall have the right to recover the excess payments from the patient, the subscriber, the provider or the
other plan.
BENEFITS COVERED BY YOUR PROGRAM
The following are Class I, Class II, and Class III covered dental benefits under this program that are subject to the
limitations and exclusions contained in this booklet. Such benefits (as defined) are available only when rendered
by a licensed dentist or other WDS-approved licensed professional when appropriate and necessary as
determined by the standards of generally accepted dental practice and Washington Dental Service.
The amounts payable by Washington Dental Service for Class I, II and III covered dental benefits are described
under Reimbursement Levels in this booklet.
DIAGNOSTIC
Class I Services
Covered Dental Benefits
Routine examination.
Limitations
Exclusions
PREVENTIVE
X-rays.
Emergency examination.
Examination by a specialist in an American Dental Association recognized specialty.
WDS - approved caries susceptibility tests.
Examination is covered twice in a benefit period.
Complete series (4 bitewing x-rays and up to 10 periapical x-rays) or panorex x-rays are
covered once in a 3-year period.
Supplementary bitewing x-rays are covered twice in a benefit period.
Diagnostic services and x-rays related to temporomandibular joints Uaw joints).
Consultations or elective second opinions.
Study models.
Covered Dental Benefits
Prophylaxis (cleaning).
Fissure sealants.
Topical application of fluoride or preventative therapies.
Space maintainers when used to maintain space eruption of permanent teeth.
Limitations
Exclusions
RESTO RA TIVE
Prophylaxis is covered twice in a benefit period.
Topical application of fluoride or preventative therapies (but not both) is covered twice
in a Benefit Period.
Fissure sealants are available for children through age 14. If eruption of permanent
molars is delayed, sealants will be allowed if applied within 12 months of eruption with
documentation from the attending Dentist. Payment for application of sealants will be for
permanent maxillary (upper) or mandibular (lower) molars with incipient or no caries
(decay) on an intact occlusal surface. The application of fissure sealants is a covered
benefit only once in a 3-year period per tooth.
Plaque control program (oral hygiene instruction , dietary instruction and home fluoride
kits).
Cleaning of a prosthetic appliance.
Replacement of a space maintainer previously paid for by WDS.
***REFER ALSO TO GENERAL EXCLUSIONS***
Class II Services
Covered Dental Benefits
Limitations
Exclusions
Amalgam, composite or filled resin restorations (fillings) for treatment of carious lesions
(visible destruction of hard tooth structure resulting from the process of dental decay) or
fracture resulting in significant loss of tooth structure (missing cusp).
Stainless steel crowns.
Restorations on the same surface(s) of the same tooth are covered once in a 2-year
period.
If a composite or filled resin restoration is placed in a posterior tooth, an amalgam
allowance will be made for such procedure. The difference in cost is your responsibility.
Stainless steel crowns are covered once in a 2-year period.
Refer to Class III Limitations if teeth are restored with crowns, inlays or onlays.
Restorations necessary to correct vertical dimension or to alter the morphology (shape)
or occlusion.
Overhang removal, re-contouring or polishing of restoration.
ORAL SURGERY
Covered Dental Benefits
Limitations
Exclusions
PERIODONTICS
Removal of teeth and surgical extractions.
Preparation of the alveolar ridge and soft tissue of the mouth for insertion of dentures.
Treatment of pathological conditions and traumatic facial injuries.
General anesthesia/intravenous sedation.
General anesthesia/intravenous sedation is covered only when administered by a licensed
dentist or other WDS-approved licensed professional who meets the educational
credentialing and privileging guidelines established by the Dental Quality Assurance
Commission of the State of Washington in conjunction with certain covered oral surgery
procedures, as determined by WDS.
Iliac crest or rib grafts to alveolar ridges.
Ridge extension for insertion of dentures (vestibuloplasty).
Tooth transplants.
Covered Dental Benefits
Limitations
Surgical and nonsurgical procedures for treatment of the tissues supporting the teeth.
Services covered include examinations, periodontal maintenance, periodontal
scaling/root planing, periodontal surgery.
Limited adjustments to occlusion (8 teeth or less).
WDS-approved localized delivery of chemotherapeutic agents.
General anesthesia/intravenous sedation.
Refer to Class III Periodontics for benefits and limitations on complete occlusal
equilibration and occlusal guards (nightguards).
Examinations are covered twice in a benefit period.
Under certain conditions of oral health, periodontal maintenance and/or prophylaxis may
be covered up to a total of 4 times in a benefit period. Please note: These benefits are
available only under certain conditions of oral health. It is strongly recommended that
you have your dentist submit a predetermination of benefits to determine if the treatment
will be covered.
Periodontal scaling/root planing is covered once in a 3-year period.
Limited occlusal adjustments are covered once in a 12-month period.
Exclusions
ENDODONTICS
Localized delivery of chemotherapeutic agents approved by WDS are a covered benefit
under certain conditions of oral health. Localized delivery of chemotherapeutic agents is
limited to two (2) teeth per quadrant and up to two (2) times (per tooth) in a benefit period.
Please note: These benefits are available only under certain conditions of oral health. It is
strongly recommended that you have your dentist submit a predetermination of benefits to
determine if the treatment will be covered.
Periodontal surgery (per site) is covered once in a 3-year period.
Soft tissue grafts (per site) are covered once in a 3-year period.
Periodontal surgery and localized delivery of chemotherapeutic agents must be preceded by
scaling and root planing a minimum of 6 weeks and a maximum of 6 months, or the patient
must have been in active supportive periodontal therapy, prior to such treatment.
General anesthesia/intravenous sedation is covered only when administered by a licensed
dentist or other WDS-approved licensed professional who meets the educational
credentialing and privileging guidelines established by the Dental Quality Assurance
Commission of the State of Washington in conjunction with certain covered periodontal
surgery procedures , as determined by WDS.
Periodontal splinting and/or crown and bridgework in conjunction with periodontal
splinting, crowns as part of periodontal therapy and periodontal appliances.
Gingival curettage.
Localized delivery of chemotherapeutic agents is not covered when used for the purpose of
maintaining non-covered dental procedures or implants.
Covered Dental Benefits
Limitations
Exclusions
Procedures for pulpal and root canal treatment.
Services covered include pulp exposure treatment, pulpotomy and apicoectomy.
General anesthesia/intravenous sedation
Root canal treatment on the same tooth is covered only once in a 2-year period.
General anesthesia/intravenous sedation is covered only when administered by a licensed
dentist or other WDS-approved licensed professional who meets the educational
credentialing and privileging guidelines established by the Dental Quality Assurance
Commission of the State of Washington in conjunction with certain covered endodontic
surgery procedures, as determined by WDS.
Refer to Class III Limitations if the root canals are placed in conjunction with a
prosthetic appliance.
Bleaching of teeth.
GENERAL ANESTHESIA
Covered Dental Benefits
Limitations
PERIODONTICS
General anesthesia, when medically necessary, for children through age 6, or a physically or
developmentally disabled person, when in conjunction with Class I, IT, ill and Orthodontic
covered dental procedures.
General anesthesia is covered only when administered by a licensed Dentist or other WDS-
approved Licensed Professional who meets the educational, credentialing and privileging
guidelines established by the Dental Quality Assurance Commission of the State of
Washington, when medically necessary, for children through age 6, or a physically or
developmentally disabled person, when in conjunction with covered dental procedures.
***REFER ALSO TO GENERAL EXCLUSIONS
Class III Services
Covered Dental Benefits
Limitations
Exclusions
RESTORATIVE
Under certain conditions of oral health , services covered are occlusal guards
(nightguards) and complete occlusal equilibration. Please note: These benefits are
available only under certain conditions of oral health. It is strongly recommended that
you have your dentist submit a predetennination of benefits to determine if the treatment
will be covered.
Occlusal guards, including repairs, are covered once in a 3-year period.
Complete occlusal equilibration is covered once in a lifetime.
Periodontal splinting, crown and bridgework in conjunction with periodontal splinting,
crowns as part of periodontal therapy and periodontal appliances.
Covered Dental Benefits
Crowns, inlays (only when used as an abutment for a fixed bridge), onlays (whether they
are gold, porcelain, WDS-approved gold substitute castings (except processed resin) or
combinations thereof) for treatment of carious lesions (visible destruction of hard tooth
structure resulting from the process of dental decay) or fracture resulting in significant
loss of tooth structure (missing cusp), when teeth cannot reasonably be restored with
filling materials such as amalgam or filled resins.
Crown buildups, subject to limitations and exclusions
Limitations
Exclusions
Crowns or onlays on the same teeth are covered once in a 5-year period. Inlays are a
covered benefit on the same teeth once in a 5-year period only when used as an abutment
for a fixed bridge. If a tooth can be restored with a filling material such as amalgam or
filled resin, an allowance will be made for such a procedure toward the cost of any other
type of restoration that may be provided. WDS will allow the appropriate amount for an
amalgam or composite restoration toward the cost of processed filled resin or processed
composite restorations.
Crown buildups are a covered benefit when more than 50% of the natural tooth structure is
missing or there is less than 2mm of circumferential tooth structure remaining around the
gingival portion.
Crown buildups are not a covered benefit within two (2) years of a restoration on the same
tooth.
A crown used as an abutment to a partial denture for purposes of re-contouring, repositioning
or to provide additional retention is not covered unless the tooth is decayed to the extent that
a crown would be required to restore the tooth whether or not a partial denture is required.
Crowns used to repair micro-fractures of tooth structure when the tooth is asymptomatic
(displays no symptoms) or existing restorations with defective margins when no pathology
exists.
Crowns and/or onlays placed because of weakened cusps or existing large restorations
without overt pathology.
Crown buildups for the purpose of improving tooth form, filling in undercuts or reducing
bulk in castings are considered basing materials and are not a covered benefit.
PROSTHODONTICS
Covered Dental Benefits
Limitations
Dentures , fixed bridges , removable partial dentures and the adjustment or repair of an
existing prosthetic device.
Surgical placement or removal of implants or attachments to implants.
Replacement of an existing prosthetic device is covered only once every 5 years and only
then if it is unserviceable and cannot be made serviceable.
Replacement of implants and superstructures is covered only after 5 years have elapsed
from any prior provision of the implant.
Full, immediate and overdentures - WDS will allow the appropriate amount for a full
immediate or overdenture toward the cost of any other procedure that may be provided
such as personalized restorations or specialized treatment.
Exclusions
Temporary/interim dentures - WDS will allow the amount of a reline toward the cost of an
interim partial or full denture. After placement of the permanent prosthesis, an initial reline
will be a benefit after 6 months.
Root canal treatment performed in conjunction with overdentures is limited to 2 teeth per
arch and is paid at the Class ill payment level.
Partial dentures - If a more elaborate or precision device is used to restore the case, WDS
will allow the cost of a cast chrome and acrylic partial denture toward the cost of any other
procedure that may be provided.
Denture adjustments and relines - Denture adjustments and relines done more than 6
months after the initial placement are covered. Subsequent relines or jump rebases (but not
both) will be covered once in a 12-month period.
Duplicate dentures.
Personalized dentures.
Cleaning of prosthetic appliances.
Crowns and copings in conjunction with overdentures
***REFER ALSO TO GENERAL EXCLUSIONS
ACCIDENTAL INJURY
Washington Dental Service will pay 100% of covered dental benefit expenses arising as a direct result of an
accidental bodily injury. However, payment for accidental injury claims will not exceed the unused program
maximum. The accidental bodily injury must have occurred while the patient was eligible. A bodily injury
does not include teeth broken or damaged during the act of chewing or biting on foreign objects. Coverage
includes necessary procedures for dental diagnosis and treatment rendered within 180 days following the date
of the accident.
ORTHODONTIC BENEFITS FOR ADULTS
AND ELIGffiLE CHILDREN
Orthodontic treatment is defined as the necessary procedures of treatment, performed by a licensed dentist
involving surgical or appliance therapy for movement of teeth and post-treatment retention.
Eligible persons include the employee, lawful spouse plus children through age 23.
The lifetime maximum amount payable by WDS for Orthodontic Benefits rendered to an eligible person shall
be $1 000. Not more that $500 of the maximum, or one-half of WDS's total responsibility shall be payable
for treatment during the "construction phase." Subsequent payments of WDS' s responsibility shall be made
on a monthly basis, providing the employee is eligible and the dependent is in compliance with the age
limitation.
WDS will pay a constant 50% of the lesser of the Maximum Allowable Fees or the fees actually charged for
Orthodontic Benefits.
It is strongly suggested that orthodontic treatment be submitted to, and authorized by, WDS
prior to commencement of treatment.
Covered Dental Benefits
Treatment of malalignment of teeth and/or jaws.
Limitations - Payment is limited to:
Completion, or through age 23 , whichever occurs first
Termination of the treatment plan prior to completion of the case.
Termination of this program.
Exclusions
Charges for replacement or repair of an appliance.
Orthognathic Surgery
No benefits will be provided for services considered inappropriate and unnecessary, as
determined by WDS.
General Exclusions
Services for injuries or conditions that are compensable under Worker s Compensation or Employers
Liability laws , and services that are provided to the eligible person by any federal or state or provincial
government agency or provided without cost to the eligible person by any municipality, county, or other
political subdivision, other than medical assistance in this state, under medical assistance RCW 74.09.500, or
any other state, under 42 D., Section 1396a, section 1902 of the Social Security Act.
Dentistry for cosmetic reasons
Restorations or appliances necessary to correct vertical dimension or to restore the occlusion. Such
procedures include restoration of tooth structure lost from attrition, abrasion or erosion and restorations for
malalignment of teeth.
Application of desensitizing agents
Experimental services or supplies. Experimental services or supplies are those whose use and acceptance
a course of dental treatment for a specific condition is still under investigation/observation. In determining
whether services are experimental, Washington Dental Service, in conjunction with the American Dental
Association, will consider if: (1) the services are in general use in the dental community in the state of
Washington; (2) the services are under continued scientific testing and research; (3) the services show a
demonstrable benefit for a particular dental condition; and (4) they are proven to be safe and effective. Any
individual whose claim is denied due to this experimental exclusion clause will be notified of the denial
within 20 working days of receipt of a fully documented request.
Any denial of benefits by Washington Dental Service on the grounds that a given procedure is deemed
experimental, may be appealed to Washington Dental Service. By law , Washington Dental Service must
respond to such appeal within 20 working days after receipt of all documentation reasonably required to
make a decision. The 20-day period may be extended only with written consent ofthe covered individual.
Genera! anesthesia/intravenous (deep) sedation, except as specified by WDS for certain oral, periodontal , or
endodontic surgical procedures. Genera! anesthesia except when medicalJy necessary, for children through
age 6, or a physically or developmentally disabled person, when in conjunction with covered dental
procedures.
Analgesics such as nitrous oxide, conscious sedation, euphoric drugs , injections or prescription drugs
In the event an Eligible Person fails to obtain a required examination from a WDS-appointed consultant
dentist for certain treatments, no benefits shall be provided for such treatment
Hospitalization charges and any additional fees charged by the dentist for hospital treatment
Broken appointments
Patient management problems
Cornpleting insurance forms
Habit breaking appliances
Washington Dental Service shall have the discretionary authority to determine whether services are covered
benefits in accordance with the general limitations and exclusions shown in the Contract, but it shall not
exercise this authority arbitrarily or capriciously or in violation of the provisions of the contract.
This program does not provide benefits for services or supplies to the extent that benefits are payable for
them under any motor vehicle medical, motor vehicle no-fault, uninsured motorist, underinsured motorist
personal injury protection (PIP), commercial liability, homeowner s policy, or other similar type of coverage.
All other services not specifically included in this program as covered dental benefits.
MEDICAL COVERAGE IN RETIREMENT
(For Retirements After January 1 1992 and Retirees Under Age 65)
Avista Corp. offers medical benefits to retiring employees who have reached a minimum of age 55 and have
completed 15 years of service. Retirees under age 65 are provided the same medical benefits as active
employees.
The cost to you for coverage depends on the plan you choose and your family coverage category. The portion
Avista Corp. pays for your coverage varies based on the date of your retirement and your length of service.
The Company Contribution amount has been "capped" for retirees, so the retiree will responsible for all
premiums beyond the maximum Company contribution amounts.
The premiums for retirees under age 65 are listed below based on years of service:
20 + Years of Service
Retiree Company Total
RETIREE Under 65 Premium Premium Premium % of total Caps
Retiree only 109.$255.364.30.$255.
Retiree +Spouse 159.530.689.23.530.
Retiree +child(ren)183.445.628.29.445.
Retiree + Family 187.765.952.44 19.765.
19 years of service
Retiree Company Total
RETIREE Under 65 Premium Premi urn Premi urn % of total Caps
Retiree only 122.242.364.33.242.
Retiree +Spouse 185.503.689.26.503.50
Retiree +child(ren)205.422.628.32.422.
Retiree + Family 225.726.952.44 23.726.
years 0 serVIce
Retiree Company Total
RETIREE Under 65 Premi urn Premium Premi urn % of total Caps
Retiree only 135.42 229.364.37.229.
Retiree +Spouse 212.477.689.30.477.
Retiree +child(ren)227.400.50 628.36.400.50
Retiree + Family 263.688.50 952.44 27.688.50
years 0 serVIce
Retiree Company Total
RETIREE Under 65 Premi urn Premium Premium % of total Caps
Retiree only 148.216.364.40.216.
Retiree +Spouse 238.450.50 689.34.450.
Retiree +child(ren)249.378.628.39.378.25
Retiree + Family 302.650.952.44 31.73 650.
years 0 serVice
Retiree Company Total
RETIREE Under 65 Premi urn Premium Premium % of total Caps
Retiree only 160.204.364.44.204.
Retiree +Spouse 265.424.689.38.48 424.
Retiree +child(ren)272.356.628.43.356.
Retiree + Family 340.612.952.35.612.
15 Years of Service
Retiree Company Total
RETIREE Under 65 Premi urn Premi urn Premium % of total Caps
Retiree only 173.$191.25 364.47.59 $191.25
Retiree +Spouse 291.397.50 689.42.397.50
Retiree +child(ren)294.333.628.46.333.
Retiree + Family 378.573.952.39.573.
MEDICAL COVERAGE IN RETIREMENT
(For Retirements After January 1 1992 and Retirees Over Age 65)
Once a retiree reaches age 65 he/she is provided with a Retiree Medical Medicare Supplemental Plan.
The cost to you for coverage depends on the plan you choose and your family coverage category. The portion
A vista Corp. pays for your coverage varies based on the date of your retirement and your length of service.
The Current Premium for Over age 65 retirees (with 20+ years of service) are listed below. The Company
Contribution amount has been "capped" for retirees, so the retiree will responsible for all premiums beyond the
maximum Company contribution amounts.
20 + Years of Service
Retiree Company Total
RETIREE Over 65 Premi urn Premium Premium Caps
Retiree over 65 25.226.251.73 255.
Retiree over 65 +Spouse Under 65 57.521.578.530.
Retiree over 65 +2 Under 65 96.765.861.765.
Retiree over 65 + Spouse Over 65 52.475.528.530.
RETIREE MEDICAL MEDICARE SUPPLEMENT PLAN FOR RETIREES/DEPENDENTS OVER AGE 65
(FOR RETIREMENTS ON OR AFTER JANUARY 1, 1992)
SUBSCRIBER:
Must be retired from active service
Have attained age 65 and have been covered immediately prior to the attainment of age 65 under one of the
medical coverage options offered by A vista Corp., and
Must be enrolled in Medicare Parts A and B.
DEPENDENT SPOUSE:
The lawful dependent spouse of the subscriber must have attained age 65, and
Have been covered by the subscriber immediately prior to the attainment of age 65 under one of the medical
coverage options offered by Avista Corp., and
Must be enrolled in Medicare Parts A and B.
DATE OF ELIGIBILITY:
The Subscriber and/or dependent spouse becomes eligible on the first day of the month coincident with
eligibility to enroll in Medicare.
LIFETIME MAXIMUMS, DEDUCTIBLES AND STOP LOSS PROVISIONS
Subject to the other terms and conditions of the Plan, the service and benefits indicated below will be paid for
conditions for which treatment is medically necessary
LIFETIME MAXIMUMS:
Two Hundred and Fifty thousand dollars ($250 000) for all covered conditions for each beneficiary.
INCLUDED IN THE MAXIMUM IS:
Six thousand dollars ($6 000) for inpatient services for treatment of chemical dependency
Two thousand dollars ($2 000) for inpatient mental health services
Two thousand dollars ($2 000) combined for outpatient mental health services and treatment of chemical
dependency.
DEDUCTIBLE:
. Seventy-five ($75) for each beneficiary each benefit year for Medicare Part B services.
Benefits under Medicare Part B shall apply only after the deductible has been satisfied. Benefits provided by this
Plan , except as otherwise specified, shall apply only for allowable medical expense within each benefit year.
STOP Loss PROVISION:
Medicare Part B Services
For each beneficiary for each benefit year, the Company will be responsible for payment of 80% of the
reasonable charge for Medicare Part B services after satisfaction of the deductible. The beneficiary will be
responsible for payment of the remaining percentage of the reasonable charge, up to a maximum out-of-
pocket expense for Medicare Part B services of Two Hundred Dollars ($200). The Company will then be
responsible for payment of 100% of the allowed charge for Medicare Part B services for the remainder of
that benefit year. Any amounts paid to satisfy the deductible or any amounts in excess of the allowed charge
will not be applied to the stop loss amount. Charges for services from non-participating providers are not
included in the stop loss provision.
BENEFITS PROVIDED
Subject to the other terms and conditions of this Plan, including Exclusions and Limitations, the Company
will provide benefits and service or will pay benefits and service as listed below, provided the condition for
which the beneficiary is beneficiary is being treated is eligible under Medicare.
MEDICARE PART A - HOSPITAL SERVICES
The Medicare Part A is deductible.
Medicare Part A coinsurance amount for 615t through 90th day in any Medicare benefit period
Coverage of Medicare Part A eligible expenses incurred as daily hospital charges during the use of
Medicare s lifetime hospital inpatient reserve days
Upon exhaustion of all Medicare hospital inpatient coverage including the lifetime reserve days
coverage of one hundred percent (100%) of all Medicare Part A eligible expenses for hospitalization not
covered by Medicare subject to a lifetime maximum benefit of an additional thirty (30) days or up to the
Fifty Thousand Dollar ($50 000) lifetime maximum, whichever is less.
Coinsurance for post-hospital care in a skilled nursing facility as follows:
One hundred percent (100%) for the Twenty-first (2151) through one-hundredth (100th) day. The
one hundred first (10151) through one hundred thirtieth (BOth) day will be paid to a maximum of
Twelve Dollars ($12) per day after Medicare Payment.
The three (3) pint deductible for whole blood as applied under Medicare Parts A and B
Coinsurance for inpatient mental health services up to a lifetime maximum of Two Thousand Dollars
($2 000) when referred by a physician or an Employee Assistance Program (EAP) counselor.
(Professional services also apply to this lifetime maximum.)
Coinsurance for inpatient chemical dependency treatment up to a lifetime maximum of Six Thousand
Dollars ($6,000) (Professional services also apply to this lifetime maximum.
Coinsurance for outpatient mental health services and outpatient chemical dependency treatment up to a
combined lifetime maximum of Two Thousand Dollars ($2 000). (Professional services also apply to
this lifetime maximum.)
MEDICARE PART B MEDICAL
After the deductible has been satisfied, the coinsurance (20%) of Medicare s allowed charge as determined
under the provisions of Medicare for:
Medical or surgical service rendered in the doctor s office, the hospital, or the member s home
Hospital outpatient services;
Inpatient mental health services up to a lifetime maximum of Two Thousand Dollars ($2 000) when
refelTed by a physician or an Employee Assistance Program (EAP) counselor. (Institutional services also
apply to this lifetime maximum.
Chemical dependency treatment up to a lifetime maximum of Six Thousand Dollars ($6 000)
(Institutional services also apply to this lifetime maximum.);
Outpatient mental health services when referred by a physician or an Employee Assistance Program
(EAP) counselor and outpatient chemical dependency treatment up to a combined lifetime maximum of
Two Thousand Dollars ($2 000) (Institutional services also apply to this lifetime maximum.
Mammography screening benefits for screening or diagnostic mammography services, when rendered by
a provider.
PRESCRIPTION DRUGS:
Generic Prescriptions:(30-day supply): $5.00 co-pay for Generic Drugs
Brand Name Prescriptions:(30-day supply) (When a generic drug is not available):
$20.00 co-pay for Non-Generic when Generic is not
available
Brand Name Prescriptions:(30-day supply) (When a generic drug~ available):
$40 co-pay for Non-Generic drugs when a generic lli
available
Mail Order Prescriptions:(90-day supply): Same as Above
EXCLUSIONS AND LIMITATIONS
Expenses incurred for the following will not be covered:
Any illness, injury, or condition which is not eligible for coverage under Medicare, except as specifically
provided in this Plan; and
No benefits will be provided to the extent such benefits are available to any beneficiary hereunder for
any injury, condition, or illness under the terms of any automobile medical, personal injury protection
automobile no-fault, or similar contract or insurance, when such a contract or insurance is issued to or
provides benefits for any beneficiary under this Plan. Any benefits provided by the Company contrary to
this exclusion are provided solely to assist the beneficiary. By providing such benefits, the Company is
not waiving any right to reimbursement or to subrogation as provided in this plan.
Limitations as to particular conditions:
Benefits under this Plan for reconstructive breast surgery following a rnastectomy, as a result of illness
injury or disease, and all stages of one reconstructive breast reduction on the nondiseased breast to make it
equal size with the diseased breast after reconstructive surgery on the diseased breast has been performed
will be paid the same as for any other eligible medical condition.
Benefits which are rendered in the service area by a non-participating provider, will be paid upon presentation of
the completely itemized bill to the Insurance Company or Third Party Administrator. The amount the Company
will be obligated to pay on behalf of the beneficiary shall not exceed the sum the Company would have paid if
the beneficiary had been under the care of a participating provider.
This is only a brief SUlnlnary of benefits. In the event a question or dispute
arises on coverage or service, the official contract of benefits would be the
ruling dOCUlnent.
Contact Premera Blue Cross at 1-800-572-0778 for more complete Plan
informa tion.
Initial COBRA Notice
Federal law requires most employers sponsOling group health plans to offer employees and their families the
opportunity to elect a temporary extension of health coverage (called "continuation coverage" or "COBRA
coverage ) in certain instances when coverage under a group health plan would otherwise end. A group health
plan includes any major medical plan, dental plan , vision plan, health FSA, or other plan that we may maintain
and that provides medical care. For simplicity, any such group health plan is referred to in this Notice as the
Plan." You do not have to show that you are insurable to elect continuation coverage. However, you will have
to pay all of the premium for your continuation coverage. At the end of the maximum coverage period (described
below), you will be allowed to enroll in an individual conversion health plan if it is otherwise available under the
Plan, subject to the requirement to pay the premiums required by the individual conversion health plan.
This Notice provides a brief overview of your rights and obligations under current law. The Plan offers no
greater COBRA rights than what the COBRA statute requires, and this Notice should be construed accordingly.
Both you (the employee) and your spouse should read this summary
carefully and keep it with your records!
Qualifying Events
If you are an employee of the Employer and are covered by the Plan, you have the right to elect continuation
coverage if you lose coverage under the Plan because of anyone of the following two "qualifying events
1. Termination of your employment (for reasons other than gross misconduct).2. Reduction in the hours of your employment.
If you are the spouse of an employee covered by the Plan , you have the right to elect continuation coverage if you
lose coverage under the Plan because of any of the following four "qualifying events
I. The death of your spouse.
2. A termination of your spouse s employment (for reasons other than gross misconduct) or reduction in
your spouse s hours of employment with the Employer.
3. Divorce or legal separation from your spouse. (Also, if an employee eliminates coverage for his or her
spouse in anticipation of a divorce or legal separation , and a divorce or legal separation later occurs , then
the later divorce or legal separation will be considered a qualifying event even though the ex-spouse lost
coverage earlier. If the ex-spouse notifies the administrator within 60 days after the later divorce or legal
separation and can establish that the coverage was eliminated earlier in anticipation of the divorce or
legal separation, then COBRA coverage may be available for the period after the divorce or legal
separation.
4. Your spouse becomes entitled to Medicare benefits.
In the case of a dependent child of an employee covered by the Plan, the dependent child has the right to elect
continuation coverage if group health coverage under the Plan is lost because of any of the following fi
qualifying events
1. The death of the employee-parent.
2. The termination of the employee-parent's employment (for reasons other than gross misconduct) or
reduction in the employee-parent s hours of employment with the Employer.
3. Parent's divorce or legal separation.
4. The employee-parent becomes entitled to Medicare benefits.
S. The dependent child ceases to be a "dependent child" under the Plan.
Your IMPORTANT Notice Obligations
If your spouse or dependent child loses coverage under the Plan because of divorce, legal separation or the
child's losing dependent status under the Plan, then you (the employee) or your spouse or dependent has the
responsibility to notify the Plan Administrator of the divorce, legal separation, or the child's losing dependent
status. You or your spouse or dependent must provide this notice no later than 60 days after the date coverage
terminates under the plan (see summary plan description for details regarding when plan coverage terminates).
you or your spouse or dependent childfails to provide this notice to the Plan Administrator during this 60-day
notice period, any spouse or dependent child who loses coverage will NOT be offered the option to elect
continuation coverage. Furthermore, if you or your spouse or dependent child fails to provide this notice to the
Plan Administrator, and if any claims are mistakenly paid for expenses incurred after the date coverage is
supposed to terminate upon the divorce, legal separation, or a child's losing dependent status, then you, your
spouse and dependent children will be required to reimburse the Plan for any claims so paid.
If the Plan Administrator is timely provided with notice of a divorce, legal separation, or a child's losing
dependent status that has caused a loss of coverage, then the Plan Administrator will notify the affected family
member of the right to elect continuation coverage (but only to the extent that the Plan Administrator has been
notified in writing of the affected family member s current mailing address---see the YOU MUST NOTIFY US
paragraph below).
The Plan Administrator will also notify you (the employee), your spouse and dependent children of the right to
elect continuation coverage after it receives notice of the following events that result in a loss of coverage: the
employee s termination of employment (other than for gross misconduct), reduction in hours, or death, or the
employee s becoming entitled to Medicare.
Election Procedures
You (the employee) and/or your spouse and dependent children must elect continuation coverage within 60 days
after Plan coverage ends, or, if later, 60 days after the Plan Administrator provides you or your family member
with notice of the right to elect continuation coverage. If you or your spouse and dependent children do not elect
continuation coverage within this 60-day election period, you will lose your right to elect continuation coverage.
A COBRA election mailed to the Plan Administrator is considered to be made on the date of the mailing.
You (the employee) and/or your spouse and dependent children may elect continuation coverage for all
qualifying family members. You, your spouse and dependent children each have an independent right to elect
continuation coverage. Thus, a spouse or dependent child may elect continuation coverage even if the covered
employee does not (or is not deemed to) elect it.
You (the employee) and/or your spouse and dependent children may elect continuation coverage even if covered
under another employer-sponsored group health plan or entitled to Medicare.
Type of Coverage
Ordinarily, the continuation coverage that is offered will be the same coverage that you, your spouse or
dependent children had on the day before the qualifying event. Therefore, an employee, spouse or dependent
child who is not covered under the Plan on the day before the qualifying event generally is not entitled to
COBRA coverage except, for example, when there is no coverage because it was eliminated in anticipation of a
quaJifying event such as divorce. If the coverage is modified for similarly situated employees or their spouses or
dependent children, then COBRA coverage will be modified in the same way.
If the Employer maintains more than one group health plan (or offers a choice of separate benefit packages under
a single plan), you (or your spouse or dependent children) may elect COBRA coverage under one or more of
those plans (or separate benefit packages) in which you have coverage. For example, if you are covered under
three separate Employer plans (e.g. a medical plan, a dental plan , and a vision plan), you could elect COBRA
coverage under the medical plan and decline coverage under either or both of the dental plan and vision plans.
But if the Employer maintains one consolidated group health plan (for example, one that provides medical
dental , and vision benefits under a single plan), you must elect or decline COBRA coverage for the plan as a
whole.
If the Employer maintains a health flexible spending arrangement (health FSA) under which you are reimbursed
for medical expenses, you (or your spouse or dependent children) may elect to continue the health FSA coverage
under COBRA, but only if there is a positive account balance (i., year-to-date contributions exceed year-to-date
claims) on the day before the qualifying event (taking into account all claims submitted by that date). COBRA
coverage under the health FSA will continue only for the remainder of the Plan year in which the qualifying
event occurred. If there is a negative account balance (i., year-to-date contributions are less than year-to-date
claims), then no qualified beneficiary may elect COBRA coverage under the health FSA.
COBRA Premiums That You Must Pay
The premium payments for the "initial premium months" must be paid for you (the employee) and for any spouse
or dependent child by the 45th day after electing continuation coverage. The initial premium months are the
months that end on or before the 451h day after the election of continuation coverage is made.
Once continuation coverage is elected , the right to continue coverage is subject to timely payment of the required
COBRA premiums. Coverage will not be effective for any initial premium month until that month's premium is
paid within the 45-day period after the election of continuation coverage is made.
All other premiums are due on the 151 of the month for which the premium is paid, subject to a 30-day grace
period. A premium payment that is mailed is considered to be made on the date it is sent. If you don t make the
full premium payment by the due date or within the 30-day grace period, then COBRA coverage will be canceled
retroactively to the 151 of the month, with no possibility of reinstatement.
Maximum Coverage Periods
The maximum duration for COBRA coverage is described below. COBRA coverage terminates before the
maximum coverage period in certain situations described later under the heading "Termination of COBRA
Coverage Before the END of the Maximum Coverage Period.
36 Months. If you (the spouse or dependent child) lose group health coverage because of the employee s death
divorce, legal separation, or the employee s becoming entitled to Medicare, or because you lose your status as a
dependent child under the Plan, then the maximum coverage period (for spouse and dependent child) is three
years from the date of the qualifying event.
18 Months. If you (the employee, spouse or dependent child) lose group health coverage because of the
employee s termination of employment (other than for gross misconduct) or reduction in hours, then the
maximum continuation coverage period (for the employee, spouse and dependent child) is 18 months from the
date of termination or reduction in hours. There are three exceptions:
If an employee or family member is disabled at any time during the first 60 days after the date of termination
of employment or reduction in hours, then the continuation coverage period for all qualified beneficiaries
under the qualifying event is 29 months from the date of termination or reduction in hours. The Social
Security Administration must fonnally determine under Title II (Old Age, Survivors , and Disability
Insurance) or Title XVI (Supplemental Security Income) of the SociaJ Security Act that the disability exists
and when it began. For the 29-month continuation coverage period to apply, notice of the determination of
disability under the Social Security Act must be provided to the Plan Administrator within both the 18-month
coverage period and 60 days after the date of the determination.
If a second qualifying event that gives rise to a 36-month maximum coverage period for the spouse or
dependent child (for example, the employee dies or becomes divorced) occurs within the l8-month or 29-
month coverage period, then the maximum coverage period (for a spouse or dependent child) becomes three
years from the date of the initial termination or reduction in hours. For the 36-month maximum coverage
period to apply, notice of the second qualifying event must be provided to the Plan Administrator within 60
days after the date of the event. If no notice is given within the required 60-day period , no extension of
COBRA coverage will occur.
If the qualifying event occurs within the 18 months after the employee becomes entitled to Medicare, then the
maximum coverage period (for the spouse and dependent child) ends three years from the date the employee
became entitled to Medicare.
Shorter Maximum for Health FSAs. The maximum COBRA period for a health flexible spending
arrangement (health FSA) maintained by the Employer (if there is a positive account balance as of the date of the
qualifying event, as explained above) ends on the last day of the Plan year in which the qualifying event
occurred. If there is a negative account balance as of the date of the qualifying event, no COBRA coverage will
be offered.
Children Born to or Placed for Adoption With the Covered Employee During COBRA Period
A child born to, adopted by or placed for adoption with a covered employee during a period of continuation
coverage is considered to be a qualified beneficiary provided that, if the covered employee is a qualified
beneficiary, the covered employee has elected continuation coverage for himself or herself. The child's COBRA
coverage begins when the child is enrolled in the Plan, whether through special enrollment or open enrollment
and it lasts for as long as COBRA coverage lasts for other family members of the employee. To be enrolled in
the Plan, the child must satisfy the otherwise applicable Plan eligibility requirements (for example, regarding
age).
Open Enrollment Rights and HIPAA Special Enrollment Rights
Qualified beneficiaries who have elected COBRA will be given the same opportunity available to similarly
situated active employees to change their coverage options or to add or eliminate coverage for dependents at open
enrollment. In addition, HIPAA's special enrollment rights will apply to those who have elected COBRA.
HIPAA, a federal law, gives a person already on COBRA certain rights to add coverage for dependents if such
person acquires a new dependent (through marriage, birth, adoption, or placement for adoption), or if an eligible
dependent declines coverage because of other coverage and later loses such coverage due to certain qualifying
reasons. Except for certain children described above under "Children Born to or Placed for Adoption With the
Covered Employee During COBRA Period " dependents who are enrolled in a special enrollment period or open
enrollment period do not become qualified beneficiaries---their coverage will end at the same time that coverage
ends for the person who elected COBRA and later added them as dependents.
Alternate Recipients Under QMCSOs
A child of yours (the employee s) who is receiving benefits under the Plan pursuant to a Qualified Medical Child
Support Order (QMCSO) received by the Plan Administrator during your (the employee s) period of employment
with the employer is entitled to the same rights under COBRA as a dependent child of yours , regardless of
whether that child would otherwise be considered your dependent.
Termination of COBRA Coverage Before the End of Maximum Coverage Period
Continuation coverage of the employee, spouse and/or dependent child will automatically terminate (before the
end of the maximum coverage period) when anyone of the following six events occur:
1. The Employer no longer provides group health coverage to any of its employees.
2. The premium for the qualified beneficiary s COBRA coverage is not timely paid.
3. After electing COBRA, you (the employee , spouse or dependent child) become covered under another
group health plan (as an employee or otherwise) that has no exclusion or limitation with respect to any
preexisting condition that you have. If the other plan has applicable exclusions or limitations, then your
COBRA coverage will terminate after the exclusion or limitation no longer applies (for example, after a
12-month preexisting condition waiting period expires). This rule applies only to the qualified
beneficiary who becomes covered by another group health plan. (Note that under HlPAA, an exclusion
or limitation of the other group health plan might not apply at all to the qualified beneficiary, depending
on the length of his or her credible health plan coverage prior to enrolling in the other group health plan.4. After electing COBRA coverage, you (the employee, spouse or dependent child) become entitled to
Medicare benefits. This will apply only to the person who becomes entitled to Medicare.
5. You (the employee, spouse or dependent child) became entitled to a 29-monthmaximum coverage period
due to disability of a qualified beneficiary, but then there is a final determination under Title II or XVI of
the Social Security Act that the qualified beneficiary is no longer disabled (however, continuation
coverage will not end until the month that begins more than 30 days after the determination).
6. Occurrence of any event (e., submission of fraudulent benefit claims) that permits termination of
coverage for cause with respect to covered employees or their spouses or dependent children who have
coverage under the Plan for a reason other than the COBRA coverage requirements of federal law.
You Must Notify Us About Address Changes, Marital Status Changes, Dependent Status Changes and Disability
Status Changes
If you or your spouse s address changes , you must promptly notify the Plan Administrator in writing (the Plan
Administrator needs up-to-date addresses in order to mail important COBRA notices and other information).
Also, if your marital status changes or if a dependent ceases to be a dependent eligible for coverage under the
Plan terms, you or your spouse or dependent must promptly notify the Plan Administrator in writing (such
notification is necessary to protect COBRA rights for your spouse and dependent children). In addition, you
must notify us if a disabled employee or family member is determined to be no longer disabled.
Plan Administrator
The Employer is the Plan Administrator. All notices and other communications regarding the Plan and regarding
COBRA must be directed to the following individual who is acting on behalf ofthe Plan Administrator: (Keith
Rust, Benefits Administrator, telephone [phone]. Mailing address is: Keith Rust, Benefits Administrator
Avista Corp., 1411 E. Mission Ave., Spokane, WA 99220.
For More Information
If you, your spouse or dependent children have any questions about this notice or COBRA, please contact the
Plan Administrator. Also, please contact the Plan Administrator if you wish to receive the most recent copy of
the Plan s Summary Plan Description, which contains important information about Plan benefits, eligibility,
exclusions and limitations.
vista Corp.
Holidays
January 1,2004
(Thursday)
May 31, 2004
(Monday)
July 4, 2004 (Falls on Sunday)
(Monday July 5lh Off)
September 6, 2004
(Monday)
THANKSG rVrNG';&';TUE'I)AY,AFTER'"
November 25 & 26, 2004
(Thursday & Friday)
December 25,2004 (Falls on
Saturday)
(Friday 24th off)
A vista Corp.
FMLA (The Federal Family and Medical Leave Act)
OVERVIEW
Any employee absence, with the exception of scheduled vacation, that exceeds or is anticipated to exceed
five (5) days must be reported to the Occupational Health Nurse regardless of the reason for leave.
FMLA-THE FEDERAL FAMll., Y AND MEDICAL LEAVE ACT: Effective as of August 5 , 1993, the FMLA
was enacted to allow employees to balance the demands of the workplace with the needs of family. The Act
provides for up to twelve weeks of job-protected leave per 12 month period to eligible employees for the birth of
a child, or for the serious illness of the employee or a family member. This act is administered by the
Department of Labor s (DOL) Employment Standards Administration (ESA). It is the responsibility ofthe
employer to notify an employee of his rights of eligibility for FMLA leave and clearly document when leave is
granted.
Job-protected FMLA leave is triggered by one of the following events:
Birth of the Employee s child or placement for adoption or Foster Care of a child with the employee.
The employee is needed to care for an immediate family member (spouse, child, or parent) who has a
serious health condition.
The employee has a serious health condition arise.
These triggering events have specific , detailed descriptions under the law and require the "Certification of
Physician or Practitioner . Dependant upon the triggering event, FMLA leave may be paid or unpaid.
A vista Corp. requires the employee to use all paid leave benefits (STD/One Leave) first, as part of his/her
FMLA, before taking unpaid leave. For a more in-depth definition of qualifying events and specific paid
benefits, please contact the Occupational Health Nurse or your Human Resources Business Partner.
If you have questions or would like more detail on a specific disability benefit, please contact Rita Gregovich
, COHN/CM at extension 4712.
A vista Corp.
Worker s Compensation
OVERVIEW
Benefits paid for medical expenses and lost wages due to an "on the job" injury or illness. If injured on the job, a
claim must be filed within one year of the event that caused the injury. An occupational illness claim must be
filed within one year of the date of diagnosis, and a causal relationship must exist between the development of
the illness and the nature of the work.
Worker s Compensation benefits for medical treatment and temporary total disability are paid in accordance with
Washington State s Industrial Insurance Laws (RCW's) as directed by the Washington Adrninistrative Codes
(WAC's). An employee who is unable to work due to an occupational illness or injury may concurrently qualify
forFMLA leave.
Employees must report an occupational injury to their supervisor as soon as possible.
. An "Employee Injury Accident Report" must be completed ~ndsent to Occupational health within two
(2) days
If the injury requires immediate medical attention, a Worker s Compensation Claim form must be
completed. Contact the Occupational Health Nurse if you need a claim form or assistance completing the
report. This must be done as soon as possible to insure benefits are paid in a timely manner.
The Occupational Health Nurse will coordinate paperwork for FMLA leave and provide payroll with appropriate
time-loss information.
If you have questions or would like more detail on a specific disability benefit, please contact Rita Gregovich
, COHN/CM at extension 4712.
Benefits begin immediately after an industrial accident or injury.
Benefit Level (subject to limitations and maximums). The employee will receive an amount from the Company
which, when combined with temporary Workers' Compensation benefits will equal 100 % of his/her regular pay
as long as he/she receives temporary disability payments under Workers ' Compensation (not to exceed the weeks
shown in the following schedule according to years of service). After this time the employee will receive
Workers' Compensation benefits according to the state schedule (at least 60%) as long as they continue to be off
work due to an industrial injury.
. .. ... .. "
i .Y~~~~~;~fni
" '
:ii/'~~~~~f~~~~~:'=:~ed~~1~~~i
Years of Service
5 (6 mos)
10 +
Wks. Pd. at 100% of Salar
A vista Corp.
STD (Short Term Disability)
STD
Short-Term Disability: The company s non-occupational temporary disability benefit plan may provide for up to
twenty-six (26) weeks of disability compensation for eligible employees following a waiting period and
certification from the employee s physician. To qualify for STD, you must be a regularly scheduled employee
working twenty (20) or more hours per week and have at least six months of service with the company. The
number of weeks of STD benefit and the level of benefit pay for which the employee is entitled is based upon
years of service. Once the employee returns to work from STD leave with no further utilization of benefits for
six (6) months, his/her STD benefits bank is fully restored.
1. The waitin$? period consists of consecutive, regularly scheduled workdays (or 40 consecutive
hours).STD will begin on the sixth consecutive day of absence due to the employee s own serious
health condition. Occurrences of illness or injury lasting less than the waiting period may be covered by
the One Leave Plan.
2. For an elective, planned absence from work for treatment of a health condition, the employee must
notify the supervisor and the Occupational Health Nurse in advance of the leave of absence.
3. For an unexpected illness or injury, the employee or his/her supervisor must notify the Occupational
Health Nurse as soon as it is anticipated that STD will be activated.
4. If payroll receives an employee s time sheet for wage benefits under STD that has not been
authorized by the Occupational Health Nurse Case Manager, STD will not be paid. It is the
responsibility of the employee and his/her supervisor to notify the Occupational Health Nurse
soon as it is apparent the employee s absence will exceed the 5-day waiting period. The
Occupational Health Nurse Case Manager will determine the employee s STD benefits eligibility
based of length of service and applicable medical information. Once eligibility criteria are
satisfied, a written notice is provided to payroll authorizing payment of wages under STD.
Amount of Benefit
Amount of benefit depends on years of service at the time of the disability. Years of service determine the
number of weeks at 100% or 60% of base pay up to 26 weeks in combination.
5 (6 mos.
10 +
If you have questions or would like more detail on a specific disability benefit, please contact Rita Gregovich
, COHN/CM at extension 4712.
vista Corp.
Long Term Disability
ELIGIBILITY
You are eligible to participate in the Plan if you are a:
Regular or full-time employee, or (Who have completed at 1 000 or more hours and have completed
at least 12 months of service.
Employees with less than one year of service will not be eligible for LTD. They will automatically
be enrolled for coverage on their one-year anniversary.
OVERVIEW
Benefits begin 26 weeks after a covered disability begins.
Benefit Level: Eligible employees will receive L TD benefits at 60% (70% if you are eligible for Social
Security Benefits) until they qualify as eligible for retirement benefits under A vista s Defined Benefit
Pension (DBP) plan, at which time their L TD benefit will be at 50% (60% if you are eligible for Social
Security Benefits) of their straight time earnings. The 50% (60%) LTD benefit will continue for eligible
employees until they retire under the A vista DBP or until they reach Normal Retirement Age (65), whichever
comes first.
While disabled, generally to age 65 (longer if you become disabled after age 60).
Employees with one to ten (1-10) years of service are eligible for one (1) year of benefit for each year of
service. Employees with ten (10) or more years of service are eligible for benefits as defined by the Plan.
DEFINITION OF TOTAL DISABILITY
Total Disability (for long-term disability benefits): During the first 24 months of disability, you are unable to
perform your own occupation; after that time you must be unable to perform any occupation for which you are
reasonably qualified. Pre-existing conditions may not be covered.
vista Corp.
One Leave Program
ELIGIBILITY
You are eligible to participate in the Plan if you are a:
Regular (FIT or PIT) employee, or
. Regular Temporary Employee, scheduled for 20+ hour per wk for a minimum of 6 months.
To maintain compliance with the Fair Labor Standards Act) exempt employees (employees who are exempt
from overtime) must take one leave in full day (8 hour) increments. Non-exempt employees (employees who
are not exempt from overtime) may take partial or full days of one leave.
During the 1st Year 18.06924
During the 2nd Year 18.07200
During the 3rd Year 19.07462
During the 4th Year 20.07725
During the 5th Year 20.07987
During the 6th Year 21.45 08250
During the 7th Year 22.08525
During the 8th Year 22.08787
During the 9th Year 23.09050
During the 10th Year 24.7.45 09312
During the 11 th Year 24.09587
During the 12th Year 25.09850
During the 13th Year 26.10112
During the 14th Year 26.10375
During the 15th Year 27.10637
During the 16th Year 28.10912
During the 17th Year 29.11175
During the 18th Year 29.11437
During the 19th Year 30.42 11700
During the 20th Year 31.11 11975
During the 21st Year 31.80 12237
During the 22nd Year 32.49 10..12500
During the 23rd Year 33.10.12762
During the 24th Year 33.10.43 13037
During the 25th Year 34.10.13300
During the 26th Year 35.10.13562
During the 27th Year 35.11.06 13825
During the 28th Year 36.11.28 14100
During the 29th Year 37.11.49 14362
During the 30th Year 38.11.70 14620
Thereafter 38.00 days or 11.70 hrs per pay period 14620
Maximum Cap effective is 750 hours
A vista Corp.
One Leave Program
The One Leave Program is a benefit that allows employees to accrue a "bank" of hours, based on years
of service, to use for vacation, personal business, family illness, doctor/dental visits, funerals or recovery
from sickness or accident. An employee may also sell the time back to the Company for cash in
accordance with the One Leave Cash-Out rules.
Maximum number of "banked" One Leave Hours is 750 hours
You may have a maximum bank of750 hours. Once you reach 750 hours, you will no longer accrue
One Leave. You will need to decrease your bank below the maximum, either through cash out or
regular use, before accrual can resume.
You will be responsible for managing your one leave bank during the calendar year, keeping in mind
that you will no longer accrue One Leave if your bank is at the maximum of 750 hours.
The One Leave Program provides you a choice of usin2 One Leave hours or selling (cash-out)
hours to maintain a maximum bank of 750 hours
You may cash-out One Leave hours at 100% of your pay rate for the first 120 hours. All additional
hours after the first 120 will be paid at 80% (not to exceed your annual accrual rate as of the first pay
period of January each year).
Your total cash out is limited to your annual accrual rate during each calendar year.
All One Leave sold is considered taxable income.
A vista Corp.
Health Care Reimbursement Plan (HCR)
ELIGIBILITY
You are eligible to participate in the Plan if you are a:
Regular (FIT or PIT) employee
Medical Care Expense Reimbursement Benefits
Under the Medical Care Reimbursement component, you purchase a specific level of Medical Care
Reimbursement benefits, paying for coverage through the Salary Reduction Agreement with A vista Corp, in lieu
of a corresponding amount of current pay, which means that the premiums you pay will be with pre-tax funds. In
return, you may be reimbursed from the Plan for certain eligible Medical Expenses. This arrangement helps you
because the level of coverage you elect is non-taxable, thereby saving you social security and income taxes on the
amount of the premiums you pay.
Medical Care Expense Reimbursement Account
If you elect benefits under this portion of the Plan , a Medical Expense Reimbursement Account will be set up in
your name to keep a record of the reimbursements you are entitled to, as well as the premiums you have paid for
such benefits during the Plan Year. Your Medical Care Reimbursement Account is merely a record keeping
account; it is not funded (all reimbursements are paid from the general assets of A vista Corp).
What annual benefits are available under the Medical Care Reimbursement component, and how much
will they cost?
You may choose any amount of Plan Year reimbursement you desire, subject to a maximum reimbursement
amount of $5 000 per year and a minimum of $1 a/month or $ 120/year. You will be required to pay the annual
premium equal to the coverage level you have chosen.
How is my Medical Care Expense Reimbursement benefit paid for?
When you complete the Salary Reduction Agreement, you specify the amount of Medical Care Reimbursement
you wish to pay with your salary reduction. Thereafter, you must pay a premium for such coverage by having an
equal portion of the annual premium deducted from each paycheck. The full amount of the coverage you have
elected will be available to reimburse you for certain Medical Expenses at any time during the Plan Year, so long
as you continue to pay the premiums.
What amounts will be available for Medical Care Expense Reimbursement at any particular time during
the Plan Year?
Provided that you have continued to pay the periodic premiums due for this benefit, then the full annual amount
of coverage that you have elected will be available at any time during the Plan Year, although reduced by the
amount of prior reimbursements received during the Year.
How do I receive reimbursement under the Plan?
If you elect to participate in this Plan, then you will have to take certain steps to be reimbursed for your Medical
Expenses. When you incur an expense that is eligible for payment, you must submit a claim to the Plan
contract administrator, A. W. Rehn & Associates, Inc. on a claim form that will be supplied to you. You must
include written statement(s) from an independent third party(ies) stating that the medical expense(s) have been
incurred, and the amount of such expense(s) along with the claim form. In addition, you must include an
Explanation of Benefits (EOB) Form(s) from any primary medical and/or dental insurance carrieres) indicating
the amount(s) that you are obligated to pay. Claims should be submitted to:
A.W. Rehn & Associates, Inc.
O. Box 5433
Spokane, W A 99205
[phone]
Claims are paid on a weekly basis through the contract administrator. Remember, though, you cannot be
reimbursed for any total expenses above the annual reimbursement amount you have elected.
You have 90 days from the end of the Plan Year in which to submit a claim for reimbursement for Medical
Expenses incurred during the previous Plan Year. You will be notified in writing if any claim for benefits is
denied.
Please note that it is not necessary for you to have actually paid the bill for a Medical Expense - only for you to
have incurred the expense and that it is not being paid for or reimbursed from any other source.
What is a "Medical Expense
A "Medical Expense" generally means an item for which you could have claimed a Medical Expense deduction
on an itemized federal income tax return (see IRS Publication 502) for which you have not otherwise been
reimbursed from insurance or from some other source. Medical Expenses are limited to generally recognized
health care expenses, which are defined to mean (a) expenses incurred for diagnosis, cure, mitigation, treatment
or prevention of disease or for the purpose of affecting any structure or function of the body, and (b) for
transportation primarily for and essential to such medical and dental care. They include, for example, expenses
you, your spouse or eligible dependents have incurred for:
Medicine, drugs, birth control pills and vaccines that your doctor prescribed.
Over the counter drugs and pregnancy kits;
Medical doctors, dentists, eye doctors , optometrists, chiropractors , osteopaths, podiatrists
psychiatrists, psychologists, physical therapists, acupuncturists, chiropodists, Christian Science
practitioners and naturopaths.
Medical examination, x-ray and laboratory service.
Nursing care services.
Hospital care (including meals and lodging), clinic costs and lab fees.
Medical treatment at a center for drug and alcohol addiction.
Medical aids such as hearing aids (including batteries), dentures, eyeglasses, contact lenses
braces, artificial limbs, orthopedic shoes, elastic hose as medically prescribed, crutches,
wheelchairs, guide dogs and the cost of maintaining them.
Ambulance service and other travel costs to get medical care. If you use your own car, you can
claim what you spent for gas and oil to go to and from the place you received the care; or you can
claim $.14 a mile. Add parking and tolls to the amounts you claim under either method.
Expenses for weight loss programs or treatments for a specific medical condition. Meal
replacements, dietary supplements and vitamins are excluded.
Stop smoking programs (but not non prescription drugs to aid in smoking cessation)
Automobile modifications (hand controls, special equipment, mechanical lifts)
Eye surgery to correct vision
Vasectomy
However, the following items are not Medical Expenses, even if they meet the criteria of IRS Publication 502:
EXCLUSIONS
Health insurance premiums that you or your spouse pay for coverage under another health plan;
Basic cost of Medicare Insurance, life insurance or income protection policies;
Long-term care services;
Cosmetic surgery or other similar procedures, unless the surgery or procedure is necessary to
ameliorate a deformity arising from, or directly related to, a congenital abnormality, a personal
injury resulting from an accident or trauma, or disfiguring disease. "Cosmetic surgery" means
any procedure or drug which is directed at improving the patient's appearance and does not
meaningfully promote the proper function of the body or prevent or treat illness or disease;
The salary expense of a nurse to care for a healthy newborn at home;
Household and domestic help (even though recommended by a qualified physician due to an
employee s or dependent's inability to perform physical housework);
Custodial care;
Health club dues , or fitness programs;
Social activities, such as dance lessons (even though recommended by a qualified physician for
general health improvement;
Bottled water;
Maternity clothes;
Diaper service or diapers;
Cosmetics, toiletries, toothpaste, etc.
Vitamins, food supplements or special foods, even if prescribed;
Marijuana and other controlled substances, even if prescribed; and
Travel your doctor tells you to take for rest or change.
ORTHODONTIC TREATMENT
Expenses for orthodontic treatment can only be reimbursed for the expenses incurred during the Plan Year. The
Plan will reimburse up to one third of the entire cost of the orthodontic treatment when the braces are installed
and amortize the remaining amount of the cost over the treatment period.
When must the expenses be incurred?
Medical Expenses must have been incurred during the Plan Year. You may not be reimbursed for any expenses
arising before the Plan became effective, before your Salary Reduction Agreement became effective, for any
expenses incurred after the close of the Plan Year, or after a separation from service (except for Continuation
Coverage).
What if the Medical Expenses I incur during the Plan Year are less than the annual amount I have elected
for Medical Care Reimbursement?
You will not be entitled to receive any direct or indirect payment of any amount that represents the difference
between the actual medical expenses you have inculTed and the annual coverage level you have elected and paid
for. Any unused annual coverage benefit not used shall be forfeited and used to offset administrative expenses
and future costs.
A vista Corp.
Dependent Care Reimbursement Plan (DCR)
ELIGIBILITY
You are eligible to participate in the Plan if you are a:
Regular (FIT or prr) employee
Dependent Care Expense Reimbursement Benefits
Under the Dependent Care Expense Reimbursement (DCR) component, you provide a source of pre-tax funds to
reimburse yourself for your Eligible Dependent Care Expenses by entering into a Salary Reduction Agreement
with A vista Corp under which you agree to a salary reduction to fund Dependent Care Expenses in lieu of a
corresponding amount of your regular pay. This arrangement helps you because the coverage you elect is non-
taxable, thereby saving you social security and income taxes on the amount of salary conversion.
Dependent Care Expense Reimbursement Account
If you elect benefits under this portion of the Plan, a Dependent Care Expense Reimbursement Account will be
set up in your name to keep a record of the reimbursements you are entitled to. Your Dependent Care
Reimbursement Account is merely a record keeping account; it is not funded (all reimbursements are paid out of
the general assets of A vista Corp).
What is the maximum Dependent Care Reimbursement benefit I may elect?
This amount can not exceed the maximum amount specified in Section 129 of the Internal Revenue Code. The
maximum amount is currently $5 000 per Plan Year if you:
are married and file a joint return;
are married, but you furnish more than one-half the cost of maintaining those dependents for
whom you are eligible to receive tax-free reimbursements under the DCR, your spouse maintains
a separate residence for the last six months of the calendar year, and you file a separate tax
return; or
are single or are the head of the household for tax purposes.
If you are married and reside with your spouse, but you file a separate federal income tax return, then the
maximum DCR benefit you may elect is $2 500.
How is my Dependent Care Expense benefit funded?
When you complete the Salary Reduction Agreement, you specify the amount of DCR benefits for which you
wish to pay with your salary reduction. Thereafter, your Dependent Care Reimbursement Account will be
credited with the portion of your gross income that you have elected to forego through salary reduction. These
portions will be credited as of each pay period. The amount that is available for reimbursement at any particular
time will be whatever has been credited to your Dependent Care Reimbursement Account, less any
reimbursements already paid.
What is a "Dependent Care Expense" for which I can claim a reimbursement?
You may be reimbursed for work-related expenses incurred on behalf of any individual in your family who is
under the age of 13, who resides with you and whom you could claim as a dependent on your federal income tax
return; any other dependent who is mentally or physically incapable of self-care; or your spouse, if the spouse is
likewise physically or mentally incapacitated.
Generally, these expenses must meet all of the following conditions for them to be eligible Dependent Care
Expenses:
1. the expenses are incurred for services rendered after the date of your election to receive Dependent
Care Expense Reimbursement, and during the calendar year to which it applies:
2. each individual for whom you incur the expenses is:
(a) a dependent under age 13 whom you are entitled to a personal tax exemption as a dependent;
(b) a spouse or other tax dependent who is physically or mentally incapable of caring for himself or
herself;3. the expenses are incurred for the care of a dependent (as described above), or for related household
services, and are incurred to enable you to be gainfully employed;
4. if the expenses are incurred for services outside your household and such expenses are incurred for
the care of a spouse or other tax dependent age 13 or older who is incapable of self-care, such
individual regularly spends at least eight hours per day in your home;
5. if the expenses are incurred for services provided by a dependent care center (i., a facility that
provides care for more than six individuals not residing at the facility), the center complies with all
applicable state and local laws and regulations;6. the expenses are not paid or payable to a child of yours who is under age 19 at the end of the year in
which the expenses are incurred or an individual for whom you or your spouse is entitled to a
personal tax exemption as a dependent; and7. this reimbursement (when aggregated with all other Dependent Care Reimbursements during the
same year) may not exceed the least of the following limits:
(a) $5 000;
(b) $2 500, if you are married but you and your spouse file separate tax returns;
(c) your taxable compensation (after your Salary Reduction under this Plan); and
(d) if you are married, your spouse s actual or deemed Earned Income.
For purposes of (d) above, your spouse will be deemed to have Earned Income of $200 ($400 if you have two or
more dependents described in paragraph 2 above), for each month in which your spouse is (i) physically or
mentally incapable of self-care, or (ii) a full-time student at an educational institution.
You are encouraged to consult your personal tax advisor or IRS Publication 17 "Your Federal Income Tax" for
further guidance as to what is or is not an Eligible Expense, if you have any doubts.
How do I receive a Dependent Care Expense Reimbursement under the Plan?
If you have elected to participate in this portion of the Plan, you will have to take certain steps in order to be
reimbursed for your Dependent Care Expenses. When you incur an expense that is eligible for payment, you
must submit a claim to the contract administrator, A. W. Rehn & Associates, Inc. on a claim form that will be
supplied to you. Your claim must include a statement from the dependent care provider showing the dates the
expenses were incurred, the name of the dependent cared for, the cost of the care and the provider s taxpayer
identification number. If there are enough credits in your Dependent Care Expense Reimbursement Account, you
will be reimbursed for your eligible expenses. Please read the claims instructions with which you have been
furnished and sent claims to:
W. Rehn & Associates, Inc.
O. Box 5433
Spokane, W A 99205
[phone]
If a claim is for an amount that is more than your current Dependent Care Reimbursement Account balance, then
the excess part of the claim will be carried over into the next payment cycle, to be paid out as your balance
becomes adequate. Remember, though, that you can not be reimbursed for any total expenses above the available
annual credits to your Dependent Care Reimbursement Account. You may not be reimbursed for any expenses
that arise before your Salary Reduction Agreement becomes effective, or for any expense incurred after the close
of the Plan Year.
Please note that it is not necessary for you to have actually paid an amount due for Dependent Care Expenses -
only for you to have incurred the expense, and that it is not being paid for or reimbursed from any other source.
You will have 90 days after the end of the Plan Year in which to submit a claim for reimbursement for Dependent
Care Expenses incurred during the previous Plan Year. You will be notified in writing if any clai m for benefits isdenied.
What if the Dependent Care Expenses I incur during the Plan Year are less than the annual amount of
coverage I have elected for Dependent Care Expense Reimbursement?
You will not be entitled to receive any direct or indirect payment of any amount that represents the difference
between the actual Dependent Care Expenses you have incurred and the annual coverage level you have elected
and paid for. Any unused annual coverage benefit not used shall be forfeited and used to offset administrative
expenses and future costs.
Will I be taxed on the DCR benefits I receive?
You will not normally be taxed on your DCR benefits, up to the limits set out in Q-29 of this summary.
However, to qualify for tax-free treatment, you will be required to file IRS Form 2441 or a similar form with your
annual income tax return to list the names and taxpayer identification numbers of any persons who provided you
with dependent care services during the calendar year for which you have claimed tax-free reimbursement.
If I participate in the DCR, will I still be able to claim the household and dependent care credit on my
federal income tax return?
You may not claim any other tax benefit for the tax-free amounts received by you under this Plan, although the
balance of your Dependent Care Expenses may be eligible for the dependent care credit.
What is the household and dependent care credit?
The household and dependent care credit is an allowance for a percentage of your annual dependent care
expenses as a credit against your federal income tax liability under the U.S. Tax Code. In determining what the
tax credit would be, you may take into account only $3 000 such expenses for one dependent, or $6 000 for two
or more dependents. Depending on your adjusted gross income, the percentage could be as much as 35% of your
qualifying expenses (to a maximum credit amount of $1 050 for one dependent or $2 100 for two or more
dependents), to a minimum of 20% of such expenses (producing a maximum credit of $600 for one dependent or
200 for two or more dependents). The maximum 35% rate must be reduced by 1 % (but not below 20%) for
each $2 000 portion (or any fraction of $2 000) of your adjusted gross income over $15 000.
When would I be better off to include the reimbursements in my income and claim the credit, rather than
to treat the reimbursements as tax-free?
Generally, if you are in one of the lower income tax brackets, you might come out ahead by including the DCR
benefits in income and by claiming the credits for dependent care and earned income. On the other hand, it will
generally be better to treat DCR benefits as tax-free the more income taxes you are required to pay. Because the
actual determination of the preferable method for treating benefit payments depends on a number factors such as
one s tax filing status (e.g. married, single, head of household), number of dependents, etc., each Participant will
have to determine his or her tax position individually in order to make the decision between taxable and tax-free
benefits. Use IRS Form 2441 to help you.
A vista Corp.
Premium Payment Plan
ELIGIBILITY
You are eligible to participate in the Plan if you are a:
. Regular (Frr or prr) employee
How THE PREMIUM PAYMENT PLAN WORKS
The Premium Payment Plan allows you to pay the premiums for some of your Company benefits
with pre-tax dollars. This results in tax savings. You may use the Plan to pay premiums for:
~ MSC-EBA Medical Plans
~ WDS Dental Plans
Group Health Medical Plan
~ AD&D (Accidental Death & Dismemberment Insurance)
You will automatically be enrolled in the Premium Payment Plan if you participate in any of these plans.
If you do not want these premiums to be paid on a pre-tax basis for any year, you must complete and
submit a written request to that effect no later than December 31 of the preceding year.
EXAMPLE OF TAX BENEFIT
Suppose you earn $24 000 a year and have a federal income tax rate of 20%. Suppose, also, that you pay
$300 a year in premiums for EBA coverage for you and your family, and $103 a year in premiums for
$100 000 of family AD&D coverage. You would save $111 a year in taxes by using the Premium
Payment Plan. Here s how the savings are calculated:
With POP Without POP
Annual gross income $24 000 $24 000
EBA premium (pre-tax) 300
AD&D premium (pre-tax)103
Adjusted gross income $23 597 $24 000
Federal income tax (20%)720 800
Social Security Tax 805 836
EBA premium (after tax)300
AD&D premium (after tax)103
Take-home pay $17 072 $16 961
Tax savings $111
(This example is intended to illustrate the effect that the Plan has on an employee s take-home pay. The
tax assumptions used here will most likely be slightly different than your own situation.
A vista Corp.
401(k) Plan Investment Options
Artisan International Fund
Avista Corp. Stock Fund
Dodge & Cox Stock Fund
Julius Baer Int l Equity A
Sentinal Small Company A
Sterling Small Cap Value Fund
Vanguard PRIMECAP Fund
Vanguard 500 Index Fund
Vanguard Retirement Savings Trust Fund
Vanguard Small-Cap Value Index Fund
Vanguard Total Bond Fund
Vanguard Value Index Fund
Vanguard Wellington Fund
Vanguard Brokerage Option
Contact Vanguard at 1-800-523-1188 for more complete plan information. Or go to
their website at Vanguard.com
A vista Corp.
Investment Plan - 401(k)
ELIGIBILITY
Eligible on the enrollment date that immediately follows your employment date. (You must have at least
one complete payclose in order to be recognized by Vanguard as an eligible participant.Students &
leased employees are not eligible.
PARTICIPANT DEFERRAL PERCENTAGE CHANGES
Changes are allowed monthly. The transaction deadline is the 20th of the month. The effective date is
the first day of the month following the transaction. Deductions are taken out of each paycheck and can
be in whole percentage increments between 1 % and 25%.
FUND TRANSFER & FUTURE INVESTMENT DIRECTION CHANGES
Changes are allowed daily. Transfers and investment changes made before 1 p.m. Pacific time will be
effective the next day. Investment elections are effective for the first payclose following the transaction.
Exchanges in the A vista Stock Fund must be made before lOam Pacific Time.
CONFIRMATIONS
Confirmations are provided for each transaction completed. Confirmations are mailed directly to
participant's home. Participants can also request an immediate FAX confirmation.
QUARTERL Y FEES
Participants are responsible for investment management fees for the funds they invest. Also , record
keeping, trustee and custodian, consulting, legal and counting fees are paid from the trust and allocated
to participant accounts based on investment balances.
DISTRIBUTIONS
Distributions are processed daily. Proceeds are distributed within 45 days of the end of the month
processed.
IF You LEAVE THE COMPANY
Termination Distributions: Allowed for retirement, death or termination of employment.
In-Service Distributions: Allowed at age 59 Yz and upon disability.
All Distributions: Participants are allowed to choose how their A vista Common Stock is distributed.
Participants may choose either stock certificates or cash.
Retiree Distributions: Retired participants may elect monthly installment payments from their account
over a period not to exceed 15 years. An annual fee of $100 per year will be assessed to the Retiree.
Changes in the montWy amount are allowed annually.
A vista Corp.
Investment Plan - 401(k)
COMPANY STOCK DIVERSIFICA TION
Participants at least age 50 and older, with 5 years in the plan can diversify up to 50% of their year-end
Company ESOP match balance.
Diversification Prior to age 50: Participants may elect to diversify up to 100% of their Non-ESOP
Company match account at anytime.
Retiree Diversification: Retirees may di versify 100% of the Company match portion of their account at
any time.
LOANS
Loan Set Up Fee: Loan set-up fee of $100
Initiating A Loan: Loans are modeled and set up through Vanguard Participant Services 1-800-523-
1188.
Types of loans: You can request a 5-year general loan for any reason. The lO-year loan must be for the
purchase of your primary residence only. The purchase agreement will be required as documentation for
the primary residence loan.
Process Dates: Loans are processed after the loan is requested from Vanguard Participant Services 1-
800-523-1188.
Withdrawal from the participant account, for the loan proceeds, is made on a prorated basis from all
funds.
Number of Loan(s) Allowed: Two outstanding loans at a time, but no more than one home loan.
Therefore, either two general OR one general and one home loan are allowed at anyone time.
Repayment of Loan(s): Maximum payback on general loans is 5 years. Maximum payback for the
primary residence loan is 10 years (Documentation is required).
Repayment to the account is made in the same investments as most current payroll investment election.
Payment Set Up: All loan payments made via payroll! pension deduction. Cash payment not accepted
except for lump sum payoff.
Minimum 1 Maximum: You can borrow a Minimum of $1 000; Maximum of the lesser of 50% of
account balance or $50 000 reduced by your highest outstanding loan balance during the 12 - month
period ending on the date of the loan. Loan proceeds are withdrawn only from the Non Company match
accounts.
Interest Rate: Interest rate of Prime + 1 % at the time of the loan request.
IrYou Leave the Company: If you terminate employment with the Company, other than Retirement
you have 60 days following termination to repay the loan in full. If you default, the outstanding balance
is considered a taxable distribution subject to both income tax and a 10% penalty tax.
RETIREE LOAN(S)
Retirees are eligible for loans. At no time will a loan be granted in which the monthly payment exceeds
net pension benefits.
Vesting: The balance of participant contributions & earnings are 100% vested at all times. Employer
contributions are vested after the participant's one-year employment anniversary.
vista Corp.
Retirement Bonus
How THE RETIREMENT BONUS WORKS
In recognition of years of service to the Company, a Retirement Bonus will be paid to employees retiring
from active service (with a minimum of 15 years) as defined under provisions of the Retirement Plan for
Employees of A vista Corp.
Completed
Years of Days Pay
Service
30 +
I5-year minimum: 1 day for each year or partial year of service.
vista Corp.
Retirement Plan
OVERVIEW
The Retirement Plan provides you with a continuing source of monthly income upon retirement from the
Company. This benefit is funded entirely by the Company.
ELIGIBILITY
After completion of one year of service and a minimum of 1000 hours an eligible employee becomes a
Member of the Plan if they are employed by a Participating Employer.
VESTING
Vesting is a fOlID of ownership or right to receive a pension benefit. Vesting Service is time, which is
counted toward earning a vested pension benefit. Benefits are vested after five years of service.
NORMAL RETIREMENT FORMULA
Nonnal Retirement Date is the first day of the month coincident with or next following your 65
birthday or the fifth anniversary of your employment date, whichever is later. When you retire on or
after your Nonna! Retirement Date , you are entitled to an unreduced pension benefit calculated using the
Normal Retirement Formula described below. If you have at least 15 years of Vesting Service you may
retire with a reduced benefit as early as age 55, or retire as early as age 62 and receive an unreduced
benefit. See "Early Retirement" section for more detail.
Formula: The Plan formula averages your highest consecutive 36 months of base pay during the last
ten-year period worked. This is called your "3- Year Final Average Pay
1.5% of 3-Year Final Average Pay for each year of Benefit Service.
The amount resulting from this calculation is called your "accrued benefit"
Example Calculation: If you have 20 years of Benefit Service and 3-Year Final Average Pay of
$25 000, your benefit will be $7 500 per year or $625.00 per month calculated as follows:
5% x 20 years = 30%
30% x $25 000 = $7 500
500 + 12 months = $625.
This benefit, called a Life Annuity, is paid in equal monthly installments for as long as you live.
vista Corp.
Retirement Plan
EARLY RETIREMENT
Retirement from ACTIVE Service: If you are actively employed by the Company and you are at least
age 55 you can elect to retire if you have at least 15 years of service. Since monthly benefits will be
paid over a longer period of time, they will be reduced by a percentage according to your age when
payments begin.
Early Retirement Reduction
Factors (ERRF):
A~e at Retirement of Normal Retirement Benefit
Pavable
72%
76%
80%
84%
88%
92%
96%
100%
100%
100%
100%
Early Retirement Reduction Factors
Adjustment: For each year of Benefit Service in excess of 15, the reduction for early retirement is
decreased by 1
For example, with 27 years of Benefit Service, you can retire as early as age 59 with afull, unreduced
pension!
27 years - 15 years = 12
age 59 ERRF = 88%
12 + 88% = 100% of Nonnal Retirement Benefit
Example Calculation: Suppose you choose to retire at age 55 and elect to receive your benefits
immediately. Your Final Average Pay is $35 000 and you have 16 years of Benefit Service. Your
annual pension (Life Annuity) will be $6 132 or $511 per month.
1.5% x 16 years = 24%
24% x $35 000 = $8 400
16 years - 15 years = 1 (which equals 1 %)
age 55 ERRF = 72%
1 + 72% = 73% of Nonnal Retirement Benefit
400 x 73% = $6,132
132 -;- 12 months = $511
A vista Corp.
Retirement Plan
BENEFITS FOR VESTED TERMINEES
Vested employees who leave the Company before qualifying for early or normal retirement receive
benefits according to the following table. To be eligible for pension benefits, which begin prior to age
65 you, must have completed at least 15 years of Vesting Service. The Early Retirement Reduction
Factor - Adjustment of 1 % for every year over 15 years also applies to Vested Terminees.
ERRF for Vested Terminees:Aee Benefit Berzins of Normal Retirement Benefit
Pavable
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
FORMS OF BENEFITS
In addition to choosing whether to retire early or on your Normal Retirement Date, you may choose the
form in which your pension is paid. If you are married at the time of retirement your choices are:
Life Annuity, or
Social Security Level Income Benefit, or
Lump Sum Cash Out
If you are single, your choices are:
Life Annuity Benefit, or
. Ten-year Certain and Life Benefit, or
Social Security Level Income Benefit, or
Lump Sum Cash Out
Life Annuity Benefit: The Life Annuity Benefit is paid to you for as long as you live. Eligible
dependents receive survivor benefits. You will automatically receive your pension in this form unless
you elect otherwise. The Life Annuity Benefit is reduced if you retire early based upon the ERRF
described previously.
Social Security Level Income Benefit: This form of benefit is available to you if you retire before age
62. Under this option, your pension payments would be higher before age 62, and then reduced to reflect
the amount received from Social Security. The intent of this option is to provide you with a somewhat
level income before and after Social Security benefits begin.
If you are married and choose this option , the reduction shall apply to only your benefit; it will have no
effect on survivor benefits.
A vista Corp.
Retirement Plan
Ten- Year Certain and Life: If you are single, but want to provide coverage for an ineligible dependent
or other beneficiary, you may elect the Ten-Year Certain and Life Annuity. This option provides a
reduced lifetime pension for you, but it assures that a total of at least 120 equal monthly payments will
be made to either you or your beneficiary. If you die before receiving 120 payments, the remaining
payments are made to your beneficiary. However, if you die after receiving 120 monthly payments, no
benefits will be payable to your beneficiary.
The following table shows what your reduced Ten-Year Certain and Life Annuity would be as a
percentage of the Life Annuity Benefit you would be entitled to receive at a given retirement age:
A.e-e
65 or older
Reduced Benefit as a of Life Annuitv
Benefit
98%
97%
96%
95%
94%
93%
92%
91%
90%
89%
88%
If you retire early and choose the Ten-Year Certain and Life Annuity, your monthly benefit is further
reduced. In the previous example, you retired with 16 years service at age 55 and received a reduced
Lifetime Annuity Benefit of $511 per month. If you chose the Ten- Year Certain and Life Annuity, the
monthly benefit would be $$500.78. The table above shows that the Ten-Year Certain and Life Annuity
at age 55 is 98% of the benefit you would otherwise be entitled to receive. Therefore, 98% of $511 is
$500.78.
Lump-Sum Cash Payment: The Plan permits you the option of electing a single lump sum cash
payment distribution in lieu of the normal form of annuity benefit. This single lump sum cash payment
would be the actuarial equivalent of your benefit otherwise payable in annuity form. If you are married
your spouse must consent to this election. A lump sum election means you receive a single payment
from the Plan and no other benefit payable to you or a survivor upon your death.
Benefit Less Than $5 000: If the present value of your accrued benefit is less than $5 000 at the time of
your termination from the Company, the Plan will distribute the actuarial equivalent of your benefit in a
single lump sum cash payment.
vista Corp.
Retirement Plan
SURVIVOR BENEFITS
If you choose either the Life Annuity Benefit or the Social Security Level Income Benefit, your eligible
surviving dependents will receive a survivor benefit after you die.
To be eligible for benefits, your spouse must have been married to you at the time benefits commenced
and have been your spouse for at least 12 months at the time of your death. After your death, 66 2/3% of
your pension will be paid to your Eligible Surviving Spouse until he or she reaches age 60. After age 60
50% of your pension will be paid for his or her life.
Example: Suppose your Life Annuity Benefit is calculated to be $1 500 a month. If your Eligible Spouse
survives you, the survivor s monthly pension would be $1000 until he or she reaches age 60. After age
60 the survivor pension would be $750 for his or her life.
The example above assumes that you are not more than five years older than your spouse is. Benefit
percentages are reduced two percent for each full year that you are more than five years older than your
spouse IS.
Example: If you are Ih years older than your Eligible Spouse, the benefit payable if he or she survives
you would be 64 2/3% of your benefit until your spouse reaches age 60, and 48% after age 60 for life. If
your pension was $1 500 per month, the survivors monthly benefit would be $970 until age 60 and $720
thereafter.
If you have no Eligible Spouse when you die, but do have Eligible Children, 66 2/3% of your pension
will be shared equally amount your children until they reach age 19.
Pre-Retirement Survivor Income Death Benefit: If you die after becoming fully vested in the Plan
but before you begin receiving benefits, your Eligible Surviving Spouse or Eligible Dependent Children
will receive pension payments. The date upon which benefits begin depends on whether you die before
or after becoming eligible for early retirement.
After Eligibility for Early Retirement
If you die after becoming eligible for early retirement, your eligible survivor(s) islare entitled to receive a
pension benefit starting the first day of the month following your death.
Before Eligibility for Early Retirement
If you die before becoming eligible for early retirement, your eligible survivor(s) is/are entitled to the
same survivor benefit that would have been paid had you tenninated rather than died. The survivor
benefit will commence on the earliest date you could have received a pension benefit.
A vista Corp.
HIPAA Privacy Notice
THIS NOTICE DESCRIBES How MEDICAL INFORMATION ABOUT You MAyBE USED AND DISCLOSED AND
How You CAN GET ACCESS To THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This notice is required by a federal law called the Health Information Portability and Accountability Act of 1996
(HIPAA). Under HIPAA , Avista must take steps to protect the privacy of your "protected health information
(PHI.). PHI includes information that we have created or received regarding your health or payment for your
health. It includes both your medical records and personal information such as your name, social security
number, address, and phone number.
UNDER FEDERAL LAW, WE ARE REQUIRED TO:
Protect the privacy of your PHI. All of our employees are required to maintain the confidentiality of PHI and
receive appropriate privacy training.
Provide you with this Notice of Privacy Practices explaining our duties and practices regarding your Pill.
Follow the practices and procedures set forth in the Notice.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION BY A VISTA THAT DO NOT REQUIRE
YOUR AUTHORIZATION
Avista uses and discloses PHI in a number of ways connected to payment for your care and health care
operations. Some examples of how we may use or disclose your PHI without your authorization are listed
below:
1. Payment Functions We may use or disclose health information about you to determine eligibility for
plan benefits , obtain premiums, facilitate payment for the treatment and services you receive from health
care providers, determine plan responsibility for benefits, and to coordinate benefits. For example
payment functions may include reviewing the medical necessity of health care services , determining
whether a particular treatment is experimental or investigational, or determining whether a treatment is
covered under your plan.
2. Health Care Operations. We may use and disclose health information about you to carry out necessary
insurance-related activities. For example, such activities may include underwriting, premium rating and
other activities relating to plan coverage; conducting quality assessment and improvement activities;
submitting claims for stop-loss coverage; conducting or arranging for medical review, legal services,
audit services, and fraud and abuse detection programs; and business planning, management and general
administration.
3. Public Health. As required by law, we may disclose your health information to public health authorities
for purposes related to: preventing or controlling disease, injury or disability; reporting child abuse or
neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with
products and reactions to medications; and reporting disease or infection exposure.
4. Required by Law. As required by law, we may use and disclose your health information.
5. Health Oversight Activities We may disclose your health information to health agencies during the
course of audits, investigations, inspections, licensure and other proceedings related to oversight of the
health care system.
6. Judicial and Administrative Proceedings.We may disclose your health information in the course of
any administrative or judicial proceeding.
7, Law Enforcement.We may disclose your health information to a law enforcement official for purposes
such as identifying or locating a suspect , fugitive, material witness or missing person , complying with a
court order or subpoena and other law enforcement purposes.
8. Coroners, Medical Examiners and Funeral Directors. We may disclose your health information to
coroners, medical examiners and funeral directors. For example, this may be necessary to identify a
deceased person or determine the cause of death.
9. Organ and Tissue Donation . We may disclose your health information to organizations involved in
procuring, banking or transplanting organs and tissues, as necessary.
10. Public Safety. We may disclose your health information to appropriate persons in order to prevent or
lessen a serious and imminent threat to the health or safety of a particular person or the general public.
11. National Security.We may disclose your health information for military, national security, and
government benefits purposes.
12. Worker s Compensation. We may disclose your health information as necessary to comply with
worker s compensation or similar laws.
13. Education.We may contact you to give you information about health-related benefits and services that
may be of interest to you.
14. Disclosures to Plan Sponsors We may disclose your health information to the sponsor of your group
health plan, for purposes of administering benefits under the plan.
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION BY A VISTA THAT REQUIRE US TO
OBTAIN YOUR AUTHORIZATION
Except as described in this Notice of Privacy Practices, we will not use or disclose your health information
without written authorization from you. If you do authorize us to use or disclose your health information for
another purpose, you may revoke your authorization in writing at any time. If you revoke your authorization, we
will no longer be able to use or disclose health information about you for the reasons covered by your written
authorization, though we will be unable to take back any disclosures we have already made with your permission.
Statement of Your Health Information Rights
1. Right to Request Restrictions. You have the right to request restrictions on certain uses and disclosures of
your health information. A vista is not required to agree to the restrictions that you request. If you would like
to make a request for restrictions, you must submit your request in writing to the Privacy Administrator -
MSC-39, Avista Corp, 1411 E. Mission Ave., Spokane, WA 99202.
2. Right to Request Confidential Communications. You have the right to receive your health information
through a reasonable alternative means or at an alternative location. To request confidential
communications, you must submit your request in writing to the Privacy Administrator - MSC-, Avista
Corp, 1411 E. Mission Ave., Spokane, W A 99202. We are not required to agree to your request.
3. Right to Inspect and COpy. You have the right to inspect and copy health information about you that may
be used to make decisions about your plan benefits. To inspect and copy such information , you must submit
your request in writing to the Privacy Administrator - MSC-, Avista Corp, 1411 E. Mission Ave., Spokane
W A 99202. If you request a copy of the information , we may charge you a reasonable fee to cover expenses
associated with your request.
4. Right to Request Amendment. You have a right to request that A vista amend your health information that
you believe is incolTect or incomplete. We are not required to change your health information and if your
request is denied, we will provide you with information about our denial and how you can disagree with the
denial. To request an amendment, you must make you request in writing to the Privacy Administrator -
MSC-39, Avista Corp, 1411 E. Mission Ave., Spokane, W A 99202. You must also provide a reason for your
request.
5. Right to Accounting of Disclosures. You have the right to receive a list or "accounting of disclosures" of
your health information made by us, except that we do not have to account for disclosures made for purposes
of payment functions or health care operations, or made to you. To request this accounting of disclosures
you must submit your request in writing to the Privacy Administrator - MSC-39, Avista Corp, 1411 E.
Mission Ave. Spokane, W A 99202. Your request should specify a time period of up to six years and may
not include dates before April 14, 2003. Avista will provide one list per 12-month period free of charge; we
may charge you for additional lists.
6. Right to Paper COpy. You have a right to receive a paper copy of this Notice of Privacy Practices at any
time. To obtain a paper copy of this Notice, send your written request to the Privacy Administrator - MSC-
39, Avista Corp, 1411 E. Mission Ave., Spokane, WA 99202. You may also obtain a copy of this Notice at
our HR website, http://avanet/departmentslhr/.
CHANGES TO THIS NOTICE OF PRIVACY PRACTICES
Avista reserves the right to amend this Notice of Privacy Practices at any time in the future and to make the new
Notice provisions effective for all health information that it maintains. We will promptly revise our Notice and
distribute it to you whenever we make material changes to the Notice. Until such time, Avista is required by law
to cornply with the current version of this Notice.
COMPLAINTS
Complaints about this Notice of Privacy Practices or about how we handle your health information should be
directed to the Privacy Administrator - MSC-39, A vista Corp, 1411 E. Mission Ave. Spokane, W A 99202.
A vista will not retaliate against you in any way for filing a complaint. All complaints to A vista must be
submitted in writing. If you believe your privacy rights have been violated, you may file a complaint with the
Secretary of the Department of Health and Human Services.
CONTACT INFORMATION FOR QUESTIONS
Questions about this Notice of Privacy Practices or about how we handle your health information should be
directed to Keith Rust - Benefits Administrator, Avista Corp, 1411 E. Mission Ave. Spokane, WA 99202. (509)
495-4751.
EFFECTIVE DATE OF THIS NOTICE: APRIL 14, 2003
Notice
Every effort has been made to describe the provisions of the Benefits Plans with accuracy and
clarity. This summary and the summaries of the plans that make up the Benefits Plans will give
you a good overview of how the Benefits Plan works. Because it is only a summary, however, it
omits much of the detail found in the Benefits Plan document itself. Should any discrepancy exist
between the Benefits Plan and this summary or the summaries of the plans that make up the
Benefits Plan, the official Benefits Plan is the controlling document and is binding upon all
parties. The Benefits Plan is available to any Benefits Plan participant for review at A vista
Corporation in the Human Resources office during regular business hours.
This summary and the summaries of the plans that make up the Benefits Plan are important
documents, and you should keep them in a safe place for future reference. You can access
Benefits Plan summaries on-line at http://avanet. If the Benefits Plan is changed in any way that
affects your eligibility or benefits, you will be given an explanation of the changes.
Prompt execution of the enclosed proxy will save the expense of an additional mailing.
Your immediate attention is appreciated.
~~'"'STII.
Corp.
March 31 , 2003
Dear Shareholder:
On behalf of the Board of Directors, it's my pleasure to invite you to the 2003 Annual Meeting of Shareholders.
The doors open at 9: 15 a.m. and the Annual Meeting will begin promptly at 10:00 a.
Date:
Time:
Thursday Morning, May 8, 2003
9:15 a.m. Doors Open
9:30 a.m. Refreshments
10:00 a.m. Annual Meeting Convenes
Place:A vista Corp. Main Office Building
Auditorium
1411 E. Mission Avenue
Spokane, Washington
Please take the opportunity to review the enclosed Proxy Statement, 2002 Annual Report, and 2002 Financial
Report. Your vote is important regardless of the number of shares you own. Whether or not you plan to attend
the Annual Meeting in person, we urge you to vote and submit your proxy by mail, telephone, or the
Internet as promptly as possible. If you are submitting your proxy by mail, you should complete, sign, and date
your proxy card, and return it in the enclosed envelope. If you plan to vote by telephone or the Internet, voting
instructions are printed on your proxy card. If you hold your shares through an account with a brokerage fmn
bank, or other nominee, please follow the instructions you receive from them to vote your shares. Voting your
proxy prior to the meeting will allow for a more efficient and timely meeting.
For your convenience, we re pleased to offer an audio webcast of the Annual Meeting if you cannot attend in
person. If you choose to listen to the webcast, go to www.avistacorp.com shortly before the meeting time and
follow the instructions for the webcast. Or, you can listen to a replay of the webcast at www.avistacorp.com up to
5:00 p.m. (Pacific Time) on May 15 2003.
Thank you for your continued support.
Sincerely,
/f/f/
Gary G. Ely
Chainnan of the Board
President & Chief Executive Officer
Avista Corp.1411 E. Mission Ave.Spokane, Washington 99202
Investor Relations-[phone]
If you require special accommodations at the Annual Meeting due to a disability, please call our Investor
Relations Department by April 18.
SEE CASE FILE FOR
COMPLETE BOOKLET
VISTA CORPORATION
RESPONSE TO REQUEST FOR INFORMATION
JURISDICTION:
CASE NO:
REQUESTER:
TYPE:
REQUEST NO.
Idaho
A VU-04-01 1 A VU-04-
IPUC
pata Request
Staff 168
DATE PREPARED:
WITNESS:
RESPONDER:
D EP AR TMENT:
TELEPHONE:
03/2312004
Don Kopczynski
Dennis Crumb
IS App. Support
[phone]
REQUEST:
Regarding Avista s E-billing, how many customers need to signup for E-billing to reach the
break-even point wherein the savings from not mailing bills equals the cost of offering E-billing?
How many Idaho customers are now signed up for E-billing?
RESPONSE:
It took Avista approximately 100 hours and cost approximately $7 600 to develop the eBill
delivery program. At a monthly cost of approximately $.45 to present a one-page paper bill to an
A vista customer, via the US Postal Service, A vista needed to present approximately 17 000 e-
bills to reach the break even point. Since the April 1 , 2003 eBill program s inception
approximately 10 760 total custorners (over 128 000 e-billings annually), 2 723 Idaho customers
have signed up to receive their monthly bill in electronic format through A vista eBill, which
means A vista has surpassed the breakeven point.