2019 ASSOCIATE BENEFITS

OPEN ENROLLMENT
NOW IS YOUR CHANCE TO ENROLL...
YOUR COVERAGE CHOICES
We value the contributions of our associates and strive to provide quality benefits to our workforce. In appreciation of your dedicated
service we are pleased to offer a variety of affordable coverage options through The American Worker. We encourage you to review this
guide so you understand your benefit options and can make the right choices for you and your family.

MEDICAL OPTIONS: Choose 1 of 5 Plans

Med Enhanced EXCITING NEWS FOR 2019...
• Copays for Dr. Visits, Labs, X-rays and Generic Drugs Med Enhanced: Better benefits for the same cost
• 100% in-network coverage for ACA required preventive services • Lower Copays for Dr. Visits, Labs, and X-rays
Med Enhanced Plus • Added Copay for Specialist Visits
• Includes all the Med Enhanced benefits PLUS Med Enhanced Plus: Better benefits for the same cost
• Coverage for Accidents, Hospital Stays, Surgeries and more • All of the Med Enhanced upgrades PLUS
Med Advantage • Increased Surgery and Admission benefits
• 100% in-network coverage for ACA required preventive services • Added coverage for Advanced Studies

Med Advantage Plus Med Advantage and Med Advantage Plus

• Includes all the Med Advantage benefits PLUS • Lower cost for the same great benefits
• Coverage for Dr. Visits, Labs, X-rays, Prescription discounts and more Med Basic and Additional Coverage Options
Med Basic • Same great benefits at the same low cost
• Coverage for Dr. Visits, Labs, X-rays, Prescription discounts and more

ADDITIONAL COVERAGE OPTIONS

You can elect any of these benefit plans on a freestanding basis or in addition to medical coverage.
• Dental: Pays up to $500 per year • Short-term Disability: Pays $200 per week for up to 26 weeks
• Vision: Coverage for eye exams and corrective eyewear • Life and AD&D Insurance: $20,000 of coverage for associates

2019 OPEN ENROLLMENT: Monday, October 1 - Wednesday, October 31, 2018

COVERAGE EFFECTIVE DATE: Monday, December 31, 2018
If you are currently enrolled your coverage will continue for 2019 unless you make a change during Open Enrollment.
Deductions for 2019 coverage begin the week of December 24, 2018.

ENROLL NOW Enrolling Online...

Click “Register and Enroll” at the top of the page
Online: [Link] Select “Returning User?” or “New User?”
Available anytime • Returning Users: Login using your username and password
• New Users: Select “Employee ID” and in the fields below enter
Phone: (877) 220-1862 - Employee ID #: Your Social Security Number
Monday - Friday, 8 AM to 8 PM ET - Group #: 98418
- Date of Birth: Your Date of Birth
Mobile Device: Text Staff2019 to 24587 Click “Continue” to enroll yourself and your dependents
Available anytime Note: New users will need to create an account before enrolling

Para información o ayuda en Español llame al (877) 220-1862 EmployBridge Benefits Department: (877) 785-5125
 MEDICAL COVERAGE OPTIONS OVERVIEW
You can choose ONE of the five medical options below. The benefits vary by plan, so an overview of each plan has been included to help
you better understand and compare your options. Review the following chart so you can make the right choice for you and your family.

Coverage Overview Basic Advantage Advantage Plus Enhanced Enhanced Plus

First Health Network     
Primary Care Office Visit You Pay $10* You Pay $10*
Pays $100/Day Pays $100/Day
Specialist Office Visit You Pay $75* You Pay $75*
Teladoc   
Outpatient Diagnostic Lab Pays $75/Day Pays $75/Day
You Pay $20* You Pay $20*
Outpatient Diagnostic X-ray Pays $200/Day Pays $200/Day
Outpatient Diagnostic Advanced Studies Pays $300/Day Pays $300/Day Pays $300/Day
Preventive Care Plan Pays 100%* Plan Pays 100%* Plan Pays 100%* Plan Pays 100%*
Accident (per occurrence) Pays up to $300 Pays up to $300 Pays up to $1,000
Emergency Room Sickness Pays $150/Day
Inpatient Surgery Pays $1,000/Day Pays $1,000/Day Pays $2,000/Day
Hospital Admission (lump sum) Pays $500/ Pays $500/ Pays $1,000/
Confinement Confinement Confinement
Inpatient Hospital Indemnity Pays $100/Day Pays $100/Day Pays $600/Day
Inpatient Intensive Care Unit Pays $200/Day Pays $200/Day Pays $1,200/Day
Prescription Drug Generic & Brand Generic & Brand Generic Copays Generic Copays
Discounts Discounts Brand Discounts Brand Discounts
*You MUST visit a First Health Network provider for services to be covered. Services from out-of-network providers are NOT covered.

Weekly Rates (Note: Biweekly rates are twice the weekly rates. Monthly rates are slightly more than 4 times the weekly rates.)
Associate Only $18.59** $3.23 $21.82** $17.00 $32.08**
Associate & Spouse $31.24** $5.10 $36.34** $42.14 $77.74**
Associate & Child(ren) $31.37** $5.29 $36.66** $51.00 $77.02**
Associate & Family $47.30** $5.97 $53.27** $68.72 $108.23**
**Rates include a $0.25 weekly administrative fee

First Health Network* Teladoc: Talk to a Doctor Anytime for FREE***

Members have access to one of the nations largest networks Quality care in minutes from U.S. board-certified doctors 24
providing savings on Physician and Hospital services hours a day, 365 days a year by phone, online video or mobile app
• Over 490,000 provider locations across the country • Convenient and effective care at no cost to you
• To locate a provider, visit [Link] • Doctors diagnose, treat and, if needed, prescribe medication
Tip... When making an appointment, make sure to tell your • Avoid expensive urgent care or ER visits for non-emergencies
provider your coverage includes the First Health network Registration required prior to use
and confirm they participate in the network.

BENEFIT DEDUCTIONS & CHANGES DURING THE YEAR

The cost of coverage is deducted from your paycheck before taxes are taken out, which saves you money. Since deductions are processed
pretax, IRS regulations determine when you can enroll, change or cancel coverage during the year.
You must enroll when initially eligible or during Open Enrollment and the coverage you elect will remain in place for the entire year. If
you don’t, you must wait until the next Open Enrollment to enroll. However, if you experience a Qualifying Life Event (QLE) during the
year, you may be eligible to enroll in new coverage, make changes to existing coverage or cancel your current coverage.
Qualifying Life Events include, but are not limited to: birth, adoption or legal guardianship of a child; marriage, divorce, or legal
separation; death of a spouse or child; spousal change of employment affecting insurance coverage.
You have 30 days from the date of the QLE to call The American Worker to make a change. If you do not, you will not be able to make a
change until the next Open Enrollment. Coverage changes must be consistent with the QLE and documentation may be required.

2 ***Teladoc state requirements: AR and DE require initial consultations to be done via video. ID requires all consultations are done via video.
MED BASIC - PLAN HIGHLIGHTS
The Med Basic Plan provides coverage for basic healthcare services due to an accident or illness. The plan pays a fixed amount per day for
covered services. The plan pays in addition to other coverage, which can help offset out-of-pocket costs when receiving treatment.
The Med Basic Plan gives you coverage both in and out of the First Health Network. Visiting a First Health Network provider can reduce
your costs. The plan also includes Teladoc and prescription drug discounts to help you save on medical expenses.

Coverage Overview Med Basic

First Health Network Included - See page 2 for details
Primary Care Office Visit
Plan Pays $100 per Day, 6 Days per Person per Year
Specialist Office Visit
Teladoc Access to Doctors by Phone or Online Anytime for Free
Registration required prior to use - See page 2 for details
Outpatient Diagnostic Lab Plan Pays $75 per Testing Day, 3 Days per Person per Year
Outpatient Diagnostic X-ray Plan Pays $200 per Testing Day, 3 Days per Person per Year
Outpatient Diagnostic Advanced Studies Plan Pays $300 per Testing Day, 3 Days per Person per Year
Accidental Injury Care Plan Pays $300 Maximum per Occurrence
Surgical Indemnity
Daily Inpatient Plan Pays $1,000 per Day, 1 Day per Person Per Year
Daily Outpatient / Daily Outpatient Minor Plan Pays $500 / $100 per Day
Outpatient Benefit Maximum 1 Day per Person per Year
Anesthesia Plan Pays 30% of the Surgical Benefit
Daily In-Hospital Indemnity Plan Pays $100 per Day, 500 Days Lifetime Maximum
Hospital Admission (Lump Sum) Plan Pays $500 per Confinement
Intensive Care Unit Plan Pays $200 per Day; 30 Days per Person per Year
Substance Abuse Plan Pays $50 per Day; 30 Days per Person per Year
Mental Illness Plan Pays $50 per Day; 30 Days per Person per Year
Skilled Nursing Plan Pays $50 per Day; 60 Days per Person per Stay
Prescription Drug Coverage AWP Value Rx - See below for details

Weekly Rates
Associate Only $18.59*
Associate & Spouse $31.24*
Associate & Child(ren) $31.37*
Associate & Family $47.30*
*Rates include a $0.25 weekly administrative fee
The Med Basic Plan is underwritten by Nationwide Life Insurance Company but includes other benefits such as First Health, Teladoc and AWP Value Rx
which are provided by separate vendors.

AWP Value Rx - Provided by Phoenix Benefit Management

This program is designed to provide substantial prescription drug savings by helping you identify affordable options.
• Select Generic and Brand drugs available for $10, $20, $50 or less
• Non-Select Generic and Brand drugs are available at a discount
• Over 56,000 participating pharmacies nationwide. To locate a pharmacy visit [Link].
AWP Value Rx is a non-insurance prescription drug discount program

Notes: The Med Basic Plan (a) is not a substitute for minimum essential health coverage under the Affordable Care Act (ACA), and (b) does not qualify as
Notes: minimum essential coverage under the ACA.
Notes: The Med Basic Plan is not available to New Hampshire or Vermont residents. 3
 MED ADVANTAGE & MED ADVANTAGE PLUS - PLAN HIGHLIGHTS
Both plans provide 100% in-network coverage for all ACA required preventive services.
The Med Advantage Plan only covers preventive services. It does not provide any coverage for illness or accidents.
The Med Advantage Plus Plan adds coverage for the treatment of illnesses and accidents such as Doctor Visits, Labs, X-rays, Surgeries,
Hospital Stays, and more. It also includes Teladoc and Prescription Drug discounts.

Coverage Overview Med Advantage

First Health Network Required - See page 2 for details
Preventive Care* Plan Pays 100% for all ACA required Preventive Care Services
See page 6 for a list of Covered Preventive Care Services
*You MUST visit a First Health Network provider for services to be covered. Services from out-of-network providers are NOT covered.

Coverage Overview Med Advantage Plus

First Health Network Required - See page 2 for details
Preventive Care* Plan Pays 100% for all ACA required Preventive Care Services
See page 6 for a list of Covered Preventive Care Services
Primary Care Office Visit
Plan Pays $100 per Day, 6 Days per Person per Year
Specialist Office Visit
Teladoc Access to Doctors by Phone or Online Anytime for Free
Registration required prior to use - See page 2 for details
Outpatient Diagnostic Lab Plan Pays $75 per Testing Day, 3 Days per Person per Year
Outpatient Diagnostic X-ray Plan Pays $200 per Testing Day, 3 Days per Person per Year
Outpatient Diagnostic Advanced Studies Plan Pays $300 per Testing Day, 3 Days per Person per Year
Accidental Injury Care Plan Pays $300 Maximum per Occurrence
Surgical Indemnity
Daily Inpatient Plan Pays $1,000 per Day, 1 Day per Person Per Year
Daily Outpatient / Daily Outpatient Minor Plan Pays $500 / $100 per Day
Outpatient Benefit Maximum 1 Day per Person per Year
Anesthesia Plan Pays 30% of the Surgical Benefit
Daily In-Hospital Indemnity Plan Pays $100 per Day, 500 Days Lifetime Maximum
Hospital Admission (Lump Sum) Plan Pays $500 per Confinement
Intensive Care Unit Plan Pays $200 per Day; 30 Days per Person per Year
Substance Abuse Plan Pays $50 per Day; 30 Days per Person per Year
Mental Illness Plan Pays $50 per Day; 30 Days per Person per Year
Skilled Nursing Plan Pays $50 per Day; 60 Days per Person per Stay
Prescription Drug Coverage AWP Value Rx - See below for details
*You MUST visit a First Health Network provider for services to be covered. Services from out-of-network providers are NOT covered.

Weekly Rates Med Advantage Med Advantage Plus

Associate Only $3.23 $21.82**
Associate & Spouse $5.10 $36.34**
Associate & Child(ren) $5.29 $36.66**
Associate & Family $5.97 $53.27**
**Rates include a $0.25 weekly administrative fee

AWP Value Rx - Provided by Phoenix Benefit Management

This program is designed to provide substantial prescription drug savings by helping you identify affordable options.
• Select Generic and Brand drugs available for $10, $20, $50 or less
• Non-Select Generic and Brand drugs are available at a discount
• Over 56,000 participating pharmacies nationwide. To locate a pharmacy visit [Link].
The AWP Value Rx is a non-insurance discount program

Notes: The Med Advantage Plus Plan is not available to New Hampshire or Vermont residents.
4 Notes: The Med Advantage and Med Advantage Plus Plans do not satisfy state coverage requirements in Massachusetts.
MED ENHANCED & MED ENHANCED PLUS - PLAN HIGHLIGHTS
Both plans provide in-network coverage for Doctor Visits, Labs, X-rays, ACA required Preventive Services, and Generic Prescription Drugs.
The Med Enhanced Plus Plan adds coverage for Accidents, Surgeries, Hospital Stays, and more.

Coverage Overview Med Enhanced Plan

First Health Network Required - See page 2 for details
Preventive Care* Plan Pays 100% for all ACA required Preventive Care Services
See page 6 for a list of Covered Preventive Care Services
Primary Care Office Visit* You pay $10 per Visit, 4 Visits per Person per Year
Specialist Office Visit* You pay $75 per Visit, 1 Visit per Person per Year
Outpatient Diagnostic Lab & X-ray* You pay $20 per Visit, 4 Visits per Person per Year
Prescription Drug Coverage FBG Rx - See below for details
*You MUST visit a First Health Network provider for services to be covered. Services from out-of-network providers are NOT covered.

Coverage Overview Med Enhanced Plus Plan

First Health Network Required - See page 2 for details
Preventive Care* Plan Pays 100% for all ACA required Preventive Care Services
See page 6 for a list of Covered Preventive Care Services
Primary Care Office Visit* You pay $10 per Visit, 4 Visits per Person per Year
Specialist Office Visit* You pay $75 per Visit, 1 Visit per Person per Year
Teladoc Access to Doctors by Phone or Online Anytime for Free
Registration required prior to use - See page 2 for details
Outpatient Diagnostic Lab & X-ray* You pay $20 per Visit, 4 Visits per Person per Year
Outpatient Diagnostic Advanced Studies Plan Pays $300 per Testing Day, 3 Days per Person per Year
Emergency Room Sickness Plan Pays $150 per Day, 2 Days per Person per Year
Accidental Injury Care Plan Pays $1,000 Maximum per Occurrence
Surgical Indemnity
Daily Inpatient Plan Pays $2,000 per Day, 1 Day per Person Per Year
Daily Outpatient / Daily Outpatient Minor Plan Pays $1,000 / $200 per Day
Outpatient Benefit Maximum 1 Day per Person per Year
Anesthesia Plan Pays 30% of the Surgical Benefit
Daily In-Hospital Indemnity Plan Pays $600 per Day, 500 Days Lifetime Maximum
Hospital Admission (Lump Sum) Plan Pays $1,000 per Confinement
Intensive Care Unit Plan Pays $1,200 per Day; 30 Days per Person per Year
Substance Abuse Plan Pays $300 per Day; 30 Days per Person per Year
Mental Illness Plan Pays $300 per Day; 30 Days per Person per Year
Skilled Nursing Plan Pays $300 per Day; 60 Days per Person per Stay
Prescription Drug Coverage FBG Rx - See below for details
*You MUST visit a First Health Network provider for services to be covered. Services from out-of-network providers are NOT covered.

Weekly Rates Med Enhanced Med Enhanced Plus

Associate Only $17.00 $32.08**
Associate & Spouse $42.14 $77.74**
Associate & Child(ren) $51.00 $77.02**
Associate & Family $68.72 $108.23**
**Rates include a $0.25 weekly administrative fee

FBG Rx
Effective and reliable prescription drug coverage with a broad network of over 63,000 participating pharmacies nationwide.
• Generic drugs: $15 Copay
• To locate a pharmacy visit [Link].
• Brand drugs: Discounts

Notes: The Med Enhanced Plus Plan is not available to New Hampshire or Vermont residents.
Notes: The Med Enhanced and Med Enhanced Plus Plans do not satisfy state coverage requirements in Massachusetts. 5
 PREVENTIVE CARE BENEFIT - COVERED SERVICES OVERVIEW
Benefit included in the Med Advantage, Med Advantage Plus, Med Enhanced, and Med Enhanced Plus Plans.

To promote health and wellness the Affordable Care Act (ACA) requires most plans cover a variety of preventive care services performed
by network providers at 100%. The lists below provide an overview of the preventive care services covered at 100% in-network.

Please note, the U.S. Preventive Services Task Force periodically updates these lists and sets the requirements such as age, gender or health
conditions for services to be covered. For a current list including all requirements visit [Link]/preventive-care-benefits.

First Health Network

One of the nations largest networks with over 490,000 locations across the country. To find a provider visit [Link]
You MUST visit a First Health Network provider for services to be covered. Services from out-of-network providers are NOT covered.

Adults
Screenings: Abdominal Aortic Aneurysm, Alcohol Misuse, Blood Pressure, Cholesterol, Colorectal Cancer, Depression, Diabetes
(Type 2), Hepatitis B, Hepatitis C, HIV, Lung Cancer, Obesity, Syphilis, Tobacco Use, Tuberculosis

Counseling: Alcohol Misuse, Diet, Obesity, Sexually Transmitted Infection Prevention

Immunizations: Diphtheria, Hepatitis A, Hepatitis B, Herpes Zoster, Human Papillomavirus (HPV), Influenza (Flu Shot), Measles,
Meningococcal, Mumps, Pertussis, Pneumococcal, Rubella, Tetanus, Varicella (Chickenpox)

Other: Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer, Falls Prevention, Statin Preventive Medication,
Tobacco Use Cessation Interventions

Women including Pregnant Women or Women who may become Pregnant

Screenings: Anemia, Breast Cancer Mammography, Cervical Cancer, Chlamydia, Diabetes, Domestic and Interpersonal Violence,
Gestational Diabetes, Gonorrhea, Hepatitis B, HIV, Human Papillomavirus (HPV), Maternal Depression, Osteoporosis, Preeclampsia,
Rh Incompatibility, Syphilis, Tobacco Use, Urinary Incontinence, Urinary Tract or Other Infection

Counseling: Breast Cancer Chemoprevention, Breast Cancer Genetic Testing (BRCA), Breastfeeding, Contraception, Domestic and
Interpersonal Violence, HIV, Sexually Transmitted Infection

Other: Breastfeeding Supplies for Pregnant and Nursing Women, FDA Approved Contraceptive Methods, Folic Acid Supplements,
Tobacco Use Cessation Interventions, Well-woman Visits

Children
Screenings: Autism, Bilirubin Concentration, Blood, Blood Pressure, Cervical Dysplasia, Depression, Developmental, Dyslipidemia,
Hearing, Hematocrit or Hemoglobin, Hemoglobinopathies or Sickle Cell, Hepatitis B, HIV, Hypothyroidism, Lead, Obesity,
Phenylketonuria (PKU), Sexually Transmitted Infection, Tuberculin, Vision

Assessments: Alcohol Use, Behavioral, Drug Use, Oral Health Risk, Tobacco Use

Counseling: Obesity, Sexually Transmitted Infection Prevention

Immunizations: Diphtheria, Haemophilus Influenzae Type B, Hepatitis A, Hepatitis B, Human Papillomavirus (HPV), Inactivated
Poliovirus, Influenza (Flu Shot), Measles, Meningococcal, Pertussis, Pneumococcal, Rotavirus, Tetanus, Varicella (Chickenpox)

Other: Fluoride Chemoprevention Supplements, Fluoride Varnish, Gonorrhea Preventive Medication, Height, Weight and Body
Mass Index (BMI) Measurements, Iron Supplements, Medical History

You can access a Summary of Benefits and Coverage (SBC) for the Med Advantage, Med Advantage Plus, Med Enhanced, and Med Enhanced Plus plans
6 online at [Link]. If you are unable to access the SBC online or want a copy mailed to your home call (877) 220-1862.
DENTAL (Provided by Ameritas Life Insurance Corporation)
Keep a bright, healthy smile while supporting your overall well-being with affordable dental coverage. You can use any provider for
service, but have access to a dental network to lower out-of-pocket costs.

Calendar Year Maximum Plan Pays up to $500 per Covered Member Weekly Rates
Deductible You Pay $20 per Visit Associate Only $4.75
Covered Services Waiting Period Coinsurance Associate & Spouse $11.88
Preventive & Diagnostic Covered at 100% Associate & Child(ren) $8.55
None
Routine Exams, Cleanings, X-rays, etc. (U&C Charges) Associate & Family $12.83
Basic Treatment
Covered at 60%
Restorative Amalgams and Composites, 3 Months TO FIND A PROVIDER
(U&C Charges) Call (800) 659-2223 and select option 3
Endodontics, Periodontics, Extractions, etc.
Visit [Link] and click on
Major Treatment Covered at 50%
12 Months FIND A PROVIDER. Then select DENTAL
Onlays, Crowns, Prosthodontics, etc. (U&C Charges) and click on NETWORK PROVIDER.

VISION (Provided by Ameritas Life Insurance Corporation)

A regular eye exam won’t just help you see better, it can also detect the first signs of serious health conditions. With this plan you’ll get
coverage for exams as well as corrective eyewear. Get the most benefit from the plan by visiting a VSP Choice provider.

Deductibles You Pay $10 per Exam & $25 for Eye Glass Lenses or Frames1 Weekly Rates
Frequency Based on Date of Service Associate Only $2.07
Exam / Lens / Frame 12 Months / 12 Months / 24 Months Associate & Spouse $4.10
Covered Services VSP Choice Network Out-Of-Network Associate & Child(ren) $3.82
Annual Eye Exam Covered in Full VSP Pays Up to $45 Associate & Family $5.84
Lenses (per pair) VSP Pays 1
Deductible applies to a complete pair of glasses
Single Vision / Bifocal Covered in Full Up to $30 / Up to $50 or frames, whichever is selected.
2
Trifocal / Lenticular Covered in Full Up to $65 / Up to $100 The Costco allowance will be the wholesale
equivalent.
Contacts VSP Pays
Fit and Follow Up Exams 15% Discount No Benefit TO FIND A PROVIDER
Elective VSP Pays Up to $120 Up to $105 Call (800) 877-7195
Medically Necessary Covered in Full Up to $210 Visit [Link] and click on FIND
A PROVIDER. Then select VISION: VSP
Frames VSP Pays Up to $1202 VSP Pays Up to $70 and click on LOOK UP VSP PROVIDERS.

SHORT-TERM DISABILITY*
Your family and daily life can depend on consistent income. If you get sick or injured and can’t work, this benefit will pay you cash. Enroll
in this benefit to protect your income when you are unable to work.

Weekly Maximum Benefit Plan Pays $200 Lump Sum Benefit Weekly Rates
Maximum Benefit Period 26 Weeks Associate Only $3.87
Waiting Period 7 Days (Accidents and Sickness) Note: CA, NJ, NY & RI residents may be
Coverage includes disability due to pregnancy and childbirth entitled to additional disability benefits
through your state.

LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT (AD&D)*

Life insurance can help your loved ones during a trying time. This benefit provides cash that can assist your family in the event of your
death. Enroll in this benefit to protect the future of the ones that depend on you the most.

Life and Accidental Death & Dismemberment Insurance Weekly Rates

Associate Plan Pays $20,000 Associate Only $0.60
Dependent Life Insurance Associate & Spouse $0.90
Spouse Plan Pays $2,500
Associate & Child(ren) $0.90
Child (6 months - 26 years) Plan Pays $1,250
Associate & Family $1.80
Infant (10 days - 6 months) Plan Pays $200

*Short-term Disability and Life and AD&D, provided by Nationwide Life Insurance Company, are not available to New Hampshire or Vermont residents. 7
 ENROLLMENT & ELIGIBILITY INFORMATION
For your convenience you can enroll online, by phone or by mobile device. If you have benefit questions contact the enrollment center.

2019 OPEN ENROLLMENT: Monday, October 1 - Wednesday, October 31, 2018

COVERAGE EFFECTIVE DATE: Monday, December 31, 2018

Enroll Online: Visit [Link] Enroll By Phone: Call (877) 220-1862

Click “Register and Enroll” at the top of the page Monday - Friday, 8 AM to 8 PM ET
Select “Returning User?” or “New User?”
• Returning Users: Login using your username and password Enroll By Mobile Device:
• New Users: Select “Employee ID” and in the fields below enter Text Staff2019 to 24587
- Employee ID #: Your Social Security Number
- Group #: 98418 If you need assistance please call the EmployBridge
- Date of Birth: Your Date of Birth Benefits Department at (877) 785-5125
Click “Continue” to elect coverage for yourself and your dependents
Note: New users will need to create an account before enrolling Para asistencia en Español llame al (877) 220-1862

YOU WILL NEED THE FOLLOWING INFORMATION TO ENROLL

Associate Information: Full Name, Social Security Number, Date of Birth, Home Address, Phone Number, and Email Address
Dependent Information: Full Name, Social Security Number, and Date of Birth

IMPORTANT BENEFIT INFORMATION

PRETAX PREMIUM DEDUCTIONS (SECTION 125)
Premium for your coverage is deducted from your paycheck on a pretax basis. By enrolling you agree to the following:
I hereby elect to participate in The American Worker Plan for benefits made available under the Internal Revenue Code Section 79,
105, 106, 125, and these sections as amended. I understand that the Plan will automatically convert to pretax status any eligible payroll
deductions which are provided through the Plan. I understand that by participating in this Plan my Social Security benefits may be
reduced since these premiums will be deducted before my salary is taxed. This election will remain in effect for the entire Plan Year. My
election CANNOT be changed during the Plan Year in accordance with the Internal Revenue Service Guidelines unless a qualifying event
occurs. Qualifying events include: marriage, divorce, legal separation, death of spouse, birth or legal adoption of a child, death of a child,
or spousal change of employment affecting insurance coverage.

PAYING FOR YOUR BENEFITS

Your coverage begins the Monday following the date you receive a paycheck with a premium deduction and continues uninterrupted as
long as premiums are deducted from your paycheck. If you receive a paycheck without a deduction, your benefits will be suspended until
the Monday following the date you receive your next paycheck with a deduction, unless you make a payment for the missed deduction. To
avoid having coverage suspended you must pay missed premium every time a deduction is not processed from your paycheck.

MISSED PREMIUM PAYMENTS

You have 30 days from the date of your paycheck without a deduction to make a missed premium payment. If you do not pay for the
missed deduction within 30 days, you will not be able to pay for that coverage period at a later date. If you missed a premium deduction
and want to find out the balance due or make a payment, visit [Link] or call (877) 220-1862.
You can pay for missed deductions online, by phone or by mail. Payment options include credit or debit card, personal check, and money
order. You can also authorize an automatic payment be processed every time premium is not deducted from your paycheck.
IMPORTANT... If you setup automatic payments, you MUST contact The American Worker to cancel the automatic payment when
your employment ends. If you do not, your account will be charged for coverage and you will NOT receive a refund.

NONPAYMENT COVERAGE TERMINATION

You must make a premium payment every week, either through payroll deduction or directly to The American Worker using one of the
missed premium payment options above. If you do not pay your premium for six weeks in a row, your coverage will be terminated for
nonpayment. Please review your paycheck every week to make sure your premium is deducted. If it is not, contact The American Worker
immediately to make a payment and avoid having your coverage terminated.
8
DISCLOSURES
This enrollment guide provides an overview of some of the benefit plans you are eligible for as an EmployBridge associate. If there is any
discrepancy between the information in this guide and the applicable official plan documents, the official plan documents will govern how
your benefits are determined and administered. EmployBridge, in its sole discretion, reserves the right to amend or terminate at any time
the benefit plans described in this enrollment guide.

MED BASIC PLAN

This plan is not comprehensive health insurance and is not intended or recommended to replace comprehensive health insurance in which
you currently participate. The plan provides fixed indemnity insurance benefits. This enrollment guide is for summary purposes only. The
insurance benefits of the Med Basic Plan are underwritten by Nationwide Life Insurance Company. A detailed Certificate of Coverage is
available upon enrollment. Limitations and exclusions apply.
The Med Basic Plan (a) is not a substitute for minimum essential health coverage under the Affordable Care Act (ACA), and (b) does
not qualify as minimum essential coverage under ACA.

MED ADVANTAGE, MED ADVANTAGE PLUS, MED ENHANCED, & MED ENHANCED PLUS PLANS
These plans are designed to provide Plan Participants with minimum essential coverage under the federal income tax rules. Individuals
that do not enroll in these plans may be eligible for a federal tax credit that lowers their monthly premium or a reduction in certain
cost-sharing if they enroll in a health insurance plan through the federal or state exchange. Individuals that enroll in these plans may
not be eligible for a federal tax credit though a federal or state exchange while enrolled in these plans. These plans do not provide
comprehensive health insurance. Limitations and exclusions apply.
You can access a Summary of Benefits and Coverage (SBC) for these plans online at [Link]. If you are unable to
access the SBC online or want a copy mailed to your home call (877) 220-1862.

TELADOC
© 2017 Teladoc, Inc. All rights reserved. Teladoc and the Teladoc logo are registered trademarks of Teladoc, Inc. and may not be used
without written permission. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be
written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA controlled
substances, non therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians
reserve the right to deny care for potential misuse of services.
Arkansas and Delaware require initial consultations to be done via video. Idaho requires all consultations are done via video.

STATE RESTRICTIONS
The benefit plans described in this enrollment guide are not available in all states. Restrictions include but are not limited to the following.
Massachusetts: Residents of Massachusetts are eligible for the Med Basic, Med Advantage, Med Advantage Plus, Med Enhanced and Med
Enhanced Plus Plans, but none of these plans meet the individual health insurance requirements and do not satisfy the individual mandate
in Massachusetts.
New Hampshire and Vermont: Residents of New Hampshire and Vermont are not eligible for the Med Basic, Med Advantage Plus, Med
Enhanced Plus, Short-term Disability or Life and Accident Death & Dismemberment insurance plans.
Hawaii: Residents of Hawaii are not eligible for any of the benefits plans described in this enrollment guide.

9
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 12/312018 – 12/29/2019
Med Advantage Plan: EmployBridge Holding Company Coverage for: Individual & Family | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit [Link] or call 1-
877-220-1862. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined
terms see the Glossary. You can view the Glossary at [Link]
Important Questions Answers Why This Matters:
What is the overall
$0 See the Common Medical Events chart below for your costs for services this plan covers.
deductible?
This plan covers some items and services even if you haven’t yet met the deductible amount. But
Are there services
a copayment or coinsurance may apply. For example, this plan covers certain preventive services
covered before you meet Yes
without cost-sharing and before you meet your deductible. See a list of covered preventive
your deductible?
services at [Link]
Are there other
deductibles for specific No You don’t have to meet deductibles for specific services.
services?
What is the out-of-pocket
Not Applicable This plan does not have an out-of-pocket limit on your expenses.
limit for this plan?
What is not included in
Not Applicable This plan does not have an out-of-pocket limit on your expenses.
the out-of-pocket limit?
This plan uses a provider network. You will pay less if you use a provider in the plan’s network.
Yes. See [Link] You will pay the most if you use an out-of-network provider, and you might receive a bill from a
Will you pay less if you
or call 1-877-220-1862 for a list of provider for the difference between the provider’s charge and what your plan pays (balance
use a network provider?
network providers. billing). Be aware your network provider might use an out-of-network provider for some services
(such as lab work). Check with your provider before you get services.
Do you need a referral to You can see the specialist you choose without a referral. NOTE: the only services by a specialist
No
see a specialist? that are covered are preventive services.

1 of 5 

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

Common What You Will Pay Limitations, Exceptions, & Other Important
Services You May Need Network Provider Out-of-Network Provider
Medical Event Information
(You will pay the least) (You will pay the most)
Primary care visit to treat an
Not Covered Not Covered ---None---
injury or illness
Specialist visit Not Covered Not Covered ---None---
If you visit a health
care provider’s office You may have to pay for services that aren’t
or clinic preventive. Ask your provider if the services
Preventive care/screening/
No Charge Not Covered needed are preventive. Then check what your
immunization
plan will pay for. Certain age restrictions may
apply.
Diagnostic test (x-ray, blood
Not Covered Not Covered ---None---
If you have a test work)
Imaging (CT/PET scans, MRIs) Not Covered Not Covered ---None---
FDA approved contraceptive methods as
prescribed by a health care provider for
Generic drugs Not Covered Not Covered
women with reproductive capacity (not
If you need drugs to including abortifacient drugs).
treat your illness or FDA approved contraceptive methods as
condition prescribed by a health care provider for
Preferred brand drugs Not Covered Not Covered
More information about women with reproductive capacity (not
prescription drug including abortifacient drugs).
coverage is available FDA approved contraceptive methods as
by calling 877-220-1862 prescribed by a health care provider for
Non-preferred brand drugs Not Covered Not Covered
women with reproductive capacity (not
including abortifacient drugs).
Specialty drugs Not Covered Not Covered ---None---
Facility fee (e.g., ambulatory
If you have outpatient Not Covered Not Covered ---None---
surgery center)
surgery
Physician/surgeon fees Not Covered Not Covered ---None---
Emergency room care Not Covered Not Covered ---None---
If you need immediate Emergency medical
Not Covered Not Covered ---None---
medical attention transportation
Urgent care Not Covered Not Covered ---None---
If you have a hospital Facility fee (e.g., hospital room) Not Covered Not Covered ---None---
stay Physician/surgeon fees Not Covered Not Covered ---None---

* For more information about limitations and exceptions, see the plan or policy document at [Link]. 2 of 5 
 Common What You Will Pay Limitations, Exceptions, & Other Important
Services You May Need Network Provider Out-of-Network Provider
Medical Event Information
(You will pay the least) (You will pay the most)
If you need mental
Outpatient services Not Covered Not Covered ---None---
health, behavioral
health, or substance
Inpatient services Not Covered Not Covered ---None---
abuse services
Cost sharing does not apply for preventive
Office visits Not Covered Not Covered
services
Childbirth/delivery professional
If you are pregnant Not Covered Not Covered ---None---
services
Childbirth/delivery facility
Not Covered Not Covered ---None---
services
Home health care Not Covered Not Covered ---None---
If you need help Rehabilitation services Not Covered Not Covered ---None---
recovering or have Habilitation services Not Covered Not Covered ---None---
other special health Skilled nursing care Not Covered Not Covered ---None---
needs Durable medical equipment Not Covered Not Covered ---None---
Hospice services Not Covered Not Covered ---None---
Children’s eye exam Not Covered Not Covered ---None---
If your child needs
Children’s glasses Not Covered Not Covered ---None---
dental or eye care
Children’s dental check-up Not Covered Not Covered ---None---

Excluded Services & Other Covered Services:

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

* For more information about limitations and exceptions, see the plan or policy document at [Link]. 3 of 5 
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is: Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or [Link]/ebsa/healthreform. Other coverage options
may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace,
visit [Link] or call 1-800-318-2596.

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

Does this plan provide Minimum Essential Coverage? Yes

If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the
requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? No

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

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 877-220-1862.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

* For more information about limitations and exceptions, see the plan or policy document at [Link]. 4 of 5 
About these Coverage Examples:

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

Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow
hospital delivery) controlled condition) up care)

 The plan’s overall deductible $0  The plan’s overall deductible $0  The plan’s overall deductible $0
 Specialist [cost sharing] 100%  Specialist [cost sharing] 100%  Specialist [cost sharing] 100%
 Hospital (facility) [cost sharing] 100%  Hospital (facility) [cost sharing] 100%  Hospital (facility) [cost sharing] 100%
 Other [cost sharing] 100%  Other [cost sharing] 100%  Other [cost sharing] 100%

This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical
Childbirth/Delivery Professional Services disease education) supplies)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches)
Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)

Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,925

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $0 Deductibles $0 Deductibles $0
Copayments $0 Copayments $0 Copayments $0
Coinsurance $0 Coinsurance $0 Coinsurance $0
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $12,694 Limits or exclusions $7,239 Limits or exclusions $1,925
The total Peg would pay is $12,694 The total Joe would pay is $7,239 The total Mia would pay is $1,925

The plan would be responsible for the other costs of these EXAMPLE covered services. 5 of 5 
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 12/31/2018 – 12/29/2019
Med Enhanced Plan: EmployBridge Holding Company Coverage for: Individual & Family | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit [Link]
or call 1-877-220-1862. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other
underlined terms see the Glossary. You can view the Glossary at [Link]
Important Questions Answers Why This Matters:
What is the overall
$0 See the Common Medical Events chart below for your costs for services this plan covers.
deductible?
This plan covers some items and services even if you haven’t yet met the deductible amount. But
Are there services
a copayment or coinsurance may apply. For example, this plan covers certain preventive services
covered before you meet Yes
without cost-sharing and before you meet your deductible. See a list of covered preventive
your deductible?
services at [Link]
Are there other
deductibles for specific No You don’t have to meet deductibles for specific services.
services?
What is the out-of-pocket
Not Applicable This plan does not have an out-of-pocket limit on your expenses.
limit for this plan?
What is not included in
Not Applicable This plan does not have an out-of-pocket limit on your expenses.
the out-of-pocket limit?
This plan uses a provider network. You will pay less if you use a provider in the plan’s network.
Yes. See [Link] You will pay the most if you use an out-of-network provider, and you might receive a bill from a
Will you pay less if you
or call 877-220-1862 for a list of provider for the difference between the provider’s charge and what your plan pays (balance
use a network provider?
network providers. billing). Be aware your network provider might use an out-of-network provider for some services
(such as lab work). Check with your provider before you get services.
Do you need a referral to You can see the specialist you choose without a referral. NOTE: the only services by a specialist
No
see a specialist? that are covered are preventive services.

1 of 5 

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

Common What You Will Pay Limitations, Exceptions, & Other Important
Services You May Need Network Provider Out-of-Network Provider
Medical Event Information
(You will pay the least) (You will pay the most)
Primary care visit to treat an Combined limit of 4 Visits per Person per Year
$10 copay/office visit Not Covered
injury or illness for all office visits.
Specialist visit $75 copay/office visit Not Covered Limit of 1 Visit per Person per Year.
If you visit a health
care provider’s office You may have to pay for services that aren’t
or clinic preventive. Ask your provider if the services
Preventive care/screening/
No Charge Not Covered needed are preventive. Then check what your
immunization
plan will pay for. Certain age restrictions may
apply.
Diagnostic test (x-ray, blood Combined limit of 4 Testing Days per Person
$20 copay/testing day Not Covered
If you have a test work) per Year.
Imaging (CT/PET scans, MRIs) Not Covered Not Covered ---None---
Covers up to a 30-day supply (retail
Generic drugs $15 copay/prescription Not Covered subscription); 31-90-day supply (mail order
prescription) are Not Covered.
If you need drugs to
treat your illness or
Preferred brand drugs Not Covered Not Covered Includes FDA approved contraceptive methods
condition
as prescribed by a health care provider for
More information about
women with reproductive capacity (not
prescription drug
Non-preferred brand drugs Not Covered Not Covered including abortifacient drugs).
coverage is available
by calling 877-220-1862
Only Generic drugs are covered. Brand and
Specialty drugs Not Covered Not Covered Specialty drugs are Not Covered. Drugs from
out-of-network providers are Not Covered
Facility fee (e.g., ambulatory
If you have outpatient Not Covered Not Covered ---None---
surgery center)
surgery
Physician/surgeon fees Not Covered Not Covered ---None---
Emergency room care Not Covered Not Covered ---None---
If you need immediate Emergency medical
Not Covered Not Covered ---None---
medical attention transportation
Urgent care Not Covered Not Covered ---None---
If you have a hospital Facility fee (e.g., hospital room) Not Covered Not Covered ---None---
stay Physician/surgeon fees Not Covered Not Covered ---None---

* For more information about limitations and exceptions, see the plan or policy document at [Link]. 2 of 5 
 Common What You Will Pay Limitations, Exceptions, & Other Important
Services You May Need Network Provider Out-of-Network Provider
Medical Event Information
(You will pay the least) (You will pay the most)
If you need mental $10 copay/office visit;
Combined limit of 4 Visits per Person per Year
health, behavioral Outpatient services all other Outpatient Not Covered
for all office visits.
health, or substance services Not Covered
abuse services Inpatient services Not Covered Not Covered ---None---
Cost sharing does not apply for preventive
Office visits Not Covered Not Covered
services
Childbirth/delivery professional
If you are pregnant Not Covered Not Covered ---None---
services
Childbirth/delivery facility
Not Covered Not Covered ---None---
services
Home health care Not Covered Not Covered ---None---
If you need help Rehabilitation services Not Covered Not Covered ---None---
recovering or have Habilitation services Not Covered Not Covered ---None---
other special health Skilled nursing care Not Covered Not Covered ---None---
needs Durable medical equipment Not Covered Not Covered ---None---
Hospice services Not Covered Not Covered ---None---
Children’s eye exam Not Covered Not Covered ---None---
If your child needs
Children’s glasses Not Covered Not Covered ---None---
dental or eye care
Children’s dental check-up Not Covered Not Covered ---None---

Excluded Services & Other Covered Services:

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

* For more information about limitations and exceptions, see the plan or policy document at [Link]. 3 of 5 
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is: Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or [Link]/ebsa/healthreform. Other coverage options
may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace,
visit [Link] or call 1-800-318-2596.

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

Does this plan provide Minimum Essential Coverage? Yes

If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the
requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? No

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

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 877-220-1862.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

* For more information about limitations and exceptions, see the plan or policy document at [Link]. 4 of 5 
About these Coverage Examples:

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

Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow
hospital delivery) controlled condition) up care)

 The plan’s overall deductible $0  The plan’s overall deductible $0  The plan’s overall deductible $0
 Specialist [cost sharing] 100%  Specialist [cost sharing] 100%  Specialist [cost sharing] 100%
 Hospital (facility) [cost sharing] 100%  Hospital (facility) [cost sharing] 100%  Hospital (facility) [cost sharing] 100%
 Other [cost sharing] 100%  Other [cost sharing] 100%  Other [cost sharing] 100%

This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical
Childbirth/Delivery Professional Services disease education) supplies)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches)
Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)

Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,925

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $0 Deductibles $0 Deductibles $0
Copayments $440 Copayments $1,015 Copayments $245
Coinsurance $0 Coinsurance $0 Coinsurance $0
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $11,451 Limits or exclusions $5,515 Limits or exclusions $1,601
The total Peg would pay is $11,891 The total Joe would pay is $6,530 The total Mia would pay is $1,846

The plan would be responsible for the other costs of these EXAMPLE covered services. 5 of 5