EONE Benefits Guide 2018-19

WELCOME

Get the most out of your benefits.

Introduction WHAT’S INSIDE? Eligibility

2

Medical & Rx

3-8

Dental & Vision

9-11

Life Insurance

12-14

Disability Insurance

15-16

Employee Eligibility All full-time regular status Employees who work 30 or more hours per week are eligible to enroll in the benefits included in this guide. EONE offers comprehensive, cost effective benefits options. Employees new to EONE are eligible for coverage on the first of the month following date of hire.

EONE offers a 401k Plan. New employees become eligible the 1st of the month following 90 days of employment.

Part-time regular status Employees who work a minimum of 20 hours may be eligible for EONE benefits based on those plan documents. Please contact a member of the EONE Human Resources team for details.

Dependent Eligibility • •

Legal spouse A dependent child under the age of 26 (coverage terminates at the end of the month in which the dependent turns 26)

Note: Under the Patient Protection and Affordable Care Act (PPACA), adult children enrolled under their parent’s medical plan may maintain their coverage until the age of 26, even if they’re a student, married or employed.

2018 Benefits Guide

Changing Your Elections It is very important to consider your choices carefully before you make your benefit elections. The benefits you choose will be in place from your eligibility date through the end of the plan year, unless you have a qualifying event during the year such as: •

Marriage, Divorce, Legal Separation Birth or adoption of a child

•

Death of a spouse or child

•

You or one of your covered dependents gains or loses other benefits coverage due to a change in employment status

Note: For additional information, Qualified Event Definition is determined by www.IRS.gov guidelines.

2

Medical BlueChoice Advantage HRA Silver 1500 In-Network You Pay1

Services

Out-of-Network You Pay1

Visit www.carefirst.com/doctor to locate providers and facilities FIRSTHELP—24/7 NURSE ADVICE LINE Free advice from a registered nurse. Visit www.carefirst.com/needcare to learn more about your options for care.

When your doctor is not available, call FirstHelp at 800-535-9700 to speak with a registered nurse about your health questions and treatment options.

BLUE REWARDS Visit www.carefirst.com/bluerewards for more information

Blue Rewards is an incentive program where you can earn up to $300 for taking an active role in getting healthy and staying healthy.

ANNUAL MEDICAL DEDUCTIBLE (Benefit Period)2,3 Individual/Family

$1,500 Individual/$3,000 Family (aggregate)

$3,000 Individual/$6,000 Family (aggregate)

ANNUAL OUT-OF-POCKET MAXIMUM (Benefit Period)2,4,5 Individual/Family

$6,550 Individual/$13,100 Family (separate)

$9,000 Individual/$18,000 Family (separate)

Well-Child Care (including exams & immunizations)

No charge*

No charge*

Adult Physical Examination (including routine GYN visit)

No charge*

No charge* after deductible

Breast Cancer Screening

No charge*

No charge*

Pap Test

No charge*

No charge* after deductible

Prostate Cancer Screening

No charge*

No charge* after deductible

Colorectal Cancer Screening

No charge*

No charge* after deductible

PCP AND SPECIALIST SERVICES FACILITY CHARGE6—In addition to the physician copays/coinsurances listed below, if a service is rendered on a hospital campus, ADD facility charge if applicable (also applies to Artificial Insemination and In Vitro Fertilization on page 2) Office Visits for Illness—PCP6,7

Deductible, then $50 per visit

Deductible, then $100 per visit

Deductible, then $25 per visit

Deductible, then $70 per visit

Office Visits for Illness—Specialist6,7

Deductible, then $50 per visit

Deductible, then $70 per visit

Allergy Testing

Deductible, then $50 per visit

Deductible, then $70 per visit

Allergy Shots6

Deductible, then $50 per visit

Deductible, then $70 per visit

Physical, Speech, and Occupational Therapy6 (limited to 30 visits/illness or injury/benefit period)

Deductible, then $50 per visit

Deductible, then $70 per visit

Chiropractic6 (limited to 20 visits/benefit period)

Deductible, then $50 per visit

Deductible, then $70 per visit

Acupuncture6

Deductible, then $50 per visit

Deductible, then $70 per visit

Convenience Care (retail health clinics such as CVS MinuteClinic or Walgreens Healthcare Clinic)

Deductible, then $25 per visit

Deductible, then $70 per visit

Urgent Care Center8 (such as Patient First or ExpressCare)

Deductible, then $100 per visit

In-network deductible, then $100 per visit

Deductible, then $250 per visit (waived if admitted)

In-network deductible, then $250 per visit (waived if admitted)

Deductible, then $50 per visit

In-network deductible, then $50 per visit

Deductible, then $50 per service

In-network deductible, then $50 per service

PREVENTIVE SERVICES

6

IMMEDIATE AND EMERGENCY SERVICES

Hospital Emergency Room Services ■

Facility

■

Physician

Ambulance (if medically necessary)

8

8

Note: The information provided is only a partial, general description of plan benefits and does not constitute a contract. In case of a conflict between your plan documents and this information, the plan documents will govern.

2018 Benefits Guide

3

Medical BlueChoice Advantage HRA Silver 1500 1

Services

1

In-Network You Pay

Out-of-Network You Pay

Non-Hospital/Freestanding Facility

Deductible, then $25 per visit

Deductible, then $75 per visit

Hospital

Deductible, then $150 per visit

Deductible, then $250 per visit

Non-Hospital/Freestanding Facility

Deductible, then $50 per visit

Deductible, then $100 per visit

Hospital

Deductible, then $200 per visit

Deductible, then $300 per visit

Non-Hospital/Freestanding Facility

Deductible, then $250 per visit

Deductible, then $300 per visit

Hospital

Deductible, then $600 per visit

Deductible, then $650 per visit

DIAGNOSTIC SERVICES Labs ■ ■

9

X-ray ■ ■

Imaging ■ ■

SURGERY AND HOSPITALIZATION—(Members are responsible for both physician and facility fees) Outpatient Surgery (Non-Hospital) ■

Facility

Deductible, then $300 per visit

Deductible, then $400 per visit

Physician

Deductible, then $50 per visit

Deductible, then $70 per visit

Facility

Deductible, then $500 per visit

Deductible, then $600 per visit

Physician

Deductible, then $50 per visit

Deductible, then $70 per visit

Facility

Deductible, then $750 per day (5 day maximum payment per admission)

Deductible, then $850 per day (5 day maximum payment per admission)

Physician

Deductible, then $50 per visit

Deductible, then $70 per visit

Home Health Care

No charge* after deductible

Deductible, then $70 per visit

Hospice

No charge* after deductible

Deductible, then $70 per admission

Skilled Nursing Facility (limited to 100 days/benefit period)

Deductible, then $50 per day

Deductible, then $100 per day

Preventive Prenatal and Postnatal Office Visits

No charge*

Deductible, then $50 per visit

Delivery and Facility Services

Deductible, then $750 per (5 day maximum payment per admission)

Deductible, then $850 per day (5 day maximum payment per admission)

Deductible, then $25 per visit

Deductible, then $70 per visit

Not covered

Not covered

■

Outpatient Surgery (Hospital) ■ ■

Inpatient Surgery and Hospital Services ■ ■

HOSPITAL ALTERNATIVES

MATERNITY

Artificial and Intrauterine Insemination In Vitro Fertilization Procedures

6,10

6,10

MENTAL HEALTH AND SUBSTANCE USE DISORDER—(Members are responsible for both physician and facility fees) Office Visits

Deductible, then $25 per visit

Deductible, then $70 per visit

Facility

Deductible, then $50 per visit

Deductible, then $75 per visit

Physician

Deductible, then $50 per visit

Deductible, then $70 per visit

Facility

Deductible, then $750 per day (5 day maximum payment per admission)

Deductible, then $850 per day (5 day maximum payment per admission)

Physician

Deductible, then $50 per visit

Deductible, then $70 per visit

Durable Medical Equipment

Deductible, then 25% of Allowed Benefit

Deductible, then 45% of Allowed Benefit

Hearings Aids (limited to one hearing aid per hearing-impaired ear every 36 months)

Deductible, then 25% of Allowed Benefit

Deductible, then 45% of Allowed Benefit

Outpatient Services ■ ■

Inpatient Services ■ ■

MEDICAL DEVICES AND SUPPLIES

Note: The information provided is only a partial, general description of plan benefits and does not constitute a contract. In case of a conflict between your plan documents and this information, the plan documents will govern.

2018 Benefits Guide

4

Medical BlueChoice Advantage HRA Silver 1500 Services

In-Network You Pay1

Out-of-Network You Pay1

PRESCRIPTION DRUGS11,12 Formulary List

Visit www.carefirst.com/acarx to locate Formulary List

Annual Prescription Drug Deductible

Subject to combined medical and prescription drug deductible

Preventive Drugs

No charge*

Oral Chemo Drugs and Diabetic Supplies

No charge* after deductible

Generic Drugs

30-day supply Deductible, then $10; 90-day supply Deductible, then $20 (maintenance drugs only)

Preferred Brand Drugs13

30-day supply Deductible, then $45; 90-day supply Deductible, then $90 (maintenance drugs only)

Non-preferred Brand Drugs14

30-day supply Deductible, then $65; 90-day supply Deductible, then $130 (maintenance drugs only)

Specialty Drugs (must be filled through Exclusive Specialty Pharmacy Network)

30-day supply Deductible, then 50% up to $150 maximum; 90-day supply Deductible, then 50% up to $300 maximum (maintenance drugs only)

PEDIATRIC VISION—(Through the end of the calendar year in which the dependent turns 19) Routine Exam (limited to 1 visit/benefit period)

No charge*

Total charge minus $40 reimbursement

Frames and Contact Lenses—Pediatric Collection Only

No charge*

Reimbursements apply

Spectacle Lenses

No charge*

Reimbursements apply

PEDIATRIC DENTAL—(Through the end of the calendar year in which the dependent turns 19) Annual Dental Deductible

$25

$50

Class I Preventative & Diagnostic Services— Exams (2 per year). Cleanings (2 per year), fluoride treatments (2 per year), sealants, bitewing X-rays (2 per year), full mouth X-ray (one every 3 years)

No charge*

20% of Allowed Benefit

Class II Basic Services—Fillings (amalgam or composite), simple extractions, non-surgical periodontics

Deductible, then 20% of Allowed Benefit

Deductible, then 40% of Allowed Benefit

Class III Major Services—Surgical periodontics, endodontics, oral surgery

Deductible, then 20% of Allowed Benefit

Deductible, then 40% of Allowed Benefit

Class IV Major Services—Restorative Crowns, dentures, inlays and onlays

Deductible, then 50% of Allowed Benefit

Deductible, then 65% of Allowed Benefit

Class V Medically Necessary Orthodontic Services

50% of Allowed Benefit

65% of Allowed Benefit

* No copayment or coinsurance.

1

When multiple services are rendered on the same day by more than one provider, Member payments are required for each provider .

2

In- and out-of-network deductible and out-of-pocket maximums do not contribute to each other.

3

Aggregate - For family coverage only: The family deductible must be met before any member starts receiving benefits as indicated above. The deductible may be met by one member or any combination of members.

4

Separate - For family coverage only: When one family member meets the individual out-of-pocket maximum, their services will be covered at 100% up to the Allowed Benefit. Each family member cannot contribute more than the individual out-of-pocket maximum amount. The family out-of-pocket maximum must be met before the services for all remaining family members will be covered at 100% up to the Allowed Benefit. The out-of-pocket maximum includes deductibles, copays and coinsurance.

5

All drug costs are subject to the in-network out-of-pocket maximum.

6

If a service is rendered on a hospital campus you could receive two bills, one from the physician and one from the facility.

7

“Telemedicine services” refers to the use of a combination of interactive audio, video, or other electronic media used for the purpose of diagnosis, consultation, or treatment. Use of audio-only telephone, electronic mail message (e-mail), or facsimile transmission (FAX) is not considered a telemedicine service.

8

If the out-of-network benefit is listed as contributing toward the in-network deductible, then it also contributes toward the in-network out-of-pocket maximum.

9

Members accessing laboratory services inside the CareFirst Service area (Maryland, D.C., Northern Virginia) must use LabCorp as their Lab Test facility and a non-hospital/ freestanding facility for Xrays and specialty Imaging for In-Network benefits. Services performed by any other provider, while inside the CareFirst Service area will be considered Out-of-Network. Members accessing laboratory, X-rays, and specialty Imaging services outside of Maryland, D.C. or Northern Virginia, may use any participating BlueCard PPO facility and receive in-network benefits.

10 Members who are unable to conceive have coverage for the evaluation of infertility services performed to confirm an infertility diagnosis, and some treatment options for infertility. Preauthorization required.

11 Except for emergency services or out-of-area urgent care, if a member goes to a non-participating pharmacy, the member is responsible for the copay/coinsurance for the drug plus the difference between the allowed charge and the actual charge for that drug (called balance billed amount). The balance billed amount does not contribute to the out-of- pocket maximum.

12 Benefits for Specialty Drugs are only available when Specialty Drugs are purchased from and dispensed by a specialty Pharmacy in the Exclusive Specialty Pharmacy Network.

13 If a Generic drug becomes available for a Preferred Brand drug, the Preferred Brand drug moves to the Non-preferred Brand drug tier.

14 If a provider prescribes a Non-preferred Brand drug, and the Member selects the Non-preferred Brand drug when a Generic drug is available, the Member shall pay the applicable Copayment or Coinsurance as stated in the Schedule of Benefits plus the difference between the price of the Non-preferred Brand drug and the Generic drug up to the cost of the drug. This amount will not contribute to the Out-of-Pocket Maximum.

2018 Benefits Guide

5

Medical Monthly Medical and Rx Cost Employee Coverage All benefit-eligible employees are covered at NO COST. Dependent Coverage Employees electing coverage for dependents pay the monthly age-based rates listed here. To calculate your total monthly cost, add the rate for each dependent (you will pay for a maximum of 3 dependents under the age of 21 – additional dependents under 21 are covered for no additional cost).

2018 Benefits Guide

0-14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65+

$224.06 $243.98 $251.59 $259.21 $267.41 $275.61 $284.10 $292.89 $292.89 $292.89 $292.89 $294.06 $299.92 $306.95 $318.37 $327.74 $332.43 $339.46 $346.49 $350.88 $355.57 $357.91 $360.25 $362.60 $364.94 $369.63 $374.31 $381.34 $388.08 $397.45 $409.17 $422.93 $439.34 $457.79 $478.88 $499.67 $523.10 $546.24 $571.72 $597.50 $625.32 $653.14 $683.31 $713.77 $746.28 $762.39 $794.90 $823.02 $841.47 $864.61 $878.67 $878.67

6

Health Reimbursement Arrangement

HRA

More savings. More control.

An HRA, or health reimbursement arrangement, is a kind of health spending account provided and owned by an employer.

The money in it pays for qualified expenses, like medical, pharmacy, dental and vision, as determined by the employer.

Other key things to know about HRAs are: •

Only your employer can put money in an HRA

•

You don’t pay taxes on money that comes from an HRA

•

Your employer decides whether to let unused funds roll over from one year to the next

HRAs are designed to facilitate more choice in your healthcare planning and help ensure more control of your own healthcare costs.

Benefits of an HRA Enrolling in an HRA provides two major advantages to employees: (1) a reduced health insurance premium resulting from the High Deductible Health Plan, and (2) availability of employer-sponsored funds to pay for medical expenses incurred prior to point at which the insurance deductible is met.

Depending on the plan design, expenses that may be reimbursed from the HRA include the following: deductibles, co-payments, co-insurance, prescription medications, vision expenses, dental expenses, and other out-of-pocket healthrelated expenses.

HRA funds are contributed to employees on a pre-tax basis; therefore, the funds are not taxable to the employee. As such, employees need not claim an income tax deduction for an expense that has been reimbursed under the HRA.

Refer to your Summary Plan Description (SPD) and Summary of Benefits and Coverage for more details.

HRA Employer Contributions for 2018 Single Plan: Employer contributes $1,500 Individual maximum benefit offered by employer: $1,500 Family Plan: Employer contributes $2,000 Family maximum benefit offered by employer: $2,000

2018 Benefits Guide

Benefit types allowed for reimbursement under the HRA Plan: Uninsured Medical-213d, Medical Deductible, Co-pay, Coinsurance, Prescription Medication, Dental, Orthodontia, & Vision Expenses. Benefits Card is for use with all HRA Plan eligible expenses. Reimbursement limit will be applied to the Employee and Family in Aggregate.

7

Flexible Spending Account

FSA

Health Care Flexible Spending Account A Healthcare Flexible Spending Account (FSA) is a pre-tax benefit account used to pay for eligible medical, dental, and vision care expenses that aren’t covered by your insurance plan. The 2018 max amount contribution is spread out over the entire year of bi-weekly deductions. Any money over your carryover maximum that is left unspent in your Health Care FSA at plan year end is forfeited.

Why You Need It •

Save an average of 30% on a wide variety of healthcare expenses

•

Access the full amount of your account on day one of your plan year

•

Use several convenient payment and reimbursement options

How It Works: Simply decide how much to contribute, and funds are withdrawn from each paycheck for deposit into your account before taxes are deducted. Your total annual election amount is available on day one of your plan year.

Dependent Care Flexible Spending Account A Dependent Care Flexible Spending Account (FSA) is a pre-tax benefit account used to pay for dependent care services, such as preschool, summer day camp, before or after school programs, and child or elder daycare.

Why You Need It •

Save an average of 30% on preschool, summer day camp, before/after school programs, elder daycare, and more

•

Reduce your overall tax burden: (funds are withdrawn from your paycheck for deposit into your Dependent Care FSA before taxes are deducted)

•

Take advantage of several convenient payment and reimbursement options

How It Works: Simply decide how much to contribute to your account each year, and funds are withdrawn from each paycheck for deposit into your account before taxes are deducted. As soon as your account is funded, you can use your balance to pay for many eligible dependent care expenses. Be sure to estimate your annual dependent care expenses and make your contributions carefully. Any money left unspent in your Dependent Care FSA at plan year end is forfeited.

For a complete list of FSA eligible expenses, visit: www.irs.gov/pub/irs-pdf/p969.pdf Maximum Participant Salary Reduction

Grace Period End Date

Dependent Care Expenses

$5,000

N/A

Medical or Medical-Related Premiums

Offered

N/A

Medical (Out-of-Pocket) Expenses

$2,650

N/A

FSA Benefits Offered to Employees

• • •

Plan Year: 4/01/2018 – 3/31/2019 Medical FSA Carryover Maximum: $500 Runout End Date: 6/29/2019 (90 days)

2018 Benefits Guide

8

Dental Traditional Dental Deductible applies to all basic and major services

$50 Individual / $150 Family

Annual maximum applies to all services except orthodontic

Plan pays $1,000 maximum

Preventive & diagnostic services ■

■

Oral Exams (two per benefit period) ■ Prophylaxis (two cleanings per benefit period) ■ Bitewing X-rays ■ Full mouth X-ray or panograph and bitewing X-ray combination and one cephalometric X-ray (once per 36 months)

Fluoride treatments (two per benefit period per member, until the end of the year the member reaches the age 19) ■ Sealants on permanent molars (once per tooth per 36 months per member, until the end of the year the member reaches the age 19) ■ Space maintainers (once per 60 months) ■ Palliative emergency treatment

No charge from Participating Dentist1

BASIC SERVICES ■

Direct placement fillings using approved materials (one filling per surface per 12 months)

■

Periodontal scaling and root planing (once per 24 months, one full mouth treatment) ■ Simple extractions

20% of Allowed Benefit after deductible1

MAJOR SERVICES – SURGICAL ■

Surgical periodontic services including osseous surgery, mucogingival surgery and occlusal adjustments (once per 60 months) ■ Endodontics (treatment as required involving the root and pulp of the tooth, such as root canal therapy)

■

Oral surgery (surgical extractions, treatment for cysts, tumor and abscesses, apicoectomy and hemi-section) ■ General anesthesia rendered for a covered dental service

50% of Allowed Benefit after deductible1

MAJOR SERVICES – RESTORATIVE ■

Full and/or partial dentures (once per 60 months) ■ Fixed bridges, crowns, inlays and onlays (once per 60 months) ■ Denture adjustments and relining (limits apply for regular and immediate dentures)

■

Recementation of crowns, inlays and/or bridges (once per 12 months) ■ Repair of prosthetic appliances as required (once in any 12 month period per specific area of appliance) ■ Dental implants, subject to medical necessity review (once per 60 months)

50% of Allowed Benefit after deductible1

ORTHODONTIC SERVICES2 ■

Benefits for orthodontic services may be available for covered members under age 19 who meet treatment criteria.

■

Orthodontic Lifetime Maximum

50% of Allowed Benefit1 Plan pays $1,200 Maximum

1

Note: CareFirst and CareFirst BlueChoice payments are based on the CareFirst and CareFirst BlueChoice Allowed Benefit. Participating Dentists accept 100% of the Allowed Benefit as payment in full for covered services. Non-participating dentists may bill the member for the difference between the Allowed Benefit and their charges.

2

Coverage for orthodontia may be included–ask your benefits manager for details, including lifetime maximum.

2018 Benefits Guide

9

Vision BlueVision Plus 12 month benefit period In-Network

You Pay

EYE EXAMINATIONS Routine Eye Examination with dilation (per benefit period)

$10 copay

FRAMES Davis Vision Frame Collection

No copay for approximately 400 frames

Non-Collection Frame

Plan pays $45 towards wholesale price (or equivalent allowance at a retailer), you pay balance

SPECTACLE LENSES

Out-of-Network

You Pay

Routine Eye Examination with dilation (per benefit period)

Plan pays $45, you pay balance

Frames

Plan pays $45, you pay balance

Single Lenses

Plan pays $52, you pay balance

Bifocal Lenses

Plan pays $82, you pay balance

Trifocal Lenses

Plan pays $101, you pay balance

Lenticular (post-cataract) Eyeglass Lenses

Plan pays $181, you pay balance

Basic Single Vision (including lenticular lenses)

No copay

Medically Necessary Contacts

Plan pays $285, you pay balance

Basic Bifocal

No copay

Elective Contact Lenses

Plan pays $97, you pay balance

Basic Trifocal

No copay

Elective Bifocal Contact Lenses

Plan pays $127, you pay balance

CONTACT LENSES (initial supply) Medically Necessary Contacts

No copay with prior approval

Davis Vision Contact Lens Collection

No copay with evaluation if Collection lenses are dispensed

In-Network

You Pay 1

Other Single Vision Contact Lenses

Plan pays $97, you pay balance

Other Bifocal Contact Lenses

Plan pays $127, you pay balance

1

CONTACT LENSES (mail order) DavisVisionContacts.com Mail Order Contact Lens Replacement Online

Discounted prices

LENS OPTIONS (add to spectacle lens prices above) Standard Progressive Lenses

$50 LASER VISION CORRECTION

1

Up to 25% off allowed amount or 5% off any advertised 2 special

Premium Progressive Lenses ® (Varilux , etc.)

$90

Ultra Progressive Lenses (digital)

$140

Polarized Lenses

$75

High Index Lenses

$55

Blended Segment Lenses

$20

1. Diagnostic services, except as listed in What’s Covered under the Evidence of Coverage.

Polycarbonate Lenses for children, monocular and high prescription

No copay

Polycarbonate Lenses for all other patients

$30

2. Medical care or surgery. Covered services related to medical conditions of the eye may be covered under the Evidence of Coverage.

Transition Lenses

$65

Intermediate Vision Lenses

$30

Photochromic Lenses

$20

Scratch-Resistant Coating

$20

Standard Anti-Reflective (AR) Coating

$35

Premium AR Coating

$48

Ultra AR Coating

$60

6. Replacement, within the same benefit period of frames, lenses or contact lenses that were lost.

Ultraviolet (UV) Coating

$12

7. Non-prescription glasses, sunglasses or contact lenses.

Tinting

No copay

8. Vision Care services for cosmetic use.

Oversized Lenses

No copay

Plastic Photosensitive Lenses

$65

2018 Benefits Guide

Exclusions The following services are excluded from coverage:

3. Prescription drugs obtained and self-administered by the Member for outpatient use unless the prescription drug is specifically covered under the Evidence of Coverage or a rider or endorsement purchased by your Group and attached to the Evidence of Coverage.

4. Services or supplies not specifically approved by the Vision Care Designee where required in What’s Covered under the Evidence of Coverage.

5. Orthoptics, vision training and low vision aids.

10

Dental Monthly Dental Cost Employee Coverage All benefit-eligible employees are covered at NO COST. Dependent Coverage Employees electing coverage for dependents pay the monthly costs listed here based on a 4-tier rating system.

Individual Individual + Spouse Individual + Children Family

No Cost $31.00 $43.00 $90.00

Individual Individual + Spouse Individual + Children Family

No Cost $7.00 $4.00 $9.00

Vision Monthly Vision Cost Employee Coverage All benefit-eligible employees are covered at NO COST. Dependent Coverage Employees electing coverage for dependents pay the monthly costs listed here based on a 4-tier rating system.

2018 Benefits Guide

11

Life Insurance Employer Paid Term Life Insurance ELIGIBILITY - ALL ELIGIBLE EMPLOYEES Eligibility Requirement

You must be actively working a minimum of 30 hours per week to be eligible for coverage.

Premium Payment

The premiums for this insurance are paid in full by the policyholder. There is no cost to you for this insurance.

BENEFITS Life Insurance Benefit Amount Accidental Death & Dismemberment (AD&D) Benefit Amount

For You: $50,000 In the event of death, the benefit paid will be equal to the benefit amount after any age reductions less any living care/accelerated death benefits previously paid under this plan.

For You: The Principal Sum amount is equal to the amount of your life insurance benefit.

FEATURES Living Care/ Accelerated Death Benefit

75% of the amount of the life insurance benefit is available to you if terminally ill, not to exceed $37,500.

Waiver of Premium

If it is determined that you are totally disabled, your life insurance benefit will continue without payment of premium, subject to certain conditions.

Conversion

If your employment ends, you may apply for an individual life insurance policy from Mutual of Omaha without having to provide evidence of insurability (information about your health). You will be responsible for the premium for the coverage.

SERVICES Travel Assistance

The Travel Assistance program is an added benefit that provides assistance for your travels over 100 miles away from home or outside the country.

Hearing Discount Program

The Hearing Discount Program provides you and your family discounted hearing products, including hearing aids and batteries. Call 1-888-534-1747 or visit www.amplifonusa.com/mutualofomaha to learn more.

Will Prep

We work with WillingÂŽ to offer employees an online will prep tool. In just a few clicks you can complete a customized plan to protect your family and property (valid in all 50 states). To get started visit www.willing.com/mutualofomaha

AGE REDUCTIONS AND EXCLUSIONS Insurance benefits and guarantee issue amounts are subject to age reductions: - At age 65, amounts reduce to 65% - At age 70, amounts reduce to 50% Information about the AD&D exclusions for this plan will be included in the summary of coverage, which you will receive after enrolling. Please contact your employer if you have questions prior to enrolling.

2018 Benefits Guide

12

Life Insurance Voluntary Life Insurance ELIGIBILITY - ALL ELIGIBLE EMPLOYEES Eligibility Requirement

You must be actively working a minimum of 30 hours per week to be eligible for coverage.

Dependent Eligibility Requirement

To be eligible for coverage, your dependents must be able to perform normal activities, and not be confined (at home, in a hospital, or in any other care facility), and any child(ren) must be under age 26. In order for your spouse and/or children to be eligible for coverage, you must elect coverage for yourself.

Premium Payment

The premiums for this insurance are paid in full by you.

COVERAGE GUIDELINES Minimum

Guarantee Issue

Maximum

For You

$10,000

5 times annual salary, up to $50,000

5 times annual salary, up to $300,000

Spouse

$5,000

100% of employee’s benefit, up to $25,000

100% of employee’s benefit, up to $150,000

Children

$2,000

100% of employee’s benefit

100% of employee’s benefit, up to $10,000

BENEFITS

Life Insurance Benefit Amount

Within the coverage guidelines defined above, you select the amount of life insurance coverage you want.

This plan includes the option to select coverage for your spouse and dependent children. Children include those, up to age 26. In the event of death, the benefit paid will be equal to the benefit amount after any age reductions less any living care/accelerated death benefits previously paid under this plan.

Accidental Death & Dismemberment (AD&D) Benefit Amount

For you, your spouse and your dependent child(ren): The Principal Sum amount is equal to the amount of the life insurance benefit. AD&D coverage is available if you or your dependents are injured or die as a result of an accident, and the injury or death is independent of sickness and all other causes. The benefit amount depends on the type of loss incurred, and is either all or a portion of the Principal Sum.

FEATURES Living Care/ Accelerated Death Benefit

75% of the amount of the life insurance benefit is available to you if terminally ill, not to exceed $225,000.

Waiver of Premium

If it is determined that you are totally disabled, your life insurance benefit will continue without payment of premium, subject to certain conditions.

Annual Benefit Amount Increase

If you enroll for even the minimum amount of coverage during your initial enrollment, you have the ability to enroll for additional coverage at your next enrollment by up to $10,000, provided the total amount of insurance does not exceed your maximum benefit amount. This feature allows you to secure additional life insurance protection in the event your needs change (ex. you get married or have a child).

Additional AD&D Benefits

In addition to basic AD&D benefits, you are protected by the following benefits: - Seat Belt - Airbag - Repatriation - Common Carrier

Portability

Allows you to continue this insurance program for yourself and your dependents should you leave your employer for any reason, without having to provide evidence of insurability (information about your health). You will be responsible for the premium for the coverage.

Conversion

If your employment ends, you may apply for an individual life insurance policy from Mutual of Omaha without having to provide evidence of insurability (information about your health). You will be responsible for the premium for the coverage.

2018 Benefits Guide

13

Life Insurance Voluntary Life Insurance SERVICES Travel Assistance

The Travel Assistance program is an added benefit that provides assistance for your travels over 100 miles away from home or outside the country.

Hearing Discount Program

The Hearing Discount Program provides you and your family discounted hearing products, including hearing aids and batteries. Call 1-888-534-1747 or visit www.amplifonusa.com/mutualofomaha to learn more.

Will Prep

We work with WillingÂŽ to offer employees an online will prep tool. In just a few clicks you can complete a customized plan to protect your family and property (valid in all 50 states). To get started visit www.willing.com/mutualofomaha

AGE REDUCTIONS AND EXCLUSIONS Insurance benefits and guarantee issue amounts are subject to age reductions: - At age 70, amounts reduce to 65% - At age 75, amounts reduce to 45% - At age 80, amounts reduce to 30% - At age 85, amounts reduce to 20% - At age 90, amounts reduce to 10% Spouse coverage terminates when you reach age 70.

Life insurance benefits will not be paid if the insured’s death is the result of suicide within two years from the date coverage begins. If this occurs, the sum of the premiums paid will be returned to the beneficiary. The same applies for any future increases in coverage under this plan.

Information about the AD&D exclusions for this plan will be included in the summary of coverage, which you will receive after enrolling.

Please contact your employer if you have questions prior to enrolling.

Age 0 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 65 - 69 70 - 74 75 - 79 80+

$10,000 $0.32 $0.37 $0.42 $0.60 $0.97 $1.57 $2.35 $3.65 $6.46 $11.45 $18.83 $38.08

EMPLOYEE PREMIUM TABLE (26 PAYROLL DEDUCTIONS PER YEAR) $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $0.65 $0.97 $1.29 $1.62 $1.94 $2.26 $0.74 $1.11 $1.48 $1.85 $2.22 $2.58 $0.83 $1.25 $1.66 $2.08 $2.49 $2.91 $1.20 $1.80 $2.40 $3.00 $3.60 $4.20 $1.94 $2.91 $3.88 $4.85 $5.82 $6.78 $3.14 $4.71 $6.28 $7.85 $9.42 $10.98 $4.71 $7.06 $9.42 $11.77 $14.12 $16.48 $7.29 $10.94 $14.58 $18.23 $21.88 $25.52 $12.92 $19.38 $25.85 $32.31 $38.77 $45.23 $22.89 $34.34 $45.78 $57.23 $68.68 $80.12 $37.66 $56.49 $75.32 $94.15 $112.98 $131.82 $76.15 $114.23 $152.31 $190.38 $228.46 $266.54

$80,000 $2.58 $2.95 $3.32 $4.80 $7.75 $12.55 $18.83 $29.17 $51.69 $91.57 $150.65 $304.62

$90,000 $2.91 $3.32 $3.74 $5.40 $8.72 $14.12 $21.18 $32.82 $58.15 $103.02 $169.48 $342.69

$100,000 $3.23 $3.69 $4.15 $6.00 $9.69 $15.69 $23.54 $36.46 $64.62 $114.46 $188.31 $380.77

Age 0 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 65 - 69

$5,000 $0.16 $0.18 $0.21 $0.30 $0.48 $0.78 $1.18 $1.82 $3.23

SPOUSE PREMIUM TABLE (26 PAYROLL DEDUCTIONS PER YEAR) $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $0.32 $0.48 $0.65 $0.81 $0.97 $1.13 $0.37 $0.55 $0.74 $0.92 $1.11 $1.29 $0.42 $0.62 $0.83 $1.04 $1.25 $1.45 $0.60 $0.90 $1.20 $1.50 $1.80 $2.10 $0.97 $1.45 $1.94 $2.42 $2.91 $3.39 $1.57 $2.35 $3.14 $3.92 $4.71 $5.49 $2.35 $3.53 $4.71 $5.88 $7.06 $8.24 $3.65 $5.47 $7.29 $9.12 $10.94 $12.76 $6.46 $9.69 $12.92 $16.15 $19.38 $22.62

$40,000 $1.29 $1.48 $1.66 $2.40 $3.88 $6.28 $9.42 $14.58 $25.85

$45,000 $1.45 $1.66 $1.87 $2.70 $4.36 $7.06 $10.59 $16.41 $29.08

$50,000 $1.62 $1.85 $2.08 $3.00 $4.85 $7.85 $11.77 $18.23 $32.31

$2,000 $0.13

2018 Benefits Guide

ALL CHILDREN PREMIUM TABLE (26 PAYROLL DEDUCTIONS PER YEAR)* $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $0.19 $0.26 $0.32 $0.39 $0.45 $0.52

$9,000 $0.58

$10,000 $0.65

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Disability Insurance Employer Paid Long-Term Disability Insurance ELIGIBILITY - ALL ELIGIBLE EMPLOYEES Eligibility Requirement Premium Payment

You must be actively working a minimum of 30 hours per week to be eligible for coverage.

The premiums for this insurance are paid in full by the policyholder. There is no cost to you for this insurance.

BENEFITS Elimination Period

Your benefits begin on the later of 90 calendar days after the onset of your disabling injury or illness or the date your short term disability ends.

Monthly Benefit

Your benefit is equivalent to 60% of your before-tax monthly earnings, not to exceed the plan’s maximum monthly benefit amount less other income sources. The premium for your long-term disability coverage is waived while you are receiving benefits.

Maximum Monthly Benefit Minimum Monthly Benefit

$10,000 $100

Maximum Benefit Period

If you become disabled prior to age 62, benefits are payable to age 65, your Social Security Normal Retirement Age or 3.5 years, whichever is longest. At age 62 (and older), the benefit period will be based on a reduced duration schedule.

Partial Disability Benefits

If you become disabled and can work part-time (but not full-time), you may be eligible for partial disability benefits.

DEFINITIONS Own Occupation

2 Years

Own Occupation Earnings Test

99%

Definition of Monthly Earnings

Monthly earnings for salaried employees is the gross annual salary in effect immediately prior to the date disability begins, divided by 12. Monthly earnings for hourly employees is the hourly rate of pay multiplied by the average number of hours worked during the 12 month period immediately prior to the date disability begins. If employed for part of the prior 12 month period, monthly earnings is the hourly rate of pay multiplied by the average number of hours worked.

FEATURES Vocational Rehabilitation Benefit

If you become disabled and participate in the vocational rehabilitation program, you will be eligible for a monthly benefit increase of 5%.

Survivor Benefit

If you pass away while receiving disability benefits, a lump sum equal to 3 times your monthly benefit will be paid to your eligible survivor.

SERVICES Travel Assistance

The Travel Assistance program is an added benefit that provides assistance for your travels over 100 miles away from home or outside the country.

Employee Assistance Program (EAP)

The EAP program provides you and your loved ones access to trained professionals and resources for assistance with personal and workplace issues.

Hearing Discount Program

The Hearing Discount Program provides you and your family discounted hearing products, including hearing aids and batteries. Call 1-888-534-1747 or visit www.amplifonusa.com/mutualofomaha to learn more.

2018 Benefits Guide

15

Disability Insurance Voluntary Short-Term Disability Insurance ELIGIBILITY - ALL ELIGIBLE EMPLOYEES Eligibility Requirement

You must be actively working a minimum of 30 hours per week to be eligible for coverage.

Premium Payment

The premiums for this insurance are paid in full by you.

BENEFITS Elimination Period

If you become disabled, there is an elimination period before benefits are payable. Your benefits begin: • On the day of your disabling injury.

• On the 8th day of your disabling illness.

Weekly Benefit

Your benefit is equivalent to 60% of your before-tax weekly earnings, not to exceed the plan’s maximum weekly benefit amount less other income sources. The premium for your short-term disability coverage is waived while you are receiving benefits.

Maximum Benefit Period

Up to 13 weeks

Maximum Weekly Benefit

$1,500

Minimum Weekly Benefit

$25

Partial Disability Benefits

If you become disabled and can work part-time (but not full-time), you may be eligible for partial disability benefits, which will help supplement your income until you are able to return to work full- time.

DEFINITIONS Definition of Disability

Disability and disabled mean that because of an injury or illness, a significant change in your mental or functional abilities has occurred, for which you are prevented from performing at least one of the material duties of your regular job and are unable to generate current earnings which exceed 99% of your weekly earnings from your regular job. You can be totally or partially disabled during the elimination period.

Definition of Weekly Earnings

Weekly earnings for salaried employees is the gross annual salary in effect immediately prior to the date disability begins, divided by 52. Weekly earnings for hourly employees is the hourly rate of pay multiplied by the average number of hours worked per week during the 12 month period immediately prior to the date disability begins. If employed for part of the prior 12 month period, weekly earnings is the hourly rate of pay multiplied by the average number of hours worked.

FEATURES Vocational Rehabilitation Benefit

If you become disabled and participate in the vocational rehabilitation program, you will be eligible for a monthly benefit increase of 5%.

The portability feature allows you to apply for disability insurance through a trust policy should your employment end, without having to provide evidence of insurability. You will be responsible for paying the premium for coverage.

Portability SERVICES Travel Assistance Hearing Discount Program

The Travel Assistance program is an added benefit that provides assistance for your travels over 100 miles away from home or outside the country.

The Hearing Discount Program provides you and your family discounted hearing products, including hearing aids and batteries. Call 1-888-534-1747 or visit www.amplifonusa.com/mutualofomaha to learn more.

BI-WEEKLY PREMIUM CALCULATION

EXAMPLE (42-year-old employee earning $40,000 a year)

List your weekly earnings (Maximum is $2,500) Multiply by the premium factor Your Estimated Bi-Weekly Premium

2018 Benefits Guide

$

$

769.23

$

0.0113538 8.73

0.0113538 $

16

EMPLOYEE ONE BENEFIT SOLUTIONS 921 E. Fort Ave., Suite 325 Baltimore, MD 21230 employee1.net