2015 Charts & Rates. Benefit Comparison Charts & Rates

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1 2015 Charts & Rates Benefit Comparison Charts & Rates

2 Medical Benefit Options This is not the complete Medical Comparison Chart. Refer to the Medical Summary Plan Description or the Legal Notices on the Benefits page of OurB&W. Meritain Health, Mutual Health Services (OH only) Blue Option White Option Out-of-Area Option In-Network Out-of-Network In-Network Out-of-Network Out-of-Network You Pay Annual Deductible: Employee Only Annual Deductible: Spouse Child(ren) Family Annual Out-of-Pocket Maximum: 2 Employee Only Annual Out-of-Pocket Maximum: 2 Spouse Child(ren) Family $2,000 $4,000 $1,750 $3,500 $1,500 $4,000 $8,000 $3,500 1 $7,000 1 $3,000 $4,000 $8,000 $6,350 $12,700 $3,200 $8,000 $16,000 $12,700 3 $25,400 3 $6,400 Lifetime Maximum Unlimited Unlimited Unlimited Health Reimbursement Account (HRA) N/A If you complete the wellness activities: $750/Employee Only $1,250/ Spouse, Child(ren), Family If you complete the wellness activities: $750/Employee Only $1,250/ Spouse, Child(ren), Family If you complete the wellness activities: Health Savings Account (HSA) 4 $750/Employee Only $1,250/ Spouse, Child(ren), Family N/A N/A Preventive Care Exams Covered at 100%, subject to age/gender guidelines Covered at 100%, subject to age/gender guidelines Covered at 100%, subject to age/gender guidelines Physician s Office Visits 5 20% after deductible 50% after deductible $30 50% after deductible 20% after deductible Specialist s Office Visits 5 20% after deductible 50% after deductible $45 50% after deductible 20% after deductible 1 1 One person can meet the individual annual deductible, or a combination of covered family members can meet the annual deductible for these coverage tiers. 2 The out-of-pocket maximum includes the medical deductible. Medical and prescription drug copays and coinsurance also accumulate toward the out-of-pocket maximum. 3 One person can meet the individual annual out-of-pocket maximum, or a combination of covered family members can meet the annual out-of-pocket maximum for these coverage tiers. 4 If you are not eligible for a Health Savings Account, your earned company contribution will be deposited into a Health Reimbursement Account. 5 Copay covers the general office visit. You will also pay co-insurance for additional medical services your doctor may prescribe during your visit.

3 2015 Medical Benefit Option Employee Contributions (Monthly) Coverage Tier Blue Option White Option Out-of-Area Option Employee Only $47 $120 $97 Spouse $77 $218 $176 Child(ren) $64 $173 $140 Family $91 $278 $224 Note: As applicable, the $50 tobacco surcharge and the $50 condition management surcharge will be added to the monthly employee contributions listed above. Prescription Drug Coverage Prescription drug coverage is included as part of the Medical Benefit. Blue Option White Option Out-of-Area In-Network Out-of-Network In-Network Out-of-Network Out-of-Network Prescription Drug Coverage - 30-day Supply RETAIL Generic 20% after deductible $10 copay $10 copay Preferred Brand 30% after deductible 25% of cost with $30 min /$75 max 25% of cost with $30 min /$75 max Non-Preferred Brand 45% after deductible 35% of cost with $45 min /$110 max 35% of cost with $45 min /$110 max Prescription Drug Coverage - 90-day Supply MAIL ORDER or RETAIL Maintenance at Walgreens Only Generic 20% after deductible $25 $25 Preferred Brand 30% after deductible $100 Non-Preferred Brand 45% after deductible $150 25% of cost with $75 min /$150 max 35% of cost with $125 min /$225 max Specialty (30-day supply) 20% after deductible 20% of cost up to maximum $125 copay 20% of cost up to maximum $125 copay 2

4 Dental Benefit The Dental Benefit is designed to help you maintain dental health. You have two dental options - Dental Basic or Dental Plus. The Dental Benefit is administered by MetLife. Features Dental Basic Dental Plus Annual Maximum Benefit $1,000/person $1,500/person Orthodontia Lifetime Maximum Benefit for children under age 19 Deductible You Pay $50/person $150/family $1,500/person You Pay $25/person $75/family Covered Services You Pay You Pay Preventive and diagnostic care $0, no deductible $0, no deductible Basic and restorative care 20% after deductible 20% after deductible Major care 50% after deductible 40% after deductible Orthodontia for children under age 19 50%, no deductible 2015 Dental Benefit Employee Contributions (Monthly) Coverage Tier Dental Basic Dental Plus 3 Employee Only Spouse Child(ren) Family $30 $37 $57 $74 $66 $88 $94 $121

5 Vision Benefit The Vision Benefit is administered by UnitedHealthcare Vision, which offers services through a network of providers at a lower cost. The benefit provides coverage once every 12 months for routine eye exams and glasses or contacts. When you visit an in-network provider, most services will be covered at 100 percent after you pay a copay. You may go to an out-of-network provider, but you will incur higher out-of-pocket costs and you may have to file your own claims Vision Benefit Employee Contributions (Monthly) Coverage Tier Vision Coverage Employee Only $6.30 Spouse $12.61 Child(ren) $13.20 Family $16.79 Features In-Network Benefit Pays: Out-of-Network Benefit Pays: Eye Exam 100% after $10 copay Up to $45 Glasses - Lenses Single Vision 100% after $25 copay Up to $30 Lined Bifocal 100% after $25 copay Up to $50 Lined Trifocal 100% after $25 copay Up to $65 Lenticular 100% after $25 copay Up to $100 Glasses - Frames Covered-in-Full 100% after $25 copay Up to $70 Wholesale Up to $50 Up to $70 Retail Allowance Up to $130 Up to $70 Contact Lenses Covered-in-Full Elective Contacts* 100% after $25 copay Up to $105 All Other Elective Contacts* Up to $125 Up to $105 Necessary Contacts 100% after $25 copay Up to $210 *If you select elective covered-in-full contact lenses from an in-network provider, the fitting/evaluation fees, contacts and two follow-up visits are covered (after $25 copay). For all other elective contacts, a $125 allowance is applied toward the fitting/evaluation fees and purchase of contact lenses ($25 materials copay does not apply). Toric, gas permeable and bifocal contacts are all examples of contacts that are not considered covered-in-full. 4

6 Income Protection Benefit B&W offers a variety of income protection benefits you can customize for your personal needs. No one enjoys thinking about it, but it s important to protect your loved ones in case of an accident, disability or your death. Benefit Description Coverage Life Insurance Long-Term Disability (LTD) Insurance Personal Accident Insurance Hospital Income* Critical Illness* Pays your beneficiary if you should die Monthly benefit if you are unable to work because of an accident or illness Pays a lump-sum benefit if an accidental injury results in a catastrophic loss or death Flat dollar amount per day to help you pay your share of hospital expenses, such as deductibles and coinsurance Supplements your other coverage by paying you a lump-sum benefit to be used at your discretion upon the diagnosis of a serious illness, such as stroke, heart attack, organ transplant or paralysis Basic Life Coverage: $50,000 Provided by company to all eligible full-time and part-time employees Supplemental Life Coverage: Full-time employees can elect supplemental coverage in $50,000 increments, up to the lesser of 10 times per pay or $2,500,000 Part-time employees can elect coverage of $50,000, $100,000 or $150,000 Spouse Life Coverage: All employees can elect spouse coverage of $10,000, $25,000, $50,000, $75,000 or $100,000; up to 50% of the employee supplemental life coverage amount Child(ren) Life Coverage: All employees can elect $5,000, $10,000 or $15,000 life insurance coverage per child 40% Basic LTD: Provided by company to all eligible full-time employees at no cost to employee 60% Buy-Up Option: Paid by employee Minimum monthly benefit of $100; Maximum monthly benefit of $10,000 Pays up to 10 times of base pay: Employee: $50,000 to $1,000,000 Spouse: 70% of the employee coverage amount without insured child(ren); 65% with insured child(ren) Child(ren): 25% of the employee coverage amount without insured spouse; 20% with insured spouse Options: $100 per day $200 per day Options: $10,000 $15,000 $30,000 Group Legal Easy and low-cost access to a wide variety of personal legal services Access to a national network of more than 11,000 attorneys for a variety of legal needs 5 *To enroll in these benefits, contact the providers at the numbers indicated under Contact Information on the next page.

7 Provider/Administrator Contact Information Provider/ Benefit Website Phone Number Administrator General Questions and Enrollment B&W Enrollment Center (available weekdays, 8 a.m. to 8 p.m. Eastern time, except holidays) Medical and Prescription Drug Information Care Coordinators (available weekdays, 8:30 a.m. to 10 p.m. Eastern time, except holidays) Health Savings Account (HSA) Optum Health Bank Health Reimbursement Account (HRA) ConnectYourCare (available 24 hours/day, 7 days/week) Flexible Spending Account (FSA) ConnectYourCare (available 24 hours/day, 7 days/week) Dental Benefit MetLife Vision Benefit United Healthcare Vision Life Insurance MetLife Long-Term Disability Benefit Family Medical Leave and Short-Term Disability Benefit Cigna (once a claim is filed) Cigna (once a claim is filed) Personal Accident Insurance Chubb Group Continental American Hospital Income (Aflac) COBRA - for COBRA participants bswift American Heritage Life Critical Illness Insurance Company Group Legal Benefit Hyatt Legal Thrift Plan Vanguard Retirement Benefits Charles Schwab Pension Retirement Planning Resource Work Employee Discounts On-Point Beneplace 6

8 Your Enrollment Resources Benefits Center: For questions related to the enrollment process and all benefit programs except the Medical Benefit, call Customer service representatives are available weekdays, 8 a.m. to 8 p.m. Eastern time, except holidays. Care Coordinators: For questions related to the Medical Benefit, call a Care Coordinator at Care Coordinators are available weekdays, 8:30 a.m. to 10 p.m. Eastern time, except holidays

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