Indiana University Health Benefits Guide 2015

Transcription

1 Idiaa Uiversity Health Beefits Guide 2015

2 Dear IU Health Team Member, Welcome to IU Health! IU Health values the cotributios of every team member. Without team members like you, we would ot be able to deliver the services our patiets ad their families deserve. Ad, just as you add value to our patiets lives, we believe it s importat your Total Rewards package adds value to your career with IU Health. This is why IU Health is pleased to offer you ad your family a affordable, comprehesive beefits program ad wats to ivest i your log-term health ad fiacial well-beig. Whe it comes to Total Rewards, we uderstad oe size does t ecessarily fit all. This is why we give you the flexibility to choose the beefits that work best for you ad your family. Please keep i mid the followig tips as you make your beefit decisios: Take the time to uderstad your beefits. We kow that beefits especially medical beefits are importat. At IU Health, your beefits focus o welless ad prevetio. Beig accoutable for your health decisios helps you i may ways. You ot oly improve your overall health, but you ca also ear icetives to reduce your medical isurace premiums. Review your ad your depedets healthcare eeds. Thik about your healthcare eeds for the year ahead ad how you ad your family have used healthcare i the past. Cosider the umber of doctor visits you typically make ad prescriptios you may use. The, take advatage of the tools IU Health offers to estimate your future healthcare costs, which helps you select the right pla for you. Evaluate whether oe of our Health Savigs Accout (HSA)-based medical plas suits your eeds. HSA-based medical plas have lower premiums ad are coupled with a Health Savigs Accout, to which IU Health will make a geerous cotributio (prorated o a quarterly basis depedig upo whe coverage begis). This HSA ca be used to pay for eligible out-of-pocket expeses. I additio to the IU Health cotributio, you ca choose to cotribute your ow dollars o a pretax basis, with o use-it-or-lose-it rule to pay for eligible out-of-pocket expeses. Take advatage of Healthy Results welless program opportuities. Kowig your umbers blood pressure, cholesterol, blood sugar, BMI, etc. is a importat part of good health. Whe you eroll i oe of the IU Health medical isurace plas ad participate i our volutary Healthy Results program, you ca save up to $28 per pay period o your medical premiums. If you are ot erollig i oe of the IU Health medical plas, you may still participate i the Healthy Results program. Uderstad supplemetal beefits ad their costs. Look at your beefits i total; IU Health offers a variety of supplemetal beefits, icludig life, depedet life, disability, ad accidetal death ad dismembermet. Review the available optios ad their costs, ad the determie if the volutary coverage meets your eeds. Savig for retiremet is importat for fiacial health. It is essetial to start savig ad ivestig as early as possible for your retiremet. Make sure you are takig full advatage of the retiremet pla(s) IU Health makes available to you. Bottom lie: Your well-beig is importat to yourself ad your family, ad to IU Health. Read through this guide carefully to lear about your beefits, the erollmet process ad where you ca fid resources that ca help you alog the way. I doig so, you will help yourself to make iformed choices about what s best for you ad your family. Yours i good health, IU Health Beefits Team 1

3 TABLE OF CONTENTS Erollmet Iformatio Healthy Results IU Health Team Member Well-beig Program... 6 Medical Isurace Pharmacy Beefits Detal Isurace Visio Isurace Health Savigs Accout/Flexible Spedig Accouts Life ad Accidet Isurace Short-Term Disability Isurace Log-Term Disability Isurace Accidet ad Critical Illess Isurace Plas Paid Time Off IU Health Retiremet Savigs Plas Pla Rates

4 Erollmet Iformatio To have the coverage you eed each day, it s importat to uderstad your beefits choices. Before you eroll, you should read through this beefits guide ad discuss your choices with your family. Be sure you have all the facts before makig your fial decisios. To elect beefits, just follow these simple steps. FIND OUT WHO S ELIGIBLE You are eligible for beefits if you are a full-time or part-time team member scheduled to work at least 48 hours per pay period. Depedets eligible for coverage uder your medical, detal ad/or visio plas iclude the followig: Legally married spouse Registered domestic parter Childre* to the ed of the moth of their 26th birthday Ay age adult child who is permaetly ad totally disabled (A permaetly ad totally disabled child must have bee cotiuously covered as a depedet child prior to erollig i a IU Health pla.) *Childre iclude atural or legally adopted (or placed for adoptio) childre of the team member, the team member s legal spouse or the team member s registered domestic parter; childre for whom the team member, the team member s legal spouse or the team member s registered domestic parter is the court-appoited legal guardia; ad childre who are required by a qualified medical child support order (QMCSO) to be covered by the pla. Cotact Huma Resources if you have questios about the eligibility of ayoe you would like to eroll for coverage. PROOF OF ELIGIBILITY Proof of depedet eligibility will be required for all depedets erolled i medical, detal ad/or visio coverage. If you eroll a depedet (spouse or child) i a IU Health medical, detal or visio pla, you must provide proof of eligibility (as outlied o the right) to Huma Resources withi 31 days from your origial hire date. Failure to do so may result i the depedet(s) ot beig eligible for IU Health beefits. Importat: If you are erollig your spouse/registered domestic parter i medical coverage, you must also complete ad submit a Questioaire for Medical Coverage of a Spouse/Domestic Parter so a determiatio ca be made o whether the spouse is eligible for primary or secodary coverage uder a IU Health medical pla. Acceptable Supportig Documetatio (All fiacial iformatio ad Social Security umbers should be marked out.) Legal spouse A copy of the first page of the most recetly filed federal icome tax retur Form 1040 that idicates married filig joitly or married filig separately. Your spouse s ame must appear o the lie provided after the married filig separately status. If you are recetly married ad have ot filed a joit 1040, please provide a copy of your recet valid/ legal certificate/licese, which must iclude date of marriage. Child/adult child up to age 26 A copy of ay oe of the followig: birth certificate, legal adoptio papers, official court order, legal guardiaship papers or qualified medical child support order. Disabled child over the age of 26 A copy of ay oe of the above acceptable documets for ay child/adult child, the first page of the most recetly filed Form 1040 that idicates the child as a depedet ad a statemet from a physicia certifyig that the depedet child caot work to provide self-support due to a permaet ad total disability. If acceptable documetatio is ot provided for ay erolled depedet withi 31 days from your origial hire date or status chage, the coverage for that depedet will ot become effective, ad the ext opportuity to eroll the depedet will be durig the ext Ope Erollmet period or a qualifyig evet. WORKING SPOUSE/REGISTERED DOMESTIC PARTNER RULE Workig spouses ad registered domestic parters of erolled team members will, i most situatios, be required to joi their employer s group medical coverage for primary coverage. They still may choose to be covered uder a IU Health medical pla for secodary coverage. (Secodary coverage applies oly to claims ot paid by oe s primary health pla.) However, if the workig spouse/registered domestic parter s employer s pla does ot provide either credible coverage (prevetive care, major medical ad prescriptio) or pay at least 50 percet of the premium for sigle coverage, the the spouse/registered domestic parter is eligible to eroll i a IU Health medical pla for primary coverage. WHO DO I CONTACT IF I HAVE QUESTIONS? Huma Resources Shared Services (all etities except those listed below) T T (toll free) hrform@iuhealth.org IU Health Physicias Huma Resources Service Lie T scatoiuhphr@iuhealth.org IU Health Souther Idiaa Physicias Huma Resources T iuhsiphyhr@bloomigtohospital.org 3

5 Erollmet Iformatio cotiued If the spouse or registered domestic parter is self-employed, retired, uemployed or works for a compay that does ot provide a credible level of coverage, he or she may eroll i IU Health medical plas for primary coverage. Likewise, the IU Health pla will be primary for you ad your erolled spouse/ domestic parter if he or she is employed by a IU Health etity. If you ited to provide coverage for a spouse or registered domestic parter uder a IU Health medical pla, you must complete ad retur the eclosed Questioaire for Medical Coverage of a Spouse/Domestic Parter. You should complete the first page of the questioaire ad if applicable, have your spouse/registered domestic parter s employer complete the secod page of the questioaire. If your spouse/registered domestic parter is employed at a o-iu Health etity, verificatio of the availability of coverage by a represetative from that employer is ecessary i order to determie eligibility for primary coverage uder a IU Health medical pla. The form should be retured to Huma Resources withi 31 days of your official hire date or status chage. The Workig Spouse/Registered Domestic Parter Rule applies oly to medical coverage ad does ot apply to detal, visio or ay other depedet beefits. This provisio does ot affect eligibility for primary coverage uder ay IU Health medical, detal or visio plas for eligible depedet childre. CHOOSE WHAT YOU WANT You choose the beefits that are importat to you ad your family, ad you get help from IU Health to pay for some of them. IU Health pays a large portio of the cost of your medical coverage, half the cost of detal coverage for the basic optio (IU Health will also pay a portio of the cost for the high optio pla.), the full cost of your basic life isurace ad 50 percet of log-term disability coverage. You ca purchase visio, additioal employee ad depedet life, accidet ad short-term disability coverage at a special group rate. As permitted by law, your cost for medical, detal, visio, flexible spedig accouts ad volutary accidet coverage is deducted from your pay o a pretax basis. This saves you moey because you pay o federal, state or local icome taxes or Social Security taxes o the dollars you sped for these beefits. Note: Your portio of the premium coverig your registered domestic parter ad ay eligible o-tax-depedet childre may be paid o a after-tax basis, due to IRS regulatios. CHOOSE CAREFULLY MID-YEAR CHANGES AREN T GENERALLY ALLOWED The IRS limits chages durig the year because it allows you to pay for most of your beefits o a tax-free basis. You are allowed to make chages to your medical, detal, visio, volutary accidet ad flexible spedig accout beefits durig the year oly if you have a qualified evet resultig i a chage i family status. You ca t switch to a differet pla, but you may be able to add or drop coverage ad add or drop depedets. Chages i family status may apply if: You get married, register a domestic parter, divorce, legally separate or termiate a domestic partership Your child or the child of a domestic parter is bor or adopted, or becomes disqualified or requalifies for depedet coverage Oe of your depedets dies You or your spouse/registered domestic parter has a chage i employmet status that chages eligibility for beefits Your spouse/registered domestic parter has a chage i beefits coverage durig his/her employer s erollmet period You are startig or edig a strike or lockout You are takig a upaid leave of absece You, your spouse/registered domestic parter or tax depedet becomes etitled to or loses Medicare or Medicaid coverage To chage coverage uder oe of these situatios, you must complete the ecessary forms withi 31 days of the evet (60 days i the evet of a divorce/termiatio of domestic partership) ad submit them to Huma Resources. Your chage is effective the first of the moth followig the date of the chage i family status. You may oly apply for a icrease i your life isurace (subject to the isurace compay s approval) durig Ope Erollmet. You may drop or decrease your supplemetal ad depedet life isurace coverage at ay time durig the year by completig a cacellatio form. Your chage is effective the first of the moth followig the date the request is received. GET ANSWERS TO YOUR QUESTIONS If you wat more iformatio about your beefits, refer to your olie IU Health Team Member Hadbook (available o Pulse uder Employee Tools), your erollmet materials or cotact Huma Resources. 4 WHO DO I CONTACT IF I HAVE QUESTIONS? Huma Resources Shared Services (all etities except those listed below) T T (toll free) hrform@iuhealth.org IU Health Physicias Huma Resources Service Lie T scatoiuhphr@iuhealth.org IU Health Souther Idiaa Physicias Huma Resources T iuhsiphyhr@bloomigtohospital.org

6 ENROLL ONLINE USING EMPLOYEE SELF-SERVICE (BY DEADLINE) Usig a IU Health computer, log ito Lawso (lawprod.iuhealth.org) with your Network (NT) ID ad password Select Employee Self-Service from the left had margi of the scree Select Beefits Select New Hire Erollmet to eroll i your IU Health beefits Select Olie NH Eroll Istruct for details o how to eroll i your beefits olie Importat Iformatio: Beefit effective date: Beefits electios are geerally effective the first of the moth followig your official hire date. (Basic Life 6 moth of active service i a beefit-eligible positio waitig period; Log-term Disability 12 moth of active service i a beefiteligible positio waitig period) Example: Hire date: July 2, 2015 Beefit effective date: Aug. 1, 2015 The choices you make will remai i effect for the etire caledar year 2015 ad may oly be altered as the result of a chage i family status (please refer to the Chage i Coverage/Chage i Family Status sectio of the olie IU Health Team Member Hadbook located o Pulse for a complete listig of qualifyig evets). All depedets erolled i IU Health beefits must meet eligibility requiremets for depedets as stated i this Beefits Guide. You must provide appropriate proof of eligibility for all erolled depedets withi 31 days from your official hire date failure to do so may result i the depedet(s) ot beig eligible for IU Health beefits. A complete listig of acceptable documetatio may be foud i the side pocket of your 2015 IU Health Beefits Guide. Because of tax implicatios, premiums for coverig Domestic Parters (where such coverage is available) are hadled differetly ad you should cotact Huma Resources to register your Domestic Parter ad eroll your Parter i beefits. Depedig upo the timig of whe you eroll i your beefits, you may owe retroactive premiums for the pay periods missed. Prit your cofirmatio statemet ad check your beefits deductios o your first pay after your beefits effective date. If they do t match, call Huma Resources ad they will make the adjustmets. Depedig upo the timig of whe you eroll i your beefits, you may owe retroactive premiums for the pay periods missed. Your coverage will go ito effect o the first day of the moth followig your official hire date, uless the pla has a waitig period. THE IU HEALTH ACCOUNTABLE CARE ORGANIZATION (ACO) Accoutable care orgaizatios (ACOs) are desiged to shift focus away from expesive, hospital-based acute care to a model cetered o prevetive care/welless, coordiated patiet care ad disease maagemet. As teams of physicias ad hospitals workig together to achieve higherquality patiet outcomes, icreased efficiecies ad lower costs, ACOs are resposible for providig care to patiets while meetig various quality ad efficiecy stadards. IU Health became a ACO i July The orgaizatio is well-positioed to deliver ew patiet-cetered models of care focused o overall health ad welless, which is cosistet with the core values of IU Health. AFFORDABLE CARE ACT (ACA) AND HEALTH INSURANCE MARKETPLACE EXCHANGE I 2014, The Affordable Care Act (ACA) implemeted a ew provisio i which idividuals have access to affordable coverage through a ew competitive private health isurace market the Health Isurace Marketplace Exchage. Available to everyoe, the Marketplace Exchage offers oe-stop shoppig to fid/compare private health isurace optios. Visit healthcare.gov to lear more or visit myiuhealthplas.com for iformatio o the IU Health Plas available o the Idiaa Health Isurace Marketplace. Marketplace Exchage iformatio for Idiaa ad states where IU Health team members reside is located o Pulse i the Beefits & Retiremet sectio. IU Health offers eligible team members the optio to eroll i a IU Health medical pla. IU Health is providig iformatio about the Marketplace Exchage to team members to fulfill the requiremets of the law. Note: As of Ja. 1, 2014, all U.S. citizes are required to have medical isurace coverage through oe of the followig sources: employer s beefit pla, isurace compaies, Medicare/Medicaid, or the Marketplace Exchage. Olie erollmet is due o later tha 31 days from your date of hire ad you will have 31 days from your official hire date to make chages to your olie beefit electios by submittig a Chage/Cacellatio Notice form (located o Pulse) to Huma Resources. Your ext opportuity to make chages will be durig the aual Ope Erollmet period. 5

7 Healthy Results IU Health Team Member Well-beig Program Idiaa Uiversity Health is committed to providig team members with a healthy eviromet, ad is pleased to provide the followig programs ad services desiged to help you live a healthy life. HEALTHY RESULTS WELLNESS SERVICES ARE AVAILABLE TO ALL TEAM MEMBERS All IU Health team members are eligible for all of the programs ad services offered by Healthy Results, regardless of participatio i a IU Health beefits pla. Healthy Results offers persoal health coachig, tobacco cessatio, Weight Watchers at Work ad much more. Participatio i the welless program is completely volutary, ad your iformatio is kept private ad cofidetial. For more iformatio o the IU Health Healthy Results program: I 2015, team members who are erolled i a IU Health medical pla ad choose to participate i the Welless Track ca ear up to a maximum premium reductio of $28/pay ($728/year). The icetive structure optios i the form of a premium reductio are as follows: $10/pay ($260/year) by achievig the Broze level* OR $24/pay ($624/year) by achievig the Silver level* OR $28/pay ($728/year) by achievig the Gold level* *To fid out how you ca qualify for this icetive level, visit the Healthy Results Welless Portal at Pulse > Resources > Healthy Results or cotact Healthy Results at WELL or employeewelless@iuhealth.org. Call WELL or toll free at Visit the Healthy Results Welless Portal at Pulse > Resources > Healthy Results. Sed a to employeewelless@iuhealth.org. WELLNESS INCENTIVES Ay IU Health team member who erolls i a IU Health medical pla is eligible to ear welless icetive dollars i the form of premium reductios. If you do ot participate i a IU Health medical pla, you are welcome to complete the Health Assessmet ad participate i other programs to help you kow your umbers ad care for your health. Newly hired team members may complete a Health Assessmet, which cosists of a Health Screeig ad Health Survey, to ear icetive dollars i the form of premium reductios. O-site Health Assessmets are available, ad team members ca sig up olie at Pulse > Resources > Healthy Results or call WELL (toll free at ) for a appoitmet. A Physicia Optio is also available. If you choose the Physicia Optio, your physicia ca complete the form ad fax it to Healthy Results o your behalf. Whe usig the Physicia Optio, team members must also complete the olie health survey to be eligible for the welless icetive. This form ca also be foud o the welless portal at Pulse > Resources > Healthy Results. Participatio i 2015 will qualify you for icetives i 2015 ad The Health Assessmet is your first step to participatig i the Healthy Results program. IU Health rewards both participatio ad achievig health metrics. To lear more about how to participate ad ear your maximum icetive, please visit the Healthy Results Welless Portal at Pulse > Resources > Healthy Results. Frequetly Asked Questios What if I caot atted a screeig? You ca visit your persoal physicia ad have him or her submit the Physicia Optio form to Healthy Results if you are uable to atted a screeig. How ca I ear the maximum icetive? There are may ways to ear the full icetive amout. Visit the Healthy Results Welless Portal at Pulse > Resources > Healthy Results to lear how to ear your full icetive or cotact WELL or employeewelless@iuhealth.org for more iformatio. What if I caot meet the health metric? If you take measures to improve your health, you may take advatage of the re-qualificatio opportuities. Healthy Results offers reasoable alteratives to team members who are uable to meet the health metric. You ca also ear icetive poits by participatig i programs ad learig more about your health. Please visit the Healthy Results Welless Portal (Pulse > Resources > Healthy Results) to lear more about your optios. VISIT THE HEALTHY RESULTS WELLNESS PORTAL For iformatio o programs ad services, visit the Healthy Results Welless Portal at Pulse > Resources > Healthy Results. To access other team member well-beig iitiatives ad resources, go to Pulse > Employee Tools > Wellbeig. CONTACT THE CALL CENTER FOR HELP Call Ceter represetatives are available if you eed assistace. Call WELL (toll free at ) Moday Friday from 8 am 5 pm. Voice mails ca be left after hours or sed a to employeewelless@iuhealth.org. 6

8 Medical Isurace IU Health offers eligible team members three differet medical plas. Two Health Savigs Accout (HSA)-based medical plas HSA Medical Pla ad HSA Medical Saver Pla ad a traditioal preferred provider orgaizatio (PPO) pla are available. Team members ca choose their providers ad facilities, with the percetage of care covered by the pla based o where care is received (IU Health, Ecore/PHCS or Out of Network). For all plas, the highest level of coverage is offered whe IU Health providers ad facilities are used. HSA MEDICAL PLAN AND HSA MEDICAL SAVER PLAN Plas provide lower premiums for team members willig to accept potetially higher out-of-pocket costs for care. Plas offer a tax-advataged savigs opportuity. Medical care ad prescriptios cout toward out-of-pocket maximum. Deductible, coisurace ad out-of-pocket maximums Fudig Your IU Health HSA IU Health will pre-fud its cotributio to team member HSAs the first pay of the moth i which coverage is effective, i the amouts of: $700* Employee Oly coverage $1,400* Family coverage *Amout will be prorated o a quarterly basis depedig upo whe coverage begis. Q1: Full Amout Q2: $525 Employee Oly/$1,050 Family Q3: $350 Employee Oly/$700 Family Q4: $175 Employee Oly/$350 Family Team members erollig i oe of the HSA-based medical plas will automatically be erolled i a free Accidet ad Critical Illess isurace pla this plus the HSA cotributio made by IU Health may offset the higher deductible. Additioal iformatio about the Accidet ad Critical Illess isurace plas ca be foud o page 21. based o where services are received. Team member is resposible for full cost of services (icludig prescriptios) prior to meetig the deductible (except for prevetive care services ad prevetive prescriptios). Note: Deductible applies to all salary tiers regardless of where care is received. If erolled at the family coverage level Employee & Spouse/Registered Domestic Parter, Employee & Child(re) or Family you must meet the full family deductible before the pla begis to pay. Vice presidets ad above are eligible oly for oe of the HSA plas. TRADITIONAL PPO MEDICAL PLAN Deductible, coisurace ad out-of-pocket maximums based o where services are received. Deductible waived for full-time team members i salary tier 1 if care is received by a IU Health provider/facility. Copays for medical care ad prescriptios cout toward out-of-pocket maximum. The covered perso is resposible for PCP ad specialist office visit copays, ad for 60 percet of out-of-etwork office visits. Provider listigs ad Medical Plas Summary of Beefits ad Coverages (SBCs) for all the medical pla offerigs are available o the IU Health Plas website at myiuhealthplas.com. This site also icludes summaries about each pla, pharmacy iformatio ad FAQs. The IU Health Plas Customer Service phoe umber is or toll free at WHO DO I CONTACT IF I HAVE QUESTIONS? Huma Resources Shared Services (all etities except those listed below) T T (toll free) hrform@iuhealth.org IU Health Physicias Huma Resources Service Lie T scatoiuhphr@iuhealth.org IU Health Souther Idiaa Physicias Huma Resources T iuhsiphyhr@bloomigtohospital.org 7

9 Medical Isurace cotiued Fid the pla that is right for you use the health pla employee cost estimator tool Team members ca access a olie modelig tool to compare medical plas ad help determie which medical pla ad coverage optio provides the best value for their idividual situatio. The tool factors i medical premium deductios ad the cost of aticipated healthcare eeds for It also estimates the potetial tax savigs of usig a HSA-based medical pla. The Medical Pla Cost Estimator Tool is located at PLAN DESIGN HIGHLIGHTS IU Health recogizes the importace of ecouragig team members to seek ipatiet ad outpatiet care, as well as to purchase prescriptio medicatios withi the orgaizatio. By doig this, IU Health miimizes dollars paid to other healthcare orgaizatios for care that ca be provided withi IU Health facilities. Castlight Persoal Healthcare Tool Castlight is a persoal healthcare tool providig team members ad their adult family members (18 years or older) erolled i a IU Health employee medical pla with the kowledge ad iformatio eeded to search for i-etwork medical services based o cost, quality of care ad more. With Castlight, you ca: Search for earby doctors, medical facilities ad healthcare services based o the price you ll pay ad quality of care. See persoalized cost estimates based o your locatio, your medical pla beefits ad whether you ve already met your deductible. Review step-by-step explaatios of past medical spedig so you kow how much you paid ad why. Read recommedatios about ways to save moey ad fid high-quality care. Become a more savvy healthcare cosumer today go to mycastlight.com/iuhealth to register ow. You ca also call a Castlight Guide at with ay questios. 8 WHO DO I CONTACT IF I HAVE QUESTIONS? Huma Resources Shared Services (all etities except those listed below) T T (toll free) hrform@iuhealth.org IU Health Physicias Huma Resources Service Lie T scatoiuhphr@iuhealth.org IU Health Souther Idiaa Physicias Huma Resources T iuhsiphyhr@bloomigtohospital.org

10 The chart below highlights the various medical pla optios: Traditioal PPO Medical Pla Idividual/Family (Employee & Child; Employee & Spouse/ Domestic Parter; Employee & Family) HSA Medical Pla Idividual/Family (Employee & Child; Employee & Spouse/ Domestic Parter; Employee & Family) HSA Medical Saver Pla Idividual/Family (Employee & Child; Employee & Spouse/ Domestic Parter; Employee & Family) IU Health Ecore/ PHCS Out of Network IU Health Ecore/ PHCS Out of Network IU Health Ecore/ PHCS Out of Network Aual deductible* IU Health HSA cotributio Employee HSA cotributio limits Idividual $600 $1,200 $1,200 $1,500 $2,000 $2,500 $2,000 $2,500 $3,000 Family $1,200 $2,400 $2,400 $3,000 $4,000 $5,000 $4,000 $5,000 $6,000 Idividual $700 $700 N/A Family $1,400 $1,400 Idividual $2,650** $2,650** N/A Family $5,250** $5,250** Coisurace for ipatiet or outpatiet treatmet after satisfactio of deductible*** (chart shows the employee s resposibility; pla pays balace of covered charges 20% 40% 60% 10% 30% 50% 20% 40% 60% Out-of-pocket maximum (OOPM) Idividual $3,750 $5,500 $6,500 $3,750 $5,500 $6,500 $4,250 $6,250 $7,500 Family $7,500 $11,000 $13,000 $7,500 $11,000 $13,000 $8,500 $12,500 $15,000 Deductible, copays ad coisurace apply toward the above out-of-pocket maximum amouts Office visit copaymet/ visit Primary Care $20 $20 Specialist $35 $35 60% 10% 30% 50% 20% 40% 60% Urget care copaymet/visit $20 10% 10% 10% 20% 20% 20% ER copaymet/visit for emergecy treatmet (if ot admitted) oemergecy care at ER is ot covered $200 (waived if admitted) 10% 10% 10% 20% 20% 20% Physicia etwork Facilities etwork IU Health Busiess Solutios, Ecore/PHCS, Out of Network IU Health Busiess Solutios, Ecore/PHCS, Out of Network *Traditioal PPO medical pla: deductible waived for full-time salary tier 1 team members if care is received at a IU Health provider/ facility. HSA-based medical plas: deductible applies to all salary tiers regardless of where care is received (Note: If erolled at the family coverage level Employee & Spouse/Domestic Parter, Employee & Child[re] or Family you must meet the full family deductible before the pla begis to pay.) **Employees age 55 or older may cotribute a additioal $1,000 aually. ***Precertificatio is required for most ipatiet ad outpatiet treatmets. 9

11 Medical Isurace cotiued HSA-BASED MEDICAL PLANS, HEALTH SAVINGS ACCOUNT AND LIMITED-PURPOSE FLEXIBLE SPENDING ACCOUNTS A HSA-based medical pla is a medical pla that provides lower premiums for team members willig to accept potetially higher out-of-pocket costs for their care. The pla member is resposible for payig the full cost of services for themselves ad their erolled depedets, icludig prescriptios with the exceptio of prevetive care services ad prevetive prescriptios util the aual deductible is met. Oce the deductible is met, the pla begis to pay coisurace based o where care is received. (Coisurace is a cost-sharig feature i which the employee ad the health pla each pay a certai percetage of the cost of care util the employee s out-of-pocket maximum is reached.) HSA-based medical plas allow team members to cotribute fuds to a persoal Health Savigs Accout (HSA) o a pretax basis, which ca be used to pay for eligible medical, detal ad visio expeses. IU Health will make a prefuded employer cotributio to participatig team members HSA accouts the first pay of the moth i which coverage is effective. The cotributio amout will deped o whether a team member selects Employee Oly coverage or the Family (Employee & Spouse, Employee & Child[re] or Family) coverage, ad will be prorated o a quarterly basis depedig upo whe coverage begis. IU Health will make this cotributio eve if a team member decides ot to cotribute to his or her ow HSA. A team member erolled i a HSA-based medical pla is resposible for payig the full cost of services for themselves ad their erolled depedets, icludig prescriptios with the exceptio of specific qualified prevetive care services ad prevetive prescriptios util the aual HSA-based medical pla deductible is met. Oce the deductible is met, the pla begis to pay coisurace based o where the services are received. If erolled at the family coverage level (Employee & Spouse, Employee & Childre or Family), the full family deductible must be met. Team members erollig i a HSA-based medical pla will be automatically erolled i a Accidet ad Critical Illess pla paid by IU Health. The Accidet ad Critical Illess plas help offset the HSA-based medical plas deductible ad out-of pocket expeses related to a accidet or critical illess. This will help lesse the fiacial burde of expeses. The HSA-based medical plas are coupled with a tax advataged Health Savigs Accout (HSA) to help pay for eligible expeses prior to the deductible beig met. Cotributios to HSAs are limited by federal regulatios. The limits for 2015, which iclude both team member ad employer cotributios are $3,350 for idividuals ad $6,650 for families. Team members age 55 or older may cotribute a additioal $1,000 aually. Uused HSA fuds roll over from year to year ad stay with you through retiremet or if you should leave IU Health or o loger participate i the pla. It s importat to ote, uused HSA balaces are ot lost at the ed of the year. This allows the opportuity to accumulate fuds for future qualified expeses. Oce erolled i the HSA, you will receive a welcome package from Wells Fargo (the pla admiistrator) with additioal iformatio about your HSA. More iformatio about HSAs ca be foud i the Overview of Health Savigs Accout/Flexible Spedig Accouts charts o page Similar to a 401(k) or a 403(b) pla, members ca choose to ivest their HSA fuds (miimum $2,000 balace requiremet). Wells Fargo offers a diverse rage of HSA mutual fuds to meet a variety of log-term ivestmet strategies. The ivestmet accout is simple to access olie, ad you ca set up your ivestmet electios aytime eve before you reach the miimum $2,000 balace requiremet to ivest. Team members who eroll i oe of the HSA-based medical plas should be aware oly those reimbursable charges icurred after the HSA effective date are eligible for reimbursemet from the accout. A limited-purpose FSA is available to pay for eligible, o-reimbursed detal ad visio costs. (See page 16 for iformatio o limited-purpose FSAs.) Per federal regulatios, team members erolled i a HSA-based medical pla are ot eligible for the associated HSA if: Team member is erolled i Medicare (Parts A, B, C ad/or D), Medicaid, TriCare or aother medical pla (i.e., through spouse/domestic parter s employer) Their spouse is erolled i a traditioal Health Care Flexible Spedig Accout (FSA). Their spouse is erolled i a Health Reimbursemet Accout (HRA) or Health Icetive Accout (HIA) through his/her employer that may be used to pay the team member s eligible expeses. For geeral iformatio about the HSA (icludig a complete listig of HSA-qualified expeses), please visit the Wells Fargo website at wellsfargo.com/hsa ad click o the Lear about HSA-qualified medical expeses lik. 10 WHO DO I CONTACT IF I HAVE QUESTIONS? Huma Resources Shared Services (all etities except those listed below) T T (toll free) hrform@iuhealth.org IU Health Physicias Huma Resources Service Lie T scatoiuhphr@iuhealth.org IU Health Souther Idiaa Physicias Huma Resources T iuhsiphyhr@bloomigtohospital.org

12 Pharmacy Beefits For several years, team members erolled i a IU Health medical pla have bee able to take advatage of the coveiece ad lower copaymet amouts offered at IU Health retail ad mail-order pharmacies. Expaded weekday ad Saturday hours exist at some locatios, ad you may choose to have 90-day supplies filled (except for tier 4 drugs) at the coveiet IU Health retail pharmacy sites or make arragemets for mail order. It s easy to trasfer a prescriptio from aother pharmacy. Just call the most coveiet IU Health pharmacy locatio. If available, please have your Rx umber, ad the IU Health pharmacy will be able to call the out-of-etwork pharmacy ad trasfer the prescriptio for you to fill at the lowest copay available. IU Health has expaded pharmacy optios for team members by addig Kroger/Payless pharmacies as the preferred out-of-etwork providers, allowig erolled participats to take advatage of more pharmacy locatios ad exteded hours of service. IU Health Pharmacies Offer $4 geerics Ayoe erolled i a IU Health medical pla ca fill a 30-day supply of eligible geeric drugs for $4 ad a 90-day supply for $10 at IU Health ad Kroger/ Payless pharmacies. The list of eligible geerics ad quatities is available o the IU Health Plas website: myiuhealthplas.com. If the prescriptio is a emergecy medicatio, you ca fill your prescriptio at ay local pharmacy, ad i most cases at the lower copay amout. Emergecy medicatios iclude prescriptios writte outside of ormal busiess hours such as at a urget care facility or emergecy room. Emergecy medicatios do ot iclude maiteace medicatios such as for blood pressure or cholesterol. Examples of emergecy medicatios iclude atibiotics for severe ifectios, medicatios to maage severe pai or medicatios for coditios that caot wait util the ext busiess day. Ask the pharmacist at the o-iu Health pharmacy to call whe fillig the prescriptio to get a override for the emergecy medicatio to be filled at the lower IU Health copay. The other optio for i-etwork copays o emergecy prescriptios whe IU Health pharmacies are ot available is to submit a reimbursemet form, which is available at myiuhealthplas.com. For more iformatio about the prescriptio drug beefits, visit the IU Health Plas website at myiuhealthplas.com. O the site, you will fid iformatio about prevetive medicatios, $4 geerics, mail-order or emergecy medicatios, IU Health retail pharmacy ad Kroger/Payless pharmacy locatios, alog with other details about this beefit. You will also fid the Pharmacy Call Ceter phoe umber, , for ay additioal questios you may have about pharmacy beefits. Pharmacy Iformatio Kroger/Payless pharmacies are the preferred The table o the ext page shows the cost differeces of covered prescriptios for team members isured uder a IU Health medical pla depedig o whether the team member chooses to have prescriptios filled at a IU Health pharmacy, a preferred out-of-etwork Kroger/Payless retail pharmacy or at a o-preferred, out-of-etwork retail pharmacy. Copaymet Amouts The copay amouts will apply to the aual out-of-pocket maximum for team members erolled i the traditioal PPO medical pla. For team members erolled i oe of the HSA-based offerigs, the coisurace amouts will apply to both the aual deductible ad the aual out-of-pocket maximum. Team members erolled i oe of the HSA-based medical plas will pay the full cost of their prescriptios for themselves ad their erolled depedets with the exceptio of prevetive prescriptios util the aual HSA pla deductible is met. (Note: If erolled at the family coverage level Employee & Spouse/Domestic Parter, Employee ad Child[re] or Family you must meet the full family deductible before the pla begis to pay.) Oce the deductible is met, the pla begis to pay a percetage based o the pharmacy where the prescriptio is filled. out-of-etwork providers: Icreasig the umber of pharmacies available to team members ad icreasig the hours of service. Copays for prescriptios (ad medical care) cout toward a team member s out-of-pocket maximum. Cotraceptives ad cotraceptive couselig will be covered per Health Care Reform: Wome will have access to all FDA-approved cotraceptive methods, sterilizatio procedures ad patiet educatio ad couselig. 30-day first fill: The first fill of ay maiteace prescriptio will be able to be filled for 30-day supplies maximum to esure that it is a tolerated dose ad that the member will cotiue to be o the prescriptio. After the first fill, members ca fill up to 90-day supplies at either the IU Health retail or mail-order pharmacies. Madatory geeric: Requires letter of medical ecessity for brad ame prescriptios to be filled whe there is a geeric available. 11

13 Pharmacy Beefits cotiued Here is the copaymet iformatio for covered prescriptios filled at a IU Health retail pharmacy, a Kroger/Payless pharmacy or at aother retail pharmacy. Traditioal PPO Medical Pla* Copaymets for a 30-day supply ad 90-day supply (if available) HSA Medical Pla/ HSA Medical Saver Pla** Copaymets for a 30-day supply ad 90-day supply (if available) IU Health Kroger/ Payless Out of Network IU Health Kroger/ Payless Out of Network Tier 1 Preferred Geeric $10 for 30-day supply; $25 for 90-day supply $15 for 30-day supply; 90-day supply ot available $25 for 30-day supply (except for emergecy medicie); 90-day supply ot available 20% 25% 30% Tier 2 Preferred Brads ad Selected Geerics $30 for 30-day supply; $75 for 90-day supply $35 for 30-day supply; 90-day supply ot available $50 for 30-day supply (except for emergecy medicie); 90-day supply ot available 20% 25% 30% Tier 3 No-preferred Brads ad Selected Geerics 30% of cost for 30-day supply ($50 miimum ad $100 maximum); 30% of cost for 90-day supply ($150 miimum ad $300 maximum) 33% of the cost for a 30-day supply ($60 miimum ad $120 maximum); 90-day supply ot available 50% of the cost for a 30-day supply; ($150 miimum ad $300 maximum); 90-day supply ot available 20% 25% 30% Tier 4 Specialty/Biotech 25% of cost for 30-day supply ($75 miimum ad $170 maximum); 90-day supply ot available 30% of cost for 30-day supply ($75 miimum ad $210 maximum); 90-day supply ot available Not available 20% 25% Not available *The amouts will apply to the aual out-of-pocket maximum for team members erolled i the traditioal PPO medical pla. **For team members erolled i oe of the HSA-based medical pla offerigs, the amouts will apply to both the aual deductible ad the aual out-of-pocket maximum. Team members erolled i oe of the HSA-based medical plas will pay the full cost of their prescriptios for themselves ad their erolled depedets with the exceptio of prevetive prescriptios util the aual HSA pla deductible is met. Oce the deductible is met, the pla begis to pay a percetage based o the pharmacy where the prescriptio is filled util the out-of-pocket maximum is met. (Note: If erolled at the family coverage level Employee & Spouse/Domestic Parter, Employee & Child[re] or Family you must meet the full family deductible before the pla begis to pay.) 12

14 Detal Isurace Most of your detal care takes place at home, but regular detal checkups ad cleaigs are also importat. That s why IU Health offers two detal plas to help you avoid problems with your teeth ad help pay for repairs if you eed them. The Delta Detal plas combie the affordable cost of a detal poit-of-service program with the flexibility of a traditioal pla. Delta Detal offers beefits through a etwork of detal care providers to help you save time ad moey. HOW THE PLANS WORK You ca select either the basic optio pla or the high optio pla. IU Health cotributes the same premium amout toward either selectio. The basic optio pla provides differet levels of coverage based upo whether the detist is a member of the Delta Detal PPO etwork. The high optio pla provides the same level of reimbursemet regardless of whether or ot the detist is i-etwork.* For more iformatio about the Delta Detal pla optios, refer to the olie IU Health Team Member Hadbook, cotact Delta Detal s Customer Service departmet by callig or visit the compay s website at deltadetali.com. Delta Detal referece cards are available by cotactig Huma Resources. The followig chart shows the differece betwee the two detal isurace optios. (Per pay period, 26 of 26 pays) Basic Optio High Optio Delta Detal PPO Detist Premier & Noparticipatig Detist* Ay Detist* Deductible $50 per perso $75 per perso $50 per perso Maximum pla paymet/caledar year $1,200 $750 $1,500 Class I Beefits: Prevetive services, sealats, X-rays 100% (deductible does ot apply) 90% 100% (deductible does ot apply) Class II Beefits: Filligs, crow repairs Periodotic services, root caals, extractios 75% 50% 50% 50% 80% 80% Class III Beefits: Crows, bridges, implats, detures 50% 50% 50% Class IV Beefits: Orthodotic services, icludig braces. Age limit for team member ad depedets is to the ed of the moth of age % to lifetime maximum of $1,500 50% to lifetime maximum of $500 50% to lifetime maximum of $1,500 *Whe you receive services from a oparticipatig detist, the above percetages idicate the portio of usual ad customary charges that Delta Detal will reimburse. If the charges exceed these amouts, you will be resposible for the differece. WHO DO I CONTACT IF I HAVE QUESTIONS? Huma Resources Shared Services (all etities except those listed below) T T (toll free) hrform@iuhealth.org IU Health Physicias Huma Resources Service Lie T scatoiuhphr@iuhealth.org IU Health Souther Idiaa Physicias Huma Resources T iuhsiphyhr@bloomigtohospital.org 13

15 Visio Isurace The UitedHealthcare Visio pla provides a cotact les beefit, a frame beefit that offers choice, a provider etwork that icludes private practice ad retail chai locatios, ad discouts o refractive eye surgery. The beefits of the pla are greatest whe you use i-etwork providers, which iclude optometrists, ophthalmologists ad retail chai locatios. You ca also go to o-etwork providers ad receive reimbursemet at specific rates. The pla offers exams oce a year, ew eyeglass leses or cotact leses oce every 12 moths ad ew frames every 24 moths. There is a $10 copay for the exam ad a $10 copay o materials. Visio I-Network ad No-Network Compariso I-Network Beefit No-Network Beefit Examiatio 100% $10 copay) Up to $40 Materials (frames/spectacle leses or cotact leses) $10 copay N/A Sigle-Visio Leses 100% Up to $40 Bifocal Leses (stadard ad progressive/ o-lie) 100% Up to $60 Stadard Trifocal/Leticular Les 100% Up to $80 Progressive/No-Lie Bifocals Frame* Basic Progressive Leses covered i full; High-Ed Progressives $40 copay $130 retail allowace with 30% off balace over $130 at participatig providers Up to $60 Up to $45 Elective Cotacts** 100% (12 pairs disposable) Up to $130 allowace less ay fittig ad evaluatio fee Necessary Cotacts** 100% Up to $210 *A frame from a selectio of quality covered frames o display. A predetermied allowace will be provided for frames that are ot covered. ** Participats choose from covered-i-full selectio of more tha 50 differet types of cotact leses from 15 leadig maufacturers. A $130 allowace will be provided for cotact leses that are ot covered. For more iformatio about the UitedHealthcare Visio pla, refer to the olie IU Health Team Member Hadbook, cotact the UitedHealthcare Visio Customer Service departmet by callig or visit UHC s website at myuhcvisio.com. The provider locator feature o the website allows you to idetify providers ear your home. ID cards are ot issued. Team members erollig i this coverage ca visit providers after their effective date ad idetify themselves as members. Like medical ad detal coverage, premiums for the visio pla are withheld o a pretax basis. 14 WHO DO I CONTACT IF I HAVE QUESTIONS? Huma Resources Shared Services (all etities except those listed below) T T (toll free) hrform@iuhealth.org IU Health Physicias Huma Resources Service Lie T scatoiuhphr@iuhealth.org IU Health Souther Idiaa Physicias Huma Resources T iuhsiphyhr@bloomigtohospital.org

16 Health Savigs Accout/Flexible Spedig Accouts MAKE YOUR HEALTHCARE DOLLARS GO FURTHER Cosider a Health Savigs Accout or a Depedet Care, Health Care or a Limited-Purpose Flexible Spedig Accout There are several types of flexible spedig ad savigs accouts available to help you save moey o o-reimbursed medical, detal ad visio expeses. With the exceptio of Depedet Care Flexible Spedig Accouts, the type of accout(s) i which you are eligible to participate is determied by the type of medical coverage i which you are erolled. Flexible Spedig Accouts (FSAs) offer a attractive way for you to pay may of your health care ad depedet care expeses o a tax-free basis. The moey you deposit to these accouts goes i before taxes are figured. That meas your taxable icome is lower ad you pay less i federal, state ad Social Security taxes. IU Health adopted the $500 carryover FSA optio. This allows team members to carryover up to $500 of their uused health care or limited-purpose FSA balace remaiig at the ed of the year ito the ext pla year. This meas, you ca carryover up to $500 of your 2015 cotributios to pay for 2016 expeses ad it does ot reduce the aual cotributio limit of $2,550. It is importat to remember Iteral Reveue Service regulatios require that moey i excess of the $500 carryover provisio for the health care ad limited-purpose ad/or ay moey left i your depedet care accouts at the ed of the year are forfeited. So, if you do ot use all the moey i your accouts, the uused balace caot be retured to you. However, you ca avoid this by carefully estimatig expeses i advace. Overview of Health Savigs Accout Accout Cotributios Eligibility Iformatio Aual Cotributios Health Savigs Accout (HSA) (Oly available for team members erolled i a HDHP, icludig a IU Health HSA-based medical pla) Go to the Wells Fargo website (wellsfargo.com/hsa) to verify your accout effective date, lear about eligible expeses, the reimbursemet process, check accout balace/activity ad to ivestigate ivestmet optios. The same eligible IRS-deductible medical, detal ad visio expeses ot covered uder your isurace plas as listed uder Health Care Flexible Spedig Accout above apply. Fuds i this accout which are cotributed by IU Health ad you (if you choose to do so) ca be used to reimburse expeses icurred i your HSA-based medical pla ad for your portio of the coisurace. Ulike with the Health Care ad Depedet Care Flexible Spedig Accouts, ay uused fuds will roll over util the ext caledar year. I additio, you ca ivest ad grow your HSA. Per federal regulatios, team members erolled i a HSA-based medical pla are ot eligible for the associated HSA if: Team member is erolled i Medicare (Parts A, B, C ad/or D), Medicaid, TriCare or aother medical pla (i.e. through spouse/domestic parter s employer) Their spouse is erolled i a traditioal Health Care Flexible Spedig Accout (FSA). Their spouse is erolled i a Health Reimbursemet Accout (HRA) or Health Icetive Accout (HIA) through his/her employer that may be used to pay the team member s eligible expeses Maximums: Sigle coverage $2,650*/team member plus $700** IU Health cotributio Family coverage $5,250*/team member plus $1,400** IU Health cotributio Age 55+ may cotribute additioal $1,000 aually *Team members erollig i oe of the HSA-based medical plas will automatically be erolled i a Accidet ad Critical Illess pla this plus the HSA cotributio made by IU Health may offset the higher deductible. Additioal iformatio about the Accidet ad Critical Illess plas ca be foud o pages 21. **Amout will be prorated o a quarterly basis depedig upo whe coverage begis. 15

17 Health Savigs Accout/Flexible Spedig Accouts cotiued Overview of Flexible Spedig Accouts Accout Eligibility Iformatio Aual Cotributios Depedet Care Flexible Spedig Accout (DCFSA) Go to the IU Health Plas Flex website (ezflexpla.com/iuhealth) to lear about eligible expeses, the reimbursemet process ad to check your accout balace/activity. Note: You may submit claims for reimbursemet up to the amout i your accout at the time the request is submitted. Health Care Flexible Spedig Accout (HCFSA) (Not available for team members erolled i a High Deductible Health Pla (HDHP), icludig a IU Health HSA-based medical pla) Go to the IU Health Plas Flex website (ezflexpla.com/iuhealth) to lear about eligible expeses, the reimbursemet process ad to check your accout balace/activity. Limited-Purpose Flexible Spedig Accout (LPFSA) (Oly available for team members erolled i a HDHP, icludig a IU Health HSA-based medical pla) Go to the IU Health Plas Flex website (ezflexpla.com/iuhealth) to lear about eligible expeses, the reimbursemet process ad to check your accout balace/activity. Ayoe with day care expeses for the followig depedets while you work (ad, if married, while your spouse is at work, is a full-time studet or is disabled): Your childre uder 13 Your depedet who is physically or metally disabled ad icapable of self-care, icludig your spouse or child of ay age Your depedet paret or other depedet who speds at least eight hours a day i your home Eligible depedet care expeses iclude those for care i your home, i a babysitter s home, at a licesed day care ceter or by a relative who is ot your depedet. Use it or lose it applies You must use all of the moey i your accout each year or you will forfeit the amout ot used. Eligible expeses iclude ay IRSdeductible medical, detal, visio ad hearig expeses ot covered uder your isurace plas, such as: Medical ad detal deductibles, copaymets ad other out-of-pocket expeses ot paid by your pla Routie eye exams, glasses or cotacts Prescriptio drug copaymets Hearig exams ad hearig aids Adult orthodotia ad TMJ expeses Smokig-cessatio programs Prescriptio icotie withdrawal products Weight loss programs if idividual is diagosed as obese (30+ Body Mass Idex) Over-the-couter medicies ad drugs used to treat curret illess (if your doctor writes a prescriptio) Use it or lose it applies Team members may carryover up to $500 of their HCFSA balace ito the ext pla year. Balaces above $500 will be forfeited at the ed of the curret pla year. Oly eligible IRS-deductible detal or visio expeses ot covered uder these plas ca be reimbursed from this accout. Fuds i a LPFSA caot be used for medical expeses. Use it or lose it applies Team members may carryover up to $500 of their LPFSA balace ito the ext pla year. Balaces above $500 will be forfeited at the ed of the curret pla year. Maximum: $5,000 (per family or $2,500 per spouse whe married ad fillig separate tax returs allowed by the IRS) Maximum: $2,550 (per idividual) Maximum: $2,550 (per idividual) 16

18 REIMBURSEMENT OPTIONS FOR DEPENDENT CARE, HEALTH CARE AND LIMITED-PURPOSE FLEXIBLE SPENDING ACCOUNTS Debit card you will be issued a debit card to pay for eligible expeses. Check IU Health Plas Flex will process check reimbursemets twice a week. Claims received by Tuesday at 5 pm EST will be paid that Friday. Claims received by Thursday at 5 pm EST will be paid the followig Tuesday. Checks for claim reimbursemet will be mailed to you from the IU Health Plas Columbus, Id., office o the paymet date. The miimum check amout is $5 uless the remaiig balace i your accout is less. The check stub with your reimbursemet check will show you how much has bee deposited ito your accout ad how much you have used to date. Direct Deposit Paymets for reimbursemet by direct deposit (ito a checkig or savigs accout) will be processed o a daily basis. There is o miimum amout for claims reimbursed by direct deposit. You ca check your Explaatio of Beefits olie via the IU Health customized IU Health Plas Flex webpage. IU Health Plas Flex may be cotacted at: T or toll free at iuhflex@iuhealth.org Website: ezflexpla.com/iuhealth REIMBURSEMENT OPTIONS FOR THE HEALTH SAVINGS ACCOUNT You will be issued a debit card ad may order a checkbook to pay for or reimburse yourself for eligible expeses. Wells Fargo HSA Customer Service may be cotacted at: T For geeral iformatio about the HSA (icludig a listig of HSA-qualified expeses), please log o to the Wells Fargo website at wellsfargo.com/hsa. Team members covered uder their spouse s HDHP with his/her employer ad wish to eroll i the LPFSA will eed to submit a 2015 Flexible Spedig Accout Plas Agreemet form (located o Pulse > Forms > Beefits ad Retiremet HR) to HR. Life ad Accidet Isurace A death or serious ijury ca mea some tough times for a family. That s why it s best to be prepared for the uexpected. IU Health helps out by offerig the followig life isurace coverage to give your family some fiacial security ad peace of mid if somethig should happe to you or a covered depedet. Note: You must be actively at work o the date your coverage is scheduled to be effective, or your coverage will ot become effective util you retur to active employmet. BASIC LIFE INSURANCE IU Health provides a group term life isurace policy for each eligible team member o a group basis. Term life isurace will help esure your family s security i the evet of your death by payig a lump sum to your beeficiary. The etire cost is covered by IU Health. The maximum beefit level for basic life isurace is $150,000. This meas you are isured for 1½ times your base pay, up to a maximum of $150,000. Coverage is automatically provided to beefits-eligible team members after six moths of service. However, you do eed to complete a beeficiary desigatio form. You ca obtai a form from the Forms page o Pulse, uder the Beefits & Retiremet sectio. Note: If you do t ame a beeficiary, the isurace compay will pay beefits to your estate, which ca mea a delay of beefits ad extra taxes. The IRS requires that compay-provided life isurace i excess of $50,000 be cosidered a taxable beefit to employees. If you wat to waive coverage over $50,000 ad avoid the additioal tax, please cotact Huma Resources to obtai the proper form. Did you kow that you ca chage your isurace beeficiary at ay time? It s importat that your beeficiary iformatio is curret ad you ca chage it ay time by submittig the chage-of-beeficiary form available o Pulse. If you are amig mior childre as beeficiaries, cosider establishig a trust fud to receive ad maage the life isurace proceeds o their behalf. SUPPLEMENTAL LIFE INSURANCE New team members who eroll withi 31 days of their official hire date may elect up to $150,000 of coverage without beig required to submit a Evidece of Isurability (EOI) form. To add supplemetal life isurace, eroll olie ad submit a EOI form if you wat more tha $150,000 i coverage. Coverage i excess of $150,000 will be peded util approved by the isurace admiistrator. If these amouts are approved, the effective date will be the first of the moth followig approval. 17

19 Life ad Accidet Isurace cotiued DEPENDENT LIFE INSURANCE You must eroll withi 31 days of your official hire date. There are two levels of depedet coverage (childre ages 21 to 25 must be full-time studets to be covered by this policy): Optio 1 Spouse/registered domestic parter isured to 50 percet of your IU Health life isurace coverage up to $10,000; each eligible child isured at $3,000 Optio 2 Spouse/registered domestic parter isured to 50 percet of your IU Health life isurace coverage up to $25,000; each eligible child isured at $7,500 VOLUNTARY ACCIDENT INSURANCE The coverage pays a beefit i the evet of a covered accidetal death or i the evet of certai accidets that result i serious ijury such as the loss of a had or foot, or of oe s sight, speech or hearig as examples. You ca choose amog three coverage optios: employee, spouse or child. (If elected, the child optio covers all eligible depedet childre up to age 21 or up to age 25 if the depedet is a full-time studet.) A reduced beefit of $1,000 would be payable i the evet of the accidetal death of a ewbor child less tha six moths old. Team member coverage is available i $10,000 icremets up to $500,000. Spouse/registered domestic parter coverage is available i $5,000 icremets also up to $500,000, although team member coverage must also be elected ad the spouse/registered domestic parter s coverage caot exceed the team member s coverage level. Coverage for childre is available i $2,000 icremets up to $50,000, although team member coverage must also be elected ad the amout of coverage selected caot exceed 50 percet of the team member s elected coverage levels. After your first 31 days of eligible employmet, volutary accidet isurace may oly be chaged or cacelled durig Ope Erollmet. Premiums are pretax deductios. See the olie IU Health Team Member Hadbook for additioal details. Geerally, the effective date for your life isurace electios is the first of the moth followig your official date of hire as log as you eroll olie withi 31 days of your official hire date. However, the effective date will be later if the team member or depedet to be covered is disabled, as defied by the isurace compay, o the date coverage would otherwise be effective. Basic Life Supplemetal Life Depedet Life Volutary Accidet ad Dismembermet Eligible Employees Full-time ad part-time employees scheduled to work at least 48 hours per pay period Full-time ad part-time employees scheduled to work at least 48 hours per pay period Full-time ad part-time employees scheduled to work at least 48 hours per pay period Full-time ad part-time employees scheduled to work at least 48 hours per pay period Who is Covered You Oly You Oly Your spouse/registered domestic parter ad childre (childre ages 21 to 25 must be full-time studets to be covered by this policy) Your spouse/registered domestic parter ad childre (childre ages 21 to 25 must be full-time studets to be covered by this policy) Cost of Coverage Paid by orgaizatio Paid by you if you elect coverage Paid by you if you elect coverage Paid by you if you elect coverage Beefit Amout 1½ times base pay up to $150,000* From $5,000 to $500,000, depedig upo how much coverage you elect Optio 1 Spouse/registered domestic parter: 50 percet of your IU Health life coverage up to $10,000 $10,000 to $500,000 (you) ad $5,000 to $500,000 (spouse/ registered domestic parter) ad Child: $3,000 Optio 2 Spouse/registered domestic parter: 50 percet of your IU Health life coverage up to $25,000 $2,000 to $50,000 (childre) Beefits are paid oly if you die or are dismembered i a accidet. Child: $7,500 *Physicias ad certai executives receive basic life isurace equal to two times base pay, up to $500,

20 Short-Term Disability Isurace Eve just a few weeks without a paycheck ca really set you back fiacially. IU Health offers a volutary short-term disability (STD) isurace pla that replaces a portio of your icome if you get sick or hurt ad caot work. The IU Health short-term disability pla, isured by Uum, allows you to select either 50 percet or 60 percet of your weekly base pay with a 14-day or 30-day waitig period. The choice is yours. HOW YOU QUALIFY FOR BENEFITS You ca receive a weekly beefit from the pla if you eroll for coverage ad: You are totally disabled due to a o-work-related illess or ijury (as well as pregacy) for 14 days or 30 days depedig o the optio you choose, ad You file a claim for beefits with the isurace compay. To obtai claim filig iformatio, cotact Disability Maagemet as soo as you kow that you will eed time off from work. You must be actively at work o the day your coverage becomes effective ad before the disability occurs. You may also qualify for a partial disability beefit if you ve bee totally disabled for four weeks uder this pla (plus your 14-day or 30-day waitig period) ad ca oly retur to work part time because of medical limitatios WHEN BENEFITS BEGIN AND END Whe you eroll i the pla, you choose either a 14-day or 30-day waitig period optio. If you choose the 14-day optio, beefits will start o the 15th day of your total disability. With the 30-day optio, beefits start o the 31st day of disability. Beefits for illesses ad ijuries cotiue for up to either 22 weeks or 24 weeks, depedig o the waitig period you select. (Disability date for pregacy may vary.) Beefits may ed sooer if: You ca retur to work part time but choose ot to You fail to submit proof of disability whe asked to Your earigs exceed the amout allowed BENEFIT AMOUNT The STD pla replaces up to either 50 percet or 60 percet of your base pay. With Uum, beefits will be paid weekly (for the previous week) to better help you meet your fiacial resposibilities. The miimum weekly STD beefit is $46.15, the maximum weekly beefit is $1,500. Remember, you ca select a beefit amout of either 50 percet or 60 percet of your weekly base pay. Your beefit amout will automatically chage (icrease or decrease) wheever you receive a chage to your base pay. Your pay is based upo a average of your earigs just prior to your date of disability. COORDINATING STD WITH PAID TIME OFF If you have available Paid Time Off you must use it durig your 14-day or 30-day waitig period. You may receive PTO alog with your STD beefits (if you have available time) for the first 30 days that you receive your disability paymets. After that, your STD beefits will be reduced by the amout you receive from PTO or other sources such as Social Security. See your olie IU Health Team Member Hadbook for a summary descriptio of the PTO program or ask your maager. NO TAXES ON YOUR BENEFITS Sice you pay for STD coverage with after-tax dollars from your pay, your STD beefits are ot subject to icome or Social Security taxes. PRE-EXISTING CONDITION LIMITATION If your disability is due to a illess, ijury or pregacy that occurred before your elected STD coverage becomes effective (a pre-existig coditio), o beefits for that coditio are payable for the first 12 moths you are covered uder the pla. These limitatios will o loger apply oce you ve bee treatmet-free for oe year or covered by the pla for oe year, whichever happes first. A pre-existig coditio limitatio also applies to a icrease i your coverage amouts from the 50 percet beefit level to the 60 percet beefit level at a subsequet Ope Erollmet period. COVERAGE IS GUARANTEED Proof of good health is ot required for erollmet or icrease i coverage. You caot be tured dow for coverage. However, remember that pre-existig coditio limitatios apply to your coverage. WHO DO I CONTACT IF I HAVE QUESTIONS? Huma Resources Shared Services (all etities except those listed below) T T (toll free) hrform@iuhealth.org IU Health Physicias Huma Resources Service Lie T scatoiuhphr@iuhealth.org IU Health Souther Idiaa Physicias Huma Resources T iuhsiphyhr@bloomigtohospital.org 19