benefits TABLE OF CONTENTS benefits program

Transcription

1 beefits TABLE OF CONTENTS beefits program Brookhave Sciece Associates, LLC (BSA) believes that employee beefits are a importat ad meaigful part of the compesatio received by every employee. BSA has provided its employees with a broad beefits program, which icludes the followig: MEDICAL PLAN DENTAL PLAN LIFE INSURANCE PLAN LONG TERM DISABILITY PLAN TRAVEL ACCIDENT INSURANCE PLAN RETIREMENT PLAN 401(K) PLAN FLEXIBLE SPENDING ACCOUNTS PLAN TUITION REFUND PROGRAM SEVERANCE PAY PLAN LONG TERM CARE PLAN VACATION BUY PLAN ADOPTION ASSISTANCE PROGRAM TRANSIT COMMUTER BENEFIT PLAN The iformatio i this booklet is iteded to provide oly a summary of BSA s beefits program. Nothig cotaied i ay sectio of this booklet should be costrued as a promise of employmet or cotiued employmet, or to costitute cotractual obligatios. If questios arise, official pla documets ad isurace agreemets are cotrollig ad gover fial determiatio of beefits cosistet with applicable laws ad regulatios. BSA maitais the right to modify, susped, or termiate beefit plas i whole or i part at ay time. BROOKHAVEN NATIONAL L ABOR ATORY 1

2 beefits TABLE OF CONTENTS 2 BROOKHAVEN NATIONAL L ABOR ATORY

3 beefits TABLE OF CONTENTS cotets MEDICAL PLAN part 1 WHO IS ELIGIBLE FOR THE MEDICAL PLAN?... 1 Active Employees... 1 Eligible Depedets... 1 Depedets of Deceased Participats... 1 Retirees... 2 ENROLLMENT... 3 MEDICAL PROGRAMS AVAILABLE... 3 Medical Programs Available... 3 THE OPEN ACCESS PLUS (OAP) ADMINISTERED BY CIGNA... 4 THE PREFERRED PROVIDER ORGANIZATION (PPO) ADMINISTERED BY VYTRA... 4 HEALTH MAINTENANCE ORGANIZATIONS (HMOS)... 4 Authorizatio... 5 Prevetive Services... 5 PHONE NUMBERS... 5 PROVIDER DIRECTORY... 5 COORDINATION OF BENEFITS... 5 Coverage Uder Other Employers Plas... 5 Dual Coverage... 5 Medicare... 5 CLAIMS... 5 How to File a Claim... 5 Questios About Claims... 6 How to Appeal a Claim... 6 EXCLUSIONS... 7 NEWBORNS AND MOTHERS HEALTH PROTECTION ACT... 8 WOMEN S BREAST CANCER... 8 EMPLOYEE PREMIUMS... 8 RETIREE PREMIUMS... 9 DISPLACED WORKERS HEALTH BENEFITS PROTECTION ACT (DWHBP) PREMIUMS... 9 OPEN ENROLLMENT PERIOD... 9 QUALIFYING EVENT... 9 MISCELLANEOUS Base Salary Cotiuous Service Deductible Geeral Iformatio Hospital Preadmissio Certificatio Leave of Absece Lifetime Maximum Medical Beefits Out-Of-Pocket Maximum Participats Receivig Log Term Disability Pla Beefits Qualified Medical Child Support Order Reasoable ad Customary (R&C) Secod Surgical Opiio Termiatio of Coverage BROOKHAVEN NATIONAL L ABOR ATORY 3

4 beefits TABLE OF CONTENTS COBRA What is COBRA Cotiuatio Coverage? Whe is COBRA Coverage Available? Notificatio Requiremets How is COBRA Coverage Provided? COBRA Premium Requiremets Termiatio of Coverage Uder COBRA CONVERSION ERISA EMPLOYEE PREMIUMS RETIREE PREMIUMS For Participats who were ot i the IBEW Uio For Participats who were i the IBEW Uio DWHBP PREMIUMS COBRA PREMIUMS MEDICAL PLAN COMPARISON CHARTS (A) MEDICAL PROGRAMS All Employees No-Medicare-Eligible Retirees No-Medicare-Eligible Participats o LTD (B) MEDICAL PROGRAMS Medicare-Eligible Retirees Medicare- Eligible Participats o LTD DENTAL PLAN part 2 WHO IS ELIGIBLE FOR THE DENTAL PLAN?... 1 Active Employees... 1 Eligible Depedets... 1 ENROLLMENT... 2 DENTAL PROGRAMS AVAILABLE... 3 DELTA DENTAL INDEMNITY PLAN... 3 Beefits Provided... 3 Schedule of Maximum Allowable Covered Detal Expeses... 3 Coordiatio of Beefits... 3 Coverage Uder Other Employers Plas... 3 Claims... 3 How to File a Claim... 3 Questios About Claims... 4 How to Appeal a Claim... 4 Phoe Number... 4 DELTA DENTAL DMO (DELTACARE USA) PLAN... 4 Beefits Provided... 4 Emergecy Services... 4 Specialty Referrals... 4 Coordiatio of Beefits... 5 How to File a Claim... 5 Questios About Claims... 5 How to Appeal a Claim... 5 Phoe Number... 5 Provider Directory BROOKHAVEN NATIONAL L ABOR ATORY

5 beefits TABLE OF CONTENTS DELTA DENTAL PPO PLAN... 5 Beefits Provided... 5 Coordiatio of Beefits... 5 Coverage Uder Other Employers Plas... 5 Claims... 6 How to File a Claim... 6 Questios About Claims... 6 How to Appeal a Claim... 6 Phoe Number... 6 Provider Directory... 6 DUAL COVERAGE... 6 EXCLUSIONS... 6 EMPLOYEE PREMIUMS... 7 OPEN ENROLLMENT PERIOD... 7 QUALIFYING EVENT... 7 MISCELLANEOUS... 8 Geeral Iformatio... 8 Leave of Absece... 9 Participats Receivig Log Term Disability Beefits... 9 Reasoable ad Customary (R&C)... 9 Termiatio of Coverage... 9 COBRA... 9 What is COBRA Cotiuatio Coverage?... 9 Whe is COBRA Coverage Available? Notificatio Requiremets How is COBRA Coverage Provided? COBRA Premium Requiremets Termiatio of Coverage Uder COBRA ERISA EMPLOYEE PREMIUMS COBRA PREMIUMS DENTAL PLAN COMPARISON CHARTS LIFE INSURANCE PLAN part 3 WHO IS ELIGIBLE FOR THE LIFE INSURANCE PLAN?... 1 Active Employees... 1 ENROLLMENT... 1 LIFE INSURANCE PLAN COVERAGE EMPLOYEES UNDER AGE Basic Life Isurace Beefits Provided... 1 Supplemetal Life Isurace Beefits Provided... 1 LIFE INSURANCE PLAN COVERAGE EMPLOYEES AGE 65 OR OVER... 2 Basic Life Isurace Beefits Provided... 2 Supplemetal Life Isurace Beefits Provided... 2 MAXIMUM LIFE INSURANCE PLAN COVERAGE... 3 OPTION TO ACCELERATE PAYMENT OF DEATH BENEFITS... 3 ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE... 3 Beefits Provided... 3 Exclusios... 4 Additioal Beefits... 4 BROOKHAVEN NATIONAL L ABOR ATORY 5

6 beefits TABLE OF CONTENTS CLAIMS How to File a Claim... 4 Questios About Claims... 4 How to Appeal a Claim... 4 EMPLOYEE PREMIUMS... 5 MISCELLANEOUS... 5 Aual Base Salary... 5 Assigmet of Your Life Isurace ad AD&D Beefits... 5 Beeficiary... 5 Chages i the Amout of Life ad AD&D Isurace... 5 Evidece of Isurability... 6 Geeral Iformatio... 6 Isurace Compay... 6 Leave of Absece... 6 Participats Receivig Log Term Disability Beefits... 6 Termiatio of Coverage... 6 CONVERSION... 7 LONG TERM DISABILITY PLAN part 4 WHO IS ELIGIBLE FOR THE LONG TERM DISABILITY PLAN?... 1 Active Employees... 1 ENROLLMENT... 1 LONG TERM DISABILITY PLAN COVERAGE... 1 Icome Beefits Provided... 1 Cotributios to the Retiremet Pla... 3 Portable Adaptive Equipmet... 3 Rehabilitatio... 3 CLAIMS... 3 How to File a Claim... 3 Questios About Claims... 3 How to Appeal a Claim... 4 EMPLOYEE PREMIUMS... 4 OTHER INSURANCE COVERAGES WHILE ON LTD... 4 Medical Coverage... 4 Life Isurace Coverage... 4 Detal Coverage... 4 MISCELLANEOUS... 4 Base Salary... 4 Chages i the Amout of LTD Coverage... 5 Cotiuous Service... 5 Disabilities Not Covered... 5 Employmet Status While Receivig LTD Beefits... 5 Evidece of Isurability... 5 Geeral Iformatio... 5 Isurace Compay... 5 Leave of Absece... 6 Overpaymet... 6 Reductio i Beefits Due to Earigs... 6 Social Security Beefits... 6 Successive Periods of Disability BROOKHAVEN NATIONAL L ABOR ATORY

7 beefits TABLE OF CONTENTS Termiatio of Coverage...6 Totally Disabled...7 TRAVEL ACCIDENT INSURANCE PLAN part 5 WHO IS ELIGIBLE FOR THE TRAVEL ACCIDENT INSURANCE PLAN?... 1 ENROLLMENT... 1 TRAVEL ACCIDENT INSURANCE PLAN COVERAGE... 1 Beefits Provided... 1 Exclusios... 2 Accidetal Bur ad Disfiguremet Beefit... 2 Airbag Beefit... 3 Bomb Scare ad/or Explosio Coverage: O premises... 3 Carjackig Beefit... 3 Coma Beefit Coverage... 3 Cotiuatio of Isurace Expese Beefit... 4 Emergecy Medical Evacuatio... 4 Exteded Terrorism Coverage... 4 Feloious Assault Coverage: O Premises... 5 Hijackig/Skyjackig Coverage... 5 Kidap ad Extortio Beefit... 5 O Premises Emergecy Fire/Disaster Team Coverage... 5 Persoal Deviatio Provisio... 5 Reasoable Accommodatio at Worksite Beefit... 5 Rehabilitatio Beefit... 6 Repatriatio of Remais... 6 Seat Belt Beefit... 6 Special Adaptatio Beefit... 6 Special Couselig Beefit... 7 Travel Assistace Services... 7 Travel Assistace Services Compay... 7 War Risk Coverage... 7 CLAIMS... 7 How to File a Claim... 7 Questios About Claims... 7 How to Appeal a Claim... 8 PREMIUMS... 8 MISCELLANEOUS... 8 Accidet... 8 Accidet Medical Expese... 8 Aual Salary... 8 Assigmet of Your Travel Accidet Isurace Policy... 8 Authorized Busiess Travel... 8 Automobile... 8 Beeficiary... 9 Carjackig... 9 Coma... 9 Depedet Child(re)... 9 Disfiguremet/Disfigured... 9 Emergecy Medical Beefit... 9 Geeral Iformatio... 9 BROOKHAVEN NATIONAL L ABOR ATORY 7

8 beefits TABLE OF CONTENTS Guest Leave of Absece Loss Presumptive Disability Rehabilitatio Termiatio of Coverage Vehicle RETIREMENT PLAN part 6 WHO IS ELIGIBLE FOR THE RETIREMENT PLAN?... 1 Active Employees... 1 ENROLLMENT... 1 RETIREMENT PLAN COVERAGE... 1 Beefits Provided... 1 Pla Ivestmets... 2 Allocatig Cotributios... 2 Trasferrig Betwee Fuds... 2 Desigatig a Beeficiary... 3 Rollover Cotributios... 3 Vestig... 3 Effect of Termiatio ad Re-employmet... 3 Loas... 4 Withdrawals... 4 Statemets... 4 RETIREMENT OPTIONS... 4 Cash Withdrawal... 4 Retiremet Trasitio Beefit... 4 Oe-Life Auity Optio... 5 Two-Life Auity Optio... 5 Fixed Period Auity Optio... 5 Iterest Paymet Retiremet Optio (IPRO)... 6 Miimum Distributio Optio... 6 Rollover Distributios... 6 REPURCHASE OF BENEFITS... 6 PRE-RETIREMENT DEATH BENEFITS... 6 INVESTMENT COMPANY CONTACT INFORMATION... 7 QUESTIONS ABOUT THE PLAN... 7 MISCELLANEOUS... 7 Base Salary... 7 Break i Service... 7 Cotiuous Service... 7 Discotiuatio of Cotributios... 7 Employer... 7 Geeral Iformatio... 7 Hour of Service... 7 Leave of Absece... 8 No-Alieatio of Beefits... 8 Participats Receivig Log Term Disability Beefits... 8 Pla Admiistrator... 8 Qualified Domestic Relatios Order BROOKHAVEN NATIONAL L ABOR ATORY

9 beefits TABLE OF CONTENTS Type of Pla... 8 Amedmet or Termiatio of the Pla... 8 Brookhave Sciece Associates Fuds Available for Ivestmet (k) PLAN part 7 WHO IS ELIGIBLE FOR THE 401(K) PLAN?... 1 Active Employees... 1 ENROLLMENT (K) PLAN COVERAGE... 1 Beefits Provided... 1 Catch Up Cotributios... 2 Pla Ivestmets... 2 Allocatig Cotributios... 2 Desigatig a Beeficiary... 2 Chagig the Amout Beig Cotributed... 3 Trasferrig Betwee Fuds... 3 Rollover Cotributios... 3 Vestig... 3 Loas... 3 Withdrawals... 4 Statemets... 4 RETIREMENT OPTIONS... 4 Cash Withdrawal... 5 Oe-Life Auity Optio... 5 Two-Life Auity Optio... 5 Fixed Period Auity Optio... 6 Miimum Distributio Optio... 6 Rollover Distributios... 6 REPURCHASE OF BENEFITS... 6 PRE-RETIREMENT DEATH BENEFITS... 6 INVESTMENT COMPANY CONTACT INFORMATION... 6 QUESTIONS ABOUT THE PLAN... 7 MISCELLANEOUS... 7 Base Salary... 7 Discotiuatio of Cotributios... 7 Fiscal Officer... 7 Geeral Iformatio... 7 Leave of Absece... 7 No-Alieatio of Beefits... 7 Participats Receivig Log Term Disability Beefits... 7 Pla Admiistrator... 8 Qualified Domestic Relatios Order... 8 Type of Pla... 8 Amedmet or Termiatio of the Pla... 8 Brookhave Sciece Associates Fuds Available for Ivestmet... 9 BROOKHAVEN NATIONAL L ABOR ATORY 9

10 beefits TABLE OF CONTENTS FLEXIBLE SPENDING ACCOUNTS PLAN part 8 WHO IS ELIGIBLE FOR THE FLEXIBLE SPENDING ACCOUNTS PLAN?... 1 Active Employees... 1 ENROLLMENT... 1 HEALTH CARE REIMBURSEMENT ACCOUNT... 1 Beefits Provided... 1 What Health Care Expeses are Reimbursed?... 2 How Much May You Cotribute Each Year to the Health Care Reimbursemet Accout?... 2 DEPENDENT DAY CARE REIMBURSEMENT ACCOUNT... 2 Beefits Provided... 2 What Depedet Day Care Expeses are Reimbursed?... 2 Who are Eligible Depedets?... 3 How Much May You Cotribute Each Year to the Depedet Day Care Reimbursemet Accout?... 3 Depedet Day Care Reimbursemet Accout or Tax Credit... 3 Does the Use of Before-Tax Cotributios to the Flexible Spedig Accouts Pla Affect Ay Other Beefits?... 3 CLAIMS... 4 How to File a Claim... 4 How Log Do You Have to Submit Claims for Reimbursemet?... 4 Questios About Claims... 4 How to Appeal a Claim... 4 CHANGES IN CONTRIBUTION AMOUNTS... 5 OPEN ENROLLMENT PERIOD... 5 QUALIFYING EVENT... 5 MISCELLANEOUS... 6 Geeral Iformatio... 6 Leave of Absece... 6 Restrictios... 6 Termiatio of Coverage... 7 COBRA... 7 What is COBRA Cotiuatio Coverage?... 7 Whe is COBRA Coverage Available?... 8 Notificatio Requiremets... 8 How is COBRA Coverage Provided?... 8 COBRA Premium Requiremets... 9 Termiatio of Coverage Uder COBRA... 9 TUITION ASSISTANCE PROGRAM part 9 WHO IS ELIGIBLE FOR THE TUITION ASSISTANCE PROGRAM?... 1 Active Employees... 1 ENROLLMENT... 1 TUITION ASSISTANCE PROGRAM COVERAGE... 1 Beefits Provided... 1 Allowable Courses... 1 Exclusios... 2 Approvals... 2 How to Request Reimbursemet BROOKHAVEN NATIONAL L ABOR ATORY

11 beefits TABLE OF CONTENTS Questios About the Program... 2 MISCELLANEOUS... 2 Course Schedules... 2 Geeral Iformatio... 2 Leave of Absece... 3 Log Term Disability Beefits... 3 Termiatio of Coverage... 3 SEVERANCE PAY PLAN part 10 WHO IS ELIGIBLE FOR THE SEVERANCE PAY PLAN?... 1 Active Employees... 1 ENROLLMENT... 1 SEVERANCE PAY PLAN COVERAGE... 1 Beefits Provided... 1 Maximum Beefits... 1 Paymet of Beefits... 2 Recall to Work... 2 Exclusios... 2 Questios About the Pla... 3 MISCELLANEOUS... 3 Base Pay... 3 Cotiuous Service... 3 Geeral Iformatio... 3 Part-Time Employees... 3 Termiatio of Coverage... 3 LONG TERM CARE PLAN part 11 WHO IS ELIGIBLE FOR THE LONG TERM CARE PLAN?... 1 Active Employees... 1 Eligible Depedets... 1 Retirees... 1 APPLYING FOR COVERAGE... 1 LONG TERM CARE PLAN COVERAGE... 1 Beefits Provided... 1 Beefit Eligibility Criteria... 2 Preexistig Coditios Limitatio... 2 Lifetime Maximum Beefit... 2 EXCLUSIONS... 2 CLAIMS... 2 How to File a Claim... 2 Questios About Claims... 3 How to Appeal a Claim... 3 EMPLOYEE PREMIUMS... 3 ELIGIBLE DEPENDENT PREMIUMS... 3 RETIREE PREMIUMS... 3 RETURN OF PREMIUMS... 3 BROOKHAVEN NATIONAL L ABOR ATORY 11

12 beefits TABLE OF CONTENTS WAIVER OF PREMIUMS... 3 MISCELLANEOUS... 3 Beefit Period... 3 Chages i the Amout of LTC Coverage... 3 Daily Beefit Amout... 4 Geeral Iformatio... 4 Home Care Uit... 4 Hospital... 4 Leave of Absece... 4 Loss of Fuctioal Capacity... 4 Nursig Care Facility... 5 Termiatio of Coverage... 5 Waitig Period... 5 CONTINUATION COVERAGE... 5 VACATION BUY PLAN part 12 WHO IS ELIGIBLE FOR THE VACATION BUY PLAN?... 1 Active Employees... 1 ENROLLMENT... 1 VACATION BUY PLAN COVERAGE... 1 Beefits Provided... 1 Use of Vacatio Buy Time... 1 Determiig the Cost of Purchased Vacatio Time... 1 Uused Purchased Vacatio Time... 2 OPEN ENROLLMENT PERIOD... 2 MISCELLANEOUS... 2 Base Salary... 2 Geeral Iformatio... 2 Leave of Absece... 2 Termiatio of Employmet... 2 ADOPTION ASSISTANCE PROGRAM part 13 WHO IS ELIGIBLE FOR THE ADOPTION ASSISTANCE PROGRAM?... 1 Active Employees... 1 ENROLLMENT... 1 ADOPTION ASSISTANCE PROGRAM COVERAGE... 1 Beefits Provided... 1 What Adoptio-Related Expeses are Reimbursable?... 1 How to Request Reimbursemet... 1 MISCELLANEOUS... 2 Geeral Iformatio... 2 Termiatio of Employmet BROOKHAVEN NATIONAL L ABOR ATORY

13 beefits TABLE OF CONTENTS TRANSIT COMMUTER BENEFIT PLAN part 14 WHO IS ELIGIBLE FOR THE TRANSIT COMMUTER BENEFIT PLAN?...1 Active Employees...1 ENROLLMENT...1 TRANSIT COMMUTER BENEFIT PLAN COVERAGE...1 Beefits Provided...1 How Much May You Cotribute Each Year to the Trasit Commuter Beefit Pla?...1 Does the Use of Before-Tax Cotributios to the Trasit Commuter Beefit Pla Affect Ay Other Beefits?...1 CLAIMS/PAYMENT OF EXPENSES...2 How to File a Claim or Pay for Expeses...2 How Log Do You Have to Submit Claims for Reimbursemet?...2 Questios About Claims...2 How to Appeal a Claim...2 CHANGES IN CONTRIBUTION AMOUNTS...2 MISCELLANEOUS...3 Claims Admiistrator...3 Eligible Trasportatio Expeses...3 Geeral Iformatio... 3 Leave of Absece... 3 Participats Receivig Log Term Disability Pla Beefits...3 Restrictios... 3 Termiatio of Coverage...4 GENERAL INFORMATION Pla Idetificatio Numbers...1 Pla Year...1 Pla Fudig...1 Type of Pla...1 Normal Retiremet Age...1 Pla Sposor...1 Pla Admiistrator...2 Aget for Legal Process...2 Trustees...2 Filig Claims for Beefits...2 Claims Appeal Procedure...2 Privacy of Iformatio...2 Your Rights Uder ERISA...3 Receive Iformatio About Your Plas ad Beefits...3 Cotiue Group Health Pla Coverage...3 Prudet Actios by Pla Fiduciaries...3 Eforce Your Rights...4 Assistace With Your Questios...4 BROOKHAVEN NATIONAL L ABOR ATORY 13

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15 beefits: part 1 MEDICAL PLAN part 1 MEDICAL PLAN The Medical Pla provides beefits for medical coverage. Erollmet i the Medical Pla is optioal. WHO IS ELIGIBLE FOR THE MEDICAL PLAN? Active Employees All regular employees who work at least 20 hours per week are eligible to participate i the group Medical Pla o the first day of active employmet. Eligible Depedets The followig members of your family are also eligible for Medical Pla coverage: Your spouse, defied as the perso of the opposite sex to whom you are legally married. Your eligible same-sex domestic parter ad that parter s eligible child(re). To be eligible, you must provide a copy of your marriage certificate, domestic parter registry or proof of fiacial iterdepedece. Additioal iformatio is available at Beefits/DomesticParters.asp Childre of your eligible domestic parter must meet the criteria for childre idicated below. Your child(re) up to his or her 26th birthday, icludig adopted childre ad stepchildre. Coverage may be cotiued for your eligible depedets who are or over age 26 ad who are or become metally or physically icapable of earig their ow livig while covered as a eligible depedet, by submittig proof of the child s icapacity withi 31 days after they become icapacitated. If a depedet is o loger eligible for coverage ad you do ot remove that depedet from your coverage withi the applicable period idicated i the Qualifyig Evet sectio, your depedet will be removed from your coverage as of the date the Beefits Office is otified. Depedets of Deceased Participats If you are participatig i the Medical Pla ad die while receivig Log Term Disability (LTD) Pla beefits, ad are ot eligible for retiree medical coverage or are i active service ad die, your covered depedets may cotiue i the pla, for oe year followig the date of your death, by payig the required employee premiums. After the first year: If you had less tha 3 years of Cotiuous Service, your covered depedets may cotiue i the pla uder the COBRA provisios by payig the COBRA cost of the pla. If you were ot i the caledar year of your 58th birthday or later ad do ot meet the eligibility requiremets for retiree medical coverage (see below) ad you had at least 3 but less tha 15 years of Cotiuous Service, your covered depedets may cotiue i the pla by payig the COBRA cost of the pla. If you were ot i the caledar year of your 58th birthday or later ad you had at least 15 or more years of Cotiuous Service, your covered depedets may cotiue i the pla BROOKHAVEN NATIONAL L ABOR ATORY 1

16 beefits: part 1 MEDICAL PLAN by payig the required retiree premiums. If you were i the caledar year of your 58th birthday or later ad had at least 3 years of Cotiuous Service, your covered depedets may cotiue i the pla by payig the required retiree premiums. If you meet the eligibility requiremets for the retiree medical coverage (see below), your covered depedets may cotiue i the pla by payig the required retiree premiums. If you are participatig i the Medical Pla ad die while receivig Log Term Disability (LTD) Pla beefits, ad are eligible for retiree medical coverage or die while o retiree medical coverage, your covered depedets may cotiue i the pla by payig the required retiree premiums. These provisios will ot apply to covered depedets if eligible for coverage uder aother group medical isurace pla. Coverage will termiate whe they o loger qualify as eligible depedets. Coverage will also termiate for covered depedets o the date the survivig spouse remarries. Retirees All employees who are participatig i the Medical Pla ad who termiate employmet after attaiig age 55 ad have a combiatio of age ad years of Cotiuous Service immediately prior to retiremet (10 years miimum, or for employees hired prior to Jauary 1, 2001, 5 years miimum) that total 70 years or more may participate i the Medical Pla with their covered depedets by payig the required retiree premiums. For example: A employee age 55 would be eligible for retiree medical coverage after 15 years of Cotiuous Service. A 62 year old employee would be eligible after 10 years of Cotiuous Service, if hired o or after Jauary 1, A 62 year old employee would be eligible after 8 years of Cotiuous Service, if hired before Jauary 1, I determiig eligibility for retiree medical coverage, employees who are hired by the Laboratory i coectio with the Natioal Sychrotro Light Source II ( NSLSII ) project may receive credit for their service with their prior employer i calculatig their years of Cotiuous Service. This prior service credit applies to (a) employees permaetly hired by the Laboratory o or after October 1, 2005 to work o the NSLSII project, or (b) spouses of employees permaetly hired by the Laboratory o or after October 1, 2005 to work o the NSLSII project, if the spouse is permaetly hired by the Laboratory o or after October 1, 2005, eve if the spouse is ot hired to work o the NSLSII project. The prior service credit applies oly to service with a laboratory operated uder a cotract with the Departmet of Eergy, ad oly if the employee or spouse was employed by that laboratory immediately before he or she was hired by the Laboratory. For example, if a employee is hired by the Laboratory to work o the NSLSII project o Jauary 1, 2006, ad before beig hired by the Laboratory was employed with aother laboratory operated by a etity uder a cotract with the Departmet of Eergy sice Jauary 1, 2000, the employee will have six years of Cotiuous Service whe he or she begis at the Laboratory. Also, employees who are participatig i the Medical Pla ad who termiate employmet after completig 35 years of Cotiuous Service may participate i the Medical Pla with their covered depedets by payig the required retiree premiums. I additio, whe Log Term Disability (LTD) Pla beefits cease for a participat who was receivig such beefits, the followig criteria apply i determiig retiree medical beefits eligibility, if participatig i the Medical Pla. Use Cotiuous Service prior to commecemet of LTD Pla beefits ad age at the time the LTD Pla beefits cease. Retirees otherwise eligible who are subsequetly employed elsewhere or have coverage available through their spouse s employer may susped their retiree medical coverage through the Laboratory. It may oly be reistated durig a Ope Erollmet Period (effective Jauary 1 of the followig caledar year) or whe a Qualifyig Evet occurs. As of Jauary 1, 2007, eligible employees i the positios idicated below who are participatig i the Medical Pla ad who termiate employmet after attaiig age 50 ad have 25 years or more of Cotiuous Service may participate i the Medical Pla with their covered depedets by payig the required retiree premiums. If Cotiuous Service is at least 20 years but less tha 25 years ad all other criteria idicated above are met, such eligible employees may participate i the Medical Pla by payig the COBRA cost of the pla util their age plus Cotiuous Service immediately prior to 2 BROOKHAVEN NATIONAL L ABOR ATORY

17 beefits: part 1 MEDICAL PLAN retiremet plus their age total 75 years or more (at which time they ca cotiue coverage by payig the required retiree premium). For the purpose of this paragraph, positios eligible for such coverage iclude Fire Chief, Deputy Fire Chief, Fire Captai, Police Chief, Police Captai, Police Lieuteat ad Police Security Traiig Istructor. If you die while your beefits are i a suspeded status, your eligible depedets may also reistate coverage durig a Ope Erollmet Period or whe a Qualifyig Evet occurs. ENROLLMENT Eligible employees may eroll i oe of the medical programs withi 30 days of their date of hire. Oce you eroll, you must cotiue participatio i the program util the ed of the caledar year or your termiatio date of employmet, if earlier. If you do ot eroll for coverage withi 30 days of your date of hire, you will be required to wait util the ext Ope Erollmet Period or whe you have a Qualifyig Evet to elect coverage. To eroll, you must complete a erollmet form ad list all depedets you wat covered. Erollmet forms are available through the Beefits Office. By completig the form, you will authorize the ecessary payroll premiums for the coverage you select. The coverages available are: Employee oly. Employee ad oe depedet. Employee ad two or more depedets. You caot eroll your eligible depedets without also erollig yourself for medical coverage. Employees caot eroll their depedets i a differet medical program tha the oe they select for themselves. Coverage begis o your date of hire if you complete all erollmet forms ad submit them to the Beefits Office withi 30 days of your date of hire. MEDICAL PROGRAMS AVAILABLE Eligible employees ad their depedets may eroll i oe of the o-medicare medical programs. No-Medicare-eligible retirees, o-medicare-eligible participats receivig LTD Pla beefits, ad o-medicare eligible depedets of retirees ad participats receivig LTD Pla beefits may eroll i oe of the o-medicare medical programs. Medicare-eligible retirees, Medicare-eligible participats receivig LTD Pla beefits, ad Medicareeligible depedets of retirees ad participats receivig LTD Pla beefits may eroll i oe of the Medicare medical programs. A brief summary of the beefits provided uder each program is at the ed of the Medical Pla sectio. Medical Programs Available No-Medicare-Eligible Participats Medicare-Eligible Participats Aeta HMO CIGNA Ope Access Plus CIGNA Ope Access Plus HIP VIP HMO HIP HMO Vytra PPO If you ad your spouse are ot eligible for Medicare, you may both participate i a o- Medicare pla but must both elect the same pla. If you ad your spouse are eligible for Medicare, you may both participate i a Medicare pla but must both elect the same pla. BROOKHAVEN NATIONAL L ABOR ATORY 3

18 beefits: part 1 MEDICAL PLAN If you are ot eligible for Medicare but your spouse is eligible for Medicare (or vice versa), the Medicare-eligible participat may participate i ay of the Medicare plas. The o- Medicare-eligible participat may participate i ay of the o-medicare plas. THE OPEN ACCESS PLUS (OAP) ADMINISTERED BY CIGNA Uder the CIGNA OAP program, services are provided through a etwork of physicias ad facilities, but beefits are also provided for use of providers who are ot i the etwork. If services are received from a i-etwork provider, there is o claim filig. Most i-etwork services are covered i full after a small co-paymet. If services are received from a provider who is ot i the CIGNA OAP etwork (thus is out-ofetwork), you have a deductible, must file claim forms, ad most services are covered at a percetage of the Reasoable ad Customary (R&C) amout. The CIGNA OAP program provides beefits to cover i-hospital ad out-of-hospital expeses. Uder this program, you use the physicia of your choice for medical care for you ad your covered depedets. For expeses to be covered by the program, they must be for ecessary ad essetial care ad treatmet of a ijury, illess, or pregacy. Certai facilities ad care providers may ot be covered by this program. Additioal iformatio o beefits, exclusios, ad limitatios is provided i your CIGNA Isurace Certificate which is available at o charge i the Beefits Office. THE PREFERRED PROVIDER ORGANIZATION (PPO) ADMINISTERED BY VYTRA Uder the Vytra PPO program, services are provided through a etwork of physicias ad facilities, but beefits are also provided for use of providers who are ot i the etwork. If services are received from a i-etwork provider, there is o claim filig. Most i-etwork services are covered i full after a small co-paymet. If services are received from a provider who is ot i the Vytra PPO etwork (thus is out-of-etwork), you have a deductible, must file claim forms, ad most services are covered at a percetage of the Reasoable ad Customary (R&C) amout. The Vytra PPO program provides beefits to cover i-hospital ad out-of-hospital expeses. Uder this program, you use the physicia of your choice for medical care for you ad your covered depedets. For expeses to be covered by the program, they must be for ecessary ad essetial care ad treatmet of a ijury, illess, or pregacy. Certai facilities ad care providers may ot be covered by this program. Prescriptio drug coverage for Vytra participats is provided through CIGNA. Additioal iformatio o beefits, exclusios, ad limitatios is provided i your Vytra Isurace Certificate which is available at o charge i the Beefits Office. HEALTH MAINTENANCE ORGANIZATIONS (HMOs) HMO programs are available for medical coverage. Curretly, o-medicare HMOs are provided through Aeta ad HIP ad a Medicare HMO is provided through HIP. Iformatio o the beefits provided through the HMOs is cotaied i literature available at o charge i the Beefits Office. Uder the HMOs, services are provided through a etwork of participatig physicias ad facilities. Coverage is ot provided for providers who are ot i the HMO s etwork. To chage providers i your HMO, you must cotact the HMO. If you require the care of a medical specialist, your participatig physicia must give you a referral to a specialist i that HMO s etwork. May of the services are provided for a small co-paymet. There are o deductibles or claim forms to file. Please ote that coverage uder the HMOs is subject to chage by the HMO ad is based o provisios at the time the service is provided. May prevetive services, such as a aual physical, are provided by the HMOs. If you have ay questios about your HMO, cotact the HMO. 4 BROOKHAVEN NATIONAL L ABOR ATORY

19 beefits: part 1 MEDICAL PLAN Authorizatio If your primary care physicia believes you eed to see a specialist, he or she will provide you with a referral. Prevetive Services I case of a emergecy, you do ot require prior approval or authorizatio by your primary care physicia or isurace compay. However, you must otify your primary care physicia ad your isurace compay of your visit to the emergecy room as soo as reasoably possible. Services such as well child care, routie physicals, ad routie gyecological examiatios are provided. For a list of such services, refer to your member hadbook. PHONE NUMBERS PROVIDER DIRECTORY* AETNA (800) CIGNA (800) HIP (800) VYTRA (631) *Provider directories are available olie at the websites idicated above. COORDINATION OF BENEFITS Coverage Uder Other Employers Plas If you ad your covered depedets are eligible to receive beefits uder aother group medical pla, coordiatio of beefits is based o the terms of those plas. I may cases the HMOs do ot provide additioal reimbursemet whe coordiated with aother group medical pla. I the case of depedet childre who are covered by more tha oe group pla, the isurace pla of the paret whose birthday occurs earlier i the caledar year will be the primary isurace pla for the childre. To obtai all the beefits available, you ad your family members must file claims uder each pla. Dual Coverage Prior to Jauary 1, 2006, dual coverage allowed both spouses to participate i the CIGNA programs where they could elect to cover each other ad their eligible depedets i such programs provided they paid the required premiums. Dual coverage was elimiated as of Jauary 1, Dual coverage was also elimiated for members of the IBEW uio as of Jauary 1, Medicare For retired employees, participats who are receivig LTD Pla beefits ad their depedets who are eligible for Medicare, the medical programs will ot pay for ay medical expeses that are eligible for reimbursemet uder Medicare. Retired employees, participats who are receivig LTD Pla beefits ad their depedets who are eligible for Medicare must eroll for both Parts A ad B of Medicare. If the participat does ot eroll for Medicare Parts A ad B, (a) the participat is ot eligible to eroll i a Medicare HMO ad (b) the OAP program, admiistered by CIGNA, will reduce beefits as if Medicare coverage is i place. CLAIMS How to File a Claim To file a claim uder the out-of-etwork portio of the OAP or PPO programs you must complete a claim form that is available i the Beefits Office or through the Beefits Office website at: BROOKHAVEN NATIONAL L ABOR ATORY 5

20 beefits: part 1 MEDICAL PLAN If you are retired, o log term disability or a depedet ad covered by Medicare, you should submit your bills to Medicare first. For items ot covered i full by Medicare, submit the explaatio of beefits from Medicare, copies of the bills, ad a completed claim form to CIGNA (for the OAP program). Completed CIGNA program claim forms ad copies of your bills should be submitted to the address o the back of your idetificatio card. Vytra claims should be submitted to the address o the claim form. There are o claim forms to file uder the HMOs. The providers will bill the HMO for you. Questios About Claims If you have a questio about your CIGNA OAP program claim, you should cotact CIGNA. If you have a questio about your Vytra PPO claim, you should cotact Vytra. If you participate i the Vytra PPO ad have a questio about your prescriptio drugs, you should cotact CIGNA (ot Vytra) at (800) Whe discussig your claim, please refer to the explaatio of beefits, the claim form, ad ay other correspodece that you may have received. You ca cotact the CIGNA claims admiistrator at (800) or the Vytra claims admiistrator at (631) How to Appeal a Claim Uder the CIGNA OAP program, you may request a review of the deied claim i writig to the isurace compay withi 365 days of the receipt of the otice of deial. You should state the reasos why your claim should ot have bee deied, icludig ay additioal documets which you believe support your claim. I ormal cases, the isurace compay will reder a decisio withi 30 days of the date your request for review is received. Uder the Vytra PPO, your explaatio of beefits will idetify if a claim is deied ad the reaso for the deial. You may request a review of the deied claim i writig to the isurace compay withi 180 days of the receipt of the otice of deial. You should state the reasos why your claim should ot have bee deied, icludig ay additioal documets which you believe support your claim. You will the receive a writte ackowledgmet withi 15 busiess days of receipt of your request. I ormal cases, the isurace compay will provide resolutio of your appeal withi 30 caledar days of receivig all ecessary iformatio. Uder the Aeta program, you may request a review of the deied claim by cotactig the isurace compay at (800) You will the receive a writte ackowledgemet that you must sig ad retur to the isurace compay. Withi 15 days of receipt, the isurace compay will request additioal iformatio. You should provide ay additioal iformatio to assist them i reviewig the claim. I ormal cases, the isurace compay will reder a decisio withi 30 days of the date your request for review is received. Uder the HIP program, you may request a review of the deied claim withi 180 days of the receipt of a adverse determiatio otice by cotactig the isurace compay at (800) , or submit your request i writig to HIP Grievace ad Appeal Departmet, JAF Statio, P.O. Box 2844, New York, N.Y or submit your request i perso to the Customer Service Walk-I Uit, 55 Water Street Lobby, New York, N.Y If the isurace compay requests additioal iformatio you should provide such iformatio to assist them i reviewig the claim. I ormal cases the isurace compay will reder a decisio withi 30 busiess days of the date your request for review is received. 6 BROOKHAVEN NATIONAL L ABOR ATORY

21 beefits: part 1 MEDICAL PLAN EXCLUSIONS The OAP program, admiistered by CIGNA, will ot provide paymet for: Expeses that are covered by Workers Compesatio, o-fault automobile isurace, or uisured motorist isurace law. Charges for uecessary services or charges which you would ot be legally required to pay or which would ot have bee made if there was o isurace. Charges for supplies, care, treatmet or surgery which are ot cosidered essetial for the care ad treatmet of a ijury or sickess. Charges i excess of reasoable ad customary limits or program maximums. Charges for private duty ursig while cofied as a ipatiet. Charges for or i coectio with custodial services, educatio or traiig. Expeses for or i coectio with experimetal procedures, treatmet methods, drugs or substaces ot approved by the America Medical Associatio, the Food ad Drug Admiistratio, or the appropriate medical society. Charges for or i coectio with routie refractios, eye exercises, surgical treatmet of a refractive error, or purchase or replacemet of cotact leses or eyeglasses. Charges for or i coectio with speech therapy if (a) used to improve speech skills that have ot fully developed, (b) cosidered custodial or educatioal, or (c) iteded to maitai speech commuicatio. Charges made by a provider who is a member of your or your depedet s family. Charges covered by Medicare. Detal x-rays ad examiatios, ad detal work uless made ecessary by accidetal ijury to soud atural teeth. Additioal exclusios may apply. Refer to your CIGNA Isurace Certificate for additioal iformatio. The Vytra PPO program will ot provide coverage for: Cosmetic, plastic or recostructive surgery, except as specified i your Certificate of Coverage. Disabilities coected to military service. Examiatios required for employmet, school, licesig, isurace, etc.. Trasportatio, except i the case of a emergecy. Detal care, except as specified i your Certificate of Coverage. Custodial care, except as may be covered through Hospice Care or by a Skilled Nursig Facility. Persoal or comfort items, subject to your rights to a appeal, ad exteral review. Additioal exclusios may apply. Cotact Vytra for iformatio o such exclusios. The Aeta ad HIP HMO programs will ot provide coverage for: Expeses that are covered by Workers Compesatio, o-fault automobile isurace, or uisured motorist isurace law. Charges for or i coectio with custodial services, educatio or traiig. Expeses for or i coectio with experimetal procedures, treatmet methods, drugs or substaces ot approved by the America Medical Associatio, the Food ad Drug Admiistratio, or the appropriate medical society. BROOKHAVEN NATIONAL L ABOR ATORY 7

22 beefits: part 1 MEDICAL PLAN Charges for cosmetic surgery except whe such service is icidetal to or follows surgery for trauma, ifectio or other diseases of the part of the body ivolved. For a covered child, coverage is provided for recostructive surgery to treat cogeital disease or aomaly which results i a fuctioal defect. Hearig aids. Certai expeses for ifertility services. Charges made by a provider who is a member of your or your depedet s family. Charges covered by Medicare. Detal x-rays ad examiatios, ad detal work uless made ecessary by accidetal ijury to soud atural teeth (Aeta). Additioal exclusios may apply. For a list of such exclusios refer to your HMO s member hadbook. NEWBORNS AND MOTHERS HEALTH PROTECTION ACT Group health plas ad health isurace issuers geerally may ot, uder Federal law, restrict beefits for ay hospital legth of stay i coectio with childbirth for the mother or ewbor child to less tha 48 hours followig a vagial delivery, or less tha 96 hours followig a cesarea sectio. However, Federal law geerally does ot prohibit the mother s or ewbor s attedig provider, after cosultig with the mother, from dischargig the mother or her ewbor earlier tha 48 hours (or 96 hours as applicable). I ay case, plas ad isurace issuers may ot, uder Federal law, require that a provider obtai authorizatio from the pla or the isurace issuer for prescribig a legth of stay ot i excess of 48 hours (or 96 hours as applicable). WOMEN S BREAST CANCER Federal law requires group health plas to provide coverage for the followig services to a idividual receivig pla beefits i coectio with a mastectomy: Recostructio of the breast o which the mastectomy has bee performed. Surgery ad recostructio of the other breast to produce a symmetrical appearace. The group health pla must determie the maer of coverage i cosultatio with the attedig physicia ad patiet. Coverage for breast recostructio ad related services are subject to deductibles, co-isurace ad co-paymet amouts that are cosistet with those that apply to other beefits uder the pla. EMPLOYEE PREMIUMS Employees who elect to participate i the Medical Pla must pay the required premiums. Your premiums are based o your Base Salary, the cost of the pla you elect, ad whether you elect to cover (a) yourself oly, (b) yourself ad oe depedet or (c) yourself ad two or more depedets. You may pay your premiums with before-tax or after-tax dollars. Before-tax premiums are deducted from your pay before state ad federal icome taxes ad Social Security taxes are withheld, resultig i a lower actual cost to you. After-tax premiums are deducted from your pay after taxes are withheld ad result i o tax savigs to you. Employee premiums are idicated at the ed of the Medical Pla sectio. If your aual salary is below the Social Security wage base ad you pay your premiums with before-tax dollars, your future Social Security beefits may be reduced. 8 BROOKHAVEN NATIONAL L ABOR ATORY

23 beefits: part 1 MEDICAL PLAN RETIREE PREMIUMS Retiree premiums are affected by both your eligibility for Medicare ad the Medicare eligibility of your covered depedets. If a participat lives outside of the Uited States ad is ieligible for Medicare, the premium for that participat for Medical Pla coverage will be the Medicare Part B premium i additio to ay other required Medical Pla premium. Retiree premiums are idicated at the ed of the Medical Pla sectio, ad are subject to chage. DISPLACED WORKERS HEALTH BENEFITS PROTECTION ACT (DWHBP) PREMIUMS Employees who are termiated from employmet as part of a reductio-i-force may cotiue their medical coverage by payig the required premiums. Premiums durig the first year after termiatio of employmet will be the active employee premium based o your Base Salary o the day immediately precedig termiatio of employmet. Durig the secod year, premiums will be oe-half of the applicable COBRA premium. After the secod year, such participats may cotiue coverage uder COBRA for up to 18 moths. Premiums are idicated at the ed of the Medical Pla sectio. Such DWHBP beefits as described i this sectio are ot available to participats, their spouse or their depedet child if eligible for Medicare, retiree medical coverage, or for coverage uder aother employer s group health pla. If a participat is ieligible for DWHBP beefits, they may be eligible to cotiue coverage for up to 18 moths uder COBRA. OPEN ENROLLMENT PERIOD Ope erollmet is held oce a year. Durig a Ope Erollmet Period, you may chage medical programs, drop coverage ad/or add or drop depedets from your coverage. Employees who did ot previously elect medical coverage may elect it durig the Ope Erollmet Period. Participats receivig LTD Pla beefits, retirees, ad their depedets who did ot previously elect medical coverage, may ot elect it durig the Ope Erollmet Period. Chages you elect durig the Ope Erollmet Period will be effective Jauary 1 of the followig caledar year. Your electios will be i effect for the remaider of the caledar year uless you otify the Beefits Office of a Qualifyig Evet withi 31 days of the evet. QUALIFYING EVENT A Qualifyig Evet is a chage i your family status ad icludes: (a) Chage i legal marital status 1. marriage 2. death of spouse 3. divorce 4. legal separatio 5. aulmet (b) Chage i the umber of depedets 1. birth 2. adoptio 3. placemet for adoptio 4. death of a depedet (c) Chage i employmet status 1. termiatio or commecemet of employmet of the employee, spouse or depedet (other tha for miscoduct) BROOKHAVEN NATIONAL L ABOR ATORY 9

24 beefits: part 1 MEDICAL PLAN (d) Chages i work schedule 1. a icrease or decrease i the umber of hours of employmet by the employee, spouse or depedet 2. a switch betwee full-time ad part-time status 3. a strike or lockout 4. commecemet or retur from a upaid leave of absece (e) The depedet satisfies or ceases to satisfy the requiremets for depedets 1. attaimet of age (f) A chage i the place of residece or work site of the employee, spouse or depedet I additio, based o the provisios of the Childre s Health Isurace Reauthorizatio Act of 2009 (CHIPRA), employees ad depedets that are eligible but ot erolled for BSA health isurace pla coverage may eroll for coverage if oe the followig coditios is met: The employee or depedet loses eligibility ad is termiated from Medicaid or CHIP* coverage or The employee or depedet becomes eligible for a premium assistace subsidy uder Medicaid or CHIP*. *CHIP (Childre s Health Isurace Program) is a state program desiged to provide health care coverage for uisured childre ad some adults. You have 31 days from the date of a Qualifyig Evet to make chages to your medical coverage for all items idicated above except (a)(3), (a)(4), ad (e)(1). You have 60 days from the date of a Qualifyig Evet to make chages to your medical coverage for items (a)(3), (a)(4), (e)(1), ad chages related to CHIPRA. The chage requested must relate to the chage that affects eligibility for medical coverage. Chages are made by completig a erollmet form, available i the Beefits Office. The completed form must be submitted, with proof of the Qualifyig Evet, to the Beefits Office. Your premiums will the be chaged for the remaider of the caledar year. Coverage will become effective as of the date of the evet. If you do ot make a chage to your medical coverage withi the applicable period idicated above, you must wait util the ext Ope Erollmet Period. If a depedet is o loger eligible for coverage ad you do ot remove that depedet from your coverage withi the applicable period idicated above, your depedet will be removed from your coverage as of the date the Beefits Office is otified. MISCELLANEOUS Base Salary Base Salary for the purpose of the medical programs meas your basic rate of pay, before ay salary reductios. It does ot iclude overtime, bouses, or ay other compesatio. For part-time employees, Base Salary is based o the full-time equivalet basic rate of pay. For uio employees, Base Salary is based o the terms of the uio cotract. Cotiuous Service Cotiuous Service meas service from your most recet hire date. Service performed prior to a break i employmet is ot icluded i Cotiuous Service. Cotiuous Service will be reduced by periods o approved Leave of Absece ad will ot iclude periods whe the employee is ot eligible for medical beefits. Cotiuous Service shall iclude Cotiuous Service, if ay, with Associated Uiversities, Ic., Battelle Memorial Istitute, Research Foudatio of the State Uiversity of New York or the State Uiversity of New York at Stoy Brook immediately prior to a trasfer of employmet to Brookhave Sciece Associates, LLC. 10 BROOKHAVEN NATIONAL L ABOR ATORY

25 beefits: part 1 MEDICAL PLAN Deductible Uder the out-of-etwork portio of the OAP ad the PPO programs, the Deductible is the amout you pay out of your pocket before you receive reimbursemet for covered medical expeses. The Deductible does ot iclude expeses that exceed the Reasoable ad Customary charges. For all participats: The aual Deductible for the OAP program, admiistered by CIGNA, is $500 per idividual ($1500 per family) per caledar year. The aual Deductible for the Vytra PPO program is $2,000 per idividual ($4,000 per family) per caledar year. I geeral: I-etwork OAP ad PPO medical expeses do ot have a Deductible or do they cout toward the Deductible. If three or more members of a family icur total out-of-pocket expeses, durig the caledar year, i excess of the Family Deductible, o further Deductible amouts are required for the etire family durig the remaider of that year. The deductibles idicated above do ot apply to the HMOs. I additio to the above, there is a separate $100 per idividual ($300 per family) aual prescriptio deductible for the OAP ad PPO programs. This applies, i total, to both the retail pharmacy ad mail order portios of the program. Geeral Iformatio Iformatio regardig the pla idetificatio umber, pla year, pla fudig, type of pla, pla sposor, pla admiistrator, aget for legal process, your rights uder ERISA, prudet actios by pla fiduciaries, modificatio, suspesio, or termiatio of the pla, ad privacy of iformatio ca be foud i the Geeral Iformatio sectio of this booklet. Hospital Preadmissio Certificatio Uder the OAP ad PPO programs, all covered participats must obtai Hospital Preadmissio Certificatio. This certificatio is madatory for a hospital stay of oe or more ights. If you are retired or disabled ad covered by Medicare, you are ot required to pre-certify your hospital admissio. If Hospital Preadmissio Certificatio is ot obtaied, a $250 pealty will be applied to the OAP ad PPO programs. I additio, uder the OAP ad PPO programs, beefits for ay days ot approved by the isurace compay will be reduced by 50% of the amout otherwise payable. The expeses that you icur because of these beefit limitatios will ot apply to your Out-Of-Pocket Maximum. For Hospital Preadmissio Certificatio, call the toll free phoe umber provided o your medical idetificatio card before admissio to the hospital or withi 48 hours of a emergecy admissio. Uder the HMOs, you must call the telephoe umber show o your medical idetificatio card to obtai approval for hospital care or the applicable claims will be deied. Leave of Absece If you are o a approved Leave of Absece, icludig for military duty, you may cotiue your medical coverage durig the term of the approved leave from the startig date of your leave by payig the required employee premiums. This coverage will cease whe the employee is o loger o the approved Leave of Absece. Participats o approved military leave may drop medical coverage for themselves while cotiuig to cover their depedets. Cotiuatio of isurace is ot allowed while o leave for other employmet whe (1) the other employer offers coverage or (2) the other employer is a agecy or prime cotractor of the federal govermet that will cover you uder its isurace program. BROOKHAVEN NATIONAL L ABOR ATORY 11