YOUR 2013 BENEFITS ENROLLMENT GUIDE

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1 YOUR 2013 BENEFITS ENROLLMENT GUIDE YOUR CHOICES YOUR BENEFITS YOUR HEALTH

2 COVENTRY S BENEFITS PROGRAM reflects a strong commitment to our employees by providing a comprehensive and competitive choice of benefits at the best possible value. Your Coventry Benefits Program includes a wide range of options designed to meet the health care and financial needs of you and your family. YOUR CHOICES Coventry Health Care is dedicated to promoting improvement in the overall health of our employees and their family members by offering benefit programs that reward taking action for your health. IN THIS GUIDE This Benefits Enrollment Guide describes available 2013 benefits, including eligibility requirements, 2013 benefit costs, and how to use your benefits. It also provides you with the information you need to make important decisions about which benefits are most valuable for you and your dependents, and how to get the most value out of the benefits you elect. We encourage you to review this information carefully. 2 Enrollment Guide

3 COSTS AND CONTRIBUTIONS In 2013, costs for Coventry s medical and dental coverage will be about $124 million. That is an average of $9,495 per enrolled employee for annual medical and dental coverage. Coventry pays $89 million, while our employees pay the remaining $35 million. For 2013, Coventry will contribute on average 78% of the total employee only medical premium, and 70% of eligible dependents medical premiums. You have a choice of medical plans in which to enroll. This choice allows you to decide whether to pay more of your medical expenses up front in the form of premium contributions (the HMOs and EPO Plan) or pay more at the time of service, but you will have the ability to access funds contributed by Coventry (the HRA Plan). Despite the increased ongoing costs for medical and dental coverage, Coventry continues to make significant contributions toward all premiums in order to provide you with valuable benefits coverage. SUPPLEMENTAL MEDICAL PREMIUMS As health care costs continue to rise, Coventry s contribution strategy for medical coverage is designed to ensure the long-term effectiveness of our overall benefits program. As part of this strategy, our premium structure shares benefit cost increases proportionally among Highly Compensated s (HCE). This cost sharing is achieved through the following supplemental premiums: HCE 35 If your eligible earnings 1 are equal to or greater than $100,000 and less than $150,000, you will pay an additional $35 per pay period for medical coverage. This earnings-based premium applies to all medical plans. HCE 75 If your eligible earnings 1 are equal to or greater than $150,000 and less than $200,000, you will pay an additional $75 per pay period for medical coverage. This earnings-based premium applies to all medical plans. HCE 100 If your eligible earnings 1 are equal to or greater than $200,000, you will pay an additional $100 per pay period for medical coverage. This earnings-based premium applies to all medical plans. While Coventry s contribution toward any of the available medical coverage will lower your overall medical costs, the type of plan you choose also has an important impact on your out-of-pocket costs when you receive medical services. It is important that you consider not only the per-paycheck premium contributions, but also the out-of-pocket costs for each plan as you evaluate your medical choices. You may be further able to reduce your overall medical expenses if you move to a spouse s benefit plan (if available) or take advantage of tax savings by making Spending Account (FSA) Health Care contributions and participating in the Wellness Fund (see pages 9 and 37 for more information). Remember, Your Health can be improved and maintained through smart utilization of Your Benefits by Your Choices among available 2013 Coventry benefits for you and your dependents that promote a healthy lifestyle and fit your needs. 1 Eligible earnings are equal to your 2011 W-2 compensation, including base salary, incentives (bonuses and commissions), overtime, and pre-tax deferrals, but excluding proceeds of employee stock options sold and/or relocation expenses. Eligible earnings for employees hired after January 1, 2012 and employees with less than 12 months of earnings in 2011 are equal to base wages as of date of hire. 3 Enrollment Guide

4 Eligibility for Benefits EMPLOYEES You are eligible to participate in the Coventry Benefits Program if you are: A regular full-time employee scheduled to work up to 40 hours per week A regular part-time employee scheduled to work 32 to 39 hours per week A limited part-time employee scheduled to work 20 to 31 hours per week part-time employees are not eligible for the Coventry Benefits Program, except for the 401(k) Plan. DEPENDENTS For all applicable benefit plans, except 1, eligible dependents include: Your legal spouse (excludes common law spouse) Your same-sex domestic partner (for all the medical plans, dental coverage, and Long- Term only) who: Is at least 18 years old and the same gender Is not legally married to or separated from anyone Is not related in any way that would prohibit marriage in the State in which you reside Is your sole domestic partner Is sharing a permanent residence with you as a member of the same household Is in a committed relationship of mutual support and has shared financial obligations and living expenses with you for at least six months with the intent to do so indefinitely Is not in a relationship solely to obtain insurance Your child or your domestic partner s child under the age of 26 if he or she is: Your son or daughter Your legally adopted child Your step child A grandchild, niece, or nephew under the age of 26 if you are the legal guardian of the child An unmarried child over age 26 if he or she has a mental or physical handicap IMPORTANT NOTE: 1 Refer to page 45 for a complete definition of eligible family members for. Documentation, such as birth and marriage certificates or Coventryrecognized documentation will be required as proof of dependent eligibility. If you change your elections during the year due to a qualified change in status, you will be required to provide specific information applicable to your event. Enrolling ineligible individuals is a serious violation of both benefit plan rules and Company policy. Doing so may result in termination of your benefits coverage and termination of employment with the Company. 4 Enrollment Guide

5 IMPORTANT INFORMATION ABOUT DOMESTIC PARTNERS Same-sex domestic partners are eligible for select Coventry benefit plans specifically all the Medical Plans, the Dental Plan, and the Plan. Due to IRS regulations, domestic partners and their children are not eligible to receive benefits from: The Coventry Consumer Choice HRA Fund Wellness Fund The Coventry Consumer Choice FSA Health Care (FSA Health Care) The Coventry Consumer Choice FSA Dependent Care (FSA Dependent Care) In addition, there may be tax implications for covering your same-sex domestic partner and/or your domestic partner s children under Coventry s benefits. Consider speaking with a tax advisor for more information. If you wish to enroll your same-sex domestic partner for medical or dental coverage, contact your Human Resources Representative. QUALIFIED CHANGES IN STATUS Contributions for certain benefit premiums are made on a pre-tax basis. IRS regulations require that you enroll for these benefits before the enrollment deadline and that your elections remain in effect for the entire calendar year. You may only change your benefits coverage during the year if you experience a qualified change in status, as defined by IRS regulations. Examples of a qualified change in status include but are not limited to: You gain or lose a dependent (such as through birth, death, adoption, marriage, divorce, or legal separation). Your dependent is no longer eligible for coverage because he or she has reached age 26. Your spouse s loss or gain of eligibility under his or her own employer s benefit plan. Any changes you request must also be consistent with your Coventry-recognized qualified change in status event. Generally, this means you may only add or delete dependents from your current coverage as the result of the Coventry-recognized qualified change in status. Documentation to support the qualified change in status event and dependents benefits eligibility will be required. Please refer to your Handbook for additional details. To make a change in coverage due to a qualified change in status, you must report the change in status and complete your enrollment, including the verification of applicable dependents, within 31 days of the event. If you do not notify Human Resources of a change in status and complete your enrollment within 31 days of the qualifying event, you will not be able to make a change to your benefits until the Open Enrollment period. 5 Enrollment Guide

6 Coventry s Benefits Program provides you with the ability to make Your Choices to select Your Benefits from a wide range of plans to help you focus on improving and maintaining Your Health. Coventry provides the following benefits to eligible employees at no cost: Basic Life Insurance Basic Accidental Death & Dismemberment (AD&D) Insurance Business Travel Accident (BTA) Insurance Basic Disability (LTD) Benefits (EAP) In addition, Coventry pays a large portion of your medical and dental premiums, and you have the option to elect additional benefits at your own cost: Vision FSA Health Care FSA Dependent Care Supplemental Life Insurance Spousal Life Insurance Child Life Insurance Supplemental AD&D Insurance Supplemental LTD Insurance Legal benefits Under the Medical, Dental, and Vision Plans, you choose which plans to enroll in and eligible family members you want to cover in each plan. There are four coverage level categories: COVERAGE LEVEL CATEGORIES + Spouse or Domestic Partner + Children Family You are the only person covered You and your legal spouse (or domestic partner) are covered You and all your eligible dependent children are covered You and your legal spouse (or domestic partner) and any eligible dependent children (including children of a domestic partner) are covered Remember, same-sex domestic partners are only eligible for medical, dental, and Long- Term coverage. To enroll a same-sex domestic partner, you must contact your Human Resources Representative. Certain of the benefits presented in this Guide are not plans or programs sponsored by Coventry Health Care. Rather, these non-sponsored plans and programs are merely being made available to Coventry employees and their family members on a voluntary basis. These benefits are not covered by the Retirement Income Security Act of 1974 ( ERISA ) and any provisions of this Guide or other descriptive materials that explain or describe any rights mandated by ERISA do not apply to such benefits. The non-erisa benefits are: FSA Dependent Care 6 Enrollment Guide

7 2013 FULL-TIME AND REGULAR PART-TIME BENEFITS SUMMARY 1 The chart below provides an overview of the basic benefits and optional coverages offered to you and your eligible dependents (as defined on page 4). Medical BENEFIT YOUR OPTIONS COVERAGE LEVELS COST SHARING Assistance Program (EAP) Dental Vision HRA Plan at all locations (except Bismarck, ND and GDS, Rockville, MD) HMO or EPO depending on your location (except Bismarck, ND) PPO (Bismarck, ND and GDS, Rockville, MD only) Provides counseling and referrals for personal and professional issues Coventry Dental 3 Delta Dental 3 Vision + Spouse or domestic partner 2 + child(ren) Family Coventry pays on average 78% for employees and 70% for dependents Remember: additional premiums apply to highly compensated employees. and household members Coventry pays 100% + spouse or domestic partner 2 + child(ren) Family + spouse + child(ren) Family Coventry pays 60% to 65% for employees and 57% to 59% for dependents paid FSA Health Care Up to $2,500 per calendar year and eligible dependents paid FSA Dependent Care Up to $5,000 per calendar year and eligible dependents paid Basic Life Insurance Supplemental Life Insurance Spousal Life Insurance 1.5 x base salary 4 up to a maximum of $600,000 1, 2, 3, 4, 5, or 6 x base salary 4 up to a maximum of $900,000 $10,000, $25,000, $50,000, $75,000, $100,000, $150,000, or $250,000 Coventry pays 100% Spouse paid paid Child Life Insurance $10,000 or $20,000 for each child Eligible children paid 1 Benefits are effective on your date of hire, except for Disability benefits. This chart is a summary of benefits for full-time employees who work a regular 40-hour week and regular part-time employees who regularly work at least 32 hours per week. Please refer to the Summary Plan Description for detailed information. 2 Same-sex domestic partners are eligible for the Coventry Medical Plans, dental coverage, and. 3 Except GDS, Rockville, MD. 4 See page 40 for a definition of base salary. 7 Enrollment Guide

8 BENEFIT YOUR OPTIONS COVERAGE LEVELS COST SHARING Basic Accidental Death & Dismemberment (AD&D) Insurance Supplemental AD&D Insurance Business Travel Accident Insurance Basic Disability (LTD) Benefits Supplemental LTD Benefits 1.5 x base salary 4, up to a maximum of $600,000 Coventry pays 100% $25,000, $50,000, $75,000, $100,000, $200,000, $300,000, $400,000, $500,000, or $750,000 Up to 4 x base salary 4 up to a maximum of $750,000 50% of base salary 4 up to $10,000 per month (eligible after 90 days of employment) Additional 10% of base salary 4 up to $15,000 per month (eligible after 90 days of employment) and eligible dependents paid Coventry pays 100% Coventry pays 100% paid Legal advice and representation and eligible dependents paid Care and eligible family members paid 1 Benefits are effective on your date of hire, except for Disability benefits. This chart is a summary of benefits for full-time employees who work a regular 40-hour week and regular part-time employees who regularly work at least 32 hours per week. Please refer to the Summary Plan Description for detailed information. 2 Same-sex domestic partners are eligible for the Coventry Medical Plans, dental coverage, and. 3 Except GDS, Rockville, MD. 4 See page 40 for a definition of base salary. LOCATING IN-NETWORK PROVIDERS Local Health Plans: You can check to see if your doctor is in the local Health Plan network by visiting the website for that plan. (You can find links to these plans websites on page 49 of this Guide). Please visit the Find a Doctor section on the plan s website, or call Customer Service for your plan. Delta Dental Network: Find participating dental providers at The Coventry National Network: If your office is not located in a Coventry Health Plan local service area, you can check to see if your doctor is in the Coventry National Network by visiting the Find a Doctor section or and selecting Coventry National Network when prompted to select a product, or by calling Customer Service at (800) Coventry Dental Network: Find participating dental providers at 8 Enrollment Guide

9 Coventry Health Care is dedicated to promoting improvement in the overall health of our employees and their family members by offering benefit programs that reward taking action for Your Health. The Coventry Medical Plans described in this Guide are available to all employees except Bismarck, ND and GDS employees. A summary of each of your options follows: COVENTRY MOBILE Upload this app to your mobile device for access to your: Medical Health Record Medical Claims History Search Formulary (coming soon) Find a Doctor...and More! WELLNESS FUND When you enroll in any Coventry Health Care Medical Plan* you can qualify to receive up to $250 in a Wellness Fund that can pay for your out-of-pocket expenses to offset your copays or deductibles. You can earn your Wellness Fund rewards by taking action to complete any or all of three Wellness Activities by December 31, 2013, including: 1. Complete a Health Risk Assessment and you will receive $100 in your Wellness Fund 2. Complete any of nine Digital Health Coaching Programs and you will receive $100 in your Wellness Fund, including: Balance Weight Management Breathe Smoking Cessation Relax Stress Management Nourish Nutrition Improvement Move Physical Activity Achieve For Cholesterol Cholesterol Management Care For Blood Pressure Blood Pressure Management Care For Depression Depression Management Care For Sleep Sleep Improvement 3. An questionnaire will be sent to you 90 days after you complete either the Health Risk Assessment or a Digital Health Coaching Program. By completing this 90-Day Evaluation, you will receive $50 in your Wellness Fund. To get started, you must first register on My Online Services through your health plan website or on Coventry Today. NOTE: In order to receive the 90-Day Evaluation prior to December 31, 2013, you must complete the Health Risk Assessment or Digital Health Coaching Program before October 1, For more details on the Coventry WellBeing Programs, see page 27. *The Wellness Fund is available in all locations except Bismarck, ND and GDS Rockville, MD. 9 Enrollment Guide

10 HOW TO USE YOUR WELLNESS FUND As you complete each Wellness Activity, Coventry Health Care will deposit your rewards into a Wellness Fund administered by Coventry Consumer Choice (C3). Your Wellness Fund gives you an opportunity to take more control over how you spend your health care dollars. Your Wellness Fund rewards are tax-free and can be used to pay for covered medical expenses. You can use your Wellness Fund rewards to pay for any covered medical expenses such as office visits, copays, coinsurance, deductibles, and prescriptions, as well as eligible dental and vision expenses. HOW YOUR WELLNESS FUND WORKS WITH YOUR OTHER BENEFIT FUNDS TO SAVE YOU MONEY What medical plans can include the fund? HEALTH CARE FLEXIBLE SPENDING ACCOUNT (FSA) HMO, EPO, HRA including North Dakota BCBS PPO WELLNESS FUND CHC HMO, EPO, HRA only (excludes GDS Medical plans and Bismarck, ND) Annual maximum contribution $2,500 $250 Who contributes Coventry, after earns contribution by completing Wellness Activities HEALTH CARE REIMBURSEMENT ACCOUNT (HRA) CHC HRA plans only $500 employee only $1,125 employee/spouse $1,125 employee/child/ren $1,750 employee/family Coventry Which fund pays first Pays first Pays second Pays last Do unused balances carry over to the year? What expenses can be paid from the fund? Who is eligible to use the fund? No. You forfeit your unused balance each year. Yes, unused balances carry over Yes, unused balances carry over up to: $3,000 employee only $5,500 employee/spouse $5,500 employee/child(ren) $8,000 family Medical, prescription, dental, vision deductibles, coinsurance and copays (IRS Section 213(d) allowable expenses)* Any eligible family member whether or not they are enrolled in Coventry HMO/ EPO or HRA Medical Plan After you receive services, be sure to have your providers send claims to Coventry first, so we can apply the network discount. At the time of service, you should only pay your copayment, if applicable. After you ve met the upfront deductible, when a claim is submitted for medical services, the money is automatically withdrawn from your Wellness Fund. Coventry processes your claims and automatically pays you or the provider for eligible expenses. Payment can be sent through electronic funds transfer and deposited directly into the bank or by check. s and family members enrolled in Coventry HMO/EPO or HRA Medical Plan s and family members enrolled in Coventry HRA Medical Plan Can you cash out your fund? No No No * Due to IRS regulations, domestic partners and their children are not eligible to receive benefits from the Spending Account -- Health Care, Wellness Fund, or HRA Fund. 10 Enrollment Guide

11 VALUE BASED INSURANCE DESIGN (VBID) Coventry encourages you to take an active role in maintaining Your Health. When you or a covered family member choose to take responsibility for Your Health by following medical treatment plans and adhering to your prescribed medications, you are helping to maintain Your Health. Under the VBID plan design for both the HMO/EPO and HRA plans, you will have no medical and prescription copays for certain services when you participate in Disease Management and receive care from participating providers. You must remain actively enrolled in Disease Management or your prescription drug copay waivers and discounts will cease*. The VBID plan design applies to the following five diseases and specific related services: DISEASE MEDICAL SERVICE COVERED 100% (no deductible or coinsurance) COVERED PHARMACY RELATED EXPENSES Tier 1A and Tier 1 Rx Covered 100% Tier 2 Rx Covered 50% of copay Asthma Pulse Oximetry, Spirometry Pulmonary Function Test Inhaler Diabetes LDL, Microalbumin, HbAlc, Eye Exam Diabetic Medications & Supplies: One Touch test strips, lancets, syringes, and pen needles covered at 50% of normal copay Congestive Heart Failure Cardiac Rehab ACE Inhibitor or ARBRx and Beta Blocker Coronary Artery Disease LDL, Cardiac Rehab ACE Inhibitor or ARBRx and Beta Blocker Chronic Obstructive Pulmonary Disease Pulmonary Function Test, Pulse Oximetry Bronchodilator *The VBID plan design is available in all locations except Bismarck,ND and GDS Rockville, MD. 11 Enrollment Guide

12 Coventry Consumer Choice Health Reimbursement Arrangement (HRA) Plan 1 OVERVIEW The HRA Plan is a consumer-directed health plan (CDHP) that is paired with a Health Reimbursement Arrangement (HRA) Fund. With the combination of the HRA Fund set up by Coventry and the health care coverage the plan provides, you have more control of your health care costs while still having the protection you need for you and your family. In addition to the HRA Fund, you can earn additional money in a separate Wellness Fund when you complete up to three Wellness Activities. See page 9 for more information. The HRA Plan is a PPO plan in which you have a deductible, coinsurance, and access to coverage for services obtained either in-network or out-of-network. Coventry establishes an HRA Fund that you can use to pay for qualified medical expenses. If you do not use all of the money in your HRA Fund during the plan year, you may roll some or all of the remaining money to the year (see HRA Fund on page). 1 The HRA Plan is available in all locations except Bismarck, ND and GDS, Rockville, MD. You can offset your HRA deductibles in 2013 by earning up to $250 in Wellness Fund rewards paid by Coventry Health Care when you complete all three Wellness Activities. For details see page 9 of this Guide. Value Based Insurance Design (VBID) allows you and your covered family members to receive 100% coverage without copays or deductibles for certain services for five diseases when you actively participate in Disease Management and Complex Case Management. For details see page 11 of this Guide. FEATURES OF THE HRA PLAN Network With the HRA Plan, you always have the choice of using in-network or out-of-network providers at any time. You do not have to choose a primary care physician and do not need to be referred to most specialists by your doctor. In-network services are processed at contractual/discounted rates, which you money when you seek care. However, no discounts are available for out-of-network services, and you may be responsible for costs above the allowable charges. If you choose to receive out-of-network care, the provider may require that you file a claim to be reimbursed for the service. If you have dependents who live outside of your local health plan s service area and are covered on your plan, check with the plan to see what coverage is available for them. 12 Enrollment Guide

13 HRA Fund Once you are enrolled in the HRA Plan, Coventry will establish an HRA Fund in your name and contribute the following amounts (based on a full calendar year of participation): $500 for employee coverage $1,125 for employee + spouse coverage $1,125 for employee + child(ren) coverage $1,750 for family coverage You may use your HRA Fund to reimburse yourself, or your provider, for covered medical expenses such as office visits, copays, coinsurance, deductibles, and prescriptions, as well as eligible dental and vision expenses. If you do not participate for a full calendar year, the amount of your HRA Fund will be prorated based on your date of hire. Any unused money remaining in your HRA Fund at the end of the year can be rolled over to the year. The maximum amount that can be rolled over is two times the current innetwork deductible for the level of coverage in which you are enrolled. For 2013, the in-network deductibles for each level of coverage are: $1,500 for employee coverage $2,750 for employee + spouse coverage $2,750 for employee + child(ren) coverage $4,000 for family coverage The maximum amount you can roll over is: $3,000 for employee coverage $5,500 for employee + spouse coverage $5,500 for employee + child(ren) coverage $8,000 for family coverage If you terminate your HRA Plan coverage, the remaining balance in the HRA Fund is forfeited. Due to IRS regulations, domestic partners and their children are not eligible to receive benefits from the HRA Fund. However, domestic partners and their children are permitted to use benefits under the HRA Plan. NOTE: The HRA Plan uses either the local Health Plan network or the Coventry National Network, depending on your office location. If you enroll in the HRA Plan for 2013 and are assigned to an office location within a Coventry Health Plan local service area, you will use that Health Plan s local provider network. If your office assignment is outside of a Coventry Health Plan local service area and you choose the HRA Plan, you will use the Coventry National Network of providers. 1 1 The HRA Plan is available in all locations except Bismarck, ND and GDS, Rockville, MD. 13 Enrollment Guide

14 Deductible All medical services covered under the plan (other than copays) count toward your deductible. While you may use your HRA Fund to reimburse these copays, the charges for these services do not count toward your deductible. If you use all the money in your HRA Fund for qualified medical expenses, as well as all your Wellness Fund earnings, you will be responsible for paying the cost of services until you meet the annual deductible. If you and any of your family members are enrolled in the plan, your deductible can be met with a combination of expenses from all of your enrolled family members. However, the maximum deductible for any one member of your family is the individual deductible amount. Generally, you can estimate the total out-ofpocket expense you may incur before meeting your annual deductible by subtracting your HRA Fund amount from your deductible. Below is an example of your possible outof-pocket expense. Keep in mind that your situation may vary based on: Where you receive services (in-network or out-of-network) If you use your HRA Fund to cover costs that do not count toward your deductible (such as copays or dental or vision expenses) If you have a rollover in your HRA Fund from the previous year The HRA Fund can be used to pay part of your deductible. Once you meet your deductible, in-network and out-of-network services are covered under the HRA Plan at the corresponding coinsurance level. Please note, the in-network deductible is separate from the out-ofnetwork deductible. In-network expenses do not apply toward the out-of-network deductible and out-of-network expenses do not apply to the in-network deductible. LEVEL OF COVERAGE ANNUAL DEDUCTIBLE MINUS HOW TO MEET YOUR IN-NETWORK DEDUCTIBLE WELLNESS FUND (PROVIDED BY COVENTRY WHEN EARNED BY EMPLOYEE) MINUS HRA FUND AMOUNT (PROVIDED BY COVENTRY) EQUALS YOUR POSSIBLE EXPENSE TO MEET DEDUCTIBLE $1,500 $250 $500 = $750 + Spouse $2,750 $250 $1,125 = $1,375 + Child(ren) $2,750 $250 $1,125 = $1,375 Family $4,000 $250 $1,750 = $2, Enrollment Guide

15 Copays There are a few instances when members in the HRA Plan will only need to pay a copay for health care, such as when you: Seek maternity care you pay a $15 copay for the first visit to either a primary care doctor or a specialist Have a prescription filled at a participating pharmacy or through the mail order service Keep in mind, when you pay copays for these services, these copays can be reimbursed to you from your HRA Fund and Wellness Fund, but they do not count toward your annual deductible or your out-of-pocket maximum. In addition, there is no cost to you for preventive care services. Coinsurance Most services are subject to 15% in-network and 35% out-of-network coinsurance after you meet your deductible. These services include physician office visits, inpatient hospitalization, home health care, skilled nursing, maternity services for delivery, and rehabilitation services, such as physical, speech, and occupational therapy. Out-of-Pocket Maximum If your out-of-pocket medical expenses reach your out-of-pocket maximum, the plan pays 100% of the allowable maximum charges for the rest of the plan year. Your deductible and coinsurance count toward the out-of-pocket maximum, but copays do not. Like the deductible, if you and any of your family members are enrolled in the plan, your out-of-pocket maximum can be met with a combination of expenses from all of your enrolled family members. However, the maximum out-of-pocket for any one member of your family is the individual out-of-pocket maximum amount. Mental Health/Chemical Dependency See page 23 of this Guide for a description of mental health benefits available through this plan. HRA Fund Coordination With Spending Account Health Care and Wellness Fund If you enroll in an FSA Health Care and the HRA Medical Plan, benefits will be paid first from your FSA Health Care account. After your FSA account is exhausted, benefits will be paid from your Wellness Fund rewards. After your FSA and Wellness Fund, your benefits are paid from the HRA Fund. Remember: Your unused FSA funds do not roll over from year to year. However, any unused balance in your Wellness Fund or HRA does rollover year to year. Additionally, expenses you submit to your FSA Health Care for reimbursement cannot also be reimbursed from your Wellness Fund or HRA Fund. See page 10 for more information. 15 Enrollment Guide

16 How The HRA Plan Works You use the money in your HRA Fund for any qualified medical expenses. Medical and pharmacy claims are reimbursed without submitting a paper request (claims crossover). When you see your provider for services, your provider will submit the bill to the HRA Plan for you. Once the plan processes the claim, it will then submit the claim information to your HRA Fund. Under the HRA Fund, your copays will automatically be reimbursed to you and your share of the deductible and coinsurance will automatically be deducted from your HRA Fund and reimbursed to your provider. If you do not want Coventry to automatically send these payments to your providers, you can make a request to customize this service and have the reimbursements paid to you through Coventry s Smart Payment feature. Once you meet the annual deductible, your medical claims will be reimbursed at the coinsurance level. The Plan pays 85% for innetwork medical services and 65% for out-ofnetwork medical services. Coventry will send your provider payment for the Plan s portion of covered expenses and you are responsible for your portion of the covered expenses. Prescription drugs are available for a copay and are never subject to the deductible or coinsurance. If you reach your out-of-pocket maximum during the plan year, the plan will pay 100% of allowable charges for the rest of the year. If you use all of the money in your HRA Fund, you will be responsible for paying the cost of services until you meet the annual deductible. Step 1 Step 2 Step 3 Step 4 If you meet the out-of-pocket maximum, the plan pays 100% for the rest of the year The coinsurance feature of the plan begins and you pay coinsurance In-Network: 15% Out-of-Network: 35% You meet the annual deductible and coinsurance In-Network/Out-of-Network Ee: $1,500/$3,000 Ee+child: $2,750/$5,500 Ee+spouse or $2,750/$5,500 Family: $4,000/$8,000 domestic partner: HRA Fund pays first Ee: $500 Ee+spouse: $1,125 Ee+child: $1,125 Family: $1,750 NOTE: In-Network/Out-of-Network Ee: $3,250/$6,500 Ee+spouse or $5,750/$11,500 domestic partner: + Then you pay In-Network/ Out-of-Network Ee: $1,000/$2,500 Ee+spouse: $1,625/$4,375 Ee+child: $1,625/$4,375 Family: $2,250/$6,250 Ee+child: $5,750/$11,500 Family: $8,250/$16,500 Copays ELIGIBLE URGENT CARE SERVICES: $50 copay after annual deductible is met PRESCRIPTION DRUGS: Retail 31-day Supply: $3/$15/$45/$75 At Walgreens: $3/$10/$35/$65 90-day Supply: Mail Order: $3/$15/$87.50/$195 At Walgreens: $3/$15/$87.50/$195 These copays do not count toward your annual deductible or your out-of-pocket maximum. You can change your reimbursement options by going to the My Online Services section of your health plan web page. You may also review the information on Coventry Today. 16 Enrollment Guide

17 Health Maintenance Organizations (HMOs) If you are assigned to an office location within a Coventry HMO service area and choose to enroll in this option, you will be enrolled in the local HMO Plan. 1 OVERVIEW Each HMO Plan offers a local network of Coventry doctors, hospitals, and pharmacies that provide health care services. When you enroll in an HMO, you may be asked to select a primary care physician (PCP) who will provide most of your care. While your PCP may refer you to a specialist when necessary, you do not need a referral to visit most specialists. You generally pay a copay each time you visit an HMO provider or are hospitalized, without having to pay coinsurance or file claims. Coventry s goal is to maintain consistent copays and coverage service levels for all HMOs throughout the country; however, there are some differences due to our local Health Plans practices. The HMO Plans differ from the HRA Plan in that there is no employer-funded HRA Fund, and little or no coverage for out-of-network services. You may be subject to a deductible for certain services. You can offset Your HMO deductibles in 2013 by earning up to $250 in Wellness Fund dollars paid by Coventry Health Care when you complete all three Wellness Activities. For details see page 9 of this guide. Value Based Insurance Design (VBID) allows you and your covered family members to receive 100% coverage without copays or deductibles for certain services for five diseases when you actively participate in Disease Management and Complex Case Management. For details see page 11 of this Guide. FEATURES OF THE HMO PLANS Network You can check to see if your doctor is in the local Health Plan network by visiting the website for that plan. (You can find links to these plans websites on page 49 of this Guide.) Please visit the Find a Doctor section on the plan s website, or call customer service for your plan. If you receive medical services from a provider outside the HMO network, the HMO will pay none of the costs, unless the situation is a medical emergency. If you have dependents who live outside of your local Health Plan s service area and are covered on your plan, check with the plan to see what coverage is available for them. Deductible All medical services covered under the plan (other than copays) count toward your deductible. If you and any of your family members are enrolled in the plan, your deductible can be met with a combination of expenses from all your enrolled family members. However, the maximum deductible for any one member of your family is the individual deductible amount. However, you may still earn Wellness Fund dollars to offset your HMO deductible or copays, as well as for dental, vision and prescription out-of-pocket costs. See page 9 for more information. Copays You pay only a per-visit copay of $20 for a PCP. You pay $50 for a specialist office visit after meeting your deductible. Each HMO determines which providers are considered PCPs and which are considered specialists. Preventive care services are available at no cost to you. For inpatient hospitalization and skilled nursing facility care, the plan will pay the full cost after a $200 daily copay for the first five days per admission, up to an annual out-of-pocket maximum of $1,200 individual / $3,600 family after your annual deductible is met. The plan also pays the full cost of outpatient surgery services after you meet your annual deductible and pay a $250 copay per outpatient surgery. Mental Health/Chemical Dependency See page 23 of this Guide for a description of mental health benefits available through this plan. Remember, if you choose to participate in the FSA Health Care, all unreimbursed medical expenses (except for premiums) can be reimbursed from your FSA Health Care account. These reimbursements you money, because they are tax-free! Earn Wellness Fund rewards to help pay additional out of pocket expenses! See page 10 for information. 1 Except GDS and Bismarck, ND employees. 17 Enrollment Guide

18 Exclusive Provider Organization (EPO) This plan is available only to employees who are assigned to an office location that is not in a Coventry service area (except for employees in Bismarck, ND and all GDS employees). The EPO operates like an HMO Plan. OVERVIEW The EPO Plan uses the Coventry National Network of doctors, hospitals, and pharmacies for health care services. When you enroll in the EPO, you will not be required to select a primary care physician (PCP). You also do not need a referral to visit most specialists. The EPO Plan is similar to the HMO except it uses our Coventry National Network of providers instead of a local HMO network. You generally pay a copay each time you visit an EPO provider or are hospitalized, without having to pay coinsurance or file claims. Covered services and copay amounts under the EPO are the same nationwide. The EPO differs from the HRA Plan in that there is no employer-funded HRA Fund, and little or no coverage for out-of-network services. You may be subject to a deductible for certain services. Remember, if you choose to participate in the FSA Health Care, all unreimbursed medical expenses (except for premiums) can be reimbursed from your FSA Health Care account. These reimbursements you money, because they are tax-free! Earn Wellness Fund rewards to help pay additional out-of-pocket expenses! See page 10 for information. FEATURES OF THE EPO Network This plan uses the Coventry National Network and is only available in locations that do not offer a local Coventry HMO Plan. If you receive medical services from a provider outside the EPO network, the EPO may pay little or none of the costs, unless the situation is a medical emergency. You can check to see if your doctor is in the Coventry National Network by visiting the Find a Doctor section at and selecting Coventry National Network when prompted to select a product, or by calling customer service at (800) Deductible All medical services covered under the plan (other than copays) count toward your deductible. If you and any of your family members are enrolled in the plan, your deductible can be met with a combination of expenses from all your enrolled family members. However, the maximum deductible for any one member of your family is the individual deductible amount. However, you may still earn Wellness Fund rewards to offset your EPO deductibles or copays, as well as for dental, vision, and prescription out-of-pocket costs. See page 9 for more information. Copays You only pay a per-visit copay of $20 for a PCP. You pay $50 for a specialist office visit after meeting your deductible. For the EPO, PCPs include internists, pediatricians, and general family practitioners. Preventive care services are available at no cost to you. For inpatient hospitalization and skilled nursing facility care, the plan will pay the full cost after a $200 daily copay for the first five days per admission, up to an annual out-of-pocket maximum of $1,200 individual /$3,600 family, after your annual deductible has been met. The plan also pays the full cost of outpatient surgery services after you meet your annual deductible and pay a $250 copay per outpatient surgery. Mental Health/Chemical Dependency See page 23 of this Guide for a description of mental health benefits available through this plan. You can offset your EPO deductibles in 2013 by earning up to $250 in Wellness Fund rewards paid by Coventry Health Care when you complete all three Wellness Activities. For details see page 9 of this Guide. Value Based Insurance Design (VBID) allows you and your covered family members to receive 100% coverage without copays or deductibles for certain services for five diseases when you actively participate in Disease Management and Complex Case Management. For details see page 11 of this Guide. 18 Enrollment Guide

19 Prescription Benefits If you enroll in one of the Coventry medical plan options, you automatically receive prescription drug coverage without making a separate election or paying an additional premium. New for 2013 is a lower prescription copay of only $3 when you use generic drugs that fall under the Tier One A drug list. For a list of Tier One A generics, as well as other formulary prescriptions, go to Coventry Today or your local health plan website. Also changing is the Medco prescription mail-order and website name. Sometime in 2013, Medco will transition its name to Express Scripts. You may fill your prescription at participating retail pharmacies for a copay and fill longerterm plan approved maintenance medication through the mail order program with a savings on Tier One A, Tier One, and Tier Two drugs. Coventry has a formulary list of prescription drugs that is based on the effectiveness, safety, and cost of the drugs. The formulary is the same nationwide (except for the Bismarck, TIERS ND PPO). You can find the formulary on the website for your medical plan, as well as at Coventry Today or your local health plan website. You can money by purchasing your prescriptions at a Walgreens Pharmacy, or by purchasing Tier One A, Tier One, or Tier Two drugs. Before you fill your prescription, ask your doctor or pharmacist if a Tier One A, Tier One, or Tier Two drug listed on the formulary is appropriate for your condition. If both a generic drug and brand name drug are available and you choose the brand name version, you will be required to pay the applicable copay plus the difference between the cost of the generic and the brand name drug. PHARMACY (UP TO A 31-DAY SUPPLY) You will pay the highest copay for Tier Three and Tier Four drugs. Log on to your plan s website or call the number on the of your ID card for a list of formulary drugs and other pertinent information. You can also money on your Tier One A, Tier One and Tier Two prescription drug costs by using the mail order service for maintenance medications. When you use mail order for these drugs, you can receive up to a 90-day supply of your prescription for less than the price you would pay for threemonth supplies at a retail pharmacy. Other advantages of the mail order program include the ability to fill your prescriptions online or over the phone anytime, home delivery including free standard shipping, and the availability of a licensed pharmacist by phone 24 hours a day, 7 days a week. PRESCRIPTION DRUG BENEFITS WALGREENS PHARMACY (UP TO A 31- DAY SUPPLY) Your Coventry Health Care prescription drug coverage is creditable coverage under Medicare. MAIL ORDER (UP TO A 90-DAY SUPPLY) WALGREENS PHARMACY (UP TO A 90-DAY SUPPLY) Tier One A (Generic Formulary) $3 copay $3 copay $3 copay $3 copay Tier One (Generic Formulary) $15 copay $10 copay $15 copay $15 copay Tier Two (Brand Name Formulary) $45 copay $35 copay $87.50 copay $87.50 copay Tier Three (Generic or Brand Name Non-Formulary) $75 copay $65 copay $195 copay $195 copay Tier Four (Specialty Drugs) $200 copay 19 Enrollment Guide

20 FINDING PRESCRIPTION DRUG INFORMATION TOBACCO CESSATION DRUGS* The prescription drug plan provides coverage for tobacco cessation drugs. Coventry Health Care will cover generic and brand name overthe-counter (OTC) and prescription smoking cessation products with a prescription from a physician for employees and dependents who have pharmacy benefits through the HMO, EPO, or HRA plans. A one-month supply is available for a copay per prescription. The plans will cover up to $250 of OTC and prescription smoking cessation products per person per year. HOW TO GET COVERAGE FOR TOBACCO CESSATION DRUGS 1. See your doctor for advice on how to quit smoking. 2. If appropriate, have your doctor give you a prescription for smoking cessation drugs (even if it is for OTC medication). 3. Fill your one-month supply of medication at a participating pharmacy and pay the appropriate copay. 4. Receive up to $250 per covered person per year for smoking cessation medication. SPECIALTY DRUGS These drugs are used to treat complex medical conditions, generally require close monitoring, and are normally expensive. Specialty drugs are covered through a Specialty Pharmacy for up to a 31-day supply per fill. There is a $200 copay per prescription. On your formulary, drugs with SP following the drug name indicate those drugs that are specialty drugs. Most specialty drugs require prior authorization to be covered. For prior authorization, your doctor should call (877) FINDING PARTICIPATING PHARMACIES Keep in mind that you only receive benefits for prescription drugs at participating pharmacies. To find a list of participating pharmacies, visit the website for your plan. Check the Locate a Pharmacy section of the website for information on locating a participating pharmacy. You can create a secure account through My Online Services at Coventry Today that will take you to Express Scripts site. Using this site, you can: Check coverage of a particular drug, confirm the copay associated with the drug, and determine whether it is available through mail order; Ask Express Scripts to contact your doctor for certain mail order prescriptions; Check on the status of mail order prescriptions; View your medication history; Compare the costs of various drugs that are used to treat the same conditions; and Get information on drugs that are prescribed for you. Prescription drugs available at Walgreens will follow the Coventry formulary. The formulary can be found in the formulary section of the website for your health plan. *Except GDS employees. 20 Enrollment Guide

21 MEDICAL PLAN COMPARISON CHART HRA FUND BENEFIT HRA PLAN HMO/EPO PLAN HRA FUND 1 IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK $500 + Spouse $1,125 + Children $1,125 Family $1,750 WELLNESS FUND (EMPLOYEE MUST EARN BY COMPLETING WELLNESS ACTIVITIES) $250 $250 + Spouse $250 $250 + Children $250 $250 Family $250 $250 DEDUCTIBLES AND MAXIMUMS $1,500/$3,250 $3,000/$6,500 $1,000 + Spouse/Domestic Partner $2,750/$5,750 $5,500/$11,500 $1,500 + Children $2,750/$5,750 $5,500/$11,500 $1,500 Family $4,000/$8,250 $8,000/$16,500 $2,000 Lifetime Maximum Per Individual Unlimited Unlimited Unlimited N/A Value Based Insurance Design (VBID) OUTPATIENT SERVICES Primary Care Physician (PCP) Office Visit 100% coverage for certain services related to Asthma, Diabetes, Coronary Artery Disease, Congestive Heart Failure or Chronic Obstructive Pulmonary Disease See Page 11 for details N/A N/A 100% coverage for certain services related to Asthma, Diabetes, Coronary Artery Disease, Congestive Heart Failure or Chronic Obstructive Pulmonary Disease See Page 11 for details You pay 15% 2 You pay 35% 2 $20 copay N/A Specialist Office Visit You pay 15% 2 You pay 35% 2 $50 copay 2 N/A Preventive Care Visits $0 copay You pay 35% 2 $0 copay N/A Preventive Care Screenings $0 copay You pay 35% 2 $0 copay N/A Outpatient Surgery $250 copay 2 You pay 35% 2 $250 copay per surgery 2 N/A Medical Injectables 15% of Allowable Charge 2 35% of Allowable Charge 2 $200 for medical injectable drugs administered in a provider s medical office for chronic medical conditions 1 Coverage is available for + Domestic Partner in medical portion of the HRA Plan. The HRA Fund is not available for domestic partners and/or children of domestic partners, per IRS regulations. 2 Coinsurance and/or copay applies after deductible is met. Before deductible is met, use your FSA -- Health Care, Wellness Fund, or HRA Fund or pay the full cost. N/A N/A N/A N/A 21 Enrollment Guide

22 BENEFIT HRA PLAN HMO/EPO PLAN HRA FUND 1 IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK HOSPITAL & NURSING SERVICES Inpatient You pay 15% 2 You pay 35% 2 first five days up to annual maximum of $1,200 $200 copay per day for the individual / $3,600 family 2 Emergency Services $200 copay (ER copay waived if admitted) 2 $200 copay (ER copay waived if admitted) 2 $200 copay (ER copay waived if admitted) 2 N/A $200 copay (ER copay waived if admitted) 2 Urgent Care $50 copay 2 $50 copay 2 $50 copay 2 $50 copay 2 Inpatient Skilled Nursing 100-day limit per calendar year You pay 15% 2 You pay 35% 2 first five days up to annual maximum of $1,200 $200 copay per day for the individual / $3,600 family 2 Home Health Care no limit You pay 15% 2 You pay 35% 2 $0% 2 N/A MATERNITY SERVICES Office Visits $15 copay for first visit You pay 35% 2 Copay for first visit only: $20 PCP; $50 Specialist Delivery You pay 15% for delivery 2 You pay 35% 2 first five days up to annual maximum of $1,200 $200 copay per day for the individual / $3,600 family 2 LAB & RADIOLOGY Lab Services You pay 15% 2 You pay 35% 2 $20 copay 2 N/A Diagnostic X-rays You pay 15% 2 You pay 35% 2 $0 N/A High Technology Diagnostic Services (i.e., MRIs, CAT Scans, Ultrasounds, etc.) PRESCRIPTIONS (RETAIL, 31-DAY SUPPLY) RETAIL $125 copay 2 You pay 35% 2 $125 copay 2 N/A WALGREENS PHARMACY Tier One A (Generic Formulary) $3 $3 RETAIL WALGREENS PHARMACY $3 $3 Tier One (Generic Formulary) $15 $10 $15 $10 Tier Two (Brand Name Formulary) Tier Three (Generic or Brand Name non-formulary) $45 $35 $45 $35 N/A $75 $65 $75 $65 Tier Four (Specialty Drugs) $200 $200 1 Coverage is available for + Domestic Partner in medical portion of the HRA Plan. The HRA Fund is not available for domestic partners and/or children of domestic partners, per IRS regulations. 2 Coinsurance and/or copay applies after deductible is met. Before deductible is met, use your FSA Health Care, Wellness Fund, or HRA Fund or pay the full cost. N/A N/A N/A N/A 22 Enrollment Guide