County of Greenville Employee Health Benefits Information

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1 County of Greenville Health Benefits Information Medical Plan Prescription Drug Co-pays $4 Specific Generic List Vision Dental Plan Rates (medical & dental) Flexible Spending Nurse Practitioner Registered Dietitian Diabetic Program Gym Membership reimbursement WELLNESS PAY-OFFS The County of Greenville is committed to providing a comprehensive healthcare plan. But, as costs continue to rise, your actions can have an important impact on controlling costs. Staying healthy should be the goal of us all. Your medical plan has an excellent preventive care benefit with only a small co-pay. Annual Physicals and other preventative care are covered up to $400 annually and you are encouraged to utilize this benefit. Also, take advantage of the preventive care dental benefits. A cleaning every six months is the basic benefit of the plan and is covered at 100% (reasonable & customary fee). NURSE PRACTITIONER Hours of Operation Locations: (1) County Square between suites 2500 and 3800 (Public Works) Mondays (8am 4pm) Tuesdays (8am 12noon) Wednesdays (8am 4pm) Thursday (12:30 4:30pm) Fridays (8am 1pm) (2) Detention Center (Hours of Operation are different Tuesday afternoon)

2 REGISTERED DIETITIAN Thursdays 8:30 12:00 noon (Wellness Center County Square) DIABETIC PROGRAM Voluntary Program available to employees and/or dependent on the medical plan. Program requirements: Participants meet with their assigned Pharamacy Health Educator once a month during the first quarter and then once a quarter afterwards. Co-pays are waived on diabetic drugs and diabetic supplies. Enrollment forms will be available at Open Enrollment meetings and Human Resources. GYM MEMBERSHIP REIMBURSEMENT The Physical Activity Promotion Wellness Program is designed to support our employees engaging in healthy behaviors, such as regular physical activity. The County of Greenville will reimburse an employee $20 per month upon verification of attendance at a fitness center three times per week on average per month. Forms are to be submitted every three months. We expect that your visit to the fitness center will be to engage in at least 30 minutes of moderate intensity exercise while at the fitness center. The form requires that someone from the gym you attend initial your visits. Forms may be submitted to Human Resources quarterly. The reimbursement claim is available on Human Resources intranet page.

3 SUMMARY OF MEDICAL PLAN BENEFITS FOR 2014 BENEFIT YEAR ITEM Annual Deductible Individual Family Annual Out of Pocket Limit Individual Family Physician Office Services Primary Care Specialist Hospital Service Physician In-Patient Out-Patient PREMIUM PLAN (Preferred Blue network) In Network/Out of Network (90%/75%) None/ $250 None /$500 $1000/ $3000 $2000/ $5000 $15 co-pay then 100%/ 75% $20 co-pay then 100%/ 75% 90% / 75% 90% / 75% (after $250 copay 90% / 75% PLUS PLAN (Preferred Blue network) In Network/Out of Network (85%/60%) $100/ $350 $200/ $700 $1500/ $4000 $3000/ $8000 $20 co-pay then 100%/ 60% $30 co-pay then 100%/ 60% 85% / 60% 85% / 60% (after $250 copay 85% / 60% STANDARD PLAN (Preferred Blue network) In Network/Out of Network (80%/50%) $250/ $500 $500/ $1000 $2000/ $4500 $4000/ $ %/ 50% 80%/ 50% Out-Patient Surgery 90% / 75% 85% / 60% 80% / 50% Emergency Room 90%/ 75% 85%/ 60% 80% / 50% 80% / 50% 80% / 50% (after $250 copay 80% / 50% Urgent Care Center $35 co-pay then 100% / $75 co-pay then 75% $35 co-pay then 100% / $75 co-pay then 60% 80% / 50% Vision Using the Vision CARE Network (*Dependents age 12 and younger may receive a basic eye exam once every 12 months in the Vision CARE Network) Free Basic eye exam biennially (24 months) Hardware credit biennially in the Vi- Care Network. (Frames - $150; lens - $150 OR contact lens $300 credit) Free Basic eye exam - biennially (24 months) Hardware credit biennially in the Vi- Care Network. (Frames - $150; lens - $150 OR contact lens $300 credit) Free Basic eye exam - biennially (24 months) Hardware credit biennially in the Vi- Care Network. (Frames - $150; lens - $150 OR contact lens $300 credit) Ambulance 90% 85% 80% Smoking Cessation ($500 life time max) 100% 100% 100% Medical Supplies 90% / 75% 85% / 60% 80% / 50% Allergy Services Primary Care Specialist $15 co-pay then 90%/ 75% $20 co-pay then 90%/ 75% $20 co-pay then 85% / 60% $30 co-pay then 85% / 60% Serum not covered 80% / 50% Serum not covered Chiropractic $1000 Annual Limit 90%/ 75% 85%/ 60% 80%/ 50% Contraceptives Yes Oral contraceptives Oral contraceptives Durable Medical Equipment (Pre-authorization required if over $100) 90%/ 75% 85%/ 60% 80%/ 50%

4 Skilled Nursing Facility (Limited to 120 days per benefit year) 90%/ 75% 85%/ 60% 80%/ 50% Wellness Program PREMIUM PLAN PLUS PLAN STANDARD PLAN (in Network Only) Annual Physical and child well care not to exceed $400 annually. $10 co-pay then 100%/ 75% $400 cap does not include Mammogram, colonoscopy, refer to notes under Wellness Program. $20 co-pay, 100%/ 60% $400 cap does not include Mammogram, colonoscopy, refer to notes under Wellness Program. $25 co-pay, 100%/ 50% $400 cap does not include Mammogram, colonoscopy, refer to notes under Wellness Program. In addition to the $400 benefit, the following screenings will be paid at 100%: Beginning at age 40 - one yearly mammogram Beginning at age 50: one sigmoidoscopy every 5 years one colonoscopy every 10 years. one double contrast barium enema every 5 years. one PSA test and digital rectal examination annually. The above screenings will be processed as out- patient hospital services when medically necessary at any age. In-Patient Mental Health/Substance Abuse Out-Patient Mental Health/Substance Abuse 90%/ 75% (after $250 copay $20 co-pay individual session then 100% / 75% 85%/ 60% (after $250 copay $30 co-pay then 100% / 60% 80%/ 50% (after $250 copay Weight Loss (For Obesity limited to $500 life time max) 100% 100% N/A

5 Prescription Drugs Retail (up to 30 day supply) PREMIUM PLAN PLUS PLAN STANDARD PLAN Specified Generic List Other Generics Preferred Brand Non-preferred Brand $4 ** $8 co-pay $20 co-pay $35 co-pay $4 ** $10 co-pay $30 co-pay $45 co-pay $4 ** $12 co-pay $40 co-pay $55 co-pay Mail Order (3 months supply) Generic Preferred Brand Non-preferred Brand Monthly Rates Only /Spouse /Children /Full Family $16 co-pay $40 co-pay $70 co-pay $ $ $ $ $20 co-pay $60 co-pay $90 co-pay $50.00 $ $ $ $24 co-pay $80 co-pay $110 co-pay $0 *$50.00 FSA Account Credit receives $600 per benefit year max. (12 months) $ $ $ *All out-of network benefits are paid at the usual and customary rate (UCR). This summary of benefits is for illustrative purposes only. For a comprehensive listing of medical plan benefits, refer to the Medical and Dental Plan Document. The deductible must be met before benefits are paid except where co-pays apply. ** $4 Specified Generics are not available via Mail Order. Retail Pharmacy Outlets only. See $4.00 Specified Generic Drug List for details available on the County s Intranet (Drug List Specified Generics). This list will be modified by Human Resources as needed. *** Reminder: Save money and use generic drugs when possible. We do have a Mandatory Generic Drug Policy, as follows: Mandatory Generic Policy: Under the mandatory generic policy, if you request a Brand Name Drug when a Generic Drug is available and can be substituted, you will be responsible for the generic Copayment plus any difference in cost between the generic and the Brand Name Drug. The cost difference will be applied even if the physician indicates Dispense as Written on the prescription. Prescription Policy: $4.00 specified generics are available only at Retail Pharmacies. They are not available via Mail Order. Prescriptions that cost more than $250 per month will have to be filled at a Retail Pharmacy on a monthly basis and will not be available via mail order.

6 BENEFIT CATEGORY DENTAL PAI Admin. COUNTY OF GREENVILLE Summary of benefits in addition to medical BENEFIT PAID BY BENEFIT DESCRIPTION County Coverage Dependent Shared Coverage Annual Deductible $50/per person $100 / Family Maximum Annual Benefit $4,000/person Class I 100% Class II 80% Deductible Applies Class III 50% Deductible Applies Class IV Dependents only under age 50% - Lifetime Max. Benefit $1, SURVIVOR BENEFITS (Life insurance) ING/ReliaStar Basic Life / AD&D Supplemental Life/AD&D Supplemental Depend. Life Spouse County $50,000 Increments of $10,000 to max. of $500,000 Increments of $5,000 to maximum of $100,000 $5,000 or $10,000 maximum Supplemental Depend. Life Child During Open Enrollment employees & spouses who already have supplemental life insurance and you do not wish to make a change, no action is necessary. INCOME PROTECTION (Long-term Disability) ING/ReliaStar Option 1 Voluntary Long Term Disability 30-day elimination period. Benefit is 60% to $5, year benefit duration. Example: Monthly Income of $2,500 Multiply your monthly x.968 Divide the answer by 200 to find premium Bi-Weekly rate calculation: $12.10 per pay period Option 2 Voluntary Long Term Disability 90-day elimination period. Benefit is 60% to $5,000. Duration is 65 / SSNRA. Example: Monthly Income of $2,500 Multiply your monthly x Divide the answer by 200 to find premium Bi-Weekly rate calculation: $4.60 per pay period

7 LONG-TERM DISABILITY CONTINUED: If you declined coverage when you were first eligible, you would be considered a Late-Enrollee and must print out and complete an enrollment applicant and the Hartford Personal Health Application which must be approved before deductions can be taken for disability coverage. If you wish to change Options, you must complete a new enrollment form. You may change from Option 1 to Option 2 without completing a Statement of Health form. If you want to move from Option 2 to Option 1, you must complete a Statement of Health and be approved for coverage before the change will be effective. (You can remain enrolled in Option 2 during this waiting period. Submit the Hartford Personal Health Application to Shauna McAdory in a sealed envelope via inter-office mail or by bringing it to Human Resources at County Square Suite 500. During Open Enrollment employees who currently have the Voluntary LTD Plan that they wish to keep do not need to take any action. BENEFIT CATEGORY VISION COVERAGE Vision Care BENEFIT Coverage Dependent Coverage PAID BY County BENEFIT DESCRIPTION Basic Eye Exam: Free every 24 months Frames: $150 Lens: $150 Contacts: $300 Children 12 yrs of age & under: Free Basic Eye Exam Vision benefit is available to all employees and dependents who are enrolled in one of the three medical plans sponsored by the County. The benefit is for every twenty-four (24) months from the date of previous examination. To receive your vision benefit you must request a voucher by dialing CARE (2273) in advance of having your eye exam. Expect voucher arrival in 7-10 days. Call Kirk Peterson of Vision Care with any questions. The Vision Care plan document is available on the County intranet site. FLEXIBLE SPENDING ACCOUNTS Rosenfeld Einstein Offers opportunity to have certain medical expenses and/or dependent care expenses paid with pre-tax dollars. / County * (see 1 st note below) Maximum MEDICAL amount = $2,500 * Maximum DEPENDENT CARE amount = $5,000 Check balances and obtain claim forms at website: * s enrolled in the Standard Plan receive $50 / month ( $600 / yr.) from the County which is deposited into their FSA medical account. Check the County intranet site for a list of qualified reimbursable expenses and reimbursement request forms. Over-the-counter medications will not be reimbursable under the FSA unless you have a prescription for the medication. For additional questions, you may call Paula Freeman at Rosenfeld Einstein: phone (864) FSA accounts are governed by the IRS and require that you use the funds set aside each year or lose them! Also, you must re-enroll each year IRS rule. Dependent Care accounts are set up for childcare expenses in order for the employee and spouse to work. Funds must be in the account before claims can be reimbursed.

8 $4.00 SPECIFIED GENERIC DRUG LIST THERAPEUTIC CATEGORY SUB CATEGORY GENERIC COMMON BRAND NAME ANTIBIOTICS *ANTI-INFECTIVE AGENTS CLINDAMYCIN HCL CLEOCIN HCL ANTIBIOTICS *ANTI-INFECTIVE AGENTS METRONIDAZOLE FLAGYL ANTIBIOTICS *ANTI-INFECTIVE AGENTS SULFAMETHOXAZOLE-TRIMETHOPR BACTRIM ANTIBIOTICS *ANTIMYCOBACTERIAL AGENTS RIFAMPIN RIFADIN ANTIBIOTICS *CEPHALOSPORINS* CEFACLOR CECLOR ANTIBIOTICS *CEPHALOSPORINS* CEFADROXIL DURICEF ANTIBIOTICS *CEPHALOSPORINS* CEFDINIR OMNICEF ANTIBIOTICS *CEPHALOSPORINS* CEFPODOXIME PROXETIL VANTIN ANTIBIOTICS *CEPHALOSPORINS* CEFPROZIL CEFZIL ANTIBIOTICS *CEPHALOSPORINS* CEFUROXIME CEFTIN ANTIBIOTICS *CEPHALOSPORINS* CEPHALEXIN KEFLEX ANTIBIOTICS *FLUOROQUINOLONES* CIPROFLOXACIN ER CIPRO XR ANTIBIOTICS *FLUOROQUINOLONES* CIPROFLOXACIN HCL CIPRO ANTIBIOTICS *FLUOROQUINOLONES* OFLOXACIN FLOXIN ANTIBIOTICS *MACROLIDES* AZITHROMYCIN ZITHROMAX ANTIBIOTICS *MACROLIDES* CLARITHROMYCIN BIAXIN ANTIBIOTICS *MACROLIDES* CLARITHROMYCIN ER BIAXIN XL ANTIBIOTICS *MACROLIDES* ERYTHROMYCIN E-MYCIN ANTIBIOTICS *MACROLIDES* ERYTHROMYCIN ETHYLSUCCINATE E.E.S. 200 ANTIBIOTICS *PENICILLINS* AMOX TR-POTASSIUM CLAVULANA AUGMENTIN ANTIBIOTICS *PENICILLINS* AMOXICILLIN AMOXIL ANTIBIOTICS *PENICILLINS* AMPICILLIN TRIHYDRATE TRIMOX ANTIBIOTICS *PENICILLINS* DICLOXACILLIN SODIUM DYNAPEN ANTIBIOTICS *PENICILLINS* PENICILLIN V POTASSIUM V-CILLIN K ANTIBIOTICS *TETRACYCLINES* DOXYCYCLINE HYCLATE VIBRAMYCIN ANTIBIOTICS *TETRACYCLINES* DOXYCYCLINE MONOHYDRATE MONODOX ANTIBIOTICS *TETRACYCLINES* MINOCYCLINE HCL MINOCIN ANTIBIOTICS *TETRACYCLINES* TETRACYCLINE HCL SUMYCIN ASTHMA *ANTIASTHMATIC AGENTS ALBUTEROL PROVENTIL ASTHMA *ANTIASTHMATIC AGENTS ALBUTEROL SULFATE ACCUNEB ASTHMA *ANTIASTHMATIC AGENTS IPRATROPIUM BROMIDE ATROVENT ASTHMA *ANTIASTHMATIC AGENTS TERBUTALINE SULFATE BRETHINE ASTHMA *ANTIASTHMATIC AGENTS THEOPHYLLINE ANHYDROUS UNIPHYL *ANTIANGINAL AGENTS ISOSORBIDE DINITRATE ISORDIL *ANTIANGINAL AGENTS ISOSORBIDE MONONITRATE IMDUR *ANTIANGINAL AGENTS NITROGLYCERIN NITRO-BID *ANTIANGINAL AGENTS NITROGLYCERIN PATCH NITRO-DUR *ANTIARRHYTHMICS* AMIODARONE HCL PACERONE *ANTIARRHYTHMICS* FLECAINIDE ACETATE TAMBOCOR *ANTIARRHYTHMICS* QUINIDINE GLUCONATE QUINAGLUTE *ANTIHYPERLIPIDEMICS* CHOLESTYRAMINE QUESTRAN

9 *ANTIHYPERLIPIDEMICS* CHOLESTYRAMINE LIGHT QUESTRAN LIGHT *ANTIHYPERLIPIDEMICS* COLESTIPOL HCL COLESTID *ANTIHYPERLIPIDEMICS* FENOFIBRATE LOFIBRA *ANTIHYPERLIPIDEMICS* GEMFIBROZIL LOPID *ANTIHYPERLIPIDEMICS* LOVASTATIN MEVACOR *ANTIHYPERLIPIDEMICS* PRAVASTATIN SODIUM PRAVACHOL *ANTIHYPERLIPIDEMICS* SIMVASTATIN ZOCOR *ANTIHYPERTENSIVES* AMLODIPINE BESYLATE-BENAZEP LOTREL *ANTIHYPERTENSIVES* ATENOLOL-CHLORTHALIDONE TENORETIC *ANTIHYPERTENSIVES* BENAZEPRIL HCL LOTENSIN *ANTIHYPERTENSIVES* BENAZEPRIL HCL-HCTZ LOTENSIN HCT *ANTIHYPERTENSIVES* BISOPROLOL FUMARATE-HCTZ ZIAC *ANTIHYPERTENSIVES* CAPTOPRIL CAPOTEN *ANTIHYPERTENSIVES* CLONIDINE HCL CATAPRES *ANTIHYPERTENSIVES* DOXAZOSIN MESYLATE CARDURA *ANTIHYPERTENSIVES* ENALAPRIL MALEATE VASOTEC *ANTIHYPERTENSIVES* ENALAPRIL MALEATE-HCTZ VASERETIC *ANTIHYPERTENSIVES* FOSINOPRIL SODIUM MONOPRIL *ANTIHYPERTENSIVES* FOSINOPRIL-HYDROCHLOROTHIAZ MONOPRIL HCT *ANTIHYPERTENSIVES* GUANFACINE HCL TENEX *ANTIHYPERTENSIVES* HYDRALAZINE HCL APRESOLINE *ANTIHYPERTENSIVES* LISINOPRIL ZESTRIL *ANTIHYPERTENSIVES* LISINOPRIL-HCTZ ZESTORETIC *ANTIHYPERTENSIVES* METHYLDOPA ALDOMET *ANTIHYPERTENSIVES* MINOXIDIL LONITEN *ANTIHYPERTENSIVES* QUINAPRIL HCL ACCUPRIL *ANTIHYPERTENSIVES* QUINAPRIL/HYDROCHLOROTHIAZIDE ACCURETIC *ANTIHYPERTENSIVES* TERAZOSIN HCL HYTRIN *ANTIHYPERTENSIVES* TRANDOLAPRIL MAVIK *BETA BLOCKERS* ATENOLOL TENORMIN *BETA BLOCKERS* BETAXOLOL HCL KERLONE *BETA BLOCKERS* BISOPROLOL FUMARATE ZEBETA *BETA BLOCKERS* LABETALOL HCL TRANDATE *BETA BLOCKERS* METOPROLOL SUCCINATE TOPROL XL *BETA BLOCKERS* METOPROLOL TARTRATE LOPRESSOR *BETA BLOCKERS* NADOLOL CORGARD *BETA BLOCKERS* PINDOLOL VISKEN *BETA BLOCKERS* PROPRANOLOL HCL INDERAL *BETA BLOCKERS* SOTALOL BETAPACE *BETA BLOCKERS* TIMOLOL MALEATE BLOCADREN BLOCKERS AMLODIPINE BESYLATE NORVASC BLOCKERS DILTIAZEM ER CARDIZEM SR BLOCKERS DILTIAZEM HCL CARDIZEM BLOCKERS FELODIPINE ER PLENDIL BLOCKERS NIFEDIPINE ER PROCARDIA

10 BLOCKERS VERAPAMIL HCL CALAN *CARDIOTONICS* DIGOXIN LANOXIN * AGENTS PAPAVERINE HCL PAVABID *DIURETICS* ACETAZOLAMIDE DIAMOX *DIURETICS* AMILORIDE HCL-HCTZ MODURETIC *DIURETICS* BUMETANIDE BUMEX *DIURETICS* CHLORTHALIDONE HYGROTON *DIURETICS* FUROSEMIDE LASIX *DIURETICS* HYDROCHLOROTHIAZIDE HYDRODIURIL *DIURETICS* INDAPAMIDE LOZOL *DIURETICS* METOLAZONE ZAROXOLYN *DIURETICS* SPIRONOLACTONE ALDACTONE *DIURETICS* SPIRONOLACTONE-HCTZ ALDACTAZIDE *DIURETICS* TORSEMIDE DEMADEX *DIURETICS* TRIAMTERENE-HCTZ DYAZIDE *VASOPRESSORS* MIDODRINE HCL PROAMATINE DIABETIC *ANTIDIABETICS* GLIMEPIRIDE AMARYL DIABETIC *ANTIDIABETICS* GLIPIZIDE GLUCOTROL DIABETIC *ANTIDIABETICS* GLIPIZIDE ER GLUCOTROL XL DIABETIC *ANTIDIABETICS* GLIPIZIDE-METFORMIN METAGLIP DIABETIC *ANTIDIABETICS* GLYBURIDE DIABETA DIABETIC *ANTIDIABETICS* GLYBURIDE MICRONIZED GLYNASE DIABETIC *ANTIDIABETICS* GLYBURIDE-METFORMIN HCL GLUCOVANCE DIABETIC *ANTIDIABETICS* METFORMIN HCL GLUCOPHAGE DIABETIC *ANTIDIABETICS* METFORMIN HCL ER GLUCOPHAGE XR *This list is subject to change and will be updated as needed on the County s Intranet by Human Resources when necessary.

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