Coverage Comparison Chart

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1 Coverage Comparison Chart Premera Blue Cross $500 Deductible/$1000 Deductible/CDHP Deductible PPO Plans $500-Deductible PPO Alaska Plan $1,000-Deductible PPO Alaska Plan CDHP $1,500-Deductible HSA-qualifed plan PPO Medical Plan Annual Deductible Annual Out-ofPocket Maximum* $500 $1,000 $1,500 Individual $3,000 Individual $1,500 $3,000 $3,000 ** $6,000 ** $2,500 $2,500 $5,000 $5,000 $4,000 Individual $7,750 Individual $7,500 $7,500 $10,000 $10,000 $9,000 ** $17,750 ** Lifetime Maximum Unlimited *Co-pays and benefits with a coinsurance level below 80% do not apply to the out-of-pocket maximum. ** = Individual plus one or more family members. Services for all family members covered under this CDHP HSA-quaified plan apply to the family. You must meet the family before the plan will cover services for any enrolled family members. Similar for the Out-ofPocket Maximum. You will receive better rates and avoid balance billing by using PPO providers. Note: Residents of Alaska will find their coverage information for the $500 and $1,000 Deductible in the Alaska Plan column, regardless of provider status. You are also eligible for the CDHP $1,500 Deductible plan. continued on inside 7.0_CCC

2 Premera Blue Cross $500 Deductible/$1000 Deductible/CDHP Deductible PPO Plans OUTPATIENT SERVICES Office Visit Specialist Visit Outpatient Hospital Care > Facility Services > Physician Services Preventive Care * > Routine GYN > Routine Mammograms > PSA Tests > CDL Exam PPO $500-Deductible $1,000-Deductible CDHP $1,500-Deductible HSA-qualifed plan 100% 60%; Alaska Plan if PPO; if 100% if PPO; 80% if PPO 100% 60%; Alaska Plan if PPO; if 100% if PPO; 80% if PPO 100% 60%; Preventive Care * Adults and children > Routine Physical > Well Child > Immunizations > X-ray/Lab services 100% 60%; 100% if PPO; 80% if 100% 60%; 100% if PPO; 80% if 100% 60%; Allergy Injections and Serum Laboratory Services 100% X-Ray Services 100% Chiropractic Care (limited to 16 visits per calendar year) Hearing Aids (limited to 2 devices every 36 months) Outpatient Physical, Speech and Occupational Therapy Alternative Medicine (limited to 16 visits per calendar year) 80%; 100% 100% 80%; You will receive better rates and avoid balance billing by using PPO providers. Note: Residents of Alaska will find their coverage information for the $500 and $1,000 Deductible in the Alaska Plan column, regardless of provider status. You are also eligible for the CDHP $1,500 Deductible plan. * Your preventive benefits offer full coverage for many tests, screenings and immunizations. During the exam, your physician may discover an issue or problem that requires further testing or screening for an accurate diagnosis. These additional diagnostic tests often require you to pay a share of the costs.

3 Coverage Comparison Chart INPATIENT CARE Inpatient Hospital Care > Facility Services > Physician Services Home Health Care (limited to 120 visits per year) PPO $500-Deductible $1,000-Deductible CDHP $1,500-Deductible HSA-qualifed plan Alaska Plan if PPO; 60% after if PPO Alaska Plan if PPO; 60% after if PPO Hospice Care Skilled Nursing Facility (limited to 120 days) EMERGENCY SERVICES Emergency Room $100 $100 (Co-pay if admitted) Non-emergent care may be paid at 60%. Non-emergent care may be paid at 60% Non-emergent care may be paid at 60% Ambulance BEHAVIORAL HEALTH Mental Health Outpatient Mental Health Inpatient Substance Abuse Outpatient Substance Abuse Inpatient if PPO; if if PPO; 60% after if if PPO; if if PPO; 60% after if Non-PP if PPO; if if PPO; 60% after if if PPO; if if PPO; 60% after if 80% continued on back 7.0_CCC

4 Coverage Comparison Chart Premera Blue Cross $500 Deductible/$1000 Deductible/CDHP Deductible PPO Plans PRESCRIPTION DRUGS Retail (30 day supply) > Generic > Preferred Brand > Non-Preferred Brand Mail Order (90 day supply) > Generic > Preferred Brand > Non-Preferred Brand Specialty Rx (Self-Injectable) $500-Deductible $1,000-Deductible CDHP $1,500-Deductible HSA-qualifed plan $15 Co-pay $40 Co-pay $65 Co-pay $30 Co-pay $80 Co-pay $130 Co-pay 50% Coinsurance 50% Coinsurance 50% Coinsurance 20% Coinsurance 20% Coinsurance 20% Coinsurance $10 Co-pay after $25 Co-pay after $40 Co-pay after $20 Co-pay after $50 Co-pay after $80 Co-pay after $75 co-pay $75 co-pay $75 co-pay after Rx from Plan pays Plan pays Plan pays Preventive Drug Coverage under Health Care Reform * Preventive Drug Coverage for CDHP (to treat heart disease and diabetes) * * Visit pharmacy section to learn more. Covered in full Covered in full Covered in full n/a n/a Generic covered in full Note: Maintentance drugs (drugs that are taken on a regular basis or for more than 90 days) are available through the mail order program. You will save money by using mail order and your prescriptions are conveniently shipped directly to you. IMPORTANT DISCLOSURE: As an employee, the health benefits available to you represent a significant component of your compensation package. They also provide important protection for you and your family in the case of illness or injury. Your plan offers a series of health coverage options. Choosing a health coverage option is an important decision. To help you make an informed choice, your plan makes available a Summary of Benefits and Coverage (SBC), which summarizes important information about any health coverage option in a standard format, to help you compare across options. The SBC is available on the web at: A paper copy is also available, free of charge, by calling This document is neither a summary plan description nor an employee handbook. If a discrepancy arises between this document and the provisions of the plan documents, the plan documents govern. ASRC reserves the right to modify, amend or terminate its plans and programs at any time. 7.0_CCC

5 Medical, Dental, and Vision Benefits (500/1000/CDHP) COMMITTED TO OUR SHARED VISION. COMMITTED TO YOU.

6 Medical, Dental, Vision ASRC Employee Benefits Being a part of ASRC means having a shared mission, and also having talented, dedicated people who live that mission every day. To that end, the benefits program offered to our employees must live up to the same principles and standards of excellence. Our goal is to provide top-quality, people-focused programs that will support the needs of every employee. The ASRC benefits program will provide you the choice and flexibility to select appropriate benefits for you and your family. This ASRC benefits program guide is designed to help you understand the benefit options available to you and help you make informed benefit selections. The guide includes helpful information about: > Coverage Tiers > Eligibility Information > Medical Plan > Dental Plan > Vision Plan > Contact information for all plan administrators Please contact your ASRC Benefits Specialist if you have any questions about your benefits or the enrollment process. Coverage Tiers When you enroll for medical, dental and/or vision benefits, you have four coverage tiers to choose from to meet the needs of you and your family: > Employee only > Employee + Spouse > Employee + Child(ren) > Employee + Family The coverage tier you elect can be different for medical, dental and vision. For example, you can elect medical for your entire family and dental only for yourself. Remember, for each plan that you choose, you need to elect your coverage tier separately. The contribution rates for each coverage tier are shown on the Rate Sheet included in the enrollment packet. Eligibility ASRC offers health and welfare benefits to all eligible employees who have met their waiting period. Eligible employees include all regular, full-time employees normally scheduled to work 30 or more hours in a work week. You may also enroll your eligible dependents; eligible dependents include your legal opposite-sex spouse and your natural, step or legally adopted children under age 26. Enrolling disabled children requires prior approval. A copy of your marriage certificate is required to enroll your spouse, birth certificates are required to enroll children; marriage & birth certificates are required to enroll a stepchild. ASRC and the plan administrators will conduct periodic audits to ensure eligibility of enrolled dependents.

7 Medical, Dental, and Vision Medical Premera Blue Cross Premera Blue Cross is the plan administrator for the ASRC medical plans. Premera will provide ASRC employees access to care through comprehensive national and worldwide provider networks. The Blue Cross Blue Shield medical ID card is one of the most widely recognized and accepted ID cards in the world. Premera offers national health plan coverage. In order to facilitate provider recognition in Washington and Alaska, the Premera Blue Cross Blue Shield of Alaska logo will appear on your medical IDs. For plan members living in other states, you will see the Blue Cross Blue Shield logo on your medical ID card. You can find out if your doctor is in the network by visiting and clicking the Find a Doctor link. While using this directory, you can search for providers by name, location, gender, specialty, and language. When searching for a provider, please make sure to select the correct network based on your geographical region. > Alaska: AK Heritage Select > Washington: Heritage and Heritage Plus 1 > All other states: BlueCard PPO If you don t have access to a computer, Premera s customer service team can help you find a doctor. Just call (877) (ASRC) between 6:00 AM and 6:00 PM (Pacific Time). Online Resources and Customer Service Premera Blue Cross also offers a wide range of resources to help you with health-related issues. Through the Premera website at you can: > Look up claims and benefits > Search for a network doctor or hospital > Get medical and prescription drug cost estimates > Search the Preferred Drug list > Download claim and prescription drug reimbursement forms > Get information to help you live healthier Customer Service: Get help finding a doctor and your other health care questions answered via a toll-free telephone number at (877) (ASRC) between 6:00 AM and 6:00 PM (Pacific Time). 24-Hour NurseLine Premera Blue Cross offers all plan members access to a 24-Hour NurseLine. These nurses have access to highquality health resources and will listen to your health concerns, answer questions and offer advice about many health-related topics. In addition, NurseLine nurses are trained to ask the right questions, enabling them to make a recommendation about when and where you should seek treatment for an injury or illness. Nurses base their recommendations on your symptoms and other relevant health conditions or history. All calls to the NurseLine are free and confidential 24 hours a day, 7 days a week. Just call (877) (ASRC). 1.0_MDV CDHP

8 Medical Plan Options With the ASRC benefits program, eligible employees have the choice of medical plan options that include both medical and pharmacy benefits: > $500-Deductible PPO > $1,000-Deductible PPO > CDHP $1,500-Deductible PPO - HSA qualified plan Each plan offers employees a broad range of health care services. Deductibles, out-ofpocket maximums and coverage levels will vary by plan. To elect the plan that best meets the needs of you and your family, be sure to carefully evaluate each medical plan by looking at the information below and the Coverage Comparison Chart, located in your enrollment packet. If you choose to visit in-network providers, you will be able to take advantage of deeper discounts and lower costs offered by Premera s contracted providers and facilities. You will also avoid balance billing. Prescription Drugs Prescription drug benefits are included in the ASRC medical plan. When you fill a prescription, you will pay a co-pay or coinsurance. The cost varies based on the type of drug (generic, preferred brand, nonpreferred brand, or specialty) and whether you purchase medications at a retail pharmacy or through mail order. Prescription costs under the Premera Blue Cross medical plans are shown below. Premera offers members access to a nationwide network of retail pharmacies. Retail versus Mail-Order Pharmacy Retail Pharmacy: For immediate drug needs or short-term (less than 90 days) medications, you should use a retail pharmacy. You can fill your 30-day prescriptions at any of more than 60,000 retail pharmacies in the pharmacy network. Medical: Plan Options $500-DEDUCTIBLE PPO Alaska Plan $1,000-DEDUCTIBLE CDHP $1,500-DEDUCTIBLE HSA-qualified plan PPO Alaska Plan PPO Annual Deductible Annual Out-of-Pocket Maximum* Lifetime Maximum $2,500 $7,500 $500 $1,000 $1,500 Individual $3,000 Individual $1,500 $3,000 $2,500 $7,500 $5,000 $10,000 $5,000 $10,000 $3,000 ** $6,000 ** $4,000 Individual $7,750 Individual $9,000 ** Unlimited Unlimited Unlimited $17,750 ** * Co-pays and benefits with a coinsurance level below 80% do not apply to the out-of-pocket maximum. ** = Individual plus one or more family members. Services for all family members covered under this CDHP HSA-qualified plan apply to the family. You must meet the family before the plan will cover services for any enrolled family members. This requirement also applies to the Out-of-Pocket Maximum. Note: Residents of Alaska will find their coverage information for the $500 and $1,000 Deductible in the Alaska Plan column, regardless of provider status. You are also eligible for the CDHP $1,500 Deductible plan.

9 Medical, Dental, and Vision Mail Order: Maintenance drugs (drugs that are taken on a regular basis or for more than 90 days) are available through the mail order program. You will save money by using the mail order pharmacy service and your prescriptions are conveniently shipped directly to your home. It will take approximately two weeks for you to receive your prescriptions by Mail Order. To avoid any delay in starting your medicine, ask your doctor to write two separate prescriptions one for a 30-day supply which you can fill at a local network pharmacy right away, and one for a 90-day supply that you can fill through the Mail Order Pharmacy. Generic versus Brand-Name Drugs ASRC encourages the use of generic drugs versus brand-name drugs because generic drugs cost less and are virtually identical to brand-name drugs in safety and effectiveness. When filling a prescription, here are some reasons to select a generic: 1. FDA monitored. Generic drugs are regulated by the Food and Drug Administration (FDA) just like brand-name drugs and provide the same level of quality, strength and purity at less cost. 2. Dollar savings. Using a generic version of a brand-name drug can help you control your healthcare costs. Ask your doctor to prescribe a generic drug when available and appropriate. 3. Same ingredients. Generic drugs must contain the same active ingredients and produce the same effect on the body as their brand-name equivalents. You can order refills by phone at (888) or register through the pharmacy section at Medical: Prescription Drugs* Premera Blue Cross $500 Deductible/ $1000 Deductible/CDHP Deductible PPO Plans PRESCRIPTION DRUGS Retail (30 day supply) > Generic > Preferred Brand > Non-Preferred Brand Mail Order (90 day supply) > Generic > Preferred Brand > Non-Preferred Brand $500-Deductible $1,000-Deductible CDHP $1,500-Deductible HSA-qualified plan $15 Co-pay $40 Co-pay $65 Co-pay $30 Co-pay $80 Co-pay $130 Co-pay 50% Coinsurance 50% Coinsurance 50% Coinsurance 20% Coinsurance 20% Coinsurance 20% Coinsurance $10 Co-pay after $25 Co-pay after $40 Co-pay after $20 Co-pay after $50 Co-pay after $80 Co-pay after Specialty Rx (Self-Injectable) $75 co-pay $75 co-pay $75 co-pay Rx from Plan pays Plan pays Plan pays Preventive - Health Care Reform * Covered in full Covered in full Covered in full Preventive for CDHP (to treat heart disease & diabetes) * * Visit pharmacy section to learn more. n/a n/a Generic covered in full 1.0_MDV CDHP

10 Is My Dentist In the Network? You can access the provider directory by calling (877) (ASRC), toll-free, or by visiting United Concordia s website at 1. Click on the Find a Dentist link 2. Select the Advantage Plus network option 3. You can search for network dentists by specialty, city, last name, zip code, distance to a certain zip code, or county. Register for My Dental Benefits allowing secure access to benefits, claim details, procedure history, accumulations, printable ID cards and more. Dental Dental benefits are offered separately from the medical plan through United Concordia. With over 35 years of experience in dental insurance, United Concordia offers flexible dental benefits backed by excellent customer service. The two dental plan options available to ASRC employees are: > Concordia Preferred > Concordia Flex Concordia Preferred: The Concordia Preferred plan provides the most coverage when you see a preferred provider. Make sure to check for preferred providers in your area before selecting this plan. Dental benefits are limited and orthodontia is not covered if you see a non-ppo provider. Concordia Flex: The Concordia Flex plan provides the same level of coverage for preferred and nonpreferred providers. This may be the best plan for you if there are no preferred providers in your area or if you want to see a non-preferred provider. Remember, if you choose to see a non-preferred provider, you will be responsible for any charges above reasonable and customary limits. Predetermination When the amount of a proposed treatment is more than $500, we encourage you to request a predetermination from your Dentist. This lets you know if the procedure will be covered; the amount you will owe and notifies you of any alternate treatment options covered by the dental plan prior to receiving services. Dental: Concordia Preferred / Concordia Flex CONCORDIA PREFERRED CONCORDIA FLEX PPO PPO or Deductible > $50 $50 $50 > $150 $150 $150 Annual Limit (per person)* $2,000 $1,250 $2,000 Orthodontia Limit $4,000 N/A $4,000 Preventive and Diagnostic Services (routine cleanings, exams, and most x-rays) 100% 80% 100% Basic Services (extractions, space maintainers, nonsurgical periodontics, endodontics, complex oral surgery, general anesthesia, repairs of the following: Inlays, onlays, bridges, and dentures) Major Services (inlays, onlays, crowns, prosthetics (bridges & dentures), surgical periodontics) 80% 60% 80% 80% 60% 80% Orthodontia Services 80% Not Covered 80% * Preventive, basic and major services combined

11 Medical, Dental, and Vision Vision Vision benefits for you and your eligible dependents are offered through Vision Services Plan (VSP), one of the nation s most complete eye-care health plans. Using your VSP benefit is easy. ID cards aren t required for VSP. To use your VSP benefits: > Find a VSP doctor at or call (877) (ASRC) > Make an appointment and tell the doctor you are a VSP member > Provide your doctor with your Social Security Number > Your doctor and VSP will handle the rest You get the best value from your vision benefit when you visit a VSP network doctor. When you visit an in-network doctor, you are often able to take advantage of greater benefits and pay less out-of-pocket. Extra Discounts and Savings As a VSP member, you can take advantage of additional discounts and savings on: Glasses and Sunglasses > Average 20-25% savings on all noncovered lens options > 20% off additional glasses and sunglasses, including lens options, from any VSP doctor within 12 months of your last WellVision Exam Laser Vision Correction Discounts > Average 15% off the regular price or 5% off the promotional price > Discounts only available from contracted facilities Contact Lenses > 15% off cost of contact lens exam (fitting and evaluation) If you do obtain services from an out-ofnetwork doctor, please send VSP the following materials: > An itemized receipt listing the services received > The name, address and phone number of the out-of-network provider > The covered member s name, date of birth, address and phone number > The name of the organization that offers your VSP coverage Arctic Slope Regional Corporation > The patient s name, date of birth, address and phone number > The patient s relationship to the covered member (such as self, spouse, child ) Out-of-network claims must be submitted to VSP within six months. Keep a copy of the claims information for your files and send a copy to VSP, P.O. Box , Sacramento, CA For additional questions regarding your eye-care coverage, contact VSP s Member Services department at (877) (ASRC) or register at to view benefits, access rebates & special offers or printable member vision card. VSP YOUR VISION COVERAGE VSP CHOICE Non-VSP WellVision Annual Exam Lenses Covered in full after $20 co-pay; once every calendar year Single, lined bi-focal, tri-focal, and progressive lenses are covered after co-pay; once every calendar year Covered up to $43; once every calendar year Single vision lenses covered up to $26; lined bifocal lenses covered up to $43; lined trifocal lenses and progressive lenses covered up to $60; once every calendar year Frames Covered up to $175; once every twenty-four months Covered up to $40; once every twenty-four months Contact Lens Exam Fitting & Evaluation Standard and Premium fit: Covered in full after never to exceed $60 co-pay. Combined with Elective Contact allowance noted below. Elective Contacts (in lieu of glasses) Covered up to $130; once every calendar year Covered up to $100; once every calendar year 1.0_MDV CDHP

12 Medical, Dental, and Vision Contact Information For your convenience, you can call one number for assistance with most of your benefit needs. Dial (877) (ASRC) and select from the following options: This document is neither a summary plan description nor an employee handbook. If a discrepancy arises between this document and the provisions of the plan documents, the plan documents govern. ASRC reserves the right to modify, amend or terminate its plans and programs at any time. > Option 1: Premera (Medical and Rx) > Option 2: NurseLine > Option 3: Flexible Spending and Transportation Accounts > Option 4: COBRA > Option 5: United Concordia (Dental) > Option 6: VSP (Vision) > Option 7: Additional Options > 1. Employee Assistance Program > 2. Unum (Life and Disability) > K > 4. ASRC Benefits Team IMPORTANT DISCLOSURE: As an employee, the health benefits available to you represent a significant component of your compensation package. They also provide important protection for you and your family in the case of illness or injury. Your plan offers a series of health coverage options. Choosing a health coverage option is an important decision. To help you make an informed choice, your plan makes available a Summary of Benefits and Coverage (SBC), which summarizes important information about any health coverage option in a standard format to help you compare across options. The SBC is available on the web at A paper copy is also available, free of charge, by calling (877) _MDV CDHP

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