Health Benefits Simplified. Ampian HR Medical Benefits Overview. Effective 1/1/

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1 Health Benefits Simplified Ampian HR Medical Benefits Overview

2 Welcome! HealthEZ is proud to continue to serve Ampian HR in We are a national benefit administrator that specializes in helping companies like Ampian HR provide affordable, custom benefit plans. We are here to simplify your healthcare experience. What you need to do: Review this benefit overview Manage your benefits by visiting or calling customer service at What s inside: Benefit Update Online Tools Network of Doctors Medical Management Pharmacy HealthEZpay HealthEZ Smart ID Cards Summary of Medical Benefits Enrollment form Online Tools Visit your one-stop benefit website for benefit information, forms, account balances, processed claims, previous statements and much more. An online account allows you to fully manage your benefits. To sign up for online access, follow these steps: 1. Go to and click LOGIN. 2. Click Need to set up your online access? 3. Enter your Member ID - found on your ID card - your Social Security number, and your date of birth. Pick a Username and Password. Be sure to make your Password at least 8 characters long; any combination of letters or numbers is acceptable. Click Proceed to my Account and you re registered!

3 Network of Doctors Is my doctor in the network? If you live in Minnesota, North Dakota or South Dakota, your primary medical network is America s PPO If you live in Arizona, your primary medical network is Arizona Foundation If you live in Idaho, your primary medical network is IPN If you live in Alaska, your primary medical network is Beech Street If you live in Utah, both EMI and Health Utah are primary (check your ID card to see which network you are enrolled in) If you live in Washington, your primary medical network is First Choice Health If you live in any other state, your primary medical network is PHCS To find an in-network physician or facility go to and click on Find a Doctor or call customer service at Medical Management and Nurseline You have 24/7 access to HealthEZ s medical management staff. They have extensive experience helping employees navigate the medical maze. These services are available to everyone whether you have a chronic condition like asthma or diabetes, or a more complex condition such as cancer or heart disease. If you have questions about what kind of care to seek or where to seek it (do I really need to go to the ER for this?), if you ve just found out you re pregnant, or if you have any nagging questions, nurses are there to help you. Just call , 24/7. Precertification The medical system is increasingly pushing patients into expensive and unnecessary procedures. To make sure you receive the best treatment possible, we are requiring your doctor to notify us before MRI and CT scans as well as inpatient treatment and surgeries. Pharmacy MagellanRx Your pharmacy benefit manager is MagellanRx. MagellanRx is one of the nation s largest pharmacy benefits managers and can offer additional discounts - especially on higher cost drugs. Your pharmacy claims will also appear on your HealthEZ statement. Please see the back of your medical card for information on MagellanRx. You can also find more information by going to and clicking on Prescriptions. Saving on Pharmacy Costs Here are a few ways to save on pharmacy costs: Ask your doctor to start you on the lowest cost alternative Check out the $4 prescriptions at places like Wal-Mart Price shop your prescriptions at Sam s Club and Costco; you don t have to be a member to access their pharmacy

4 The EZ Way to Pay Your Medical Bills Pay your medical bills the easy and accurate way. HealthEZpay consolidates your medical bills and allows you to review online, then simply approve or decline payment for each. You save money and time by securely paying online using your credit/debit card that you have registered. Call for more information or go to www. ampianhrbenefits.com and click on My Benefits then HealthEZ Payment Service The HealthEZ SmartID Card With the SmartID card, you and your family will always have your HealthEZ ID card in reach on your smartphone! Simply login to: www. ampianhrbenefits.com to access your SmartID card. You can also print a temporary ID card from the website. Show your new ID card at the pharmacy and your doctor s office so claims will be submitted to the proper claims processing address - as shown on the back of your ID card. Jane Doe Group ID: PNA Member ID:

5 Summary of Medical Benefits Calendar Year Deductible Employee Only Family Member Coinsurance Individual Out-of-Pocket Max Family Out-of-Pocket Max Preventive Care (Routine physical, cancer screenings, eye exams, & prenatal care) Physician Services Primary Care Physician Office Visit Specialty Office Visit Radiology & Labs Inpatient/Outpatient Lab & X-Ray Services MRI, CT, PET Scans at a freestanding facility In-Network $2,000 $4,000 Silver Plan Out-of-Network $4,000 $8,000 20% 40% $7,000 $14,000 $25 copay $14,000 $28,000 Hospital Care Urgent Care Services Emergency Services Emergency Room Ambulance Mental Health/ Chemical Dependency Inpatient Outpatient Physical, Occupational, and Speech therapy (60 visit limit per therapy) Chiropractic Services - Therapy & Manipulation (20 visit limit) Home Health Care (100 day limit) Hospice (180 day limit per lifetime) Skilled Nursing Care (81 visits/days limit) $250 copay $250 copay Durable Medical Equipment Maternity Care (physician & hospital charges) Prescription Drug Coverage Generic Formulary Non-Formulary Specialty (Mail order available for a 30 day supply) Retail 30 Day Supply $15 copay $75 copay $150 copay Mail Order 90 Day Supply $30 copay $90 copay $150 copay Not available PLEASE NOTE: This only serves as a high level summary of your benefit plan. Please refer to your Summary Plan Description (SPD) for more information on coverage, limitation and exclusion provisions, how benefits are paid, how claims are filed, etc Members can access their SPD, SBCs and ERISA notices on their custom benefit site, Deductibles, copays, and coinsurance apply toward out-of-pocket maximums. Precertification requirements will be outlined in your Summary Plan Document. Out-of-Network services deemed to be true emergencies by the Plan Administrator will be paid at In-Network Benefit Rate *After deductible

6 Summary of Medical Benefits Calendar Year Deductible Employee Only Family Member Coinsurance Individual Out-of-Pocket Max Family Out-of-Pocket Max Preventive Care (Routine physical, cancer screenings, eye exams, & prenatal care) Physician Services Primary Care Physician Office Visit Specialty Office Visit Radiology & Labs Inpatient/Outpatient Lab & X-Ray Services MRI, CT, PET Scans at a freestanding facility In-Network $1,000 $2,000 Gold Plan Out-of-Network $2,000 $4,000 20% 40% $4,000 $8,000 $25 copay $20,000 Hospital Care Urgent Care Services Emergency Services Emergency Room Ambulance Mental Health/ Chemical Dependency Inpatient Outpatient Physical, Occupational, and Speech therapy (60 visit limit per therapy) Chiropractic Services - Therapy & Manipulation (20 visit limit) Home Health Care (100 day limit) Hospice (180 day limit per lifetime) Skilled Nursing Care (81 visits/days limit) $250 copay $250 copay Durable Medical Equipment Maternity Care (physician & hospital charges) Prescription Drug Coverage Generic Formulary Non-Formulary Specialty (Mail order available for a 30 day supply) Retail 30 Day Supply $15 copay $75 copay $150 copay Mail Order 90 Day Supply $30 copay $90 copay $150 copay Not available PLEASE NOTE: This only serves as a high level summary of your benefit plan. Please refer to your Summary Plan Description (SPD) for more information on coverage, limitation and exclusion provisions, how benefits are paid, how claims are filed, etc Members can access their SPD, SBCs and ERISA notices on their custom benefit site, Deductibles, copays, and coinsurance apply toward out-of-pocket maximums. Precertification requirements will be outlined in your Summary Plan Document. Out-of-Network services deemed to be true emergencies by the Plan Administrator will be paid at In-Network Benefit Rate *After deductible

7 Summary of Medical Benefits Calendar Year Deductible Employee Only Family Member Coinsurance Individual Out-of-Pocket Max Family Out-of-Pocket Max Preventive Care (Routine physical, cancer screenings, eye exams, & prenatal care) In-Network $2,500 $5,000 $2,500 HSA Plan Out-of-Network $5,000 20% 40% $5,000 $20,000 Physician Services Radiology & Labs Inpatient/Outpatient Lab & X-Ray Services MRI, CT, PET Scans at a freestanding facility Hospital Care Urgent Care Services Emergency Services Mental Health/ Chemical Dependency Physical, Occupational, and Speech therapy (60 visit limit per therapy) Chiropractic Services - Therapy & Manipulation (20 visit limit) Home Health Care (100 day limit) Hospice (180 day limit per lifetime) Skilled Nursing Care (81 visits/days limit) Durable Medical Equipment Maternity Care (physician & hospital charges) Prescription Drug Coverage Generic Formulary Non-Formulary Specialty (Mail order available for a 30 day supply) Retail 30 Day Supply * Mail Order 90 Day Supply Not available PLEASE NOTE: This only serves as a high level summary of your benefit plan. Please refer to your Summary Plan Description (SPD) for more information on coverage, limitation and exclusion provisions, how benefits are paid, how claims are filed, etc Members can access their SPD, SBCs and ERISA notices on their custom benefit site, Deductibles, copays, and coinsurance apply toward out-of-pocket maximums. Precertification requirements will be outlined in your Summary Plan Document. Out-of-Network services deemed to be true emergencies by the Plan Administrator will be paid at In-Network Benefit Rate *After deductible

8 Summary of Medical Benefits Calendar Year Deductible Employee Only Family Member Coinsurance Individual Out-of-Pocket Max Family Out-of-Pocket Max Preventive Care (Routine physical, cancer screenings, eye exams, & prenatal care) In-Network $5,000 $5,000 HSA Plan Out-of-Network $20,000 40% $5,000 $20,000 Physician Services * Radiology & Labs * Hospital Care * Urgent Care Services * Emergency Services Emergency Room Ambulance * * * Mental Health/ Chemical Dependency * Physical, Occupational, and Speech therapy (60 visit limit per therapy) Chiropractic Services - Therapy & Manipulation (20 visit limit) Home Health Care (100 day limit) Hospice (180 day limit per lifetime) Skilled Nursing Care (81 visits/days limit) * * * * * Durable Medical Equipment * Maternity Care (physician & hospital charges) * Prescription Drug Coverage Generic Formulary Non-Formulary Specialty (Mail order available for a 30 day supply) Retail 30 Day Supply * * * * Mail Order 90 Day Supply Not available PLEASE NOTE: This only serves as a high level summary of your benefit plan. Please refer to your Summary Plan Description (SPD) for more information on coverage, limitation and exclusion provisions, how benefits are paid, how claims are filed, etc Members can access their SPD, SBCs and ERISA notices on their custom benefit site, Deductibles, copays, and coinsurance apply toward out-of-pocket maximums. Precertification requirements will be outlined in your Summary Plan Document. Out-of-Network services deemed to be true emergencies by the Plan Administrator will be paid at In-Network Benefit Rate *After deductible

9 Summary of Medical Benefits Calendar Year Deductible Employee Only Family Member Coinsurance Individual Out-of-Pocket Max Family Out-of-Pocket Max Preventive Care (Routine physical, cancer screenings, eye exams, & prenatal care) In-Network $6,550 $13,100 $6,550 HSA Plan Out-of-Network $13,100 $26,200 50% $6,550 $13,100 $20,000 $40,000 Physician Services * Radiology & Labs * Hospital Care * Emergency Services * Mental Health/ Chemical Dependency * Physical, Occupational, and Speech therapy (60 visit limit per therapy) Chiropractic Services - Therapy & Manipulation (20 visit limit) Home Health Care (100 day limit) * * * Hospice (180 day limit per lifetime) * Skilled Nursing Care (81 visits/days limit) * Durable Medical Equipment * Maternity Care (physician & hospital charges) * Prescription Drug Coverage Generic Formulary Non-Formulary Specialty (Mail order available for a 30 day supply) Retail 30 Day Supply * * * * Mail Order 90 Day Supply Not available PLEASE NOTE: This only serves as a high level summary of your benefit plan. Please refer to your Summary Plan Description (SPD) for more information on coverage, limitation and exclusion provisions, how benefits are paid, how claims are filed, etc Members can access their SPD, SBCs and ERISA notices on their custom benefit site, Deductibles, copays, and coinsurance apply toward out-of-pocket maximums. Precertification requirements will be outlined in your Summary Plan Document. Out-of-Network services deemed to be true emergencies by the Plan Administrator will be paid at In-Network Benefit Rate *After deductible

10 Benefit Enrollment/Change Form A. Employee Information (all information is required) First Name: MI: Last Name: SSN#: Date of Hire: Date of Birth: Gender: o M or o F Marital Status: Address: City: State: Zip: Daytime Phone: ( ) Home phone: ( ) B. Medical Plan Options (if electing coverage please make a selection in both 1 & 2) 1. Plan applying for o Silver Plan o Gold Plan o $2,500 HSA Plan o $5,000 HSA Plan o $6,550 HSA Plan o Decline Coverage (please complete sections D. & E.) 2. Coverage applying for o Employee only o Employee + Spouse o Employee + Children o Family C. Dependent/Spouse Information (must be completed for coverage of dependents) Name (Last, First, MI) Relationship Birth date SSN M/F Disabled (Y/N) Please check below to include on medical plan o Medical o Medical o Medical o Medical o Medical D. Other Insurance Coverage Information Please check one: o I have other insurance coverage (please provide information below) o I have enrolled thru the state or federal Marketplace (please provide information below) Policyholder s Name: o I do not have other insurance coverage Policyholder s Date of Birth: Insurance Co. Name: Policy Number: Group Number: Insurance Co. Address: Names of covered individuals: E. Health Savings Account This option is available if you enroll in the HSA plan o Yes, I would like to set up a Health Savings Account Your annual deduction will be divided into equal amounts and deducted from each pay period throughout the year. o I have other insurance coverage, but intend to cancel that coverage I elect to have an ANNUAL deduction of $ (maximum of $3,400 for employee-only coverage, or $6,750 for all other levels of coverage) reduced from my salary before taxes to reimburse me for qualified expenses which I incur during the plan year. Maximum contribution to the HSA Plan will be reduced by company contribution. Employees who are age 55 or older can make a catch-up contribution of $1,000 in addition to IRS maximums. F. Enrollment Waiver (check box only if declining coverage) o I understand the benefits provided by the Group Insurance Contract under ERISA regulations include Health and/or Dental coverages. I have reviewed and understand the benefit options and requirements presented herein. I understand that I may not be eligible to enroll myself and dependents if I desire to apply for coverage at a later date, unless I qualify to enroll at a later date in accordance with the special enrollment conditions. o I understand by not enrolling in this plan or a Marketplace health plan as mandated by PPACA, that I may be subject to a tax penalty. G. Employee Authorization. Employee Authorization I understand I have the option to pay the premiums for my employer-sponsored health plan through a before-tax reduction of my salary. I understand that if this amount increases or decreases during the plan year, my salary reduction will be adjusted to reflect that increase or decrease. I hereby apply for the coverage for which I am now or may be eligible under this group policy. I hereby authorize the deduction from my earnings of the required contribution, if any, toward the cost of such coverage. I authorize payment of medical benefits to all providers, where applicable, for those charges covered by my group insurance benefits. I authorize release to or by HealthEZ of any medical information including copies of medical records or insurance information as necessary for claims adjudication, utilization review, or coordination of benefits. To the best of my knowledge and belief, the information I have provided on this form is complete and correct. I acknowledge that the terms of the Summary Plan Description govern all payments made by the Plans. Employee Signature Date H. Employer Information (to be completed by the employer or HealthEZ only) Employer: HEZ Group # HEZ Division Code: Effective Date: To be completed by HealthEZ HEZ Received: HEZ Entered: ID Cards: