2019 Benefits Guide 2019 Guía de Beneficios - The Claremont

2019 Benefits Guide 2019 Guía de Beneficios - The Claremont
2019 Benefits Guide   2019 Guía de Beneficios

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2019 Benefits Guide 2019 Guía de Beneficios - The Claremont
2019 Benefits Guide



Welcome!
This guide provides information about your benefits with
The Claremont Colleges.
                                                                                                       Your Benefits
Use this guide as your go-to source when you are first enrolling for
                                                                                                       Who’s Eligible
your benefits, when changing your benefits at Open Enrollment, or
                                                                                                       Enrolling for Benefits
throughout the year as a benefits resource.
                                                                                                       2019 Plan Rates

Your Benefits Guide                                                                                    Wellness Resources

                                                                                                       Retirement Plan
Your benefits are an important part of your overall compensation. The Claremont
Colleges are pleased to offer a comprehensive array of benefits to protect your
health, your family and your way of life, including:

●● Health care coverage, including medical, dental, and vision benefits

●● Financial protection for you and your family, including disability, life, and
  accident insurance coverage

●● Retirement savings opportunities

●● Work-life resources through the Employee Assistance Program (EAP)

●● Other voluntary benefits, including Flexible Spending Accounts (FSAs), Health
  Savings Accounts (HSAs), long-term care insurance, pet insurance, identity
  protection insurance, legal services, and other financial benefits.




                                                                                                       Who to Contact
This guide provides general benefit plan and enrollment information only. For specific details,
conditions, and exclusions, please refer to the official summary plan descriptions (SPDs). If there    Forms
is a discrepancy between this guide and an official SPD or Collective Bargaining Agreement, the
official document will govern.                                                                         Notices


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2019 Benefits Guide 2019 Guía de Beneficios - The Claremont
2019 Benefits Guide



Your Benefits
The following benefit programs are available to you. Click the benefit plan below
for more information.

●● Medical Benefits                       ●● Long-Term Disability
  –– Kaiser Permanente HMO                                                           Your Benefits
                                          ●● Life Insurance
  –– Anthem Blue Cross HMO
                                            –– Basic Life Insurance                   Your Medical Benefits
  –– Anthem Act Wise HDHP
                                            –– Supplemental Life Insurance            Your Dental Benefits
    • PNC Bank Health Savings
                                          ●● Accidental Death & Dismemberment
                                                                                      Your Vision Benefits
       Account
                                            Insurance (AD&D)                          Employee Assistance Program
●● Dental Benefits
  –– Cigna Dental Care Access (DHMO)      ●● Long-Term Care
                                                                                      Flexible Spending Accounts

  –– Cigna Dental DPPO                                                                Life Insurance Benefit
                                          ●● Pet Insurance
●● Vision Benefits
                                                                                      Evidence of Insurability
                                          ●● Legal Assistance Insurance
  –– Anthem Core Plan                                                                 Long-Term Disability

  –– Anthem Buy-Up Plan                   ●● Identity Protection Insurance            Accidental Death & Dismemberment
                                                                                      (AD&D) Insurance
●● Employee Assistance Program            ●● Retirement Plan                          Long-Term Care

●● FSAs
                                                                                      Pet Insurance

  –– Health Care FSA                                                                  Legal Assistance Insurance
  –– Limited Scope Health Care FSA                                                    Identity Protection Insurance
  –– Dependent Care FSA
                                                                                     Who’s Eligible

                                                                                     Enrolling for Benefits

                                                                                     2019 Plan Rates

                                                                                     Wellness Resources

                                                                                     Retirement Plan

                                                                                     Who to Contact

                                                                                     Forms

                                                                                     Notices


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2019 Benefits Guide 2019 Guía de Beneficios - The Claremont
2019 Benefits Guide



Your Medical Benefits
The Claremont Colleges offers three medical plans for you to choose from. Click
the plan name for more detail:

●● Kaiser Permanente HMO
                                                                                                  Your Benefits
●● Anthem Blue Cross (CaliforniaCare) HMO
                                                                                                   Your Medical Benefits
●● Anthem Act Wise HDHP
                                                                                                   Your Dental Benefits

Kaiser Permanente HMO and Anthem Blue Cross                                                        Your Vision Benefits

(CaliforniaCare) HMO Plans                                                                         Employee Assistance Program

                                                                                                   Flexible Spending Accounts
The HMO plans offer affordable health care for you and your family through a
network of health care providers. When you enroll in an HMO plan, you (and each                    Life Insurance Benefit

enrolled family member) will be asked to select a primary care physician (PCP)                     Evidence of Insurability
from the network. The PCP you choose will help you manage all aspects of your                      Long-Term Disability
health care. Anthem members: The PCP you select has to be within 15 miles or a                     Accidental Death & Dismemberment
30-minute drive from your home or work. Kaiser members: You have the right to                      (AD&D) Insurance
designate any primary care provider who participates in the plan’s network and                     Long-Term Care
who is available to accept you or your family members.                                             Pet Insurance

Plan Features:                                                                                     Legal Assistance Insurance

1. You must select and use a primary care physician (PCP) from the HMO                             Identity Protection Insurance

   network to coordinate your care.
                                                                                                  Who’s Eligible
2. HMOs do not have deductibles or coinsurance. Instead, you pay a copay when
                                                                                                  Enrolling for Benefits
   you visit your PCP or a specialist whom you have been referred to by your
   PCP.                                                                                           2019 Plan Rates

3. If you use doctors, hospitals, labs, pharmacies or other health care facilities                Wellness Resources
   outside the HMO, you are responsible for paying the full cost (except in an
                                                                                                  Retirement Plan
   emergency).
                                                                                                  Who to Contact
4. There are no claim forms to file.
                                                                                                  Forms
                                                                                     CONTINUED
                                                                                                  Notices


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2019 Benefits Guide



Kaiser Permanente HMO and Anthem Blue Cross
(CaliforniaCare) HMO Plans (Continued)
Here’s what you need to know about receiving care from the HMO plans:

Kaiser Permanente HMO
                                                                                       There’s an App for That                    Your Benefits
You have the option of going to any Kaiser Permanente facility to receive your
care. Care received from a non-Kaiser facility will not be covered (except for      Download the KP Mobile App for                 Your Medical Benefits

emergency care).                                                                    Android or Apple smartphone. You               Your Dental Benefits
                                                                                    can:                                           Your Vision Benefits
How to Find a Kaiser Permanente Provider
                                                                                    ●● Find a local doctor, network, or            Employee Assistance Program
1. Go to www.kp.org/newmember.                                                        facility and make an appointment             Flexible Spending Accounts

2. Click “Find Doctors & Locations.”                                                ●● View, refill, and check the status of a     Life Insurance Benefit

                                                                                      prescription                                 Evidence of Insurability
3. Select “California-Southern.”
                                                                                    ●● Check your latest test results              Long-Term Disability
4. Enter your location and other key words, such as a doctor’s name or specialty.                                                  Accidental Death & Dismemberment
   (Or you may select your physician on the My Doctor portal.)                      ●● Email your doctor.                          (AD&D) Insurance
                                                                                                                                   Long-Term Care
Once you have selected a primary care physician (PCP), you can use Kaiser                                                          Pet Insurance
Permanente’s My Doctor portal at www.kp.org/mydoctor to email your doctor
                                                                                                                                   Legal Assistance Insurance
and access health care tools OR you can download and use the KP Mobile App
for your Android or Apple smartphone.                                                                                              Identity Protection Insurance

                                                                                                                                  Who’s Eligible

                                                                                                                                  Enrolling for Benefits

                                                                                                                                  2019 Plan Rates

                                                                                                                                  Wellness Resources

                                                                                                                                  Retirement Plan

                                                                                                                                  Who to Contact

                                                                                                                                  Forms
                                                                                                                  CONTINUED
                                                                                                                                  Notices


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2019 Benefits Guide



Kaiser Permanente HMO and Anthem Blue Cross
(CaliforniaCare) HMO Plans (Continued)

Anthem Blue Cross (CaliforniaCare) HMO
You must receive all of your non-emergency care from doctors and hospitals
in the Anthem Blue Cross (CaliforniaCare) HMO network, and the care must be              There’s an App for That                 Your Benefits
under your PCP’s direction or the plan will not pay benefits. Women may go                                                        Your Medical Benefits
                                                                                      You can also download Anthem’s
directly to a gynecologist in their PCP’s medical group or practice association
                                                                                      mobile app to search for an in-network      Your Dental Benefits
without a referral from their PCP. Care received from an out-of-network provider
                                                                                      provider. Download the Anthem               Your Vision Benefits
will not be covered (except for emergency care).
                                                                                      Blue Cross app for Android or Apple
                                                                                                                                  Employee Assistance Program
                                                                                      smartphone.
How to Find an In-Network Anthem Provider                                                                                         Flexible Spending Accounts

1. Go to anthem.com/ca.                                                                                                           Life Insurance Benefit
                                                                                         15-Mile or 30-Minute Requirement
                                                                                                                                  Evidence of Insurability
2. Scroll down and click “Find a Doctor.”
                                                                                      If you are enrolled in the Anthem Blue      Long-Term Disability
3. Scroll down under “Search as a Guest,” click “Search by Selecting a                Cross HMO (CaliforniaCare) plan, you        Accidental Death & Dismemberment
   Plan/Network.”                                                                     must elect a primary care physician         (AD&D) Insurance
                                                                                      or medical group within 15 miles or 30      Long-Term Care
4. On the next screen, select the type of care (for example “Medical”), and the
                                                                                      minutes of where you live or work to        Pet Insurance
   state from the drop-down list.
                                                                                      receive care.
                                                                                                                                  Legal Assistance Insurance
5. Under “Select a plan/network,” you can enter the name of your plan/network
                                                                                      If you attempt to elect a doctor who        Identity Protection Insurance
   under the “Medical (Employer Sponsored)” heading, or select it from the
                                                                                      is outside of these limits, the plan
   drop-down list then choose “Select and Continue.”
                                                                                      may prevent you from electing that         Who’s Eligible
   –– The HMO plan name is “Blue Cross HMO (CA Care)-large group.”
                                                                                      doctor, even if he or she is accepting
                                                                                                                                 Enrolling for Benefits
6. Using the drop-down boxes, select what type of doctor and the location             new patients, or the medical group
   you’re looking for, then select SEARCH.                                            may disenroll you from their medical       2019 Plan Rates
                                                                                      group facility. To find out whether
7. For more info about a provider (like skills and training), just select that name                                              Wellness Resources
                                                                                      your primary care physician meets this
   in the directory.
                                                                                      requirement, contact Anthem customer       Retirement Plan
                                                                                      service.
                                                                                                                                 Who to Contact

                                                                                                                                 Forms
                                                                                                                    CONTINUED
                                                                                                                                 Notices


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2019 Benefits Guide



Anthem Act Wise HDHP
With the Anthem Act Wise High Deductible Health Plan (HDHP), you have the                 Need More Detail?
flexibility to choose any doctor or facility and receive benefits. However, if you
                                                                                       Click here to review Your Guide to the Anthem
go to Anthem Act Wise HDHP network doctors and facilities, you will pay less
                                                                                       Act Wise HDHP. This guide has more detail about
because Anthem Act Wise HDHP network providers have agreed to charge
                                                                                       how the Anthem Act Wise HDHP works, and how
lower, negotiated rates.                                                                                                                      Your Benefits
                                                                                       to make the most of the tax-advantaged Health
Plan Features:                                                                                                                                 Your Medical Benefits
                                                                                       Savings Account (HSA).
                                                                                                                                               Your Dental Benefits
1. Flexibility to go to in-network and out-of-network providers
                                                                                                                                               Your Vision Benefits
                                                                                          Think About Participating in the Limited
2. Lower out-of-pocket expenses when you see in-network providers
                                                                                       Scope Health Care FSA/Health Savings                    Employee Assistance Program
3. 100% coverage for preventive care with in-network providers                         Account (HSA)                                           Flexible Spending Accounts

4. Coinsurance for most services once you meet the plan’s deductible                   If you enroll in the Anthem Act Wise HDHP and           Life Insurance Benefit

   A Note About Reasonable And Customary Charges                                       Health Savings Account (HSA), a Limited Scope           Evidence of Insurability
   When you use in-network providers, the coinsurance percentage is lower              Health Care FSA is also available to you. The           Long-Term Disability
   due to negotiated rates. If you use out-of-network providers, the coinsurance       Limited Scope Health Care FSA allows you to             Accidental Death & Dismemberment
   percentage is higher and is based on reasonable and customary (R&C)                 pay for eligible dental and vision expenses (i.e.,      (AD&D) Insurance
   charges. You must also pay any amount over the R&C limit.                           deductibles, copays, coinsurance). You also can         Long-Term Care
                                                                                       use the Limited Scope Health Care FSA to pay for        Pet Insurance
5. Out-of-pocket maximum(s) to help protect you from the expense of a possible
                                                                                       medical expenses and prescription drugs AFTER
   catastrophic illness or injury                                                                                                              Legal Assistance Insurance
                                                                                       you’ve met your plan’s deductible. For more
6. A tax-advantaged Health Savings Account (HSA). Go to Health Savings                                                                         Identity Protection Insurance
                                                                                       details, review Using the Limited Scope Health
   Account (HSA) for more information about this unique savings account.               Care FSA & HSA Together.
                                                                                                                                              Who’s Eligible

                                                                                                                                              Enrolling for Benefits
                                                                                          Research Your Health Care Costs
                                                                                                                                              2019 Plan Rates
                                                                                       Want to know how much a particular procedure
                                                                                       or treatment may cost? Use the Healthcare              Wellness Resources
                                                                                       Bluebook to look up average medications,
                                                                                                                                              Retirement Plan
                                                                                       treatments, procedures, and more! This website
                                                                                       will help you find the fairest price for your care,    Who to Contact
                                                                                       plus information on how to save money.
                                                                                                                                              Forms
                                                                           CONTINUED
                                                                                                                                              Notices


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2019 Benefits Guide



Anthem Act Wise HDHP (continued)

How to Find an In-Network Anthem Provider
1. Go to anthem.com/ca.

2. Scroll down and click “Find a Doctor.”
                                                                                        There’s an App for That                  Your Benefits
3. On the right-hand side, under “Search as a Guest,” click “Search by Selecting                                                  Your Medical Benefits
                                                                                      You can also download Anthem’s
   a Plan/Network.”
                                                                                      mobile app to search for an in-network      Your Dental Benefits
4. On the next screen, select the type of care (for example “Medical”), and the       provider. Download the Anthem               Your Vision Benefits
   state from the drop-down list.                                                     Blue Cross app for Android or Apple
                                                                                                                                  Employee Assistance Program
                                                                                      smartphone.
5. Under “Select a plan/network,” you can enter the name of your plan/network                                                     Flexible Spending Accounts
   under the “Medical (Employer Sponsored)” heading, or select it from the                                                        Life Insurance Benefit
   drop-down list then choose “Select and Continue.”
   –– The Act Wise HDHP plan name is “Blue Cross PPO (Prudent Buyer) – Large
                                                                                                                                  Evidence of Insurability

      Group”                                                                                                                      Long-Term Disability
                                                                                                                                  Accidental Death & Dismemberment
6. Using the drop-down boxes, select what type of doctor and the location                                                         (AD&D) Insurance
   you’re looking for, then select SEARCH.                                                                                        Long-Term Care

                                                                                                                                  Pet Insurance
7. For more info about a provider (like skills and training), just select that name
   in the directory.                                                                                                              Legal Assistance Insurance

                                                                                                                                  Identity Protection Insurance

                                                                                                                                 Who’s Eligible

                                                                                                                                 Enrolling for Benefits

                                                                                                                                 2019 Plan Rates

                                                                                                                                 Wellness Resources

                                                                                                                                 Retirement Plan

                                                                                                                                 Who to Contact


                                                                                                                  CONTINUED
                                                                                                                            ›    Forms

                                                                                                                                 Notices


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How the Anthem Act Wise HDHP Works

How does an HDHP work? Let us tell you.          1. Your annual out-of-pocket maximum for in-network usage
                                                    caps your expenses. Once you reach the annual out-of-pocket
                                                    maximum for in-network usage, the plan pays 100% of your
                                                    costs for the rest of the year. Please note: your out-of-pocket
                                                    expenses could exceed your maximums when using
        OUT-OF-POCKET MAXIMUM
                                                    out-of-network providers and facilities.                           Your Benefits
                                                 2. Comprehensive coverage with coinsurance paid by you and             Your Medical Benefits
                                                    the medical plan. Once you meet the deductible, the plan pays
                                                    a percentage of the cost and you pay the rest. You can pay for      Your Dental Benefits
                                                    your portion with the tax-free money you contribute to your         Your Vision Benefits
                                                    HSA.
                                                                                                                        Employee Assistance Program
                                                 3. Your contribution to your deductible. You will pay for your
                     COINSURANCE                    health care expenses until you meet your annual deductible. You     Flexible Spending Accounts
                                                    can use the tax-free money that you contribute to your HSA to
                                                                                                                        Life Insurance Benefit
                                                    cover this amount.
                                                                                                                        Evidence of Insurability
                                                 4. Preventive care is the plan’s foundation, covered at 100% by
                                                    the medical plan. This is the point from which you grow your        Long-Term Disability
                                                    most valuable health knowledge and healthy habits. Most             Accidental Death & Dismemberment
                                                    appropriate preventive care received in-network is free to you      (AD&D) Insurance
                                                    and your family.
                                                                                                                        Long-Term Care

                                                                                                                        Pet Insurance
                                                         Facts About Your HSA
                                                                                                                        Legal Assistance Insurance
                                                      If you enroll in the Anthem Act Wise HDHP, you will
              ANNUAL DEDUCTIBLE                       automatically be enrolled in a Health Savings Account             Identity Protection Insurance

                                                      (HSA) with PNC Bank. An HSA is a special account
                                                                                                                       Who’s Eligible
                                                      that lets you pay eligible expenses—like deductibles,
                                                      coinsurance and prescription drugs—with tax-free                 Enrolling for Benefits
                                                      dollars. An HSA can be offered only with a medical
                                                                                                                       2019 Plan Rates
                                                      plan that meets the IRS high deductible health plan
         PREVENTIVE CARE—FREE                         requirements—like the Anthem Act Wise HDHP.                      Wellness Resources

                                                      Go to the Health Savings Account (HSA) section to learn          Retirement Plan
                                                      more about the HSA and how it works.
                                                                                                                       Who to Contact
                                                      Please note: If there is no activity on your HSA within
                                                                                                                       Forms
                                                      three months, your account may be closed.
                                                                                                                       Notices


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Health Savings Account (HSA)
                                                                               HSA Basics
If you choose to enroll in the Anthem Act Wise HDHP you will
                                                                               Funding         You can contribute to your HSA directly from your
automatically be enrolled in a Health Savings Account (HSA)1. An
                                                                                               salary on a pre-tax basis if you select PNC Bank
HSA is a personal savings account created from pre-tax employee                                as your HSA provider. You can also contribute to
contributions to be used for qualified medical expenses. Federal                               another financial institution’s HSA using post-tax
regulations limit HSAs to plans with a high deductible, like the                               dollars up to the IRS limit:                                        Your Benefits
Anthem Act Wise HDHP.                                                                          ●● The maximum annual contribution is $3,500 per                     Your Medical Benefits
                                                                                                 individual.*
An HSA can also be used as an investment tool because your                                                                                                          Your Dental Benefits
                                                                                               ●● The maximum annual contribution is $7,000 per
account balance can roll over from year to year. And, the HSA is                                 family.*                                                           Your Vision Benefits
completely portable—you can take it with you if you change jobs
                                                                                               ●● If you are 55 years of age or older, there is a                   Employee Assistance Program
or retire. You can then use this tax-free money to pay for eligible                              catch-up contribution option in the amount of
                                                                                                                                                                    Flexible Spending Accounts
medical expenses for you or your eligible dependents (consult with                               $1,000.
a tax professional about the eligibility of your dependents age                                                                                                     Life Insurance Benefit
                                                                                               You are not eligible for the HSA if you are enrolled in
19–24).                                                                                        Medicare Parts A and/or B.                                           Evidence of Insurability
                                                                                               * These amounts include any employer contributions. Only            Long-Term Disability
When you enroll in an HSA, you will receive a welcome kit from the
                                                                                                non-highly compensated participants (employees who had an
HSA administrator, PNC Bank, with more information about using                                                                                                      Accidental Death & Dismemberment
                                                                                                annual compensation of less than $120,000 in 2018) are eligible     (AD&D) Insurance
your HSA.                                                                                       for the employer contribution.
                                                                                                                                                                    Long-Term Care
                                                                               Qualified       The money that you put into the HSA can be used
Learn more about the HSA in Your Guide to the Anthem Act Wise                  Expenses        to pay for qualified medical expenses, including the                 Pet Insurance
HDHP. For information about the fees and rate schedule for                                     Anthem Act Wise HDHP’s deductible or coinsurance,
                                                                                                                                                                    Legal Assistance Insurance
your HSA account, please visit PNC Bank online at                                              and other out-of-pocket health care expenses like
                                                                                               dentist visits and eye exams. Additionally, the money                Identity Protection Insurance
www.anthem.com/ca, or call 844-860-3535.
                                                                                               that you roll over can be used for future eligible
1
    Enrollment in Medicare Parts A and/or B makes you ineligible for an HSA.                   expenses, including long-term care. There may be                    Who’s Eligible
                                                                                               restrictions on who the plan will cover, for more
                                                                                               details see Your Guide to the Anthem Act Wise                       Enrolling for Benefits
                                                                                               HDHP.
                                                                               FSA             If you enroll in an HSA, you will only be eligible                  2019 Plan Rates
                                                                               Participation   for the Limited Scope Health Care FSA, due to
                                                                                                                                                                   Wellness Resources
                                                                                               IRS regulations. Limited Scope Health Care FSA
                                                                                               reimbursements are for non-medical expenses that
                                                                                                                                                                   Retirement Plan
                                                                                               you choose not to use your HSA to reimburse, such
                                                                                               as dental or vision copays or coinsurance payments.
                                                                                               Refer to Using the Limited Scope Health Care FSA &                  Who to Contact
                                                                                               HSA Together for more information.
                                                                                                                                                                   Forms
                                                                                                                                                CONTINUED
                                                                                                                                                                   Notices


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Medical Benefits at a Glance
The chart below provides an overview of the most commonly used benefits.

    Benefit                     Kaiser HMO                      Anthem Blue Cross                                Anthem Act Wise HDHP
                                                                (CaliforniaCare) HMO
                                Kaiser Permanente               Anthem Blue Cross              In-Network                     Out-of-Network
                                                                                                                                                     Your Benefits
                                Network                         Providers
    HSA Contributions                                                                                                                                 Your Medical Benefits
    Employee only               N/A                             N/A                                                       $4501                       Your Dental Benefits
    Family                      N/A                             N/A                                                       $9001                       Your Vision Benefits
    Employee HSA                N/A                             N/A                                       $3,500 (employee only)/$7,000 (family)
                                                                                                                                                      Employee Assistance Program
    Contribution Maximum
    (including the employer                                                                                                                           Flexible Spending Accounts
    contribution)
                                                                                                                                                      Life Insurance Benefit
    Employee HSA Catch-Up       N/A                             N/A                                                      $1,000
    Contribution (ages 55 and                                                                                                                         Evidence of Insurability
    over)                                                                                                                                             Long-Term Disability
    Calendar-Year Deductible                                                                                                                          Accidental Death & Dismemberment
    Employee only               None                            None                           $1,500                         $2,500                  (AD&D) Insurance

    Family                      None                            None                           $3,0002                       $5,0002                  Long-Term Care

    Out-of-Pocket Maximum (per calendar year; some benefits do not apply toward the out-of-pocket maximum)                                            Pet Insurance
    Employee Only               $1,500                          $1,500                         $3,000                         $6,000                  Legal Assistance Insurance
    Family                      $3,000                          $3,000 (two party)/            $6,0003                       $12,0003
                                                                                                                                                      Identity Protection Insurance
                                                                $4,500 (family)
    Lifetime Maximum            Unlimited                       Unlimited                                               Unlimited                    Who’s Eligible
    Inpatient Services
                                                                                                                                                     Enrolling for Benefits
    Inpatient Hospital          $200 copay per                  $300 copay per                 Plan pays 80% after            Plan pays 60% after
                                admission                       admission                      deductible                     deductible
                                                                                                                                                     2019 Plan Rates
    Pre-Admission Testing       Plan pays 100%                  Plan pays 100%                 Plan pays 80% after            Plan pays 60% after
                                                                                               deductible                     deductible             Wellness Resources
1
    For employees who earned less than $120,000 in 2018, when opened through PNC Bank.                                                               Retirement Plan
2
  	Includes insured employee and one or more members of the employee’s family. An individual with
    family coverage can incur $2,700 in covered expenses, at which point the plan will pay benefits for
    that individual.
                                                                                                                                                     Who to Contact
3
  	An individual with family coverage can have out-of-pocket expenses totaling $3,000 in-network
    or $6,000 out-of-network, at which point the plan will pay 100% of that individual’s covered                                                     Forms
    expenses for the remainder of the year.
                                                                                                                                                     Notices


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Medical Benefits at a Glance (Continued)
Benefit                       Kaiser HMO                  Anthem Blue Cross                         Anthem Act Wise HDHP
                                                          (CaliforniaCare) HMO
                              Kaiser Permanente           Anthem Blue Cross           In-Network                   Out-of-Network
                              Network                     Providers
Inpatient Services (Continued)                                                                                                                   Your Benefits
Drugs, Medicine, Casts,       Plan pays 100%              Plan pays 100%              Plan pays 80% after          Plan pays 60% after
                                                                                                                                                  Your Medical Benefits
Dressings, Special Duty                                                               deductible                   deductible
Nursing (when prescribed                                                                                                                          Your Dental Benefits
and medically necessary)
                                                                                                                                                  Your Vision Benefits
X-ray, Laboratory             Plan pays 100%              Plan pays 100%              Plan pays 80% after          Plan pays 60% after
                                                                                      deductible                   deductible                     Employee Assistance Program

Cost of Administering         Plan pays 100%              Plan pays 100%              Plan pays 80% after          Plan pays 60% after            Flexible Spending Accounts
Blood Transfusions                                                                    deductible                   deductible
                                                                                                                                                  Life Insurance Benefit
Whole Blood Plasma            No charge if replaced       Plan pays 100%              Plan pays 80% after          Plan pays 60% after
                                                                                      deductible                   deductible                     Evidence of Insurability

Hospice Care                  Plan pays 100%              Plan pays 100%              Plan pays 80% after          Plan pays 60% after            Long-Term Disability
                                                                                      deductible                   deductible                     Accidental Death & Dismemberment
Skilled Nursing Facility      Plan pays 100% (limit 100   Plan pays 100% (limit 100   Plan pays 80% after          Plan pays 60% after            (AD&D) Insurance
                              days per calendar year)     days per calendar year)     deductible (limit 100 days   deductible (limit 100 days     Long-Term Care
                                                                                      per calendar year)           per calendar year)
                                                                                                                                                  Pet Insurance
Outpatient Services
                                                                                                                                                  Legal Assistance Insurance
Office Visits                 You pay a $20 copay         You pay a $25 copay         Plan pays 80% after          Plan pays 60% after
                              (PCP), or                   (PCP), or                   deductible                   deductible                     Identity Protection Insurance
                              You pay a $30 copay         You pay a $40 copay
                              (specialist)                (specialist)                                                                           Who’s Eligible
X-rays, Laboratory Tests      Plan pays 100%              Plan pays 100%              Plan pays 80% after          Plan pays 60% after
                                                                                                                                                 Enrolling for Benefits
                                                                                      deductible                   deductible
Routine Exams                 Plan pays 100%              Plan pays 100%              Plan pays 80% after          Plan pays 60% after           2019 Plan Rates
                                                                                      deductible                   deductible
                                                                                                                                                 Wellness Resources
Routine Immunization          Plan pays 100%              Plan pays 100%              Plan pays 100%               Plan pays 60% after
                                                                                                                   deductible
                                                                                                                                                 Retirement Plan
Preventive Care               Plan pays 100%              Plan pays 100%              Plan pays 100%               Plan pays 60% after
                                                                                                                   deductible                    Who to Contact
Outpatient Surgery (at a      You pay a $30 copay         You pay a $100 copay        Plan pays 80% after          Plan pays 60% after
plan facility)                                                                        deductible                   deductible                    Forms

                                                                                                                                                 Notices


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Medical Benefits at a Glance (Continued)
Benefit                      Kaiser HMO                   Anthem Blue Cross                            Anthem Act Wise HDHP
                                                          (CaliforniaCare) HMO
                             Kaiser Permanente            Anthem Blue Cross              In-Network                   Out-of-Network
                             Network                      Providers
Short-Term Rehabilitation You pay a $20 copay per         The plan pays 100% if you      Plan pays 80% after          Plan pays 60% after          Your Benefits
(physical, occupational, or visit; benefits are limited   receive rehabilitation care    deductible (maximum          deductible (maximum
speech therapy)             to medically necessary        in a hospital or facility      24 visits for both           24 visits for both            Your Medical Benefits
                            therapy authorized by a       affiliated with a hospital.    in-network and               in-network and
                                                                                                                                                    Your Dental Benefits
                            plan physician.                                              out-of-network providers)    out-of-network providers)
                                                                                                                                                    Your Vision Benefits
Chiropractic Care            Not covered                  $25 per visit, short           Plan pays 80% after          Plan pays 60% after
                                                          term (referral from PCP        deductible (limited to       deductible (limited to        Employee Assistance Program
                                                          required)                      12 visits per calendar       12 visits per calendar
                                                                                         year)                        year)                         Flexible Spending Accounts
Acupuncture                  You pay a $30 copay per      You pay a $25 copay per
                             visit                        visit                                                                                     Life Insurance Benefit
Cardiac/Pulmonary            You pay a $20 copay per      You pay a $40 copay per        Plan pays 80% after          Plan pays 60% after           Evidence of Insurability
Rehabilitation               visit                        visit                          deductible                   deductible
                                                                                                                                                    Long-Term Disability
Home Health Care             Plan pays 100% (limited      You pay a $25 copay per        Plan pays 80% after          Plan pays 60% after
                                                                                                                                                    Accidental Death & Dismemberment
                             to 100 2-hour visits per     visit (limited to 100 visits   deductible (limited to 100   deductible (limited to
                                                                                                                                                    (AD&D) Insurance
                             calendar year)               per calendar year)             visits)                      100 visits)
                                                                                                                                                    Long-Term Care
Emergency Services
                                                                                                                                                    Pet Insurance
Emergency Room               You pay a $100 copay;        You pay a $150 copay;          Plan pays 80% after          Plan pays 80% after
Services and Supplies        waived if admitted           waived if admitted             deductible                   deductible                    Legal Assistance Insurance
Ambulance                    You pay a $50 copay per      Plan pays 100%                 Plan pays 80% after          Plan pays 80% after
                                                                                                                                                    Identity Protection Insurance
                             trip                                                        deductible                   deductible
Maternity Care                                                                                                                                     Who’s Eligible
Office Visits (for mother)   Plan pays 100%               You pay a $25 copay            Plan pays 80% after          Plan pays 60% after
                                                          per visit                      deductible                   deductible                   Enrolling for Benefits
Hospital (for mother)        You pay a $200 copay per You pay a $300 copay per Plan pays 80% after                    Plan pays 60% after
                                                                                                                                                   2019 Plan Rates
                             admission                admission                deductible                             deductible
Office Visits (for baby)     Plan pays 100% for well      Plan pays 100% for well        Plan pays 100% for well      Plan pays 60% after          Wellness Resources
                             baby visits                  baby visits                    baby visits                  deductible
                                                                                                                                                   Retirement Plan

                                                                                                                                                   Who to Contact

                                                                                                                                                   Forms

                                                                                                                                                   Notices


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2019 Benefits Guide


Medical Benefits at a Glance (Continued)
Benefit                      Kaiser HMO                     Anthem Blue Cross                       Anthem Act Wise HDHP
                                                            (CaliforniaCare) HMO
                             Kaiser Permanente              Anthem Blue Cross         In-Network              Out-of-Network
                             Network                        Providers
Outpatient Family Planning                                                                                                           Your Benefits
Elective Interrupted         You pay a $30 copay            Plan pays 100%            Plan pays 80% after     Plan pays 60% after
                                                                                                                                      Your Medical Benefits
Pregnancy                                                                             deductible              deductible
Tubal Ligation               You pay a $30 copay            Plan pays 100%            Plan pays 100%          Plan pays 60% after     Your Dental Benefits
                                                                                                              deductible              Your Vision Benefits
Vasectomy                    You pay a $30 copay            You pay a $100 copay      Plan pays 100%          Plan pays 60% after
                                                                                                                                      Employee Assistance Program
                                                                                                              deductible
Counseling & Consultation Plan pays 100%                    You pay a $25 copay       Plan pays 80% after     Plan pays 60% after     Flexible Spending Accounts
                                                                                      deductible              deductible              Life Insurance Benefit
Medical Equipment
                                                                                                                                      Evidence of Insurability
Durable Medical              Plan pays 80%; in              Plan pays 100%            Plan pays 80% after     Plan pays 60% after
                                                                                                                                      Long-Term Disability
Equipment (DME)              accordance with DME                                      deductible              deductible
                             formulary and prescribed                                                                                 Accidental Death & Dismemberment
                             by a Kaiser physician                                                                                    (AD&D) Insurance

Mental Health                                                                                                                         Long-Term Care

Inpatient Care               You pay $200 per               You pay $300 per          Plan pays 80% after     Plan pays 60% after     Pet Insurance
                             admission                      admission                 deductible              deductible
                                                                                                                                      Legal Assistance Insurance
Outpatient Care              You pay a $20 copay per        You pay a $25 copay per   Plan pays 80% after     Plan pays 60% after
                             visit (individual therapy)     visit                     deductible              deductible              Identity Protection Insurance

                             You pay a $10 copay per
                                                                                                                                     Who’s Eligible
                             visit (group therapy)
Substance Abuse                                                                                                                      Enrolling for Benefits
Inpatient Care               You pay a $200 copay per You pay a $300 copay per Plan pays 80% after            Plan pays 60% after
                             admission                admission                deductible                     deductible
                                                                                                                                     2019 Plan Rates

Outpatient Care              You pay a $20 copay per        You pay a $25 copay per   Plan pays 80% after     Plan pays 60% after    Wellness Resources
                             visit for individual therapy   visit                     deductible              deductible
                                                                                                                                     Retirement Plan
                             You pay a $5 copay per
                             visit for group therapy
                                                                                                                                     Who to Contact

                                                                                                                                     Forms

                                                                                                                                     Notices


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Medical Benefits at a Glance (Continued)
    Benefit                       Kaiser HMO                  Anthem Blue Cross                     Anthem Act Wise HDHP
                                                              (CaliforniaCare) HMO
                                  Kaiser Permanente           Anthem Blue Cross       In-Network               Out-of-Network
                                  Network                     Providers
    Prescription Drugs—Preventive                                                                                                     Your Benefits
    Preventive                    N/A                         N/A                                       Plan pays 100%
                                                                                                                                       Your Medical Benefits
    Prescription Drugs—Retail (up to a 30-day supply)
                                                                                                                                       Your Dental Benefits
    Generic                       You pay a $10 copay         You pay a $10 copay     Plan pays 80% after      Plan pays 60% after
                                                                                      deductible               deductible              Your Vision Benefits
    Brand Formulary               You pay a $25 copay         You pay a $30 copay     Plan pays 80% after      Plan pays 60% after     Employee Assistance Program
                                                                                      deductible               deductible
                                                                                                                                       Flexible Spending Accounts
    Brand Non-formulary           You pay a $25 copay1        You pay a $50 copay     Plan pays 80% after      Plan pays 60% after
                                                                                      deductible               deductible              Life Insurance Benefit

    Prescription Drugs—Mail Order                                                                                                      Evidence of Insurability
    Mail-Order Supply             Up to a 100-day supply      Up to a 60-day supply   Up to a 90-day supply                            Long-Term Disability
    Generic                       You pay a $20 copay         You pay a $10 copay     Plan pays 80% after                              Accidental Death & Dismemberment
                                                                                      deductible                                       (AD&D) Insurance
    Brand Formulary               You pay a $50 copay         You pay a $60 copay     Plan pays 80% after      Not covered             Long-Term Care
                                                                                      deductible
                                                                                                                                       Pet Insurance
    Brand Non-formulary           You pay a $50 copay1        You pay a $100 copay    Plan pays 80% after
                                                                                      deductible                                       Legal Assistance Insurance
1
    On exception and if approved by a plan physician                                                                                   Identity Protection Insurance

                                                                                                                                      Who’s Eligible

                                                                                                                                      Enrolling for Benefits

                                                                                                                                      2019 Plan Rates

                                                                                                                                      Wellness Resources

                                                                                                                                      Retirement Plan

                                                                                                                                      Who to Contact

                                                                                                                                      Forms

                                                                                                                                      Notices


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Your Dental Benefits
Dental coverage is key to your overall health. Eligible
employees are offered a choice of two dental plans:

●● Cigna Dental Care Access (DHMO)

●● Cigna Dental DPPO                                                               Quick Guide to Dental Services:          Your Benefits

Use In-Network Providers                                                         ●● Preventive services include: semi-       Your Medical Benefits

                                                                                   annual checkups (including x-rays),       Your Dental Benefits
1. Go to Cigna.com, click on “Find a Doctor” at the top of the screen.
                                                                                   cleanings, and fluoride treatments        Your Vision Benefits
2. Then, choose a Directory by clicking on the “For Plans Offered through Work     (for children)
                                                                                                                             Employee Assistance Program
   or School” option.
                                                                                 ●● Basic services include: diagnostic       Flexible Spending Accounts
3. Next, click on “Find a…Dentist.”                                                x-rays, fillings, and extractions         Life Insurance Benefit

4. Enter SEARCH LOCATION — city, state or zip code.                              ●● Major services include: bridges,         Evidence of Insurability
                                                                                   crowns, implants, and dentures            Long-Term Disability
5. ELECT A PLAN by clicking on the Pick drop-down icon and selecting “Cigna
   Dental PPO” or “Cigna Dental Care Access” under the Dental Plans section.                                                 Accidental Death & Dismemberment
                                                                                                                             (AD&D) Insurance
   Then press SEARCH.
                                                                                                                             Long-Term Care
Need Help? Call Cigna at 800-244-6224.                                                                                       Pet Insurance

                                                                                                                             Legal Assistance Insurance

                                                                                                                             Identity Protection Insurance

                                                                                                                            Who’s Eligible

                                                                                                                            Enrolling for Benefits

                                                                                                                            2019 Plan Rates

                                                                                                                            Wellness Resources

                                                                                                                            Retirement Plan

                                                                                                                            Who to Contact

                                                                                                                            Forms

                                                                                                               CONTINUED    Notices


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Cigna Dental DHMO
The Cigna Dental DHMO plan works much like a medical HMO plan. When you
enroll in a DHMO plan, you (and each enrolled family member) will be asked to
select a primary care dentist (PCD) from the Cigna Total Network.

Plan Features:
                                                                                          Find a Cigna Primary Care Dentist        Your Benefits
1. You must select and use a PCD from the Cigna network to coordinate your              (PCD)                                       Your Medical Benefits
   care, including referrals to specialists within the network.
                                                                                        1. Go to www.Cigna.com and click on         Your Dental Benefits
2. There are no deductibles or annual dental maximums.                                     “Find a Doctor” at the top of the        Your Vision Benefits
                                                                                           screen.
3. First two cleanings per year, sealants and space maintainers are covered                                                         Employee Assistance Program
   at 100%.                                                                             2. Then, choose a Directory by clicking     Flexible Spending Accounts
                                                                                           on “Plans through your employer or       Life Insurance Benefit
4. Preventive and basic services are covered at 100%.
                                                                                           school” option.
                                                                                                                                    Evidence of Insurability
5. General services such as fillings and simple extractions are subject to copays.
                                                                                        3. ELECT A PLAN by clicking on the          Long-Term Disability
6. Major dental services, such as crowns, inlays and dentures, require a copay.            Pick drop-down icon and selecting        Accidental Death & Dismemberment
                                                                                           “Cigna Dental PPO” or Cigna Dental       (AD&D) Insurance
7. If you use a dentist outside the DHMO network, you are responsible for paying
                                                                                           Care Access” under the Dental Plan       Long-Term Care
   the full cost (except in an emergency).
                                                                                           section. Click CHOOSE.                   Pet Insurance
To view the Cigna Dental DHMO copayment schedule, click here.
                                                                                        4. Enter SEARCH LOCATION—city,              Legal Assistance Insurance
                                                                                           state or ZIP code. Then press            Identity Protection Insurance
How the Plans Compare                                                                      SEARCH.
                                                                                                                                   Who’s Eligible
                      Cigna Dental DHMO                      Cigna Dental DPPO          Need help? Call Cigna at
Plan Rates            Less expensive                    More expensive                  800-244-6224                               Enrolling for Benefits

Providers             You must visit a dentist within   You can visit any dentist                                                  2019 Plan Rates
                      the network
Deductible            No deductible                     You pay a deductible first                                                 Wellness Resources
                                                        before the plan begins to pay
                                                        benefits, except for annual                                                Retirement Plan
                                                        exams/cleanings
                                                                                                                                   Who to Contact
Preventive Services                Most preventive services covered 100%
Costs for Dental      You pay a copay                   You pay coinsurance after you                                              Forms
Services                                                meet the deductible                                         CONTINUED
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Cigna Dental DPPO
With the Cigna Dental DPPO Plan, you have the flexibility to choose any dentist
and receive some benefits. However, if you go to a Cigna network dentist in the
DPPO or DPPO Advantage Network, you will pay less because Cigna dentists have
agreed to charge lower, negotiated rates. You will likely achieve higher savings with
the DPPO Advantage Network.                                                                                                                  Your Benefits
                                                                                         How the Dental DPPO Works
Plan Features:                                                                                                                                Your Medical Benefits
                                                                                          See any PPO               See a provider
                                                                                                                                              Your Dental Benefits
1. You can choose any dentist, but will pay less if you choose a Cigna dentist.           network provider          outside the PPO
                                                                                                                    network                   Your Vision Benefits
2. Preventive services are covered at 100% for in-network or out-of-network
                                                                                                                                              Employee Assistance Program
   expenses (out-of-network paid up to the maximum amount allowed by the                  Pay a deductible and      Flexibility of
                                                                                                                    choosing any dentist,     Flexible Spending Accounts
   plan) and aren’t subject to the deductible.                                            any applicable
                                                                                          coinsurance, and you      but rates are not         Life Insurance Benefit
3. You pay the first $50 in eligible expenses per person ($150 maximum per                will pay less because     negotiated, so you
                                                                                          rates are negotiated      may be charged more       Evidence of Insurability
   family) each year, then the plan pays benefits.
                                                                                                                                              Long-Term Disability
4. Basic services are covered at 80%, and major services are covered at 50%,                                                                  Accidental Death & Dismemberment
   after you’ve met the deductible.                                                       Before You Get Treatment …                          (AD&D) Insurance
                                                                                                                                              Long-Term Care
5. The Cigna Dental DPPO Plan covers up to $2,000 of eligible dental expenses           When your dentist recommends treatment, you
                                                                                        should contact Cigna before you get the work          Pet Insurance
   per covered family member each calendar year. Diagnostic and preventive
   benefits are not counted toward the annual maximum. If you get preventive            done so that they can authorize the expense and       Legal Assistance Insurance
   care, your maximum dental benefit will be higher next year!                          the plan will pay benefits. Follow this procedure
                                                                                                                                              Identity Protection Insurance
                                                                                        to protect yourself from unexpected expenses.
6. The Cigna Dental DPPO Plan has a lifetime maximum of $2,500 per covered
                                                                                                                                             Who’s Eligible
   family member for orthodontia services.
                                                                                                                                             Enrolling for Benefits
Out-of-network provider charges are reimbursed only up to a maximum amount
allowed by the plan. Since rates are not negotiated, it is likely their charges will                                                         2019 Plan Rates
be higher and you will pay more.
                                                                                                                                             Wellness Resources
See Dental Benefits at a Glance for more details.
                                                                                                                                             Retirement Plan

                                                                                                                                             Who to Contact

                                                                                                                                             Forms
                                                                                                                               CONTINUED
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Get Rewards for Dental Wellness1
Each year that a covered person gets regular preventive dental care, his or her
maximum annual dental benefit for the following year will be increased by $200.

For example, if you get preventive dental care in 2019, your maximum dental
benefit in 2020 will increase from $2,000 to $2,200. For each year that you
                                                                                                     Your Benefits
receive preventive dental care, your maximum annual dental benefit will increase
by another $200, until you reach a maximum of $2,600 in annual dental benefits.                       Your Medical Benefits

                                                                                                      Your Dental Benefits
This incentive is applied on an individual basis. So, if you have family coverage and
                                                                                                      Your Vision Benefits
you are the only one to receive preventive care, yours is the only maximum that
will increase for the next year. If everyone in your family gets preventive care, the                 Employee Assistance Program
annual maximum benefit for each person will increase the following year.                              Flexible Spending Accounts
1
    Rewards for Dental Wellness applies to DPPO only.                                                 Life Insurance Benefit

                                                                                                      Evidence of Insurability
How the Dental Wellness Feature Works
                                                                                                      Long-Term Disability
                                                                                                      Accidental Death & Dismemberment
                                                                          Jeff
                                                                                                      (AD&D) Insurance
    $2,600
                                                                                                      Long-Term Care
    $2,400                                                                                            Pet Insurance
                                                                        Karen
    $2,200                                                                                            Legal Assistance Insurance
                                                                        Arthur
                                                                                                      Identity Protection Insurance
    $2,000

                                                                                                     Who’s Eligible
                  Year 1           Year 2          Year 3      Year 4      Year 5
                                                                                                     Enrolling for Benefits

Jeff gets preventive care each year and receives a $200 increase in his maximum                      2019 Plan Rates
dental benefits each following year, until reaching the maximum of $2,600.                           Wellness Resources
Karen gets preventive care in year one and receives a $200 increase in her                           Retirement Plan
maximum dental benefit for the following year. Karen does not get preventive
care afterward, so her maximum dental benefit remains at $2,200.                                     Who to Contact

Arthur does not get preventive care, so his maximum dental benefit remains                           Forms
at $2,000.                                                                              CONTINUED
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Dental Benefits at a Glance
The chart below provides an overview of the most commonly used dental benefits.

    Benefit                               Cigna Dental DHMO                                                 Cigna Dental DPPO
                                          In-Network                             In-Network                            Out-of-Network
    Calendar-Year Deductible1             None                                   Individual: $50/Family: $150          Individual: $50/Family: $150                Your Benefits
    Calendar-Year Maximum                 Unlimited                              Plan pays up to $2,000 per            Plan pays up to $2,000 per
                                                                                                                                                                    Your Medical Benefits
    Benefit1                                                                     person/year2                          person/year2
    Preventive/Diagnostic1                                                                                                                                          Your Dental Benefits

    Routine Examination: Cleaning,        Two cleanings per year                 Three cleanings per year              Three cleanings per year                     Your Vision Benefits
    Fluoride Treatment (including
                                          You pay $0                             Plan pays 100%; deductible does       Plan pays 100% of maximum                    Employee Assistance Program
    bitewing x-rays)
                                                                                 not apply                             allowed amount; deductible does
                                                                                                                                                                    Flexible Spending Accounts
                                                                                                                       not apply
    Office Visits                         You pay $0                             Plan pays 80% after deductible        Plan pays 80% of maximum                     Life Insurance Benefit
                                                                                                                       allowed amount after deductible              Evidence of Insurability
    General Services (Restorative)
                                                                                                                                                                    Long-Term Disability
    Fillings: Amalgam Composite/          You pay a $0 – $40 copay               Plan pays 80% after deductible        Plan pays 80% of maximum
                                                                                                                                                                    Accidental Death & Dismemberment
    Resin                                 (depending on number of                                                      allowed amount after deductible              (AD&D) Insurance
                                          surfaces)
                                                                                                                                                                    Long-Term Care
    Simple Extractions                    You pay a $5 copay                     Plan pays 80% after deductible        Plan pays 80% of maximum
                                                                                                                       allowed amount after deductible              Pet Insurance

    Major Services                                                                                                                                                  Legal Assistance Insurance
    Caps, Crowns, Dentures,               Copays as listed in the schedule       Plan pays 50% after deductible        Plan pays 50% of maximum                     Identity Protection Insurance
    Implants                              of covered services and copays                                               allowed amount after deductible
    Orthodontia                                                                                                                                                    Who’s Eligible
    Adults                                You pay a $0 – $1,488 copay
                                          depending on the service                                                                                                 Enrolling for Benefits
                                          performed
                                                                                 Plan pays 50% up to $2,500 lifetime maximum benefit; deductible                   2019 Plan Rates
    Dependent Children (to age 19)        You pay a $0 – $984 copay
                                                                                 does not apply
                                          depending on the service                                                                                                 Wellness Resources
                                          performed
    Retention                             $250 copay                                                                                                               Retirement Plan
1
    Calendar-year deductible and maximum benefit is not applicable to preventive or diagnostic services.
                                                                                                                                                                   Who to Contact
2
    I f you receive preventive dental care during a plan year, your calendar-year maximum benefit for the next year
    will increase by $200, until you reach a maximum dental benefit of $2,600.                                                                                     Forms
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Vision Benefits
Eligible employees are automatically enrolled in the core vision coverage through
Anthem (EyeMed) at no cost. This plan includes coverage for eye exams and
eyeglasses or contact lenses. You receive a higher level of coverage when you
use network providers; however, you can use this claim form to file claims with
Anthem if you visit a provider outside Anthem’s EyeMed network. Anthem uses                                            Find the right Anthem eye doctor    Your Benefits
a network of nationwide providers, including national retailers like Target and                                     for you at www.anthem.com/ca.           Your Medical Benefits
LensCrafters.
                                                                                                                                                            Your Dental Benefits
Increased coverage is available for purchase through the Buy-Up Plan.                                                                                       Your Vision Benefits

                                                                                                                                                            Employee Assistance Program
Vision Benefits at a Glance
                                                                                                                                                            Flexible Spending Accounts
The chart below provides an overview of the most commonly used vision benefits.                                                                             Life Insurance Benefit

 Benefit                      Core Plan                                                               Buy-Up Plan                                           Evidence of Insurability

                              In-Network                             In-Network                                 Out-of-Network                              Long-Term Disability
 Eye Exam (Once every 12 months)                                                                                                                            Accidental Death & Dismemberment
                                                                                                                                                            (AD&D) Insurance
                              Plan pays 100% after a $10 copay       Plan pays 100% after a $10 copay           Plan pays up to $79
                              You pay $79 out-of-network                                                                                                    Long-Term Care

 Frames (Once every 12 months)                                                                                                                              Pet Insurance
                              You receive a 35% discount             Plan pays up to a $130 allowance; you      Plan pays up to $100                        Legal Assistance Insurance
                              No out-of-network coverage             receive a 20% discount on amounts
                                                                     over allowance                                                                         Identity Protection Insurance
 Lenses* (Once every 12 months)
                                                                                                                                                           Who’s Eligible
 Single Vision                You pay $50                            Plan pays 100% after a $15 copay           Plan pays up to $36
 Lined Bifocal                You pay $70                                                                       Plan pays up to $60                        Enrolling for Benefits
 Lined Trifocal               You pay $105                                                                      Plan pays up to $79
                              No out-of-network coverage                                                                                                   2019 Plan Rates
 Contact Lenses (Once every 12 months, in lieu of glasses)
                                                                                                                                                           Wellness Resources
                              You receive a 15% discount             Plan pays up to a $130 allowance; you      Plan pays up to $115
                              No out-of-network coverage             receive a 15% discount on doctors’                                                    Retirement Plan
                                                                     professional fees. Materials are paid at
                                                                     usual & customary rates
                                                                                                                                                           Who to Contact
* Special materials or coatings are subject to additional copays.
                                                                                                                                                           Forms

                                                                                                                                                           Notices


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Employee Assistance Program (EAP)
Confidential advice and counseling are available at no cost to you through the
Employee Assistance Program (EAP). When you contact the EAP you can speak
confidentially to a counselor or other professional who can help with issues,
such as:
                                                                                         Did You Know?                    Your Benefits
●● Parenting issues                        ●● Self-improvement
                                                                                       The EAP is 100% paid for by The     Your Medical Benefits
●● Loss or grieving issues                 ●● Mental health issues
                                                                                       Claremont Colleges!                 Your Dental Benefits
●● Relationship problems                   ●● Financial concerns                                                           Your Vision Benefits

●● Substance abuse issues                  ●● Legal-referral assistance.                                                   Employee Assistance Program

                                                                                                                           Flexible Spending Accounts
Employees and their legal spouse, domestic partner, and eligible dependents
receive up to five counseling sessions with a licensed/certified therapist by                                              Life Insurance Benefit

phone or in person per family member, per issue, each calendar year. Call                                                  Evidence of Insurability
800-234-5465 or log on to www.liveandworkwell.com (use access code:                                                        Long-Term Disability
claremontcolleges) to get started.                                                                                         Accidental Death & Dismemberment
                                                                                                                           (AD&D) Insurance
You can also receive support for everyday tasks through the EAP’s WorkLife
                                                                                                                           Long-Term Care
Services. Get referrals and consultations for such concerns as childcare and
                                                                                                                           Pet Insurance
eldercare, household care and services, and personal services (such as shopping,
translators, or even dog walkers). Read this WorkLife Services flyer for more                                              Legal Assistance Insurance
information.                                                                                                               Identity Protection Insurance

Access to the EAP is available 24/7 year-round. All records, including medical
                                                                                                                          Who’s Eligible
information, referrals and evaluations, are kept strictly confidential in accordance
with federal and state laws.                                                                                              Enrolling for Benefits

More information is available in the EAP Brochure.                                                                        2019 Plan Rates

                                                                                                                          Wellness Resources

                                                                                                                          Retirement Plan

                                                                                                                          Who to Contact

                                                                                                                          Forms

                                                                                                                          Notices


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Flexible Spending Accounts (FSAs)
FSAs help you make your money go further by letting you set aside pre-tax
dollars to pay for certain out-of-pocket eligible expenses and dependent care
costs. Here’s how they work:

●● You make contributions from your pay on a pre-tax basis. Contributions and
                                                                                                  Your Benefits
  eligible reimbursed expenses aren’t subject to federal income tax, Social
  Security tax, and, in most cases, state income tax.                                              Your Medical Benefits

                                                                                                   Your Dental Benefits
●● The tax savings help offset the cost of eligible health care and dependent care
                                                                                                   Your Vision Benefits
  expenses.
                                                                                                   Employee Assistance Program
●● You are not taxed on reimbursements from your FSAs.
                                                                                                   Flexible Spending Accounts
The Claremont Colleges offers three types of FSAs:                                                 Life Insurance Benefit

●● Health Care FSA—To pay for eligible medical, dental, and vision expenses                        Evidence of Insurability

●● Limited Scope Health Care FSA—To pay for eligible dental and vision expenses                    Long-Term Disability

  if you participate in an HSA                                                                     Accidental Death & Dismemberment
                                                                                                   (AD&D) Insurance
●● Dependent Care FSA—To pay for eligible childcare and eldercare expenses                         Long-Term Care

                                                                                                   Pet Insurance
Making FSA Contributions
                                                                                                   Legal Assistance Insurance
The annual amount you contribute to your FSA is deducted from your paychecks                       Identity Protection Insurance
in equal installments, on a pre-tax basis, from January through December 31, 2019,
and credited to your FSA account(s).                                                              Who’s Eligible

                                                                                                  Enrolling for Benefits
Incurring Claims
                                                                                                  2019 Plan Rates
You can incur claims for eligible expenses from January 1, 2019 through
March 15, 2020, so you have until March 15, 2020 to use your 2019 funds. You will                 Wellness Resources
have until June 30, 2020 to submit claims for reimbursement.
                                                                                                  Retirement Plan

                                                                                                  Who to Contact



                                                                                             ›
                                                                                     CONTINUED
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Health Care FSA
You can use the funds in your Health Care FSA to pay for eligible expenses like
deductibles, copays, and coinsurance for you and your eligible dependents. You
can contribute a minimum of $300 and a maximum of $2,650 per plan year,
before tax. You don’t have to have medical, dental, or vision coverage through The
Claremont Colleges to enroll in the Health Care FSA. The full annual election is        Eligible/Ineligible expenses                         Your Benefits
available immediately (or January 1).                                                                                                         Your Medical Benefits
                                                                                     Here are a few common examples of expenses
                                                                                     you can reimburse from your Health Care FSA:             Your Dental Benefits
Limited Scope Health Care FSA
                                                                                     ●● Ambulance services
                                                                                                                                              Your Vision Benefits
If you participate in an HSA or if you are enrolled in Medicare Parts A and/or B,
                                                                                     ●● Artificial teeth/limbs                                Employee Assistance Program
you can participate in a Limited Scope Health Care FSA. You can contribute a
                                                                                     ●● Copays                                                Flexible Spending Accounts
minimum of $300 and a maximum of $2,650 for eligible expenses.
                                                                                     ●● Chiropractic care                                     Life Insurance Benefit
The Limited Scope Health Care FSA offers limited scope reimbursements for            ●● Contact lenses
                                                                                     ●● Crutches
                                                                                                                                              Evidence of Insurability
eligible non-medical expenses, such as dental and vision plan deductibles,
copays and coinsurance. Additionally, once you’ve met your medical plan’s            ●● Deductibles and coinsurance                           Long-Term Disability

deductible, you can use the Limited Scope Health Care FSA to cover medical           ●● Hearing aids                                          Accidental Death & Dismemberment
                                                                                                                                              (AD&D) Insurance
expenses and prescription drug costs.                                                ●● Insulin
                                                                                                                                              Long-Term Care
                                                                                     ●● Laser eye surgery
Keep in mind that you cannot use a Limited Scope Health Care FSA for any
                                                                                     ●● Long-term care expenses (but not insurance
                                                                                                                                              Pet Insurance
of the expenses that are not eligible for reimbursement from a regular Health
                                                                                       premiums)                                              Legal Assistance Insurance
Care FSA.
                                                                                     ●● Stop-smoking programs                                 Identity Protection Insurance
The Limited Scope Health Care FSA is a great option if you want to save the
                                                                                     Below are some examples of ineligible expenses:
money in your HSA for future health care expenses (because HSA funds roll                                                                    Who’s Eligible
                                                                                     ●● Cosmetic surgery (if not medically necessary)
over each year). To learn more about how a Limited Scope Health Care FSA
                                                                                     ●● Teeth bleaching                                      Enrolling for Benefits
works with an HSA, check out Using the Limited Scope Health Care FSA &
                                                                                     ●● Health insurance premiums
HSA Together.                                                                                                                                2019 Plan Rates
                                                                                     ●● Over-the-counter medications
                                                                                                                                             Wellness Resources
When using your FSA for dental claims …                                              For a full list of eligible and ineligible expenses,
                                                                                     go to www.payflex.com.                                  Retirement Plan
If you use your Health Care FSA or Limited Scope Health Care FSA to pay
for dental expenses before your insurance has processed the expense, the                                                                     Who to Contact
claim may result in requests for additional information. See the tip sheet,
                                                                                                                                             Forms
Substantiating Claims for Your Health Care Flexible Spending Account (FSA),
                                                                                                                               CONTINUED
for more information about Dental Claim substantiation.                                                                                      Notices


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2019 Benefits Guide



Dependent Care FSA
The Dependent Care FSA may be used to pay for expenses that allow you (or
your spouse, if married) to work. In any calendar year, you can contribute, before
tax, a minimum of $300 and a maximum of $5,000 ($2,500 if married and filing
separately). The limit applies to all contributions made by you and your spouse to
any dependent care spending accounts through The Claremont Colleges and any            Eligible Dependents                     Your Benefits
other employer combined.                                                                                                        Your Medical Benefits
                                                                                     An eligible dependent is a person
Eligible/Ineligible expenses                                                         who shares the same primary place of       Your Dental Benefits
                                                                                     residence with you for more than six       Your Vision Benefits
Here are some examples of eligible expenses you can reimburse from your
                                                                                     months each year and is:
Dependent Care FSA:                                                                                                             Employee Assistance Program
                                                                                     ●● Your child under age 13 whom you
●● At-home child and elder day care
                                                                                                                                Flexible Spending Accounts
                                                                                       can claim as a dependent on your         Life Insurance Benefit
●● Before- or after-school care                                                        federal income tax return;
                                                                                                                                Evidence of Insurability
●● Care at certain child and elder day care centers                                  ●● Your spouse who is mentally or          Long-Term Disability
                                                                                       physically disabled; or
●● Charges from certain child and elder day care providers                                                                      Accidental Death & Dismemberment
                                                                                                                                (AD&D) Insurance
                                                                                     ●● Your dependent who is mentally or
●● Pre-school and nursery schools                                                                                               Long-Term Care
                                                                                       physically disabled and whom you
●● Summer day camp.
                                                                                                                                Pet Insurance
                                                                                       can claim on your federal income tax
                                                                                       return.                                  Legal Assistance Insurance
Below are some examples of ineligible expenses:                                                                                 Identity Protection Insurance
                                                                                     In most cases, your domestic partner
●● Tuition                                                                           and children of your domestic partner
                                                                                                                               Who’s Eligible
                                                                                     are not considered eligible dependents
●● Child or elder day care provided by someone living in your home
                                                                                     for purposes of your Dependent Care       Enrolling for Benefits
●● Overnight camp.                                                                   FSA.
                                                                                                                               2019 Plan Rates

                                                                                                                               Wellness Resources

                                                                                                                               Retirement Plan

                                                                                                                               Who to Contact

                                                                                                                               Forms
                                                                                                                 CONTINUED
                                                                                                                               Notices


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2019 Benefits Guide



FSA Reimbursements
Health Care FSA and Limited Scope Health Care FSA Reimbursements                          Don’t Forget: If You Do Not “Use It” You Will
                                                                                       “Lose It!”
If you enroll in the Health Care FSA or the Limited Scope Health Care FSA, you
will have two ways to pay for eligible expenses:                                       When estimating your annual expenses, consider
                                                                                       only those that you are reasonably certain you
1. You will receive a debit card, which you can use to pay at the doctor’s office or                                                           Your Benefits
                                                                                       will incur. Any amount left in your FSA after
   pharmacy; or                                                                                                                                 Your Medical Benefits
                                                                                       March 15, 2020 will be forfeited. This is called the
2. You may submit a claim by mail, FAX, or online.                                     “use it or lose it” rule.                                Your Dental Benefits

                                                                                                                                                Your Vision Benefits
If you choose to submit a claim, you will need to include your receipt for the         Your account will be left open for claims until
eligible expense. If you pay for eligible expenses with the PayFlex debit card,        June 30, 2020. All FSA claims must be submitted          Employee Assistance Program
make sure you receive an itemized bill at the time of payment for your records.        within 90 days of termination or unpaid leave of         Flexible Spending Accounts
                                                                                       absence.                                                 Life Insurance Benefit
Reimbursements are generally paid through direct deposit or check by a third
party administrator. You do not pay federal income, state income, or Social                                                                     Evidence of Insurability
Security taxes on FSA expenses.                                                           Make Sure Your Claim Is Correct                       Long-Term Disability

It’s best to file a claim after your health plan has paid its portion of the expense   To get reimbursed promptly for expenses you              Accidental Death & Dismemberment
                                                                                                                                                (AD&D) Insurance
so that you will pay only the amount you owe. If you pay an estimated amount,          have paid, be sure to file your claim correctly.
                                                                                                                                                Long-Term Care
or if there’s a question about whether the expense is eligible, PayFlex may send       Claims will only be approved if they contain
                                                                                                                                                Pet Insurance
you a request for additional documentation. You have 28 days to provide the            an itemized receipt that includes the following
documentation that will enable PayFlex to reimburse you. Learn more about              information:                                             Legal Assistance Insurance
documentation requests here.                                                           ●● Provider name and address                             Identity Protection Insurance
                                                                                       ●● Patient name
Dependent Care FSA Reimbursements
                                                                                       ●● Description or type of service                       Who’s Eligible
To be reimbursed, you must save your receipts and submit a claim for any eligible      ●● Date of service (not date of payment)
                                                                                                                                               Enrolling for Benefits
expenses. The Dependent Care FSA does not issue debit cards. Reimbursements            ●● Dollar amount charged for the expense.
are generally paid through direct deposit or check by a third party administrator.                                                             2019 Plan Rates
                                                                                       Or, you can enclose a copy of your insurance
You do not pay federal income, state income, or Social Security taxes on FSA
                                                                                       plan’s Explanation of Benefits (EOB) for the            Wellness Resources
expenses. You can only be reimbursed from contributions you have made to
                                                                                       expense, showing the amount you owed.
your account.                                                                                                                                  Retirement Plan
                                                                                       You can find more information about filing FSA
The reimbursement claim form can be found here.                                                                                                Who to Contact
                                                                                       claims here.
                                                                                                                                               Forms

                                                                                                                                               Notices


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2019 Benefits Guide



Life Insurance
All benefits-eligible employees receive Basic Life Insurance. You also have the
option to purchase additional coverage—known as Supplemental Life—for you
and your eligible dependents.

Basic Life Insurance                                                                       Keep In Mind…                                     Your Benefits

Basic Life Insurance for employees is fully paid for by The Claremont Colleges.          Beginning on the first of the year following         Your Medical Benefits

Coverage is automatic—you don’t have to enroll. However, you do need to select           your 65th birthday, your life insurance coverage     Your Dental Benefits
a beneficiary. The beneficiary or beneficiaries receive your benefit amount in the       amount decreases. Your premiums will be based        Your Vision Benefits
event of your death.                                                                     on the reduced coverage amount. The Standard
                                                                                                                                              Employee Assistance Program
                                                                                         pays a percentage of your benefit amount as
The amount of the benefit is equal to one times your basic annual earnings                                                                    Flexible Spending Accounts
                                                                                         follows:
(rounded to the next $1,000). The minimum coverage amount is $20,000, and                                                                     Life Insurance Benefit
the maximum coverage amount is $50,000.                                                  ●● Age 65 to 70 = 65%
                                                                                                                                              Evidence of Insurability
                                                                                         ●● Age 70 to 75 = 50%
Supplemental Life Insurance                                                                                                                   Long-Term Disability

                                                                                         ●● Age 75+ = 30%.                                    Accidental Death & Dismemberment
You may choose to purchase additional insurance coverage for yourself                                                                         (AD&D) Insurance
through The Standard on an after-tax basis. This coverage would be in                                                                         Long-Term Care
addition to the Basic Life coverage provided by The Claremont Colleges. If you             Conversion Privilege                               Pet Insurance
purchase additional life insurance coverage for yourself, you also can purchase
                                                                                         Conversion options are available should you          Legal Assistance Insurance
Supplemental Life coverage for your eligible dependents, subject to Evidence of
                                                                                         leave The Claremont Colleges. Contact                Identity Protection Insurance
Insurability (see following page).
                                                                                         BENREPS@claremont.edu for details.
Coverage for Supplemental Life Insurance is available in the following amounts:                                                              Who’s Eligible

 Eligible Member                  Coverage Amount                                                                                            Enrolling for Benefits
 Employee                         1–4 times your basic annual earnings (rounded to                                                           2019 Plan Rates
                                  the next highest $1,000), to a maximum of $1 million
 Spouse or Domestic Partner       $10,000 increments, to a maximum of $250,000 or                                                            Wellness Resources
                                  50% of your combined Basic and Supplemental Life
                                  Insurance coverage                                                                                         Retirement Plan
 Child(ren) (up to age 26)        $5,000
                                                                                                                                             Who to Contact

                                                                                                                                             Forms

                                                                                                                                             Notices


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