2021 Benefits Annual Enrollment Guide - Enrollment Period October 7 - October 20, 2020 - Avaya
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2021 Benefits Annual Enrollment Guide Enrollment Period October 7 – October 20, 2020
Active
Salaried
Employees
Annual Enrollment is your once-a-year opportunity to review your benefit options for the coming year and select
the coverages that will work best for you and your family.
Annual Enrollment 2021 Click on a topic below
to go directly to the
October 7 – 20, 2020 information you need.
Benefits selected during this enrollment period
will be effective January 1, 2021. What's New for 2021
Please review this Guide in its entirety. It is your source of information for what’s changing in 2021. Consider all Medical Plan Comparison
of your benefit options and your financial and health care needs during Annual Enrollment. You will not need to
actively enroll in most benefits for 2021 if you do not wish to make changes, with the exception of the following
Important Reminders
elections that do not carry over from year to year:
• Health Care or Limited Flexible Spending Account elections
Helpful Links & Tools
• Dependent Care Flexible Spending Account elections to Take Control of
Your Health
• Employee tax-favored Health Savings Account contributions
Here is a highlight of enhancements to our plans for 2021: Legal Reminders
If you (and/or your dependents)
• No Medical, Dental (PPO) or Vision Contribution Increases
•N o Medical Deductible or Out-Of-Pocket Maximum Increases
have Medicare or will become Important Contacts
• New Voluntary Benefits: Critical Illness, Accident and Hospital Indemnity eligible for Medicare in the next 12
• MetLife Legal Enhancement Option to add Plus Parents Option months, a Federal law gives you
• Spouse Life and Spouse AD&D Additional Options
more choices about your
prescription drug coverage. Please
see page 25 for more details.
2 Next ▶What's New for 2021
Avaya knows how important health and insurance plans are for you New! Teladoc Behavioral Health
and your family. The following pages include a summary of what’s Beginning 2021, you can use Teladoc to speak with experienced
changing for the year ahead. Additional details are available in later psychiatrists, psychologists and Masters level therapists via an online
sections of this Guide and at https://my.adp.com. If you have questions video consultation. Providers are available seven days a week, 7 a.m. to 9
or need assistance, contact the Avaya Health & Benefits Decision Center p.m. local time. Here’s how it works:
at 1-800-526-8056 option 1 (TDD 1-800-952-0450) or via e-mail at
• Members can request appointments through the app on
avayaservicecenter@adp.com. their mobile device, through the website, or via phone, with
appointment acceptance notice within 48 hours.
Attend a What’s New Webinar to learn about 2021 benefits
• Tele-video appointments include treatment and goal setting.
October 9 at 1:30 p.m. ET
Members may use the same provider throughout the course of
October 15 at 2 p.m. ET care if desired. Teladoc has emergency protocols in place should
See the Annual Enrollment email for details. an at-risk member need crisis care. Nurse outreach for ongoing
care includes evaluation and guidance after the 2nd and 6th
Benefits Genius Bar visits.
Call in with your annual enrollment benefit questions. Open weekdays To enroll go to Teladoc.com
from October 9 - October 20 from 3 - 4p.m. ET for the Annual
Enrollment period. See the Annual Enrollment email for details. New! Teladoc - Caregiver
Beginning 2021, you can use Teladoc not only for yourself and immediate
Aetna Enhancements family members that are covered under Aetna, but also for extended
If you are enrolled with Aetna through the Avaya Medical Plan following family members for whom you are a caregiver; such as your parents or
are the benefit enhancements: grandparents. If you are a caregiver, use Teladoc to get fast and affordable
medical advice even if the one you care for is not covered by you Avaya
In 2021, there will be no increase in the individual and family deductibles
medical plan option. Here’s how it works:
and out-of-pocket (OOP) maximums!
• Add the care recipient to your Teladoc account
New! Expert Medical Opinion through 2nd.MD
• Connect with a doctor in 2-way or 3-2way phone or video visits
Once you receive a diagnosis, you can contact 2nd.MD to review the
recommended course of treatment. Your information will be reviewed • Pay $47 per visit (CDHP or POS medical plan options)
by a national board-certified physician and a specialist will schedule a • Share Teladoc visit summaries with the care recipient’s doctor
consultation to review the recommendation with you via video or phone.
If you are enrolled in Aetna in 2021 through the Avaya Medical Plan, go to To get started, visit Teladoc.com
http://www.2nd.MD/Aetna to sign up.
New! Aetna Behavioral Health Case Management Telemedicine is a convenient alternative to costly urgent care
and ER visits.
Aetna clinicians are available 24/7 to handle clinically urgent and complex
needs to ensure access to appropriate behavioral health services and With Teladoc, you can connect with a board-certified doctor
care. This also includes Autism advocacy. Aetna will provide support in any time by phone, web or mobile app for help with a variety
navigating services and assist in identifying resources for your care. of medical issues including general medicine, dermatology,
and behavioral health (7 a.m. to 9 p.m. local time).
3
▶ Back Next ▶What's New for 2021
Please review the Medical Comparison Chart for Active Salaried Accident Insurance provides you with a lump-sum benefit if you or
Employees on page 10 of this Guide for more details. your eligible family members experience the following non-work related
New! Voluntary Benefits – Beginning 2021, you can enroll in Critical Illness, accidents:
Accident and/or Hospital Indemnity Insurance.
• Fractures* • Cuts/Lacerations
Critical Illness Insurance can ease the financial impact of serious illness –
such as cancer or a heart-related condition – with a lump-sum payment to
• Dislocations* • Concussions
spend on extra medical or living expenses. Here’s how it works:
• C
overage is voluntary; you must enroll during annual enrollment • Eye Injuries • 2nd or 3rd Degree Burns
if you want coverage. You must be actively at work and enrolled
in a medical plan, but it does not have to be Avaya’s plan. • Broken tooth
• Y
ou can elect coverage of $10,000, $20,000 or $30,000 for
yourself only or elect coverage for eligible family members. *Chip fractures are paid at 25% of Fracture Benefit and partial dislocations
Spouse/domestic partners receive 100% Guaranteed Insurance are paid at 25% of Dislocation Benefit.
(GI) coverage. Children receive 50% GI. For example, if you elect Accident Insurance can help you pay for out-of-pocket expenses that may
$10,000 coverage for your family, your spouse is also covered not be covered by traditional insurance, such as deductibles, rehabilitation
up to $10,000 and the child coverage amount is up to $5,000. and transportation. Here’s how it works:
• Y
ou pay for coverage through after-tax payroll deductions. • You must be actively at work
Rates are based on your tobacco usage status, your age and
level of coverage you select. • T
here are two options you can choose: a Low Plan Option or
a High Plan Option. See schedule of benefits at https://www.
• If you elect Critical Illness, effective Jan. 1, 2021, and are metlife.com/avaya
diagnosed with a covered illness illness, file a claim with MetLife
and you will receive a lump-sum tax-free payment that can be • You pay for coverage through after-tax payroll deductions.
used to cover medical and even living expenses. • If you or your covered dependents have an accident, notify
• T
here is an annual screening benefit of $50. If you obtain a MetLife and payment will be made directly to you, not to the
routine physical exam or an age appropriate screening and doctors, hospitals or other health care providers. You will receive
notify MetLife, they will send you a one-time payment of $50. a check, payable to you, for maximum convenience.
For more in-depth information about voluntary benefits, please visit For more in-depth information about voluntary benefits, please visit
https://www.metlife.com/avaya.
https://www.metlife.com/avaya.
4
▶ Back Next ▶What's New for 2021
Voluntary Benefits - MetLife EyeMed Vision Plan Virtual Benefit Fair
Hospital Indemnity Insurance can help ease the financial impact of New! Virtual Benefit Fair so you can learn about available vision benefits
hospitalization. and find in-network providers.
Here’s how it works: To visit the Virtual Benefits Fair, copy the link into your browsers:
• You must be actively at work https://eyemedvirtualbenefitfair.com/ and enter password "KD63Z9LK"
• There are two options you can choose: a Low Plan Option of
$750 admission and $150 confinement or a High Plan Option of
$1,500 admission and $300 confinement
• You pay for coverage through after-tax payroll deductions.
• If you or your covered dependents are hospitalized, you would
notify MetLife and payments will be paid directly to you, not to
the doctors, hospitals or other health care providers. You will
receive a check, payable to you, for maximum convenience.
For more in-depth information about voluntary benefits, please visit
https://www.metlife.com/avaya.
Note: If you are a New Hampshire resident, you will be offered a slightly
different Hospital Indemnity plan. Please refer to the outline of coverage
and click on the state you reside in to see plan specific coverages.
New! MetLife Legal Plus Parents
Parents Plus covers all eligible family members including parents and
parents-in-law. You and your family members would receive fully covered
legal advice and representation for a wide range of legal matters. You pay
for coverage through after-tax payroll deductions.
Improved! Spouse Life Insurance and Spouse AD&D
Spouse Life Insurance can now be elected up to $250K (increments of
25K). Statement of Health (SOH) is required for all new entrants and
increases in coverage.
Dependent AD&D can now be elected up to $300K (increments of 25K).
Statement of Health is not required for this coverage.
5
▶ Back Next ▶What's New for 2021
Kaiser Plan Changes
2021 carrier-mandated changes (pending approval from the Department of Insurance):
Plan Benefit 2020 Avaya Plan Design 2021 Mandated Plan Design
Listed as preventative service with no
Kaiser Pre-Exposure Prophylaxis Not listed under preventative
cost share for people at high risk of HIV
All Groups (PrEP) services
infection
Certain chronic conditions can get the
following testing free of cost:
• A1c testing for diabetes
Kaiser CA and Chronic Condition Lab testing cost share applies for • Low-density lipoprotein (LDL) testing
MAS Management testing for chronic conditions for heart disease
• Internalized normalized ratio (INR)
testing for liver disease or bleeding
disorders
No charge, when provided during a
Kaiser MAS Pregnancy Tests Subject to lab test cost share
contraceptive visit
Non-Pediatric Eyewear Percent discount for standard vision Flat dollar allowance for standard vision
Kaiser MAS
and Contact Lenses hardware hardware
One copay/visit for injections and
Clinically Administered Office copay applies for clinically
Kaiser MAS infusions in addition to the office copay
Medications administered medications
for clinically administered medications
The following services/devices are
considered preventive:
• Retinopathy screening for diabetes
• A1c preventive lab for diabetes
• Low-density lipoprotein (LDL) testing
The listed 2021 preventive care
for heart disease
Kaiser GA Preventive Services services to the right are currently
• International normalized ratio testing
not covered as preventive care.
for liver and/or bleeding disorders
• Anxiety screening for women
• Glucose meters including testing strips,
lancets, and control solutions
• Peak flow meters
HMSA Medical Plan Changes
Please visit https://www.avaya.com/benefits/salariedbenefits/ to review HMSA’s 2020/2021 carrier-mandated changes.
6 ▶ Back Next ▶What's New for 2021
Annual Express Scripts (ESI) Prescription Drug Formulary Changes
The lists below describe some of the ESI carrier-mandated drug list and program changes, effective January 1, 2021. Personalized notifications, reminder
communications, and targeted alerts will go out to affected members before January 1. ESI’s formulary will continue to ensure that clinically sound, cost-
effective drugs are available to members and will drive greater savings. ESI's 2021 carrier-mandated drug exclusion list is available at
https://www.express-scripts.com/art/open_enrollment/DrugListExclusionsAndAlternatives.pdf. The 2021 formulary is available at https://my.adp.com
under the Forms & Plan Documents tile. Filter on “M” and click on the "MEDICAL BENEFITS - ESI RX PREFERRED DRUG GUIDE" link.
2021 Preferred-to-Non-Preferred Changes
ALREX BEPREVE FIRST-LANSOPRAZOLE FIRST-MOUTHWASH BLM
FIRST-OMEPRAZOLE ILEVRO ORACEA PRIVIGEN
PROLENSA QBREXZA RANITIDINE SYRUP
2021 Health Care or Limited FSA Contribution Maximum
The annual contribution maximum for Health Care or Limited Flexible Spending Account elections in 2021 has increased from $2,700 to $2,750. Please
make your new election at https://my.adp.com. 2020 elections will not carry over to 2021.
8
▶ Back Next ▶What's New for 2021
Employee Paycheck Contributions
Avaya reviews the benefit plans every year to ensure they remain comprehensive and competitive, keeping the costs for you and the company
manageable. Avaya will be picking up the plan cost increase for 2021. What does that mean for you? No medical, dental or vision plan
contribution changes for 2021! Below, please find the monthly employee contributions for the 2021 medical, dental and vision plans. These
contributions will apply in your first paycheck of 2021.
Monthly Employee Contributions
Benefit Type Benefit Plan Status Employee Only Employee + Spouse Employee + Child(ren) Family
Medical Aetna CDHP Alternative Salaried Non-Smoker $60.00 $144.00 $113.00 $200.00
Medical Aetna CDHP Alternative Salaried Smoker $80.00 $192.00 $151.00 $267.00
Medical Aetna CDHP w/HSA Salaried Non-Smoker $99.00 $246.00 $192.00 $339.00
Medical Aetna CDHP w/HSA Salaried Smoker $132.00 $328.00 $256.00 $452.00
Medical Aetna Point-of-Service (POS) Salaried Non-Smoker $172.00 $429.00 $335.00 $598.00
Medical Aetna Point-of-Service (POS) Salaried Smoker $229.00 $572.00 $447.00 $797.00
Kaiser (CA, CO, GA, MD
Medical Salaried Non-Smoker $191.00 $432.00 $377.00 $619.00
and NW only)
Kaiser (CA, CO, GA, MD
Medical Salaried Smoker $255.00 $576.00 $503.00 $825.00
and NW only)
Dental Aetna DMO $7.00 $13.00 $19.00 $30.00
Dental Aetna PPO $16.00 $41.00 $33.00 $59.00
Monthly Employee Contributions
Benefit Type Benefit Plan Status Employee Only Two-Person Family
Medical HMSA (HI residents only) Salaried Non-Smoker $99.00 $246.00 $339.00
Medical HMSA (HI residents only) Salaried Smoker $132.00 $328.00 $452.00
Vision EyeMed $8.01 $15.21 $22.33
9 ▶ Back Next ▶2021 POS and CDHP Medical and Prescription Drug Comparison Chart for Active Salaried Employees
Kaiser HMO information can be found online at https://my.adp.com under Forms & Plan Documents > Filter by the letter "S" for SBCs.
Aetna Salaried Point-of-Service (POS)1
Closed to new enrollees Aetna Healthy Direction CDHP with HSA1 Aetna CDHP Alternative1
Features
Annual HSA funding amount2:
Each time you need care, you choose: Each time you need care, you choose:
Up to $500/$1,000 (single/all other tiers)
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Any Aetna Choice POS II network Any Aetna Choice POS II Any Aetna Choice POS II
provider, including Teladoc network provider, including network provider, including
physicians and dermatologists for Teladoc physicians and Teladoc physicians and
24/7 phone or video physician dermatologists for 24/7 phone dermatologists for 24/7 phone
visits and behavior health or video physician visits and or video physician visits and
Choice of doctors through a licensed therapist by Any eligible provider behavior health through a Any eligible provider behavior health through a
Any eligible provider
licensed therapist by phone or licensed therapist by phone or
phone or video (available by video (available by downloading video (available by (available
downloading the Teladoc app on the Teladoc app on your by downloading the Teladoc
your smartphone or tablet or by smartphone or tablet or by app on your smartphone or
visiting https://www.teladoc.com/ visiting https://www.teladoc. tablet or by visiting https://www.
Aetna) com/Aetna) teladoc.com/Aetna)
Preventive care (age and Covered at 100%; deductible You pay 35% after deductible, Covered at 100%; deductible You pay 35%, plus anything over Covered at 100%; deductible You pay 40% after deductible,
frequency guidelines apply) does not apply plus anything over R&C does not apply R&C; deductible does not apply does not apply plus anything over R&C
$1,000 for single tier coverage $2,000 for single tier coverage $2,000 for single tier coverage $3,375 for single tier coverage $3,400 for single tier $6,800 for single tier
Annual deductible3 and up to $3,000 maximum for and up to $6,000 maximum for $6,750 for all other coverage coverage, $6,800 for all coverage, $13,600 for all
all other coverage tiers all other coverage tiers $4,000 for all other coverage tiers other coverage tiers other coverage tiers
tiers
Coinsurance (Plan pays)
Physician Office Visit You pay 20% after deductible You pay 35% after deductible, You pay 20% after deductible You pay 35% after deductible, You pay 20% after You pay 40% after deductible,
plus anything over R&C plus anything over R&C deductible plus anything over R&C
E mergency Room You pay 20% after deductible Paid as in-network if Aetna You pay 20% after deductible Paid as in-network if Aetna You pay 20% after Paid as in-network if Aetna
(For emergencies) Member Services is notified Member Services is notified deductible Member Services is notified
Urgent Care, Ambulance4 within 48 hours within 48 hours within 48 hours
In-Patient/Out-Patient You pay 20% after deductible You pay 35% after deductible, You pay 20% after deductible You pay 35% after deductible, You pay 20% after You pay 40% after
Services includes: Lab & plus anything over R&C plus anything over R&C deductible deductible, plus anything
X-ray, Surgery, Anesthesia, over R&C
Physician Hospital Visits/
Consultations, Room and
Board, Maternity, Radiation
Therapy, Chemotherapy
Are you responsible for Yes, unless you use a National Yes, unless you use a National Yes, unless you use a
charges in excess of the No Advantage Program (NAP) No Advantage Program (NAP) No National Advantage Program
Reasonable & Customary network provider network provider (NAP) network provider
Annual Out-of-Pocket $4,500 for single tier coverage $9,000 for single tier coverage $5,000 for single tier $10,000 for single tier
Maximum5 $3,500 for single tier coverage, $8,000 for single tier coverage
and up to $9,000 maximum for and up to $18,000 maximum coverage, $10,000 coverage, $20,000 for all
(Includes Deductible) $7,000 for all other coverage tiers $16,000 for all other coverage tiers (embedded at $7,150) 6
all other coverage tiers for all other coverage tiers other coverage tiers
Precertification Your network provider You Your network provider You Your network provider You
responsibility
Yes, unless you use a National Yes, unless you use a National Yes, unless you use a
Are claim forms required? No Advantage Program (NAP) No Advantage Program (NAP) No National Advantage Program
network provider network provider (NAP) network provider
Notes: 1) R&C: Reasonable & Customary; (continued on next page)
2) Cells shaded in light red denote change from 2020 plan design.
10 ▶ Back Next ▶2021 POS and CDHP Medical and Prescription Drug Comparison Chart for Active Salaried Employees
Aetna Salaried Point-of-Service (POS)1 Aetna CDHP Alternative1
Closed to new enrollees. Aetna Healthy Direction CDHP with HSA1
(No HSA with this option)
Features
Prescription Drug Program coverage offered Prescription Drug Program coverage offered through Prescription Drug Program coverage offered through
through Express Scripts, Inc. (ESI) Express Scripts, Inc. (ESI) Express Scripts, Inc. (ESI)
In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network
Not subject to a deductible. Not covered The full cost of the drug is applied to Not covered The full cost of the drug is applied to Not covered
the Medical deductible before the Medical deductible before
Retail Drugs benefits are considered for payment. benefits are considered for payment.
(up to a 30-day supply) After the deductible, you pay: After the deductible, you pay:
• Tier 1 (Generic)
$10 copay Retail Drugs Retail Drugs
• Tier 2 (Preferred Brand)
(up to a 30-day supply) (up to a 30-day supply)
30% Coinsurance, $30 min., • Tier 1 (Generic) $10 copay • Tier 1 (Generic) $10 copay
$80 max. • Tier 2 (Preferred Brand) • Tier 2 (Preferred Brand)
• Tier 3 (Non-preferred Brand) 25% Coinsurance, $30 min., 25% Coinsurance, $30 min.,
50% Coinsurance, $60 min., $70 max. $70 max.
Prescription Drug $120 max. • Tier 3 (Non-preferred Brand) • Tier 3 (Non-preferred Brand)
Benefits7 35% Coinsurance, $50 min., 35% Coinsurance, $50 min.,
ESI Mail Order, Walgreens $90 max. $90 max.
Retail, or CVS Retail Drugs
(up to a 90-day supply) ESI Mail Order, Walgreens Retail, ESI Mail Order, Walgreens Retail,
or CVS Retail Drugs or CVS Retail Drugs
• Tier 1 (Generic) $25 copay
(up to a 90-day supply) (up to a 90-day supply)
• Tier 2 (Preferred Brand)
• Tier 1 (Generic) $20 copay • Tier 1 (Generic) $20 copay
30% Coinsurance, $60 min.,
$200 max. • Tier 2 (Preferred Brand) • Tier 2 (Preferred Brand)
25% Coinsurance, $60 min., 25% Coinsurance, $60 min.,
• Tier 3 (Non-preferred Brand)
$175 max. $175 max.
50% Coinsurance, $120 min.,
$300 max. • Tier 3 (Non-preferred Brand) • Tier 3 (Non-preferred Brand)
35% Coinsurance, $100 min., 35% Coinsurance, $100 min.,
$225 max. $225 max.
$2,000 individual coverage tier Same as Medical Out-of-Pocket Same as Medical Out-of-Pocket
Pharmacy Out-of-Pocket Max N/A Maximum N/A Maximum N/A
$4,000 all other coverage tiers
The Prescription Drug Utilization Management Program requires prior authorization for certain types of prescription drugs, including but not limited to Nonsedating Antihistamines and Antifungals.
Prescription Drug Utilization Prior authorization means that requirements must be met before the Prescription Drug Program will cover the prescription. After three fills at the retail level, the member will pay 100% of the Express Scripts-
Management Program discounted cost for the medication for future retail fills not picked up at a Walgreens or CVS retail store. Out-of-pocket costs for long-term medications not ordered through ESI Home Delivery or CVS/Walgreens
retail do not apply to the member/family deductible or out-of-pocket maximum. If you purchase a brand name medication when a generic medication is available, you will pay the generic copay plus the difference
in cost between the brand name and the generic.
Notes: 1) R&C: Reasonable & Customary;
2) Cells shaded in light red denote change from 2020 plan design.
1 If you do not have access to in-network providers, upon approval from Aetna, you may receive benefits at the in-network level.
2 Company HSA contributions will be processed once annually for eligible employees according to the date your Health Savings Account with Fidelity is opened. Company HSA contributions will be deposited to
your Fidelity HSA within 10 business days of the paycheck in which it was processed. If you leave the company (voluntarily or involuntarily), or your coverage under the Aetna Healthy Direction CDHP with HSA
medical plan terminates for any reason before the normal payroll date the HSA funds would otherwise be processed for deposit, your employer and employee HSA contributions will not be deposited. Mid-year
qualified status changes that result in a medical plan tier change will not result in an adjustment to your company HSA contribution.
3 The medical deductible is separate from any deductible under the Prescription Drug Program for the POS. For the CDHP plans, the health care deductible must be met before plan benefits are paid, including
Prescription Drug Program benefits. Under the CDHP plans, for two-person or family coverage, the deductible is not satisfied for any family member until the two-person or family deductible is met.
4 Non-emergent Emergency Room or Ambulance services will be covered at the out-of-network level plus amounts over R&C.
5 Certain expenses (e.g., precertification penalties and any expenses in excess of the Reasonable & Customary charge) do not count toward the annual Out-of-Pocket Maximum. The annual Out-of-Pocket
Maximum for the POS Prescription Drug Program is separate from the annual Out-of-Pocket Maximum for the POS Medical plan.
6 Once one member of the family hits $7,150 in combined medical/Rx expenses, that individual will no longer incur expenses towards the family out-of-pocket maximum and most covered expenses would be
paid at 100% of the allowable amount for the rest of the calendar year for that family member; it would be up to the other covered members in the family to reach the remaining in-network out-of-pocket
maximum (before their covered expenses would be paid at 100% of the allowable amount for the remainder of the calendar year).
7 Mandatory home delivery through ESI or retail pick-up from either Walgreens or CVS applies to all long-term (maintenance) drugs.
11 ▶ Back Next ▶Important Reminders
Which Medical Plan is Right for You? Company HSA contributions will be processed once annually for eligible
ALEX, Avaya's interactive Benefits Advisor, explains your medical plan employees, as follows:
options to determine which may be best for you, It is personalized, easy
On the first
to use and confidential. Try ALEX today by visiting https://www.myalex. For HSA's opened between You are eligible for this normal payroll
com/avaya/2021! ALEX is best viewed in Google Chrome. these dates... much... date in this
month*...
Employer HSA Contribution Process
$500/indiv or $1,000/
The HSA is only available if you enroll in the Aetna Healthy Direction On/before 1/11/2021 family CDHP with HSA February
CDHP with HSA Medical Plan. election tier
From October 7, 2020 – October 20, 2020, make your 2021 HSA election $375/indiv or $750/
at https://my.adp.com. Your HSA election does not roll over each year. If 1/11/2021 - 4/12/2021 family CDHP with HSA May
you do not make a 2021 election, you will not contribute to the HSA or election tier
receive the Avaya contribution. $250/indiv or $500/
4/13/2021 - 7/12/2021 family CDHP with HSA August
If this is your first time enrolling, you will need to agree to Fidelity’s terms election tier
& conditions. Then, in December, go to www.401k.com to activate your
$125/indiv or $250/
HSA with Fidelity.
7/13/2021 - 10/12/2021 family CDHP with HSA November
See your 401(k) and HSA balance on the same website: www.401k.com election tier
Funding will begin in
Fidelity has no minimum for investing so any savings that is not needed 10/13/2021 or after
2022
for current qualified expenses can be invested. You can pay for qualified
medical expenses through a variety of options to access your funds, * If you leave the company (voluntarily or involuntarily), or your coverage under the
Aetna Healthy Direction CDHP with HSA medical plan terminates for any reason before
including using an HSA checkbook, online bill paying service, or direct the normal payroll date the HSA funds would otherwise be processed for deposit, your
debit. employer HSA contributions will be forfeited and will not be deposited. Your employee
HSA contributions will not be deposited and will be returned to you.
Active employees are eligible for Avaya's HSA contribution based on the
date your HSA is opened, not the date you enroll in the Aetna Healthy
Direction CDHP with HSA medical plan. Company HSA contributions
will be deposited to your Fidelity HSA within 10 business days of the
paycheck in which it was processed. Mid-year qualified status changes
that result in a medical plan tier change will not result in an adjustment to
your company HSA contribution. It is your responsibility to ensure you do
not exceed the annual maximum contribution.
12 ▶ Back Next ▶Important Reminders
2021 HSA Contribution Maximums Identification Process, you will not be eligible to make HSA contributions
or receive Avaya’s HSA contributions. Go to www.401k.com and click on
Based on Internal Revenue Service rules, the maximum amount you Activate Health Savings Account to complete the opening of your account.
can contribute to a Health Savings Account (HSA) in 2021 is $3,600 for
self-only CDHP medical plan coverage and $7,200 for all other coverage 2020 Flexible Spending Account Elections Do Not Rollover to 2021
tiers. If you are turning age 55 in 2020 or are already over 55, you can
contribute an additional $1,000 in HSA catch-up contributions in 2021. If you wish to participate in the Health Care Flexible Spending Account
These limits include: the contributions you make via payroll deductions, (HCFSA), Limited Flexible Spending Account (LFSA), and/or the Dependent
any contributions you make to your HSA outside of payroll deductions, Care Flexible Spending Account (DCFSA) in 2021, you must re-enroll during
and the HSA dollars Avaya contributes to your HSA. Remember, the tax- Annual Enrollment. Your 2020 elections do not carry over to 2021.
favored HSA is only available if you enroll in Avaya's Healthy Direction
CDHP with HSA medical plan. Flexible Spending Account Balance Carryover
Avaya allows HCFSA and LFSA participants to carryover up to $550
2020 Employee HSA Contribution Elections Do Not Rollover to 2021 of unused funds into the following calendar year. If you have unused
If you continue to be enrolled in the Aetna Healthy Direction CDHP with HCFSA or LFSA funds at the end of 2020, the rollover will happen for
HSA medical plan for 2021 and elected to defer tax-favored Health Savings you automatically. Please factor this in to your 2021 elections to ensure
Account contributions from your paycheck in 2020, you will need to log you don’t over-contribute in the upcoming year.
in to https://my.adp.com to continue those contributions, or elect new MetLife Legal Plan
contributions for 2021. HSA and HSA Catch-Up contributions can be
changed at any time throughout the year by selecting “DECLARE AN Annual Enrollment is the one time of year you can enroll in (if not
EVENT” under the Report a Qualifying Change tile on the home page. already enrolled) or drop the MetLife Legal Plans. To make changes to
your legal services plan coverage, visit https://my.adp.com.
HSA contributions will be deposited to your personally-owned Health
Savings Account with Fidelity within 10 business days of the paycheck Planning to Enroll in the CDHP Alternative Medical Plan in 2021?
from which they are deducted and cannot be used until deposited. HSA If you enroll in the CDHP Alternative medical plan (which does not have
contributions made by both you and Avaya will cease if you terminate an HSA) and you intend to open a private HSA through your own bank,
employment or leave the Healthy Direction CDHP with HSA medical you are strongly encouraged NOT to enroll in Avaya’s Health Care Flexible
plan. You must be actively employed and enrolled in the CDHP with Spending Account (HCFSA). Per IRS guidelines, if you are contributing
HSA medical plan on the normal payroll date your or the company HSA to or receiving contributions to an HSA, you may only be reimbursed
contributions would otherwise be processed to be eligible to receive for eligible dental and vision expenses (no medical or prescription drug
them. expense reimbursement is allowed) from a Limited Flexible Spending
Account. You are not able to enroll in Avaya’s Limited Flexible Spending
HSA Customer Identification Process Requirement Account unless you are enrolled in the Healthy Direction CDHP with HSA
If you are newly enrolling in the Healthy Direction CDHP with Health medical plan offered by Avaya.
Savings Account (HSA) medical plan and are opening an HSA with Fidelity Cutoff Date for Earning Incentives with Avaya's Well-Being Program
for the first time, Section 326 of the U.S. Patriot Act requires that you verify
your identity through the Customer Identification Process before the HSA The cutoff date for earning incentives is November 30, 2021
can be opened. If you do not complete and pass the Customer
13 ▶ Back Next ▶Important Reminders
Spousal Surcharge Beneficiaries
If you choose to cover your spouse/domestic partner under an Avaya Maintaining beneficiary information is an important part of your financial
medical plan and your spouse/domestic partner has the opportunity planning. Annual Enrollment is a good time to review your life and
to enroll in medical coverage through his/her employer, an additional AD&D insurance beneficiaries. You can update life and AD&D insurance
$100 per month will be added to your health insurance premium. This beneficiary information online at any time at https://my.adp.com by
surcharge is waived if your spouse or domestic partner works for an selecting "MANAGE" under the Manage Information tile on the home
employer who doesn't offer medical coverage, doesn’t qualify for their page. If you do not have Internet access, you may contact the Avaya
employer’s coverage, or is eligible for Medicare. Health & Benefits Decision Center at 1-800-526-8056 (option 1), TDD
Dependent Verification 1-800-952-0450 or via e-mail at avayaservicecenter@adp.com to obtain
a beneficiary form.
If you choose to enroll an eligible dependent(s) that is not currently
covered under Avaya's health benefits, you will be required to Summary of Benefits Coverage (SBC)
provide proof that they are your eligible dependent(s) per the Plan In compliance with health care reform, Avaya provides a SBC for each
guidelines. Dependent coverage will be pended until the appropriate medical plan for which you are eligible to help you compare your
documentation is received by ADP, our Dependent Verification vendor. coverage options. Please note that the SBC is not a full plan description
Upon completion of your enrollment, you will receive a verification letter like the Summary Plan Descriptions. SBCs are available at https://my.adp.
from ADP explaining how to verify dependent eligibility. Verification is com under the Forms & Plan Documents tile on the home page. Paper
due by the deadline on your request for verification form. copies are also available, free of charge, by contacting the Avaya Health &
2021 Mid-Year Changes Benefits Decision Center at 1-800-526-8056 (option 1), TDD 1-800-952-
0450, or via e-mail at avayaservicecenter@adp.com.
Once Annual Enrollment ends, you will not be able to make changes to
most benefits unless you have a qualified status change. Information on
qualified status changes is available in the Summary Plan Descriptions
(SPDs) at https://www.avaya.com/benefitanswers.
Prescription Drug Coverage
Drugs are the fastest growing category of health spending. In cases where you
select a brand name drug when a generic equivalent is available, you will be
required to pay the generic copayment plus the difference in cost between the
brand name drug and the generic drug. If you are prescribed a medication, ask
your doctor or pharmacist if your condition could be treated effectively with a
lower-cost or generic version of the drug.
Remember, the Prescription Drug Program has a mandatory fill-provision
for long-term (maintenance) medications. Aside from a limited number of
exceptions, after the third fill of a long-term medication, you must begin
obtaining your prescription through Express Scripts Pharmacy Mail Order
service, or at either a CVS or Walgreens retail location, to avoid paying a penalty.
14
▶ Back Next ▶Helpful Links and Tools to Take Control of Your Health
Taking Control of Your Health Tool (click link) Description
• Enroll in or change your benefits Your one-stop-shop for all of your benefit needs.
• Update your HSA contribution Note: Need to update your HSA or HSA Catch-Up contribution mid-year or
https://my.adp.com
• Change a beneficiary outside of Annual Enrollment? From https://my.adp.com, select "DECLARE
• Find information on your medical carrier AN EVENT" under the Report a Qualifying Change tile on the home page.
• Understand your medical plan options and determine which option may
Choose the right medical plan for you and https://www.myalex.com/avaya/2021
be best for you
your family using ALEX, our interactive (Available to Kaiser and Aetna members)
• See how you may benefit from contributing to a Flexible Spending
Benefit Advisor ALEX is best viewed in Chrome
Account and/or Health Savings Account
www.aetna.com
(for Aetna medical members)
Get the best price on health care services Search for doctors and health care services based on cost, quality and
Login using your existing Navigator
without sacrificing quality convenience.
credentials or download the Aetna Health
app at the App Store® or Google Play™ store
Current Aetna members may log on to their Aetna’s online participating directory allows you to locate physicians
account at www.aetna.com and other health care providers such as dentists and hospitals. Try the
Aetna Mobile App for quick and convenient access to in-network providers.
Locate Aetna in-network physicians or Potential members may log on to
dentists where you need them www.aetna.com > Find a doctor > Under Participating physicians are also available 24/7 via phone or video chat
“Not a member yet?", select “Plan from an through Teladoc, Avaya's telemedicine vendor through Aetna. You may
employer"> When asked to Select a Plan, download the Teladoc app on your smartphone or tablet or visit
choose Aetna Choice POS II (Open Access) https://www.teladoc.com/Aetna for access.
Review the Medical Benefits - CDHP
Learn more about the Healthy Direction
Newsletter under the Forms & Plan
Consumer Directed Health Plan (CDHP) with A great way to set aside tax-favored dollars for future medical expenses.
Documents tile on the home page at
HSA medical plan
https://my.adp.com
Express Scripts (ESI) Annual Enrollment Annual Enrollment support including formulary lookup, pharmacy lookup
www.express-scripts.com/avaya
website and pricing medications.
It’s important to find a doctor who's right for you. Choose or change
Locate Kaiser physicians in your region https://www.kp.org doctors at any time, browse online profiles by region, or call Member
Services in your area.
A Health Savings Account (HSA) is designed to help pay for your current
• Review your HSA balance
eligible health care costs and save for future health care expenses. Your
• Send a payment to a provider www.401k.com
contributions, earnings and withdrawals are all tax-favored. It’s a triple tax-
• Update your notification settings
savings opportunity that can put more money in your pocket.
15 ▶ Back Next ▶Helpful Links and Tools to Take Control of Your Health
Taking Control of Your Health Tool (click link) Description
Check out EyeMed's Virtual Benefit Fair to find an eye doctor near you and
Wondering where to get your next EyeMed other plan information:
https://www.eyemedvisioncare.com
in-network eye exam? https://eyemedvirtualbenefitfair.com/
Password: KD63Z9LK
All Avaya employees have access to a complete wellness platform. Check
Take control of your well-being with out some additional tools that will get you closer to achieving your health
https://www.aetna.com
Avaya Wellness goals. Track your activity, get wellness advice, find healthy recipes, and
much more.
An FSA (not to be confused with an HSA) may be used for reimbursement
of eligible health care* expenses, and child or elder daycare expenses. The
amount you decide to contribute to the account for the year is deducted
Go to the Forms & Plan Documents tile on from your salary before income taxes. This reduces your taxable income,
What are Flexible Spending Accounts? the home page at https://my.adp.com. Filter saving you money on taxes.
on “F” for FSA forms and resources. *If contributing to or receiving contributions to an HSA, medical expenses
are not reimbursable under a general-purpose FSA. Let ALEX teach you
about this at https://www.myalex.com/avaya/2021! ALEX is best viewed
in Google Chrome.
Now it’s really easy to figure out how much you should contribute to your
Health Care and/or Dependent Care Flexible Spending Account with this
Determine the right amount to contribute
https://www.myalex.com/avaya/2021 intuitive online tool. ALEX, our interactive Benefit Advisor (https://www.
to your Flexible Spending Account
myalex.com/avaya/2021) can also assist you with this decision! ALEX is
best viewed in Google Chrome.
Go to the Forms & Plan Documents tile on the • Saves you money on parking and transportation expenses to work
Save tax dollars on your commute to and
home page at https://my.adp.com. • Lets you pay for certain commuting expenses with pre-tax dollars
from work every day!
Filter on “C” for Commuter Benefit resources. • A great way to LOWER your taxable income
The Employee Assistance Program (EAP) is available 24/7 to help you
and your family successfully deal with life’s problems and challenges. The
Talk to someone about a personal issue https://www.magellanascend.com
EAP is a prepaid, confidential counseling and referral resource coordinated
through Magellan Behavioral Health.
The Family Resource Program provides services to busy parents
Looking for childcare and eldercare who are looking for help on issues such as adoption, senior care, and
https://www.magellanascend.com
resources? education resources. Additionally, the Family Resource Program offers
free tutoring through its Homework Connection program.
Avaya Discount Marketplace brings you some of the hottest deals of the
Avaya Discount Marketplace https://avaya.savings.beneplace.com/home
year.
16
▶ Back Next ▶Legal Reminders Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed on the following pages, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or call 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). 17 ▶ Back Next ▶
Legal Reminders
If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is
current as of July 31, 2020. Contact your State for more information on eligibility.
ALABAMA – Medicaid FLORIDA – Medicaid
Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/
Website: http://myalhipp.com/
hipp/index.html
Phone: 1-855-692-5447
Phone: 1-877-357-3268
ALASKA – Medicaid GEORGIA – Medicaid
The AK Health Insurance Premium Payment Program
Website: http://myakhipp.com/ Website: https://medicaid.georgia.gov/health-insurance-premium-payment-
Phone: 1-866-251-4861 program-hipp
Email: CustomerService@MyAKHIPP.com Phone: 678-564-1162 ext 2131
Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
ARKANSAS – Medicaid INDIANA – Medicaid
Healthy Indiana Plan for low-income adults 19-64
Website: http://www.in.gov/fssa/hip/
Website: http://myarhipp.com/ Phone: 1-877-438-4479
Phone: 1-855-MyARHIPP (855-692-7447) All other Medicaid
Website: https://www.in.gov/medicaid/
Phone 1-800-457-4584
COLORADO – Health First Colorado (Colorado's Medicaid Program) & Child Health
CALIFORNIA – Medicaid
Plan Plus (CHP+)
Health First Colorado Website: https://www.healthfirstcolorado.com/
Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711
CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plus
Website: https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx
CHP+ Customer Service: 1-800-359-1991/ State Relay 711
Phone: 916-440-5676 Health Insurance Buy-In Program (HIBI): https://www.colorado.gov/pacific/hcpf/
health-insurance-buy-program
HIBI Customer Service: 1-855-692-6442
IOWA - Medicaid and CHIP (Hawki) KANSAS – Medicaid
Medicaid Website: https://dhs.iowa.gov/ime/members
Medicaid Phone: 1-800-338-8366 Website: http://www.kdheks.gov/hcf/default.htm
Hawki Website: http://dhs.iowa.gov/Hawki Phone: 1-800-792-4884
Hawki Phone: 1-800-257-8563
KENTUCKY – Medicaid and KI-HIPP NEW HAMPSHIRE – Medicaid
Kentucky Medicaid Website: https://chfs.ky.gov
Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP)
Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Website: https://www.dhhs.nh.gov/oii/hipp.htm
Phone: 1-855-459-6328 Phone: 1-603-271-5218
Email: KIHIPP.PROGRAM@ky.gov Toll-Free: 1-800-852-3345, ext 5218
KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx
Phone: 1-877-524-4718
18 ▶ Back Next ▶Legal Reminders
LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP
Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/
Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Medicaid Phone: 1-609-631-2392
Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP) CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
MAINE – Medicaid NEW YORK – Medicaid
Enrollment Website: https://www.maine.gov/dhhs/ofi/applications-forms
Phone: 1-800-442-6003
TTY: Maine relay 711 Website: https://www.health.ny.gov/health_care/medicaid/
Private Health Insurance Premium Webpage:
Phone: 1-800-541-2831
https://www.maine.gov/dhhs/ofi/applications-forms
Phone: -800-977-6740.
TTY: Maine relay 711
MASSACHUSETTS – Medicaid and CHIP NORTH CAROLINA – Medicaid
Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Website: https://medicaid.ncdhhs.gov/
Phone: 1-800-862-4840 Phone: 919-855-4100
MINNESOTA – Medicaid NORTH DAKOTA – Medicaid
Website: https://mn.gov/dhs/people-we-serve/children-and-families/health-care/
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/
health-care-programs/programs-and-services/other-insurance.jsp
Phone: 1-844-854-4825
Phone: 1-800-657-3739
MISSOURI – Medicaid OKLAHOMA – Medicaid and CHIP
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Website: http://www.insureoklahoma.org
Phone: 573-751-2005 Phone: 1-888-365-3742
MONTANA – Medicaid OREGON – Medicaid and CHIP
Website: http://healthcare.oregon.gov/Pages/index.aspx
Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP
Website: http://www.oregonhealthcare.gov/index-es.html
Phone: 1-800-694-3084 Phone: 1-800-699-9075
NEBRASKA – Medicaid PENNSYLVANIA – Medicaid
Website: https://www.dhs.pa.gov/providers/Providers/Pages/Medical/HIPP-
Website: http://www.ACCESSNebraska.ne.gov
Program.aspx
Phone: (855) 632-7633; Lincoln: (402) 473-7000; Omaha: (402) 595-1178
Phone: 1-800-692-7462
NEVADA – Medicaid RHODE ISLAND – Medicaid
Website: http://dhcfp.nv.gov Website: http://www.eohhs.ri.gov/
Phone: 1-800-992-0900 Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)
SOUTH CAROLINA – Medicaid VIRGINIA – Medicaid and CHIP
Website: https://www.coverva.org/hipp/
Medicaid Website: https://www.scdhhs.gov
Medicaid Phone: 1-800-432-5924
Medicaid Phone: 1-888-549-0820
CHIP Phone: 1-855-242-8282
19
▶ Back Next ▶Legal Reminders
SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid
Website: http://dss.sd.gov Website: https://www.hca.wa.gov/
Phone: 1-888-828-0059 Phone: 1-800-562-3022
TEXAS – Medicaid WEST VIRGINIA – Medicaid
Website: http://gethipptexas.com/ Website: http://mywvhipp.com/
Phone: 1-800-440-0493 Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP
Medicaid Website: https://medicaid.utah.gov/
Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm
CHIP Website: http://health.utah.gov/chip
Phone: 1-800-362-3002
Phone: 1-877-543-7669
VERMONT– Medicaid WYOMING – Medicaid
Website: http://www.greenmountaincare.org/ Website: https://health.wyo.gov/healthcarefin/medicaid/programs-and-eligibility/
Phone: 1-800-250-8427 Phone: 1-800-251-1269
To see if any other states have added a premium assistance program since July 31, 2020 or for more information on special enrollment rights,
contact either:
U.S. Department of Labor U.S. Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare & Medicaid Services
www.dol.gov/agencies/ebsa www.cms.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such
collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor
a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to
respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions
of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently
valid OMB control number. See 44 U.S.C. 3512.
The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are
encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200
Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.
OMB Control Number 1210-0137 (expires 1/31/2023) 20
▶ Back Next ▶Legal Reminders
Notice of Availability: The Avaya Inc. Medical Expense Plan for a voluntary Health Quality Assessment or "HQA" that asks a series
Salaried Employees, a component of the Avaya Inc. Health & of questions about your health-related activities and behaviors and
Welfare Benefits Plan for Salaried Employees, Notice of Privacy whether you have or had certain medical conditions (e.g., cancer,
Practices diabetes, or heart disease). You may also be asked to complete
a voluntary biometric screening, which will include a blood test
THIS NOTICE DESCRIBES HOW YOU MAY OBTAIN A COPY OF THE for Glucose, HDL Cholesterol, Total Cholesterol, LDL Cholesterol,
PLAN’S NOTICE OF PRIVACY PRACTICES, WHICH DESCRIBES THE and Triglycerides. You are not required to complete the HQA or
WAYS THAT THE PLAN USES AND DISCLOSES YOUR PROTECTED participate in the blood test or other medical examinations.
HEALTH INFORMATION.
Employees who choose to participate in the well-being program will
The Avaya Inc. Medical Expense Plan for Salaried Employees, receive incentives in the form of gift cards up to a maximum of $100,
a component of the Avaya Inc. Health & Welfare Benefits Plan subject to applicable taxes, for completing the various activities listed
for Salaried Employees, (the “Plan”) provides health benefits to on the Avaya Well-Being Program page of www.aetna.com.
eligible employees of Avaya Inc. (the “Company”) and their eligible
dependents as described in the summary plan description(s) for the If you are unable to participate in any of the voluntary health related
Plan. The Plan creates, receives, uses, maintains and discloses health activities or achieve any of the health outcomes required to earn an
information about participating employees and dependents in the incentive, you may be entitled to a reasonable accommodation or an
course of providing these health benefits. The Plan is required by alternative standard. You may request a reasonable accommodation
law to provide notice to participants of the Plan’s duties and privacy or an alternative standard by contacting your plan administrator at
practices with respect to covered individuals’ protected health hwplanadmin@avaya.com.
information, and has done so by providing to Plan participants a The information from your HQA and the results from your biometric
Notice of Privacy Practices, which describes the ways that the Plan screening will be used to provide you with information to help you
uses and discloses protected health information. To receive a copy understand your current health and potential risks, and may also be
of the Plan’s Notice of Privacy Practices you should contact Avaya’s used to offer you services through the well-being program, such as
Health Plan Administrator, who has been designated as the Plan’s health coaching, physical activity opportunities, and healthy-habit
contact person for all issues regarding the Plan’s privacy practices and tracking tools. You also are encouraged to share your results or
covered individuals’ privacy rights. You can reach this contact person concerns with your own doctor.
at: 350 Mount Kemble Avenue, Morristown, NJ 07960, or via e-mail at
hwplanadmin@avaya.com.
Notice Regarding Well-Being Program
Avaya’s Well-Being program is a voluntary well-being program
available to all employees. The program is administered according
to federal rules permitting employer-sponsored well-being programs
that seek to improve employee health or prevent disease, including
the Americans with Disabilities Act of 1990, the Genetic Information
Nondiscrimination Act of 2008, and the Health Insurance Portability
and Accountability Act, as applicable, among others. If you choose to
participate in the well-being program you may be asked to complete
21 ▶ Back Next ▶Legal Reminders
Protections from Disclosure of Medical Information You may not be discriminated against in employment because of the
We are required by law to maintain the privacy and security of your medical information you provide as part of participating in the well-
personally identifiable health information. Although the well-being being program, nor may you be subjected to retaliation if you choose
program and Avaya may use aggregate information it collects to not to participate.
design a program based on identified health risks in the workplace, If you have questions or concerns regarding this notice, or about
Aetna will never disclose any of your personal information either protections against discrimination and retaliation, please contact
publicly or to the employer, except as necessary to respond to Aetna at 1-877-508-6927.
a request from you for a reasonable accommodation needed to
participate in the well-being program, or as expressly permitted by HIPAA Special Enrollment Rights for Medical Plan Coverage
law. Medical information that personally identifies you that is provided
Loss of Eligibility for Other Health Coverage
in connection with the well-being program will not be provided
to your supervisors or managers and may never be used to make If you are declining medical plan enrollment for yourself or your
decisions regarding your employment. dependents (including your spouse) because of other health insurance
or group health plan coverage, you may be able to enroll yourself and
Your health information will not be sold, exchanged, transferred, or
your dependents in the medical plans under the Avaya Inc. Health &
otherwise disclosed except to the extent permitted by law to carry
Welfare Benefits Plan, the Avaya Inc. Health & Welfare Benefits Plan
out specific activities related to the well-being program, and you will
for Salaried Employees, or any other group health plan(s) that are
not be asked or required to waive the confidentiality of your health
applicable to your health status and may be maintained by Avaya
information as a condition of participating in the well-being program
from time to time (collectively and/or individually, as applicable, the
or receiving an incentive. Anyone who receives your information for
“Plan” or “Health Plan”), or switch health benefit options under the
purposes of providing you services as part of the well-being program
applicable plan, if you or your dependents lose eligibility for that other
will abide by the same confidentiality requirements.
coverage (or if the employer stops contributing toward your or your
The only individuals who will receive your personally identifiable dependents’ other non-COBRA coverage). However, you must request
health information are the account management team at Aetna and enrollment within 31 days after the date your or your dependents’ other
Aetna Customer Care Management Unit representatives in order to coverage ends (or after the employer stops contributing toward the
provide you with services under the well-being program. other coverage) by contacting the Avaya Health & Benefits Decision
Center at 1-800-526-8056 (option 1). Loss of eligibility for coverage
In addition, all medical information obtained through the well-being includes:
program will be maintained separate from your personnel records,
information stored electronically will be encrypted, and no information
you provide as part of the well-being program will be used in making
any employment decision. Appropriate precautions will be taken to
avoid any data breach, and in the event a data breach occurs involving
information you provide in connection with the well-being program,
we will notify you immediately.
22 ▶ Back Next ▶You can also read
