employee benefit summary - ebr sheriff's office · employee benefit summary ... higgins brian...

EMPLOYEE BENEFIT SUMMARY For Benefits July 1, 2014 through June 30, 2015

East Baton Rouge Parish Sheriff’s Office is pleased to provide a comprehensive benefits program as part of your overall compensation package. This summary is designed to provide you with an overview of the benefit program available to you and your eligible dependents and the cost, if any, associated with each plan.

BENEFIT WHO PAYS FOR THIS BENEFIT? WHAT DO I COMPLETE TO ENROLL?

Medical & Prescription EBRSO Pays 100% of the Employee Cost

Dependent Coverage, if Elected, Is An Additional Cost Paid By The Employee

Benefits Enrollment & Change Form

Vision EBRSO Pays 100% of the Employee Cost



Voluntary Dental This Coverage, if Elected, Is An Additional Cost Paid By The Employee


Life and AD&D EBRSO Pays 100% of the Employee Cost


Standard Insurance Co. Enrollment & Change Form

Voluntary Life This Coverage, if Elected, Is An Additional Cost Paid By The Employee


A Medical History Statement is Required for Benefits Above

the Guaranteed Issue Amount.

Voluntary Disability This Coverage, if Elected, Is An Additional Cost Paid By The Employee


National Sheriff’s Association AD&D

EBRSO Pays 100% of the Employee Cost National Sheriff’s Association Enrollment Form

Section 125 Pre‐Tax Plan There is No Cost To Participate Premium Conversion Election Form

Employee Assistance Plan EBRSO Pays 100% of The Employee & Dependent Cost

No Enrollment Form Needed

1

MONTHLY PREMIUM COST

BASIC LIFE & ACCIDENTAL DEATH & DISMEMBERMENT

Employee Cost $0.00

Dependent Life Cost $0.76

VOLUNTARY LIFE

Age <30 30‐39 40‐44 45‐49 50‐54 55‐59 60‐64 65‐69 70+

Rate/$1,000 of Benefit $.12 $.14 $.25 $.43 $.66 $1.10 $1.25 $2.18 $6.19

NATIONAL SHERIFF’S ASSOCIATION AD&D

Employee Only $0.00

VOLUNTARY DISABILITY

Employee Only See Enclosed Rate Tables

The following premium summary is provided for your benefits package. These premiums will apply for the plan year July 1, 2014 through June 30, 2015. If you elect to participate in the Section 125 pre‐tax plan, your eligible premiums will be deducted from your paycheck before taxes. Participation in the Section 125 pre‐tax plan is voluntary. If you choose to participate, you may not change your premium deductions until the next open enrollment period, unless a change of status event occurs during the plan year, such as marriage, divorce, birth, eligibility for other coverage or dependent’s loss of other coverage. Your election to participate in the Section 125 plan will remain in effect until you submit a written request to change it. The next open enrollment period will be April 2015 with any plan changes taking effect for July 1, 2015.

Benefit Summary 2014—2015

MEDICAL & PRESCRIPTION (Gold Plan)

Total Plan Cost* EBRSO Cost Employee Cost

Employee Only $718.37 $718.37 $0.00

Employee + Spouse $1,676.95 $1,326.95 $350.00

Employee + Child(ren) $1,338.61 $1,063.61 $275.00

Employee + Family $2,285.96 $1,760.96 $525.00

VISION


Employee Only $5.90 $5.90 $0.00

Employee + Spouse $9.90 $5.90 $3.38

Employee + Child(ren) $10.36 $5.90 $3.77

Employee + Family $14.32 $5.90 $7.12

DENTAL

Employee Only $27.60 $0.00 $27.60

Employee + Family $74.16 $0.00 $74.16


*COBRA is calculated at 102% of the 2014‐2015 Total Plan Cost

2

WELLNESS CENTER


Patients will be seen by appointment only. To schedule an appointment, please call (225) 355‐1253.

The East Baton Rouge Parish Sheriff’s Office Wellness

Center is dedicated solely to employees, retirees and

their dependents (spouses and children age 14+) who

participate in the health insurance plan, and can assist

with the following:

Develop treatment plans and follow‐up for chronic

disease management

Tobacco Cessation

Weight Management

Episodic Care (i.e. ear infections, sinus infections, cold)

Order, conduct, interpret and consult on

laboratory tests

Referrals to specialists

Prescribe medication after a thorough assessment.

Important Reminders:

There is no cost to you or your covered

dependents for any services performed through

the Wellness Center.

You may visit the Wellness Center during the

workday with Supervisor approval. Visits are

limited to a one hour maximum without the use of

PTO hours.

East Baton Rouge Parish Sheriff’s Office Wellness Center

2891 Rosenwald Road Baton Rouge, LA 70807

(225) 355‐1253

Monday 8:30 a.m. ‐ 3:30 p.m.

Tuesday 8:30 a.m. ‐ 3:30 p.m.

Wednesday 8:30 a.m. ‐ 3:30 p.m.

Friday 8:30 a.m. ‐ 3:30 p.m.

Hours of Operation

Wellness Center Provider: April Madere

April has been a family nurse practitioner for four years and has 25 years

experience as a registered nurse. She graduated from nursing school in 1989,

received her BSN in 2007 and her MSN and FNP in 2009. Prior to joining

Healthstat, April practiced as a FNP in rural health clinics, in a cancer screening

clinic and in an urgent care clinic. She brings varied experience, proven expertise

and deep commitment to the employees of EBRSO.

3

MEDICAL BENEFITS

Frequently Asked Questions

Dependent Eligibility ‐ Dependent children are eligible up to age 26 regardless of student status, marital status, employment status, residence, etc.

ID Cards—You have one combined ID card for medical, prescription & vision services. Although the CVS logo appears on your card, you can use any pharmacy (not just CVS) to access prescriptions.

Baton Rouge General—They are in‐network providers through a direct contract with EBRSO. See the attached provider listing for more information.

Mail Order Services are available for your monthly maintenance prescriptions. Using mail order can save you money through lower copayments for a 90‐day supply. Please call Prescription Benefits, Inc. at (800) 334‐8134 for assistance with enrolling in this program or visit www.caremark.com.

Plan Documents & Online Medical Claim Access is available through Southern Benefit Services. Please visit www.sbstpa.com to register for this service. For assistance, please call (866) 342‐0182.


Gold Plan

Claims Administrator Southern Benefit Services, LLC

PPO Network www.ppoplus.com

Benefit Period Calendar Year

Calendar Year Maximum Unlimited

Deductible Individual Family Maximum

In‐Network $350 $700

Out‐of Network $700 $1,400

PPO & Non‐PPO deductibles are separate and do not apply towards each other.

Member’s Responsibility 20% 40%

Out of Pocket Maximum Individual

Family Maximum

$2,500 $5,000

$5,000 $10,000

PPO & Non‐PPO maximums are separate and do not apply towards each other. The following expenses will apply towards satisfying the maximum out‐of‐pocket:

medical deductible, copays, coinsurance and medical management penalties. When you reach the maximum out‐of‐pocket, the plan will cover eligible in‐network expenses at

100%. Prescription copayments and prescription deductibles are excluded from this limit.

Physician Office Visits

Primary Care: $25 Copay Per Visit Specialists: $50 Copay Per Visit

100% After Copay Up to $250 Per Visit

40% After Deductible

Preventive Care Covered At 100% Not Covered

Emergency Room Copay $100 Copay Per Visit $100 Copay Per Visit

Urgent Care Copay $50 Copay Per Visit 40% After Deductible

Services Performed at the EBRSO Wellness Center

Covered at 100%

4

Baton Rouge General Medical Center Direct Program Providers

Cardiology and Cardiovascular DiseaseGreen Garland G 59335 River West Dr Ste C Plaquemine 225 685-1052

LaMotte Lance C 3600 Florida Blvd Baton Rouge 225 819-1160

LaMotte Lance C 8888 Summa Ave Baton Rouge 225 819-1160

Newsome Nakia A 59335 River West Dr Ste C Plaquemine 225 685-1052

DermatologyEarhart Robert 333 Lee Dr Ste B Baton Rouge 225 490-3415

Earhart Robert 3801 N Blvd Baton Rouge 225 381-6620

Whatley Jordan L 8595 Picardy Ave Bldg 600 Baton Rouge 225 819-1120

EndocrinologyMatrisciano Justin G 3401 North Blvd Ste 200 Baton Rouge 225 387-0851

Endoscopy CenterBaton Rouge General - Bluebonnet 8595 Picardy Ave Baton Rouge 225 763-4000

Baton Rouge General - Mid City 3600 Florida Blvd Baton Rouge 225 387-7000

Family PracticeAnderson Derek 2645 ONeal Lane Baton Rouge 225 751-0234

Anderson Derek 3801 N Blvd Baton Rouge 225 381-6620

Batie Donnie 3401 North Blvd Ste 130 Baton Rouge 225 381-2727

Bella Timothy A 10127 Florida Blvd Baton Rouge 225 272-0106

Burnham Jeffrey M 8490 Picardy Ave Ste 100 Baton Rouge 225 763-4904

Chasuk Robert 333 Lee Dr Ste B Baton Rouge 225 490-3415

Chasuk Robert 3801 N Blvd Baton Rouge 225 381-6620

Curtis Elizabeth 17520 Old Jefferson Hwy Ste BPrairieville 225 673-8983

Family Health Center 3801 N Blvd Baton Rouge 225 381-6620

Family Health Center - South 333 Lee Dr Ste B Baton Rouge 225 490-3415

Gaspard Brad J 8595 Picardy Ave Ste 100 Baton Rouge 225 763-4900

Geno Charles Edward 3801 N Blvd Baton Rouge 225 381-6620

Higgins Brian P 402 N Vaughan St Brusly 225 749-2645

Jones Stacy D 3401 North Blvd Ste 130 Baton Rouge 225 381-2727

Munson-Whetstone Vicki Z 2645 ONeal Lane Baton Rouge 225 751-0234

Munson-Whetstone Vicki Z 402 N Vaughan St Brusly 225 749-2645

Nesheiwat Joseph 8595 Picardy Ave Ste 100 Baton Rouge 225 763-4900

Nguyen Vincent T 2645 ONeal Lane Ste B Baton Rouge 225 214-4455

Picardy Family Medical 8490 Picardy Ave Bldg 600 Baton Rouge 225 819-1170

Raina Gunjan 8595 Picardy Ave Bldg 600 Baton Rouge 225 819-1170

Schulte Brian S 333 Lee Dr Ste B Baton Rouge 225 490-3415

Schulte Brian S 3801 N Blvd Baton Rouge 225 381-6620

Shaw Vincent 2645 ONeal Lane Baton Rouge 225 751-0234

Shaw Vincent 3801 N Blvd Baton Rouge 225 381-6620

Smith Christine 11281 Old Hammond Hwy Bldg BBaton Rouge 225 275-4656

Spooner Yolonda 333 Lee Dr Ste B Baton Rouge 225 490-3415

Spooner Yolonda 3801 N Blvd Baton Rouge 225 381-6620

St Amant Robert P 8595 Picardy Ave Ste 100 Baton Rouge 225 763-4900

St Amant Robert P 8888 Summa Blvd Baton Rouge 225 819-1160

Taylor James 13960 Florida Blvd Livingston 225 686-0158

Vinayagam Vasanthi 3401 North Blvd Ste 130 Baton Rouge 225 381-2727

Wells Tina 17520 Old Jefferson Hwy Ste BPrairieville 225 673-8983

Wood Robert C 8595 Picardy Ave Ste 100 Baton Rouge 225 763-4900

Yorek Michael W 8595 Picardy Ave Ste 100 Baton Rouge 225 763-4900

Yorek Michael W 17505 Old Jefferson Hwy Prairieville 225 673-8983

Yorek Michael W 17520 Old Jefferson Hwy Ste BPrairieville 225 673-8983

GastroenterologyMcNeely Paul 8595 Picardy Ave Ste 325 Baton Rouge 225 819-1190

Sonsky Alan J 8595 Picardy Ave Ste 325 Baton Rouge 225 819-1190

General SurgeryAdhvaryu Dhaval 3600 Florida Blvd Baton Rouge 225 381-2660

Adhvaryu Dhaval 3600 Florida Blvd Baton Rouge 225 387-7000

Facundus Edward C 3600 Florida Blvd Baton Rouge 225 381-2615

Littleton Jeffrey C 3600 Florida Blvd Baton Rouge 225 387-7715

Mencer Ernest J 3600 Florida Blvd Baton Rouge 225 387-7715

Puyau Michael 3600 Florida Blvd Baton Rouge 225 381-2615

Ross Sidney O 3600 Florida Blvd Baton Rouge 225 381-2615

Ross Sidney O 8595 Picardy Ave Ste 300 Baton Rouge 225 763-4820

GeneticsNarumanchi Tarachandra M 8585 Picardy Ave Baton Rouge 225 763-4670

HospitalBaton Rouge General Medical Center 3600 Florida Blvd Baton Rouge 225 387-7000

Baton Rouge General Medical Center 8595 Picardy Ave Baton Rouge 225 763-4000

HospitalistJayasinghe Indra T 8585 Picardy Ave Baton Rouge 225 763-4670

McKnight Melanie J 3600 Florida Blvd Baton Rouge 225 387-7700

Shah Neel 8585 Picardy Ave Baton Rouge 225 763-4670

Thompson Mikah S 8585 Picardy Ave Baton Rouge 225 763-4670

Imaging CenterBaton Rouge Radiology Imaging Ctr 2550 O'Neal Lane Baton Rouge 225 663-6500

Baton Rouge Radiology Imaging Ctr 5422 Dijon Dr Baton Rouge 225 769-9337

Infectious DiseaseNjoku Patrick 3401 North Blvd Ste 325 Baton Rouge 225 381-2782

Internal MedicineCampo Nicholas J 3401 North Blvd Ste 200 Baton Rouge 225 387-0851

Depp David 3600 Florida Blvd Baton Rouge 225 387-7070

Dixon Henry C 3401 North Blvd Ste 200 Baton Rouge 225 387-0851

Garbutt Mark G 3600 Florida Blvd Baton Rouge 225 387-7700

Hargroder James A 3401 North Blvd Ste 200 Baton Rouge 225 387-0851

Matrisciano Justin G 3401 North Blvd Ste 200 Baton Rouge 225 387-0851

Minsky Louis R 8595 Picardy Ave Ste 315 Baton Rouge 225 819-1188

Neshiewat Joseph 3401 North Blvd Ste 200 Baton Rouge 225 387-0851

Shamlin Kenyatta D 8595 Picardy Ave Ste 100 Baton Rouge 225 763-4900

Shamlin Tasha C 8595 Picardy Ave Ste 100 Baton Rouge 225 763-4900

Wahid Darakhshan 3401 North Blvd Ste 130 Baton Rouge 225 381-2727

Wood Robert 3401 North Blvd Baton Rouge 225 381-2727

Mental Health FacilityBaton Rouge General - Mid City 3600 Florida Blvd Baton Rouge 225 387-7000

Multi-Specialty ClinicAdvanced Family Medical Clinic 5937 Jones Creek Rd Ste B Baton Rouge 225 214-4455

Baton Rouge Family Med- Livingston 13960 Florida Blvd Livingston 225 686-0158

Baton Rouge Family Medical Center 8595 Picardy Ave Ste 100 Baton Rouge 225 763-4900

Baton Rouge General Physicians Grou8585 Picardy Ave Ste 325 Baton Rouge 225 819-1190

Burnham Family & Sports Medicine 15165 S Harrell's Ferry Rd Baton Rouge 225 751-0234

Internal Medicine Clinic 3401 North Blvd Ste 325 Baton Rouge 225 381-2789

Medical Associates of Baton Rouge 3401 North Blvd Ste 200 Baton Rouge 225 387-0851

Oak Grove Family Practice 17520 Old Jefferson Hwy Ste BPrairieville 225 673-8983

Primary Care Group 3401 North Blvd Ste 130 Baton Rouge 225 381-2727

Sherwood Forest Medical Clinic 11281 Old Hammond Hwy Bldg BBaton Rouge 225 275-4656

Westside Family Medicine 402 N Vaughan St Brusly 225 749-2645

NeurologyAwad Amer M 3600 Florida Blvd Baton Rouge 225 381-2650

BRG Neurology Associates 3600 Florida Blvd Baton Rouge 225 381-2650

Phillips Christopher D 3600 Florida Blvd Baton Rouge 225 387-7724

NeurosurgeryMolloy Gerald 3401 North Blvd Ste 100 Baton Rouge 225 381-2650

Molloy Gerald 8585 Picardy Ave Ste 235 Baton Rouge 225 819-1130

Nurse PractitionerArboneaux Benji 3401 North Blvd Ste 200 Baton Rouge 225 387-0851

Ash Vosberg Monica 8585 Picardy Ave Baton Rouge 225 763-4670

Bennett Danielle K 3600 Florida Blvd Baton Rouge 225 387-7715

Bokun Rebecca 8585 Picardy Ave Baton Rouge 225 763-4670

Burns Heather 8595 Picardy Ave Ste 100 Baton Rouge 225 763-4900

Cambias Michelle L 3600 Florida Blvd Baton Rouge 225 763-4670

Cambias Michelle L 8585 Picardy Ave Baton Rouge 225 763-4670

Dart William D 3401 North Blvd Ste 200 Baton Rouge 225 387-0851

Duncan Susan L 17520 Old Jefferson Hwy Ste BPrairieville 225 673-8983

Genre Todd 3401 North Blvd Ste 200 Baton Rouge 225 387-0851

Haik Chris 3401 North Blvd Ste 200 Baton Rouge 225 387-0851

Hernandez Jamie A 3600 Florida Blvd Baton Rouge 225 763-4670

Information in this directory is subject to change. Before receiving healthcare from any provider, be sure to check that they are still participating with your plan.

2/24/2012 Verity HealthNet Page 15

Baton Rouge General Medical Center Direct Program Providers

Nurse PractitionerHernandez Jamie A 8585 Picardy Ave Baton Rouge 225 763-4670

Holder Sharon R 3401 North Blvd Ste 200 Baton Rouge 225 387-0851

Humbles Kirby D 3401 North Blvd Ste 200 Baton Rouge 225 387-0851

Johnson Chantelle 8595 Picardy Ave Ste 100 Baton Rouge 225 763-4900

Marcus Catherine Miller 3600 Florida Blvd Baton Rouge 225 763-4670

Marcus Catherine Miller 8585 Picardy Ave Baton Rouge 225 763-4670

Martin Julie 8595 Picardy Ave Ste 100 Baton Rouge 225 763-4900

McRae Patricia 3600 Florida Blvd Baton Rouge 225 763-4670

McRae Patricia 8585 Picardy Ave Baton Rouge 225 763-4670

Rome George J 3600 Florida Blvd Baton Rouge 225 763-4670

Rome George J 8585 Picardy Ave Baton Rouge 225 763-4670

Tate-Gobert Tammy 3600 Florida Blvd Baton Rouge 225 387-7724

Thibodeaux Michele 8585 Picardy Ave Baton Rouge 225 763-4670

Whitty Kristin K 3401 North Blvd Ste 200 Baton Rouge 225 387-0851

Williams Stacia 8595 Picardy Ave Ste 100 Baton Rouge 225 763-4900

Young Lydia 8595 Picardy Ave Ste 100 Baton Rouge 225 763-4900

Orthopedic SurgeryHubbard William 8585 Picardy Ave Baton Rouge 225 763-4629

Moukarzel Robert 8585 Picardy Ave Baton Rouge 225 763-4629

Outpatient FacilityBaton Rouge General - Bluebonnet 8595 Picardy Ave Baton Rouge 225 763-4000


Pediatric NephrologyYosypiv Ihor V 17520 Old Jefferson Hwy Ste BPrairieville 225 673-8983

PediatricsFrantz Melinda Marie 8585 Picardy Ave Baton Rouge 225 763-4670

Franz Melinda Marie 3600 Florida Blvd Baton Rouge 225 387-7070

Marcelle Dawn 3600 Florida Blvd Baton Rouge 225 387-7070

Marcelle Dawn 8585 Picardy Ave Baton Rouge 225 763-4670

Shamlin Kenyatta D 8595 Picardy Ave Ste 100 Baton Rouge 225 763-4900

Shamlin Tasha C 8595 Picardy Ave Ste 100 Baton Rouge 225 763-4900

Physical Medicine and RehabilitationColin Elsie M 3401 North Blvd Ste 130 Baton Rouge 225 381-2530

Markus John V 8595 United Plaza Blvd Baton Rouge 225 231-3046

Physical TherapyBaton Rouge General - Bluebonnet 8595 Picardy Ave Baton Rouge 225 763-4000


Physician AssistantCouvillion Darren P 3401 North Blvd. Ste 100 Baton Rouge 225 381-2650

Ellis Alencia Clayton 3401 North Blvd Ste 130 Baton Rouge 225 381-2727

Ross Terri 8585 Picardy Ave Baton Rouge 225 763-4629

Wilder Alonzo 13960 Florida Blvd Livingston 225 686-0158

PsychiatristLeBourgeois Herbert W 8585 Picardy Ave Baton Rouge 225 763-4670

Pulmonary DiseaseRoberts Floyd 3600 Florida Blvd Baton Rouge 225 387-7070

Sheybani Reza 3600 Florida Blvd Baton Rouge 225 387-7724

Radiation OncologyLauve Andrew 3601 N Blvd Baton Rouge 225 387-7280

Russell William 3601 N Blvd Baton Rouge 225 387-7280

RadiologyBaton Rouge General - Bluebonnet 8595 Picardy Ave Baton Rouge 225 763-4777


Rehabilitation HospitalBaton Rouge Rehab Hospital 8595 United Plaza Blvd Baton Rouge 225 927-0567

RheumatologyMorris Jed L 3401 North Blvd Ste 200 Baton Rouge 225 387-0851

Sleep MedicineBaton Rouge General - Bluebonnet 8595 Picardy Ave Baton Rouge 225 763-4335

Sleep MedicineBaton Rouge General - Mid City 3600 Florida Blvd Baton Rouge 225 387-7000

Social WorkerWilks Mary E 3801 N Blvd Baton Rouge 225 381-6620

Speech TherapyBaton Rouge General - Bluebonnet 8595 Picardy Ave Baton Rouge 225 763-4000


Urgent CareMid City Urgent Care 3870 Convention St Baton Rouge 225 381-6249

Information in this directory is subject to change. Before receiving healthcare from any provider, be sure to check that they are still participating with your plan.

2/24/2012 Verity HealthNet Page 26

PRESCRIPTION BENEFITS MEMBER CO‐PAY: $100 calendar year deductible per member / $300 family maximum. Deductible applies only to Brand Name medications (waived for Generic).

1‐30 days supply at local pharmacy = $ 8 Generic $35 Preferred Brand $50 Non‐Preferred Brand

90 day supply at Mail Order pharmacy = $20 Generic $87.50 Preferred Brand $125 Non‐Preferred Brand

Generic Policy: If your Doctor writes a prescription stating that a Generic may be dispensed, EBRSO will only pay for the Generic drug. If you choose to buy the Brand name drug in this situation, you will be required to pay the Generic co‐pay plus the difference in cost between the Generic and Brand name drug. The Generic Policy does not apply if your doctor requires a brand name medication.

Specialty Medications: Specialty medications must be ordered through Caremark Specialty Pharmacy at 1‐800‐237‐2767. Limited to a 30 day supply and may require prior authorization or step therapy. Step therapy categories are Autoimmune (Rheumatoid Arthritis) and Multiple Sclerosis.

ActiveCare Diabetes Wellness: Diabetic supplies are provided as part of the Prevention & Treatment Plan for diabetes and are provided to covered employees and their dependents at no cost to the employee (prescription copay is waived) when received from 4G/Activecare. These supplies include: cellular glucose meter, diabetic testing strips, control solution, lancets, lancing device(s) and alcohol pads. You can call 1‐877‐862‐5553 to enroll in this voluntary program. Diabetic supplies not received from 4G/Activecare are subject to the above copays.

DRUGS COVERED

Legend Drugs (drugs that require a prescription). See exclusions. Acne agents (prior authorization required after age 34) ADD/ADHD medications (prior authorization required age 26+)

Narcolepsy medications (prior authorization required)

Oral/Injectable Contraceptives Diabetic Care: Agents/Strips for testing, Disposable insulin needles/syringes and Lancets*

Insulin/Insulin pre‐filled syringes Growth Hormones (prior authorization required)

Impotence agents (quantity limits apply)

Migraine Medications (FDA limits apply)

Sleep Aids (quantity limits apply)

Prescription Smoking Cessation Agents

Oral/Topical Fentanyl products (prior authorization required) Extended Release controlled substances (quantity limits apply)

Compounded medication of which at least one ingredient is a legend drug. Compounded medications equal to or exceeding $300 per script will require prior authorization (quantity limits apply).

* Diabetic supplies when dispensed at the same time as insulin will be included under the same co‐payment. Disposable insulin needles/syringes, test strips and lancets must be dispensed in days supply corresponding to the amount of insulin to be dispensed and must be submitted at the same time to be included under the same co‐payment as the insulin.

**This is not an inclusive list but is a representation of the most commonly used medications. Contact customer service for specific drug coverage information.

This plan is subject to the Affordable Care Act (ACA) which requires the coverage of a number of preventive items and services at 100% and ensures these items and services are not subject to deductibles or other limitations such as annual caps or limits. You can contact Customer Service if you have specific drug questions or register at www.caremark.com to check drug costs and coverage.

EXCLUSIONS**

Anabolic Steroids

Anti‐obesity/Appetite suppression medications

OTC products

Cosmetic agents (Anti‐wrinkle agents, Hair growth stimulants and removal products)

Fertility agents

Immunization agents, blood or blood plasma

Therapeutic devices or appliances unless listed as a covered product

Vitamins (except for prenatal, fluoride and single entity)

Medication which is to be taken by or administered to an individual, in whole or in part, while he or she is a patient in a licensed hospital, rest home, sanitarium, extended care facility, convalescent hospital, nursing home or similar institution which operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals.


VISION BENEFITS


VISION PLAN—Employer Paid

Insurance Company AlwaysCare

Provider Network Locate a participating provider at www.alwaysassist.com

In‐Network Out‐of‐Network

Copays Exam Materials

$10 $25

Up to $35 See Below

Standard Plastic Lenses: Single Vision Bifocal Trifocal Lenticular Progressive

Lens Option: Standard Scratch Resistant Coating

Covered by Copay Covered by Copay Covered by Copay Covered by Copay $70 allowance

Covered in Full

Up to $25 Up to $40 Up to $50 Up to $50 Up to $40

Not Covered

Frames: Members choose from any frame available at provider locations

$130 allowance

Up to $50

Contact Lenses1: Elective Medically Necessary2 Standard Contact Lens Fitting Exam3 Specialty Contact Lens Fitting Exam Fee4

$0 Copay Up to $130 allowance Up to $130 allowance

Up to $70 Copay Not Covered

Up to $100 Up to $210 Not Covered Not Covered

Benefit Frequency Exam Standard Plastic Lenses Frames Contact Lenses

1 per 12 months 1 Per 12 Months 1 Per 24 Months 1 Per 12 Months

1 Contact lenses are in lieu of eyeglass lenses and frames. 2 Medically Necessary Contact Lenses refer to contact lenses that are prescribed solely for the purpose of correcting one of the following medical conditions. These conditions prevent the Insured from achieving a specified level of visual acuity (performance) through the wearing of conventional eyeglasses.

1. Aphakia (after cataract surgery). A pair of prescription single vision or multifocal eyeglass lenses and an eyeframe can be provided in addition to Medically Necessary Contact Lenses for this condition.

2. When visual acuity cannot be corrected to 20/70 in the better eye except through the use of Contact Lenses (must be 20/60 or better).

3. Anisometropia of 4.0 diopters or more, provided visual acuity improves to 20/60 or better in the weak eye. 4. Keratoconus.

Reimbursement of Medically Necessary Contact Lenses will be considered as payment in‐full if utilizing the services of an In‐Network Provider. This benefit provides coverage for the Materials only. It does not include the Contact Lens Fitting fee. 3 The standard contact lens fitting exam fee applies to a new or existing contact lens user who wears spherical disposal, daily wear or extended wear lenses only. 4 The specialty contact lens fitting exam fee applies to a new or existing contact lens user who wears toric, gas‐permeable, mono‐fit or multi‐focal lenses.

8

SPECIAL VISION DISCOUNTS

AlwaysCare has negotiated special fees with thousands of optical locations for extra purchases of lenses and coatings, frames, contact lenses and other products. These discounts may be used in conjunction with your insurance transaction for non‐covered services as well as with additional purchases. Providers identified as “Value Added (VA)” or “Service Plus (SP)” in the AlwaysCare online directory offer the following additional values. Members receive the fully insured plan allowances minus any copays towards everyday retail prices at Walmart, Sam’s Club and Costco locations.*

Lens Options

Add‐ons for insured purchases and additional lens purchases:

UV Coating—$15

Solid Tinting / Gradient Tinting—$15

Standard anti‐reflective coating—$45

Premium anti‐reflective coating—$70

Polarized—$75

Transition—$75

Standard Polycarbonate—$40

High Index (Single Vision) 1.56—1.60 ($60) 1.66+ (20% discount)

High Index (Multi‐focal) 1.56—1.60 ($75) 1.66+ (20% discount)

Value Added Providers (VA)

Purchase a second pair of glasses or contact lenses and receive preferred pricing:

Lenses

Single vision plastic lenses—$40

Bifocal plastic lenses—$60

Trifocal—$70

Progressive lenses (Standard) ‐ $110

Progressive lenses (Premium) ‐ 20% discount

Frames—Up to 35% discount

Contact Lenses—5‐15% discount, depending on type

Other Products—20% discount on non‐prescription sunglasses and other ancillary products / solutions**

Service Plus Providers (SP)

Receive 20% discount for the following add‐ons to insured purchases:

UV Coating

Solid Tinting/Gradient Tinting

Standard scratch resistance coating

Standard anti‐reflective coating

Premium anti‐reflective coating

Transition

Standard Polycarbonate

*Additional discounts are not applicable at these locations. **Some retail chains sell sunglasses in departments outside of their optical shops where discounts do not apply.

Laser Vision Correction Network Membership with AlwaysCare provides access to preferred pricing on laser vision correction surgery. Transactions are handed directly between members and participating providers. Visit www.alwaysassist.com for a list of participating providers in your area.


9

Hearing Savings PlanAlwaysCare is committed to your overall wellness and has partnered with EPIC Hearing Healthcare to offer hearing benefits and services often not covered by health plans.

Benefits To You and Your Family•AvailableatnocosttoyouoryourfamilywithenrollmentinanyAlwaysCaregrouporindividualproduct

•30-60%discountsoffmajornamebrandhearinginstrumentsandaccessories

•40%savingsonhearingaidbatteriesshippeddirectlytoyourhome

•On-callsupportforyourquestions,managedbyprofessionalhearingcounselors

Offered through:

WH

Y HSP EE 1110

1-888-729-5433, Ext. 2013 • Fax 888-843-5872www.AlwaysCareBenefits.comMonday-Friday 7:30 a.m. to 8:30 p.m. (CT) Saturday 9:00 a.m. to 3:00 p.m. (CT)

Hearinglossaffectsmorethan

32 million Americans,and

65%areyounger than 65.1

Studieshavelinkeduntreated hearing losstoawiderange

ofphysical and emotional conditionsincluding:

Stress,fatigue,depression,

reducedalertness,reducedjob

performanceanddiminished

psychologicalandoverallhealth.2

90 to 95% of people with hearing loss can be helped withhearingaidsandtheirquality

oflifesignificantlyimproved.2

Did you know?

1(NationalInstitutesofHealth,2009)2(BetterHearingInstitute,YourGuidetoBetterHearing)

Hearing Device Cost Comparisons

Average price for two hearing aids

Standardretailpricefortwo(2)hearingaids

$4,000-$7,000

TypicalDiscountedPrice $3,000-$5,000

Hearing Savings Plan Price

$2,400-$3,600

TheEPICprocessprovidesextensivediagnosticinformationtoassureappropriatetherapyandtreatment.Thistranslatesintofavorablepricesandlowercostsforyou.TheexamplebelowillustratesthepotentialcostsavingsandpriceadvantagesoftheAlwaysCareHearingSavingsPlanforhearingaids.

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How It WorksTobeginworkingwithaparticipatingProvider,contactAlwaysCareCustomerServiceat1-888-729-5433,wherewewillconnectyoutoanEPICHearingProfessional.

1. EPICwillsendyouareferralpacketincludingProviderandplaninformation.

2. EPICwillnotifythenearesthearingcareProvider.

3. ScheduleanappointmentwiththeProviderforahearingevaluation.

4. Followingahearingevaluation,theProviderwilldetermineyourhearingneeds.

5. Ifhearingaidsareindicated,theProviderwillassistyouinchoosingthemostappropriatehearingsystemforyourneedsatnegotiatedandreducedprices.

6. EPICwillcoordinatehearingcoverageupfront,attimeofpayment.

7. Youareentitledtoa45-daytrialperiod.

8. Atthecompletionofthetrialperiod,EPICextendsthewarrantyonthehearingaid(s)tothreeyearsandprovidesacomplementaryone-yearsupplyofbatteries.

Thisisnotacontractofinsuranceandissubjecttochange.ProductsofferedbyEPICandadministeredbyAlwaysCareBenefits,Inc.

1-888-729-5433, Ext. 2013 • Fax 888-843-5872 www.AlwaysCareBenefits.com

Monday-Friday 7:30 a.m. to 8:30 p.m. (CT) Saturday 9:00 a.m. to 3:00 p.m. (CT)

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DENTAL BENEFITS

Network Freedom of Choice

You have the freedom to choose any provider or take advantage of discounts AlwaysCare has negotiated on your behalf with the thousands of providers in their nationwide dental networks. In addition to the nationwide network, they also offer a list of thousands of ’certified’ providers who have been independently reviewed and found to have proper credentials, appropriate utilization patterns, and are subject to ongoing utilization monitoring and recredentialing. These efforts help to reduce the amount that you spend out of pocket when visiting the dentist.

AlwaysCare Online Tools

www.AlwaysAssist.com

Utilize dental cost estimator to plan dental expenditures—view real data for your area

Print and request ID cards

View benefit summaries

View certificates of coverage

Access forms and documents

Modify personal information

View claims

Dental Carryover Benefit

If you submit qualifying dental claims for covered expenses during a benefit year and, in that same benefit year, receive benefits that are less than $600 of your $1,200 annual maximum, you will be credited a carryover benefit of $300 to use during the next benefit year. This credit is available in addition to the $1,200 maximum benefit.

Your carryover benefit account can accrue up until a maximum of $1,200 (in addition to your $1,200 maximum benefit).

Please contact AlwaysCare for more information at (888) 729‐5433 ext. 346.


VOLUNTARY DENTAL PLAN

Insurer AlwaysCare

Benefit Period Calendar Year

Deductible $50 Per Benefit Period, Maximum of 3 Per Family, Applies to Basic & Major Services

Maximum Benefit $1,200 Per Person Per Benefit Period (Carryover Benefit Included)

Coinsurance Preventive Services: 100% Routine Exams, Phrophylaxis, X‐Rays, Fluoride, Sealants

Basic Services: 80% Simple restorative, Simple Extractions, Periodontics, Endodontic

Major Services: 50% Inlays, Onlays, Crowns, Bridges, Dentures & Endosteal Implants

Orthodontia 50% Coinsurance Maximum Annual Benefit: $375 Separate Maximum Lifetime Benefit: $1,000 Applies Dependent Children Up To Age 19

Waiting Period 12 Months After initial Enrollment For Major and Orthodontia Services

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LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT BENEFITS

As an employee of EBRSO, you are provided with several options for Life and Accidental Death & Dismemberment protection. Your coverage includes employer funded basic Life /AD&D insurance through EBRSO and The National Sheriff’s Association as well as an option to purchase additional life coverage for yourself and your dependents on a voluntary basis. Please note that the Voluntary Life Benefit is available to you and your dependents on a guaranteed issue basis only as a new hire. Should you choose to waive coverage as a new hire and elect coverage during a future open enrollment period, you can be declined for coverage.

Employee Assistance Plan

Did you know that EBRSO provides you and your eligible dependents with access to FREE COUNSELING SERVICES through Interface EAP? Coverage is provided for 3 sessions per person per problem per plan year (July—June).

Examples of issues commonly addressed through this benefit are:

Family Conflict

Grief

Depression/Anxiety

Alcohol/Drug Abuse Issues

In addition, Interface EAP provides Legal Services, Financial Services & Work/Life and Wellness Resources.

These counseling sessions are CONFIDENTAL and are available at a location near you. Contact Interface EAP at (800) 324‐4327 or visit www.4eap.com (ID: EBRPSO & Password: 732) for assistance and to schedule your sessions.

BASIC LIFE/AD&D

Insurer Standard Life

Life Benefit 1 ½ Times Your Annual Earnings, Plus $7,000 (Maximum of $155,000)

AD&D Benefit 1 ½ Times Your Annual Earnings, Plus $2,000 (Maximum of $155,000)

Dependent Benefit Amount Spouse: $2,000; Child(ren): $2,000

Benefit Reductions 50% At Age 70

VOLUNTARY LIFE


Life Benefit Employee: Coverage is Available in $5,000 Increments (Maximum of $250,000) Spouse: Coverage is Available in $5,000 Increments & Cannot Exceed 50% of Employee Benefit (Maximum of $25,000)

Benefit Reductions 50% At Age 70

Guaranteed Issue Amount (Available Only At Initial Hire)

$100,000 Employee, $10,000 Spouse

NATIONAL SHERIFF’S ASSOCIATION AD&D BENEFIT

Insurer Reliance Standard

AD&D Benefit $3,000


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VOLUNTARY DISABILITY BENEFITS

VOLUNTARY LONG TERM DISABILITY


LTD Monthly Benefit Increments of $100 Minimum $200 Maximum $8,000

Maximum Monthly Benefit Not to exceed 60% of EBRSO monthly earnings

Benefit Waiting Period Option 1: 60 Day Accident/60 Day Illness Option 2: 90 Day Accident/90 Day Illness Option 3: 180 Day Accident/180 Day Illness

Maximum Benefit Period Option 1: 2 Years Option 2: 5 Years Option 3: To Age 65

Pre‐Existing Limitation 6 Months Prior/12 Months Insured

Guarantee Issue Full Benefit

Annual Open Enrollment Members can increase or add coverage during the Annual Open Enrollment period. These changes are subject to the Pre‐Existing Limitation exclusion for the next policy year. If a member has elected coverage and subsequently dropped coverage, they must complete a statement of health and the coverage request may be declined.

DISABILITY FACTS

A disabling injury occurs every 1.3 seconds—on and off the job. Surprisingly, more than 90% are NOT

work‐related.

Freak accidents are NOT usually the culprit. Back injuries, cancer, heart disease and other illnesses

cause the majority of long‐term absences.

Three in 10 workers entering the workforce today will become disabled before retiring.

The average long‐term disability absence lasts 2.5 years.

As an employee of EBRSO, you have the opportunity to purchase long term disability insurance for

yourself on a voluntary basis. This coverage is offered on a guaranteed issue basis and provides the

flexibility for you to choose the benefit amount and duration that best meets your needs in the event

you were to become disabled. Please note that the Voluntary Disability Benefit is available to you on a

guaranteed issue basis.


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PLAN CONTACTS

During open enrollment and throughout the plan year, the staff at EBRSO as well as our insurance companies and agents are available to assist you. Please keep this listing as a reference of contacts you have access to for your coverage.

Human Resources East Baton Rouge Parish Sheriff’s Office Karen Fourrier (Employees With Last Name A—L) [email protected] Phone: (225) 389‐5163 Fax: (225) 389‐8254 Gloria Taplin (Employees With Last Name M—Z) [email protected] Phone: (225) 389‐5163 Fax: (225) 389‐8254

Medical Claims or Benefit Questions Southern Benefit Services, LLC Online Access to Claims & Plan Documents: www.sbstpa.com Customer Service: (866) 342‐0182 Fax: (504) 328‐7508

Prescriptions RxBenefits, Inc. www.caremark.com Customer Service: (800) 334‐8134

Vision & Dental Insurance AlwaysCare www.alwaysassist.com

Customer Service: (888) 729‐5433 ext. 346

Life & Disability Insurance Standard Life www.standard.com Customer Service: (800) 628‐8600

Employee Assistance Plan Interface EAP www.4eap.com (ID: EBRPSO & Password: 732) To Access Services, Call 800‐324‐4327 Se Habla Espanol 800‐324‐2490

Insurance Agent: General Questions Landry Harris & Company Julie Creswell julie.creswell@lh‐co.com Phone: (337) 266‐2369

PPO Network PPO Plus www.ppoplus.com

Benefit / Resource Contact Information


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MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW‐COST HEALTH COVERAGE TO CHILDREN AND FAMILIES


If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your employer, your State may have a premium assistance program that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for these programs, but also have access to health insurance through their employer. If you or your children are not eligible for Medicaid or CHIP, you will not be eligible for these premium assistance programs.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can 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, you can contact your State Medicaid or CHIP office or dial 1‐877‐KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer‐sponsored plan.

Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must permit you to enroll in your employer plan if you are not 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, you can contact the Department of Labor electronically at www.askebsa.dol.gov or by calling toll‐free 1‐866‐444‐EBSA (3272).

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 January 31, 2014. You should contact your State for further information on eligibility –

ALABAMA – Medicaid COLORADO – Medicaid

Website: http://www.medicaid.alabama.gov Phone: 1‐855‐692‐5447

Medicaid Website: http://www.colorado.gov/ Medicaid Phone (In state): 1‐800‐866‐3513 Medicaid Phone (Out of state): 1‐800‐221‐3943

ALASKA – Medicaid

Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1‐888‐318‐8890 Phone (Anchorage): 907‐269‐6529

ARIZONA – CHIP FLORIDA – Medicaid

Website: http://www.azahcccs.gov/applicants Phone (Outside of Maricopa County): 1‐877‐764‐5437 Phone (Maricopa County): 602‐417‐5437

Website: https://www.flmedicaidtplrecovery.com/ Phone: 1‐877‐357‐3268

GEORGIA – Medicaid

Website: http://dch.georgia.gov/ Click on Programs, then Medicaid, then Health Insur‐ance Premium Payment (HIPP) Phone: 1‐800‐869‐1150

IDAHO – Medicaid and CHIP MONTANA – Medicaid

Medicaid Website: www.accesstohealthinsurance.idaho.gov Medicaid Phone: 1‐800‐926‐2588 CHIP Website: www.medicaid.idaho.gov CHIP Phone: 1‐800‐926‐2588

Website: http://medicaidprovider.hhs.mt.gov/clientpages/clientindex.shtml Phone: 1‐800‐694‐3084

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INDIANA – Medicaid NEBRASKA – Medicaid

Website: http://www.in.gov/fssa Phone: 1‐800‐889‐9949

Website: www.ACCESSNebraska.ne.gov Phone: 1‐800‐383‐4278

IOWA – Medicaid NEVADA – Medicaid

Website: www.dhs.state.ia.us/hipp/ Phone: 1‐888‐346‐9562

Medicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1‐800‐992‐0900 KANSAS – Medicaid

Website: http://www.kdheks.gov/hcf/ Phone: 1‐800‐792‐4884

KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid

Website: http://chfs.ky.gov/dms/default.htm Phone: 1‐800‐635‐2570

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603‐271‐5218

LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP

Website: http://www.lahipp.dhh.louisiana.gov Phone: 1‐888‐695‐2447

Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/ Medicaid Phone: 609‐631‐2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1‐800‐701‐0710

MAINE – Medicaid

Website: http://www.maine.gov/dhhs/ofi/public‐assistance/index.html Phone: 1‐800‐977‐6740 TTY 1‐800‐977‐6741

MASSACHUSETTS – Medicaid and CHIP NEW YORK – Medicaid

Website: http://www.mass.gov/MassHealth Phone: 1‐800‐462‐1120

Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1‐800‐541‐2831

MINNESOTA – Medicaid NORTH CAROLINA – Medicaid

Website: http://www.dhs.state.mn.us/ Click on Health Care, then Medical Assistance Phone: 1‐800‐657‐3629

Website: http://www.ncdhhs.gov/dma Phone: 919‐855‐4100

MISSOURI – Medicaid NORTH DAKOTA – Medicaid

Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573‐751‐2005

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1‐800‐755‐2604

OKLAHOMA – Medicaid and CHIP UTAH – Medicaid and CHIP

Website: http://www.insureoklahoma.org Phone: 1‐888‐365‐3742

Website: http://health.utah.gov/upp Phone: 1‐866‐435‐7414

OREGON – Medicaid and CHIP VERMONT– Medicaid

Website: http://www.oregonhealthykids.gov http://www.hijossaludablesoregon.gov Phone: 1‐800‐699‐9075

Website: http://www.greenmountaincare.org/ Phone: 1‐800‐250‐8427

PENNSYLVANIA – Medicaid VIRGINIA – Medicaid and CHIP

Website: http://www.dpw.state.pa.us/hipp Phone: 1‐800‐692‐7462

Medicaid Website: http://www.dmas.virginia.gov/rcp‐HIPP.htm Medicaid Phone: 1‐800‐432‐5924 CHIP Website: http://www.famis.org/ CHIP Phone: 1‐866‐873‐2647

RHODE ISLAND – Medicaid WASHINGTON – Medicaid

Website: www.ohhs.ri.gov Phone: 401‐462‐5300

Website: http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm Phone: 1‐800‐562‐3022 ext. 15473

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SOUTH CAROLINA – Medicaid WEST VIRGINIA – Medicaid

Website: http://www.scdhhs.gov Phone: 1‐888‐549‐0820

Website: www.dhhr.wv.gov/bms/ Phone: 1‐877‐598‐5820, HMS Third Party Liability

SOUTH DAKOTA ‐ Medicaid WISCONSIN – Medicaid

Website: http://dss.sd.gov Phone: 1‐888‐828‐0059

Website: http://www.badgercareplus.org/pubs/p‐10095.htm Phone: 1‐800‐362‐3002

TEXAS – Medicaid WYOMING – Medicaid

Website: https://www.gethipptexas.com/ Phone: 1‐800‐440‐0493

Website: http://health.wyo.gov/healthcarefin/equalitycare Phone: 307‐777‐7531

To see if any more States have added a premium assistance program since January 31, 2014, or for more information on special enrollment rights, you can 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/ebsa www.cms.hhs.gov 1‐866‐444‐EBSA (3272) 1‐877‐267‐2323, Menu Option 4, Ext. 61565 OMB Control Number 1210‐0137 (expires 10/31/2016) Date of Notice: July 1, 2014

The information in this Benefits Summary is presented for illustrative purposes and is based on information provided by the employer. The text contained in this Summary was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of discrepancy between the Benefits Summary and the actual plan documents, the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any questions about this summary, contact Human Resources.

27

New Health Insurance Marketplace Coverage Options and Your Health Coverage

PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health

Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic

information about the new Marketplace and employmentbased health coverage offered by your employer.

What is the Health Insurance Marketplace?

The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The

Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible

for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance

coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.

Can I Save Money on my Health Insurance Premiums in the Marketplace?

You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or

offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on

your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?

Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible

for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be

eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does

not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your

employer that would cover you (and not any other members of your family) is more than 9.5% of your household

income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the

Affordable Care Act, you may be eligible for a tax credit.1

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your

employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer

contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for

Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-

tax basis.

How Can I Get More Information?

For more information about your coverage offered by your employer, please check your summary plan description or

contact .

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the

Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health

insurance coverage and contact information for a Health Insurance Marketplace in your area.

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered

by the plan is no less than 60 percent of such costs.

Form Approved OMB No.

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PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an

application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered

to correspond to the Marketplace application.

3. Employer name

4. Employer Identification Number (EIN) 5. Employer address 6. Employer phone number 7. City 8. State 9. ZIP code 10. Who can we contact about employee health coverage at this job? 11. Phone number (if different from above) 12. Email address

Here is some basic information about health coverage offered by this employer:

• As your employer, we offer a health plan to:

All employees.

Some employees. Eligible employees are:

• With respect to dependents:

We do offer coverage. Eligible dependents are:

We do not offer coverage.

If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to

be affordable, based on employee wages.

** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium

discount through the Marketplace. The Marketplace will use your household income, along with other factors,

to determine whether you may be eligible for a premium discount. If, for example, your wages vary from

week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly

employed mid-year, or if you have other income losses, you may still qualify for a premium discount.

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the

employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your

monthly premiums.

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