Welcome [hr.ua.edu] · Medical coverage offers valuable benefits to help you stay healthy and pay for care if you or your covered family members become sick or injured. UA offers

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Welcome Welcome to The University of Alabama – an institution rich in tradition! This guide provides pertinent information about the benefits offered to new employees. You may obtain additional information from the HR web site at http://hr.ua.edu/benefits. New Employee Enrollment New employees must enroll in benefits within 30 days of their date of hire. It is important that you review this material so you can enroll in benefits for which you are eligible and that meet your needs. The choices you make will be in effect for the remainder of the calendar year unless you experience a qualifying life event or family status change. Directions 1. To determine which benefits you are eligible to receive, review the Benefits Eligibility Matrix, locate your employment

status in the Employment Status Category Key at the bottom of the page.

2. If you are eligible for: • Medical, Dental, and Vision coverage and Flexible Spending Accounts or Health Savings Account and wish to

enroll, visit our online enrollment portal BenefitFocus and follow the instructions to enroll or make changes to your benefits. Enrollment must be completed within 30 days of your date of hire.

• University Paid Group Term and AD&D, elect your beneficiaries using our online enrollment portal, BenefitFocus. • Teachers’ Retirement System (TRS) 401(a) Plan, you may access common TRS forms to update your address,

designate beneficiaries and transfer or purchase service credit online at https://www.rsa-al.gov/trs/forms/. • The University of Alabama System 403(b) and/or 457(b) Retirement Plan(s) and wish to enroll, login to MyBama

and select the TIAA logo under ‘Voluntary Retirement Savings Plans’ in the Employee tab. BAMAbot Virtual Assistant BAMAbot is a virtual assistant to answer any questions about Human Resources on the HR website at http://hr.ua.edu. Simply click the BAMAbot icon in the lower right-hand corner and ask a question. Qualifying Life or Family Status Change If you experience a qualifying life event during the year, you have 30 days to make any benefit changes through BenefitFocus (instructions are located below). There are two types of qualifying events: 1. Family Status Changes: marriage, divorce, childbirth, adoption of a child, death of a spouse/dependent, or a dependent

child reaching the age limit

2. Employment Status Changes: the full-time equivalency (FTE) of your appointment with the university changes; your appointment type changes; or your spouse’s employment changes and affects benefit coverage

This Benefits Summary guide is an overview and does not take the place of plan documents. If there is a conflict between this guide and The University of Alabama’s plan documents, the plan documents will govern.

http://hr.ua.edu/benefits

https://www.rsa-al.gov/trs/forms/

http://hr.ua.edu/

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Table of Contents Benefits At A Glance Matrix ..................................................................................................................................................... 3 Benefits Eligibility Matrix .......................................................................................................................................................... 4 Benefit Programs Summary ..................................................................................................................................................... 5 Medical Plan – BlueCard® PPO ............................................................................................................................................. 8 Medical Plan – BlueCard® PPO HSA Qualified HDHP ......................................................................................................... 16 Prescription Drug Plan ........................................................................................................................................................... 23 Home Delivery Prescription Drug Service .............................................................................................................................. 26 Dental Plan ............................................................................................................................................................................ 27 Vision Plan ............................................................................................................................................................................. 28 Flexible Spending Accounts (FSA) ........................................................................................................................................ 30 FSA Eligible Healthcare Expenses ........................................................................................................................................ 31 FSA Worksheet...................................................................................................................................................................... 32 Health Savings Accounts (HSA) ............................................................................................................................................ 33 University-Paid Group Term Life and AD&D .......................................................................................................................... 34 University-Paid Long Term Disability ..................................................................................................................................... 35 Voluntary Short Term Disability ............................................................................................................................................. 36 Voluntary Group Term Life and AD&D ................................................................................................................................... 37 LifeLock Identity Theft Protection ........................................................................................................................................... 38 Retirement Plans ................................................................................................................................................................... 39 Educational Benefit Program ................................................................................................................................................. 40 WellBama .............................................................................................................................................................................. 41 Employee Assistance Plan (EAP) .......................................................................................................................................... 42 Current Rates ........................................................................................................................................................................ 43 BenefitFocus: How To Enroll in Benefits ................................................................................................................................ 44 BenefitFocus: How to Make Changes to Your Benefits ......................................................................................................... 45 Continuation of Coverage Notice ........................................................................................................................................... 46

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Benefits At A Glance Matrix

Benefit Who Pays When Eligible** What to Know

Medical Plan UA & Employee

PPO – Immediately HDHP – 1st day of month

following hire date Administered by Blue Cross Blue Shield

Pharmacy Benefits UA & Employee

PPO – Immediately HDHP – 1st day of month

following hire date Administered by Prime Therapeutics

Dental Plan Employee 1st day of month following hire date Administered by Blue Cross Blue Shield

Vision Plan Employee 1st day of month following hire date Administered by UnitedHealthcare

Flexible Spending Accounts Employee Immediately Tax savings on medical and dependent care

Health Savings Accounts Employee 1st day of month following

hire date (if enrolled in HDHP)

Tax savings on HDHP expenses

University Paid LTD Insurance UA Immediately Payments after 90 days of disability

University Paid Group Term Life Insurance UA Immediately Coverage varies with salary

University Paid AD&D Insurance UA Immediately $22,500 coverage

Voluntary Group Term Life Insurance Employee Immediately Additional group term life insurance

Voluntary AD&D Insurance Employee Immediately Additional AD&D insurance

Voluntary Short Term Disability Employee Immediately Payments up to 90 days of disability, after 14- or 29-day waiting period

Identity Theft Protection Employee Immediately Administered by NortonLifeLock

Teachers’ Retirement System 401(a) Plan UA & Employee Immediately * Mandatory employee contribution

University of Alabama System 403(b) Plan UA &/or Employee Immediately Tax exempt savings plan

University of Alabama System 457(b) Plan Employee Immediately Deferral of income & taxes to later date

Educational Benefit Program UA Immediately for employee & 6 months for dependent Employee & dependent tuition benefits

WellBama UA Immediately UA Office of Health Promotion & Wellness

Employee Assistance Program UA Immediately Confidential counseling & referral services

Annual Leave (vacation) UA Immediately Generous paid vacation

Sick Leave UA Immediately Equates to 1 day earned per mo. (PT leave prorated)

Holiday & Administrative Leave UA Immediately Generous leave benefits

* TRS is not mandatory for Temporary Full-Time & Temporary Part-Time Faculty in year 1 but are eligible if FTE > .50. TRS is mandatory beginning 13th month. ** Most benefits require active enrollment by employee – some require enrollment within 30 days of start date or eligibility date.

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Benefits Eligibility Matrix (Employees must have at least a .5 FTE to be eligible for the benefits indicated in the below matrix)

Benefits # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Medical Plan

Dental Plan

Vision Plan

Flexible Spending Accounts

University Paid LTD Insurance; Voluntary STD

University Paid Group Term Life Insurance

University Paid AD&D Insurance

Voluntary Group Term Life Insurance

Voluntary AD&D Insurance

Identity Theft Protection Insurance

Teachers’ Retirement System - 401(a) Plan 1 1 1 1 1 1 1

The University of Alabama - 403(b) Plan 2 2 2 2 2 2 2 2 2 2

The University of Alabama - 457(b) Plan

Educational Benefit Program

WellBama

Employee Assistance Program

Annual & Sick Leave

Holiday & Administrative Leave

# Faculty and Staff Definition Employee Class Codes

1 Staff regular full-time A1, B1, G1, GG, H1, HG, P1, P2, Q1, Q2, T1, T2, U1, U2, V1

2 Staff regular part-time A3, B3, G3, H3, P3, P4, Q3, Q4, T3, T4, U3, U4

3 Staff temporary full-time, temporary part-time, contingent on call A2, A4, B2, B4, B5, G2, G4, H2, H4

4 Resident physicians R1

5 Post-Doctoral fellows L1, L3

6 Faculty regular full-time 9/12 – tenure/tenure track only (includes Asst/Assoc Deans, Dept Heads, admin. appointments) I1

7 Faculty renewable full-time 9/12 – non tenure/non tenure track I2

8 Faculty regular part-time & renewable part-time 9/12 – tenure/tenure track & not TT (includes all tenure status types & clinical, multi-year, contract & renewable appointments) I3

9 Faculty temporary part-time 9/9 – non tenure/non tenure track (temporary academic appointments, 1 or 2 semester appointments only, not renewable) I4

10 Faculty temporary full-time 9/9 – non tenure/non tenure track (temporary appointments, one academic semester/year only, not hired as renewable, e.g., full-time visiting faculty & full-time temp academic appt.) I8

11 Faculty renewable full-time 9/9 – non tenure/non tenure track (multi-year, contract, clinical & renewable appointees who choose to be paid 9 over 9 rather than 9 over 12) I9

12 Faculty regular full-time 9/9 – tenure/tenure track only (includes Asst/Assoc Deans, Dept Heads, & administrative appointments, for faculty who choose to be paid 9 over 9 rather than 9 over 12.) IR

13 Faculty regular full-time 12/12 – tenure/ tenure track only (includes Dept Heads & other administrative appointments) J1

14 Faculty renewable full-time 12/12 – non tenure/non tenure track (multi-year, contract, clinical & renewable appointments) J2

15 Faculty regular part-time & renewable part-time 12/12 – tenure/tenure track & not TT (includes all tenure status types & clinical, multi-year, contract & renewable appointments) J3

16 Faculty temporary part-time 12/12 – non tenure/non tenure track (appointments are 1 yr or less & are not renewable) J4

17 Faculty temporary full-time 12/12 – non tenure/non tenure track (appointments are 1 year or less & are not renewable) J8

18 Deans, Asst/Assoc Deans, Asst/Assoc Provost 12/12 – tenure/tenure track & clinical (includes clinical executive appointments) JD

19 Deans, Asst/Assoc Deans, Asst/Assoc Provost 9/12 – tenure/tenure track & clinical (includes clinical executive appointments) ID

(1) Participation is mandatory for appointments of one academic year or longer. Employees who are current members in TRS will be required to contribute regardless of length of appointment or FTE.

(2) Non-exempt (bi-weekly paid), Post-Doc Fellow I, Temporary, and/or part-time employees may participate but are not eligible for the match. Post-Doc Fellow II are match eligible and must contribute to TRS.

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Benefit Programs Summary This quick reference guide provides a summary of the core benefits available to eligible employees. Questions about benefits, payroll or employment should be directed to the HR Service Center:

HR Service Center 1670 Ruby Tyler Parkway HR Administration Building, Suite 1001

Phone: 205-348-7732 Fax: 205-348-8755

Health Plans Rates for health plans are detailed in the Rates section in the back of this packet. Medical Plans Vendor: Blue Cross Blue Shield of Alabama Website: https://www.bcbsal.org/ Phone: 800-292-8868 Medical coverage offers valuable benefits to help you stay healthy and pay for care if you or your covered family members become sick or injured. UA offers a choice of medical plans with a range of coverage levels and costs, so you have the flexibility to select the option that’s best for you. In choosing your coverage options, you can choose to cover just yourself or cover yourself and your eligible dependents. Choose from two options from Blue Cross Blue Shield of Alabama: Preferred Provider Organization (PPO) Plan or the High Deductible Health Plan (HDHP) with Health Savings Account (HSA). PPO Plan – The PPO plan has higher monthly premiums in exchange for lower annual deductibles. You have the flexibility to choose any provider you want, although you’ll save money by seeing in-network providers. Coverage can be effective on your date of hire OR the first day of the month following the date of hire. This plan is compatible with the Healthcare Flexible Spending Account (FSA). HDHP Plan with HSA - The HDHP with HSA is designed to put you in charge of your spending through lower premiums, higher deductible, and an employer allocation to help fund your HSA. You have the flexibility to choose any provider you want, although you’ll save money by seeing in-network providers. Funds remaining in your HSA at the end of the year will roll over to the following year. Coverage is effective the first day of the month following the date of hire. This plan is compatible with the Health Savings Account (HSA). Pharmacy Benefits Vendor: Prime Therapeutics Website: https://www.primetherapeutics.com/ Phone: 800-292-8868 The University provides prescription drug coverage administered by Prime Therapeutics. Prime Therapeutics is an independent company that provides pharmacy benefit management services to Blue Cross. Prescription Drug Coverage is automatically provided to employees enrolled in either medical plan and the cost is included in the medical plan premium.

Dental Plan Vendor: Blue Cross Blue Shield of Alabama Website: https://www.bcbsal.org/ Phone: 800-292-8868 A comprehensive dental plan is offered through Blue Cross. The plan allows participants the freedom to seek care from any dentist, but participants could incur significantly higher out-of-pocket expenses when out-of-network dentists are used. UA retirees enrolled in dental coverage as of the date of retirement are eligible to continue dental coverage with direct billing from Blue Cross and Blue Shield. Vision Plan Vendor: UnitedHealthcare Vision Website: www.myuhcvision.com Phone: 800-638-3120 The vision plan is offered by UnitedHealthcare Vision, which has a provider network consisting of more than 30,000 private practice and retail chains nationwide. Eligible employees can receive a comprehensive eye exam and a pair of lenses once every 12 months and frames once every 24 months. UA retirees enrolled in vision coverage as of the date of retirement are eligible to continue coverage with direct billing from UnitedHealthcare (plus $3/mo. service fee). Flexible Spending Accounts Vendor: TASC Website: www.tasconline.com Phone: 800-422-4661 Eligible employees can take advantage of flexible spending accounts which are administered by TASC. Participants can set aside pretax money via payroll deductions to pay for qualified healthcare and dependent care expenses not covered by benefit plans. Money set aside in these accounts will reduce taxable income, providing participants with more value for the dollar. Health Savings Account Vendor: TASC Website: https://partners.tasconline.com/TASC1PPT Phone: 877-933-3539 If you enroll in the High Deductible Health Plan (HDHP), you will receive an employer contribution to help cover the costs of your health care. UA contributes $400 Individual or $800 Family to your HSA account that can be used to pay for your eligible health care expenses like deductible, coinsurance, prescription drugs, dental and vision expenses and hearing aids. This money is not taxed.

https://www.bcbsal.org/

https://www.primetherapeutics.com/

https://www.bcbsal.org/

http://www.myuhcvision.com/

http://www.tasconline.com/

https://partners.tasconline.com/TASC1PPT

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Disability and Life Insurance Plans University-Paid Long Term Disability Insurance Vendor: The Standard Website: https://www.standard.com/ Phone: 800-368-1135 The University provides at no cost to eligible employees long term disability insurance through The Standard. The policy provides for salary continuation at 66 2/3% of current salary, not to exceed $10,000 per month, and begins on the 91st day of "total disability." After 90 days of benefit payments, the plan changes from 66 2/3% to 60% of current salary and continues at that rate for the duration of the claim. Additional information is available online in the group brochure. University-Paid Group Term Life Insurance Vendor: The Standard Website: https://www.standard.com/ Phone: 855-757-4714 The University provides at no cost to eligible employees a group term life insurance plan from The Standard. Coverage varies as follows:

Annual Base Salary Coverage Amounts Up to $23,999 $30,000 $24,000 to $29,999 $37,500 $30,000 to $39,999 $50,000

> $40,000 125% salary ($300,000 max. benefit)

University-Paid Accidental Death & Dismemberment Plan Vendor: The Standard Website: https://www.standard.com/ Phone: 855-757-4714 The University provides at no cost to eligible employees an Accidental Death & Dismemberment (AD&D) policy from The Standard in the amount of $22,500 payable if death was caused by an accident. For example, the employee’s beneficiary would receive both the University-Paid Group Term Life and AD&D benefit if he/she dies in an accident. AD&D also pays a benefit if a serious injury results in dismemberment. For example, part of the benefit may be paid if the employee loses a limb or the ability to see. AD&D coverage also includes Travel Assistance Services. This service offers participants and dependents with medical, travel, legal and financial assistance services when faced with an emergency while traveling more than 100 miles away from home.

Voluntary Group Term Life Insurance Vendor: The Standard Website: https://www.standard.com/ Phone: 855-757-4714 Eligible employees have the option of purchasing additional term life insurance of up to five times the eligible employee’s salary rounded up to the nearest $10,000 with a maximum of $1.4 million. The policy is guaranteed to be issued for employees electing the lesser of three times their salary or $500,000 if the application is approved during the first 60 days of employment. Additional information is available online in the group brochure. Voluntary Accidental Death & Dismemberment Plan Vendor: The Standard Website: https://www.standard.com/ Phone: 855-757-4714 Eligible employees have the option of purchasing additional Accidental Death & Dismemberment (AD&D) coverage with a minimum coverage of $25,000. The amount selected is the lesser of ten times the base annual earnings or $500,000. New employees must enroll in the plan during their first 60 days of employment. Additional information is available online in the group brochure. Voluntary Short Term Disability Insurance Vendor: The Standard Website: https://www.standard.com/ Phone: 855-757-4714 Eligible employees have the option of purchasing additional Short Term Disability (STD) insurance that pays 60% of the eligible employee’s salary up to a maximum weekly benefit of $1,000. Premiums vary by plan option (elimination/waiting period of 14 days or 29 days) and the employee’s age. The policy is guaranteed to be issued for all employees if the application is approved during the first 60 days of employment. If approved after the first 60 days, employees will be subject to a late enrollment penalty with a 60-day extended benefit waiting period for the first 12 months. Additional information is available online in the group brochure. Identity Theft Protection Plan Identity Theft Protection Insurance Vendor: LifeLock with Norton Benefit Premier Website: https://www.lifelock.com/ Phone: 800-607-9174 Eligible employees have the option to purchase identity theft protection from LifeLock with Norton Benefit Premier beginning Jan. 1, 2021. LifeLock combines comprehensive identity theft protection with device security and protection against online privacy threats with SafeCam. Enhanced features include Home Title Monitoring, Bank Account Takeover Alerts and Three Bureau Credit Monitoring. Additional information is available online.

https://www.standard.com/

https://hr-estus.fa.ua.edu/HRFormsOnlinePub/HR%20Forms%20%20Online/LongTermDisability.pdf




https://www.standard.com/eforms/10391d_643197.pdf

https://www.standard.com/eforms/10391d_643197.pdf


https://www.standard.com/eforms/15199_643197nh.pdf


https://www.standard.com/eforms/20359_643197tuscaloosa.pdf

https://www.standard.com/eforms/20359_643197tuscaloosa.pdf

https://www.lifelock.com/

https://hr.ua.edu/benefits/lifelock

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Retirement Plans Teachers’ Retirement System 401(a) Organization: Teachers' Retirement System (TRS) Website: www.rsa-al.gov Phone: 877-517-0020 All eligible employees are required by state law to contribute a percentage of their gross annual salary to TRS.

Tier 1 Employee Tier 2 Employee

Hire Date Prior to 1-1-2013 On or after 1-1-2013

Contribution 7.5% regular employee 8.5% police

6.0% regular employee

7.0% police

Retirement Eligibility

25 yrs of svc at any age 10 yrs of svc at age 60

10 yrs of svc at age 62 (age 56 for police)

Sick Leave Can convert maximum of 12 days per yr of svc Not available

Benefit Cap None Cannot exceed 80% of average final salary

This defined benefit program provides retired employees with a specific benefit payable monthly for the lifetime of the member. Upon service retirement, employees are also eligible to join the state’s Public Education Employee Health Insurance Plan (PEEHIP). Rates for this plan vary based on years of TRS service and age at retirement. Individuals resigning from employment before vesting in the program, or before qualifying to receive benefits, may request a refund of their contributions and applicable interest. University of Alabama System 403(b) Plan Vendor: TIAA Website: www.tiaa.org Phone: 800-842-2252 TIAA is the vendor through which eligible employees can participate in the University of Alabama System 403(b) plan. The plan allows participants to invest in mutual funds. Contributions are normally made on a pre-tax basis, but Roth post-tax contributions are also available. The University makes a matching contribution of up to 5% of gross monthly pay for all regular full-time faculty and exempt staff contributions to the 403(b) plan. Any contributions above 5% are not matched.

University of Alabama System 457(b) Plans Organization: Retirement System of Alabama (RSA-1) Website: www.rsa-al.gov Phone: 877-517-0020 Vendor: TIAA Website: www.tiaa.org Phone: 800-842-2252 457(b) plans allow eligible employees to defer receipt of a portion of their salary until some later date, usually at retirement or termination of employment. Contributions are normally made on a pre-tax basis, but Roth post-tax contributions are also available. Contributions to 457(b) plans may be made instead of, or in addition to, any 403(b) contributions. Eligible employees may participate in both 403(b) and 457(b) plans in the same year, contributing up to the maximum amount allowed by federal law to each plan. Miscellaneous Plans Educational Benefit Program Employees may be eligible for tuition assistance as of their hire date, subject to certain application deadlines per semester. Spouses and dependent children may be eligible for tuition assistance after the employee has completed 6 months of continuous eligible employment. WellBama Organization: The University of Alabama - Office of Health Promotion and Wellness Website: wellness.ua.edu Phone: 205-348-0077 WellBama is the University’s signature wellness program for faculty and staff. Designed to promote health and improve the quality of life for eligible employees. This free, personalized program includes confidential health screening, health coaching, and a preventive examination, along with a wide range of resources and programs to motivate and support individual health goals. Employee Assistance Program (EAP) Vendor: American Behavioral Website: www.americanbehavioral.com Phone: 800-925-5327 American Behavioral offers eligible employees up to five free confidential face-to-face counseling sessions per episode for issues such as marital and family issues, emotional problems; substance abuse; financial and job-related concerns. Additionally, eligible employees can schedule unlimited telephonic sessions for non-clinical work/life issues such as grief, change, relationship issues and stress.

http://www.rsa-al.gov/

http://www.tiaa.org/

http://www.rsa-al.gov/

http://www.tiaa-cref.org/

http://www.wellness.ua.edu/

http://www.americanbehavioral.com/

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Medical Plan – BlueCard® PPO (Effective 1-1-2021)

BENEFIT IN-NETWORK OUT-OF-NETWORK

Benefit payments are based on the amount of the provider’s charge that Blue Cross and/or Blue Shield plans recognize for payment of benefits. The allowed amount may vary depending upon the type provider and where services are received.

SUMMARY OF COST SHARING PROVISIONS (Includes Mental Health Disorders and Substance Abuse)

Calendar Year Deductible (medical and pharmacy combined)

$400 per individual per calendar year

Calendar Year Out-of-Pocket Maximums All deductibles, copays and coinsurance for covered in-network services apply to the out-of-pocket maximum, including prescription drugs. After you reach your Calendar Year Out-of-Pocket Maximum, all applicable covered expenses for you will be covered at 100% of the allowance for the remainder of the year.

$5,000 individual coverage; $14,300 family coverage

There is no out-of-pocket maximum for out-of-network services.

INPATIENT HOSPITAL AND PHYSICIAN BENEFITS (Includes Mental Health Disorders and Substance Abuse)

Precertification is required for inpatient admissions (except medical emergency services and maternity); notification within 48 hours for medical emergencies. Generally, if precertification is not obtained, no benefits are available. Call 1-800-248-2342 (toll-free) for

precertification. Inpatient Hospital and Residential Treatment Facilities

Covered at 100% of the allowed amount for semi-private room and board, intensive care units, general nursing services and usual hospital ancillaries, subject to $400 per admission copay and subject to calendar year deductible; 365 days per confinement.

In Alabama, available only for medical emergency services or accidental injury. Covered at 80% of the allowed amount for semi-private room and board, intensive care units, general nursing services and usual hospital ancillaries, subject to $400 per admission copay and subject to calendar year deductible; 365 days per confinement.

Inpatient Physician Visits and Consultations

Covered at 100% of the allowed amount, subject to calendar year deductible

In Alabama, covered at 50% of the allowed amount, subject to calendar year deductible Outside Alabama, covered at 80% of the allowed amount, subject to calendar year deductible

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OUTPATIENT HOSPITAL BENEFITS (Includes Mental Health Disorders and Substance Abuse)

Precertification is required for some outpatient hospital benefits and provider-administered drugs; visit AlabamaBlue.com/ProviderAdministeredPrecertificationDrugList. Please see your benefit booklet or call 1-800-248-2342.

If precertification is not obtained, no benefits are available. Outpatient Surgery (Including Ambulatory Surgical Centers)

Covered at 100% of the allowed amount, subject to $150 hospital copay and subject to calendar year deductible


Emergency Room (Medical Emergency) Covered at 100% of the allowed amount, subject to $150 hospital copay and subject to calendar year deductible

Covered at 100% of the allowed amount, subject to $150 hospital copay and subject to calendar year deductible Mental Health Disorders and Substance Abuse Services apply to the in-network out-of-pocket maximum

Emergency Room (Non-Medical Emergency)



Emergency Room (Accident) Covered at 100% of the allowed amount, subject to $150 hospital copay and subject to calendar year deductible


Emergency Room (Physician) Covered at 100% of the allowed amount, subject to $50 physician copay and subject to calendar year deductible

Covered at 100% of the allowed amount, subject to $50 physician copay and subject to calendar year deductible Mental Health Disorders and Substance Abuse Services apply to the in-network out-of-pocket maximum

Chemotherapy, Hemodialysis, IV Therapy & Radiation Therapy



Diagnostic Lab & X-ray

Covered at 100% of the allowed amount, subject to calendar year deductible MRI(s), CAT, PET & Thallium Scans, Cardiac Scans, heart catheterizations, colonoscopy and endoscopy covered at the specified allowed amount, subject to $125 copay and calendar year deductible. Note: If there is more than one procedure done on the same date of service there will be only one copayment taken for the facility and only one copayment taken for the physician.


Intensive Outpatient Services and Partial Hospitalization for Mental Health Disorders and Substance Abuse Services

Covered at 100% of the allowed amount, subject to $50 daily hospital copay and subject to calendar year deductible


http://www.alabamablue.com/ProviderAdministeredPrecertificationDrugList

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PHYSICIAN BENEFITS (Includes Mental Health Disorders and Substance Abuse)

Precertification is required for some physician benefits and provider-administered drugs; please see your benefit booklet or call 1-800-248-2342 (toll-free) for precertification. If precertification is not obtained, no benefits are available.

Office Visits and Outpatient Consultations Rendered by a Primary Care Physician (Includes: Internist, Family & General Practitioner, Pediatrician, OB/GYN & Geriatrician, Psychiatrist, Psychologist, Master’s Level Licensed Counselor, Licensed Clinical Social Workers and Licensed Professional Counselor)

Covered at 100% of the allowed amount, subject to $35 physician copay and subject to calendar year deductible

In Alabama, covered at 50% of the allowed amount, subject to calendar year deductible Outside Alabama, covered at 80% of the allowed amount, subject to calendar year deductible Mental Health and Substance Abuse services: In Alabama: Covered at 70% of the allowance, subject to the calendar year deductible. Outside Alabama: Covered at 80% of the allowance, subject to the calendar year deductible.

Office Visits and Outpatient Consultations Rendered by a Specialist



Nurse Practitioner/Nurse Midwife/Clinical Nurse Specialist/Mental Health Nurse Practitioner/Mental Health Clinical Nurse Specialist and Physician Assistant's Office Visits and Consultations

Covered at 100% of the allowed amount, subject to $20 physician copay and subject to calendar year deductible Services must be rendered under the supervision of a doctor.


Teledoc - Telephone and Online Video Consultation Program A service available to diagnose, treat and prescribe medication (when necessary) for certain medical issues. To enroll, go to Teledoc.com/Alabama or call 1-855-477-4549.

Covered at 100% of the allowed amount subject to a $20 physician copay per consultation and subject to calendar year deductible

Not covered

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Surgery & Anesthesia Covered at 100% of the allowed amount, subject to calendar year deductible


Surgery Performed in a Physician's Office

Covered at 100% of the allowed amount, subject to $35 office visit copay and subject to calendar year deductible if performed by a Primary Care Physician Covered at 100% of the allowed amount subject to $50 office visit copay and subject to calendar year deductible if performed by a Specialist


Maternity Care Covered at 100% of the allowed amount, subject to calendar year deductible

In Alabama, covered at 50% of the allowed amount, subject to calendar year deductible Outside Alabama covered at 80% of the allowed amount, subject to calendar year deductible

Hemodialysis, Chemotherapy, Radiation Therapy, & IV Therapy



Diagnostic Lab & X-ray

Covered at 100% of the allowed amount, subject to calendar year deductible MRI(s), CAT, PET & Thallium Scans, Cardiac Scans, heart catheterizations, colonoscopy and endoscopy are covered at the specified allowed amount, subject to a $35 copay and calendar year medical deductible Note: If there is more than one procedure done on the same date of service there will be only one copayment taken for the facility and only one copayment taken for the physician.

In Alabama, covered at 50% of the allowed amount, subject to calendar year deductible. Outside Alabama, covered at 80% of the allowed amount, subject to calendar year deductible. Mental Health and Substance Abuse services: In Alabama: Covered at 70% of the allowance, subject to the calendar year deductible. Outside Alabama: Covered at 80% of the allowance, subject to the calendar year deductible.

Applied Behavioral Analysis (ABA) Therapy Limited to ages 0-18 for autism spectrum disorder. Ages 0-9 limited to an annual maximum of $20,000 per child, ages 10-13 limited to an annual maximum of $15,000 per child, and ages 14-18 limited to an annual maximum of $10,000 per child. Note: Home based therapy is excluded.



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PREVENTIVE CARE BENEFITS (Includes Mental Health Disorders and Substance Abuse)

Routine Immunizations and Preventive Services

Covered at 100% of the allowed amount, no coinsurance or deductible See AlabamaBlue.com/PreventiveServices and AlabamaBlue.com/ NetResultsACAPreventiveDrugList for a listing of the specific drugs, immunizations and preventive services or call Blue Cross and Blue Shield Customer Service for a printed copy. Certain immunizations may also be obtained through the Pharmacy Vaccine Network. See AlabamaBlue.com/VaccineNetworkDrugList for more information

Not Covered

Note: In some cases, office visit copays or facility copays may apply. Blue Cross and Blue Shield of Alabama will process these claims as required by Section 1557 of the Affordable Care Act.

OTHER COVERED SERVICES BENEFITS (Includes Mental Health Disorders and Substance Abuse)

Precertification is required for some other covered services; please see your benefit booklet or call 1-800-248-2342 (toll-free) for precertification. If precertification is not obtained, no benefits are available.

Allergy Testing & Treatment Covered at 100% of the allowed amount, subject to calendar year deductible


Ambulance Service Covered at 80% of the allowed amount, subject to calendar year deductible


Chiropractic Services Limited to a maximum of 24 visits per person each calendar year

Covered at 80% of the allowed amount, subject to calendar year deductible when services are provided by a participating in- network chiropractor

In Alabama, covered at 50% of the allowed amount, subject to calendar year deductible when services are provided by a non-Participating Chiropractor Outside Alabama, covered at 80% of the allowed amount, subject to calendar year deductible

Durable Medical Equipment (DME) Covered at 80% of the allowed amount, subject to calendar year deductible


Rehabilitative Occupational, Physical and Speech Therapy Limited to a maximum of 30 visits per person per therapy each calendar year



Habilitative Occupational, Physical and Speech Therapy Limited to a maximum of 30 visits per person per therapy each calendar year



http://www.alabamablue.com/PreventiveServices

http://www.alabamablue.com/NetResultsACAPreventiveDrugList


http://www.alabamablue.com/VaccineNetworkDrugList

13

Nutritionist Visits

Limited to a maximum of eight visits per person each calendar year. Note: Employee is also responsible for any charges above the allowance.



Home Health and Hospice Covered at 100% of the allowed amount, subject to calendar year deductible

In Alabama, no benefits are available if a non-preferred provider is used. Outside Alabama, covered at 80% of the allowed amount, subject to calendar year deductible Note: Precertification is required for services rendered outside Alabama. Call 1-800-821-7231

Routine Vision Exam Covered at 80% of the allowed amount, subject to calendar year deductible for one routine eye exam per person per calendar year

Covered at 80% of the allowed amount, subject to calendar year deductible for one routine eye exam per person per calendar year

HEALTH MANAGEMENT BENEFITS

(Includes Mental Health Disorders and Substance Abuse)

Individual Case Management Coordinates care in event of catastrophic or lengthy illness or injury. For more information, please call 1-800-821-7231.

Disease Management

Coordinates care for members with chronic conditions such as heart failure, coronary artery disease, diabetes, chronic obstructive pulmonary disease, asthma, and other specialized conditions. This program offers personalized care designed to meet your lifestyle and health concerns. A staff of healthcare professionals will help you cope with your illness and serve as a source of information and education. Participation in the program is completely voluntary. If you would like to enroll in the program or obtain more information, call 1-888-841-5741 or e-mail [email protected].

Baby Yourself®

A maternity program that offers the opportunity to have a Blue Cross and Blue Shield registered nurse case manager to monitor a covered member’s pregnancy while enrolled in this medical plan. Note: The $400 inpatient hospital copayment per admission will be waived for Baby Yourself participants who enroll within the first trimester of pregnancy and continue participation until the baby is born. For more information, please call 1-800-222-4379 as soon as you find out you are pregnant. You can also enroll online at AlabamaBlue.com/BabyYourself.

Contraceptive Management

Covers prescription contraceptives, which include: birth control pills, injectables, diaphragms, IUDs and other non-experimental FDA approved contraceptives; subject to applicable deductibles, copays and coinsurance.

Quit for Life Tobacco Cessation Program

A tobacco cessation program for subscriber, spouse and dependents that provides support to participants through telephone-based counseling and nicotine replacement therapy. Call 1-888-768-7848 for participation information.

Air Medical Services

If a member is hospitalized while traveling more than 150 miles from home, air ambulance transportation is available to transport the member to an in-network hospital of their choice near the member’s home. Members call AirMed at 1-877-872-8624 (available 24 hours a day, 7 days a week) to arrange air transportation services.

http://www.alabamablue.com/BabyYourself

14

Useful Information to Maximize Benefits • To maximize your benefits, always use in-network providers for services covered by your health benefit plan. To find in-network providers, check a provider

directory, provider finder website (AlabamaBlue.com) or call 1-800-810-BLUE (2583). • In-network hospitals, physicians and other healthcare providers have a contract with a Blue Cross and/or Blue Shield Plan for furnishing healthcare services at a

reduced price (examples: BlueCard® PPO, PMD). In Alabama, in-network services provided by mental health disorders and substance abuse professionals are available through the Blue Choice Behavioral Health Network. In-network pharmacies are pharmacies that participate with Blue Cross and Blue Shield of Alabama or its Pharmacy Benefit Manager(s). Sometimes an in-network provider may furnish a service to you that is not covered under the contract between the provider and a Blue Cross and/or Blue Shield Plan. When this happens, benefits may be denied or reduced. Please refer to your benefit booklet for the type of provider network that we determine to be an in-network provider for a particular service or supply.

• Out-of-network providers generally do not contract with Blue Cross and/or Blue Shield Plans. If you use out-of-network providers, you may be responsible for filing your own claims and paying the difference between the provider’s charge and the allowed amount. The allowed amount may be based on the negotiated rate payable to in-network providers in the same area or the average charge for care in the area.

• Teladoc Health is an independent company that Blue Cross and Blue Shield of Alabama has contracted with to provide you with teleconsultation services. Blue Cross and Blue Shield of Alabama is an independent licensee of the Blue Cross and Blue Shield Association.

• Please be aware that providers/specialists may be listed in a PPO directory or provider finder website, but not covered under this benefit plan. Please check your benefit booklet for more detailed coverage information.

• Please refer to your benefit book or contact Blue Cross directly about coverage for your hospital charges and other related medical services. Approval for air medical services does not mean that hospitalization and other medical expenses will be covered. All coverage determinations for medical benefits are subject to the terms, conditions, limitations and exclusions of the health plan. Air medical transport services are provided through a contract with AirMed International, LLC, an independent company that does not provide Blue Cross and Blue Shield of Alabama products. Blue Cross is not responsible for any mistakes, errors or omissions that AirMed, its employees or staff members make. Air medical services terminate if coverage by your health plan ends.

• Prime Therapeutics LLC® is an independent company providing pharmacy benefit management services for Blue Cross and Blue Shield of Alabama, an independent licensee of the Blue Cross and Blue Shield Association.

• Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all employees. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact us at 1-800-222-4379 and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status.

This is not a contract, benefit booklet or Summary Plan Description. Benefits are subject to the terms, limitations and conditions of the

group contract (including your benefit booklet). Check your benefit booklet for more detailed coverage information. Please visit our website, AlabamaBlue.com.

http://www.bcbsal.com/

15

Notice of Nondiscrimination

Blue Cross and Blue Shield of Alabama complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Blue Cross and Blue Shield of Alabama:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language

interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as qualified interpreters and

information written in other languages

If you need these services, contact our 1557 Compliance Coordinator. If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance in person or by mail, fax, or email at: Blue Cross and Blue Shield of Alabama, Compliance Office, 450 Riverchase Parkway East, Birmingham, Alabama 35244, Attn: 1557 Compliance Coordinator, 1-855-216-3144, 711 (TTY), 1-205-220-2984 (fax), [email protected] (email). If you need help filing a grievance, our 1557 Compliance Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Foreign Language Assistance Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-216-3144 (TTY: 711) Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-855-216-3144 (TTY: 711)번으로 전화해 주십시오. Chinese: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-855-216-3144 (TTY: 711）。 Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-216-3144 (TTY: 711). :Arabic انتب اه :إذا كنت تتح دث الع ربية، توجد خ دما ت م ساع دة ف ي ما يت ع لق باللغة ، بدون تكل فة، م ت احة ل ك. اتصل بـ 1-855-216-3144 )ال هاتف ال نص ي: (.711German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-216-3144 (TTY: 711). French: ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-855-216-3144 (ATS: 711). French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-855-216-3144 (TTY: 711). Gujarati: ધ્યાન આપો: જો તમે �જરાતી બોલતા હોય, તો ભાષા સહાયતા સવ . 1-855-216- 3144 ઉપલબ્ધ છ◌ે. 1-855-216-3144 પર (TTY: 711). Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-216-3144 (TTY: 711). Hindi: ध◌्य◌ान द�: अगर आपक� भ◌ाष◌ा �ह◌ंद� ह◌ै, त◌ो आपक◌े �लए भ◌ाषा सह◌ायत◌ा सव◌ाएँ �न◌ः श◌ुल◌्क उपलब◌्ध ह�। 1-855-216-3144 (TTY: 711) पर क◌ॉल कर�। Laotian: : ໂປດຊາບ: ຖ◌້ າວ◌່ າ ທ◌່ ານເ◌ົວ◌້ າພາສາ ລາວ, ການ◌ໍບ◌ິລການຊ◌່ ວຍເຫ◌ື ອດ◌້ ານພາສາ, ໂດຍ◌ໍບເສ◌ັ ຽຄ◌່ າ, ແມ◌່ ນມ◌ີ ພ◌້ ອມໃຫ◌້ ທ◌່ ານ. ໂທຣ 1-855-216-3144 (TTY: 711). Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-855-216-3144 (телетайп: 711). Portuguese: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-855-216-3144 (TTY: 711). Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-855-216-3144 (TTY: 711). Turkish: DİKKAT: Eğer Türkçe konuşuyor iseniz, dil yardımı hizmetlerinden ücretsiz olarak yararlanabilirsiniz. 1-855-216-3144 (TTY: 711) irtibat numaralarını arayın. Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-216- 3144 (TTY: 711). Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-855-216-3144（TTY: 711）まで、お電話にて

ご連絡ください。

mailto:[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html

16

Medical Plan – BlueCard® PPO HSA Qualified HDHP

(Effective 1-1-2021)


Benefit payments are based on the amount of the provider’s charge that Blue Cross and/or Blue Shield plans recognize for payment of benefits. The allowed amount may vary depending upon the type provider and where services are received.

HEALTH SAVINGS ACCOUNT (HSA)

A Health Savings Account (HSA) is an account established with pre-taxed money in order to save for future medical expenses. In order to establish an HSA you must first be enrolled in an HSA-Qualified High Deductible Health Plan (HDHP). A HDHP is a health plan that satisfies certain government requirements for use in conjunction with an HSA. This plan is designed to meet those government requirements. Enrolling in a HDHP allows you the opportunity to make contributions to an HSA on a pre-tax basis. Maximum Contribution: The maximum contribution amount is indexed each year by the U.S. Treasury. The 2021 maximum contribution is $3,600 for single coverage and $7,200 for family coverage. If you have any questions about the benefits of an HSA, please consult your tax accountant.

SUMMARY OF COST SHARING PROVISIONS (Includes Mental Health Disorders and Substance Abuse)

Calendar Year Deductible $1,400 individual coverage; $2,800 family coverage

Calendar Year Out-of-Pocket Maximum All deductibles, copays and coinsurance for covered in-network services and out-of-network mental health disorders and substance abuse emergency services apply to the out-of-pocket maximum. After you reach your individual calendar year out-of-pocket maximum, all applicable covered expenses for you will be covered at 100% of the allowance for the remainder of the year.

$3,500 individual coverage; $7,000 family coverage

There is no out-of-pocket maximum for out-of-network services.

INPATIENT HOSPITAL AND PHYSICIAN BENEFITS (Includes Mental Health Disorders and Substance Abuse)

Precertification is required for inpatient admissions (except medical emergency services and maternity); notification within 48 hours for medical emergencies. Generally, if precertification is not obtained, no benefits are available. Call 1-800-248-2342 (toll-free) for

precertification. Inpatient Hospital and Residential Treatment Facilities

Covered at 80% of the allowed amount, subject to calendar year deductible; 365 days per confinement

In Alabama, available only for medical emergency services or accidental injury

Outside Alabama, covered at 60% of the allowed amount, subject to calendar year deductible; 365 days per confinement

Inpatient Physician Visits and Consultations


In Alabama, covered at 50% of the allowed amount, subject to calendar year deductible

Outside Alabama, covered at 60% of the allowed amount, subject to calendar year deductible

17


OUTPATIENT HOSPITAL BENEFITS (Includes Mental Health Disorders and Substance Abuse)

Precertification is required for some outpatient hospital benefits and provider-administered drugs; visit AlabamaBlue.com/ProviderAdministeredPrecertificationDrugList. Please see your benefit booklet or call 1-800-248-2342.

If precertification is not obtained, no benefits are available. Outpatient Surgery (Including Ambulatory Surgical Centers)



Emergency Room (Medical Emergency)



Mental Health Disorders and Substance Abuse Services apply to in-network out- of-pocket maximum

Emergency Room (Non-Medical Emergency)



Emergency Room (Accident) Covered at 80% of the allowed amount, subject to calendar year deductible


Emergency Room (Physician) Covered at 80% of the allowed amount, subject to calendar year deductible


Mental Health Disorders and Substance Abuse Services apply to the in-network out-of-pocket maximum

Chemotherapy, Hemodialysis, IV Therapy & Radiation Therapy



Intensive Outpatient Services and Partial Hospitalization for Mental Health Disorders and Substance Abuse Services


In Alabama, not covered Outside Alabama, covered at 60% of the allowed amount, subject to calendar year deductible

http://www.alabamablue.com/ProviderAdministeredPrecertificationDrugList

18


PHYSICIAN BENEFITS (Includes Mental Health Disorders and Substance Abuse)

Precertification is required for some physician benefits and provider-administered drugs; please see your benefit booklet or call 1-800-248-2342 (toll-free) for precertification. If precertification is not obtained, no benefits are available.

Office Visits and Outpatient Consultations




Teledoc - Telephone and Online Video Consultation Program A service available to diagnose, treat and prescribe medication (when necessary) for certain medical issues. To enroll, go to Teledoc.com/Alabama or call 1-855-477-4549.

Covered at 80% of the allowed amount, subject to the calendar year deductible

Not Covered

Nurse Practitioner/Nurse Midwife/Clinical Nurse Specialist/Mental Health Nurse Practitioner/Mental Health Clinical Nurse Specialist and Physician Assistant's Office Visits and Consultations




Surgery & Anesthesia Covered at 80% of the allowed amount, subject to calendar year deductible



Maternity Care Covered at 80% of the allowed amount, subject to calendar year deductible



Chemotherapy, Diagnostic Lab Hemodialysis, IV Therapy, Radiation Therapy & X-ray




Applied Behavioral Analysis (ABA) Therapy Limited to ages 0-18 for autism spectrum disorder. Ages 0-9 limited to an annual maximum of $20,000 per child, ages 10-13 limited to an annual maximum of $15,000 per child, and ages 14-18 limited to an annual maximum of $10,000 per child. Note: Home based therapy is excluded.



19


PREVENTIVE CARE BENEFITS (Includes Mental Health Disorders and Substance Abuse)

Routine Immunizations and Preventive Services

Covered at 100% of the allowed amount, no coinsurance or deductible See AlabamaBlue.com/PreventiveServices and AlabamaBlue.com/ NetResultsACAPreventiveDrugList for a listing of the specific drugs, immunizations and preventive services or call Blue Cross and Blue Shield Customer Service for a printed copy. Certain immunizations may also be obtained through the Pharmacy Vaccine Network. See AlabamaBlue.com/VaccineNetworkDrugList for more information

Not Covered

Note: In some cases, office visit copays or facility copays may apply. Blue Cross and Blue Shield of Alabama will process these claims as required by Section 1557 of the Affordable Care Act.

BENEFIT IN-NETWORK OUT-OF-NETWORK OTHER COVERED SERVICES BENEFITS

(Includes Mental Health Disorders and Substance Abuse) Precertification is required for some other covered services; please see your benefit booklet or call 1-800-248-2342 (toll-free) for

precertification. If precertification is not obtained, no benefits are available. Allergy Testing & Treatment Covered at 80% of the allowed amount, subject

to calendar year deductible Covered at 60% of the allowed amount, subject to calendar year deductible

Ambulance Service Covered at 80% of the allowed amount, subject to calendar year deductible


Chiropractic Services Limited to a maximum of 24 visits per person each calendar year




Durable Medical Equipment (DME) Covered at 80% of the allowed amount, subject to calendar year deductible


Rehabilitative Occupational, Physical and Speech Therapy Limited to a maximum of 30 visits per person per therapy each calendar year



Habilitative Occupational, Physical and Speech Therapy Limited to a maximum of 30 visits per person per therapy each calendar year



http://www.alabamablue.com/PreventiveServices



http://www.alabamablue.com/VaccineNetworkDrugList

20


Nutritionist Visits

Limited to a maximum of eight visits per person each calendar year. Note: Employee is also responsible for any charges above the allowance.



Home Health and Hospice Covered at 80% of the allowed amount, subject to calendar year deductible

In Alabama, no benefits are available if a non-preferred provider is used


Routine Vision Exam Covered at 80% of the allowed amount, subject to calendar year deductible for one routine eye exam per person per calendar year

Covered at 60% of the allowed amount, subject to calendar year deductible for one routine eye exam per person per calendar year

HEALTH MANAGEMENT BENEFITS

(Includes Mental Health Disorders and Substance Abuse)

Individual Case Management Coordinates care in event of catastrophic or lengthy illness or injury. For more information, please call 1-800-821-7231.

Disease Management

Coordinates care for members with chronic conditions such as heart failure, coronary artery disease, diabetes, chronic obstructive pulmonary disease, asthma, and other specialized conditions. This program offers personalized care designed to meet your lifestyle and health concerns. A staff of healthcare professionals will help you cope with your illness and serve as a source of information and education. Participation in the program is completely voluntary. If you would like to enroll in the program or obtain more information, call 1-888-841-5741 or e-mail [email protected].

Baby Yourself®

A maternity program that offers the opportunity to have a Blue Cross and Blue Shield registered nurse case manager to monitor a covered member’s pregnancy while enrolled in this medical plan. Note: Participants who enroll within the first trimester of pregnancy and continue participation until the baby is born will receive a one-time contribution to their Health Savings Account equivalent to the inpatient hospital copayment on the PPO plan. For more information, please call 1-800-222-4379 as soon as you find out you are pregnant. You can also enroll online at AlabamaBlue.com/BabyYourself.

Contraceptive Management Covers prescription contraceptives, which include: birth control pills, injectables, diaphragms, IUDs and other non-experimental FDA approved contraceptives; subject to applicable deductibles, copays and coinsurance.

Quit for Life Tobacco Cessation Program

A tobacco cessation program for subscriber, spouse and dependents that provides support to participants through telephone-based counseling and nicotine replacement therapy. Call 1-888-768-7848 for participation information.

Air Medical Transport

If a member is hospitalized while traveling more than 150 miles from home, AirMed transportation is available to transport the member to an in-network hospital of their choice near the member’s home. Members call AirMed at 1-877-872-8624 (available 24 hours a day, 7 days a week) to arrange air transportation services.

http://www.alabamablue.com/BabyYourself

21

Useful Information to Maximize Benefits • To maximize your benefits, always use in-network providers for services covered by your health benefit plan. To find in-network providers, check

a provider directory, provider finder website (AlabamaBlue.com) or call 1-800-810-BLUE (2583). • In-network hospitals, physicians and other healthcare providers have a contract with a Blue Cross and/or Blue Shield Plan for furnishing

healthcare services at a reduced price (examples: BlueCard® PPO, PMD). In-network pharmacies are pharmacies that participate with Blue Cross and Blue Shield of Alabama or its Pharmacy Benefit Manager(s). In Alabama, in-network services provided by mental health disorders and substance abuse professionals are available through the Blue Choice Behavioral Health Network. Sometimes an in-network provider may furnish a service to you that is not covered under the contract between the provider and a Blue Cross and/or Blue Shield Plan. When this happens, benefits may be denied or reduced. Please refer to your benefit booklet for the type of provider network that we determine to be an in-network provider for a particular service or supply.

• Out-of-network providers generally do not contract with Blue Cross and/or Blue Shield Plans. If you use out-of-network providers, you may be responsible for filing your own claims and paying the difference between the provider’s charge and the allowed amount. The allowed amount may be based on the negotiated rate payable to in-network providers in the same area or the average charge for care in the area.

• Please be aware that providers/specialists may be listed in a PPO directory or provider finder website, but not covered under this benefit plan. Please check your benefit booklet for more detailed coverage information.

• Teladoc Health is an independent company that Blue Cross and Blue Shield of Alabama has contracted with to provide you with teleconsultation services. Blue Cross and Blue Shield of Alabama is an independent licensee of the Blue Cross and Blue Shield Association.

• Prime Therapeutics LLC® is an independent company providing pharmacy benefit management services for Blue Cross and Blue Shield of Alabama, an independent licensee of the Blue Cross and Blue Shield Association.

• Please refer to your benefit book or contact Blue Cross directly about coverage for your hospital charges and other related medical services. Approval for air medical transportation does not mean that hospitalization and other medical expenses will be covered. All coverage determinations for medical benefits are subject to the terms, conditions, limitations and exclusions of the health plan. Air medical transportation services are provided through a contract with AirMed International, LLC, an independent company that does not provide Blue Cross and Blue Shield of Alabama products. Blue Cross is not responsible for any mistakes, errors or omissions that AirMed, its employees or staff members make. Air medical transportation services terminate if coverage by your health plan ends.

This is not a contract, benefit booklet or Summary Plan Description. Benefits are subject to the terms, limitations and conditions of the

group contract (including your benefit booklet). Check your benefit booklet for more detailed coverage information. Please visit our website, AlabamaBlue.com.

http://www.bcbsal.com/

22

Notice of Nondiscrimination

Blue Cross and Blue Shield of Alabama complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of Alabama:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages

If you need these services, contact our 1557 Compliance Coordinator. If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance in person or by mail, fax, or email at: Blue Cross and Blue Shield of Alabama, Compliance Office, 450 Riverchase Parkway East, Birmingham, Alabama 35244, Attn: 1557 Compliance Coordinator, 1-855-216-3144, 711 (TTY), 1-205-220-2984 (fax), [email protected] (email). If you need help filing a grievance, our 1557 Compliance Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Foreign Language Assistance

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-216-3144 (TTY: 711) Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-855-216-3144 (TTY: 711)번으로 전화해 주십시오. Chinese: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-855-216-3144 (TTY: 711）。 Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-216-3144 (TTY: 711). :Arabic انتباه :إذا كنت ت ت حد ث ا ل عربي ة، ت وجد خدم ا ت مساع دة فيما يتع ل ق ب ا ل لغة ، بدون تك ل فة ، م ت ا حة لك. اتصل بـ 1-855-216-3144 )ا لهات ف ا لن ص ي: (.711German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-216-3144 (TTY: 711). French: ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-855-216-3144 (ATS: 711). French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-855-216-3144 (TTY: 711). Gujarati: ધ્યાન આપો: જો તમે �જરાતી બોલતા હોય, તો ભાષા સહાયતા સવ . 1-855-216- 3144 ઉપલ�ધ્ છ◌ે. 1-855-216-3144 પર (TTY: 711). Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-216-3144 (TTY: 711). Hindi: ध◌्य◌ान द�: अगर आपक� भ◌ाष◌ा �ह◌ंद� ह◌ै, त◌ो आपक◌े �लए भ◌ाषा सह◌ायत◌ा सव◌ाएँ �न◌ःश◌ुल◌्क उपलब◌्ध ह�। 1-855-216-3144 (TTY: 711) पर क◌ॉल कर�। Laotian: : ໂປດຊາບ: ຖ◌້ າວ◌່ າ ທ◌່ ານເ◌ົ ວ◌້ າພາສາ ລາວ, ການ◌ໍ ບ◌ິ ລການຊ◌່ ວຍເຫ◌ື ອດ◌້ ານພາສາ, ໂດຍ◌ໍ ບເສ◌ັ ຽຄ◌່ າ, ແມ◌່ ນມ◌ີ ພ◌້ ອມໃຫ◌້ ທ◌່ ານ. ໂທຣ 1-855-216-3144 (TTY: 711). Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-855-216-3144 (телетайп: 711). Portuguese: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-855-216-3144 (TTY: 711). Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-855-216-3144 (TTY: 711). Turkish: DİKKAT: Eğer Türkçe konuşuyor iseniz, dil yardımı hizmetlerinden ücretsiz olarak yararlanabilirsiniz. 1-855-216-3144 (TTY: 711) irtibat numaralarını arayın. Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-216- 3144 (TTY: 711). Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-855-216-3144（TTY: 711）まで、

お電話にてご連絡ください。

mailto:[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html

23

Prescription Drug Plan (Effective 1-1-2021)

Pharmacy Benefits are administered by Prime Therapeutics® and employees who participate in the UA PPO or HDHP Medical Plans are automatically enrolled. You will receive one (1) Medical Insurance card for both Medical and Rx Benefits.

PRESCRIPTION DRUG BENEFITS (Includes Mental Health Disorders and Substance Abuse)

Precertification is required for some drugs; if precertification is not obtained, no benefits are available. Only one deductible and out-of-pocket maximum will apply if a member uses a retail pharmacy, extended supply pharmacy and/or the mail order program.

Formulary View the NetResults 1.0 (4 Tier) drug list that applies to the plan at AlabamaBlue.com/NetResults1DrugList4T

Pharmacy Locator Locate a Prime Participating Network pharmacy at AlabamaBlue.com/PrimeParticipatingPharmacyLocator

Diabetic Supplies

Diabetic supplies are only covered under your prescription drug program and limited to a 60 or 90 day supply at a participating retail pharmacy or through mail order, subject to the following copayment limitations for PPO plan participants only: • Insulin, insulin needles and syringes purchased on the same day will require only one copay. • Blood glucose strips and lancets purchased on the same day will require only one copay. • Glucose monitors always require a separate copay.

Maintenance Drug Quantity Limit The first prescription for a drug on the maintenance list requires a 31 day supply. Subsequent refills for 60 or 90 days can be made at a participating supply pharmacy.

EMPLOYEE PLAN COST SHARE

BENEFIT PPO IN-NETWORK HDHP IN-NETWORK

Calendar Year Deductible Combined pharmacy and medical deductible

$400 per person Each prescription covered at 100% of the allowed amount after deductible, subject to applicable copayments.

$1,400 self-only coverage; $2,800 family coverage Each prescription covered at 80% of the allowed amount after deductible.

Annual Out-Of-Pocket Maximum Combined pharmacy and medical OOP All coinsurance, deductibles and copays for in-network covered pharmacy benefits apply to the out-of-pocket maximum. Once the out-of-pocket maximum is met, applicable claims will pay at 100% of the allowed amount for the remainder of the year.

$5,000 self-only coverage; $14,300 family coverage The out-of-pocket maximum does not apply to out-of-network pharmacy benefits.

$3,500 self-only coverage; $7,000 family coverage The out-of-pocket maximum does not apply to out-of-network pharmacy benefits.

https://www.myprime.com/content/dam/prime/memberportal/forms/2019/FullyQualified/Other/ALL/BCBSAL/COMMERCIAL/ALASOF4T/NetResults_1.0_Four_Tier_Prescription_Drug_Guide.pdf

https://www.bcbsal.org/web/find-a-pharmacy#/deeplink/Pharmacy/Prime%20Participating%20Pharmacy

24

RETAIL PRESCRIPTION DRUG BENEFITS


• The pharmacy network is Prime Participating Network

• Fertility medications are excluded • Non-Maintenance prescription drugs - up to

31 day supply • The only in-network pharmacy for some

Tier 4 (specialty) drugs is the Pharmacy Select Network; view the Specialty Drug Lists at AlabamaBlue.com/SelfAdministered SpecialtyDrugList and AlabamaBlue.com/Provider AdministeredSpecialtyDrugList

• Specialty Drug Coupon Program (PPO Plans Only). Member cost share for specialty drugs filled thru Prime’s Specialty Pharmacy will be the greater of $125 copayment or the full amount available manufacturer or provider cost share assistance program payments. All available manufacturer or provider cost share assistance program payments under this Specialty Drug Coupon Program will not apply to the in-network deductible or out-of-pocket maximum. Members can opt out of this program.

Each prescription covered at 100% of the allowed amount after pharmacy deductible, subject to the following copays: Tier 1 drugs $15 copayment for 1-31 day supply Tier 2 drugs $45 copayment for 1-31 day supply Tier 3 drugs $65 copayment for 1-31 day supply Tier 4 (specialty) Drugs: $125 copayment for 1-31 day supply

Each prescription covered at 80% of the allowed amount subject to calendar year deductible: Tier 1 Drugs: Member pays 20% of the allowed amount Tier 2 Drugs: Member pays 20% of the allowed amount

Tier 3 Drugs: Member pays 20% of the allowed amount Tier 4 (specialty) Drugs: Member pays 20% of the allowed amount

EXTENDED SUPPLY PRESCRIPTION DRUG BENEFITS


• The extended supply pharmacy network is the Prime Participating Network ESN Network

• Only maintenance prescription drugs can be purchased through this extended supply pharmacy service up to a 90-day supply

• Tier 4 (specialty) drugs are not available through extended supply pharmacy service

Each prescription covered at 100% of the allowed amount after pharmacy deductible, subject to the following copays: Tier 1 drugs $30 copayment for 32-60 day supply $45 copayment for 61-90 day supply Tier 2 drugs $90 copayment for 32-60 day supply $135 copayment for 61-90 day supply Tier 3 drugs $130 copayment for 32-60 day supply $195 copayment for 61-90 day supply Tier 4 (specialty) Drugs: Not Covered through extended supply


Tier 3 Drugs: Member pays 20% of the allowed amount Tier 4 (specialty) Drugs: Not Covered through extended supply

http://www.alabamablue.com/SelfAdministered

http://www.alabamablue.com/SelfAdministered

http://www.alabamablue.com/ProviderAdministeredSpecialtyDrugList

http://www.alabamablue.com/ProviderAdministeredSpecialtyDrugList

25

MAIL ORDER / HOME DELIVERY PROGRAM


• Maintenance and Non-Maintenance drugs can be purchased through this mail order pharmacy

• Non-Maintenance - up to 31 day supply • Maintenance - one copay per 31 days

up to a 90 day supply • Mail Order Drugs are available through

Home Delivery Network (Enroll online at AlabamaBlue.com or call 1-800-391- 1886)

• View the maintenance drug list that applies to the plan at AlabamaBlue.com/MaintenanceDrug List

Each prescription covered at 100% of the allowed amount after pharmacy deductible, subject to the following copays: Tier 1 drugs $10 copayment for 1-31 day supply $20 copayment for 32-60 day supply $30 copayment for 61-90 day supply Tier 2 drugs $35 copayment for 1-31 day supply $70 copayment for 32-60 day supply $105 copayment for 61-90 day supply Tier 3 drugs $55 copayment for 1-31 day supply $110 copayment for 32-60 day supply $165 copayment for 61-90 day supply Tier 4 (specialty) Drugs: Not Covered through mail order


Tier 3 Drugs: Member pays 20% of the allowed amount Tier 4 (specialty) Drugs: Not Covered through mail order

http://www.alabamablue.com/

http://www.alabamablue.com/MaintenanceDrugList

http://www.alabamablue.com/MaintenanceDrugList

26

Home Delivery Prescription Drug Service AllianceRx Walgreens Prime Home delivery is a convenient and cost-effective way for you to order up to a 90-day supply of maintenance or long-term medication for delivery to your home. This prescription drug service is administered by AllianceRx Walgreens Prime and is available to employees enrolled in UA’s medical plan. You may be taking medication for an extended period of time, but not all medications are considered maintenance medications by the plan. Please call Prime Therapeutics at 1-800-216-9920 to determine if your medication is classified as a maintenance drug

Contact for benefit or eligibility questions Questions concerning home delivery benefits or eligibility should be directed to AllianceRx Walgreens Prime at 1-800-391-1886. Ordering prescriptions or checking order status To order prescriptions or check the status of an order, contact AllianceRx Walgreens Prime at 1-800-391-1886. You may also order refills and check the status of an order online at https://www.alliancerxwp.com/home-delivery. Home delivery cost - Applicable copays are as follows: Tier 1 Drugs: $10 copay for a 1-31 day supply $20 copay for a 32-60 day supply $30 copay for a 61-90 day supply Tier 2 Drugs: $35 copay for a 1-31 day supply $70 copay for a 32-60 day supply $105 copay for a 61-90 day supply Tier 3 Drugs: $55 copay for a 1-31 day supply $110 copay for a 32-60 day supply $165 copay for a 61-90 day supply Note: There is a separate $175 prescription drug deductible per person per calendar year. Prescription drugs will be covered at 100% of the allowed charge after the deductible and is subject to the above indicated copays. Receiving home delivery prescription drugs Your prescription will be delivered to you, free of charge, by U.S. Mail or other carrier, within approximately 10 days from receipt of the order. Rush shipping is available for an additional charge. If you wish to obtain a brand name drug when a generic is available, your doctor must write “dispense as written” or “brand necessary” on the prescription. Otherwise, generic will be dispensed when appropriate and permitted by your physician.

Enrolling in the Home Delivery Service 1. Enroll in home delivery online at

https://www.alliancerxwp.com/home-delivery. You’ll need to provide your address and payment details as well as health and allergy information. Or, you can fill out the order form found in the back of this guide. Additional forms are available on the AllianceRx Walgreens Prime website.

2. Have your doctor write your prescription for the number of days allowed for your medication (up to 90 days for home delivery). For written prescriptions, always fill out an order form. Alternatively, your doctor may call, fax, or electronically prescribe your medications for home delivery. Call customer service at 1-800-391-1886 for details.

3. Mail your order form(s), original written prescription(s) and payment

(check or credit card information) to: AllianceRx Walgreens Prime P.O. Box 29061 Phoenix, AZ 85038-9061

Ordering Refills You can order refills by using one of the following methods at least two weeks before your current supply runs out. Be prepared to provide the patient’s date of birth, member ID number, prescription number(s) and credit card information. • Online – Log into https://www.alliancerxwp.com/home-delivery.

Choose “Home Delivery” on “My Prescription Dashboard” and then select “Refill Prescriptions”.

• By mail – Send in the refill slip that came with your previous order. Be

sure to include your copay. • By phone - Call AllianceRx Walgreens Prime at 800-391-1886. • By fax – Your prescriber can complete the order form and fax it with

your medication information to 1-800-332-9581. • Automatic Refills – Some prescriptions are eligible for automatic

refills. Ask AllianceRx Walgreens Prime customer service for details. No refills left on the Home Delivery Prescription If your prescription label indicates “0” refills or your refill request states “your prescription has expired,” please do the following: • Request a new prescription from your doctor • Mail your order form, the original (not duplicate) written prescription(s)

and payment (check or credit card information) to AllianceRx Walgreens Prime.

https://www.alliancerxwp.com/

https://www.alliancerxwp.com/home-delivery



27

Dental Plan The University’s dental plan is offered through Blue Cross and Blue Shield of Alabama. Participants have the freedom to seek care from any licensed dentist, but they will have lower out-of-pocket costs if an in-network Blue Cross and Blue Shield Preferred Dentist is used. An in-network Preferred Dentist is a general dentist or specialist who has agreed to accept negotiated fees as payment in-full for services provided to plan participants. A list of in-network Preferred Dentists is available online at https://www.bcbsal.org/web/provider-finder or by calling 1-800-292-8868. Participants who receive services from an in-network Preferred Dentist are only responsible for the difference between the Preferred Dental Fee Schedule and the plan’s payment which is based on the dental network fee schedule or the allowed amount. However, those who choose dentists out-of-network, may experience significantly higher out-of-pocket expenses since they will incur balance billing and will be responsible for paying any difference between their dentists’ fees and the plan’s payment. Any plan participant whose current dentist does not participate in the Preferred Dental Network can encourage him or her to apply for membership, by visiting the dental professional website at https://www.bcbsal.org/web/provider-finder or calling1-800-373-4879 for an application.

Customer Service Center: 1-800-292-8868 Find an in-network Preferred Dentist: www.bcbsal.org or call 1-800-292-8868 Customer Service Hours Mon - Fri from 7:30 a.m. to 6:00 p.m. CT

Note: This is not a contract. Benefits are subject to the terms, limitations and conditions of the group contract.

GENERAL PROVISIONS

Deductible $50 deductible per member per calendar year; $150 aggregate family maximum.

Annual Dental Maximum Combined in and out-of-network maximum of $1,000 per member each calendar year. Additional $500 benefit available if services are received in-network.

Lifetime Orthodontic Maximum $1,000 lifetime maximum per person.

Waiting Period 12 month waiting period for new entrants into the plan for Restorative (except fillings and simple extractions), Supplemental, Periodontic, Prosthetic and Orthodontic services. The waiting period will be waived for those new entrants with proof of prior coverage and no more than a 63 day break in that coverage.

DIAGNOSTIC AND PREVENTIVE (Exams and Cleanings) RESTORATIVE (Fillings and Root Canals) Covered at 100% of the allowed amount, no deductible. Includes: • Dental exams up to twice per benefit period • Full mouth x-rays, one set during any 36 consecutive months • Bitewing x-rays, one set per benefit period • Other dental x-rays, used to diagnose a specific condition • Routine cleanings, twice per benefit period • Tooth sealants on teeth numbers 3, 14, 19, and 30, limited to one application

per tooth per 48 months. Benefits are limited to a maximum payment of $20 per tooth. Limited to the first permanent molars of children through age 13

• Fluoride treatment for children under age 19 twice per benefit period • Space maintainers (not made of precious metals) that replace prematurely

lost teeth for children under age 17

Covered at 80% of the allowed amount, subject to the deductible. Includes: • Fillings made of silver amalgam and synthetic tooth color materials on teeth

numbers 5-12 and 21-28 • Simple tooth extractions • Direct pulp capping, removal of pulp and root canal treatment • Repairs to removable dentures • Emergency treatment for pain

SUPPLEMENTAL (Oral Surgery and Anesthesia) PERIODONTIC (Gum Disease) Covered at 80% of the allowed amount, subject to the deductible. Includes: • Oral surgery for tooth extractions and impacted teeth • General anesthesia given for oral or dental surgery. This means drugs

injected, inhaled for relaxation, to lessen pain, or to make unconscious, but not analgesics, drugs given by local infiltration, or nitrous oxide

• Treatment of the root tip of the tooth including its removal

Covered at 80% of the allowed amount, subject to the deductible. Includes: • Periodontic exams twice each 12 months • Removal of diseased gum tissue and reconstructing gums • Removal of diseased bone • Reconstruction of gums and mucous membranes by surgery • Removing plaque and calculus below the gum line for periodontal disease

per quadrant every two years • Periodontal surgery once per quadrant, every three years

PROSTHETIC (Crowns and Dentures) ORTHODONTIC (Braces) Covered at 50% of the allowed amount, subject to the deductible. Includes: • Full or partial dentures • Dental implants • Fixed or removable bridges • Inlays, onlays, or crowns to restore diseased or accidentally broken teeth, if

less expensive fillings are not adequate

Covered at 50%, no deductible. • Limited to a lifetime maximum of $1,000 • For dependent children up to the end of the month of their 19th birthday

https://www.bcbsal.org/web/provider-finder



http://www.bcbsal.org/

28

Vision Plan The University offers eligible employees a vision plan through UnitedHealthcare Vision (UHC Vision) which offers members access to a nationwide network of over 30,000 private practices and retail chain locations. Members can get a complete eye exam and new eyeglass lenses every 12 months. New eyeglass frames are covered every 24 months. UHC Vision providers have a wide selection of frames that are available for a small co-pay only. Participants can also choose frames from outside the UHC Vision collection and get a generous frame allowance. Those who prefer contact lenses can have an eye exam and a supply of contacts each year. The following is a summary of the plan benefits: In-Network Benefits

Comprehensive Vision Exam A comprehensive eye examination from a UHC Vision network optometrist or ophthalmologist is covered once every 12 months at 100% after a $10 co-pay. Materials The plan’s $20 materials co-pay is a single payment that applies to the entire purchase of eyeglasses (lenses and frames), or contacts in lieu of eyeglasses. After the co-pay, the plan provides these benefits: Lenses – once every 12 months

• One pair of standard single vision, lined bifocal, lined trifocal or standard lenticular lenses for eyeglasses is covered at 100%.

• Standard scratch-resistant coating and polycarbonate lenses are covered at 100%.

• Progressive lenses, tints, UV and anti-reflective coating may be available at a discount

Frames – once every 24 months

Members have two frame options to choose from: • Select frames from the UHC Vision frame collection covered at

100%, or receive a $130 frame allowance at private practice providers.

• Utilize a $130 frame allowance at any of the retail chain providers.

Laser Vision Correction – UHC Vision has partnered with the Laser Vision Network of America (LVNA) to provide our members with access to discounted laser vision correction providers. For more information, call 888-563-4497 or visit www.uhclasik.com.

Contact Lenses in Lieu of Eyeglasses – once every 12 months Covered-in-full elective contact lenses – The fitting/evaluation fees, contacts (including disposables), and up to two follow-up visits are covered at 100% (after the materials co-pay) for many of the most popular brands on the market. If covered disposable contact lenses are chosen, up to 6 boxes (depending on prescription) are included when obtained from a network provider. It is important to note that UHC Vision’s covered-in-full contact lenses may vary by provider

• All other elective contacts – A $150 allowance applies toward the fitting/evaluation fees and purchase of contact lenses outside of UHC Vision’s covered-in-full contacts (materials co-pay does not apply). Toric, gas permeable, and bifocal contacts are all examples of contacts that are outside of UHC Vision’s covered-in-full selection.

• Medically Necessary contact lenses – Covered-in-full (after materials co-pay). Medically necessary contact lenses are used to treat specific conditions as determined by eye care providers. Participants with conditions warranting medically necessary contacts should ask their providers to contact UHC Vision concerning the reimbursement that UHC Vision will make before they purchase such contacts.

Out-of-Network Benefits Schedule If a non-network provider is used, the plan will reimburse up to:

Exam (once every 12 months) Optometrist $40 Ophthalmologist $40 Lenses (once every 12 months) Single vision $40 Bifocal $60 Trifocal $80 Lenticular $80 Frames (once every 24 months) $45 Contact Lenses (in lieu of spectacle lenses and frames) Medically Necessary $210 Elective $150

Out-of-Network Reimbursement If a non-network provider is used, itemized paid receipts, with the primary insured’s Social Security number, patient’s name and patient’s date of birth must be sent to:

UnitedHealthcare Vision P. O. Box 30978 Salt Lake City, UT 84130 Attention: Claims Department FAX: 248-733-6060

Please note: Receipts for services and materials purchased on different dates must all be submitted at the same time to receive reimbursement. Receipts must be submitted within 12 months of the date of service. UHC Vision will reimburse you according to the schedule.

http://www.uhclasik.com/

29

How To Use the UHC Vision Plan

Step 1 - Review the Benefits Materials Carefully review this material to understand the plan design and applicable co-pays. Step 2 - Find a Provider Locate a provider by logging on to www.myuhcvision.com and selecting the provider locator option. Participants may also contact UHC Vision’s 24-hour, toll-free Interactive Voice Response system at 1-800-839-3242 to locate a nearby provider. Step 3 - Schedule an Appointment Once a provider has been chosen, simply call the provider directly to schedule an appointment. Provide the primary insured’s Member ID, the patient’s name and date of birth, and state that UHC Vision Plan coverage is in effect. Step 4 - Receive an Eye Exam The network provider, a state-licensed optometrist or ophthalmologist, will perform a complete eye examination, including a case history of the patient, an examination for eye pathology and abnormalities, visual analysis (refraction), confrontation visual fields testing, condition diagnosis, and prescription determination. Step 5 - Choose Eyewear If prescription eyewear is necessary, the UHC Vision provider will write a prescription, assist with eyewear selection and order the eyewear. The UHC Vision provider will telephone the participant when the eyewear arrives. Eyewear is dispensed at the provider’s office to ensure optical accuracy and proper fit. Important Items to Remember

• An ID card will not be issued by UHC Vision. All plan participants should go to the website www.myuhcvision.com and print ID cards for yourself and your dependents. ID cards contain Member ID numbers and are required for doctors’ visits and billing purposes. To print an ID card for a family member, the plan member may log in to the UHC Vision website with his or her credentials, select “print ID card”, and select the desired dependent from the drop-down menu.

• Benefits are available every 12 or 24 months based on last date of service. • Contact lenses are in lieu of lenses and frame. Providers will help determine which contact lenses are covered under the plan. • The $150 contact lens allowance applies to the fitting/evaluation fee as well as the purchase of contact lenses. For example, if the

fitting/evaluation fee is $30, the participant will have $120 towards the purchase of contact lenses. At some retail chain locations the allowance may be shared between the examining physician and the optical store. Toric, gas permeable, and bifocal contacts are all examples of contacts that are outside of the covered-in-full selection.

• The following services and materials are excluded from coverage under the Policy: Post cataract lenses; Non-prescription items; Medical or surgical treatment for eye disease that requires the services of a physician; Workers’ Compensation services or materials; Services or materials that the patient, without cost, obtains from any governmental organization or program; Services or material that are not specifically covered by the Policy; Replacement or repair of lenses and/or frames that have been lost or broken; Cosmetic extras, except as stated in the Policy’s Table of Benefits.

If you have any questions or concerns about your vision options, please contact UHC Vision’s: Customer Service Center: 1-800-638-3120 or TDD 1-800-524-3157 for the hearing impaired. Customer Service Hours: Mon – Fri from 7:00 a.m. to 10:00 p.m. CT Sat from 8:00 a.m. to 5:30 p.m. CT www.myuhcvision.com




30

Flexible Spending Accounts (FSA) An FSA is a voluntary program that allows you to pay for a variety of out-of-pocket healthcare and/or dependent care expenses through pre-tax payroll deductions. TASC (TASC) is the FSA administrator for the University. When enrolling, you determine how much money you want to contribute to each account. The money is then withheld from your pay before taxes are calculated providing you with more value for your dollar. FSA participants will be able to use a special debit MasterCard® to pay their eligible FSA expenses. You will also be able to manually file for reimbursement from your account. The University provides two types of FSAs: Healthcare Flexible Spending Account (HFSA) This account can be used to pay for many healthcare expenses incurred by you and eligible IRS tax dependents that are not covered by your medical, dental or vision insurance. The maximum annual amount allowed for this plan is $2,750. If you and your spouse both work at UA and are eligible to participate in the HFSA, you may each contribute up to $2,750 into the HFSA for a total of $5,500. Some common eligible expenses include orthodontia, coinsurance, co-pays, prescriptions and some over-the-counter medications (if prescribed by a physician). To be considered eligible for reimbursement, healthcare expenses cannot be paid by or reimbursed through any benefit plan. You may be reimbursed your full HFSA annual election amount prior to having the full amount of payroll contributions deducted and deposited in your account. You do not have to enroll in a medical plan to participate in the HFSA. Dependent Care Flexible Spending Account (DCFSA) This account can be used to reimburse you for expenses associated with the care of your qualified IRS dependents, as long as the expenses are incurred: • so you and your spouse can work or attend school full-time • for services relating to the care of a dependent child under the age of

13 or your dependent or spouse who is physically or mentally incapable of self-care and who lives with you for more than one-half of the year

• for dependent care services provided during the plan year while employed with the University.

If you and your spouse both work at UA and are eligible to participate in the DCFSA, the maximum amount allowed is $5,000 if a joint tax return is filed or up to $2,500 each if you file separate tax returns. Reimbursements from the DCFSA cannot exceed the amount deposited in your account at the time your reimbursement is processed. Eligible expenses include: • licensed nursery school and daycare facilities for children • child care in or outside your home • day care for an elderly disabled dependent There are other tax considerations you must weigh when making decisions about this account, such as the Child Care Tax Credit. The IRS allows you to take a credit on your federal income taxes for your work-related dependent day care expenses if you file an itemized return. Depending on your income and tax filing status, this Child Care Tax Credit may offer more, or less, tax savings than the DCFSA. You can use both the tax credit and the DCFSA (not for the same expenses), but any tax credit you take reduces the amount you can contribute to, and claim from, the account. Only you can decide which method is best for your situation.

Eligible FSA Expenses You can obtain a detailed list of eligible and ineligible expenses for both accounts by accessing www.irs.gov. Under “Forms and Instructions,” enter “502” for the healthcare plan and “503” for dependent care plan. Using This Benefit You must enroll and indicate how much to contribute within the first 30 days of hire, within 30 days after a qualifying event or during the annual open enrollment period. The amount you elect will be deducted from your pay in equal amounts depending on your pay schedule. After you enroll, you will receive a welcome letter from TASC with information about your account. Getting Reimbursed Healthcare Expenses – The TASC debit MasterCard® is the easiest and best way to access the money set aside in your HFSA account. However, any charges paid for with a method other than the debit card, or if you are filing for eligible over-the-counter expenses, you must send a Request for Reimbursement form with appropriate documentation to TASC. Dependent Care Expenses – If the daycare facilities you choose do not accept the provided MasterCard ®, you will need to send a Request for Reimbursement FSA form with the appropriate documentation to TASC in order to be reimbursed. You may set up direct deposit with TASC for a faster refund. Tax Savings Examples Participating in an FSA can reduce your taxes by reducing your taxable income. Using these pre-tax accounts can make a significant difference in your take-home pay. The chart below illustrates what would happen if your annual pay was $45,000 and you had $2,000 in eligible health or dependent care expenses.

FSA Pre-tax contribution 0 - 2,000 Estimated taxes - 9,000 - 8,600 Out-of-pocket expenses - 2,000 0 Take-home pay $34,000 $34,400 Extra take-home pay with FSA $400

Important Facts to Remember • You cannot change the amount to be contributed to your FSA during

the year unless you experience a qualifying event and then you must make any changes within 30 days of the qualifying event.

• Any amounts remaining in your FSAs not incurred by December 31st will be forfeited, as required by the IRS.

• Any claims for reimbursement of eligible health and dependent care expenses incurred from January 1 – December 31 must be submitted by March 31 of the following year.

• Your Social Security benefits may be reduced by this election. • You cannot use funds from one FSA account (i.e. HFSA) to pay for

expenses that apply to the other FSA account (i.e. DCFSA).

http://www.irs.gov/

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FSA Eligible Healthcare Expenses Healthcare expenses that are deductible under the Internal Revenue Code and not covered by insurance or any other source that provides benefits are usually eligible for reimbursement through the Healthcare FSA. The exceptions to this are expenses for cosmetic procedures, expenses incurred for general health and well-being and health insurance premiums. Some over-the-counter medications and supplies are allowed and as of January 1, 2020, over-the-counter (OTC) medicines and drugs are reimbursable via FSA, HRA, and HSA. The receipt for over-the-counter medications must clearly indicate the name of the item purchased. Following is a partial listing of eligible and ineligible healthcare expenses:

Eligible Healthcare Expenses • Acupuncture • Artificial limbs • Bandages • Birth control, contraceptive devices • Birthing classes/Lamaze – only the mother’s portion (not the coach/spouse) and the class must be only for birthing instruction, not child rearing • Blood pressure monitor • Chiropractic therapy/exams/adjustments • Contact lens and contact lens solutions • Co-payments • Crutches (purchased or rented) • Deductibles and co-insurance • Diabetic supplies • Eye exams • Eyeglasses, contacts, or safety glasses (prescription) • Flu shots • Hearing aids and hearing aid batteries • Heating pad • Incontinence supplies • Infertility treatments • Insulin • Lactation expenses (breast pumps, etc.) • Laser eye surgery; LASIK • Legal sterilization • Medical supplies to treat an injury or illness • Mileage to and from doctor appointments • Nasal strips • Optometrist’s or ophthalmologist’s fees • Orthopedic inserts • Physical exams • Physical therapy (as medical treatment) • Physician’s fee and hospital services • Pregnancy test • Prescription drugs and medications • Psychotherapy, psychiatric and psychological service • Sales tax on eligible expenses • Sleep apnea services/products (as prescribed) • Smoking cessation programs • Treatment for alcoholism or drug dependency • Vaccinations • Wrist supports, elastic wraps

• Specialized equipment for disabled persons • Special devices, such as a tape recorder and typewriter, for persons

who are visually impaired • Speech therapy • Sterilization surgery • Transportation expenses related to medical care • Weight reduction program for physician diagnosed obesity • Wheelchairs • Wigs for hair loss due to any disease (must have doctor’s

certification) • X-rays Eligible Over-the-Counter Expenses As of January 1, 2020, over-the-counter (OTC) medicines and drugs are reimbursable via FSA, HRA, and HSA. • Bengay, Flexall, pain relieving creams or gels • Calamine lotion • Canker/cold sore relievers • Cold medicines • Corn removal • Diaper rash ointment • GasX, baby gas drops • Hemorrhoid creams and treatments • Hydrogen peroxide or rubbing alcohol • Indigestion or anti-acid relievers • Laxatives • NEW: Menstrual care products • Nicotine patch • Pain relievers (Tylenol, Advil, Aspirin, etc.) • Sinus medicines • Suppositories • Teething gel • Wart removal medication

Ineligible Expenses • Dietary supplements not considered a medical necessity • Face cream, moisturizers, • Make-up, lipstick, eye-cream • One-a-day vitamins • Perfume, body sprays, deodorants • Protein bars • Shampoos and soaps • Suntan lotion • Teeth whitening procedures • Toothpaste, toothbrushes, dental floss

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FSA Worksheet Use this worksheet to help calculate your eligible FSA expenses. This is not an all-inclusive list of eligible expenses, but it contains some of the most common ones. Identify the amounts you spent last year, adjust the expenses based on your future health care needs and enter the amounts in the spaces below. Remember, to be eligible for reimbursement, incurred expenses cannot be reimbursed from another source, e.g., a covered medical or prescription drug expense under the UA Medical Plan. It is your responsibility to be sure that expenses qualify for reimbursement. Call TASC at 800-422-4661 to ensure that your anticipated expenses qualify for reimbursement. After an election is made, it cannot be revised or revoked unless you experience a qualified family status change.

ANTICIPATED MEDICAL EXPENSES – not reimbursed by your medical insurance Cost Estimate 1. Co-pays (office visit/prescription co-pay amounts x number of anticipated visits/prescriptions) $ 2. Deductibles (for you and eligible dependents) $ 3. Coinsurance amount (e.g., 20% of the services after deductible) $ 4. Routine exam (annual physical, yearly exams, well-baby) $ 5. Hearing care expenses (hearing aids, exams, etc.) $ 6. Prescription drugs (not covered by insurance) $ 7. Eligible over-the-counter medications (may require prescription) $ 8. Alternative care (chiropractor, acupuncture office visits) $ 9. Weight loss program (must submit a letter from doctor regarding medical condition) $ 10. Massage Therapy (must submit a letter from doctor regarding medical condition) $ 11. Other anticipated qualified expenses not listed $ Sub Total $

ANTICIPATED DENTAL EXPENSES – not reimbursed by your dental insurance Cost Estimate 1. Deductibles (for you and eligible dependents) $ 2. Coinsurance amount (e.g., 20%, 50% of services after deductible) $ 3. Examinations, cleanings, fluoride treatments, x-rays, space maintainers, sealants $ 4. Fillings, extractions, root canals, denture repairs $ 5. Crowns, inlays, onlays, bridges, dentures $ 6. Orthodontia treatment $ 7. Other anticipated qualified dental expenses not listed $ Sub Total $

ANTICIPATED VISION EXPENSES – not reimbursed by your vision insurance Cost Estimate 1. Deductibles (for you and eligible dependents) $ 2. Co-pays (exam and material co-pays x number of visits) $ 3. Vision examinations $ 4. Frames, lenses, contact lenses $ 5. Laser vision correction procedures $ 6. Other anticipated qualified vision expenses not listed $ Sub Total $

Total Anticipated Annual Medical, Dental & Vision Expenses (enter amount on FSA Election Form)

ANTICIPATED DEPENDENT CARE EXPENSES Cost Estimate 1. Dependent care center fees (qualifying child or adult day care) $ 2. Licensed nursery school fees $ 3. Other anticipated eligible dependent care expenses $

Total Anticipated Annual Dependent Care Expenses (enter amount on FSA Election Form)ANTICIPA

$

$

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Health Savings Accounts (HSA) An HSA is a voluntary tax-advantaged savings account available only to individuals enrolled in a qualified HDHP (High Deductible Health Plan). HSA’s are individual savings accounts, but the money in the account may only be used to pay for qualified medical, dental, and vision expenses. Contributions are deposited into the account by you and/or the University and are limited to a maximum amount each calendar year, per IRS regulations. Any unused money in the account automatically rolls over to next year and is yours to keep. TASC is the HSA administrator for this plan. When enrolling, you determine how much money you want to contribute to your health savings account. The money is then withheld from your pay before taxes are calculated, thus providing you with more value for your dollar. HSA participants will be able to use a special debit MasterCard® to pay their eligible HSA expenses incurred by the eligible individual and any eligible IRS tax dependents. You will also be able to manually file for reimbursement from your account or make withdrawals up to your current account balance. HSA Eligibility As a tax favored benefit plan, the HSA must meet certain criteria as outlined by the IRS. Employees must be enrolled in the BCBS HDHP to be eligible to participate in the HSA. If you are claimed as a dependent on someone else’s taxes or are covered by any other health insurance policy that is not an HDHP, including Medicare, you are not eligible for an HSA. If you participate in a healthcare FSA or HRA through your employer or spouse’s employer, you are not eligible for an HSA. This account can be used by you and your eligible IRS tax dependents to pay for qualified medical, dental or vision expenses. The maximum annual pre-tax contribution limit allowed for this plan in 2021 is $3,600 for employee only or $7,200 for families. Eligible HSA Expenses Some common eligible expenses include orthodontia, coinsurance, co-pays, prescriptions and some over-the-counter medications (if prescribed by a physician). You can obtain a detailed list of eligible and ineligible expenses by visiting www.irs.gov. Under “Forms and Instructions,” enter “502” for the healthcare plan. Using This Benefit You must enroll in this plan within the first 30 days of hire or during annual Benefits Open Enrollment. Funds are added to your account following each pay period based on your contribution election. The contribution amount may be changed at any time during the year (effective the next available pay period) and you will have access to the amount of funds that you have contributed to date. For each month that you are HSA-eligible, you may contribute up to one-twelfth of the applicable maximum contribution limits stated above. After you enroll, you will receive a welcome email and letter from TASC with information about your account. HSA account balances will be carried over indefinitely from year to year.

Getting Reimbursed The TASC debit MasterCard® is the easiest and best way to access the money set aside in your HSA account. However, for any charges paid for with a method other than the debit card, you must send a Request for Reimbursement form with appropriate documentation to TASC. Withdrawals Reimbursements for qualified medical expenses are tax-free and you may only request a distribution up to the current balance of your TASC HSA account. If you are disabled or reach age 65, you can receive non-medical distributions without penalty, but you must report the distribution as taxable income. You may also use your funds for a spouse or dependent not covered under your HDHP, as long as they are your eligible IRS tax dependent per IRS Publication 501 (e.g., children must be (a) under the age of 19, (b) under the age of 24 and a student, or (c) any age if permanently and totally disabled). Investing If you maintain a minimum cash balance of $2,000, any excess funds may be invested in mutual funds yielding tax-free earnings. Tax Savings Examples Participating in an HSA can reduce your taxes by reducing your taxable income. Using these pre-tax accounts can make a significant difference in your take-home pay. The chart below illustrates what would happen if your annual pay was $45,000 and you had $2,000 in eligible healthcare expenses.

Example Without HSA With HSA Annual pay $45,000 $45,000 HSA Pre-tax contribution 0 - 2,000 Estimated taxes - 9,000 - 8,600 Out-of-pocket expenses - 2,000 0 Take-home pay $34,000 $34,400 Extra take-home pay with HSA $400

Important Facts to Remember • If you are claimed as a dependent on someone else’s taxes or

are covered by any other health insurance policy that is not an HDHP, including Medicare, you are not eligible for an HSA.

• If you participate in a healthcare FSA or HRA through your employer or spouse’s employer, you are not eligible for an HSA.

• You CAN change the amount to be contributed to your HSA during the year through BenefitFocus. Any changes will be effective on the next available paycheck.

• Any amounts remaining in your HSA on December 31st will be carried over to the next plan year and is yours to keep.

• Your Social Security benefits may be reduced by this election. • Withdrawals you use for non-eligible expenses will be taxed at

your regular income tax rate and may be subject to additional penalties, if you are under age 65.

• The funds in your HSA account stay with you, even if you change jobs. And, if you are no longer covered by an HDHP, your HSA stays active and remaining funds can still be used for medical expenses.

http://www.irs.gov/

https://www.irs.gov/publications/p501

34

University-Paid Group Term Life and AD&D The University provides eligible employees with Group Term Life insurance and Accidental Death & Dismemberment (AD&D) insurance from The Standard Insurance Company. The University pays the full cost for this coverage. Group Term Life Insurance Group Term Life coverage pays your beneficiary a designated amount upon your death. The Group Term Life coverage comes with a special feature called the Accelerated Benefit Option. This option allows you to access up to 80% of your group term life insurance proceeds to a maximum of $240,000 should you become terminally ill and are diagnosed with less than twelve months to live. The amount varies with annual salary:

Annual Base Salary Coverage Amounts Up to $23,999 $30,000 $24,000 to $29,999 $37,500 $30,000 to $39,999 $50,000 > $40,000 125% salary ($300,000 maximum benefit)

Accidental Death & Dismemberment Insurance (AD&D) The AD&D insurance pays $22,500 if death was caused by an accident. In instances where death was caused by an accident, your beneficiary would receive both the group term life and AD&D benefit. AD&D also pays a benefit if a serious injury results in dismemberment. For example, if you lose a limb or the ability to see, you may be paid a part of your benefit. Beneficiaries Beneficiaries for University-Paid Group Term Life insurance and Accidental Death & Dismemberment (AD&D) insurance should be designated through our online portal, BenefitFocus. Instructions are in the Forms section. Additional Services In addition to the University paid group term life and AD&D coverage, The Standard provides you with a Life Services Toolkit. Through the Life Services Toolkit, The Standard gives you access to services that help you and loved ones prepare for, and manage, life’s major events. You, your spouse, and your children up to age 26 can access these services 24 hours a day, seven days a week. The Life Services Toolkit is included in your Group Life insurance, which means there’s no additional cost to you.

Travel Assistance http://www.standard.com/travel

Group #: D2STD Activation Code: 181002

Travel Assistance Services include a full range of medical, travel, legal and emergency evacuation services when you travel more than 100 miles from home or internationally on trips up to 180 days. More information in the travel brochure https://www.standard.com/eforms/14684.pdf.

Funeral Planning & Concierge Services,

Digital Identity Archive http://www.everestfuneral.com/thestandard

Enrollment code: Standard 1.866.400.4945

Funeral Planning & Concierge Services This offering provides personalized assistance with all funeral-related matters, both before and during your need, including local funeral home price comparisons and the negotiation of final funeral service costs with the funeral home your family chooses.

Online Estate Planning http://www.standard.com/mytoolkit

Username: assurance

Online Estate Planning You’ll have access to an online library of legal forms, including a will, that enables you to prepare, view and print documents which can be notarized and stored in a secure place.

Digital Identity Archive® To help make retrieving your online information easy in the future, this service provides a secure website for recording, storing and updating items like usernames and passwords. The information can be accessed by your designated person(s) as needed, any time after your death. When Employment Ends Should you terminate employment with the University, you can continue your Group Term Life coverage. You must apply and pay for coverage within 31 days after your coverage ends. Coverage continuation is subject to plan design and state availability so contact the HR Service Center at 205-348-7732 for more details.

http://www.standard.com/travel

https://www.standard.com/eforms/14684.pdf

http://www.everestfuneral.com/thestandard

http://www.standard.com/mytoolkit

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University-Paid Long Term Disability The University provides at no cost to eligible employees Long Term Disability (LTD) insurance through The Standard. Benefit Amount Your LTD coverage provides income replacement after a 90-day waiting period if you are unable to return to work due to a non-work- related injury or illness. LTD benefits are not payable during the 90-day waiting period. If your claim is approved by The Standard, benefits are payable on the 91st day from the date of disability. Your monthly benefit is 66 2/3% of your current salary not to exceed $10,000 per month for the first 90 days. After 90 days of benefit payments, the plan changes from 66 2/3% to 60% of your insured pre-disability earnings reduced by deductible income. Definition of Disability You are considered disabled and eligible for benefits if, after the waiting period and the 24-month own occupation period, you continue to meet the definition of disability under the plan. Maximum Benefit Period If you become disabled before age 62, LTD benefits may continue during disability until you reach age 65. If you become disabled at age 62 or older, the benefit duration is determined by your age when disability begins:

Age Maximum Benefit Period 62 3 years 6 months 63 3 years 64 2 years 6 months 65 2 years 66 1 year 9 months 67 1 year 6 months 68 1 year 3 months 69+ 1 year

When Benefits End LTD Benefits end automatically on the earliest of: • The date you are no longer disabled. • The date your maximum benefit period ends. • The date you die. • The date benefits become payable under any other LTD plan under which you become insured through employment during a period of temporary

recovery. • The date you fail to provide proof of continued disability and entitlement to benefits.

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Voluntary Short Term Disability The University offers a voluntary, Short Term Disability (STD) insurance to all full-time employees through The Standard. Benefit Amount Your STD coverage provides income replacement after a 14-day waiting period (Option 1) or 29-day waiting period (Option 2) if you are temporarily unable to return to work due to a non-work-related injury or illness. STD benefits are not payable during the applicable waiting period, but employees may use accrued sick leave during this time. If your claim is approved by The Standard, benefits are payable on the 15th or 30th day from the date of disability depending on your applicable waiting period. Your monthly benefit is 60% of your current salary not to exceed $1,000 per week for the first 90 days. After 90 days of benefit payments if you are still unable to return to work, you will be automatically transitioned to the University-Paid Long Term Disability (LTD) insurance. Definition of Disability You will be considered disabled if, as a result of physical disease, injury, pregnancy or mental disorder:

• You are unable to perform with reasonable continuity the material duties of your own occupation, and • You suffer a loss of at least 20 percent in your pre-disability earnings when working in your own occupation.

Premiums Monthly premiums are calculated based on salary and age. Use this formula to calculate your premium payment: _________________ x 0.60 x ___________________ / 10 = ______________________________ Enter your weekly earnings Enter your rate from the table below This is your estimated monthly premium Example: John is a 35-year-old employee with an annual salary of $60,000 and he elects Short Term Disability Option 1. What is his premium?

$60,000 / 52 weeks = $1,153.85 weekly earnings x 60% = $692.31 x $0.18 (rate for Option 1, Age < 54) / 10 = $12.46 per month

Option 1 (14-day waiting period)

Option 2 (29-day waiting period)

Your Age (as of January 1) Rate per $10 of weekly benefit Your Age (as of January 1) Rate per $10 of weekly benefit < 54 $0.18 < 54 $0.13

55 – 59 $0.24 55 – 59 $0.17 60 – 64 $0.29 60 – 64 $0.21 65 – 69 $0.31 65 – 69 $0.23 70 – 74 $0.35 70 – 74 $0.26

75+ $0.39 75+ $0.28 Late Enrollment Penalty Current employees were offered the option to enroll during Open Enrollment (November 1 – 15, 2019) for guaranteed issue. Employees who enrolled after this initial Open Enrollment period will be subject to a late enrollment penalty with a 60-day extended benefit waiting period for the first 12 months of coverage. Thereafter, the applicable benefit waiting period of 14- or 29-days will apply. New employees will have 60 days from date of hire to enroll without penalty. Deductible Income Limitations In order to receive benefits once disabled, the employee requesting short-term disability benefits must be in an unpaid status with The University (i.e., not currently receiving on-the-job injury benefits or sick leave, but annual leave and compensatory time are permissible). Your benefits will be reduced if you have deductible income, which is income you receive or are eligible to receive while receiving Short Term Disability benefits. When Benefits End STD Benefits end on the date any of the following occur:

• You are no longer disabled • Your maximum benefit period ends • Long term disability benefits become payable to you under a long term disability plan • Benefits become payable under any other disability insurance plan which you become insured through employment during a period of

temporary recovery • You fail to provide proof of continued disability and entitlement to benefits • You pass away

37

Voluntary Group Term Life and AD&D The University provides eligible employees the opportunity to purchase additional Group Term Life insurance and Accidental Death and Dismemberment (AD&D) insurance through The Standard Life Insurance Company. Additional coverage can help defray the loss of income and help your family maintain the household in the event of your death. You have the option of choosing your coverage amount and obtaining coverage for your spouse and dependent children. New employees can enroll in the plan during their first 60 days of employment with no medical questions.

Voluntary Term Life Insurance Coverage Options For You 1 to 5 times your basic annual

earnings (BAE) or, in $50,000 increments, to the lesser of 5 times BAE and $1,400,000

For Your Spouse $10,000 increments, to the lesser of employee’s voluntary Life amount and $150,000

For Your Dependent Children

$10,000 for dependent children up to age 26

Monthly Cost for Voluntary Term Life Insurance

Employee’s Age

Monthly Cost per $1,000 of Employee coverage

Monthly Cost per $1,000 of Spouse coverage

Under 25 $0.036 $0.036 25 - 29 $0.045 $0. 045 30 - 34 $0.054 $0.054 35 - 39 $0.071 $0.071 40 - 44 $0.091 $0.091 45 - 49 $0.136 $0.136 50 - 54 $0.208 $0.208 55 - 59 $0.359 $0.359 60 - 64 $0.553 $0.553 65 - 69 $0.993 $0.993 70 + $1.722 $1.722 Cost for all of your eligible Children $0.90 per month

Monthly Cost for Voluntary AD&D Insurance

Voluntary AD&D Benefit Amount

Monthly Cost Employee Only Plan $0.014 per $1,000

Monthly Cost Family Plan $0.019 per $1,000

$25,000 $0.35 $0.48 $50,000 $0.70 $0.95 $75,000 $1.05 $1.43 $100,000 $1.40 $1.90 $125,000 $1.75 $2.38 $150,000 $2.10 $2.85 $175,000 $2.45 $3.33 $200,000 $2.80 $3.80 $225,000 $3.15 $4.28 $250,000 $3.50 $4.75 $275,000 $3.85 $5.23 $300,000 $4.20 $5.70 $350,000 $4.90 $6.65 $400,000 $5.60 $7.60 $450,000 $6.30 $8.55 Max $500,000 $7.00 $9.50

Features of Voluntary Term Life Policy Life Services Toolkit The Life Services Toolkit provides you with a full suite of services and assistance that can be accessed 24 hours a day, seven days a week. The services include: Travel Assistance, Funeral Planning & Concierge Services, Digital Archive and Online Estate Planning at no additional cost to you. Accelerated Benefits Option You can receive up to 80% of your Voluntary Life insurance coverage amount to a maximum of $500,000 in the event that you become terminally ill and are diagnosed with less than 12 months to live. Waiver of Premiums for Disability Your life insurance coverage can be continued at no cost to you should you become unable to work due to total disability.

Features of Voluntary AD&D Policy Coverage Amounts for You Eligible employees can elect Voluntary AD&D insurance in increments of $25,000. The maximum amount of coverage you can receive is the lesser of 10 times earnings and $500,000. Coverage for Your Spouse and Children You can choose coverage for yourself, your spouse and/or your dependent children under the Family Plan. If you cover your Spouse and Dependent Child(ren):

• Spouse - Covered at 40% of your coverage amount • Child(ren) - 10% of your coverage amount

If you cover Spouse only - 50% of your coverage amount If you cover Child(ren) only - 15% of your coverage amount

How To Enroll You can enroll in the Voluntary Group Term Life and AD&D Insurance quickly and securely by using our online enrollment portal, BenefitFocus. Detailed instructions can be found in the Forms section.

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LifeLock Identity Theft Protection

The University of Alabama now offers identity theft protection from LifeLock with Norton Benefit Premier beginning January 1, 2021. LifeLock helps provide employees peace of mind with comprehensive protection for their identity, connected devices, and online privacy with SafeCam. Enhanced features include Home Title Monitoring, Bank Account Takeover Alerts and Three Bureau Credit Monitoring. If a potential identity threat is detected in our network, the employee is notified via email, text, phone or mobile app alerts.

LifeLock with Norton Benefit Premier also combines leading identity theft protection with device security and protection against online threats to help protect against identity thieves trying to steal personal information from PCs, Macs, and mobile devices. This plan also includes up to 50 GB of Norton Cloud Backup as a preventive measure to data loss due to hard drive failures and ransomware, Parental Controls to help members manage their kids’ online time and Password Manager to securely manage passwords and logins.

LifeLock Identity Protection features: Home Title Monitoring LifeLock Identity Alert System Credit, Bank & Utility Account Freezer Dark Web Monitoring LifeLock Privacy Monitor LifeLock Skill for Amazon Alexa 24/7 Live Member Support Identity Verification Monitoring Fictitious Identity Monitoring Bank & Credit Card Activity Alerts One-Bureau Monthly Credit Score Tracking Million Dollar Protection Package Stolen Wallet Protection Bank Account Takeover Alerts U.S.-Based Identity Restoration Specialists Checking & Savings Account Application Alerts One-Bureau Credit Application Alerts Three-Bureau Credit Monitoring 401K & Investment Account Activity Alerts Three-Bureau Annual Credit Reports & Scores Norton Device Security features: Parental Control SafeCam Cloud Backup Online Threat Protection Password Manager Smart Firewall

Premiums: Employee Only (18+ Years Old) - $8.89 per month

Employee + Family - $15.89 per month

How to enroll? Employees should login to myBama and select the BenefitFocus single sign-on link to elect this new benefit.

Family Documentation Requirement: Employees who select ‘Family’ coverage with LifeLock will be required to provide the following information for covered dependents upon enrollment: 1) full name, 2) date of birth, and 3) social security number. If your dependent’s information is already on file with BenefitFocus then additional dependent documentation will not be required.

Questions? Contact LifeLock with Norton Benefit Premier at 800-607-9174. Additional information is available online.

https://hr.ua.edu/benefits/lifelock

39

Retirement Plans The University of Alabama offers eligible employees a variety of retirement savings plans in order to help provide financial security during retirement. Eligible employees have three plans available – one mandated plan and two voluntary plans. Teachers’ Retirement System (TRS) – 401(a) The TRS plan is a defined benefit retirement plan governed by Internal Revenue Code 401(a). The 401(a) plan is mandated by the state and all eligible employees are required by law to contribute the following percentage of their gross annual salary to the Teachers’ Retirement System: • Individuals employed before January 1, 2013 are classified as Tier

1 employees and contribute 7.5%. Tier 1 employees are eligible for retirement benefits at age 60 with 10 years of participating service, or at any age with 25 years of participating service. Accumulated sick leave at retirement may be converted to additional service credit.

• Individuals employed on or after January 1, 2013 and have never previously contributed to TRS are classified as Tier 2 employees and contribute 6%. Tier 2 employees are eligible for retirement after 10 years of service at age 62. Accumulated sick leave at retirement cannot be converted to additional service credit.

In addition to the employee contribution, the University contributes a percentage which is determined by the Alabama Legislature. The 401(a) plan provides retired employees with a specific benefit payable monthly for the lifetime of the member. Upon service retirement, employees are also eligible to join the state’s Public Education Employee Health Insurance Plan (PEEHIP). Rates for this plan vary based on years of TRS service and age at retirement. Individuals who separate from employment before vesting in the program, or before qualifying to receive benefits, may request a refund of their contributions and applicable interest. University of Alabama System 403(b) Plan The University of Alabama System 403(b) Plan is a voluntary retirement savings plan that is governed by Internal Revenue Code 403(b). TIAA is the vendor currently offering 403(b) accounts to University employees. The University’s 403(b) plan allows eligible employees to invest in a wide variety of mutual funds. Most employee contributions are made on a pre-tax basis and accumulate tax-free until withdrawal, but Roth post-tax contributions are available. The University provides a matching contribution of up to 5% of gross monthly pay for all regular full-time faculty and exempt staff. Employees may enroll in the 403(b) retirement plan via single sign-on in MyBama by selecting the TIAA logo under ‘Voluntary Retirement Savings Plans’ in the Employee tab.

University of Alabama 457(b) Plans The University of Alabama’s 457(b) plans are voluntary deferred compensation plans governed by Internal Revenue Code 457(b). The Retirement Systems of Alabama and TIAA are the two service providers currently offering 457(b) accounts to University employees. The plans allow eligible employees to invest a portion of their salary until some later date, usually at retirement or termination of employment. Most employee contributions are made on a pre-tax basis and accumulate tax-free until withdrawal, but Roth post-tax contributions are available. Employees may enroll in the 457(b) retirement plan via single sign-on in MyBama by selecting the TIAA logo under ‘Voluntary Retirement Savings Plans’ in the Employee tab. Key Points for 403(b) and 457(b) Plans • The University’s 403(b) and 457(b) plans accept both pre-tax and

Roth post-tax contributions. The 403(b) Plan also accepts post-tax contributions.

• Employees may participate in both 403(b) and 457(b) plans in the same year. Participants can contribute a maximum of $19,500 to each plan using a combination of pre-tax and Roth post-tax contributions, or $39,000 total in 2021. For employees who have reached age 50, the maximum would be $26,000 to each plan, or $52,000 total in 2021. Additional post-tax contributions can be made to the 403(b) plan.

• Since the University’s 403(b) and the 457(b) are qualified retirement savings plans, they both have certain restrictions on withdrawals before retirement age.

• The 403(b) plan restricts withdrawals by participants who are under age 59 ½ by imposing a 10% tax penalty.

• The 457(b) plan does not contain the early retirement withdrawal penalty applicable to the 403(b) plan, but the 457(b) cannot be withdrawn while currently employed by UA.

• The 457(b) plan might work better for someone who wants to contribute substantially more as s/he nears retirement, because of more generous catch-up provisions.

Summary Category 403(b) Plan 457(b) Plan Pre-tax contributions Yes Yes Post-tax contributions Yes No Roth post-tax contributions Yes Yes Match contributions 5% NA Pre-tax/Roth post-tax annual limit $19,500 * $19,500 * *Annual limit for participants age 50+ is $26,000

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Educational Benefit Program The University of Alabama offers educational benefits to eligible employees. Additional information, including a link to the official policy, is available on the Human Resources website at https://hr.ua.edu/wellness-work-life/financial-wellness/educational-benefit. Who is eligible? • All regular (not temporary) full-time and part-time employees • Spouses and child dependents after the employee completes six (6)

months of continuous eligible employment • All University retirees, the spouses, and child dependents of retirees

(if eligible on last day before retirement) What is covered for employees? • Full-time employees - The educational benefit provides eligible full-

time employees an amount to assist with educational costs equal to 100% of the tuition costs for up to three (3) credit hours during the fall semester, three (3) credit hours during the spring semester, and up to six (6) credit hours during the summer terms at the undergraduate or graduate campus resident tuition rate. All other hours taken will result in assistance at an amount equal to 50% of the tuition costs at the undergraduate or graduate campus resident tuition rate. The applicable rate is based on the classification of the enrolled student; i.e. undergraduate or graduate.

• Part-time employees - Eligible part-time employees will receive a prorated amount of educational assistance based upon their full-time equivalency (FTE). For example: an eligible part-time employee of .50 FTE would be eligible for an amount equal to 50% of the tuition costs for up to three (3) credit hours in the fall and spring semesters and for 50% for up to six (6) credit hours in the summer term, and for 25% for all other credit hours at the undergraduate or graduate campus resident tuition rate. The applicable rate is based on the enrolled student's classification; i.e. undergraduate or, graduate.

What is covered for employee dependents? • Spouses and child dependents - After eligible employees have

been employed six (6) continuous months, spouses and/or children may receive an amount to assist with educational costs up to the maximum of 50% of the undergraduate or graduate campus resident tuition rate. The applicable rate is based on the classification of the enrolled student; i.e. undergraduate or graduate. If the sponsoring employee is a regular part-time employee this benefit is prorated based on the employee's FTE. Child dependents must be unmarried and under age 26 on the first day of classes.

How do I apply? 1. All applicants must obtain admission to The University of Alabama in

accordance with usual academic rules. You may contact the Office of Admissions for assistance with this process.

2. Applicants should complete an online application at least one month prior to the beginning of the academic year. • Applications are available on the HR website:

https://hr.ua.edu/hr-forms • Employee - complete Employee Information Section and

Applicant Section. In the applicant section, the eligible student’s CWID is required for dependents.

• Only one application per student is necessary for the academic year which begins with the fall semester and ends with the summer term.

3. Eligible employees and dependents will receive the benefit as a credit applied to the enrolled student's account maintained by the Office of Student Account Services.

Things to remember:

• The deadline to apply for the benefit each semester corresponds to the ‘Last Day to Add a Course or Drop a Course Without a Grade of “W” for the Full Term‘ per the University Registrar’s Academic Calendar.

• Higher tuition rates for enrolled in specialized graduate programs, including but not limited to law, medical, executive doctoral programs, etc., do not entitle the covered dependents to amounts above the undergraduate or graduate campus resident tuition rate.

• The employee must be in an eligible employment status through the first day of classes to receive an educational benefit for the fall semester, spring semester or summer terms. If it is later determined that the employee was not eligible, the educational benefit will be recalled, and the appropriate charges will be billed to the employee’s student account. Employees are responsible for notifying the HR Service Center of any information that may affect eligibility for the educational benefit.

• If the employee terminates employment with the University or a

dependent becomes ineligible during the course of the term, the educational benefit will remain in effect for the remainder of that term only.

• Book fees and other course related fees, such as laboratory or engineering equipment fees, etc. are not covered by this policy and must be paid by the student.

• This educational benefit applies to The University of Alabama

only. The University does not have a reciprocity agreement with The University of Alabama at Birmingham or The University of Alabama in Huntsville.

• Education benefits received by University employees and/or

dependents may be taxable to the employee. For those educational benefits which are taxable, Federal, State, and Social Security taxes will be withheld from the employee’s payroll checks at the end of each semester in which the dependent was enrolled and received an educational benefit. This will usually occur in May for the spring semester, August for the summer semesters, and November for the fall semester. The following three (3) groups are subject to income and employment tax withholding:

o A spouse/child who is a GRADUATE student (**taxation does not apply to qualified Teaching Assistants or Research Assistants)

o A spouse/child who is NOT AN IRS TAX DEPENDENT of the eligible employee, per Section 152 of the Internal Revenue Code

o An employee who is a GRADUATE student is subject to tax withholding for tuition benefits paid in excess of the IRS limit of $5,250 per calendar year, per IRC Section 127. (**an exception may apply in limited cases if the education qualifies as a working condition fringe benefit per IRC Section 132 and 162.

https://hr.ua.edu/wellness-work-life/financial-wellness/educational-benefit

https://hr.ua.edu/hr-forms

https://registrar.ua.edu/academiccalendar/

https://registrar.ua.edu/academiccalendar/

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WellBama WellBAMA is The University of Alabama’s signature health and wellness program for eligible faculty and staff. Designed to promote health and improve the quality of life for employees, program includes confidential health screening, health coaching, and a preventive examination, along with a wide range of resources and programs to motivate and support individual health goals. The program was designed to create and sustain a culture of health and well-being for faculty and staff. The Wellness and Work-Life office administers WellBAMA and offers additional services through a partnership with the College of Community Health Sciences, College of Capstone Nursing, University Recreation Center and the Benefit office. WellBAMA offers: Health Screenings Confidential, free health screenings by qualified health professionals. The screening takes approximately 20 minutes. A small sample of blood is taking via fingerstick for lab work to evaluate cholesterol, glucose and triglyceride levels. Additionally, body measurements, blood pressure and a health history are taken. Participation in the WellBAMA health screening includes a financial WellBAMA Reward. WellBAMA program is confidential, voluntary and strongly encouraged. Health screenings are offered at specific times, dates and locations throughout campus, with full details listed at www.wellness.ua.edu or contact the Wellness and Work-Life office at 205-348-0077. Health Coaching Immediately following the health screening, participants meet with a health coach to review results and discuss concerns. With fitness, nutrition and life balance in mind, health coaches help participants understand their current level of health, identify health goals to create a customized plan to achieve these goals, and provide resources and programs available for optimal health and wellness. Programs WellBAMA is the foundation program of the Office of Work-Life and Wellness, which offers a range of programs to inspire, support and motivate employees throughout the year. Designed to promote, motivate and support individual health goals and improve the quality of life for employees throughout the year. The current programs offered include:

• Strive for Five • Crimson Couch to 5K Training • Sleep More, Stress Less • Better Bites • MoveSpring Activity Challenges • Financial Wellness Seminars

All OHPW programs include access to nutritional tips, counseling and education, in addition to materials that support individual and team-based health and wellness initiatives. Full program details can be found at www.wellness.ua.edu. Wellness Classes 45-minute educational sessions are offered year-round covering a multitude of topics from mental health, exercise, nutrition and disease management to general wellness. Contact Details Office of Work-Life and Wellness wellness.ua.edu 205-348-0077



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Employee Assistance Plan (EAP) American Behavioral is a full-service behavioral health care organization with a nationwide network of licensed and credentialed providers in 38 specialties. The Employee Assistance Program (EAP) offers confidential assessment and short-term, professional counseling services. Eligible employees and dependents may receive up to five (5) free face-to-face sessions per episode per year to address pressures associated with marital and family issues, grief and loss, interpersonal relationship difficulties and more. American Behavioral also provides unlimited access to scheduled telephonic counseling or coaching sessions. What kind of issues does my EAP address? The University of Alabama’s Employee Assistance Program (EAP) is an employee assistance and counseling program designed to provide eligible employees and their family members with resources for resolving work-related and personal problems that interfere with everyday living. Available services include:

• Marital and Relational Concerns • Parent-Child • Behavioral Problems of Child • Mental Health and Substance Abuse • Emotional and Stress-Related • Job-Related • Personal and Household Budgeting • Extended Family

How does the program work? When someone calls EAP, he/she will be scheduled for an appointment to talk with one of our counselors. It’s as simple as that. In the event their issues are beyond the scope of EAP services, you will be assisted with finding other agencies or professionals who can help. Every effort will be made to not only find an excellent match between client and provider, but takes into account insurance needs as well. When there is a need after traditional office hours, an EAP counselor is just a phone call away. The local and toll-free numbers are answered, live, 24 hours a day. The caller will be connected to the counselor on call who will speak with you personally.

How do I contact EAP?

To find out more information about how the EAP may help you or to schedule an appointment, contact American Behavioral:

Toll-free: (800) 925-5327

Visit www.americanbehavioral.com and click on Member Login. To register, use the company name UofA to create your username and password.

Employees can also utilize the robust American Behavioral website which offers webinars and additional resources on topics like work-life, elder care, legal and financial assistance.

http://www.americanbehavioral.com/

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Current Rates

Medical Rates (Plan Administered by BCBS of Alabama)

BCBS PREFERRED PROVIDER ORGANIZATION (PPO)

Employee Biweekly Paid Monthly Paid

$53.54 $116.00

Family without Spouse Coverage Biweekly Paid Monthly Paid

$187.38 $387.23

Family with Spouse Coverage: Biweekly Paid Monthly Paid

$220.62 $478.00

BCBS HIGH DEDUCTIBLE HEALTH PLAN (HDHP)

Employee Biweekly Paid Monthly Paid

$26.31 $ 57.00

Family without Spouse Coverage Biweekly Paid Monthly Paid

$91.38 $198.00

Family with Spouse Coverage Biweekly Paid Monthly Paid

$108.00 $234.00

Dental Rates (Plan Administered by BCBS of Alabama)

MONTHLY RATES:

Employee Coverage: $28.38

Employee + 1 Coverage: $55.60

Family Coverage: $80.58

Vision Rates (Plan Administered by UnitedHealthcare)

MONTHLY RATES:

Employee Coverage: $5.74

Employee + 1 Coverage: $10.59

Family Coverage: $18.52

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BenefitFocus: How To Enroll in Benefits Employees can initiate enrollment in The University of Alabama’s Benefits plan through BenefitFocus, our on-line enrollment portal. Follow these step-by-step instructions to begin your enrollment: 1. Go to http://mybama.ua.edu/ and login using your myBama username and password.

2. Under the Employee tab, click on the logo in the center of the screen. 3. Once you log in to the portal and see the welcome screen, you should click the green box that says “New Hires Enroll Here” on the right side of the screen. 4. You will be guided through each page in order to enroll or decline participation in medical, dental, vision, and flexible spending accounts. You will be prompted to enter demographic information for each dependent that you will be enrolling on each plan. 5. You will also be prompted to enroll in the death and disability benefits. You will not be able to decline the University-paid benefits. You will be required to designate beneficiaries for the life insurance benefits that you elect. 6. Once all of your options are selected, the system will notify you when your enrollment is complete and you will be able to view/print a summary of your elections. *IMPORTANT: Documentation is required to enroll dependents on your medical plans. You can upload electronic copies of your required documentation through the “My Document Center” link located on the welcome screen. If documentation is required, your enrollment will not be complete until all of your documentation is received and approved.

http://mybama.ua.edu/

https://hr.ua.edu/benefits/benefits-eligibility

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BenefitFocus: How to Make Changes to Your Benefits Qualifying Life Events Employees have the option to make changes to their benefits within 30 days of a qualifying life event (i.e. marriage, divorce, birth of a child, unpaid leave of absence, etc.). Failure to make changes within the 30-day time frame will require the employee to wait until the next annual open enrollment period to change current coverage(s). 1. If you are using the BenefitFocus portal for the first time, follow steps 1 through 3 of How To Enroll in Benefits by clicking the green button labeled “New Hires Enroll Here” on the right side of the screen. If you have used BenefitFocus, select the blue button labeled “Review or Change Your Current Benefits.” 2. Once logged into the portal, on the left side of the screen, under "Manage Account", click on the box that says "Life Change". 3. Select a reason for changing your benefits from the drop down list and enter the date of the qualifying event. 4. Click the “Edit coverage” box under each benefit that you wish to change. You will be able to add or remove dependents and/or change your coverage levels by clicking the appropriate icon. Be sure to save your changes. 5. Once your changes are saved, you will be prompted to upload any required documentation through the Document Manager. Once you have completed your enrollment, you will be able to view/print an Employee Detail Summary that lists all of your benefits elections. Please remember that all of your elections are subject to approval by the Benefits Office pending verification of all required documentation. You will receive a confirmation e-mail when your enrollment is complete.

https://hr.ua.edu/benefits/benefits-eligibility

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Continuation of Coverage Notice

*** VERY IMPORTANT NOTICE *** COBRA CONTINUATION OF COVERAGE

A Federal Law (Public Law 99-272, Title X, commonly known as C.O.B.R.A.) requires that most employers sponsoring group health plans offer employees and their families the opportunity for temporary extension of health coverage (called “continuation of coverage”) at group rates in certain instances where coverage under the plan would otherwise end. The Health Insurance Portability and Accountability Act (HIPAA) of 1996, made changes to three areas of the C.O.B.R.A. continuation coverage rules. This notice is intended to inform you, in a summary fashion, of your rights and obligations under the C.O.B.R.A. continuation coverage provisions. Both you and your spouse/dependents (if any) should take time to read this notice carefully. If you are covered under our group health plan, you have the right to choose this continuation coverage if you lose your group health coverage because of reduction in your hours of employment or the termination of your employment (for reasons other than gross misconduct on your part). Individuals entitled to C.O.B.R.A. continuation coverage are called qualified beneficiaries. Individuals who may be qualified beneficiaries are the spouse and dependent children of a covered employee and, in certain cases, the covered employee. In order to be a qualified beneficiary, an individual must generally be covered under a group health program on the day before the event that caused a loss of coverage (such as a termination of employment, divorce from or death of a covered employee). A child who is born to the covered employee or who is placed for adoption with the covered employee, during a period of C.O.B.R.A. continuation coverage, is also a qualified beneficiary. If you are the spouse of an employee covered by our group health plan, you have the right to choose continuation coverage under C.O.B.R.A. for yourself if you lose group health coverage under our group health plan for any of the following reasons:

1. The death of your spouse; 2. A termination of your spouse’s employment (for reasons other than gross misconduct) or reduction in your spouse’s hours of

employment; 3. Divorce or legal separation from your spouse; or 4. Your spouse becomes entitled to Medicare.

In the case of a dependent child of an employee covered by our group health plan, he or she has the right to C.O.B.R.A. continuation coverage if group health coverage under our group health plan is lost for any of the following reasons:

1. The death of a parent; 2. A termination of a parent’s employment (for reasons other than misconduct) or reduction in a parent’s hours of employment; 3. Parents divorce or legal separation; 4. A parent becomes entitled to Medicare; or 5. The dependent ceases to be a “dependent child” under the provisions of our group plan.

A child born to or placed for adoption with the covered employee during COBRA coverage is also a qualified beneficiary with all rights of any other qualified beneficiary. Disability: Under current law, C.O.B.R.A. continuation coverage is available for 18 months for an individual entitled to C.O.B.R.A. because termination of employment or reduction of hours of employment. However, if the individual entitled to C.O.B.R.A. is disabled (as determined under Social Security Act) at the time of termination of employment or reduction in hours, the C.O.B.R.A. coverage period may be extended to 29 months. The disability extension will also apply if the individual becomes disabled at any time during the first 60 days of C.O.B.R.A. continuation coverage. The law also provides that non-disabled family members who are qualified beneficiaries (as previously defined) entitled to C.O.B.R.A. are also entitled to the 29 months disability extension. Under the law, you (the employee or your spouse/dependent) have the responsibility to inform the employer of a divorce, legal separation, or a child losing dependent status under the group health plan within 30 days of the event.

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When we are notified by you that a qualifying event has happened, we will provide you with information regarding your right to choose continuation coverage. Under current law, you have at least 60 days from the date you would lose coverage to elect continuation coverage. If you do not choose continuation coverage within 60 days, your health coverage will end. If you choose continuation coverage within 60 days, your C.O.B.R.A. will become effective and you will owe premiums from the date you otherwise would have lost coverage. If you choose continuation coverage, we are required to give you coverage which, as of the time coverage is being provided, is identical to the coverage provided under the program to similarly situated employees or family members. The law requires that you be afforded the opportunity to maintain continuation coverage for 36 months unless you lost health coverage because of a termination of employment or reduction in hours. In this case, the coverage period is 18 months. This 18 months period may be extended if other events (for example – divorce, legal separation, or death) occur during that 18 months period. In no event will coverage last beyond 36 months from the date of the event that originally made you eligible to elect coverage. The law also provides that your continuation coverage may be cut short for any of the following reasons:

1. We no longer provide group health coverage to any of our employees. 2. The premium for your continuation coverage is not paid on time (within the applicable grace period). 3. After electing C.O.B.R.A. you become covered under another health plan that does not contain any pre-existing condition limitations or

exclusions that is not satisfied by the Health Insurance Portability and Accountability Act of 1996. 4. After electing C.O.B.R.A. you become entitled to Medicare. 5. Coverage has been extended for up to 29 months due to disability and a final determination has been made that the individual is no

longer disabled. You do not have to show that you are insurable to choose continuation coverage. However, under the law, you will have to pay all or part of the premium for your continuation coverage. There is a grace period of 30 days for the regularly scheduled premium. Once your continuation coverage terminates for any reason, it cannot be reinstated. Please contact the HR Service Center (205) 348-7732 if you have questions about this letter or any other provision about COBRA.

Documents

Welcome [hr.ua.edu] · Medical coverage offers valuable benefits to help you stay healthy and pay for care if you or your covered family members become sick or injured. UA offers