come together - mercyhealth

2017 Mercyhealth Benefits Enrollment

Come Together

2017

Table of Contents

Welcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Health insurance benefits overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Domestic partner coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

MercyCare EPO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

EPO Summary of coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

MercyCare EPO HDHP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

EPO HDHP Summary of coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

MercyCare PPO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

PPO Summary of coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

MercyCare PPO HDHP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

PPO HDHP Summary of coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

CHIP notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Prescription drug coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Dental insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Life insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Mercy Health Corporation Employees’ Retirement Plan . . . . . . . . . . . . . . . . . . . . . . . . . 19

Flex spending plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Voluntery benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Vision appliance insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Short term disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Long term disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Important contact information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Qualifying event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Mercyhealth Benefits

Welcome to our 2017 Partner Benefit BookWhether you are reviewing this at Open Enrollment or if you’re a new partner, this book is filled with important information for you and your family .

Our partners are our most valuable resource . As such, Mercyhealth is committed to offering a comprehensive benefit program with multiple options to meet our partners’ varied needs . Health and dental premiums are paid with pre-tax dollars and we offer multiple ways for you to set aside other pre-tax dollars with flexible spending and health savings accounts . Some benefits are paid completely by Mercyhealth, some of the cost is shared, and for a few voluntary options, you would pay the entire cost, but enjoy the benefit of group pricing .

We encourage you to review the materials thoroughly and make your decisions carefully . Please contact your human resource representatives if you would like additional information or have any questions about benefits, policies or services .

Coverage begins: For open enrollment, January 1, 2017 .

For a new partner, or newly benefit-eligible partner, coverage begins under the following schedule:

First of the month following 30-days of employment or eligibility • Health Insurance • Dental Insurance • Vision Insurance • MetLife critical illness, accident, hospitalization and

pet insurance • Flex Spending Accounts

First of the month following 90-days of employment or eligibility • Life Insurance

• Universal Life Insurance

• Short Term Disability

• Long Term Disability

Important to notePlease refer to the summary plan descriptions or plan documents for additional information . If there happens to be a conflict between this material and the plan documents, the plan documents govern .

1

Be sure to readthis booklet carefully before making your benefit selections .

This booklet is a summary of benefits available .

Contact Human Resources for additional information .

The programs and policies can be modified, changed or discontinued at any time at the discretion of Mercyhealth .

Health insurance benefits overviewVendor: MercyCare

You and Mercyhealth share responsibility for the cost of health care coverage for you, your spouse/ domestic partner, and qualified dependents . Under the Affordable Care Act, eligibility is determined by the number of hours you work over a pre-determined eligibility period . Partners who work an average of 30 hours per week or more, are considered full-time for health insurance premium purposes .

Partners who work an average of 20-29 hours per week, are considered part-time for health insurance premium purposes . Your premium contribution also depends on who is covered and the type of plan you choose .

Partners and their spouse/domestic partner enrolling in health insurance who are tobacco-free will be eligible for a reduction in health insurance premium . To receive the appropriate premium, partners and their spouse/domestic partner must attest they are tobacco-free when enrolling online .

Partners eligible for health insurance who choose not to elect coverage are required to waive coverage . Partners who do not enroll or waive coverage will automatically be enrolled in the MercyCare EPO HDHP plan .

2

Non-Tobacco User Tobacco User

MercyCare EPO

Full-Time

Part-Time

Partner +Child(ren)

Single

Partner+ Spouse

Family

Partner +Child(ren)

Single

Partner+ Spouse

Family $1,114 .36

$639 .00

$733 .06

$344 .50

$988 .08

$569 .08

$651 .88

$309 .54

$837 .20

$485 .48

$555 .12

$267 .74

$763 .31

$443 .12

$507 .86

$246 .56

$1,064 .36

$589 .00

$683 .06

$294 .50

$938 .08

$519 .08

$601 .88

$259 .54

$787 .20

$435 .48

$505 .12

$217 .74

$713 .31

$393 .12

$457 .86

$196 .56

$699 .00

$391 .00

$466 .50

$220 .50

$622 .00

$350 .52

$417 .00

$200 .26

$530 .00

$302 .12

$358 .00

$139 .52

$470 .67

$268 .40

$320 .02

$159 .20

$649 .00

$341 .00

$416 .50

$170 .50

$572 .00

$300 .52

$367 .00

$150 .26

$480 .00

$252 .12

$308 .00

$89 .52

$420 .67

$218 .40

$270 .02

$109 .20

MercyCare EPO HDHP

MercyCare PPO

MercyCare PPO HDHP

MercyCare EPO

MercyCare EPO HDHP

MercyCare PPO

MercyCare PPO HDHP

Monthly Premium Contributions

Self-Employed Family Members: MercyCare insurance plans do not cover healthcare costs related to injuries on the job . Mercyhealth partners with self-employed family members are advised to obtain workers compensation coverage of those members who are on the partner’s MercyCare Plan .

Domestic partner coverageA domestic partner:

• is a person of the same or opposite gender as a Mercyhealth employee; the partner must be emotionally committed to each other and intend to remain each other’s interdependent domestic partner indefinitely . Tangible demonstration of interdependence may be achieved by the following:

• Common ownership of property;

• Common ownership of a motor vehicle;

• Proof of joint bank accounts or credit accounts;

• Proof of a partner being designated as primary beneficiary for life benefits;

• Assignment of a durable property or health care Power of Attorney to each other;

• and Mercyhealth employee must both be at least 18 years of age or older and be mentally competent to enter into a contractual agreement;

• must have the same place of residence as a Mercyhealth employee and have cohabitated there for a minimum of 12 months, with the intent of doing so permanently;

• is not legally married or involved in another domestic partnership within the last 12 months;

• is jointly responsible for each other’s welfare and financial obligations; and

• is not related to the Mercyhealth partner by blood closer than would bar marriage in the state where he or she resides .

Children of domestic partners are eligible for health and dental insurance coverage . Benefit eligibility requirements are the same .

The employer portion of the insurance premium that covers domestic partners and their children will be considered taxable income to the employee .

Domestic partners and children of domestic partners are not eligible for COBRA benefits should they lose coverage for any reason .

Domestic Partner Certification: All Mercyhealth employees wishing to add a domestic partner and any domestic partner child(ren) to their health or dental plan will need to complete a “Certification of Domestic Partnership” form which is available in the human resource department .

Cancel Date of Domestic Partner Coverage: In the event the domestic partnership is terminated, you must notify the human resource department within 30 days . Insurance coverage will end at the end of the month in which the termination occurred .

Domestic partners of Mercyhealth employees are only eligible for Mercyhealth health and dental insurance coverage . Domestic partners are not eligible for any other Mercyhealth benefits including, flex benefit plans, life insurance, and voluntary benefit plans .

Health insurance eligibility for adult child(ren)Your adult child(ren) can be added to your MercyCare health insurance plan at the time of hire, qualifying event or open enrollment if they are less than 26 years old (regardless of marital status) .

Your adult child(ren) can choose to stay on your (parent’s) health plan until the end of the month they turn age 26, even if they are eligible for their own employer-sponsored insurance plan .

Military Dependent- requires individual consultation .

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MercyCare EPO summary of benefitsThe foundation of MercyCare Health Plans is to partner our members with a Primary Care Physician (PCP) who will coordinate and manage your medical care in a quality, professional manner with a passion for making lives better . All MercyCare plans require members to use our provider network established except in the case of emergency care .

Provider network A group of providers contracted with the plan to provide services for members within a specific geographic location (as specified in MercyCare’s Provider Directory) . Participating provider means that provider is listed in the MercyCare provider directory and he or she is a participating provider in that specific network .

Choosing a Primary Care Physician (PCP) A PCP is a doctor who practices in one or more of these primary care fields: Family Medicine, Internal Medicine and Pediatrics . Each family member must select a doctor in one of these fields . Women may also select an OB/GYN for routine gynecologic and obstetrical care, and must also select a PCP for all other care . Please refer to our Provider Directory for a complete list of network PCPs .

Specialist providers MercyCare Health Plan has a comprehensive list of specialists and hundreds of sub-specialists to meet the health care needs for you and your family . You do not need a referral from your PCP to see any of our network specialists, but we encourage you to coordinate specialist care with your PCP .

Emergency care Members who have a medical emergency within the MercyCare service area should, if possible, seek immediate attention at the nearest network provider . If a medical emergency happens outside the MercyCare service area, you should seek care at the nearest emergency facility . Please notify MercyCare within 48 hours, or as soon as possible .

MercyCare EPOMonthly premium contribution

Non-Tobacco UserMercyCare EPO

Full-Time

Part-Time

Partner +Child(ren)

Single

Partner+ Spouse

Family

Partner +Child(ren)

Single

Partner+ Spouse

Family $763 .31

$443 .12

$507 .86

$246 .56

$713 .31

$393 .12

$457 .86

$196 .56

$470 .67

$268 .40

$320 .02

$159 .20

$420 .67

$218 .40

$270 .02

$109 .20

Tobacco UserMercyCare EPO

4

Deductible

Coinsurance

Office visit charge-Primary Care Provider

Office visit charge-Specialist

Medical maximum out-of-pocket

RX maximum out-of-pocket

Preventive Services

Diagnostic Services (lab and x-ray) includes office location

Hospital inpatient services**

Hospital outpatient services**

Emergency room charge (waived upon admission)

Ambulance

Urgent and Immediate care charge

Mental health inpatient**

Mental health day treatment**

Mental health outpatient

Durable medical equipment & prosthetics

Physical, Speech and Occupational therapy

Stay Healthy Benefit

$0 Single, $0 Family

10 % coinsurance

$30 Copay

$40 Copay

$3,000 Single, $6,000 Family


$0

10 % coinsurance

$750 copay per hospital admission per stay per member . 10 % coinsurance

10 % coinsurance

$100 Copay

$0

$50 Copay


10 % coinsurance

$40 Copay

20 % coinsurance

10 % coinsurance

$200 maximum benefit per year per adult / $400 maximum per family

N/A

N/A

N/A

N/A

N/A

N/A

Not Covered

Not Covered

Not Covered

Not Covered

$100 Copay

$0

$60 Copay

Not Covered

Not Covered

Not Covered

Not Covered

Not Covered

N/A

Non-Network ProvidersYou Pay

** Prior authorization required for these services

Tier 1

Tier 2

Tier 3

Tier 4

Prescription drug coverage

$15 Copay

$30 copay or 20% coinsurance up to max $50


25% Coinsurance

Not Covered

Not Covered

Not Covered

Not Covered

Network ProvidersYou Pay

These benefits are a partial outline of health services under the Policy . Refer to your Schedule of Benefits for applicable limits regarding these health services . If differences exist between this Summary and the Summary Plan Description (SPD), the SPD governs .

5

EPO Summary of coverage

MercyCare EPO HDHP summary of benefitsThe foundation of MercyCare Health Plans is to partner our members with a Primary Care Physician (PCP) who will coordinate and manage your medical care in a quality, professional manner with a passion for making lives better . All MercyCare plans require members to use our provider network established except in the case of emergency care .

Provider network A group of providers contracted with the plan to provide services for members within a specific geographic location (as specified in MercyCare’s Provider Directory) . Participating provider means that provider is listed in the MercyCare provider directory and he or she is a participating provider in that specific network .

Choosing a Primary Care Physician (PCP) A PCP is a doctor who practices in one or more of these primary care fields: Family Medicine, Internal Medicine and Pediatrics . Each family member must select a doctor in one of these fields . Women may also select an OB/GYN for routine gynecologic and obstetrical care, and must also select a PCP for all other care . Please refer to our Provider Directory for a complete list of network PCPs .

Specialist providers MercyCare Health Plan has a comprehensive list of specialists and hundreds of sub-specialists to meet the health care needs for you and your family . You do not need a referral from your PCP to see any of our network specialists, but we encourage you to coordinate specialist care with your PCP .

Emergency care Members who have a medical emergency within the MercyCare service area should, if possible, seek immediate attention at the nearest network provider . If a medical emergency happens outside the MercyCare service area, you should seek care at the nearest emergency facility . Please notify MercyCare within 48 hours, or as soon as possible .

MercyCare EPO HDHPMonthly premium contribution

6

Non-Tobacco UserMercyCare EPO HDHP

Full-Time

Part-Time

Partner +Child(ren)

Single

Partner+ Spouse

Family

Partner +Child(ren)

Single

Partner+ Spouse

Family $837 .20

$485 .48

$555 .12

$267 .74

$787 .20

$435 .48

$505 .12

$217 .74

$530 .00

$302 .12

$358 .00

$139 .52

$480 .00

$252 .12

$308 .00

$89 .52

Tobacco UserMercyCare EPO HDHP


7

Deductible

Coinsurance

Office visit charge-Primary Care Provider

Office visit charge-Specialist

Medical maximum out-of-pocket

RX maximum out-of-pocket

Preventive Services

Diagnostic Services (lab and x-ray)




Ambulance

Urgent care charge




Durable medical equipment




0 % coinsurance after deductible




N/A

$0












N/A

N/A

N/A

N/A

N/A

N/A

Not Covered

Not Covered

Not Covered

Not Covered




Not Covered

Not Covered

Not Covered

Not Covered

Not Covered

Non-Network ProvidersYou Pay


Tier 1-4


0 % coinsurance after deductible Not Covered

Network ProvidersYou Pay

Health Savings Account (HSA) Partners choosing this plan have the option to participate and make contributions to a health savings account . The money you contribute to your HSA is portable, meaning it is not subject to the “use it or lose it” rules the Flex Spending Accounts (FSA) have and can be carried over from year to year . Partners that choose to participate in this plan and also participate in the Mercyhealth Flex Spending Account will be required to participate in a limited purpose Flex Spending Account .

EPO HDHP Summary of coverage

$200 maximum benefit per adult / $400 maximum per family

MercyCare PPO Coverage Levels and ProvidersLEVEL 1: MercyCare PPO provides the highest level of benefits whenever you obtain health care services from a Mercyhealth provider . Level 1 providers are located in the provider directory . The highest level of benefit is described in the Level 1 Benefits column of the Schedule of Benefits . 1. On the web, go to www .mercycarehealthplans .com . 2. Click on Find a Doctor/Facility . 3. Select a plan (MercyCare PPO) and then follow the instructions .

LEVEL 2: Level 2 providers are those who are not Level 1 providers but are found in the First Health network of providers . When you use this level of benefits, you pay a greater share of the cost of health care services you receive . This level of benefit is described in the Level 2 Benefits column of the Schedule of Benefits . On the web go to www .firsthealth .com to find the providers who are participating at this level . Please be aware that even though the following provider/hospital groups may be found on the First Health website, they are not available to you as a Level 2 provider. These include: Aurora Health Care, Beloit Health System, SSM Health – formerly Dean Health System/St. Mary’s Hospital, OSF HealthCare System, Swedish American HealthSystem.

LEVEL 3: A Level 3 provider is any provider who is not listed in the MercyCare directory or on the First Health website . When you use this level of benefits, you will pay the greatest share of the cost of health care services you receive . Level 3 Benefits are subject to usual and customary charge limitations . This level of benefit is described in the Level 3 Benefits column of the Schedule of Benefits .

Referral Requirements for Level 1 Benefits: In order to obtain Level 1 Benefits for specialty services and treatment that cannot be obtained from a provider listed in our provider directory the following is required:

• A referral from your Level 1 or Level 2 provider, and;• prior approval from the Plan

The referring provider and the Quality Health Management Department will determine the duration of the referral or the number of visits authorized based on what is medically appropriate . If a referral is not approved by the Quality Health Management Department, it is not considered valid and the services are not considered authorized . The Plan reserves the right to direct you to a specialist of its choice .

MercyCare PPOMonthly premium contribution

8

Non-Tobacco UserMercyCare PPO

Full-Time

Part-Time

Partner +Child(ren)

Single

Partner+ Spouse

Family

Partner +Child(ren)

Single

Partner+ Spouse

Family $988 .08

$569 .08

$651 .88

$309 .54

$938 .08

$519 .08

$601 .88

$259 .54

$622 .00

$350 .52

$417 .00

$200 .26

$572 .00

$300 .52

$367 .00

$150 .26

Tobacco UserMercyCare PPO


9

Deductible

Coinsurance

Office visit charge-primary care provider

Office visit charge-specialist

Medical MOOP (Level 1 and Level 2 combined)

RX MOOP

Preventive services

Diagnostic services (lab and x-ray), includes office location




Ambulance

Urgent care charge








15 % coinsurance

$30 Copay

$40 Copay



$0

15 % coinsurance


15 % coinsurance

$100 Copay

$0

$50 Copay


15 % coinsurance

$40 Copay

20 % coinsurance

15 % coinsurance


25 % coinsurance

$50 Copay

$60 Copay

$0

25 % coinsurance

$1,600 copay per hospital admission per stay per member . 25 % coinsurance

25 % coinsurance

$100 Copay

$0

$75 Copay


25 % coinsurance

$60 Copay

25 % coinsurance

25 % coinsurance


50 % coinsurance

$60 Copay

$70 Copay


50 % coinsurance

50 % coinsurance


50 % coinsurance

$100 Copay

$0

$75 Copay


50 % coinsurance

50% coinsurance

50% coinsurance

50 % coinsurance

Tier 1 Tier 2 Tier 3


Tier 1

Tier 2

Tier 3

Tier 4


$15 Copay



25% coinsurance

Not Covered

Not Covered

Not Covered

Not Covered

PPO Summary of coverage

$200 maximum benefit per adult / $400 maximum per family

MercyCare PPO HDHP Coverage Levels and ProvidersLEVEL 1: MercyCare PPO HDHP provides the highest level of benefits whenever you obtain health care services, whether from a Mercyhealth provider or not . Level 1 providers are located in the provider directory . The highest level of benefit is described in the Level 1 Benefits column of the Schedule of Benefits . To find a provider, 1. On the web, go to www .mercycarehealthplans .com . 2. Click on Find a Doctor/Facility . 3. Select a plan (MercyCare PPO) and then follow the instructions .

LEVEL 2: Level 2 providers are those who are not Level 1 providers but are found in the First Health . When you use this level of benefits, you pay a greater share of the cost of health care services you receive . This level of benefit is described in the Level 2 Benefits column of the Schedule of Benefits . On the web go to www . Firsthealth .com to find the providers who are participating at this level . Please be aware that even though the following provider/hospital groups may be found on the First Health website, they are not available to you as a Level 2 provider. These include: Aurora Health Care, Beloit Health System, SSM Health – formerly Dean Health System/St. Mary’s Hospital, OSF HealthCare System, Swedish American Health System.

LEVEL 3: A Level 3 provider is any provider who is not listed in the MercyCare provider directory or on First Health website . When you use this level of benefits, you will pay the greatest share of the cost of health care services you receive . Level 3 Benefits are subject to usual and customary charge limitations . This level of benefit is described in the Level 3 Benefits column of the Schedule of Benefits .

Referral Requirements for Level 1 Benefits: In order to obtain Level 1 Benefits for specialty services and treatment that cannot be obtained from a provider listed in our provider directory the following is required:

• A referral from your Level 1 or Level 2 provider, and; • prior approval from the Health Plan

The referring provider and the Quality Health Management Department will determine the duration of the referral or the number of visits authorized based on what is medically appropriate . If a referral is not approved by the Quality Health Management Department, it is not considered valid and the services are not considered authorized . The Plan reserves the right to direct you to a specialist of its choice .

MercyCare PPO HDHPMonthly premium contribution

10

Non-Tobacco UserMercyCare PPO HDHP

Full-Time

Part-Time

Partner +Child(ren)

Single

Partner+ Spouse

Family

Partner +Child(ren)

Single

Partner+ Spouse

Family $1,114 .36

$639 .00

$733 .06

$344 .50

$1,064 .26

$589 .00

$638 .06

$294 .50

$699 .00

$391 .00

$466 .50

$220 .50

$649 .00

$341 .00

$416 .50

$170 .50

Tobacco UserMercyCare PPO HDHP


11

Deductible

Coinsurance

Office visit charge-primary care provider

Office visit charge-specialist

Medical + RX MOOP (Integrated MOOP)


Preventive services

Diagnostic Services (lab and x-ray), includes office location




Ambulance

Urgent care charge







0% coinsurance after deductible




100% coverage

















100% coverage












$7000 Single, $14,000 Family




$7000 Single, $14,000 Family

100 % coverage














Tier 1-4


0% coinsurance after deductible Not Covered

$200 maximum benefit per year per adult / $400 maximum benefit per family

Health Savings Account (HSA) Partners choosing this plan have the option to participate and make contributions to a health savings account . The money that you contribute to your HSA is portable, meaning that it is not subject to the “use it or lose it” rules that the Flex Spending Accounts (FSA) have and can be carried over from year to year . Those who choose to participate in this plan and also participate in the Mercyhealth Flex Spending Account, will be required to participate in a limited purpose Flex Spending Account .

PPO HDHP Summary of coverage

CHIP notificationPremium Assistance under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from Mercyhealth, the state you live in may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs . If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace . For more information, visit www .healthcare .gov .

If you or your dependents are already enrolled in Medicaid or CHIP and you live in Wisconsin, you can contact the Wisconsin Medicaid office at 1-800-362-3002 . (https://www .dhs .wisconsin .gov/publications/p1/p100095 .pdf) to find out if premium assistance is available .

If you or your dependents are already enrolled in Medicaid or CHIP and you live in Illinois, you can contact the Illinois Comprehensive Health Insurance Plan at 1-800-962-8384 or email infodesk .chip@illinois .gov .

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your state Medicaid or CHIP office or dial 1-877-KIDS NOW or www .insurekidsnow .gov to find out how to apply . If you qualify, you can ask your state if it has a program that might help you pay the premiums for an employer- sponsored plan .

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under a Mercyhealth insurance plan, Mercyhealth must allow you to enroll in a plan if you aren’t already enrolled . This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance . If you have questions about enrolling in a health insurance plan contact the Department of Labor at www .askebsa .dol .gov or call 1-866-444-EBSA (3272) .

If you live in a state other than Wisconsin or Illinois and you would like to see if a premium assistance program is available or you would like more information on special enrollment rights, you can contact either:

12

U.S. Department of Labor Employee Benefits Security Administration

www .dol .gov/ebsa

1-866-444-EBSA (3272)

U.S. Department of Health and Human ServicesCenters for Medicare & Medicaid Services

www .cms .hhs .gov

1-877-267-2323, ext . 61565

Prescription drug coverageFour tier drug plan for MercyCare EPO & PPO plans

13

What is a four-tiered drug plan? This four-tiered drug plan incorporates four levels of benefits .• Tier 1 is for preferred generic drugs, which has the lowest copay .• Tier 2 covers our preferred brand name drugs and some select generics, and has the second lowest copay .• Tier 3 represents all non-preferred brand and generic drugs .• Tier 4 represents specialty drugs and will have co-insurance .This drug plan uses a defined formulary, which lists the covered drugs and tier placement, and all drugs listed are available to our members unless otherwise determined to be excluded . Our designated Pharmacy Benefit Manager and/or MercyCare determines the placement of drugs within each tier of this formulary .

Other changes may occur to this formulary as determined by MercyCare or our designated Pharmacy Benefit Manager . A current formulary is available online at http://www .mercycarehealthplans .com/ .

Paying for your prescription Participating Pharmacy Benefits: Tier 1: Preferred Generic Drugs: • $15 copay per prescription drug order (30-day supply)Tier 2: Preferred Brand Name and Select Generic Drugs: • $30 minimum copay or 20% of total cost up to a maximum of $50 copay per prescription drug order

(30-day supply) Tier 3: Non-Preferred Brand and Non Preferred Generic Drugs: • $100 minimum copay or 50% of total cost up to a maximum $150 copay per prescription drug order

(30-day supply) If the price of your prescription drug is less than your copay, you will pay the charged amount. Tier 4: Specialty Drugs: • 25% of total cost and do not typically qualify for mail orderThe maximum out-of-pocket expense for this plan is $3,600 (single) / $7,200 (family) . After reaching the maximum out-of-pocket, prescription drugs are covered at 100% . If the price of your prescription drug is less than your copay, you will pay the lower amount .

Prior approval Certain formulary drugs require prior approval from MercyCare before coverage is provided . If you are presently on a medication and would like to know if it requires a prior approval, please call Customer Service at 800-895-2421 .

Non-covered drugs• Fertility drugs .• Any drug or medicine which is taken by or administered to you while you are a patient in a licensed hospital,

rest home or sanitarium, extended care facility, convalescent hospital, skilled nursing facility or similar institution .

• Anti-obesity and anorexients .• Prescription drugs, which the eligible person is entitled to receive without charge from any Worker’s

Compensation laws or any municipal state or federal program .

• Any drug when used for a cosmetic treatment or for the treatment of the aging process .• Any drug when used for treatment of hair loss or excessive hair growth .• Any medication used to obtain, treat or enhance sexual performance and/or function . This includes

dysfunction caused by organic diseases .• Special formulations of covered drugs such as sustained release intended primarily for convenience of the

patient, as deemed by MercyCare, are not covered .• Special packaging of covered drugs intended primarily for convenience of the patient, as deemed by

MercyCare, are not covered .• Retin-A, for members age 40 and older .

Definitions Generic: A generic equivalent means a prescription drug available from more than one drug manufacturer that has the same active therapeutic ingredient as the brand or trade name prescription drug prescribed to you .

Preferred drug: Branded and generic drugs on our preferred drug list as determined by our designated Pharmacy Benefit Manager and MercyCare .

Non-preferred drug: All branded and generic drugs not on our preferred drug list .

Specialty drug: Drugs that typically require special storage, handling, or administration . Medications included in this designation are required to be dispensed by a specialty pharmacy as noted in the formulary .

This is a Summary of Benefits only, and does not outline all the benefits and exclusions.

Mercyhealth pharmacy extended supply programAll Mercyhealth Pharmacies will offer the three-month supply for the price of two months . You will have the option to pick up your 90-day prescription at any Mercyhealth retail pharmacy . If you choose to have your 90-day supply mailed, the Mercyhealth Medical Mall Pharmacy will be the mail order pharmacy .

Not all medications are good candidates for extended supply, such as antibiotics, medications that are taken on an “as needed” basis and medications that require special handling like refrigeration . This includes the specialty drugs listed on Tier 4, which are only covered as a 30-day supply .

Extended supply copay reductions cannot be combined and are not additive with other copay reduction programs, such as pill splitting . Partners can benefit from the incentive that reduces their copays the greatest, but unfortunately cannot combine programs . For more information or to sign up call (608) 755-8700 or (877) 597-6627 . Information is also available on the MercyCare website at www. mercycarehealthplans.com.

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Dental insuranceVendor: Delta Dental IL

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Your dental benefit plan provides a comprehensive program to ensure your dental health . Coverage is included for important preventive care and also for treatment needed as a result of dental disease or accidental injury . Partners hired to work 20 to 29 hours per week ( .5 - .74 FTE) are considered part-time for premium purposes . Partners hired to work 30 hours per week or more ( .75 – 1 .0 FTE) are considered full-time for premium purposes .The following summary does not cover all plan details . Further information can be found in the summary plan description . That document provides a thorough explanation of your dental plan, including any limitations or exclusions that might apply . If there are any discrepancies between information found here and the group contract, the group contract shall govern .

Dental insurance eligibility for adult child(ren)Your adult child(ren) can be added to your Mercyhealth dental insurance plan at the time of hire, qualifying event or open enrollment if they are less than 26 years old (regardless of marital status) .

Your adult child(ren) can choose to stay on their parents dental plan until the end of the month in which they turn age 26, even if they are eligible for their own employer-sponsored insurance plan .

Domestic partner coverageRefer to domestic partner coverage eligibility under health insurance .

With Delta Dental PPO and Premier Networks:• You can go to any licensed general or specialty dentist .• You will maximize your benefits by receiving care from a Delta Dental PPO or Delta Dental Premier network

dentist .• Delta Dental’s network dentists have agreed to reduced fees as payment in full, which means you will likely

save money by going to a Delta Dental PPO or Delta Dental Premier network dentist . Non-network dentists have not agreed to accept our reduced fees as payment in full, which means they may bill you for any charges over our allowed fees .

• You are charged only the patient’s share at the time of treatment . Delta Dental pays its portion directly to network dentists .

• Enhanced Benefit Program offers additional coverage for individuals who have specific health conditions (including pregnancy, diabetes, high-risk cardiac conditions, and suppressed immune systems) that can be positively affected by additional oral health care .

Member ConnectionYou may register on Delta Dental of Illinois’ website, www .deltadentalil .com . Once registered, you can get real time benefit information, check claim status, sign up for electronic Explanation of Benefits and print a temporary ID card .

Partner +Spouse

Full-Time

Part-Time

Work Status

$20 .00

$15 .00

Partner+ Child(ren)

$51 .00

$39 .00

Single

$72 .00

$56 .00

Family

$40 .00

$32 .00

Monthly premium contribution

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Finding a DentistVisit our web site at www .deltadentalil .com and click on Provider Search .Example of Your Copayment with Delta Dental Network Dentists and Non-Network Dentists• Delta Dental PPO: Lowest out-of-pocket costs and network protection .• Delta Dental Premier: Higher out-of-pocket costs than PPO, but may be lower than non-network and

network protection .• Non-network: You may have the highest out-of- pocket costs .

Customer ServiceCall 1-800-323-1743 to access the automated phone system or speak to a customer service representative from 7 am to 7 pm Monday through Thursday and 7 am to 6 pm Friday, Central time . The automated phone system is available 24 hours a day, seven days a week, and offers dentist listings and claim information .

Learn MoreYou can learn more about your Delta Dental of Illinois dental plan by reading the information included in your enrollment kit .

The information on the following page is a brief summary of your dental plan and the services it covers . There are some limitations on the expenses for which your dental plan pays . If you have specific questions regarding benefit coverage, limitations, exclusions, or non-covered services, please refer to your certificate of coverage/dental benefit booklet or contact Delta Dental of Illinois .

Patient’s share is the coinsurance/copayment, any remaining deductible, any amount over the annual maximum and any services your plan does not cover .

Note: Delta Dental imposes no restrictions on the method of diagnosis or treatment by a treating dentist. A benefit determination relates only to the level of payment that your group dental plan is required to make.

The current ADA recommendation is for the child’s first dental visit to be by age one or first tooth – whichever is sooner . It is suggested to add the newborn at time of birth or next open enrollment . If you would like more information on this recommendation please visit the ADA website at www .ada .org .

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Delta Dental insuranceSummary of benefits and covered services

Prescription drug coverageAnnual maximum

Annual deductible(applies to Basic/Major only)

Dependents eligible to age 26

Preventive/Diagnostic

• oral evaluations (two per calendar year)

• x-rays (bitewings – once per calendar year; full mouth series - once every three years)

• prophylaxis (cleaning; two per calendar year)

• fluoride treatment (twice per calendar year for children under age 19)

• space maintainers

• sealants

Basic

• fillings

• posterior composites

• panoramic x-ray

• oral surgery

• periodontics

• endodontics

• general anesthesia (in conjunction with oral surgery)

• non surgical TMJ

Major

• crowns, jackets, cast restorations

• fixed/removable bridges

• partial/full dentures

• implants

Orthodontia

• Lifetime ortho . Maximum (for dependents under age 19 only)

Billing

$1,500/person

$50/person$100/family

Delta Dental PPO Network

100% of reduced fee*

80% of reduced fee*

50% of reduced fee*

$1,000/per dependent

50% of reduced fee* subject to lifetime maximum

*You will not be “balance” billed” for charges exceeding Delta Dental’s allowed PPO fees

$1,500/person

$50/person$100/ family

Delta Dental Premier Network

100% of MPA**

80% of MPA**

50% of MPA**


50% of dentist’s usual fee subject to lifetime maximum

**You will not be “balance billed” for charges exceeding Delta Dental’s maximum plan allowances (MPAs)

$1,500/person

$100/person$300/ family

Out-of-Network

100% of MPA***

80% of MPA***

50% of MPA***


50% of dentist’s usual fee subject to lifetime maximum

***You are responsible for charges exceeding Delta Dental’s maximum plan allowances (MPAs)


Life insuranceVendor: The Standard

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Group Term Life: Mercyhealth provides Term Life Insurance benefits to partners that are hired to work 20 hours or more a week ( .5 FTE) . Eligibility begins the first of the month following 90 days of employment . Term life is equal to 1 times annual salary up to $150,000* with Accidental Death and Dismemberment (ADD) . Further information can be found in the summary plan description .

*Physician maximum $350,000

Supplemental Life: You may purchase your own supplemental life insurance coverage up to 4x your annual earnings up to a maximum of $1,000,000 . Eligibility begins the first of the month following 90 days of employment for partners that are hired to work 20 hours or more a week ( .5 FTE) . You may increase the coverage during each open enrollment by 1x your annual earnings without proof of insurability . Evidence of insurability is required if you want to request more than $600,000 worth of coverage, enroll or increase your coverage during the plan year . However, you may discontinue your coverage any time .Your premium is based on your age bracket and the amount of coverage chosen . The table below shows the monthly rates per $1,000 of coverage based on age:• You can choose to purchase additional term life insurance, in increments of 1, 2, 3, or 4 times your

benefit pay .• Premium contributions are made with after-tax dollars; premiums adjust the month following a salary

increase and/or a birthday if your age ends in 5 or 0, beginning at age 35 (e .g .; 35, 40, 45, etc .)• You can choose Supplement life insurance if you want a greater level of coverage . Remember: you may

not increase your life insurance by more than one level of Benefit Pay from year to year, unless you submit evidence of insurability .

Monthly rate

35 - 39

Under 30

30 - 34

$0 .11

$0 .10

$0 .08

Age Monthly rate

50 - 54

40 - 44

45 - 49

$0 .40

$0 .24

$0 .15

Age Monthly rate

65 - 69

55 - 59

60 - 64

$1 .38

$0 .69

$0 .46

Age Monthly rate

70 - 74

75+ $6 .37

$3 .18

Age

Dependent Term Life: You may purchase life insurance at two levels of coverage for eligible dependents . Eligibility begins the first of the month following 90 days of employment for partners that are hired to work 20 hours or more a week ( .5 FTE) . Dependent child means:

1. Your unmarried child from live birth through the end of the calendar month in which your child reaches age 26 or

2. Your unmarried child who meets either of the following requirements a. The child is insured under the group policy and, on and after the date on which insurance would

otherwise end because of the child’s age, is continuously disabled . . b. The child was insured under the prior plan on the day before the effective date of your Employer’s

coverage under the group policy and was disabled on that day, and is continuously disabled thereafter .3. The date dependent life insurance ends is the date the dependent ceases to be a dependent .

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You may increase the coverage by one level during each open enrollment without proof of insurability . During the plan year, you may enroll if there is a change in your family status, or increase the level of coverage with approved evidence of insurability . However, you may discontinue the coverage anytime during the plan year .Note: A partner may not be insured as both a partner and a dependent. A child may not be insured by more than one partner.

Mercy Health Corporation Employees’ Retirement PlanVendor: Voya

403(b)Mercyhealth partners are offered a 403(b) plan that allows the option to contribute on a pre-tax basis a portion of your earnings to an account, up to the annual federal maximum, with Voya . There are over 30 investment options from which to choose . You can enroll anytime by contacting Rohlik Financial Services at (800) 236-2608 . You may also change your investment options, beneficiaries, and deferral electives at any time by contacting Rohlik Financial Services or going online at www.voyaretirementplans.com .

Auto-enrollment Mercyhealth believes that all partners should take an active approach in contributing toward their retirement; therefore, Mercyhealth will automatically enroll partners into a Voya retirement plan at 3% . If you do not want to contribute to your plan, you have the option to opt-out, but your account will remain open for any qualifying discretionary contributions .

Auto-escalationFor partners who want to contribute to a 403(b) account but do not want to be actively involved will be eligible for an automatic contribution increase of 1% each calendar year up to a maximum contribution of 6% .

Matching contribution If you work a minimum of 1,000 hours by your first anniversary you will be eligible for a matching contribution . Otherwise, matching eligibility will begin after the calendar year in which you complete 1,000 hours of service . Mercyhealth will contribute up to 100% of the first 4% of your earnings that you contribute up to the federal compensation limit . The matching contribution will be deposited into your Voya account at the same time your contribution is deposited . When you have two years of service with Mercyhealth, as defined by the Plan, you are vested (gain ownership) in this benefit .

Discretionary contribution For each year you work a minimum of 1,000 hours, Mercyhealth will contribute a discretionary contribution of up to 2% based on your W-2 earnings up to the federal compensation limit from the previous calendar year to your Voya account . When you have one year of service with Mercyhealth, as defined by the Plan, you are vested (gain ownership) in this benefit . The discretionary contribution is deposited into your Voya account in October each year and is based on the successful completion of system-wide performance and financial goals . Partners do not have to contribute their own earnings to be eligible for the discretionary contribution .

Premium Per Month

Option 1: $10,000 Coverage for Spouse, $5,000 per Child

Option 2: $25,000 Coverage for Spouse, $10,000 per Child

Level of Coverage

$3 .00

$6 .50

* Dependent coverage is limited to $500 for any dependent between the ages of birthto 6 months

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Roth contributionMercyhealth partners may also make Roth contributions to their Voya 403(b) account .

457(b)In addition to contributing to the Mercy Health Corporation Employees’ Retirement Plan, all highly compensated partners have the option to increase their tax-deferred contributions by contributing to a 457(b) account through Voya . The 457(b) account is not eligible for any matching contributions . Federal contribution maximums apply . Partners can enroll at any time through Rohlik Financial Services and the same investment options as the 403(b) .

All accounts are accessible online at www.voyaretirementplans.com or contact a representative at Rohlik Financial Services at 1-800-236-2608 .

Flex spending plansHealth savings account/Medical/Dependent careVendor: Health Equity

Mercyhealth partners hired to work 20 or more hours per week ( .5 FTE) are eligible to participate in the flexible benefit plan . The flexible benefit plan allows you to set aside pre-tax dollars from your paycheck to pay for qualified medical and dependent care expenses . Consequently, you pay less income tax and increase your take-home pay . Eligible medical expenses include out-of-pocket health, dental and vision related expenses . The appropriate amount will be deducted bi-weekly from your paycheck on a pre-tax basis .

Please evaluate your situation carefully and conservatively before determining how much, if any, you want to set aside for the various expenses in a flexible spending plan as restrictions apply . You may change the benefits elected during the plan year only if there is a major family status change (qualifying event) . Call Human Resources or Health Equity at (866) 346-5800 with any questions .

Health savings accounts (HSA)Participants in the MercyCare EPO HDHP or PPO HDHP may elect to contribute to a Health Savings Account (HSA) . The dollars are set aside on a pre-tax basis to pay for medical expenses . Partners can contribute up to $3,400 with a single plan or $6,750 with a family plan to the health savings account .

If you participate in a health savings account (HSA), you can also enroll in a limited purpose medical account for planned dental and vision expenses . You may also use it for medical expenses after you have satisfied your annual deductible .

Flexible Spending MedicalYou can choose to set aside money from each paycheck to pay for those expenses not covered by insurance . For example, expenses such as your deductible, your co-insurance, and your co-pays . This is a pre- tax deduction, which means that you don’t pay any federal, state, or social security taxes on the dollars that you set aside .

The maximum amount that you can set aside is $2,550 . The money can be used to reimburse you for any expenses incurred between January 1, 2017 and December 31, 2017 . Your reimbursement claim must be submitted by March 31, 2018 . Under federal law, the medical plan allows for a carryover of $500 for the next plan year, however, any remaining amount over $500 will be forfeited .

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Dependent Care:You can choose to set aside up to $5,000 annually from your paycheck to pay for eligible dependent care expenses that allows you (and your spouse if you’re married) to work, look for work, or attend school full-time . Expenses must be related to:

• Dependent children under age 13

• A person of any age you claim as a dependent on your Federal Income Tax return, and who is mentally or physically incapable of self-care . This would include an elder or other adult dependent .

Under federal law, any unused dollars remaining at the end of the plan year in a dependent care plan will be forfeited .

Note: You cannot change the amount of a flexible spending account deduction, except at open enrollment, unless you have a change in family status.

Voluntary benefitsLong Term Care Insurance (Legacy Services)All partners and family members are eligible to purchase long-term care insurance at any time through Legacy Services . Long-term care insurance is a benefit that goes beyond medical care and nursing care to include assistance you could need if you ever have a chronic illness or disability that leaves you unable to care for yourself for an extended period of time . You can receive long-term care in a nursing home or in your own home, in the form of help with such activities as dressing or bathing, etc . . Long-term care can be helpful to a young or middle-aged person who has been in an accident or suffered a debilitating illness, but older adults use most long-term care services . Your premium is based on your age and the type of coverage you select . For further information, contact Legacy Services at (800) 230-3398 .

Universal Life Insurance (Voya)If you are hired to work 20 or more hours per week ( .5 FTE), you are eligible to purchase Universal Life Insurance Coverage underwritten by Voya . This program allows you to apply for an individual life insurance policy . You can also apply for individual life insurance policies for your spouse, dependent children and, in most cases, grandchildren, even if you choose not to apply for your own policy . The premium you pay is based on the death benefit you select . For further information or to enroll contact Rohlik Financial Services at (800)236-2608.

529 College Savings ProgramsAll Mercyheath partners are eligible at any time to participate in 529 College Savings Programs through payroll deduction . These programs allow partners to set aside dollars specific to college education costs and interest earned is tax-free . For additional information or to enroll, contact Rohlik Financial Group at (800) 236-2608.

Auto and Home Insurance (Travelers)If you are hired to work 20 or more hours per week ( .5 FTE), you are eligible to receive special program rates through Travelers Insurance on your auto, home, and other personal insurance . Periodically, eligible partners receive information packets sent directly to their home from Travelers . This benefit is available to partners throughout the year . For additional information, please call Travelers at (800) 842-5075.

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MetLife PlansIf you are hired to work 20 or more hours per week (0 .5 FTE), you are eligible to purchase the following benefits .

Accident InsuranceAccident insurance will cover your family for a wide variety of accidental injuries including broken bones, cuts, concussions, dislocations and second or third degree burns . It provides a lump sum payment when a person has medical services and treatments related to accidental injuries, such as certain doctor visits, ambulance transportation, medical testing and physical therapy and can be a valuable compliment to your medical insurance .

This type of insurance can help protect your savings from unexpected expenses and provides payment directly to you, that you can use any way you see fit .

Critical IllnessA serious illness such as cancer, heart attack or stroke will bring unexpected expenses that are not covered by your health insurance . At the same time, a critical illness may affect your ability to earn an income, which may cause you to dip into your savings . This plan can help you pay for expenses such as essential living expenses if you’re not able to work, pay for medical co-pays and deductibles, or for additional care while you recover .

Hospitalization InsuranceWill allow you to receive a lump-sum payment when you first go into the hospital, then receive daily amounts paid for each day in the hospital . Payments will be paid directly to you to use as you see fit .

Pet InsurancePets play an important role in a family’s life, however when an accident or illness occurs it can set you back thousands of dollars . This plan allows you reimbursment for eligible veterinary expenses for medical problems and conditions such as accidental injuries, poisonings and illness-even cancer . Office procedures include diagnostic tests, X-rays, lab fees surgeries and hospitalization . Your pet’s prescriptions are even covered . There are plans for dogs and cats starting at six weeks of age and plans also available for birds, ferrets, reptiles and other exotic pets .

For further information on any of these insurance plans, contact

Williams-Manny Insurance Group at (815) 227-8923.

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Vision appliance insuranceVendor: Delta Dental IL

Mercyhealth partners hired to work a minimum of 20 hours per week (0 .5 FTE) are eligible to enroll in a voluntary vision plan . This plan is for appliance only (ie: glasses, contacts) . Vision exams are covered under the MercyCare Health Plan .

DeltaVision® is provided by ProTec Insurance Company, a wholly-owned subsidiary of Delta Dental of Illinois, in association with EyeMed Vision Care networks . DeltaVision offers members vision care benefits that combine choice, value and wellness . Your DeltaVision program provides vision care insurance to you (and your family, if applicable) according to the following information .


Exam with dilation as necessary

Contact lens fit & follow-up:(Available once a comprehensive eye exam has been completed)

Standard* Premium**

Frames:(Any available frame at provider location)

Standard plastic lenses: Single visionBifocal TrifocalStandard progressive (in addition to lens) Premium progressive (in addition to lens)

Lens Options: UV coatingTint (solid and gradient)Standard plastic scratch coatingStandard polycarbonateStandard anti-reflective coatingOther add-ons and services

Contact lenses:(Contact lens allowance covers materials only)Conventional

Disposable

Visually required

Frequency: ExaminationLenses or contact lenses Frames

Not covered

Not covered Not covered

$130 allowance, 20% off balance over allowance

$25 copay$25 copay$25 copay$65 copay$65, 20% off retail price, then apply $120 allowance

$15$15$15$40$4520% discount off retail price

$0 copay, $100 allowance, 15% off balance over $100

$0 copay, $100 allowance, balance over $100

$0 copay, paid-in-full

N/A

N/AN/A

$65

$25$40$55$40$40

N/AN/AN/AN/AN/AN/A

$80

$80

$210

Out-of-Network AllowanceSelect Network Member CostVision Care Services

N/AOnce every 12 monthsOnce every 24 months

Partner +Spouse

$4 .34

Partner+ Child(ren)

$9 .51

Single

$13 .72

Family

$8 .48

Monthly premium contribution

* Standard contact lens fitting - spherical clear contact lenses in conventional wear and planned replacement (examples include, but are not limited to, disposable and frequent replacement) .

** Premium contact lens fitting - all lens designs, materials and specialty fittings, other than standard contact lenses (examples include toric and multifocal) .

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Additional discountsMember will receive a 20% discount with in-network providers on items not covered by the program . This discount may not be combined with any other discounts or promotional offers and the discount does not apply to contact lenses or an in-network provider’s professional services . Retail prices may vary by location .

Members also receive a 40% discount off complete pair eyeglass purchases and a 15% discount off conventional contact lenses with in- network providers once the funded benefit has been used .

After initial purchase, replacement contact lenses may be obtained via the Internet at substantial savings and mailed directly to the member . Details are available at www.deltadentalil.com/deltavision . The contact lens benefit allowance is not applicable to this service .

Network informationYou may choose to go to any licensed optometrist, ophthalmologist and/or dispensing optician whenever you need vision care . However, there may be significant cost advantages when you receive treatment from an in-network provider .

We offer two easy ways to locate an in-network provider 7 days a week, 24 hours a day . You can either:• search our online provider directory at www.deltadentalil.com/deltavision; or• use the automated phone system by calling 1-866-723-0513 .

Using your vision program1. Have your DeltaVision information card available when scheduling and visiting an in-network provider .

An in-network provider participates in the EyeMed Vision Care Provider network . It’s very important you know which network your benefit plan utilizes (your plan uses the Select network) . You will only receive in- network benefits from Select network providers . Please note: the network provider will need the primary enrollee’s name and date of birth to verify eligibility .

2. Pay your copayment and any other charges not covered at the time of service . No paperwork is required .You continue to save on additional eyewear purchases any time you present your card to an in-network provider .

If you select a provider who is not in the network, you do not receive preferred pricing and you may be asked to provide full payment to your out-of-network provider at the time of service . To receive benefit reimbursement, submit a completed claim form (available on our website), along with itemized receipts from your provider and your prescription to:

DeltaVision Claims Processing c/o EyeMed Vision CareP.O. Box 8504 Mason, OH 45040-7111

ExclusionsIn no event will coverage exceed the lesser of:

1. the actual cost of covered services or materials; or

2. the limits of the policy, shown in the schedule .

Lost or broken lenses, frames, glasses or contact lenses will not be replaced except in the next benefit period .

Benefits may not be combined with any discount, promotional offering or other group benefit programs . Benefit allowances provide no remaining balance for future use within the same benefit period .

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There is no coverage for professional services or materials connected with:

1. Orthoptic or vision training, sub-normal vision aids and any associated supplemental testing;

2. Aniseikonic lenses;

3. Medical and/or surgical treatment of the eye, eyes or supporting structures;

4. Corrective eyewear required by an employer as a condition of employment and safety eyewear unless specifically covered under this program;

5. Services provided as a result of any Workers’ Compensation law;

6. Plano lenses (lenses that have no refractive power), non-prescription lenses and non- prescription sunglasses (except for 20% discount);

7. Two pair of glasses in lieu of bifocals .

The preceding information is a brief summary of the Mercy Health Corporation Complete Vision Program and the services it covers .

If you have specific questions regarding benefit coverage, limitations or exclusions, contact DeltaVision® customer service department at 1-866-723-0513.

DeltaVision® is provided by ProTec Insurance Company, a wholly-owned subsidiary of Delta Dental of Illinois, in association with EyeMed Vision Care networks .

111 Shuman Blvd Naperville, IL 60563

800-335-8215www .deltadentalil .com/deltavision

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Short term disabilityVendor: The Standard

Mercyhealth provides short term disability insurance (STD) benefits to partners in two levels . Eligibility begins the first of the month following 90 days of employment and is paid 100% by Mercyhealth . The monthly benefit for those who are disabled is defined by the plan . Plan highlights are listed below . For further information review the SPD or contact the human resource department .

Partners must apply for this benefit through the Standard by calling (866) 756-8116 or online at www.standard.com . Benefit will be paid out through your regular paycheck .

Short Term Disability Plan – Level 1

• Eligibility:

• FT status for .75 fte (30 hrs/wk or greater)

• PT status .5 fte (20 hrs/wk to 29/hrs/week)

• Plan Design

• Coverage begins on the 8th calendar day missed for own disability through 90 days .

• 91 days of employment up to 4 .99 years = 60% of base salary

• 5 years and up = 70% of base pay

• Coverage Limited to $15,000 per month maximum benefit

Short Term Disability Plan – Level 2• Eligibility:

• FT status for .75 fte (30 hrs/wk or greater)

• Plan Design

• Coverage beginning on the 91st day missed for own disability through 180th day .

• 60% of base pay

• Coverage Limited to $15,000 per month maximum benefit

Long term disabilityVendor: The Standard

Mercyhealth provides long term disability insurance (LTD) benefits to partners who are hired to work 30 hours or more a week ( .75 FTE) . Eligibility begins the first of the month following 90 days of employment and is paid 100% by Mercyhealth . The monthly benefit for those who are disabled, as defined by the plan, equals 60% of base pay to a max of $15,000 . This benefit will be paid directly to the partner by The Standard . See below for plan highlights . For further information review the SPD or contact the human resource department .

• Plan Design:

• Coverage for LTD begins after 180 day elimination period

• 60% of base pay to a max of $15,000 .

• Coverage for own disability only

• Own Occupation first 24 months and any occupation thereafter .

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Important contact informationIf you have a change of name/address/phone number, please contact the Human Resource department to update your information . If you participate in the following benefit plans, please notify them directly .

Health Equity (Flex Spending) - (866) 346-5800Delta Dental Illinois - (800) 323-1743Delta Vision - (800) 323-1743MercyCare - (800) 895-2421FMLA Standard - (866) 756-8116Rohlik Financial Group - (800) 236-2608

Long Term Care Insurance - (800) 230-3398Short Term Disability - (866) 756-8116 Universal Life Insurance - (800) 236-2608Travelers Insurance - (800) 842-5075Voya - (800) 584-6001Williams-Manny Insurance Group - (815) 227-8923

Qualifying eventMarriage: Health and Dental Insurance:

Dependent Life:Group Life/Supplemental Life:Mercy Health Corporation Employees’ Retirement Plan:

You have 30 days from the date of marriage to add your spouse/stepchildren to your health and dental insurance . (For adult children, please see additional information under section adult children)

You have 30 days from the date of marriage to enroll your spouse/stepchildren .

Do you want to change the beneficiary? Change your beneficiary in your self-service portal .

Your spouse is automatically the beneficiary for your pension plan . New beneficiary forms should be completed . If a different beneficiary is named, a spousal beneficiary consent form must be signed by the spouse and notarized .

Divorce/death of spouse/end of domestic partnership:Health and Dental Insurance:

Group Life/Supplemental Life:

Dependent Life:Mercy Health Corporation Employees’ Retirement Plan:

Spouse/domestic partner/stepchildren/domestic partner children should be dropped at the time the divorce is final or at the end of a domestic partner relationship . If you are losing insurance at the time of divorce or end of your domestic partnership, you must enroll yourself/children within 30 days of the qualifying event . (For adult children, please see additional information under section ADULT CHILDREN) In the case of the death of a spouse contact the human resource department .

Do you want to change the beneficiary? Change your beneficiary in your self-service portal .

Can be dropped at any time . Contact the human resource department .

Do you want to change the beneficiary? Contact Rohlik Financial Services at 800-236-2608 .

Loss of coverage:You have 30 days from the date of your loss of coverage to enroll yourself/spouse/children . Domestic partner/domestic partner children may be added if qualifications under domestic partner are met . (For adult children, please see additional information under section adult children)

Birth/adoption:

Adult children:

Divorce/death of spouse/end of domestic partnership:

Health and Dental Insurance:

Dependent Life:

Do you want to add the child to your insurance?

If you aren’t already enrolled, do you want to enroll child?

Health, Dental, and Vision Insurance:

Children may continue coverage up to age 26 (regardless of marital status) and will be covered through the end of the month in which they turn 26 . Children under age 26 may be added if they have a loss of coverage or at open enrollment .*

*There can be other age exceptions for adult children in the military. Contact the human resource department for more information.

Health and Dental Insurance: Domestic partner/domestic partner children may be added with a qualifying event as long as other conditions are met (see domestic partner) and a notarized form is provided .

The Fair Market Value (FMV) of insurance coverage provided for an individual who does not qualify as a dependent under Internal Revenue Code (IRC) Section 125, is taxable for employees .

Health and Dental Insurance:

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We hope you have found this Partner Benefit Book to be helpful . Additional information is available in Summary Plan Descriptions and should there be any difference between this document and any Summary Plan Description, the Summary Plan Description would govern . For any additional questions, please contact your human resources department .

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