employee - archgh.org

2021 EMPLOYEE

BENEFITS GUIDE

Your 2021 Benefits

Medical Benefits

Pharmacy Benefits

Dental Benefits

Vision Benefits

Life, AD&D Disability

Additional Benefits

1 Archdiocese of Galveston-Houston

YOUR 2021 BENEFITS

The benefits described in this guide are effective January 1—December 31, 2021.

Welcome! The Archdiocese of Galveston-Houston is proud to offer a comprehensive benefits package that can be customized to meet the needs of you and your family. We are committed to promoting better health for our Lay employees and their eligible dependents. This means you have access to annual physicals and more—all at no cost to you. Please review this guide carefully and consider your options so that you can make the best choices for you and your dependents.

Each year during the open enrollment process, we engage in a detailed review of our benefits programs and related costs, evaluate coverage options, leverage and contain costs, and identify additional programs and services to offer. We strive to provide our employees a best-in-class benefits program, with high value benefits offered at an affordable cost.

This benefit guide has been prepared to summarize the many benefit programs and plans available to our eligible employees. Please read this information carefully. This benefit guide is a summary and not intended to be comprehensive, so please refer to the plan documents pertaining to each plan for more information.

Please note: effective January 1, 2021, Continuation of Benefits (COB) will no longer be offered. If you are currently a COB participant, your COB coverage will end on December 31, 2020. If your employment and health coverage through the Archdiocese of Galveston-Houston ends, there are a number of health coverage options we encourage you to explore, including the Healthcare Marketplace (www.healthcare.gov). For more information, please reference the “When Your Coverage Ends” document posted on the Archdiocese of Galveston-Houston Human Resources website.

Open Enrollment Open Enrollment begins October 1st and ends November 4th, 2020. Any changes you make to your benefit elections during Open Enrollment will become effective on January 1, 2021. To enroll or make changes to your benefit elections, you must log on to the ADP web portal. Please see the instructions on the following page for details.

If you and/or your dependents have Medicare or will become eligible for Medicare in the next 12 months, a federal law gives you more choices about your prescription drug coverage. Please see the separate legal disclosure booklet for more details.

Your 2021 Benefits

Medical Benefits

Pharmacy Benefits

Dental Benefits

Vision Benefits


Additional Benefits


Enrolling in Benefits

You can complete your enrollment quickly and easily online by

logging onto ADP. Follow these steps to get started:

Go to www.workforcenow.adp.com

Log into ADP using your username and password. For login help or

to reset your password, click on “Forgot Your User ID/Password?”

Detailed instructions are available on the Human Resources website:

www.archgh.org/offices-ministries/administration/human-resources

Determining Eligibility You are eligible for benefits if you are a regular, full-time employee who is scheduled to work at least 30 hours per week. For clergy, religious, school teachers and principals, benefits become effective on the first of the

month following or coinciding with your date of hire. For lay persons, benefits become effective on the first of the month following or coinciding with 60 days of active employment.

The Archdiocese of Galveston-Houston also offers Medical/Rx, Dental, and Vision coverage to your eligible dependents. Eligible family members include:

Your opposite sex legal spouse

Your dependent children up to age 26

A child over the age of 26 who is handicapped and chiefly depends on you for support

Eligible dependent children include your biological child, stepchild, legally adopted child (including a child for

whom legal adoption proceedings have been initiated), a child whose parent is your child and your child is covered as a dependent under the plan, and a child for whom you have obtained legal guardianship or for

whom benefits must be provided under a Qualified Medical Child Support Order (QMCSO).

Dependent Verification The Archdiocese of Galveston-Houston requires documentation to establish confirmation of dependent

eligibility at any time. Please review the above eligibility criteria to ensure your dependents meet the definition

of an eligible dependent. Dependents will not be enrolled in the plan without supporting documentation. If

you have questions about the documentation required to confirm eligibility for your dependent(s), please

contact Human Resources.

Changing Your Benefits During the Year The benefit choices you make during open enrollment will remain in effect for the entire plan year (January 1—

December 31) unless you have a Qualifying Life Event. Qualifying Life Events include but are not limited to:

Marriage or divorce

Birth or adoption of a child

Change in employment for you or your spouse that affects your benefit eligibility

Loss or gain of other health coverage

You have 31 calendar days following the date of the Qualifying Life Event to submit your benefit election changes. Please note supporting documentation is required. Any changes you make must be related to the

status change, as required by IRS regulations.

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Your 2021 Benefits

Medical Benefits

Pharmacy Benefits

Dental Benefits

Vision Benefits


Additional Benefits


The Benefits Help Line

The Archdiocese of Galveston-Houston Benefits Help Line is a

valuable resource for your health, welfare, and insurance

benefits. Talk to a personal benefits advocate about your

eligibility, enrollment, benefit questions, finding a provider,

billing or claim questions, and more!

The Benefits Help Line is available Monday—Friday, 7:00 AM

to 6:00 PM Central Time.

855-664-8164 [email protected]

Important Contacts

Benefit Vendor Phone Website/Email

Human Resources Archdiocese of

Galveston-Houston 713-652-8265 www.archgh.org

Medical (Group #274679)

Blue Cross Blue Shield of Texas (BCBSTX)

800-521-2227 www.bcbstx.com

Prescription Drugs OptumRx 1-855-524-0381 www.optumrx.com

Virtual Visits MDLive 888-680-8646 www.mdlive.com/bcbstx

Nurseline Blue Cross Blue Shield

of Texas (BCBSTX) 800-581-0393 N/A

Diabetes Support (Registration Code: ARCHGH)

Livongo 800-945-4355 join.livongo.com/ARCHGH

Dental (Group #274852)



Vision (Group #12001362)

VSP 1-800-877-7195 www.vsp.com

Life and AD&D (Group #756955)

The Standard 1-833-229-4173 www.standard.com

Disability & Leave Management (Group #756955)

The Standard 1-833-229-4173 www.standard.com/absence

Employee Assistance Program

(Group #756955)

The Standard (Morneau Shepell)

888-293-6948TTY: 800-327-1833

www.workhealthlife.com/Standard3

Travel Assistance The Standard

(Assist America)

USA, Canada, Puerto Rico, USVI & Bermuda: 800-872-1414

Worldwide: +1-609-986-1234

Text: +1-609-334-0807

[email protected]

Reference Number: 01-AA-STD-5201

Download the Assist America Mobile App on the App Store or Google Play

Life Services Toolkit The Standard 800-378-5742www.standard.com/mytoolkit

Username: assurance

mdiaz

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Your 2021 Benefits

Medical Benefits

Pharmacy Benefits

Dental Benefits

Vision Benefits


Additional Benefits

2021 Employee Benefits Guide 4

MEDICAL BENEFITS

The Archdiocese of Galveston-Houston offers two medical plans through Blue Cross Blue Shield of Texas

(BCBSTX). The Archdiocese pays 100% of the “employee only” premium for all eligible employees. If you have

eligible dependents, you pay a premium for dependent coverage (see page 12). Employees choosing

“employee only” coverage are enrolled in the Standard Plan. Employees who wish to cover their eligible

dependents can choose to enroll in either the Standard Plan or the Economy Plan.

Medical Services Standard Plan Economy Plan

BCBSTX Blue Choice Network In-Network Out-of-Network In-Network Out-of-Network

Annual Deductible Individual / Family

$800 / $1,600 $1,600 / $3,200 $1,200 / $2,400 $2,400 / $4,800

Coinsurance You pay 20% after

deductible You pay 50% after



deductible

Out-of-Pocket Maximum Individual / Family

$3,300 / $6,600 $6,000 / $12,000 $7,000 / $14,000 $12,000 / $24,000

Preventive Care Plan pays 100% 50% after deductible Plan pays 100% 50% after deductible

Primary Care Office Visit $25 copay 50% after deductible $35 copay 50% after deductible

Specialist Office Visit $40 copay 50% after deductible $50 copay 50% after deductible

MDLive Virtual Visit $25 copay Not Covered $35 copay Not Covered

Urgent Care Center $40 copay 50% after deductible $40 copay 50% after deductible

Emergency Room $170 copay

(copay waived if admitted)

$170 copay

(copay waived if admitted) $230 copay

(copay waived if admitted) $230 copay

(copay waived if admitted)

Diagnostic Tests X-ray, labs, blood work

Plan pays 100% (LabCorp or Quest Diagnostics) 50% after deductible Plan pays 100%

(LabCorp or Quest Diagnostics) 50% after deductible

Imaging MRI, CT/PET Scan

20% after deductible 50% after deductible 30% after deductible 50% after deductible

Inpatient Services 20% after deductible 50% after deductible 30% after deductible 50% after deductible

Outpatient Services 20% after deductible 50% after deductible 30% after deductible 50% after deductible

The Archdiocese of Galveston-Houston believes its Medical and Pharmacy Plan as described in this guide is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (PPACA). As permitted by PPACA, a grandfathered health plan must preserve certain basic health coverage that was already in the Plan when that law was enacted. Being a grandfathered health plan means that your Plan may not include certain consumer protections (health and pharmaceutical coverages) of PPACA that apply to other (non-grandfathered) plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, the grandfathered plans must comply with certain other consumer protections in PPACA, for example, the elimination of lifetime limits on benefits. As a grandfathered plan, this Plan, self-funded by the Archdiocese of Galveston-Houston, does not provide medical and pharmaceutical coverage that contravenes with Catholic teachings. Questions regarding which protections (Medical and Pharmaceutical coverages) apply and which protections (Medical and Pharmaceutical coverages) do not apply to our grandfathered health plan status can be directed to the plan administrator, Charlie Pavlovsky, at 713-652-8261.

Your 2021 Benefits

Medical Benefits

Pharmacy Benefits

Dental Benefits

Vision Benefits


Additional Benefits


Blue Access For Members

Get information about your health benefits anytime, anywhere. Use your computer, phone or tablet to access

the Blue Cross Blue Shield of Texas (BCBSTX) secure member website, Blue Access for Members. With Blue

Access for Members, you can:

Provider Finder Locate a doctor, hospital or facility in the BCBSTX Blue Choice PPO Network

ID Cards Request a new ID card, or print a temporary one

Wellness Tools & Resources Access handy tools like Well onTarget, which has fitness trackers, food diaries,

and more

Claims View or print Explanation of Benefits statements, and check the status or

history of a claim

My Coverage See your benefits at a glance or in detail

Customer Service Use secure messaging to get in touch with helpful customer service

representatives

It’s easy to get started! Visit www.bcbstx.com/member and click on “Register Now” under the blue Member

Login button. You will need the information on your BCBSTX ID card to complete your registration. If you do

not have this information, you can call the BCBSTX Help Desk at 888-706-0583 for assistance.

24/7 Nurseline

Health happens—good or bad, 24 hours a day, 7 days a week. That

is why BCBSTX has registered nurses waiting to talk to you

whenever you call the 24/7 Nurseline. Registered nurses are

available to answer health questions and to help you decide

whether you should go to the emergency room, urgent care, or

make an appointment with your doctor. Plus when you call, you can

also access an audio library of more than 1,000 health topics—from

allergies to surgeries—with more than 500 topics available in

Spanish. Call the 24/7 Nurseline anytime at 800-581-0393.

IT’S EASY TO GET

CONNECTED

BCBSTX Mobile App Many of the services and resources available through Blue Access for Members can also be found right in the palm of your hand! With the BCBSTX Mobile App, you can access your important health plan information wherever you are. Text* BCBSTXAPP to 33633 to get the app, or download it directly from the App Store or Google Play. *Message and data rates may apply. Terms and conditions and privacy policy at bcbstx.com/mobile/text-messaging.

Your 2021 Benefits

Medical Benefits

Pharmacy Benefits

Dental Benefits

Vision Benefits


Additional Benefits


Blue365 Discounts

Blue365 is just one more advantage you have by being a Blue Cross Blue Shield of Texas (BCBSTX) member!

With this program, you may save money on health and wellness products and services from top retailers that

are not covered by insurance. There are no claims to file and no referrals or preauthorizations.

Once you sign up for Blue365 at blue365deals.com/bcbstx, weekly “Featured Deals” will be emailed to you.

These deals offer special savings for a short period of time. Below are some of the ongoing deals you can

access on the Blue365 website:

EyeMed | Davis Vision You can save on eye exams, eyeglasses, contact lenses and accessories. You have access to national and regional retail stores and local eye doctors. You may also get possible savings on laser vision correction.

TruHearing® | Beltone™ | American Hearing Benefits You could get savings on hearing tests, evaluations and hearing aids. Discounts may also be available for your immediate family members.

Jenny Craig® | Sun Basket | Nutrisystem® Help reach your weight loss goals with savings from leading programs. You may save on healthy meals, membership fees (where applicable), and nutritional products and services.

Fitbit® You can customize your workout routine with Fitbit’s family of trackers and smartwatches that can be employed seamlessly with your lifestyle, your budget, and your goals. You’ll get a 20% discount on Fitbit devices plus free shipping.

Reebok | SKECHERS® Reebok makes top athletic equipment for all people, from professional athletes to kids. Get 20% off select models. SKECHERS, a leader in the footwear industry, offers exclusive pricing on men’s and women’s styles—get 30% off plus free shipping online.

Livekick Livekick is the future of private fitness. Choose from training or yoga over live video with a private coach. Get fit and feel healthier with action-packed 30-minute sessions that you can do from home or in the gym. Get a free 2-week trial and 20% off a monthly plan.

Your 2021 Benefits

Medical Benefits

Pharmacy Benefits

Dental Benefits

Vision Benefits


Additional Benefits


PHARMACY BENEFITS

The Archdiocese of Galveston-Houston Medical/Rx plans include comprehensive prescription drug coverage.

You are automatically enrolled in prescription drug coverage when you enroll in either the Standard Plan or the

Economy Plan. Our prescription drug benefits administered by OptumRx.

Prescription Drug Benefits Standard Plan Economy Plan

OptumRx In-Network Out-of-Network In-Network Out-of-Network

Retail Pharmacy 30-day supply

Generic *Preferred Brand

*Non-Preferred Brand

$10 copay $50 copay $75 copay

50% after $10 copay 50% after $50 copay 50% after $75 copay


50% after $10 copay 50% after $55 copay 50% after $80 copay

OptumRx Home Delivery 90-day supply

Generic *Preferred Brand

*Non-Preferred Brand

$5 copay $95 copay

$145 copay

Not Covered


Not Covered

* For certain preferred brand and non-preferred brand drugs, you may be required to try a generic equivalent first. See below for more details.

TERMS TO

KNOW

Generic Drugs You can save on your out-of-pocket costs by choosing generic drugs. Brand and generic drugs are regulated by the FDA and are chemically and medically the same. However, generic drugs typically cost significantly less. Talk to your doctor to find out if generic drugs are right for you.

Non-Preferred Brand Drug A name brand drug that may have a therapeutic alternative available as either a generic or preferred brand drug. These drugs will generally be the most expensive.

Formulary The list of prescription drugs covered by the plan. Also called a “drug list.”

Preferred Brand Drug Preferred brand drugs are commonly prescribed name-brand drugs that has been selected based on its clinical effectiveness, safety, and cost. Preferred brand drugs will generally be more expensive than generic drugs, but less expensive than non-preferred brand drugs.

About Step Therapy

The Step Therapy Program encourages safe and cost-effective medication use. The program is designed to

keep members safe and save money when possible. To receive coverage for certain medications, you may

need to first try a proven, generic equivalent before using a more costly treatment, if needed. For a complete

list of drugs covered by your plan, as well as a list of Step Therapy drugs, visit www.optumrx.com.

Your 2021 Benefits

Medical Benefits

Pharmacy Benefits

Dental Benefits

Vision Benefits


Additional Benefits


Save with Generic Drugs

Both prescription and over-the-counter generic drugs

can be less costly than brand name drugs. You can

save on your out-of-pocket costs by choosing

generic medications. Both brand and generic drugs

are regulated by the Food and Drug Administration

(FDA) and are chemically and medically the same.

However, generic drugs tend to cost significantly less

than their brand name equivalents! We encourage

you to talk to your doctor to find out if generic drugs

are right for you.

OptumRx Mail Saver

Do you take medicine every day for diabetes, asthma, or another condition? These are called maintenance

medications. Mail Service Saver is a program that helps you better manage your maintenance medications on

an ongoing basis. You can save both time and money by filling your prescriptions for maintenance

medications through OptumRx Home Delivery. Not only is home delivery safe and reliable, it also offers some

advantages:

Cost Savings — You may pay less for your medication

with a 90-day supply from OptumRx Home Delivery.

Convenience — Get free standard shipping on

medications delivered to your mailbox.

24/7 Access & Reminders — Speak to a licensed

pharmacist who can answer your questions any time,

any day. You can even set up text reminders to help you

remember to take or refill your medications.

Please note that all maintenance medications are required to participate in the OptumRx Home Delivery

program after 60 days. You may fill your prescription at a retail pharmacy for the first 60 days (i.e. two 30-

day fills). After 60 days, you must fill your prescription through OptumRx Home Delivery. If you try to fill a

maintenance medication at a retail pharmacy after the 60-day retail grace period, your medication will NOT

be covered.

IT’S EASY TO GET

CONNECTED

OptumRx Member Website & Mobile App From the OptumRx member website and mobile app, you can easily refill a medication, transfer a retail prescription to home delivery, access the most current drug coverage information, compare potential cost savings, and more! To register, visit www.optumrx.com or download the OptumRx Mobile App from the App Store or Google Play.

Your 2021 Benefits

Medical Benefits

Pharmacy Benefits

Dental Benefits

Vision Benefits


Additional Benefits


Get Care When and Where You Need It

MDLive provides you and your covered dependents with access to board-certified doctors anytime and

anywhere it’s most convenient for you—at home, work, or on the go. MDLive has the nation’s largest telehealth

network of doctors ready to provide convenient, quality care by phone or secure video. Doctors can diagnose a

wide range of non-emergency medical issues and even send prescribed medications to your pharmacy of

choice. MDLive physicians can treat the following:

TELEHEALTH

BENEFITS

Flu

Allergies

Cough

Sore throat

Fever

Sinus infection

Headache

Nausea/vomiting

Pink eye

Rash

Ear problems

UTI

STANDARD PLAN:

$25 COPAY ECONOMY PLAN:

$35 COPAY

How to Get Started

To register, go to www.mdlive.com/bcbstx. Enter

your first and last name, date of birth, and BCBSTX

member ID number. Once you have an account, you

can browse doctor profiles, view available

appointment times, and schedule an appointment

with the doctor of your choice.

www.mdlive.com/bcbstx

888-680-8646

www.mdlive.com/getapp

Your 2021 Benefits

Medical Benefits

Pharmacy Benefits

Dental Benefits

Vision Benefits


Additional Benefits


LIVONGO DIABETES SUPPORT

The Simpler Way to a Healthier You

Testing and tracking your blood glucose levels is critical to successfully managing your diabetes, but it can be a time-consuming, manual process. Now, there’s a better way! Livongo provides you with an advanced blood

glucose meter, unlimited test strips, and on-demand coaching anytime, 100% paid for by the Archdiocese of Galveston-Houston.

Join Livongo and You’ll Get:

Reorder test strips right from your meter

Automatic uploads mean no more logbooks

Real-time support from coaches when you need it

Send health summary reports to your doctor directly from your meter

Personalized tips with each blood glucose check

Optional family alerts keep everyone in the loop

Register at join.livongo.com/ARCHGH beginning January 1, 2021

or call 800-945-4355 with code: ARCHGH

A more helpful meter Get advice on what to do next. Livongo’s meter gives you a personalized tip right after each blood glucose check.

Unlimited test strips, no cost to you With Livongo, test strips are ordered directly from your meter and delivered for free right to your door.

Your 2021 Benefits

Medical Benefits

Pharmacy Benefits

Dental Benefits

Vision Benefits


Additional Benefits


DENTAL BENEFITS

Dental coverage is important to your overall health and wellness. Eligible employees can enroll in dental

benefits through Blue Cross Blue Shield of Texas (BCBSTX). The Dental PPO Plan helps you with the cost of

preventive, basic, and major dental services for yourself and your eligible dependents.

This plan gives you the freedom to select any dentist, but you will pay less out-of-pocket when you choose a

provider in the BCBSTX Dental Network. To find an in-network provider, go to www.bcbstx.com and click on

“Find a Doctor.” Next scroll to the bottom of the page and select “Find a Dentist.” Enter your search criteria to

find in-network dentists near you.

Dental Services Dental PPO Plan

BCBSTX Dental PPO Network In-Network and Out-of-Network

Annual Deductible Individual / Family

$50 / $150

Annual Benefit Maximum $1,500 per person

Diagnostic & Preventive Services Exams, cleanings, bitewing x-rays, sealants

Plan pays 100%; deductible waived

Basic Services Endodontics, periodontics, root canals, oral surgery

You pay 20% after deductible

Major Services Crowns, inlays, onlays, prosthodontics, implants

You pay 50% after deductible

Orthodontic Services Lifetime Orthodontic Deductible Lifetime Benefit Maximum Eligibility

You pay 50% after lifetime orthodontic deductible $50 per person

$1,500 per person Adults & dependent children (up to age 19)

Out-of-Network Dental Claims

While benefits appear to be the same for in-network and out-of-network dentists, please remember that if you

choose an out-of-network dentist, there will be a maximum limit that BCBSTX will reimburse. If an out-of-

network provider charges over this amount, you may be balance billed by your dentist for the difference

between the provider’s charge and the maximum reimbursement allowed by the plan. Additionally, you must

file your own claim to be reimbursed for out-of-network services. You can find the claim form and instructions

posted under the “Forms” section of the Archdiocese of Galveston-Houston Human Resources website.

Your 2021 Benefits

Medical Benefits

Pharmacy Benefits

Dental Benefits

Vision Benefits


Additional Benefits


VISION BENEFITS

The Archdiocese of Galveston-Houston offers all eligible employees vision coverage through VSP. Eye care is a

vital component of a healthy lifestyle. Regular eye examinations can not only determine your need for

corrective eyewear but also may detect general health problems in their earliest stages. Your vision plan makes

regular exams and purchasing contacts or glasses simple and affordable.

With your vision coverage, you and your covered dependents have access to quality vision care. The plan uses

VSP’s network of vision care providers, including retail optical centers, optometrists, and opticians. Although

you can see any eye doctor you choose, you’ll save the most money if you choose an eye doctor from VSP’s

extensive network of providers. Your plan also offers special pricing for LASIK and PRK correction procedures

from contracted providers. To access a list of in-network providers and retail centers, or to see a list of

contracted LASIK and PRK correction providers, visit www.vsp.com or call 1-800-877-7195.

Vision Services Vision Plan

VSP Vision Network In-Network Out-of-Network

Eye Examinations $20 copay Reimbursed up to $50

Lenses Single Vision Lined Bifocal

Lined Trifocal Lenticular

Photochromic/Transition *Standard Progressive

$20 copay $20 copay $20 copay $20 copay $20 copay $20 copay

Reimbursed up to $50 Reimbursed up to $75



Frames $150 allowance Reimbursed up to $70

Elective Contact Lenses $150 allowance Applies to materials and exam (fitting & evaluation)

Reimbursed up to $105

Benefit Frequency Examination

Lenses OR Contact Lenses Frames

Once every 12 months Once every 12 months Once every 12 months

* $80—$90 copay for Premium Progressive Lenses, $120—$160 copay for Custom Progressive Lenses. All out-of-network progressive lenses are reimbursed up to $75.

Your 2021 Benefits

Medical Benefits

Pharmacy Benefits

Dental Benefits

Vision Benefits


Additional Benefits


Medical/Rx Rates

Biweekly Premium: Monthly Premium:

Standard Plan Employee Only

Employee + Spouse Employee + Child(ren)

Employee + Family

$0.00

$210.46 $161.54 $263.08

$0.00

$456.00 $350.00 $570.00

Economy Plan Employee Only

Employee + Spouse Employee + Child(ren)

Employee + Family

N/A

$179.08 $104.77 $183.23

N/A

$388.00 $227.00 $397.00

Dental & Vision Rates

Biweekly Premium: Monthly Premium:

Dental Plan Employee Only

Employee + One Dependent Employee + Two or More Dependents

$0.00

$25.22 $42.04

$0.00

$54.65 $91.08

Vision Plan Employee Only

Employee + One Dependent Employee + Two or More Dependents

$4.21 $6.08

$11.72

$9.13

$13.18 $25.40

Supplemental Life Rates

2021 PAYROLL DEDUCTIONS

Employee Age Bracket <25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+

Employee Coverage Monthly premium per $1,000 benefit

$0.042 $0.050 $0.067 $0.076 $0.084 $0.126 $0.194 $0.362 $0.555 $1.068 $2.060

Dependent Coverage Per family

Biweekly Premium: $0.57 Monthly Premium: $1.23

Your 2021 Benefits

Medical Benefits

Pharmacy Benefits

Dental Benefits

Vision Benefits


Additional Benefits


LIFE, AD&D & DISABILITY

Life and AD&D

With Life and Accidental Death & Dismemberment (AD&D) insurance provided through The Standard, your

family will be protected with benefits and a variety of support services designed to help cope with both

emotional and financial issues. The Archdiocese of Galveston-Houston provides all eligible employees with

Basic Life and AD&D insurance at no cost to you, and you also have the option to purchase Supplemental Life

Insurance for yourself and your child(ren). Review the chart below for details.

Basic Life/AD&D Insurance Supplemental Life Insurance3

Lay & Religious Employees1 Lay & Religious Employees Child(ren) (live birth—age 26)

Benefit Amount 1.5x your annual earnings Increments of $25,000 $10,000

Maximum Benefit $50,000 5x your annual earnings, not to

exceed $100,0004 $10,000

Age Reduction Schedule To 67% at age 65 To 50% at age 702

To 67% at age 65 To 50% at age 705

N/A

Benefit Paid By Archdiocese of Galveston-Houston Employee Employee

(1) Active Seminarians receive a flat $5,000 Basic Life/AD&D benefit.

(2) Benefit reduces on January 1st following the date you attain age 65 and age 70.

(3) Spouse Supplemental Life Insurance is no longer offered as of 1/1/2016; however, spouses currently covered under the Spouse Life benefit are grandfathered, and rates will match the Supplemental Life Insurance rates for Employees.

(4) If you are newly eligible, you may elect up to the guarantee issue amount without Evidence of Insurability (EOI). If you waived coverage when you were first eligible or were denied coverage, any amount elected will be subject to EOI. If you currently have coverage, any increases in coverage will require EOI. Elections requiring EOI will not become effective until and unless approved by The Standard.

Keep Your Beneficiary Information Updated When you enroll in benefits, you must designate a beneficiary (the person who will receive the benefit) for your Life and AD&D

insurance. You may have both a primary and contingent (secondary) beneficiary, as long as the total percentage adds up

to 100%. Annual enrollment is a great time to revisit your beneficiary information. It is important to confirm that your

beneficiary information (i.e., address, Social Security Number, date of birth) is correct. To update and/or confirm your

beneficiary information, please complete a beneficiary form and

submit it to Human Resources.

Your 2021 Benefits

Medical Benefits

Pharmacy Benefits

Dental Benefits

Vision Benefits


Additional Benefits


Short-Term & Long-Term Disability At no cost to the employee, Archdiocese of Galveston-Houston provides Short-Term Disability and Long-Term Disability Insurance through The Standard for all eligible employees. Disability Insurance is designed to

replace a portion of your income when you are unable to work due to a covered, non work-related injury or illness.

The eligible employee must file a claim with The Standard. Your physician will be required to certify your disability and if qualified, The Standard will determine Short-Term Disability, Long-Term Disability, and Family

Medical Leave Act (FMLA) eligibility. Health and Dental benefits continue while on approved FMLA. ONCE AN

EMPLOYEE QUALIFIES FOR LONG-TERM DISABILITY, EMPLOYMENT AND ALL BENEFITS ARE TERMINATED.

Leaves of Absence If you need to take a leave of absence from work, you can rest assured that you have protection. The Standard will administer all leave requests for any of the following reasons:

Please contact The Standard 30 days prior to the last day you plan to work before taking your leave. If a

sudden event results in an unscheduled leave, please contact The Standard as soon as possible.

Disability Benefits

Short-Term Disability (STD) Benefit Description

Weekly Benefit 60% of your pre-disability weekly salary

Elimination Period 14 days

Maximum Weekly Benefit $1,000

Maximum Benefit Duration 12 weeks

Long-Term Disability (LTD) Benefit Description

Monthly Benefit 60% of your pre-disability monthly salary

Elimination Period Later of 90 days or the end of the STD maximum benefit duration

Maximum Monthly Benefit $8,500

Maximum Benefit Duration Social Security Normal Retirement Age

Your own serious health condition

Caring for an immediate family member with a serious health condition

The birth of a child

Time to bond with a newborn or newly placed (adoption or foster care) child

Qualifying exigency when an immediate family member is a military service member on covered active duty or has been notified of an impending call/order to covered active duty status

Caring for a covered military service member with a serious injury or illness, to whom you are an immediate family member or next of kin

Need to file a disability claim or request a leave of absence? Your group number is 756955.

www.standard.com/absence 1-833-229-4173

Your 2021 Benefits

Medical Benefits

Pharmacy Benefits

Dental Benefits

Vision Benefits


Additional Benefits


WORK-LIFE BALANCE


We all experience times when we need a little help preparing for and dealing with the stresses of life. Your

Employee Assistance Program (EAP), which is provided to you at no additional cost, gives you, your

dependents, and all household members the ability to contact master’s-degreed clinicians 24/7 by phone,

online, live chat, email, and text. There’s even a mobile app for assistance on the go. Receive referrals to

support groups, a network counselor, community resources, or your health plan. If necessary, you’ll be

connected to emergency services.

Your Employee Assistance Program (EAP) includes up to 3 face-to-face counseling sessions per issue.

Assistance is immediate, personal, and available when you need it. EAP services can help you with:

To take advantage of the services available to you through your EAP, call 888-293-6948 (TTY 800-327-1833)

or visit www.workhealthlife.com/Standard3 to explore a wealth of information online, including videos, guides,

articles, webinars, resources, self-assessments and calculators. Morneau Shepell is the EAP vendor that The

Standard utilizes for Archdiocese of Galveston-Houston members.

Depression, grief, loss, and emotional wellbeing

Family and relationship issues

Life improvement and goal setting

Addictions and substance abuse

Financial and legal concerns

Identity theft and fraud resolution

Stress or anxiety with work or family

Online will preparation

Travel Assistance

You and your family can get support while traveling 100+ miles from home or

internationally, including passport, visa, weather and currency exchange

information, help replacing lost passports or credit cards, referrals to medical

providers, emergency medical evacuation, legal and interpreter services, and more!

Travel assistance is available worldwide 24/7.

In the US, Canada, Puerto Rico, USVI & Bermuda: 800-872-1414

Everywhere else: +1-609-986-1234 *Download the Mobile App

Text Message: +1-609-334-0807 by scanning the QR code

Email: [email protected] Reference Number: 01-AA-STD-5201

Your 2021 Benefits

Medical Benefits

Pharmacy Benefits

Dental Benefits

Vision Benefits


Additional Benefits


Life Services Toolkit

The Standard offers a lineup of additional services that can make a difference to you and your loved ones both

now and in the future. Online tools and services can help you create a will, make advance funeral plans, and put

your finances in order. After a loss, your beneficiary can consult experts by phone or in person, and obtain

other helpful information online.

Services to Help You Now

Estate Planning Assistance

Online tools, found in the Legal Forms section of

the Life Services Toolkit website, walk you through

the steps to prepare a will and create other

documents such as living wills, powers of attorney

and health care agent forms.

Financial Planning

Consult online services to help you manage debt,

calculate mortgage and loan payments, and take

care of other financial matters with confidence.

Health and Wellness

Access to timely articles about nutrition, stress

management and wellness help employees and

their families lead healthy lives.

Identity Theft Prevention

Check the Life Services Toolkit website for ways

to thwart identity thieves and resolve issues if

identity theft occurs.

Funeral Arrangements

Use the website to calculate funeral costs, find

funeral-related services and make decisions

about funeral arrangements in advance.

Services to Help Your Beneficiary

Grief Support

Clinicians with master’s degrees are on call to

provide confidential grief counseling sessions.

Your beneficiaries are eligible for up to 6 face-to-

face sessions and unlimited phone contact.

Financial Assistance

Your beneficiaries will have unlimited phone

access to financial counselors who can help with

issues such as budgeting, credit and debt

management and more.

Legal Services

Obtain an estate planning package that consists of

a simple will, living will, health care agent form and

a durable power of attorney. Beneficiaries who

choose to retain a participating attorney after an

initial consultation receive a 25% discount.

Support Services

During an emotional time, your beneficiaries can

receive help planning a funeral or memorial

service. Advisors can guide them to resources to

help manage household repairs and chores, find

child care and elder care providers, or organize a

move or relocation.

Take advantage of the helpful resources available with your Life Services Toolkit

www.standard.com/mytoolkit (username = assurance)

800-378-5742

Your 2021 Benefits

Medical Benefits

Pharmacy Benefits

Dental Benefits

Vision Benefits


Additional Benefits


Important Contacts

Know Your Numbers Use the space below to write in your identification number (located on the front of your BCBSTX ID card)

Identification Number:

Medical Group Number: 274679

Dental Group Number: 274852

Benefit Vendor Phone Website/Email

Human Resources Archdiocese of

Galveston-Houston 713-652-8265 www.archgh.org

Medical (Group #274679)



Prescription Drugs OptumRx 1-855-524-0381 www.optumrx.com

Virtual Visits MDLive 888-680-8646 www.mdlive.com/bcbstx

Nurseline Blue Cross Blue Shield

of Texas (BCBSTX) 800-581-0393 N/A

Diabetes Support (Registration Code: ARCHGH)

Livongo 800-945-4355 join.livongo.com/ARCHGH

Dental (Group #274852)



Vision (Group #12001362)

VSP 1-800-877-7195 www.vsp.com

Life and AD&D (Group #756955)

The Standard 1-833-229-4173 www.standard.com

Disability & Leave Management (Group #756955)

The Standard 1-833-229-4173 www.standard.com/absence


(Group #756955)

The Standard (Morneau Shepell)

888-293-6948 TTY: 800-327-1833

www.workhealthlife.com/Standard3

Travel Assistance The Standard

(Assist America)

USA, Canada, Puerto Rico, USVI & Bermuda: 800-872-1414

Worldwide: +1-609-986-1234

Text: +1-609-334-0807

[email protected]

Reference Number: 01-AA-STD-5201

Download the Assist America Mobile App on the App Store or Google Play

Life Services Toolkit The Standard 800-378-5742 www.standard.com/mytoolkit

Username: assurance

Benefits Help Line The Archdiocese of Galveston-Houston

855-664-8164 [email protected]

This benefits guide prepared by

This Employee Benefits Guide highlights recent plan design changes and is intended to fully comply with the requirements of a self-funded Church Plan

Sponsor as a Summary of Material Modifications and should be kept with your most recent Summary Plan Description.

This document is an outline of the coverage proposed by the carrier(s), based on information provided by your company. It does not include all of the

terms, coverage, exclusions, limitations and conditions of the actual contract language. The policies and contracts themselves must be read for those

details. Policy forms for your reference will be made available upon request. The intent of this document is to provide you with general information

regarding the status of, and/or potential concerns related to, your current employee benefits environment. It does not necessarily fully address all of your

specific issues. It should not be construed as, nor is it intended to provide, legal advice. Questions regarding specific issues should be addressed by your

general counsel or an attorney who specializes in this practice area.

The Archdiocese of Galveston-Houston believes its Medical and Pharmacy Plan as described in this guide is a “grandfathered health plan” under the

Patient Protection and Affordable Care Act (PPACA). As permitted by PPACA, a grandfathered health plan must preserve certain basic health coverage

that was already in the Plan when that law was enacted. Being a grandfathered health plan means that your Plan may not include certain consumer

protections (health and pharmaceutical coverages) of PPACA that apply to other (non-grandfathered) plans, for example, the requirement for the

provision of preventive health services without any cost sharing. However, the grandfathered plans must comply with certain other consumer

protections in PPACA, for example, the elimination of lifetime limits on benefits. As a grandfathered plan, this Plan, self-funded by the Archdiocese of

Galveston-Houston, does not provide medical and pharmaceutical coverage that contravenes with Catholic teachings. Questions regarding which

protections (Medical and Pharmaceutical coverages) apply and which protections (Medical and Pharmaceutical coverages) do not apply to our

grandfathered health plan status can be directed to the plan administrator, Charlie Pavlovsky, at 713-652-8261.

employee - archgh.org

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