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Northwest Retiree Benefit Trust Benefits Guide

2020

This guide includes detailed information regarding the benefit options available to you through the Northwest Retiree Benefit Trust.

In this guide, you will find information on the following:

2020 NORTHWEST RETIREE BENEFIT TRUST MEDICAL PLAN—PAGE 2 This plan is being offered through The Hartford.

2020 PRESCRIPTION DRUG PLAN—PAGE 11 This Express Scripts Medicare™ plan is being offered through Express Scripts Insurance Company, a Prescription Drug Plan (PDP) sponsor with a Medicare contract.

2020 DENTAL PLAN—PAGE 16This plan is being offered through MetLife Dental PPO.

2020 VISION PLAN—PAGE 17This plan is being offered through Superior Vision.

2020 QUALITYCARE CONNECT—PAGE 18This plan is provided through ArmadaHealth.

Welcome to the 2020 Northwest Retiree Benefit Trust Plans

Important NotesIf you have any questions or need assistance as you review this information, please contact us. The Retiree Service Center customer care representatives are available between the hours of 7:00 a.m. and 7:00 p.m. CT to assist you. Our dedicated toll-free customer care phone number is 1-844-413-2843.

You will now have access to a Care Advocate specialist at Gilsbar, L.L.C. to assist you with understanding your benefits, what they cover, claims medical billing and coordination of your healthcare needs.

You may enroll in the Prescription Drug Plan unless you currently participate in a government-sponsored plan, such as VA or TRICARE. Enrollees in the Prescription Drug Plan must continue to pay their Medicare Part B premium. Prescription Drug Plan benefits are provided by Express Scripts Insurance Company, a PDP plan sponsor with a Medicare contract.

You must enroll in the medical plan to be eligible for the vision plan.

Discounted services for hearing diagnostics, evaluations, and hearing aids are offered to our retirees at no cost through American Hearing Benefits. Call American Hearing Benefits at 1-888-612-6837 to speak with an American Hearing Benefits professional representative. You can also visit www.americanhearingbenefits.com/partners/thehartford. There is no enrollment form to complete.

For more information on the benefit plans available, visit our website at www.gilsbar.com/northwestretiree.

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Prepare. Protect. Prevail. With The Hartford.® GRH2019

GROUP BENEFITS

GROUP RETIREE INSURANCE PLAN

SUMMARY OF COVERAGE - "Premium Plan"

PLAN FOR RETIREES OF: NORTHWEST RETIREE BENEFIT TRUST UNDERWRITTEN BY: HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY

Calendar Year Deductible: $0 Calendar Year Maximum: $1,750

PART A SERVICES

SERVICES MEDICARE PAYS(1) PLAN PAYS(1) YOU PAY

HOSPITALIZATION (2) Semi-private room and board, general nursing, and miscellaneous services and supplies: First 60 days All but the Part A

Deductible 100% of Medicare Part A

Deductible $0

61st through 90th day All but 25% of the Part A Deductible

100% of Medicare Part A Coinsurance

$0

91st through 150th day (60 day Lifetime Reserve Period)

All but 50% of the Part A Deductible


$0

Once Lifetime Reserve days are used (or would have ended if used) additional 365 days of confinement per person per lifetime

$0 100% $0

SKILLED NURSING FACILITY CARE Semi-private room and board, skilled nursing and rehabilitative services and other services and supplies. You must meet Medicare's requirement which includes hospitalization of at least 3 days. You must enter a Medicare-approved facility within 30 days after leaving the hospital: First 20 days All approved amounts $0 $0

21st through 100th day All but 12.5% of the Part A Deductible per

day

Up to 100% of Medicare SNF Coinsurance

$0

GBD-2500 (AGP-7020)

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GROUP RETIREE INSURANCE PLAN SUMMARY OF

COVERAGE - "Premium Plan"


BLOOD DEDUCTIBLE – Hospital Confinement and Out-Patient Medical Expenses

When furnished by a hospital or skilled nursing facility during a covered stay.

First 3 pints Additional amounts

$0 100%

100% $0

$0 $0

HOSPICE CARE Pain relief, symptom management and support services for terminally ill.

As long as Physician certifies the need

All costs, but limited to costs for out-patient drug and in-patient

respite care

Co-insurance charges for in-patient respite care, drugs and biologicals

approved by Medicare

All other charges

PART B SERVICES


OUT-PATIENT MEDICAL EXPENSES The Policy may cover the following Medicare Part B Benefits:

Physician Services Benefit

Specialist Services Benefit

Outpatient Hospital Services and Ambulatory Surgical Care Benefit

Outpatient Diagnostic and Radiology Services Benefit

Outpatient Mental Health and Substance Abuse Services Benefit

Outpatient Rehabilitative and Cardiac Rehabilitative Services Benefit

Emergency Care Benefit

Urgent Care Benefit

Ambulance Services Benefit

Durable Medical Equipment and Prosthetics Benefit

All Medicare Part B Benefits are based on per vist, except Ambulance Services Benefit, which is based on per trip, and Durable Medical Equipment and Prosthetics Benefit, which is based on per device.

Medicare Part B Deductible $0 $0 100%

Remainder of Medicare-approved amounts

80% Remaining balance after Medicare is payable at

50% until out-of-pocket expenses reach $1,750, then plan pays 100% of the remaining Medicare

Part B Coinsurance

50% of the remaining Medicare Part B

Coinsurance

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Part B Excess Charges for Non-Participating Medicare providers covers the difference between the 115% Medicare limiting fee and the Medicare-approved Part B charge

$0 100% $0

ADDITIONAL SERVICES


PREVENTIVE MEDICAL CARE & CANCER SCREENINGS(3) Coverage for expenses incurred by a covered person for physical exams, preventive screening tests and services, cancer screenings, and any other tests or preventive measures determined to be appropriate by the attending Physician. Refer to your Medicare and You handbook for more information on Preventive services. “Welcome to Medicare” Physical Exam

-within first 12 months of Part Benrollment

100% $0 $0

Annual Wellness Visit 100% $0 $0

Vaccinations 100% $0 $0

Preventive Care Cancer Screening Benefits(3)

Generally 100% for most preventive screenings. Some

screenings subject to the Medicare Part B

Deductible and Coinsurance

100% of remaining covered expenses

Incurred not covered by Medicare

$0

FOREIGN TRAVEL EMERGENCY Medically necessary emergency care services. Emergency services needed due to Injury or Sickness of sudden and unexpected onset during the first 60 days while traveling outside the United States.

$0 80% after $250 Deductible

(to a lifetime maximum of $100,000)

$250 Deductible and then 20% of expenses

incurred (to a lifetime

maximum of

$100,000, then 100%

thereafter)

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CHIROPRACTIC SERVICES

Services performed by a licensed chiropractor to correct structural alignment

$0 100% of remaining covered expenses incurred, after the

copayment, up to the benefit maximum of

$1,000 per calendar year

$0 copay per exam

(to a calendar year maximum of $1,000,

then 100% thereafter)

ACUPUNCTURE SERVICES

Services performed by a licensed acupuncturist to treat pain



$500 per calendar year

$25 copay per exam

(to a calendar year maximum of $500,


ANNUAL PHYSICAL EXAM

The exam may include a review of medical history and a discussion of risk factor reductions and other services performed as part of an annual exam which are not covered by Medicare or under another benefit in the policy

After the “Welcome to Medicare Physical

Exam” $0

100% of remaining covered expenses incurred, after the



$25 copay per exam



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GROUP BENEFITS

GROUP RETIREE INSURANCE PLAN SUMMARY OF COVERAGE - "Value Plan"

Prepare. Protect. Prevail. With The Hartford.® GRH2019

PLAN FOR RETIREES OF: NORTHWEST RETIREE BENEFIT PLAN UNDERWRITTEN BY: HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY

Calendar Year Deductible: $400 Calendar Year Maximum: $1,750

PART A SERVICES


HOSPITALIZATION (2) Semi-private room and board, general nursing, and miscellaneous services and supplies: First 60 days All but the Part A

Deductible 100% of Medicare Part A

Deductible $0

61st through 90th day All but 25% of the Part A Deductible


$0

91st through 150th day (60 day Lifetime Reserve Period)

All but 50% of the Part A Deductible


$0

Once Lifetime Reserve days are used (or would have ended if used) additional 365 days of confinement per person per lifetime

$0 100% $0

SKILLED NURSING FACILITY CARE Semi-private room and board, skilled nursing and rehabilitative services and other services and supplies. You must meet Medicare's requirement which includes hospitalization of at least 3 days. You must enter a Medicare-approved facility within 30 days after leaving the hospital: First 20 days All approved amounts $0 $0

21st through 100th day All but 12.5% of the Part A Deductible per

day

Up to 100% of Medicare SNF Coinsurance

$0

GBD-2500 (AGP-7022)

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GROUP RETIREE INSURANCE PLAN SUMMARY OF COVERAGE "Value Plan"


BLOOD DEDUCTIBLE – Hospital Confinement and Out-Patient Medical Expenses

When furnished by a hospital or skilled nursing facility during a covered stay.

First 3 pints Additional amounts

$0 100%

100% $0

$0 $0

HOSPICE CARE Pain relief, symptom management and support services for terminally ill.

As long as Physician certifies the need

All costs, but limited to costs for out-patient drug and in-patient

respite care

Co-insurance charges for in-patient respite care, drugs and biologicals

approved by Medicare

All other charges

PART B SERVICES


OUT-PATIENT MEDICAL EXPENSES The Policy may cover the following Medicare Part B Benefits:

Physician Services Benefit

Specialist Services Benefit

Outpatient Hospital Services and Ambulatory Surgical Care Benefit

Outpatient Diagnostic and Radiology Services Benefit

Outpatient Mental Health and Substance Abuse Services Benefit

Outpatient Rehabilitative and Cardiac Rehabilitative Services Benefit

Emergency Care Benefit

Urgent Care Benefit

Ambulance Services Benefit

Durable Medical Equipment and Prosthetics Benefit

All Medicare Part B Benefits are based on per vist, except Ambulance Services Benefit, which is based on per trip, and Durable Medical Equipment and Prosthetics Benefit, which is based on per device.

Medicare Part B Deductible $0 $0 100%

Remainder of Medicare-approved amounts

80% Remaining balance after Medicare is payable at

50% until out-of-pocket expenses reach $1,750, then plan pays 100% of the remaining Medicare

Part B Coinsurance

50% of the remaining Medicare Part B

Coinsurance

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Part B Excess Charges for Non-Participating Medicare providers covers the difference between the 115% Medicare limiting fee and the Medicare-approved Part B charge

$0 100% $0

ADDITIONAL SERVICES


PREVENTIVE MEDICAL CARE & CANCER SCREENINGS(3) Coverage for expenses incurred by a covered person for physical exams, preventive screening tests and services, cancer screenings, and any other tests or preventive measures determined to be appropriate by the attending Physician. Refer to your Medicare and You handbook for more information on Preventive services. “Welcome to Medicare” Physical Exam

-within first 12 months of Part Benrollment

100% $0 $0

Annual Wellness Visit 100% $0 $0

Vaccinations 100% $0 $0

Preventive Care Cancer Screening Benefits(3)

Generally 100% for most preventive screenings. Some

screenings subject to the Medicare Part B

Deductible and Coinsurance

100% of remaining covered expenses

Incurred not covered by Medicare

$0

FOREIGN TRAVEL EMERGENCY Medically necessary emergency care services. Emergency services needed due to Injury or Sickness of sudden and unexpected onset during the first 60 days while traveling outside the United States.

$0 80% after $250 Deductible

(to a lifetime maximum of $100,000)

$250 Deductible and then 20% of expenses

incurred (to a lifetime

maximum of $100,000,


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CHIROPRACTIC SERVICES

Services performed by a licensed chiropractor to correct structural alignment



$1,000 per calendar year

$0 copay per exam

(to a calendar year maximum of $1,000,


ACUPUNCTURE SERVICES

Services performed by a licensed acupuncturist to treat pain




$25 copay per exam



ANNUAL PHYSICAL EXAM

The exam may include a review of medical history and a discussion of risk factor reductions and other services performed as part of an annual exam which are not covered by Medicare or under another benefit in the policy

After the “Welcome to Medicare Physical

Exam” $0

100% of remaining covered expenses incurred, after the



$25 copay per exam



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GROUP RETIREE INSURANCE PLAN SUMMARY OF COVERAGE

The Calendar Year Deductible applies to Medicare Part B Services. The Calendar Year Deductible must be met before the Plan will pay and applies toward the out of pocket expense maximum. The Calendar Year Maximum applies to Medicare Part B out of pocket expenses. The plan pays the remaining Medicare Part B coinsurance, if any, after your copayment until your Medicare Part B expenses reach the calendar year maximum stated, then the plan pays 100%. The Foreign Travel Emergency deductible is a separate deductible.

1 This chart describes coverage that is only available to persons who are Medicare-eligible. Medicare amounts typically change January 1 of each year.

2 A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. Hospital does not include any institution or part thereof that is used primarily as a nursing home, convalescent home, or Skilled Nursing Facility; a place for rest, custodial, educational or rehabilitory care; a place for the aged; or, a place for alcoholism or drug addiction.

3 If any of the cancer screening tests are not covered by Medicare, the plan will pay the usual and customary charges incurred. Please refer to your certificate for a full description of preventive screenings.

Please note this policy also may cover certain benefits mandated by the state where the employer is sitused or the state where you reside. Refer to your certificate for a description of any additional benefits.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including underwriting companies Hartford Life and Accident Insurance Company and Hartford Fire Insurance Company. Home Office is Hartford, CT. All benefits are subject to the terms and conditions of the policy. Policies underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. This brochure/presentation explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this brochure and the policy, the terms of the policy apply. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder. Benefits are subject to state availability. © 2019 The Hartford.

Not connected with or endorsed by the U.S. Government or the federal Medicare program.

Limitations & Exclusions: The Hartford’s Insurance Plan does not cover any expense that is not a Medicare Eligible Expense or beyond the limits imposed by Medicare for such expenses or excluded by name or specific description by Medicare, except as specifically provided in the policy. The plan does not cover: Any part of a covered expense to the extent paid by Medicare; benefits payable under one benefit of the policy to the extent covered under another benefit of the policy; or expense incurred after coverage terminates, except as stated in the Extension-of-Benefits provision of the policy.

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2020 Prescription Drug Plan

Express Scripts is an industry-leading pharmacy benefit manager (PBM) with extensive knowledge of Medicare programs and requirements. Express Scripts serves tens of millions of Americans as a PBM for health maintenance organizations, health insurers, employers, union-sponsored benefit plans, third-party administrators, and workers’ compensation and government health programs.

Express Scripts’ focus is driving out waste while improving health outcomes by coordinating the distribution of prescription drugs. The company offers a combination of services, including clinical management programs, retail drug card programs, home delivery of maintenance medications from the Express Scripts Pharmacy, formulary management programs, and specialty patient care and clinical programs spanning both the pharmacy and medical benefit to enhance care and reduce waste.

Community PharmaciesExpress Scripts has more than 67,000 community pharmacies for your use, including most chain drug stores and many independents. Express Scripts also has the largest Employer Group Waiver Plan (EGWP) in the market.

Mail Order PharmacyOrdering prescriptions by mail is like having a pharmacy at your door. It can save you trips to the pharmacy while providing confidentiality in your prescription needs.

Only you know what pharmacy options best suit you. Express Scripts is pleased to offer you the choice of local pharmacies, prescriptions by mail, and specialty pharmacies that support you and your specific needs.

1-888-345-2560 www.Express-Scripts.com

If you have questions on any of these pharmacy options or your Express Scripts plan, please contact the Express Scripts Member Services staff at:

OR

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Express Scripts Home

Delivery

1-31 Day Supply (MirrorsRetail Cost Share)

32-90 Day Supply (HomeDelivery Cost Share)

Preferred Standard Preferred Standard Preferred Standard Home Delivery

Generic $15.00 $20.00 $30.00 $35.00 $45.00 $50.00 $30.00

Preferred Brand $30.00 $35.00 $60.00 $65.00 $90.00 $95.00 $60.00

Non-Preferred Drugs $50.00 $55.00 $100.00 $105.00 $150.00 $155.00 $100.00

Specialty 32.5% 33.0% 32.5% 33.0% 32.5% 33.0% 32.5%

Initial Coverage Limit (ICL) $4,020

Compound Management Solution Compound Management Solution in place to mitigate compound drug abuse by means of inclusion and exclusion listFederal Poverty Limits Standard Federal Poverty Limit (FPL) guidelines apply

Formulary Medicare Premier Access OpenNon Part D Drugs

2 Covered Excluding Lifestyle drugs

NA

Generics Policy Voluntary

High Cost Generic DrugsAs defined by Express Scripts, some High Cost Generic and High Risk Drugs, (excluding Specialty Tier Generics, when applicable) will be subject to the Non-Preferred Drug copay

Utilization Management Program Approved Standard Part D PA, QLL, ST, CMS Required and High Risk Medication edits

$6,350

Catastrophic Coverage

Retail Pharmacy Network Retail Maintenance Drug Program (MDP) Pharmacy

Day Supply Up to 31 Day Supply 32-60 Day Supply Up to 90 day supply

Member cost share post-TrOOP ($6,350) is the greater of 5% or $3.60 for generic or preferred multi-source drugs with a maximum of the member cost share in the initial coverage level for generics and the greater of 5% or $8.95 for brand drugs

Network: Medicare Preferred Value

Network

Initial

Coverage

Period

Member Cost

Share

Deductible

Part B and ESRD Drugs2 Not Covered

Coverage Gap1 Retail, MDP & Home Delivery copays above apply for generic drugs. Member cost share on brand drugs will be 25% (Non Discount) and

25% (Discount), the maximum allowable cost share as defined by CMS

Member True Out of Pocket (TrOOP)

2020 Prescription Drug PlanBenefit Overview

Express Scripts Medicare™ (PDP) for Airline Retiree Benefit Trust

YOUR 2020 PRESCRIPTION DRUG PLAN BENEFIT The following table provides a summary of your benefit, including deductible and cost-sharing information.

1 Coverage Gap begins at the Initial Coverage Limit which is $4,020 in 2020. In cases where the client’s co-insurance in the Coverage Gap exceeds the maximum, beneficiaries’ co-insurance will be reduced in the Coverage Gap so as not to exceed the maximum allowable co-insurance as defined by CMS.

2 Some states require coverage for certain Non Part D, Part B, and ESRD drugs.

Express Scripts will comply with all state requirements on your behalf as well as any plan specific coverage requirement.

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Please note that most specialty medications can only be dispensed up to a 31-day supply to Medicare members, or up to a 30-day supply if they are found on the Carelogic drug list.

The Medicare Preferred Value Network offers Medicare members the choice of going to a Medicare preferred pharmacy (Tier 1), or to a standard pharmacy (Tier 2) at a higher copay. Medicare Preferred Value is anchored by preferred pharmacies (CVS) along with the Express Scripts mail order pharmacies and regional and independent pharmacies. Medicare Preferred Value has National presence with an estimated 27K+ providers. Pharmacy participation is contingent on contract renewal and is subject to change.

This group Medicare Part D plan has additional benefits to enhance the Medicare Part D coverage, as required by the Centers for Medicare and Medicaid Services (CMS). Per CMS regulations, the benefit enhancements are considered other health benefits and require filing with and approval by the state department of insurance. Express Scripts Medicare will offer this product in conjunction with Companion Life Insurance Company. The total premium amount consists of two distinct components as outlined below.

Employer Group Waiver Plan Premium - offered by Benistar and Express Scripts Medicare through its contracts with the Centers for Medicare and Medicaid Services. $155.00

Additional Enhanced Insurance Premium - offered above and beyond the CMS defined standard benefit. $0.40

Total Premium Per Member Per Month (PMPM) $155.40

Unless otherwise notified, the terms and conditions of this proposal are binding, accepted, and agreed to by the Plan.

If you choose to not renew your EGWP benefit for the 2020 plan year, you must notify Benistar of your intentions to terminate in accordance with the timeframe required within the Express Scripts agreement.

If you have any questions, please contact Benistar at 888-497-9500.

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IMPORTANT PLAN INFORMATION

Long-Term Care (LTC) Pharmacy If you reside in an LTC facility, you pay the same as at a network retail pharmacy. LTC pharmacies must dispense brand-name drugs in amounts of 14 days or less at a time. They may also dispense less than a one-month supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

Out-of-Network Coverage You must use Express Scripts Medicare network pharmacies to fill your prescriptions. Covered Medicare Part D drugs are available at out-of-network pharmacies only in special circumstances, such as illness while traveling outside of the plan’s service area where there is no network pharmacy. You generally have to pay the full cost for drugs received at an out-of-network pharmacy at the time you fill your prescription. You can ask us to reimburse you for our share of the cost. Please contact the plan or the Retiree Customer Service Center for more details.

Additional Information About This Coverage The service area for this plan is all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands and American Samoa. You must live in one of these areas to participate in this plan.

• The amount you pay may differ depending on what type of pharmacy you use; for example, retail, home infusion, LTC or home delivery.

• To find a network pharmacy near you, visit our website at www.Express-Scripts.com.• Your plan uses a formulary – a list of covered drugs. The amount you pay depends on

the drug’s tier and on the coverage stage that you’ve reached. From time to time, a drug may move to a different tier. If a drug you are taking is going to move to a higher (or more expensive) tier, or if the change limits your ability to fill a prescription, Express Scripts will notify you before the change is made.

• To access your plan’s list of covered drugs, visit our website at www.Express-Scripts.com.• The plan may require you to first try one drug to treat your condition before it will cover

another drug for that condition.• Your healthcare provider must get prior authorization from Express Scripts Medicare for

certain drugs.• If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will

pay the actual cost, not the higher cost-sharing amount.• Each month, you may need to pay a monthly premium amount to continue your

participation in this plan. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or by another third party, even if your Medicare Part D plan premium is $0.

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Example of how you could get in the Donut Hole: Assume that during the calendar year in the Initial Coverage Phase, Express Scripts has paid $3,160 in drug costs and you have paid $860 in copays.

$3,160 + $860 = $4,020 (You have reached the Initial Coverage Limit)

Please note: this is only an illustration of how the $4,020 Initial Coverage Limit can be reached; it could be a different combination of shared costs between you and Express Scripts depending on how your cost-sharing adds up and how much the Express Scripts Plan pays for the drugs. Regardless of how it is met, the total limit is $4,020.

What happens when I am in the Donut Hole? For the 2020 Medicare Preferred Value Plan in the Donut Hole: Preferred Brand and Non-Preferred Brand Drugs: You pay 35% of the cost; the pharmaceutical companies and your drug plan have committed through healthcare reform to pay the other 65%. Generic Drugs: You will continue to pay the same cost-sharing amount as in the Initial Coverage Stage.

Catastrophic Coverage Limit: In 2020, the limit for Catastrophic Coverage has been set at $6,350. After your yearly out-of-pocket drug costs reach $6,350, you will pay the greater of 5% coinsurance or:

• a $3.60 copayment for covered generic drugs (including brand drugs treated as generics) witha maximum of the Initial Coverage Stage member cost share

• a $8.95 copayment for all other covered drugs

NOTICE ABOUT THE COVERAGE GAP (DONUT HOLE)

During the INITIAL COVERAGE LIMIT, your cost-sharing for the Medicare Preferred Value Plan will be: $15 Generic, $30 Preferred Brand, $50 Non-Preferred Brand, and 32.5% Specialty. When the shared costs (what you contribute through your copay and what the Medicare Express Scripts Plan pays) for your drugs exceed $4,020, you leave the Initial Coverage Phase and enter the coverage gap, also called the “donut hole”.

Please note: the above cost-sharing is for a 31-day supply using the Medicare Preferred Value Plan.

IN-NETWORK OUT-OF-NETWORK

Annual Deductible (per person) $50 per person $50 per person

Preventive Care Exam - (twice per calendar year) Prophylaxis - (twice per calendar year)

No deductible The Plan pays 100% of

Reasonable & Customary (R&C) charges, after annual

deductible (deductible applies to minor and major care combined)

No deductible The Plan pays 80% of

Reasonable & Customary (R&C) charges

Minor Care Oral surgery Extractions Amalgams Endodontics Periodontics

The Plan pays 80% of R&C charges, after annual



deductible (deductible applies to minor and major

care combined)

Major Care Bridgework Dentures Crowns Inlays and onlays Reparation and replacement of bridges, crowns, inlays, onlays, Dentures Implants—1. Provided no more than once for thesame tooth position in a 60-monthperiod.2. Repaired not more than once in a 12-month period.3. Supported prosthetics but no morethan once for the same tooth positionin a 5-year period.





$1,500/person $1,000/person

If you have questions, need additional information, or help in locating a participating MetLife dentist (there are over 125,000 nationwide) please call MetLife at 866-526-0965 M-F 8:00 a.m. to 11:00 p.m. EST or the Northwest Retiree Benefits Trust Service Center at 1-844-413-2843.

*For residents of TX, LA, MS and MT, out-of-network preventive care will be covered at 100% due to state mandates.

Like most group benefits programs, benefit programs offered by MetLife contain certain exclusions, exceptions, waiting periods, reductions, limitations, and terms for keeping them in force.

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2020 Dental Plan MetLife Dental PPO

Annual Benefit Maximum

IN-NETWORK OUT-OF-NETWORK

Copayments $15 Comprehensive Eye Exams; $25 Materials; $10 Contact Lens Fitting

Comprehensive Eye Exam - Ophthalmologist (MD) Covered in Full Up to $37

Comprehensive Eye Exam - Optometrist (OD) Covered in Full Up to $28

Standard Lenses (Per pair):Single Vision Bifocal Trifocal Lenticular

Covered in Full Covered in Full Covered in Full Covered in Full

Up to $32Up to $46Up to $57Up to $84

Contact Lenses (Per pair):*Medically Necessary Elective**

Covered in Full $100 Retail Allowance

Up to $210Up to $80

Frames—Standard** $125 Retail Allowance Up to $64

*Contact lenses are in lieu of eyeglass lenses and frames benefit.**The insured is responsible for paying any charges in excess of this allowance.

PLAN FREQUENCY

Comprehensive Exam 12 months

Lenses 12 monthsFrames 24 monthsContact Lenses 12 months

MATERIALS DISCOUNT SVP8-20

These discounts apply to upgrades on the covered frame and lenses only. For discounts on additional pairs, please refer to the Discounts on Additional Purchases. Frames 20% off the difference between the

covered frame allowance and the retail price of the selected frame.

Note: Discounts do not apply when prohibited by the manufacturer.

MATERIALS DISCOUNTS ON ADDITIONAL PURCHASES

Discounts up to 20% on Materials and 30% on Additional Purchases are available through Superior Vision contracted providers identified in the provider directory.

Lens Options and Upgrades (covered pair of lenses)

Member pays 20%off retail up to:

Factory scratch coat $13Ultraviolet coat $15Standard anti-reflective coat $50High Index 1.6 $55Polycarbonate $40Standard photochromic $80Glass coloring $35Plastic, tints, solid, or gradients $25

Member pays:

Power over 4.00 Sphere, 2.00D Cylinder & 5.00 Prism

20% discount off retail

Cosmetic finishing, beveling, edging & mounting

20% discount off retail

Miscellaneous options 20% discount off retail

Higher end or brand name lens upgrades are at an additional expense to you. These upgrades will be available at a 20% discount off retail.All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance Coverage for your vision plan.

View your benefits and provider listing at www.superiorvision.com.

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2020 Vision PlanSuperior Vision Plan

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2020 QualityCare ConnectArmadaHealth

WHAT IS QUALITYCARE CONNECT®?Northwest Retiree Benefit Trust provides you with exclusive access to QualityCare Connect®, a program that connects you with the best possible specialists and, effective January 2020, primary care physicians for you and your family’s healthcare needs. Don’t trust your health to an online search or the advice of friends – let QualityCare Connect find the best doctors for you.

Highlights• Convenient access online or by phone• At least three physicians are recommended based on objective evaluation of their

expertise with your specific condition• Detailed profiles for recommended physicians provided via email• Insurance acceptance, appointment availability and required medical records confirmed

for you• QualityCare Connect has no legal or financial relationship with recommended physicians

Why Do I Need This Service?QualityCare Connect uses your diagnosis to identify physicians that have experience and expertise in treating your specific condition or injury. We give you peace of mind and save you time by connecting you to the right doctors based on your family’s needs and preferences.We also verify insurance acceptance, appointment availability, current legal status and convenience of locations.

Questions? Call us M-F, 8:30am to 8:00pm EST | 888-302-5735*This private and confidential service is provided by Northwest Retiree Benefit Trust at no cost to you. Please be aware that we cannot provide

recommendations for behavioral health or addiction. There’s no obligation to use the specialists we recommend, and we are not compensated by any physician for recommending them.

Help is at Your Fingertips

Go online or call for access to this valuable service.

Visit My.ArmadaHealth.com/gilsbar/nrbt to learn more.

Requesting a Doctor is EasySTEP 1 - Create an account by visiting your benefits site, My.ArmadaHealth.com/gilsbar/nrbt OR Log in by going to ArmadaHealth.com/Request STEP 2 - Request a doctor. You can search for either a primary care physician, a specialist or both. Click the FIND PHYSICIANS button to request a doctor.STEP 3 - Fill out the online form with your information.STEP 4 - Be sure to check your email! Within several business days, you will receive at least three profiles of physicians suited to your preference selection. If you don’t see the email, check your spam folder.

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