Page 2 - 2013 Allied Printing Benefits & Notices

Allied Printing Co., Inc. 2013

Table of Contents

Introduction ........................................................................................................................................ 3

Changing Your Benefits ....................................................................................................................... 3

Newborns’ & Mothers’ Health Protection ............................................................................................ 4
Women’s Health & Cancer Rights Act (WHCRA) ................................................................................... 4

Protecting Your Privacy ....................................................................................................................... 4
Michelle’s Law .................................................................................................................................... 4

New Health Insurance Marketplace Coverage Options and Your Health Coverage................................ 5
Medical Coverage ............................................................................................................................... 8

Patient Protection Notice .................................................................................................................... 9

Waiver of Medical Coverage – Opt Out Option .................................................................................... 9
Dental Coverage ............................................................................................................................... 12

Vision Coverage ................................................................................................................................ 12
Flexible Spending Accounts (FSA) ....................................................................................................... 13

Basic Life/AD&D and Optional Life/AD&D Coverage .......................................................................... 15
Short Term Disability (STD) Coverage ................................................................................................ 16

Long Term Disability (LTD) Coverage ................................................................................................. 16

Employee Contributions .................................................................................................................... 18
For More Information About Our Coverage ....................................................................................... 18

General Notice of COBRA Continuation Coverage Rights .................................................................... 19
Notice of Creditable Coverage for Medicare Rx .................................................................................. 23

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) ................. 25
Summary of Benefits Coverage – BCBSM HSA PPO Plan ..................................................................... 28

Summary of Benefits Coverage – BCN High Deductible HMO Plan ...................................................... 35

Notes ................................................................................................................................................ 42

Information about Medicare

If you have Medicare or will become eligible for Medicare within the next 12 months, a new Federal law gives you more choices about
your prescription drug coverage. Please see pages 23-24 for details.

Important Note

This Benefits Enrollment Guide is only a brief summary of your benefits. It is not intended to provide a complete description of each plan. Please refer to the
Summary Plan Description and any other official documents for complete information about each benefit. We have tried to ensure its accuracy but if there is any
discrepancy between the benefits discussed in the guide and the official plan documents, the official plan documents will rule. The company reserves the right to
amend or terminate the Plan at any time and for any reason. The information in the guide and accompanying materials applies to the Allied Printing Employee
Benefit Plan, Plan Number 501, and meets the requirements for a Summary of Material Modification as required by the Employee Retirement Income Security Act
(ERISA).

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