Page 35 - Fort Health Care 2022 Benefit Guide

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Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you
provide in connection with the wellness program, we will notify you immediately.

You may not be discriminated against in employment because of the medical information you provide as part of participating in the
wellness program, nor may you be subjected to retaliation if you choose not to participate.

If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact
Nancy Alstad, Sr. Director, Human Resources at (920) 568-5020.

Health-Contingent Wellness Program Notice – Reasonable Alternative Standards

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

Summary of Benefits

The Affordable Care Act requires us to provide you with benefits summaries called Summaries of Benefits and Coverage (SBCs), starting
in 2013. They summarize important information about your health coverage options in a standard format to help you compare and
select the plan that is best for you and your family. The current SBCs are available on the FHC’s Resource Library under Human
Resources. You can also request a paper copy free of charge by calling Human Resources at (920) 568-5143 or (920) 568-5246.

Medicare Part D Creditable Prescription Drug Coverage
Important Notice from Fort HealthCare About
Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug
coverage with Fort HealthCare and about your options under Medicare’s prescription drug coverage. This information can help you
decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current
coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription
drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at
the end of this notice.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join
a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage.
All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage
for a higher monthly premium.

2. Fort HealthCare has determined that the prescription drug coverage offered by the Fort HealthCare Medical Benefit Plan is, on
average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is
therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and
not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

Because your existing coverage is, on average, at least as good as standard Medicare prescription drug coverage, you can keep this
coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 to December 7.
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a
two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

If you decide to join a Medicare drug plan, your current Fort HealthCare coverage will not be affected. Your medical plan already
comes with a prescription drug plan attached to it. Therefore, you cannot take Medical without the Prescription Drug Coverage. For
those individuals who elect Part D Coverage, your coverage under the entity’s plan will not end for the individual and all covered
dependents unless you want to drop both Medical and Prescription Drug coverage. You can enroll in a Part D plan as a supplement to
the other coverage.

Guide to Your Benefits | May 1, 2022 – April 30, 2023