Page 2 - 2015 Advia CU Benefits & Notices WI/IL
P. 2
Advia CU – WI/IL 2015
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
Summary of Benefits & Coverage (SBC) ................................................................................................. 9
Dental Coverage .................................................................................................................................... 12
Vision Coverage (CORE - Employer Paid) 12/24/24 .............................................................................. 13
Vision Coverage (Buy Up Option - VOLUNTARY) 12/12/12................................................................... 14
Health Reimbursement Arrangement (HRA) .......................................................................................... 15
Flexible Spending Accounts (FSA)......................................................................................................... 15
Employee Assistance Program (EAP).................................................................................................... 18
Basic Life/AD&D and Optional Life/AD&D Coverage.............................................................................. 19
Short Term Disability (STD) Coverage ................................................................................................... 20
Long Term Disability (LTD) Coverage .................................................................................................... 20
Employee Contributions - 2015 .............................................................................................................. 22
For More Information About Our Coverage ............................................................................................ 22
General Notice of COBRA Continuation Coverage Rights ..................................................................... 23
About Your Prescription Drug Coverage and Medicare – Notice of Creditable Coverage....................... 26
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) ................. 28
Summary of Benefits & Coverage (SBC) – Active/Retired EEs – PPO 250 ............................................ 31
Summary of Benefits & Coverage (SBC) – Active EEs – HRA PPO 1500.............................................. 39
Notes ..................................................................................................................................................... 47
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 26-27 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 Advia CU 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).
Salus Group© Copyright 2014 Page | 2
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
Summary of Benefits & Coverage (SBC) ................................................................................................. 9
Dental Coverage .................................................................................................................................... 12
Vision Coverage (CORE - Employer Paid) 12/24/24 .............................................................................. 13
Vision Coverage (Buy Up Option - VOLUNTARY) 12/12/12................................................................... 14
Health Reimbursement Arrangement (HRA) .......................................................................................... 15
Flexible Spending Accounts (FSA)......................................................................................................... 15
Employee Assistance Program (EAP).................................................................................................... 18
Basic Life/AD&D and Optional Life/AD&D Coverage.............................................................................. 19
Short Term Disability (STD) Coverage ................................................................................................... 20
Long Term Disability (LTD) Coverage .................................................................................................... 20
Employee Contributions - 2015 .............................................................................................................. 22
For More Information About Our Coverage ............................................................................................ 22
General Notice of COBRA Continuation Coverage Rights ..................................................................... 23
About Your Prescription Drug Coverage and Medicare – Notice of Creditable Coverage....................... 26
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) ................. 28
Summary of Benefits & Coverage (SBC) – Active/Retired EEs – PPO 250 ............................................ 31
Summary of Benefits & Coverage (SBC) – Active EEs – HRA PPO 1500.............................................. 39
Notes ..................................................................................................................................................... 47
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 26-27 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 Advia CU 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).
Salus Group© Copyright 2014 Page | 2
