© CDW LLC | 200 N. Milwaukee Avenue, Vernon Hills IL 60061 | … · 2020. 12. 30. · CDW...

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© CDW LLC | 200 N. Milwaukee Avenue, Vernon Hills IL 60061 | CDW.com | 800.800.4239

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TABLE OF CONTENTS

What you need to do ............................................................................................................... 3

What happens if you DON’T make new benefit elections? ...................................................... 3

Key Highlights .......................................................................................................................... 4

How to Enroll........................................................................................................................... 7

Eligible Dependents ................................................................................................................. 8

2021 Benefit Plans ................................................................................................................... 9

2021 Premiums...................................................................................................................... 12

Medical ................................................................................................................................. 15

2021 Medical Comparison Chart ............................................................................................ 15

Prescription Drug Benefits ..................................................................................................... 18

Health Savings Account (HSA) ................................................................................................ 20

Dental ................................................................................................................................... 23

Vision .................................................................................................................................... 24

Flexible Spending Accounts (FSAs) ......................................................................................... 27

Group Accident Insurance ..................................................................................................... 33

Group Critical Illness Insurance .............................................................................................. 34

Supplemental Life Insurance and Accidental Death & Dismemberment (AD&D) Plans .......... 35

Long-Term Disability .............................................................................................................. 36

Life Lock ................................................................................................................................ 36

Decision-Making Tips ............................................................................................................. 37

PPO Summary of Benefits and Covarage………………………………………………………………………………39

Healthy Advantage Summary of Benefits and Coverage……………………………….........................48

Prescription Drug Coverage and Medicare……………………………………………………………………………56

Children’s Health Insurance Program (CHIP)……………………………………………………………………..…58

Health Exchange Notice..…………………………………………………………………………………………………….62

Women’s Health and Cancer Rights Act Notice………………….…………………………………………..…...64

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Annual Benefit Enrollment is your opportunity to choose the benefit coverage that fits your needs for the coming year. All elections you make during Annual Benefit Enrollment are effective January 1, 2021 through December 31, 2021 and cannot be changed unless you have a qualified life event or change in employment status.

What you need to do between November 9 and November 24 for Annual Benefit Enrollment Review the 2021 Coworker Benefit Presentation and information provided on the Benefit

Enrollment & Communication Portal to understand your 2021 benefit options.

Review/update your personal information and tobacco-user status.

Review/update your eligible dependents and provide appropriate dependent verification documentation. *The deadline to provide the required documentation for dependent verification is December 1.

Make your 2021 benefit elections and enter beneficiary information.

Elect Flexible Spending Account(s) or Health Savings Account, if interested

Call the CDW Benefits Center at (855) 692-3923 from 7:30 A.M. to 6:00 P.M., CT, Monday through Friday or email [email protected] with any questions.

What happens if you DON’T make new benefit elections by November 24? Your current medical, dental, vision, supplemental life, AD&D, critical illness, accident and

LifeLock elections will continue for 2021. That means, if you waived coverage in 2020, you will not have coverage in 2021.

Your current Health Care FSA, Dependent Care FSA and Health Savings Account elections will not carry over to 2021.

Note: After Annual Benefit Enrollment, mid-year benefit changes can only be made within 31 days of a qualified life event (such as a marriage/new domestic partnership, divorce, birth/adoption of a child or a change in your spouse’s / domestic partner’s employment status).

https://cdw.benefit-info.com/index.html


mailto:[email protected]

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2021 Key Highlights Medical Plan

Your medical plan options are not changing. Blue Cross Blue Shield (BCBS) will continue to administer your medical benefits and you will have the choice of the same two medical plans.

Your medical premiums are increasing at a lower rate than annual medical and pharmacy inflation.

To help you with the cost of medical premiums, CDW continues to invest in the wellness medical premium credit of $27 per pay period ($702 / year).

Your CDW medical copays, coinsurance and out-of-pocket maximums are not changing.

CDW continues to pay the majority of the cost of these benefits.

Your CDW annual deductibles are changing.

PPO Plan

In Network: Individual $600/ Family $1,800

Out of Network: Individual $1,200 / Family $3,600

Healthy Advantage Plan

In Network: Individual $1,600/ Family $3,200

Out of Network: Individual $1,600 / Family $3,200

CDW is partnering with Hinge Health to help with back, knee, hip, shoulder or neck pain. Hinge Health can help to prevent injury, address chronic pain and provide virtual physical therapy. This program will be available at no cost to coworkers and family members enrolled in a CDW medical plan. Services include:

Twelve-week coach-led program, plus cognitive behavioral therapy and peer support

Unlimited 1:1 health coaching via email, text & phone

Clinically-proven exercises guided by a provided wearable sensor and pre-installed tablet for real-time feedback

Personalized interactive curriculum providing education on chronic pain & tips for reducing pain

CDW is partnering with Progyny to bring a smarter approach to fertility. The Progyny benefit includes comprehensive treatment coverage leveraging the latest technologies and treatments, access to high-quality care through a premier network of fertility specialists, and personalized emotional support and guidance from dedicated Patient Care Advocates. Progyny will replace the current fertility benefits being offered through Blue Cross Blue Shield of Illinois. You must be enrolled in a CDW Medical plan to take advantage of

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Progyny. Your Spouse/Domestic Partner must be a covered dependent on your plan for this benefit to also be available to them. Advantages includes:

Assigned Patient Care Advocate

Integrated Fertility Medication Benefit

Custom Digital Emotional Support Tools

Lifetime maximum 4 treatment cycles

Prescription Drug Plan

OptumRx will continue to administer your pharmacy benefits.

Your CDW pharmacy copays and coinsurance amounts are not changing.

There may be changes to medications on the formulary list or the prescription drug exclusion list. Visit the Prescription Drugs page of the Benefits Enrollment & Communication Portal (to view the 2021 Formulary or Exclusion Lists).

Dental PPO Plan

Your dental plan options are not changing. Cigna will continue to administer your dental benefits and you will have the choice of the same two dental plans.

Dental premiums are not increasing.

Vision Plan

VSP will continue to administer your vision benefits.

Vision premiums are not changing.

Health Savings Accounts

Fidelity will continue to administer your health savings account.

The Health Savings Account maximum for “coworker only” coverage will increase to $3,600. The maximum for “coworker plus” coverage will increase to $7,200. These limits include CDW’s quarterly contribution.

https://cdw.benefit-info.com/prescription-drug-benefit.html


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Flexible Savings Accounts

WageWorks will continue to administer your flexible spending accounts.

The Healthcare Care Flexible Spending Account (FSA) maximum is increasing to $2,750. Coworkers will have the option to carry over up to $550 of their Healthcare FSA balances from 2021 to 2022.

The Dependent Care FSA maximum will remain at $5,000.

401(k)

The annual contribution limit will remain at $19,500.

Voluntary Benefits

No changes to premiums for supplemental life, AD&D and long-term disability insurance, Group Accident, Critical Illness or LifeLock coverage.

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How to Enroll Complete enrollment by:

Login to the Benefits Enrollment & Communication Portal (www.cdwbenefits.com)

If you are logged into CDW’s Office applications, select the “Manage Your Benefits (SSO)” icon in the upper right-hand corner for single sign-on access.

If you are not logged into CDW’s Office applications, select the “Manage Your Benefits” icon in the upper right-hand corner to log-in with your username and initial password.

NEW! Spanish web enrollment available. Once logged into your personalized enrollment site, click “Language” at the top right and select Spanish.

Call a CDW Benefit Service Center representative at (855) 692-3923 Monday through Friday between the hours of 7:30 A.M. and 6:00 P.M., CT

Spanish speaking representatives and a language translation line are available.

Via the Benefitexpressway mobile app – login with your username and password


http://www.cdwbenefits.com/

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Eligible Dependents Your benefit eligible dependents include:

Spouse — the lawful husband or wife of an eligible coworker by marriage

Domestic Partner

Child — a dependent through the age of 25 who is one of the following:

o Your natural born child

o Your legally adopted child

o Child placed with you for adoption

o Your stepchild

o The child of your domestic partner

o Your foster child

o Other children for whom you are the legal guardian

A child who is the subject of a Qualified Medical Child Support Order (QMCSO) issued to you

A child as defined above, over the age of 25, who is mentally or physically handicapped and incapable of engaging in self-sustaining employment due to such incapacity may be eligible

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2021 Benefit Plans The 2021 Benefit Plans chart provides you with an overview of the decisions you will need to make during the Annual Benefit Enrollment period. Review this chart and the 2021 Benefit Premiums as a guide when deciding what benefit plans may work best for you.

Your Benefit Plans – An Overview

Available Coverage Your options during Annual Benefit Enrollment

Medical and Prescription Drugs

You will have the choice of two health plans through Blue Cross Blue Shield:

Healthy Advantage Plan

PPO Plan

What you pay for healthcare will vary from plan to plan based on your needs and how you receive care. Take some time to review your options. Your enrollment decision will impact how much you pay for quality healthcare throughout the year.

Prescription Drug coverage is included with both medical plans and is administered through OptumRx.

Health Savings Account (HSA)

The Health Savings Account is a tax-favored account that can be used to pay for eligible current and future healthcare expenses (if you enroll in the Healthy Advantage Plan). CDW will contribute to your Health Savings Account in four equal quarterly payments. CDW's annual contribution for coworker-only coverage is $250 and $500 for all other coverage levels.

Coworker only coverage — Contribute up to $3,350

All other coverage levels — Contribute up to $6,700

Catch-up contribution — Coworkers age 55 and older or coworkers who reach age 55 by the end of the plan year can make a catch-up contribution up to $1,000.

Dental

Whether you need routine exams or major dental work, CDW’s dental plans provide coverage to meet your needs. Choose from two plans administered by CIGNA:

Dental PPO

Dental HMO (this plan is not available in certain locations)

Check out the provider directory to see if your dentist is participating in the CIGNA network. Please refer to the “Cigna Dental Care Access Plus” for the DHMO Plan.

https://hcpdirectory.cigna.com/web/public/providers

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Vision You must enroll in the vision plan, through VSP, to get coverage for glasses or contacts.

Flexible Spending Accounts

Flexible Spending Accounts allow you to pay for certain healthcare expenses and dependent care expenses with pre-tax dollars.

Healthcare FSA — Contribute up to $2,750

Dependent care FSA — Contribute up to $5,000

See Eligible Expense Items (Healthcare / Dependent Care) for a complete list of approved expenses.

Group Accident Insurance

Group Accident Insurance helps to cover costs when unexpected medical and everyday expenses begin to add up after an accident. This voluntary insurance is 100% paid by coworkers. Some features include:

24-hour coverage

No limit on number of claims

Pays regardless of other insurance

Benefits available for your spouse/domestic partner and children

Coverage is portable

Group Critical Illness Insurance

Group Critical Illness Insurance complements your medical and disability coverage. It provides a lump-sum payment to help you with additional out-of-pocket costs associated with certain critical illnesses, such as cancer, heart attack or stroke. This voluntary insurance is 100% paid by coworkers. Some features:

Coverage levels for coworkers and spouses/domestic partners are $10,000, $20,000 or $30,000

Premiums are based on your age, benefit amount you select and tobacco-user status

Full benefits for each additional critical illness

Additional coverage for a recurring condition

Coverage is portable

Company-Provided Basic Life and Accidental Death & Dismemberment (AD&D)

CDW provides automatic coverage at 1 times your salary up to a maximum of $100,000 (minimum coverage of $35,000) at no cost to you.

https://www.wageworks.com/employees/benefits/healthcare-flexible-spending-accounts-fsa/fsa-eligible-expenses.aspx

https://www.wageworks.com/employees/benefits/dependent-care-flexible-spending-account-fsa/eligible-expenses.aspx

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Supplemental Life and Accidental death and Dismemberment (AD&D)

Purchase additional life insurance and/or AD&D coverage for you and your eligible dependents:

Coworker coverage — Elect a minimum of $20,000 or a maximum coverage amount of $1,000,000, not to exceed five times your salary

Spouse/domestic partner coverage — Elect a minimum of $10,000 or a maximum coverage amount of $500,000, without exceeding 100% of the coworker’s elected coverage level

Dependent child — $10,000 (coworker must be enrolled in order to select coverage for dependent children)

Long-Term Disability

This option provides you with an opportunity to enhance your CDW provided Group Long-Term Disability (LTD) coverage. Your current Group LTD plan provides basic coverage of 60% taxable income replacement to a maximum benefit of $10,000 per month. The Supplemental LTD Plan increases your coverage to 70% income replacement to a maximum benefit of $15,000 per month. This additional benefit amount is tax-free.

LifeLock with Norton Identity Theft and Device Security Protection

LifeLock with Norton Benefit Plans combine leading identity theft protection and device security against online threats, viruses, ransomware and malware, at home and on-the-go. You’re alerted of suspicious activity by email, text or a phone call. Choose from two plan options – Benefit Essential and Benefit Premier.

Tobacco Cessation Program

Join the confidential and free tobacco cessation program through Quit for Life by calling (866) 784-8454. This program includes:

Coaching calls

Nicotine replacement therapy

Web programs

Coworkers who use tobacco products will pay an additional $15 surcharge each paycheck for medical coverage.

https://quitnow.net/mve/quitnow

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2021 Benefit Premiums Medical Plans

Medical Premiums – Hourly Coworkers:

Biweekly Premiums

PPO Plan Healthy Advantage Plan

Wellness

Premiums

Non Wellness Premiums

Wellness

Premiums


Coworker $61.05 $88.05 $33.23 $60.23

Plus Spouse / DP $176.19 $203.19 $122.36 $149.36

Plus Child(ren) $161.84 $188.84 $111.31 $138.31

Family $255.71 $282.71 $176.58 $203.58

Medical Premiums – Salaried Coworkers (includes all Account Managers):

Biweekly Premiums

PPO Plan Healthy Advantage Plan

Wellness

Premiums


Wellness

Premiums


Coworker $77.90 $104.90 $46.03 $73.03

Plus Spouse / DP $219.13 $246.13 $155.13 $182.13

Plus Child(ren) $199.95 $226.95 $140.43 $167.43

Family $316.24 $343.24 $220.73 $247.73

Don’t Forget: If you complete the annual wellness criteria by November 24, 2020, you will be eligible for the Wellness medical rates which save you money on your 2021 medical premiums.

In 2021, if you are a tobacco user and enrolled in a CDW medical plan, you will pay an additional $15 per pay period toward your medical premiums. You can eliminate the $15 smoking premium by enrolling in and completing the Tobacco Cessation Program through Quit for Life. Learn more about the Tobacco Cessation Programs available to CDW coworkers on the Benefit Enrollment & Communication Portal.

https://quitnow.net/mve/quitnow

https://cdw.benefit-info.com/

https://cdw.benefit-info.com/

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Dental Plans

Biweekly Premiums Dental HMO Dental PPO

Coworker $8.72 $17.60

Plus Spouse / Domestic Partner $15.43 $38.02

Plus Child(ren) $15.42 $35.20

Family $23.75 $57.20

Vision Plan

Biweekly Premiums

Coworker $6.13

Plus Spouse / Domestic Partner $6.98

Plus Child(ren) $7.32

Family $12.59

Group Accident Insurance

Biweekly Premiums

Coworker $5.90

Plus Spouse / Domestic Partner $9.62

Plus Child(ren) $12.03

Plus Family $15.75

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Group Critical Illness Insurance

Non Tobacco-User Coworker Rates:

Age Biweekly Premium

$10,000 $20,000 $30,000

18–29 $2.94 $5.17 $7.41

30–39 $4.25 $7.80 $11.35

40–49 $8.36 $16.02 $23.68

50–59 $14.85 $29 $43.15

60+ $26.94 $53.18 $79.43

Tobacco-User Coworker Rates:

Age Biweekly Premium

$10,000 $20,000 $30,000

18–29 $4.06 $7.42 $10.78

30–39 $6.81 $12.92 $19.03

40–49 $13.87 $27.03 $40.20

50–59 $25.30 $49.91 $74.51

60+ $45.92 $91.14 $136.35

LifeLock Identity Theft Protection

Biweekly Premiums

Benefit Essential Benefit Premier

Coworker $3.46 $5.53

Plus Spouse/DP $6.91 $11.07

Plus Child(ren) $6.91 $11.07

Plus Family $6.91 $11.07

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Medical You have the choice of two health plans through Blue Cross Blue Shield:

The PPO Plan

The Healthy Advantage Plan

Both plans provide prescription drug benefits through OptumRx.

Medical Comparison Chart

Plan Feature PPO Plan Healthy Advantage Plan

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

CDW Health Savings Contribution

Individual NA NA $250

Family NA NA $500

Annual Deductible Deductible applies to the out-of-pocket maximum

Deductible applies to the out-of-pocket maximum

Individual $6001 $1,2001 $1,600 $1,600

Family $1,800 $3,600 $3,2003 $3,2003

Annual Out-of-Pocket Maximum

Individual $4,0002 $8,000 $3,250 $3,250

Family $8,500 $17,000 $6,5004 $6,5004

Under the PPO Medical Plan:

1. No individual family member's deductible will exceed $600 (in-network) or $1,200 (out-of-network) during the calendar year. Copays for medical services or prescription drugs do not count towards the medical deductible.

2. No individual family member's out-of-pocket maximum will exceed $4,000 (in-network) or $8,000 (out-of-network) during the calendar year. Copays for prescription drugs do not count towards the medical out-of-pocket maximum. They apply to a separate prescription drug out-of-pocket maximum.

Under the Healthy Advantage Medical Plan:

3. If you choose Coworker Plus coverage, an individual will reach their deductible when the family's total expense reaches the family deductible, regardless of which family members incur the costs.

4. Once the Family out-of-pocket maximum is met, all family members will be considered as having met their out-of-pocket maximum for the remainder of the calendar year.

http://mycdwbenefits.com/healthcare/medical.html#T2







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Doctor’s Office PPO Plan Healthy Advantage Plan


Well Care/Preventive Care

(routine physical exam, routine diagnostic tests, immunizations)

You pay $0 copay; deductible waived

You pay 40%; deductible waived

You pay $0; deductible waived

You pay 40% after deductible

Primary Care Physician Visit

(internal medicine, general & family practice, pediatrician, OB/GYN, mental health and substance abuse, chiropractor and physical, occupational and speech therapist) Note: If you visit your PCP in a Hospital setting, you may be billed an ‘outpatient facilities charge’ (and not as a PCP office visit). Contact BCBS for more information.





Specialist Office Visit

(all other providers not listed above under Primary Care Physician)





Allergist Doctor's Office Visit $30 copay You pay 40% after deductible



Allergy Injection You pay $0 copay; deductible waived


You pay $0; deductible waived


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Hospital Services PPO Plan Healthy Advantage Plan


Inpatient Care

(includes maternity, inpatient mental health and substance abuse)


You pay 40% after deductible + $250 per admission copay



Outpatient Surgery You pay 20% after deductible




Emergency Room You pay 20% after deductible




Urgent Care

(freestanding urgent care facility) $50 copay $50 copay You pay 20% after

deductible You pay 20% after deductible

Ambulance You pay 20% after deductible




Other Services PPO Plan Healthy Advantage Plan


Routine Eye Exam You pay $0 copay; deductible waived

You pay 40%; deductible waived



Outpatient Speech, Physical, and Occupational Therapy

(limited to 60 visits each per calendar year)

You pay $30 copay; deductible

waived




Chiropractic Care

(limited to 26 visits per calendar year for muscle manipulations)

You pay $30 copay,

deductible waived




Lifetime Maximum No maximum No maximum

For more information about the CDW medical plans, review the Healthy Advantage Plan and PPO Plan Summary of Benefits and Coverage available on the Benefit Enrollment & Communication Portal.

https://cdw.benefit-info.com/medical.html



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Prescription Drug Benefits Both the PPO Plan and Healthy Advantage Plan provide prescription drug benefits through OptumRx. Below is a high-level overview of the prescription drug benefit.

Plan Feature PPO Plan Healthy Advantage Plan

In-Network In-Network Out-of-Network

Retail (30-day supply)

Generic

Brand Formulary

Brand Non-Formulary

$10 copay

$40 copay

$60 copay

Preventative drugs: 20%, no deductible (For a list of preventative drugs, visit the prescription page on

the Benefit Enrollment and Communication Portal).

All others: 20% after deductible (you pay 100% until deductible is met)

Mail Order (90-day supply)

Generic

Brand Formulary

Brand Non-Formulary

$25 copay

$100 copay

$150 copay

Self-Injectable Must be purchased through OptumRx Specialty Pharmacy

Rx Out-of-Pocket Maximum Individual $2,000 | Family $4,000 No Separate Rx Out-of-Pocket

Maximum; Medical Out-of-Pocket Maximum Applies

Additional information regarding your prescription drug coverage: Prior Authorization and Step Therapy

Step Therapy and Prior Authorization requirements will continue to apply for certain drugs. These requirements encourage safe and cost-effective use of medications for certain medical conditions. New prescriptions that require Prior Authorization or Step Therapy will need to be approved by OptumRx before the drug will be covered under your medical plan.

Generic or Formulary Brand Equivalents

To see if your prescription has a generic or formulary brand equivalent, review the OptumRx Drug Formulary List (available on the Benefit Enrollment & Communication Portal).


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Over-the-counter Equivalent Exclusion Program

As a means of keeping overall prescription drug costs more affordable, prescription versions of medications that are available over-the-counter (OTC) will not be covered under CDW’s prescription drug program. You may still purchase the medication — either by prescription or over-the-counter — but you will be responsible for the full cost of the drug. Choosing to purchase the OTC version will often save you money.

Note: The Healthcare FSA requires a prescription for over-the-counter drugs to receive reimbursement. If you want to claim expenses for over-the-counter medications through a Healthcare FSA, ask your doctor for a prescription. Review a complete list of eligible Healthcare FSA expenses.

Preventive Care Prescription Drugs in the Healthy Advantage Plan

OptumRx has identified certain prescription drugs that help prevent the onset of more serious conditions (like high blood pressure and asthma). If your prescription is considered a preventive drug, your deductible is waived and only the 20% coinsurance will apply. Your share of the coinsurance will count towards your out-of-pocket maximum. Review the Preventive Drug List (located on the prescription page of the Benefit Enrollment & Communication Portal to see if your drug is used for preventive purposes.

Mandatory Mail Order Program or Walgreens Select 90

Certain maintenance medications will be required to be filled through Mandatory Mail Order. The mail order program permits 90-days of specific medication to be delivered directly to the members’ home address. Excluded from this are short-term medications, such as antibiotics; select controlled substances and medications included in the specialty pharmacy program.

Walgreens Select 90 is for coworkers not interested in mail order, these impacted medications can be filled through a Walgreens retail pharmacy only.

If a new prescription is not converted to mail order or to Walgreens, the patient will still be able to pick up the medication, up to a maximum of 2 times, at their regular pharmacy before the prescription is denied. Reminder notifications of this requirement will be mailed to members with each of the refills.




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Health Savings Account (HSA) A Health Savings Account is a tax-favored account you can use to pay for eligible current and future healthcare expenses with pre-tax dollars. You must enroll in the Healthy Advantage Plan to be eligible to open a Health Savings Account. The design of the Health Savings Account is determined by the IRS. Participation in an HSA requires a new enrollment election each year.

Your account balance earns interest (tax-free) and once your account balance reaches $2,500, you can invest your money in a selection of mutual funds. Any investment growth will also be tax-free. You own the account, which means if you leave CDW, you keep control of the account.

Quick Facts About the Health Savings Account You must enroll in the Healthy Advantage Plan to be eligible to open a Health Savings

Account through CDW.

CDW will contribute to coworker accounts in four equal quarterly payments. Each year at annual benefits enrollment, CDW will announce whether, and in what amounts, the company will be contributing in the coming year.

Coworkers must either actively enroll or select $0 HSA contributions on the benefit enrollment system to be eligible for company HSA contributions in 2021.

Your balance earns interest and can be carried forward from year to year.

How to Open an HSA

Once the HSA plan and associated biweekly contribution amounts have been elected through the benefits enrollment site, coworkers must agree to the Terms & Conditions of the Fidelity HSA as part of the enrollment process to enable the Health Savings Account to begin accepting funds.

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Eligible Expenses Expenses that are eligible for payment with Health Savings Account funds are defined by the Internal Revenue Service (IRS). These expenses include:

Most medical care and services

Dental care (non-cosmetic)

Vision care

Orthodontia

Prescription drugs

The expenses must be incurred by you or a dependent that you can claim on your federal tax return.

Federal tax law prohibits the use of Health Savings Accounts for the expenses of same-gender domestic partners or their children unless they are dependents listed on your federal tax return. Their medical expenses are still covered by the Healthy Advantage Plan. If you use HSA funds for non-qualified medical expenses before age 65, you'll pay a 20% tax penalty. This penalty is on top of the income tax you pay for using HSA funds for non-qualified medical expenses.

Funding Your Account Coworker contributions will be made over the course of the entire year based on the coworkers’ contribution schedule. CDW contributions will be made in four equal payments as soon as administratively possible following the first pay date in each quarter. Below are the HSA maximum contribution amounts.

Coverage Tier 2021 Annual Contribution Limit

CDW Annual Contribution

Your 2021 Annual Maximum Contribution

Coworker Only $3,600 $250 $3,350

All other coverage levels $7,200 $500 $6,700

Individuals who are not enrolled in Medicare and are age 55 and older or will reach age 55 by December 31, 2021 can make a $1,000 catch up contribution.

Opening Your HSA Coworkers begin by electing the Health Savings Account during enrollment and then reviewing the Health Savings Account Certification and selecting “I Agree.”

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Using Your Health Savings Account Your Health Savings Account comes with several options to use your money.

Pay on the spot using a HSA Debit Card

Upload receipts and pay from your mobile device (sign up at www.Fidelity.com/HealthExpense)

Schedule online payments through Fidelity BillPay

Pay out of pocket and reimburse yourself

Since you own the account, there are two important things to remember when using your HSA debit card.

You cannot overdraw your account. If you do not have enough funds to cover the expense, you must pay out of pocket. However, you can reimburse yourself through withdrawals as your balance builds up.

If you make a withdrawal for a non-eligible expense, you should see your tax advisor to ensure that your personal tax return does not violate federal tax rules.

You can view your account balance at any time by logging on to the Fidelity website at www.netbenefits.com.

Account Fees Like many bank and brokerage accounts, there are certain fees associated with Health Savings Accounts. CDW pays the monthly administration fee for all coworker HSAs. You will be responsible for any ATM withdrawal fees and insufficient fund charges.

Always keep receipts for your Health Savings Account expenditures for tax purposes.

http://www.fidelity.com/HealthExpense

http://www.netbenefits.com/

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Dental You have the choice of two dental plans administered by Cigna Dental. All coworkers are eligible for the Cigna Dental PPO Plan, but eligibility for the Cigna DHMO is based on your zip code. Go to the Cigna Provider Directory to see if you have DHMO dental providers in your area (Cigna Dental Care Access Plus network). Also, be sure to review the dental plan premiums.

Dental Plan Comparison

Feature Cigna Dental HMO Plan Cigna Dental PPO Plan

In-Network Services Covered Covered

Out-of-Network Services Not Covered Covered

Primary Dentist You must select a primary dentist for each covered person at the time of enrollment

You can seek treatment by any dentist of choice. You do not select a primary dentist under this plan

Referrals to Specialists Required under this plan N/A

How to Find an In-Network Dentist - go to Cigna’s provider directory

Cigna Dental Care Access Plus - You will need the 6-digit number under the dentist’s name when enrolling

Cigna Dental PPO



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*For a list of HMO dental costs, review the Cigna Dental Care DHMO Patient Charge Schedule available on the Benefit Enrollment & Communication Portal.

Vision

Feature Cigna Dental HMO Plan Cigna Dental PPO Plan

Deductible No deductible under this plan $50 – coworker

$150 – coworker plus

Preventive and Diagnostic Care — includes oral exams, cleanings, bitewing x-rays up to 2 times a year

Covered at 100% after a $5 co-pay for each visit

Covered at 100% of reasonable and customary charges

Basic Restorative Care — includes fillings and root canals Out-of-pocket costs vary You pay 20% after deductible of

reasonable and customary charges

Certain Major Restorative Care — includes crowns, dentures, bridges Out-of-pocket costs vary You pay 50% after deductible of

reasonable and customary charges

Maximum Annual Benefit N/A $1,250

Orthodontia Out-of-pocket costs vary You pay 50% after deductible

Orthodontia Lifetime Maximum Lifetime maximum of 24 months of interceptive /comprehensive treatment

$1,000

Online: Go to Cigna’s online provider

directory Enter your search criteria and click

on Search Click on Select a Plan. Choose: Cigna

DPPO or Cigna Dental Care Access Plus (HMO)

On the Search Results page, choose the Dentists option to view your list

Phone: Call (800) 244-6224 and talk directly

to a Cigna customer service rep. 24/7 or use the automated Dental Office Locator.

https://cdw.benefit-info.com/dental.html



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Besides helping you see better, routine eye exams can detect a number of serious health problems such as glaucoma, cataracts, diabetes and even cancer. Eye exams for kids can detect problems that can impact learning and development. The CDW Vision Plan — administered by VSP — is a way to assist you with your eye care and keep your out-of-pocket costs down. You can visit any ophthalmologist or optometrist of your choice; however, you pay less when you visit a VSP doctor.

No ID cards. No claim forms.

1. Find a VSP network doctor or call (800) 877-7195.

2. Make an appointment and tell the doctor you are a VSP member.

3. Your doctor and VSP will handle the rest.

The chart below summarizes VSP vision coverage. Be sure to review the premiums for the Vision Plan.

Feature VSP In-Network VSP Out-of-Network

Exams – Once every calendar year No charge after $10 co-pay After $10 co-pay, you

receive up to $50 allowance

Frames – Once every calendar year

After $25 co-pay, you receive up to $225 allowance plus 20% off the amount over your allowance.

Note: You will only pay one materials co-pay if you get both lenses and frames.

After $25 co-pay, you receive up to $70 allowance

Lenses - Once every calendar year

Single vision

Lined bifocal

Lined trifocal

No charge after $25 co-pay

Note: You will only pay one materials co-pay if you get both lenses and frames.

After $25 co-pay, you receive allowance of:

$50

$75

$100

Contact Lenses – Once every calendar year instead of frames and lenses

You receive up to $225 allowance toward cost of contacts, fitting and evaluation exam

You receive up to $105 allowance

https://vsp.com/

26


Note: With your VSP coverage, you can get either glasses or contacts each year, not both.

*If you decide not to see a VSP network doctor, co-pays still apply. You will also receive a reduced benefit and typically pay more out-of-pocket expenses. You will be required to pay the provider in full at the time of service and submit a claim to VSP for partial reimbursement. If you decide to see a provider not in the VSP network, please call VSP first at (800) 877-7195.

Extra Discounts and Savings

Laser Vision Correction Discounts

Average 15% off the regular price or 5% off the promotional price (at contracted facilities only)

After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor

Prescription Glasses

Polycarbonate lenses for dependent children covered in full after $25 co-pay

Average 35% - 40% savings on all non-covered lens options

30% off additional glasses and sunglasses, including lens options, from the same VSP doctor on the same day as your vision exam

20% off additional prescription glasses and sunglasses (available from the same VSP doctor who provided your eye exam within the last 12 months)

Contacts

15% off cost of contact lens exam — fitting and evaluation

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Flexible Spending Accounts (FSAs) Flexible Spending Accounts allow you to pay for certain Health and Dependent Care expenses with pre-tax dollars. A Flexible Spending Account (FSA) can help reduce your taxes and increase your take-home pay because the benefit is deducted on a pre-tax basis from your gross pay each pay period. CDW offers coworkers two flexible spending accounts: Healthcare FSA and Dependent Care FSA. All claims submitted to your 2021 FSA must be for claims incurred in 2021.

Participation in an FSA requires a new enrollment election each year.

Healthcare FSA

Coworkers can contribute up to $2,750 (a minimum of $130) to a Healthcare FSA to pay for eligible expenses not already covered by the health, dental or vision plans, such as co-pays, and deductibles. You can elect an annual contribution goal amount for 2021 and that amount will be divided over each pay period to be deducted on a pre-tax basis from your gross pay each pay period.

If you enroll in the Healthy Advantage Plan (with the Health Savings Account), government regulations place some restrictions on how you can use the Healthcare FSA along with your Health Savings Account. You will have the option to participate in a Limited Purpose Healthcare FSA.

You will use your Health Savings Account for eligible medical and prescription drug expenses. Your Limited Purpose Healthcare FSA will be used only for eligible vision, dental and orthodontia expenses.

Healthcare FSAs require a prescription for over-the-counter drugs. If you want to claim costs for over-the-counter medications under the Healthcare FSA, ask your doctor for a prescription. Review the list of eligible healthcare expenses.

Quick Facts About Flexible

Spending Accounts

You will need to use your Healthcare Flexible Spending Account differently if you enroll in the Healthy Advantage Plan (with the Health Savings Account).

Estimate your expenses carefully. You have the flexibility to carry over $550 of your unused 2021 Healthcare FSA account balance to 2022. Any remaining balance over $550 will follow the Use it or Lose it Rule.

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Why Consider a Limited Purpose Healthcare FSA?

To pay for vision, dental and orthodontia expenses that you can reasonably predict (remember, you don’t want to forfeit unused money due to the FSA “use it or lose it” rule).

If you have other uses for your Health Savings Account and want to take advantage of the FSA tax savings for your out-of-pocket vision, dental and orthodontia expenses.

To avoid spending the money in your Health Savings Account for FSA-eligible expenses, since the Health Savings Account money can accumulate as a tax-free investment.

Dependent Care FSA

Coworkers can contribute up to $5,000 (a minimum of $130) to a Dependent Care FSA to pay for eligible dependent care expenses, such as day care for your child, elderly parent or disabled spouse. It’s important to remember that you decide how much you want to contribute to an FSA. Deductions from your paycheck will begin with your first paycheck in the year and continue throughout the year.

Notice for Highly Compensated Coworkers with a Dependent Care FSA

The Internal Revenue Code (IRC) allows pretax contributions to FSAs as long as the benefit does not favor highly compensated employees (HCEs). You are considered "highly compensated" if your gross earnings are above the annual amount set by the Internal Revenue Service (see the IRS website for details).

In accordance with IRS regulations, CDW examines Dependent Care FSA elections each year to ensure that the benefit does not disproportionately benefit HCEs and that the Plan remains compliant. If the benefit is found to "discriminate" against non-highly compensated coworkers, CDW will reduce contributions made by HCEs to a level that enables compliance with the IRC.

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Comparing Flexible Spending Accounts and the Health Savings Account

There are a number of key differences between the Flexible Spending Accounts and the Health Savings Account. See how they compare below.

Plan Feature Dependent Care FSA Healthcare FSA Limited Purpose Healthcare FSA

Health Savings Account

Eligibility Does not require a health plan election

Coworkers who are not enrolled in the Healthy Advantage Plan (or other high deductible health plan)

Does not require a health plan election

Participants in the Healthy Advantage Plan only

Participants in the Healthy Advantage Plan only

Eligible Expenses – visit Wage Works for a Complete listing of FSA eligible expenses

Eligible dependent care expenses, such as day care for your child, elderly parent or disabled spouse.

Does not cover dependent medical expenses.


Vision care


Orthodontia

Over-the-Counter drugs that are not covered by health insurance or otherwise noted as eligible expenses with a doctor’s prescription.

Vision care


Orthodontia


Vision care


Orthodontia

Over-the-Counter drugs that are not covered by health insurance or otherwise noted as eligible expenses with a doctor’s prescription.

Coworker Annual Contribution Limit – deductions begin with your first paycheck in the year and continue throughout the year

$5,000 $2,750 $2,750 $3,350 – coworker only | $6,700 – coworker plus

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CDW Annual Contribution – made in four equal quarterly payments

$0 $0 $0 $250 – coworker only | $500 – coworker plus

Catch-up Contribution – for individuals age 55 and older or individuals who reach age 55 by the end of the plan year

N/A N/A N/A $1,000

Access to Funds

File claims via EZ receipts mobile app

Pay provider directly from WageWorks website

Request reimbursement by filing a claim through the WageWorks website

Pay for eligible expenses with the Wage Works Debit Card




Pay for eligible expenses with the Wage Works Debit Card




Pay using a HSA Debit Card

Upload receipts and pay from your mobile device

Schedule online payments through Fidelity BillPay

Pay out of pocket and reimburse yourself

https://www.wageworks.com/employees.aspx












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Tax Savings

Contributions are pre-tax

Qualified withdrawals are tax-free






Interest and other investment income is tax-free


Investment Income

N/A N/A N/A

Your balance earns interest

Once your balance reaches $2,500, you can transfer a portion of your money into a selection of mutual funds

Your account balance grows based on the performance of your investment.

Fees CDW pays monthly administration fees

CDW pays monthly administration fees



You are responsible for any ATM withdrawal fees, insufficient fund charges and paper statement fees.

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Rollover or Forfeit

Use it or Lose it – you will forfeit any unused money in your FSA if you do not submit 2021 expenses equal to your 2021 contributions amount by 3/31/2022.

You have the flexibility to carry over $550 of your unused 2021 Healthcare FSA account balance to 2022. These funds will carry over after the 3/31/2022 claim submission deadline. Any remaining balance over $550 will follow the Use it or Lose it Rule.

You have the flexibility to carry over $550 of your unused 2021 Healthcare FSA account balance to 2022. These funds will carry over after the 3/31/2022 claim submission deadline. Any remaining balance over $550 will follow the Use it or Lose it Rule.

Unused money rolls over each year to cover future qualified healthcare expenses

Portability

If you leave CDW, you can use the account for eligible expenses incurred prior to your last day.

If you leave CDW, you can use the account for eligible expenses incurred prior to your last day unless you elect Healthcare FSA COBRA coverage

If you leave CDW, you can use the account for eligible expenses incurred prior to your last day unless you elect Healthcare FSA COBRA coverage.

Your account balance is yours. If you leave CDW for any reason, your account goes with you.

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Group Accident Insurance After an accident, you may have unexpected expenses. Group Accident Insurance provides benefits to help you cover the costs associated with unexpected bills. CDW coworkers can purchase voluntary accident insurance from Continental American Insurance Company, a member of the Aflac family, at group rates. Be sure to review the coverage levels and premiums for Group Accident Insurance.

About Group Accident Insurance

The plan provides cash benefits for medical expenses as a result of an accident and other out-of-pocket expenses for you, your spouse/domestic partner and children — from the initial emergency treatment or hospitalization, to follow-up treatments or physical therapy.

You'll receive cash benefits for these and other expenses that may not be fully covered by your medical plan:

Ambulance, ground and air

Emergency room visits

Lacerations

Broken teeth

Concussions

Intensive care unit confinement

Wheelchairs

Crutches

The plan also provides accidental death and dismemberment benefits in addition to the benefits paid under CDW’s Accidental Death and Dismemberment (AD&D) plan.

Features

The plan includes 24-hour coverage

There is no limit on the number of claims

You pay your premium through automatic, payroll deductions

Coverage is portable – you can continue the coverage if you leave CDW or retire

For more information, review the Group Accident Insurance brochure (available on the Benefit Enrollment & Communication Portal) or contact Aflac at (800) 433-3036.

https://cdw.benefit-info.com/group-accident-insurance.html

https://cdw.benefit-info.com/group-accident-insurance.html

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Group Critical Illness Insurance Group Critical Illness Insurance complements your medical and disability coverage and can ease the financial impact of a critical illness. CDW coworkers can purchase voluntary critical illness insurance from Continental American Insurance Company, a member of the Aflac family, at group rates. Be sure to review the benefit amounts and premiums for Group Critical Illness Insurance. Note: Premiums are discounted for non-tobacco users.

About Group Critical Illness Insurance

The plan provides a lump-sum payment to help you with some of your additional out-of-pocket expenses related to a covered critical illness. Covered illnesses include:

Internal cancer

Heart attack

Stroke

Major organ transplant

Renal failure (end-stage)

In addition, critical illness insurance provides cash benefits after undergoing certain screenings such as mammography, colonoscopy, Pap smear and others.

Features

You select a benefit amount ($10,000, $20,000 or $30,000) for you and your eligible dependents (rates are discounted for non-tobacco users)

You pay your premium through automatic, payroll deductions

Full benefits for each additional critical illness you might have (additional occurrence benefit)

Additional coverage if a condition re-occurs

Coverage is portable – you can continue the coverage if you leave CDW or retire

For more information, review the Group Critical Illness Insurance brochure (available on the Benefit Enrollment & Communication Portal) or contact Aflac at (800) 433-3036.

https://cdw.benefit-info.com/group-critical-illness-insurance.html

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Supplemental Life Insurance and Accidental Death & Dismemberment (AD&D) Plans Financial protection for you and your family is important. CDW offers company-provided and supplemental life insurance and AD&D coverage through Cigna.

The life insurance premiums are based on your age, tobacco status and coverage amount. Log on to the Benefit Enrollment and Communication Portal to view your life and AD&D biweekly premiums.

Available Coverage Options During Annual Benefit Enrollment

Company-paid Basic Life Insurance and AD&D Each eligible coworker is enrolled for up to 1 times salary* to a maximum of $100,000 (minimum coverage of $35,000).

Supplemental Coworker Life Insurance and AD&D Coworkers may elect a minimum coverage amount of $20,000 or a maximum coverage amount of $1,000,000, but not to exceed 5 times their salary.

Spouse/Domestic Partner Life Insurance and AD&D

Spouses or domestic partners may elect as little as $10,000 worth of coverage or elect the maximum, which is 100% of the coworker’s elected coverage level, without exceeding $500,000.

Dependent Child Life Insurance and AD&D

Dependent Child Life Insurance and AD&D Coverage for children is set at a flat $10,000 per child. Coworker must be enrolled in order to select coverage for dependent children.

*Salary is defined as your earnings during the 12 months prior to annual benefit enrollment. This includes base salary, regular monthly, quarterly or annual bonuses and commissions. If your annual earnings during this time period are less than your annualized base salary, your annualized base salary will be used.

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Evidence of Insurability — Supplemental Life and AD&D

Certain levels of life insurance and AD&D coverage require you to demonstrate your good health by providing medical evidence of insurability (EOI). In most cases, the EOI requirement can be satisfied by completing a short medical questionnaire. If medical problems are indicated, Cigna may require you to have an examination by a physician. Any requests for additional information will be communicated to you by Cigna.

Evidence of insurability will be required for any new requests to enroll in or increase coverage during annual benefit enrollment.

Long-Term Disability CDW automatically provides Long-Term Disability (LTD) coverage to regular coworkers working at least 20 hours a week with one year of service. LTD benefits replace 60% of your total average earnings after 90 consecutive days of disability up to a maximum of $10,000 per month.

When enrolling in the Supplemental Long-Term Disability Plan through Cigna, you can increase your LTD coverage to 70% of your total average earnings up to a maximum benefit of $15,000 per month. The additional benefit amount is tax-free. To see how much the additional coverage costs, go to the Benefit Enrollment and Communication Portal.

Note: Coworkers earning $100,000 or more. The definition of “disability” means that due to illness or injury, you are unable to perform the material duties of your own occupation. After benefits have been payable for 24 months, the definition of “Disability” means that due to illness or injury, you are unable to perform the material duties of any occupation for which you are (or may reasonably become) qualified by education, training or experience, and you are unable to earn 50% or more of your indexed earnings.

LifeLock with Norton Everyday activities like online shopping, banking, and even browsing can expose your personal information, making you more vulnerable to cybercriminals. LifeLock with Norton Benefit Plans combine leading identity theft protection and device security. Your personal information is monitored and when activity occurs, you’re alerted by email, text or a phone call. Choose from two plan options – Benefit Essential and Benefit Premier.

You can purchase Life Lock with Norton Protection anytime during the year. For more information, review the Life Lock with Norton brochure (available on the Benefit Enrollment & Communication Portal).

https://cdw.benefit-info.com/lifelock.html




37


Decision-Making Tips Know What’s Important to You

Being a smart healthcare consumer means making plan and provider selections that are right for you and your family. Before you make your benefit elections, think about how you and your family use your benefits and if you will have any changing needs in the upcoming year.

CDW is offering two medical options that are each designed to give you control and choice in how you access and pay for healthcare. Which of these choices is right for your situation is something that only you can decide based on your family’s specific needs.

Your participation in CDW's Wellness Program can help you better understand your health and save on next year's medical premiums.

Key Considerations When Choosing a Health Plan option

When it comes to selecting healthcare coverage, many of us tend to buy more than we really need or use. The truth is, most of us spend more time researching and understanding our car insurance options than we do when considering our healthcare coverage costs and options. Think about it. Would you buy full coverage for a car you weren’t planning to drive? So, why pay for healthcare coverage you aren’t likely to use? Of course, we are all smart enough to know that we need to have coverage in case of emergency — that’s a given. But, just how much of your health plan coverage do you really use?

Your family status: Are you single with no dependents and rarely need to see a doctor, or are you the head of a large family with constant medical needs? Someone who is single and seldom needs to see a doctor might be more inclined to choose a plan with a higher level of out-of-pocket responsibility, simply so he or she can save the money normally spent on premiums and use that money for medical expenses only as needed. Someone with young children or someone with a chronic condition who often needs to see doctors may want a plan that has lower costs upfront, so that the plan will start paying benefits sooner.

Your spouse’s or domestic partner’s coverage: Does your spouse/domestic partner have coverage available from another source — from his or her employer? If so, you may want to compare that company’s benefit plans to your CDW options and see which plan provides you and your family with the best option for your situation. If your spouse/domestic partner is automatically covered under a company plan, then you may not need to enroll him or her through CDW. In most cases, the plans will coordinate coverage and you will be unable to collect full benefits from both plans.

Your healthcare expenses: Do you have predictable medical expenses each year? What are they and which plan option will help you meet your needs most easily and cost

38


effectively? Do you have any upcoming major healthcare expenses, such as a scheduled surgery? If you know what your healthcare expenses may look like this coming year, consider how each plan helps you pay for those expenses and pick the one that meets your needs. Be sure to think about the future and look for a plan that gives you the opportunity to reduce future out-of-pocket healthcare costs by saving for them today.

Your preferences for using certain providers: Do you or any members of your family have a doctor or specialist you like or prefer to see? Maybe you have a doctor you are comfortable with who knows you and your medical history. Review BCBS in-network doctors. If the doctor is not a part of the BCBS network, you will generally have higher out-of-pocket costs than if your doctor is “in network.” In-network doctors and hospitals have agreed to discounts for their services.

Your financial situation: What is your current financial situation? What does it look like for the upcoming year? Consider your priorities. Is it more important for you to be able to spend less on medical coverage so that you have more money to save for other things? Or does it make more sense for you to pay ahead for healthcare that you know you are likely to need in the future? For example, a mother with three boys knows that she will be making a few visits to the pediatrician next year. But a 25-year-old, single athlete knows he isn’t likely to need a lot of medical attention, so he might pick a plan that covers him for the big things (a broken arm or head injury) but that allows him to save money to buy a house. In comparing plans, consider which one will allow you to best meet your medical and financial needs for next year.

If any of the information in this Enrollment Guide conflicts with information provided in a benefit plan document or a summary plan description, the information in a benefit plan document or summary plan description will control.

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CDW Health and Welfare Plan: PPO Plan Coverage Period: 01/01/2021 - 12/31/2021 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Coworker & Family | Plan Type: PPO

Questions: Call 1-800-327-8497 or visit bcbsil.com/cdw for medical questions or call 1-855-430-5542 or visit optumrx.com for pharmacy questions. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at http://www.dol.gov/ebsa/healthreform or call 1-847-465-6000 and ask for “CDW Benefits Department” to request a copy.

This is only a summary. If you want more detail about your medical coverage and costs, you can get the complete terms in the policy or plan document at bcbsil.com/cdw or 1-800-327-8497. For pharmacy coverage, contact OptumRx at optumrx.com or 1-855-430-5542.

Important Questions Answers Why this Matters:

What is the overall deductible?

For Participating Providers $600 Person /$1,800 Family For Non-Participating Providers $1,200 Person /$3,600 Family Doesn’t apply to preventive care.

You must pay all the costs up to the deductible amount before this plan begins to pay for certain covered services you use. Copayments for medical services and prescription drugs do not count towards the calendar year deductible.

Are there other deductibles for specific services?

Yes. $250 per admission deductible for Non-PPO inpatient hospital benefits. There are no other specific deductibles.

You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

Is there an out–of–pocket limit on my expenses?

Yes. For Participating Providers $4,000 Person /$8,500 Family For Non-Participating Providers $8,000 Person /$17,000 Family

The out-of-pocket limit is the most you could pay during a coverage period (usually one calendar year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in the out–of–pocket limit?

Premiums, prescription drug copays, balance-billed charges, and health care this plan does not cover.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Is there an overall annual limit on what the plan pays?

No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

Does this plan use a network of providers?

Yes. See www.bcbsil.com/cdw or call 1-800-327-8497 for a list of participating providers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Out-of-network providers may balance bill.

Do I need a referral to see a specialist? No. You can see the specialist you choose without permission from this plan.

Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 4. See your policy or plan

document for additional information about excluded services.

http://www.bcbsil.com/cdw

http://www.dol.gov/ebsa/healthreform

http://bcbsil.com/cdw%20or%201-800-327-8497

http://www.optumrx.com/

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• Copayments are fixed dollar amounts (for example, $30) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if

the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.

• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

• This plan may encourage you to use Participating providers by charging you lower deductibles, copayments and coinsurance amounts.

Common Medical Event Services You May Need

Your Cost If You Use an

Participating Provider


Non-Participating

Provider

Limitations & Exceptions

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness $30 copay/visit 40% coinsurance Copay applies to office visit only.

Specialist visit $50 copay/visit 40% coinsurance

Other practitioner office visit $30 copay/visit 40% coinsurance Limited to 26 visits per benefit period for chiropractic and osteopathic manipulations.

Preventive care/screening/immunization No Charge 40% coinsurance ---none---

If you have a test

Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance Subject to medical necessity. Pre-determination of benefits is recommended. Outpatient precertification may be required.

Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance



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Non-Participating

Provider


If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbsil.com/cdw.

Generic drugs

$10 copay retail prescription $25 copay mail order prescription

Not Covered Retail: 30-day supply. Mail order: 90-day supply. Includes copay plus the difference between the generic and brand name drug costs if generic is available. Prior Authorization and Step Therapy may be required for certain medications. Rx Out-of-Pocket Expense Limit: $2,000 Person / $4,000 Family

Preferred brand drugs


Not Covered

Non-preferred brand drugs


Not Covered

Specialty drugs Covered only through Optum Specialty Pharmacy

Not Covered

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance Outpatient precertification may be required.

Physician/surgeon fees 20% coinsurance 40% coinsurance Outpatient precertification may be required.

If you need immediate medical attention

Emergency room services 20% coinsurance 20% coinsurance

Non-emergency use of the ER subject to overall plan deductible and coinsurance specific to network status. Pre-certification required if admitted.

Emergency medical transportation 20% coinsurance 20% coinsurance ---none---

Urgent care $50 copay/visit $50 copay/visit ---none---



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Non-Participating

Provider


If you have a hospital stay

Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance $250 per admission copay for Non-PPO inpatient hospital benefits. Pre-certification required.

Physician/surgeon fee 20% coinsurance 40% coinsurance ---none---

If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services $30 copay / visit 40% coinsurance PCP copay applies for Psychotherapy provided in office visit and in the outpatient setting.

Mental/Behavioral health inpatient services 20% coinsurance 40% coinsurance $250 per admission copay for Non-PPO inpatient hospital benefits. Pre-certification required.

Substance use disorder outpatient services $30 copay / visit 40% coinsurance PCP copay applies for Psychotherapy provided in office visit and in the outpatient setting.

Substance use disorder inpatient services 20% coinsurance 40% coinsurance $250 per admission copay for Non-PPO inpatient hospital benefits. Pre-certification required.

If you are pregnant

Prenatal and postnatal care $30 copay 40% coinsurance

Copay applies to the first prenatal visit. Diagnostic test (x-ray, blood work) will be covered at 80% after deductible for PPO and 60% after deductible for Non-PPO.

Delivery and all inpatient services 20% coinsurance 40% coinsurance $250 per admission copay for Non-PPO inpatient hospital benefits. Pre-certification required.



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Non-Participating

Provider


If you need help recovering or have other special health needs

Home health care 20% coinsurance 40% coinsurance $250 per admission copay for Non-PPO inpatient hospital benefits. Pre-certification required.

Rehabilitation services 20% coinsurance 40% coinsurance Limited to 60 visits combined for Occupational, Physical and Speech Therapies. Habilitation services 20% coinsurance 40% coinsurance

Skilled nursing care 20% coinsurance 40% coinsurance $250 per admission copay for Non-PPO inpatient hospital benefits. Pre-certification required.

Durable medical equipment 20% coinsurance 40% coinsurance ---none---

Hospice service 20% coinsurance 40% coinsurance $250 per admission copay for Non-PPO inpatient hospital benefits.

If your child needs dental or eye care

Eye exam No Charge 40% coinsurance Routine care only. Out of network providers may balance bill.

Glasses Not Covered Not Covered Not covered under the medical plan. Dental check-up Not Covered Not Covered Not covered under the medical plan.



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Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

• Cosmetic surgery

• Dental care

• Long-term care • Most coverage provided outside the

United States. See www.bcbsil.com/cdw

• Routine foot care (With the exception of those with diabetes)

• Weight loss programs

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

• Acupuncture

• Bariatric surgery

• Chiropractic care

• Hearing aids • Infertility treatment • Non-emergency care when traveling

outside the U.S.

• Private-duty nursing (with the exception of those with diabetes)

• Routine eye care

Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the CDW COBRA administrator, benefitexpress, at 1-877-837-5017. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact bcbsil.com/cdw or 1-800-327-8497. Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan does provide minimum essential coverage.




http://www.cciio.cms.gov/

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Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-327-8497. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-327-8497. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-327-8497. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-327-8497.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––



8 of 9



Having a baby (normal delivery)

Managing type 2 diabetes (routine maintenance of

a well-controlled condition)

About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

Amount owed to providers: $12,700 Plan pays $10,126 Patient pays $2,574

Sample care costs:

Hospital charges (Facility) $7,060 Routine obstetric care $2,600 Hospital charges (Professional) $1,400 Radiology $350 Laboratory tests $1,160 Prescriptions $20 Over-the-counter drugs $60 Vaccines, other preventive $50 Total $12,740

Patient pays:

Deductibles $600 Copays $40 Coinsurance $1,874 Limits or exclusions $60 Total $2,574


Sample care costs:

Prescriptions $3,490 Over-the-counter drugs $20 Office Visits and Procedures $1,010 Medical supplies $800 Laboratory tests $120 Vaccines, other preventive $160 Total $5,600

Patient pays:

Deductibles $600 Copays $600 Coinsurance $64 Limits or exclusions $20 Total $1,284

This is not a cost estimator.

Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different.

See the next page for important information about these examples.

Note: These examples are based on individual coverage only.



9 of 9



Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples?

• Costs don’t include premiums. • Sample care costs are based on national

averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.

• The patient’s condition was not an excluded or preexisting condition.

• All services and treatments started and ended in the same coverage period.

• There are no other medical expenses for any member covered under this plan.

• Out-of-pocket expenses are based only on treating the condition in the example.

• The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should consider when comparing plans?

Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to a healthcare FSA that help you pay out-of-pocket expenses. You should also take into consideration that up to six mental health counseling sessions per presenting problem and six coaching sessions are provided free of charge under the Coworker Assistance Program. For details login at www.modernhealth.com or email [email protected].






1 of 8

CDW Health and Welfare Plan: Healthy Advantage Plan Coverage Period: 01/01/2021 - 12/31/2021 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Coworker & Family | Plan Type: HDHP


This is only a summary. If you want more detail about your medical coverage and costs, you can get the complete terms in the policy or plan document at bcbsil.com/cdw or 1-800-327-8497. For pharmacy coverage, contact OptumRx at optumrx.com or 1-855-430-5542.

Important Questions Answers Why this Matters:

What is the overall deductible?

For Participating and Non-Participating Providers $1,600 Person/$3,200 Family Doesn’t apply to preventive care

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use.

Are there other deductibles for specific services?

No. You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.

Is there an out–of–pocket limit on my expenses?

Yes. For Participating and Non-Participating Providers $3,250 Person/$6,500 Family

The out-of-pocket limit is the most you could pay during a coverage period (usually one calendar year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in the out–of–pocket limit?

Premiums, balance-billed charges, and health care services this plan does not cover.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Is there an overall annual limit on what the plan pays?

No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

Does this plan use a network of providers?

Yes. See www.bcbsil.com/cdw or call 1-800-327-8497 for a list of participating providers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Out-of-network providers may balance bill.

Do I need a referral to see a specialist? No. You can see the specialist you choose without permission from this plan.

Are there services this plan doesn’t cover? Yes. Some of the services this plan doesn’t cover are listed on page 4. See your policy or plan

document for additional information about excluded services.



http://bcbsil.com/cdw%20or%201-800-327-8497

http://www.optumrx.com/

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• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if

the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.

• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

• This plan may encourage you to use Participating providers by charging you lower deductibles and coinsurance amounts.





Non-Participating

Provider


If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness 20% coinsurance 40% coinsurance ---none--- Specialist visit 20% coinsurance 40% coinsurance ---none---

Other practitioner office visit 20% coinsurance 40% coinsurance Limited to 26 visits per benefit period for chiropractic and osteopathic manipulations.

Preventive care/screening/immunization No Charge 40% coinsurance ---none---

If you have a test

Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance Subject to medical necessity. Pre-determination of benefits is recommended. Outpatient precertification may be required.

Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance



3 of 8







Non-Participating

Provider


If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbsil.com/cdw.

Generic drugs 20% coinsurance for retail and mail order prescriptions.

Not Covered Retail: 30-day supply. Mail order: 90-day supply. Prior Authorization and Step Therapy may be required for certain medications. Specialty Drugs covered only when obtained through Optum Specialty Pharmacy.

Preferred brand drugs 20% coinsurance for retail and mail order prescriptions.

Not Covered

Non-preferred brand drugs 20% coinsurance for retail and mail order prescriptions.

Not Covered

Specialty drugs 20% coinsurance Not Covered

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance Outpatient precertification may be required.

Physician/surgeon fees 20% coinsurance 40% coinsurance Outpatient precertification may be required.

If you need immediate medical attention

Emergency room services 20% coinsurance 20% coinsurance

Non-emergency use of the ER subject to overall plan deductible and coinsurance specific to network status. Pre-certification required if admitted.

Emergency medical transportation 20% coinsurance 20% coinsurance ---none--- Urgent care 20% coinsurance 20% coinsurance ---none---

If you have a hospital stay

Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance Pre-certification required. Physician/surgeon fee 20% coinsurance 40% coinsurance ---none---



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Non-Participating

Provider


If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services 20% coinsurance 40% coinsurance ---none--- Mental/Behavioral health inpatient services 20% coinsurance 40% coinsurance Pre-certification required. Substance use disorder outpatient services 20% coinsurance 40% coinsurance ---none--- Substance use disorder inpatient services 20% coinsurance 40% coinsurance Pre-certification required.

If you are pregnant Prenatal and postnatal care 20% coinsurance 40% coinsurance ---none--- Delivery and all inpatient services 20% coinsurance 40% coinsurance Pre-certification required.

If you need help recovering or have other special health needs

Home health care 20% coinsurance 40% coinsurance Limited to 120 visits per benefit period. Pre-certification required.

Rehabilitation services 20% coinsurance 40% coinsurance Limited to 60 visits combined for Occupational, Physical and Speech Therapies. Habilitation services 20% coinsurance 40% coinsurance

Skilled nursing care 20% coinsurance 40% coinsurance Limited to 120 days per benefit period. Pre-certification required.

Durable medical equipment 20% coinsurance 40% coinsurance ---none--- Hospice service 20% coinsurance 40% coinsurance ---none---

If your child needs dental or eye care

Eye exam No Charge 40% coinsurance Routine care only. Out of network providers may balance bill.

Glasses Not Covered Not Covered Not covered under the medical plan. Dental check-up Not Covered Not Covered Not covered under the medical plan.



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Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

• Cosmetic surgery • Dental care

• Long-term care • Most coverage provided outside the

United States. See www.bcbsil.com/cdw

• Routine foot care (With the exception of those with diabetes)

• Weight loss programs Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

• Acupuncture

• Bariatric surgery

• Chiropractic care

• Hearing aids • Infertility treatment • Non-emergency care when traveling

outside the U.S.

• Private-duty nursing (with the exception of those with diabetes)

• Routine eye care

Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the CDW COBRA administrator, benefitexpress, at 1-877-837-5017. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact bcbsil.com/cdw or 1-800-327-8497. Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan does provide minimum essential coverage.




http://www.cciio.cms.gov/

6 of 8



Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-327-8497. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-327-8497. Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-327-8497. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-327-8497.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––



7 of 8



Having a baby (normal delivery)

Managing type 2 diabetes (routine maintenance of

a well-controlled condition)

About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.


Sample care costs:

Hospital charges (Facility) $7,060 Routine obstetric care $2,600 Hospital charges (Professional) $1,400 Radiology $350 Laboratory tests $1,160 Prescriptions $20 Over-the-counter drugs $60 Vaccines, other preventive $50 Total $12,700

Patient pays:

Deductibles $1,600 Copays $0 Coinsurance $2,198 Limits or exclusions $60 Total $3,310


Sample care costs:

Prescriptions $3,490 Over-the-counter drugs $20 Office Visits and Procedures $1,010 Medical supplies $800 Laboratory tests $120 Vaccines, other preventive $160 Total $5,600

Patient pays:

Deductibles $1,600 Copays $0 Coinsurance $764 Limits or exclusions $20 Total $2,424

This is not a cost estimator.

Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different.

See the next page for important information about these examples.

Note: These examples are based on individual coverage only.



8 of 8



Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples?

• Costs don’t include premiums. • Sample care costs are based on national

averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.

• The patient’s condition was not an excluded or preexisting condition.

• All services and treatments started and ended in the same coverage period.

• There are no other medical expenses for any member covered under this plan.

• Out-of-pocket expenses are based only on treating the condition in the example.

• The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should consider when comparing plans?

Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as a Health Savings Account (HSA) or limited purpose healthcare FSA that help you pay out-of-pocket expenses. You should also take into consideration that up to six mental health counseling sessions per presenting problem and six coaching sessions are provided free of charge under the Coworker Assistance Program. For details login at www.modernhealth.com or email [email protected].






1

Important Notice from CDW

About Your Prescription Drug Coverage and Medicare

If you are not now eligible for Medicare – for instance, because you are not 65 or older – and

will not be eligible during the next year, you may disregard this notice.

Please read this notice carefully and keep it where you can find it. This notice has information

about your current prescription drug coverage under the CDW Welfare Benefits Plan 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. 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

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. CDW has determined that the prescription drug coverage offered by the CDW Welfare

Benefit Plan is, on average for all plan participants, expected to pay out as much as standard

Medicare prescription drug coverage pays and is considered Creditable Coverage. 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 15th through December 7th. However, if you lose creditable prescription drug

coverage, through no fault of your own, you will be eligible for a sixty (60) day Special

Enrollment Period (SEP), because you lost creditable coverage, to join a Part D plan.

If you decide to join a Medicare drug plan, your current CDW Welfare Benefit Plan

coverage will not be affected. Your CDW coverage will coordinate with the Part D

coverage.

If you do decide to join a Medicare drug plan and drop your coverage under the CDW

Welfare Benefit Plan, be aware that you and your dependents may not be able to get this

coverage back.

You should also know that if you drop or lose your coverage under the CDW Welfare Benefit

Plan and don’t join a Medicare drug plan within 63 continuous days after your current coverage

2

ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without prescription drug coverage that’s at least as good as

Medicare’s prescription drug coverage, your monthly premium may go up by at least 1% of the base

beneficiary premium per month for every month that you did not have that coverage. For

example, if you go nineteen months without coverage, your premium may consistently be at

least 19% higher than the base beneficiary premium. You may have to pay this higher premium

(a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to

wait until the following October to join.

For more information about this notice or your current prescription drug coverage...

Contact Amy Raupp at (847)-419-6133 for further information. NOTE: You will get this

notice each year. You will also get it before the next period you can join a Medicare drug plan, and

if this coverage through the CDW Welfare Benefit Plan changes. You also may request a copy.

For more information about your options under Medicare prescription drug coverage...

More detailed information about Medicare plans that offer prescription drug coverage is in

the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from

Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage:

• Visit www.medicare.gov

• Call your State Health Insurance Assistance Program (see the inside back cover of your

copy of the “Medicare & You” handbook for their telephone number) for personalized

help,

• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug

coverage is available. For information about this extra help, visit Social Security on the web

at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the

Medicare drug plans, you may be required to provide a copy of this notice when you join

to show whether or not you have maintained creditable coverage and whether or not you

are required to pay a higher premium (a penalty).

Date: October 2020

Name of Entity/Sender: CDW Corporation

Contact--Position/Office: Amy Raupp

Address: 200 N. Milwaukee Ave., Vernon Hills, IL 60061

Phone Number: (847) 419-6133

http://www.medicare.gov/

http://www.medicare.gov/

http://www.socialsecurity.gov/

http://www.socialsecurity.gov/

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2020. Contact your State for more information on eligibility –

ALABAMA – Medicaid COLORADO – Health First Colorado

(Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+)

Website: http://myalhipp.com/ Phone: 1-855-692-5447

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711 Health Insurance Buy-In Program (HIBI): https://www.colorado.gov/pacific/hcpf/health-insurance-buy-program HIBI Customer Service: 1-855-692-6442

ALASKA – Medicaid FLORIDA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: [email protected] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/index.html Phone: 1-877-357-3268

ARKANSAS – Medicaid GEORGIA – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

Website: https://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp Phone: 678-564-1162 ext 2131

http://www.healthcare.gov/


http://www.insurekidsnow.gov/

http://www.insurekidsnow.gov/

http://www.askebsa.dol.gov/

http://www.askebsa.dol.gov/

http://myalhipp.com/

http://myalhipp.com/

https://www.healthfirstcolorado.com/

https://www.healthfirstcolorado.com/

https://www.colorado.gov/pacific/hcpf/child-health-plan-plus




https://www.colorado.gov/pacific/hcpf/health-insurance-buy-program




http://myakhipp.com/

http://myakhipp.com/



http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx




https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/index.html




http://myarhipp.com/

http://myarhipp.com/

https://gcc01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fmedicaid.georgia.gov%2Fhealth-insurance-premium-payment-program-hipp&data=02%7C01%7Cstashlaw%40dch.ga.gov%7C98b18a96ce1b49d087f708d709449652%7C512da10d071b4b948abc9ec4044d1516%7C0%7C0%7C636988062560854968&sdata=7rziGawQfBKcW1N2%2Bdi2j8cyHpaCYURGdtF8Hk%2By6FM%3D&reserved=0




CALIFORNIA – Medicaid INDIANA – Medicaid Website: https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx Phone: 916-440-5676

Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: https://www.in.gov/medicaid/ Phone 1-800-457-4584

IOWA – Medicaid and CHIP (Hawki) MONTANA – Medicaid Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563

Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

KANSAS – Medicaid NEBRASKA – Medicaid Website: http://www.kdheks.gov/hcf/default.htm Phone: 1-800-792-4884

Website: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178

KENTUCKY – Medicaid NEVADA – Medicaid Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: [email protected] KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov

Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900

LOUISIANA – Medicaid NEW HAMPSHIRE – Medicaid Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)

Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext 5218

MAINE – Medicaid NEW JERSEY – Medicaid and CHIP Enrollment Website: https://www.maine.gov/dhhs/ofi/applications-forms Phone: 1-800-442-6003 TTY: Maine relay 711 Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-forms Phone: -800-977-6740. TTY: Maine relay 711

Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

MASSACHUSETTS – Medicaid and CHIP NEW YORK – Medicaid Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-862-4840

Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831

MINNESOTA – Medicaid NORTH CAROLINA – Medicaid Website: https://mn.gov/dhs/people-we-serve/children-and-families/health-care/health-care-programs/programs-and-services/other-insurance.jsp Phone: 1-800-657-3739

Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100

https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx




https://www.in.gov/medicaid/

https://www.in.gov/medicaid/

https://dhs.iowa.gov/ime/members

https://dhs.iowa.gov/ime/members

http://dhs.iowa.gov/Hawki




http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP

http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP

http://www.kdheks.gov/hcf/default.htm

http://www.kdheks.gov/hcf/default.htm

http://www.accessnebraska.ne.gov/

http://www.accessnebraska.ne.gov/

https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx






https://kidshealth.ky.gov/Pages/index.aspx

https://kidshealth.ky.gov/Pages/index.aspx

https://chfs.ky.gov/

https://chfs.ky.gov/

http://dhcfp.nv.gov/

http://dhcfp.nv.gov/

http://dhh.louisiana.gov/index.cfm/subhome/1/n/331

http://dhh.louisiana.gov/index.cfm/subhome/1/n/331

http://www.ldh.la.gov/lahipp

http://www.ldh.la.gov/lahipp

https://www.dhhs.nh.gov/oii/hipp.htm

https://www.dhhs.nh.gov/oii/hipp.htm

https://www.maine.gov/dhhs/ofi/applications-forms




http://www.state.nj.us/humanservices/dmahs/clients/medicaid/




http://www.njfamilycare.org/index.html

http://www.njfamilycare.org/index.html

http://www.mass.gov/eohhs/gov/departments/masshealth/




https://www.health.ny.gov/health_care/medicaid/

https://www.health.ny.gov/health_care/medicaid/

https://mn.gov/dhs/people-we-serve/children-and-families/health-care/health-care-programs/programs-and-services/other-insurance.jsp






https://medicaid.ncdhhs.gov/

https://medicaid.ncdhhs.gov/

OKLAHOMA – Medicaid and CHIP UTAH – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

OREGON – Medicaid VERMONT– Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

PENNSYLVANIA – Medicaid VIRGINIA – Medicaid and CHIP Website: https://www.dhs.pa.gov/providers/Providers/Pages/Medical/HIPP-Program.aspx Phone: 1-800-692-7462

Website: https://www.coverva.org/hipp/ Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282

RHODE ISLAND – Medicaid and CHIP WASHINGTON – Medicaid

Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)

Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022

SOUTH CAROLINA – Medicaid WEST VIRGINIA – Medicaid Website: https://www.scdhhs.gov Phone: 1-888-549-0820

Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

SOUTH DAKOTA - Medicaid WISCONSIN – Medicaid and CHIP Website: http://dss.sd.gov Phone: 1-888-828-0059

Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002

TEXAS – Medicaid WYOMING – Medicaid

Website: http://gethipptexas.com/ Phone: 1-800-440-0493

Website: https://health.wyo.gov/healthcarefin/medicaid/programs-and-eligibility/ Phone: 1-800-251-1269

To see if any other states have added a premium assistance program since July 31, 2020, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number.

MISSOURI – Medicaid NORTH DAKOTA – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

http://www.insureoklahoma.org/

http://www.insureoklahoma.org/

https://medicaid.utah.gov/

https://medicaid.utah.gov/

http://health.utah.gov/chip

http://health.utah.gov/chip

http://healthcare.oregon.gov/Pages/index.aspx

http://healthcare.oregon.gov/Pages/index.aspx

http://www.oregonhealthcare.gov/index-es.html

http://www.oregonhealthcare.gov/index-es.html

http://www.greenmountaincare.org/

http://www.greenmountaincare.org/

https://www.dhs.pa.gov/providers/Providers/Pages/Medical/HIPP-Program.aspx




https://www.coverva.org/hipp/

https://www.coverva.org/hipp/

http://www.eohhs.ri.gov/

http://www.eohhs.ri.gov/

https://www.hca.wa.gov/

https://www.hca.wa.gov/

https://www.scdhhs.gov/

https://www.scdhhs.gov/

http://mywvhipp.com/

http://mywvhipp.com/

http://dss.sd.gov/

http://dss.sd.gov/

https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm




http://gethipptexas.com/

http://gethipptexas.com/

https://health.wyo.gov/healthcarefin/medicaid/programs-and-eligibility/




https://www.dol.gov/agencies/ebsa

https://www.dol.gov/agencies/ebsa

http://www.cms.hhs.gov/

http://www.cms.hhs.gov/

http://www.dss.mo.gov/mhd/participants/pages/hipp.htm




http://www.nd.gov/dhs/services/medicalserv/medicaid/

http://www.nd.gov/dhs/services/medicalserv/medicaid/

The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137 (expires 1/31/2023)



New Health Insurance Marketplace Coverage Options and Your Health Coverage

PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health

Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic

information about the new Marketplace and employmentbased health coverage offered by your employer.

What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The

Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible

for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance

coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.

Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or

offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on

your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible

for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be

eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does

not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your

employer that would cover you (and not any other members of your family) is more than 9.5% of your household

income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the

Affordable Care Act, you may be eligible for a tax credit.1

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your

employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer

contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for

Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-

tax basis.

How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or

email CDW’s Benefits Department at [email protected].

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the

Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health

insurance coverage and contact information for a Health Insurance Marketplace in your area.

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered

by the plan is no less than 60 percent of such costs.

Form Approved OMB No. 1210-0149

(expires 6-30-2023)



CDW LLC 36-3310735 200 N. Milwaukee Ave. 847-465-6000 Vernon Hills IL 60061 CDW Benefits Department

PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an

application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered

to correspond to the Marketplace application.

3. Employer name

4. Employer Identification Number (EIN)

5. Employer address 6. Employer phone number 7. City 8. State 9. ZIP code 10. Who can we contact about employee health coverage at this job? 11. Phone number (if different from above) 12. Email address [email protected]

Here is some basic information about health coverage offered by this employer:

• As your employer, we offer a health plan to:

All employees. Eligible employees are:

Some employees. Eligible employees are:

• With respect to dependents:

We do offer coverage. Eligible dependents are:

• Spouse — the lawful husband or wife of an eligible coworker by marriage

• Same-Gender Domestic Partner

• Opposite-Gender Domestic Partner

• Child — a dependent through the age of 25 who is one of the following:

- Your natural born child

- Your legally adopted child

- Child placed with you for adoption

- Your stepchild whose primary place of residence is with you

- Other children for whom you are the legal guardian;

• A child who is the subject of a Qualified Medical Child Support Order (QMCSO) issued to you

• A child as defined above, over the age of 25, who is mentally or physically handicapped and incapable of engaging in self-sustaining

employment due to such incapacity, may be eligible.

We do not offer coverage.

If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to

be affordable, based on employee wages.

** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium

discount through the Marketplace. The Marketplace will use your household income, along with other factors,

to determine whether you may be eligible for a premium discount. If, for example, your wages vary from

week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly

employed mid-year, or if you have other income losses, you may still qualify for a premium discount.

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the

employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your

monthly premiums.

X

X

Regular coworkers, with at least 30 continuous days of service, regularly scheduled to work at least 20 hours per week.





Women’s Health and Cancer Rights Act Notice

If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

• all stages of reconstruction of the breast on which the mastectomy was performed; • surgery and reconstruction of the other breast to produce a symmetrical appearance; • prostheses; and • treatment of physical complications of the mastectomy, including lymphedema.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. Please reference the plan booklet for specific coverage details. If you would like more information on WHCRA benefits, call Blue Cross and Blue Shield at 800-327-8497.

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Transcript of © CDW LLC | 200 N. Milwaukee Avenue, Vernon Hills IL 60061 | … · 2020. 12. 30. · CDW...