(888) 883‐1920

www.BeaconPath.com

Employee Benefit Booklet

June 1, 2020 ‐ May 31, 2021

Group Medical

FSA

Group Vision

Carrier: Service Number: Website/Email:

E.D.I.S.                                    

Group #788A11(888) 886‐7973 www.yourbenportal.com

USAvision                              

Group# 2099(800) 877‐7195 www.vsp.com

Discovery Benefits                

Group #27995(866) 451‐3399 www.discoverybenefits.com

BeaconPath(949) 716‐9099         

(888) 883‐1920customerservice@beaconpath.com

SO CAL DENTAL PARTNERS

Employee Benefit Options

The Benefit Explanations on these pages are meant as a brief summary only. The Plan

Documents take precedence over this summary.

Plan Year 2020‐2021

Benefit Summaries

MEDICAL BENEFIT Employee Pays Plan PaysDEDUCTIBLE $1,000 $0

(Family Max / 2 Deductible Aggregate) $2,000

PHYSICIAN OFFICE VISITS $20 copay             Deductible Waived

100% after copay

SPECIALIST OFFICE VISITS $30 copay             Deductible Waived

100% after copay

CALL‐A‐DOC $0 Copay              Deductible Waived

100%

DIAGNOSTIC LAB & X‐RAY  $20 copay             Deductible Waived

100% after copay

COMPLEX IMAGING (1) $200 Copay            Deductible Waived

100% after copay

INPATIENT HOSPITAL

Hospital Services 20% 80%

Physician & Professional Services 20% 80%

OUTPATIENT HOSPITAL

Outpatient Surgery 20% 80%

Other outpatient services 20% 80%

Emergency Room $250 copay + 20% 80% after copay

Non‐emergency use of the Emergency Room

OUTPATIENT SURGERY 20% 80%

OUTPATIENT DIALYSIS / CHEMOTHERAPY 20% 80%

URGENT CARE (including CVS MinuteClinic) $40 Copay             Deductible Waived

100% after copay

MENTAL ILLNESS

Inpatient Services 20% 80%

Outpatient Services (12 visits per calendar year) 20% 80%

PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY 20% 80%

(30 visits per treatment or 60 visits for a combination per calendar year)

ACUPUNCTURE / CHIROPRACTIC THERAPY 20% 80%

(12 combined visits per calendar year)

AMBULANCE 20% 80%

SKILLED NURSING (100 days per year) 20% 80%

HOME HEALTHCARE / HOSPICE 20% 80%

DURABLE MEDICAL EQUIPMENT / PROSTHETICS / ORTHOTICS 20% 80%

ROUTINE ADULT PHYSICAL / WELL CHILD / WOMEN'S HEALTH 0% 100%

ALL OTHER COVERED SERVICES & SUPPLIES 20% 80%

OUT OF NETWORK SERVICES

PRESCRIPTION DRUG SERVICES (2)                                                                                     

*Separate $250 deductible per member applies

Tier 1 $15 copay       

Tier 2 $30 copay*      

Tier 3 $50 copay*

SELF INJECTABLES 20% 80%

PRE‐CERTIFICATION PENALTY  50% reduction in 

benefits

50%

TOTAL OUT OF POCKET MAXIMUM

HRA/LUFSA Allowance

Employee Only

Employee + Family

1. Precertification is required on all complex imaging

2. The three Rx tiers are Tier 1) Generic Formulary; Tier 2) Brand Formulary; Tier 3) Brand Non‐Formulary

Medical Schedule of BenefitsFor

So Cal Dental PartnersWith

Cigna PPO Network

No primary care physician required.

This document is a summary only. It is not intended to replace the Summary Plan Description which describes in detail the complete provisions of the plan.                       

Final interpretation of any provision of any plan is governed by the legal document for the plan.    

NOT COVERED

NOT COVERED

Employee

$2,800

$5,600

*If you have a life-threatening situation, go to your nearest emergency room or call 911

 BE A BETTER HEALTH CARE CONSUMER 

   

CALL-A-DOC VS. CONVENIENCE CLINIC VS. URGENT CARE VS. EMERGENCY ROOM

The cost of medical care can vary widely. Your costs depend on where and how you receive care. Know the facts to get the best value for your health care dollars. If you need immediate medical attention, your first thought may be to go to the ER. But if your condition isn’t serious or life-threatening, you may have a less expensive choice. Selecting the right provider of service can save you hundreds of dollars.

Call-A-Doc Convenience Clinic Urgent Care Emergency Room

With Call-A-Doc help is a simple phone call away. Need a diagnosis? Medical advice? Short-term prescription or refill? Try Call-A-Doc.

• Acid Reflux

• Allergies

• Asthma

• Bronchitis

• Cold & Flu Symptoms

• Constipation

• Ear Infection

• Pink Eye

• Poison Ivy

• Rashes

• Respiratory Infection

• Sinus & Nasal Congestion

• Sore Throat

• Stomach Virus

• Urinary Tract Infection

• Vomiting

CVS MinuteClinics are designed to provide you with fast, appointment-free health care for minor illness and injuries.

• Fever

• Sore Throat (strep testing available)

• Earache

• Cough/ Congestion

• Sinus Infection

• Minor Injuries (abrasions/ scrapes)

• Vomiting

• Rashes (poison ivy, etc.)

• Bug Bites

• Minor cuts that may need a few stitches

Urgent Care centers are equipped to handle the same ailments that convenient care centers can handle and more.

• Sprains

• Strains

• Minor Broken Bones (finger, toe)

• Minor Infections

• Small cuts that may need a few stitches

• Minor burns

• X-rays

Emergency Rooms are designed for people with serious health events.

• Heavy Bleeding

• Large Open Wounds

• Sudden Change in Vision

• Chest Pain

• Sudden Weakness or Trouble Talking

• Major Burns

• Spinal Injuries

• Severe Head Injury

• Difficulty Breathing

• Major Broken Bones

CONVENIENCECARE CLINICS

Helping you and your doctor better manage your health

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates.

836761 f 02/15

When you need treatment for common ailments and injuries, you have more choices. You have already come to trust the health care services offered through our broad provider networks. Now you can get high-quality, affordable services for a wide variety of routine medical conditions through convenience care clinics located throughout the country.

Because we believe that your doctor has primary responsibility for your care and treatment, the results of your diagnosis and treatment are sent to your doctor with your permission. If you have a more severe condition, or require treatment in a different setting, the convenience care clinician will refer you to a doctor or an emergency room.

The convenience care clinics available include:

• MinuteClinic • Take Care Health

• RediClinic • Target Clinic

• Sutter Express Care • The Little Clinic

Refer to the provider directory for a complete list of clinics in the Cigna network.

The medical care delivered by the health teams at the convenience care clinics is covered by Cigna, just like any other service you receive from a health care professional.

Imagine:› Not waiting for an appointment – when you need

care, you walk right in. Wait times average 15 minutes or less.

› Finding a convenience care clinic in or near your favorite retail store, with hours that fit into your busy schedule.

› Receiving high-quality medical care in a facility overseen by doctors and staffed by certified nurse practitioners and physician assistants.

› Getting all this and more – and the cost for these services are handled the same as primary care physician office visits.

Consider convenience care for help with the following conditions:*• Allergies

• Athlete’s foot

• Bladder infections

• Bronchitis

• Chlamydia

• Cold sores

• Deer tick bites

• Ear infections

• Influenza

• Impetigo

• Laryngitis

• Minor burns, rashes or skin infections

• Minor sunburn

• Mononucleosis

• Pinkeye and styes

• Poison ivy

• Pregnancy testing

• Ringworm

• Sinus infections

• Strep throat

• Swimmer’s ear

• Swimmer’s itch

• Wart removal

*Call the clinic near you to learn which treatments are available.

“Cigna” and the “Tree of Life“ logo are registered service marks, and “Together, all the way.” is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. In Arizona, HMO plans are offered by Cigna HealthCare of Arizona, Inc. In California, HMO plans are offered by Cigna HealthCare of California, Inc. In Connecticut, HMO plans are offered by Cigna HealthCare of Connecticut, Inc. In North Carolina, HMO plans are offered by Cigna HealthCare of North Carolina, Inc. All other medical plans in these states are insured or administered by CGLIC or CHLIC. All models are used for illustrative purposes only.

836761 f 02/15 © 2015 Cigna. Some content provided under license.

The Little Clinics are conveniently housed in select Kroger and Publix stores in the following states.

• Arizona

• Colorado

• Florida

• Georgia

• Kentucky

• Ohio

• Tennessee

Take Care Health Systems provides walk-in health care services in the Health Corner Clinic in select Walgreens® drugstores and Eckerd pharmacies in the following states.

• Arizona

• Colorado

• Delaware

• Florida

• Georgia

• Illinois

• Indiana

• Kansas

• Kentucky

• Louisiana

• Mississippi

• Missouri

• Nevada

• New Jersey

• Ohio

• Pennsylvania

• Tennessee

• Texas

• Wisconsin

RediClinics can be found in select H-E-B® stores in Texas.

• Austin • Houston • Pasadena • San Antonio

Target Clinics can be found in select Target stores in the following states.

• Florida • Illinois • Minnesota • Maryland

Look for MinuteClinic health care centers in retail outlets like CVS/pharmacy®, Cub Foods®, and QFC in the following states.

• Arizona

• California

• Connecticut

• Florida

• Georgia

• Illinois

• Indiana

• Kansas

• Maryland

• Massachusetts

• Michigan

• Minnesota

• Missouri

• Nevada

• New Jersey

• New York

• North Carolina

• Ohio

• Oklahoma

• Pennsylvania

• Rhode Island

• South Carolina

• Tennessee

• Texas

• Virginia

We also provide vaccinations* for:• DTaP (diphtheria, tetanus,

pertussis)

• Influenza

• Hepatitis A and B

• Polio

• Meningitis

• MMR (measles, mumps, rubella)

• Pneumonia

• Td (tetanus, diphtheria)

Clinics are located within Rite Aid Pharmacies in the following Greater Sacramento communities.

• Roseville • Sacramento/South

› Clicking the Find a Doctor or Service button on the top menu bar.

› Click Find a Hospital.

› Click Convenience Care Clinic.

Or call the toll-free number on your ID card.

To locate a convenience care clinic near you:Access the Cigna provider directory on myCigna.com by:

24/7 CALL-A-DOC is not an insurance provider. 24/7 CALL-A-DOC does not supersede your association with your primary physician. You must submit the entire electronic medical record (EMR) before your consultation. 24/7 CALL-A-DOC does not guarantee a prescription will be written. 24/7 CALL-A-DOC does not prescribe controlled substances or any other drugs with a high risk for abuse.

www.247calladoc.com • 1-844-DOC-24HR

Welcome to 24/7 Call-A-DocCourtesy of your employer, you’ll soon have access to medical care anytime day or night. Welcome information will be available shortly with directions for setting up your 24/7 Call-A-Doc account. Visit www.247calladoc.com or call 844-DOC-24HR to complete the required information, including your medical history. Then you’ll be able to access quality care by licensed, U.S.-based doctors. Care is there when you need it!

What Is 24/7 Call-A-Doc? With 24/7Call-A-Doc, you can visit with licensed U.S. doctors from anywhere – the comfort of your own home, office or even hotel room – at your convenience, 24 hours a day, 7 days a week. And because the consultation is free, you’ll avoid costly urgent care or ER visit bills.

When Can I Use 24/7 Call-A-Doc?24/7 Call-A-Doc is for non-emergency issues when you can’t get in to see your primary care physician. (24/7 Call-A-Doc does not take the place of your regular primary care physician.)Give us a call or click when:✔ You need care right now✔ You’re thinking about visiting the ER or urgent care

for a non-emergency health concern✔ You need a short-term prescription refill✔ You’re out of town on business or pleasure

Care Is There When You Need ItOur highly qualified doctors can help you feel better fast by treating:: Ear infections: Cold and flu symptoms: Urinary tract infections: Pink eye (conjunctivitis): Allergies and sinus problems: Respiratory infections: Acne and skin rashes: Plus so much more!

Want to keep your primary care physician in the loop? With your consent, 24/7 Call-A-Doc will provide a record of your consultation to your PCP. Just ask!

Frames: Tints: Lined Trifocal Lenses: Lenticular Lenses:Progressive Lenses:

sm

Once every months for a Co-Pay.

Once every months pay a Deductible for Materials(Lenses and/or Frames).

Once every months get single, lined bifocal or lined trifocal lenses (subject to the Materials Deductible if not already met). Or, receive Standard Progressive (no-line) lenses for a Co-Pay, Premium Progressive Lenses for an Co-Pay, or Custom Progressive Lenses for a Co-Pay on top of the Materials Deductible (unless the Optional Progressive Lens Plan Enhancement is chosen).

Tints & Dyes, Photochromic and Polycarbonate Lenses are .

Once every months use up to and receive a discount over that (subject to the Materials Deductible if not already met, this does not reduce the frame allowance).

Instead of Lenses & FramesOnce every months spend up to .

Once every months get a discount off the contact lens fitting & evaluation and pay a maximum of , this does not reduce the amount available to spend on contact lenses.

Included.

This is any provider that is not a VSP provider (not in the VSP network). Members can use out-of-network providers, but they will be required to pay the provider in full at the time of service. Members can then apply for a partial reimbursement directly from VSP. Claims must be filed within 6 months of the date of service. Members may receive reimbursement up to the following allowances, after any applicable co-pay:

Exam: Single Vision Lenses: Lined Bifocal Lenses: Elective Contact Lenses:

Premium Offset PlanMedical, dental and vision contributions are 

deducted on a pre‐tax basis.

Dependent Care Account

Uses tax free dollars to pay for the cost of 

dependent care expenses. The Dependent Care 

Account limit is $5,000 per calendar year.

Health Care Reimbursement 

Account

Uses tax free dollars to pay for eligible health 

expenses.  The Health Care Reimbursement 

Account limit is $1,500 per calendar year.

Flexible Spending Account

This document is a summary only. It is not intended to replace the Summary Plan Descriptions which describe in detail the 

complete provisions of each plan. Final interpretation of any provision of any plan is governed by the legal documents supplied by 

each carrier for each plan.

FLEXIBLE SPENDING ACCOUNT (FSA)EMPLOYEE HANDOUT

AN FSA THAT SIMPLIFIES SAVINGS

ONE ONLINE ACCOUNT, ONE MOBILE APP AND ONE

DEBIT CARD FOR ALL OF YOUR BENEFITS

AVERAGE DEBIT CARD AUTO-SUBSTANTIATION

RATE OF MORE THAN 85 PERCENT

EASY DOCUMENTATION UPLOADING USING OUR BENEFITS MOBILE APP

THOUSANDS OF ELIGIBLE EXPENSES FOR PURCHASE

AT THE FSA STORE

DOWNLOAD THE APP FOR FREE ON APPLE AND ANDROID SMARTPHONES AND TABLETS

Flexible Spending Account OverviewA Flexible Spending Account (FSA) allows you to budget and save for qualified medical expenses incurred over the course of your plan year. Dollars invested in an FSA are tax-free. That makes an FSA a great tool for saving money, especially when big expenses are anticipated.

Eligible ExpensesIn order to have an expense covered by your FSA dollars, that expense has to be considered eligible by the IRS. To find out which specific expenses are eligible, view our searchable eligibility list at www.DiscoveryBenefits.com/eligibleexpenses.

Using FundsFor easy access to your FSA funds, you can swipe your Discovery Benefits debit card and avoid out-of-pocket costs. If you use your card at a provider with an Inventory Information Approval System (IIAS), the expense will automatically be approved at the point of sale.

If the card is swiped at a merchant that meets the IRS’ 90% rule, you may need to provide documentation to show the expense is eligible.

SubstantiationThe IRS requires FSA participants to provide documentation (e.g. an Explanation of Benefits) to show that an expense is FSA-eligible. You can easily upload documentation for a claim by logging in to your online account. You can also submit documentation by taking a photo with your phone’s camera and uploading it through the Benefits Mobile App by Discovery Benefits.

ELIGIBLE EXPENSE LISTwww.DiscoveryBenefits.com/eligibleexpenses

FSA CALCULATORwww.DiscoveryBenefits.com/fsacalculator

BENEFITS MOBILE APP VIDEOwww.DiscoveryBenefits.com/mobileappvideo

FSA 101 VIDEOwww.DiscoveryBenefits.com/fsa101

FSA STOREwww.DiscoveryBenefits.com/fsastore

RESOURCES

20007/17/19

Employee Only $750.05

Employee & Spouse $1,519.59

Employee & Child(ren) $1,263.09

Family $2,032.59

0 ‐ 3 Years* $450.03

4 ‐ 5 Years* $525.04

6 ‐ 10 Years* $600.04

11 Years* + $750.05

0 ‐ 3 Years* 4 ‐ 5 Years* 6 ‐ 10 Years* 11 Years +

Employee Only $150.01 $112.51 $75.01 $0.00

Employee & 

Spouse$534.78 $497.28 $459.78 $384.77

Employee & 

Child(ren)$406.53 $369.03 $331.53 $256.52

Family $791.28 $753.78 $716.28 $641.27

So Cal Dental Partners2020 Employee Contribution Breakdown

FULL MONTHLY PREMIUMPPO 1000 $20/20%

EMPLOYER MONTHLY CONTRIBUTION

EMPLOYEE PER PAYCHECK CONTRIBUTION ‐ MEDICAL

* Eligibility for next tier is effective upon completion of prior tier (in years)

EDIS & Cigna PPO Network

USAvision

Employee Only $12.48

Employee & Spouse $21.74

Employee & Child(ren) $22.74

Family $38.24

0 ‐ 3 Years* $7.49

4 ‐ 5 Years* $8.74

6 ‐ 10 Years* $9.98

11 Years* + $12.48

0 ‐ 3 Years* 4 ‐ 5 Years* 6 ‐ 10 Years* 11 Years +

Employee Only $2.50 $1.87 $1.25 $0.00

Employee & 

Spouse$7.13 $6.50 $5.88 $4.63

Employee & 

Child(ren)$7.63 $7.00 $6.38 $5.13

Family $15.38 $14.75 $14.13 $12.88

* Eligibility for next tier is effective upon completion of prior tier (in years)

So Cal Dental Partners2020 Employee Contribution Breakdown

FULL MONTHLY PREMIUMDeluxe Plan

EMPLOYER MONTHLY CONTRIBUTION

EMPLOYEE PER PAYCHECK CONTRIBUTION ‐ VISION

Federal Notices

Federal Notices Women’s Health and Cancer Rights Act of 1998. Under the Women's Health and Cancer Rights Act of 1998 (WHRCA), group health plans, insurance companies and HMOs offering coverage for mastectomies must also provide coverage for reconstructive surgery in a manner determined in consultation with the attending physician and the patient. The purpose of this section is to remind you of the following:

Under this Plan, coverage will be provided to a Participant or beneficiary who is receiving benefits for a Medically Necessary mastectomy and who elects breast reconstruction after the mastectomy for the following medical services:

• Reconstruction of the breast on which a mastectomy has been performed. • Surgery and reconstruction of the other breast to produce a symmetrical appearance. • Prostheses; and • Treatment of physical complications of all stages of mastectomy, including lymphedemas.

This coverage will be provided in consultation with the attending physician (Doctor) and the patient and will be subject to the same Co-pays that are applicable to other medical and surgical benefits under this Plan. If you would like more information on WHCRA benefits, call your plan administrator.

Newborns’ Act of 1996. Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

The statement above should not be interpreted by Participants to mean that the Plan may not apply its pre- authorization provisions for maternity benefits. Pre-authorization of any maternity confinement is still necessary to obtain the highest level of reimbursement available. The Claim Administrator will provide maternity benefits in a manner that complies with the requirements of this federal law. If you have any questions, contact the Plan Administrator for assistance.

Children’s Health Insurance Program Reauthorization Act of 2009. If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your employer, your State may have a premium assistance program that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for these programs, but also have access to health insurance through their employer. If you or your children are not eligible for Medicaid or CHIP, you will not be eligible for these premium assistance programs.

If you or your dependents are already enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial 1-888 KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan.

Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or

CHIP, as well as eligible under your employer plan, your employer must permit you to enroll in your employer plan if you are not 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, you can contact the Department of Labor electronically at www.askebsa.dol.gov or by calling toll free 1-866-444-EBSA (3272) For more information on premium assistance or special enrollment rights, you can contact either:

U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/ebsa 1-866-444-EBSA (3272)

U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565

Genetic Information Nondiscrimination Act of 2008. “GINA” prohibits group health plans, issuers of individual health care policies, and employers from discriminating based on genetic information.

The term “genetic information” means, with respect to any individual, information about:

• Such individual’s genetic tests • The genetic tests of family members of such individual; and • The manifestation of a disease or disorder in family members of such individual.

The term “genetic information” includes participating in clinical research involving genetic services. Genetic tests would include analysis of human DNA, RNA, chromosomes, proteins, or metabolite that detect genotypes, mutations, or chromosomal changes. Genetic information is a form of Protected Health Information (PHI) as defined by and in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and is subject to applicable Privacy and Security Standards.

Family members as it relates to GINA include dependents, plus all relatives to the fourth degree, without regard to whether they are related by blood, marriage, or adoption. Underwriting as it relates to GINA includes any rules for determining eligibility, computing premiums or contributions, and applying preexisting conditions. Offering reduced premiums or other rewards for providing genetic information would be impermissible underwriting.

GINA will not prohibit a health care Provider who is treating an individual from requesting that the patient undergo genetic testing. The rules permit the Plan to obtain genetic test results and use them to make claims payment determinations when it is necessary to do so to determine whether the treatment provided to the patient was medically advisable and/or necessary.

The Plan may request, but not require, genetic testing in certain very limited circumstances involving research, so long as the results are not used for underwriting, and then only with written notice to the individual that participation is voluntary and will not affect eligibility for benefits, premiums or contributions. In addition, the Plan will notify and describe its activity to the Health and Human Services secretary of its activities falling within this exception.

While the Plan may collect genetic information after initial enrollment, it may not do so in connection with any annual renewal process where the collection of information affects subsequent enrollment. The Plan will not adjust premiums or increase group contributions based upon genetic information, request or require genetic testing or collect genetic information either prior to or in connection with enrollment or for

underwriting purposes. Qualified Medical Child Support Order (QMCSO). A 1993 amendment to the Employee Retirement Income Security Act (ERISA) requires employment-based group health plans to extend health care coverage to the children of a parent-employee who is divorced, separated, or never married when ordered to do so by state authorities.

Generally, a state court or agency may require an ERISA-covered health plan to provide health benefits coverage to children by issuing a medical child support order (MCSO), sometimes even where the child may not be a “dependent” under the terms of the group health plan. Participants and beneficiaries of The Plan may obtain a copy of the QMCSO procedure from the Plan Administrator, free of charge, upon request. Mental Health Parity. Pursuant to the Mental Health Parity and Addiction Equity Act of 2008, this Plan applies its terms uniformly and enforces parity between covered health care benefits and covered mental health and substance disorder benefits relating to financial cost sharing restrictions and treatment duration limitations. For further details, please contact the Plan Administrator. Special Enrollment Rights. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides you with certain special enrollment rights pertaining to your health care coverage. If you decline enrollment for yourself or your Eligible Dependents (including your Spouse) because of other health insurance coverage (such as coverage through another employer), you may in the future be able to enroll yourself or your Eligible Dependents in this Plan, provided that you request enrollment within 31 days after the other coverage ends.

In addition, if you have a new dependent as a result of marriage, you may be able to enroll yourself and your dependents, provided that you request enrollment in writing within 30 days of the marriage. You must provide documentation of the event.

If you also have a new dependent as a result of birth, adoption, or placement for adoption, you may be able to enroll yourself, your eligible spouse and your newborn child, adopted child or child placed for adoption provided that you request enrollment in writing within 30 days of the birth, adoption, or placement for adoption. You must provide documentation of the event.

Note children previously declined are not eligible to enroll during this special enrollment period. HIPAA Privacy. The Plan will comply with the Standards for Privacy of Individually Identifiable Health Information (i.e., the “Privacy Rule”) set forth by the U.S. Department of Health and Human Services (“HHS”) pursuant to the Health Insurance Portability and Accountability Act (“HIPAA”). Such standards control the dissemination of “protected health information” (“PHI”) of Plan Participants. Privacy standards will be implemented and enforced in the offices of the Employer and Plan Sponsor and any other entity that may assist in the operation of the Plan.

Patient Protection. You do not need prior authorization from the medical carrier or from any other person

(including a primary care physician) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. General Notice of COBRA Continuation Coverage Rights Introduction You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees. What is COBRA continuation coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.

If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

• Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct.

If you are the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

• Your spouse dies. • Your spouse’s hours of employment are reduced. • Your spouse’s employment ends for any reason other than his or her gross misconduct.

• Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: • The parent-employee dies. • The parent-employee’s hours of employment are reduced. • The parent-employee’s employment ends for any reason other than his or her gross misconduct. • The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both). • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a “dependent child.”

When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events:

• The end of employment or reduction of hours of employment. • Death of the employee; or • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).

For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 30 days after the qualifying event occurs. How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. Second qualifying event extension of 18-month period of continuation coverage

If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicare, Medicaid, Children’s Health Insurance Program (CHIP), or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov. Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends? In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial enrollment period, you have an 8-month special enrollment period1 to sign up for Medicare Part A or B, beginning on the earlier of

• The month after your employment ends; or • The month after group health plan coverage based on current employment ends.

If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment penalty and you may have a gap in coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in Medicare Part A or B before the COBRA continuation coverage ends, the Plan may terminate your continuation coverage. However, if Medicare Part A or B is effective on or before the date of the COBRA election, COBRA coverage may not be discontinued on account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage. If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare. For more information visit https://www.medicare.gov/medicare-and-you. If you have questions Questions concerning your Plan, or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S.

1 https://www.medicare.gov/sign-up-change-plans/how-do-i-get-parts-a-b/part-a-part-b-sign-up-periods.

Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov.

Keep your Plan informed of address changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Prescription Drug Coverage and Medicare. Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage and about your options under Medicare’s prescription drug coverage. This information can help you decide whether you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

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

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

______________________________________________________________________ When Can You 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 your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens to Your Current Coverage If You Decide to Join a Medicare Drug Plan? Your current coverage may be affected for you and your dependents if you decide to join a Medicare drug plan. To determine whether your current coverage will be affected, please contact your broker, BeaconPath at (949) 716-9099 or CustomerService@BeaconPath.com. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage and don’t join a Medicare drug plan within 63 continuous days after your current coverage 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 creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) if 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 the Plan Administrator listed below for further information. NOTE: You will get this notice each year. You also may request a copy of this notice at any time. 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 will 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, therefore, whether or not you are required to pay a higher premium (a penalty). Plan Administrator: So Cal Dental Partners HR Administrator 27 Spectrum Pointe Drive #305 Lake Forest, CA 92630 (949) 600-7046 Telephone

www.BeaconPath.com

888-883-1920 Toll Free888-258-0907 Fax

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