Flexible Benefits Plan 2021Enrollment Guide · 2020. 11. 2. · Auto and Home Insurance 32 Allstate...

Personal SolutionsFlexible Benefits PlanEnrollment Guide

2021www.mysahsbenefits.comCOMPANY KEY: SAHS

OE 2021

http://www.mysahsbenefits.com

What You Need to Know 3-6What’s New or Changing 5-6

Enrolling for Benefits 7-11Dependents 10Who You Can Cover 11My Medical 12-24Medical Coverage 12Prescription Drug Coverage 16Dental Coverage 21Vision Coverage 24

My Wellness 25Wellness Dollars 25

My Tax-free Spending 26-27Tax-Free Spending Accounts 26

My Life Insurance 28-32Basic coverage 28

Additional coverage 29Disability coverage 31

My Voluntary Benefits 32-33Group Legal Coverage 32Identity Theft Protection 32Auto and Home Insurance 32Allstate Voluntary Benefits 33

My contacts 34Key contact information 34

Personal Solutions Contents

About This Guide The information in this guide is intended to help you make your

benefit decisions. It’s based on the plan provisions and laws in effect on January 1, 2021. If any conflicts arise between this guide and any plan

provisions, the terms of the actual plan documents and/or insurance and administrative contracts will govern in all cases. SwedishAmerican intends to continue the plans but reserves the right to change or end them at any time.

Participation in the plans does not imply a contract of employment.Personal Solutions Flexible Benefits Plan Enrollment Guide | 2

What you Need to Know Enrolling My Medical My Wellness My Tax-free Spending My Life Insurance My Voluntary Benefits My Contacts

What You Need to Know Open Enrollment is November 2 - 15, 2020 SwedishAmerican offers the Personal Solutions benefits package to provide you and your family with a comprehensive range of benefits. You decide which options are right for you and your family – the mix you choose can be as individual as your lifestyle.

Your Core Insurance Options • Health & Prescription Coverage

(bundled)• Dental Coverage• Vision Coverage• Tax-Free Spending Accounts

• Health Care • Dependent Care

Your SwedishAmerican Provided (No-Cost) Options• Employee Life Insurance• Short-Term Disability Coverage• Long-Term Disability Coverage• Employee Assistance Program• Annual Leave Payout

Your Voluntary Options• Voluntary Employee Life Insurance• Voluntary Spousal Life Insurance• Voluntary Children’s Life Insurance• Group Legal Coverage• Identity Theft• Voluntary AD&D (accidental death

and dismemberment)• Voluntary Benefits (Allstate)• Group Auto/Home (Liberty Mutual)• IncentiveSAVER Retirement Plan

SwedishAmerican Personal Solutions Benefit Programs at a Glance

Personal Solutions Flexible Benefits Plan Enrollment Guide | 3

Enrolling My Medical My Wellness My Tax-free Spending My Life Insurance My Voluntary Benefits My ContactsWhat you Need to Know

What’s New or Changing?

Medical & Prescription Coverages BundledPrescription coverage will no longer be a separate choice; it will be bundled with the medical option if you choose the 80 Plan or the 80HD Plan. You will not be able to opt out of prescription coverage unless you also opt out of medical coverage. Walgreens will no longer be a covered pharmacy under the plan in 2021. Please see pages 16-19 for details on the new prescription coverage.

Medical Plan Deductibles & Out-of-Pocket Maximum ChangesThe deductibles and the out-of-pocket limits for calendar year 2021 are changing. Please refer to the chart below for the calendar year 2021 deductible and out-of-pocket limits.

Changes for 2021 Every year, SwedishAmerican reviews the Personal Solutions benefits offerings to ensure they remain competitive and meet our associates’ needs. Here’s a quick overview of what is changing for 2021.

Plan Tier 1 Tier 2 Tier 380 Plan – Deductible

$600 per person $1,000 per person $1,650 per person$1,100 per family $1,850 per family $3,150 per family

80 Plan – Out-of-Pocket

$2,100 per person $4,100 per person $7,100 per person$4,100 per family $8,100 per family $14,100 per family

80HD Plan – Deductible

$1,650 per person $3,200 per personNo Coverage

$3,200 per family $6,250 per family

80HD Plan – Out-of-Pocket

$2,100 per person $4,100 per personNo Coverage

$4,100 per family $8,100 per family

Pharmacy Benefit Manager (PBM) Name

ChangeAs of September 1, 2020, Envision Rx Options changed its name to Elixir. You may already be aware of this change as new logos have been introduced on web pages,

emails, and member portals.


What you Need to Know Enrolling My Medical My Wellness My Tax-free Spending My Life Insurance My Voluntary Benefits My Contacts

What’s New or Changing?Wellness Discounts Automatically Included in 2021 RatesThe 2021 rates for the bundled medical and prescription options will automatically include the wellness screening discount and the wellness point discount. We encourage you and your family to continue to participate in healthy, wellness related activities.

Dental Plan ChangesWe have consolidated our dental plan offerings for 2021 and will offer just one dental plan. The dental plan is very similar to the former Maximum dental plan. We have made a few changes to the benefit levels. The individual deductible is now $75. The annual benefit plan maximum has been increased to $2,000, and the lifetime orthodontic plan maximum has been increased to $1,500. Please see pages 21-22 for details on the dental plan coverage.

New Vision PlanWe will be offering a new vision plan through VSP for 2021. This new plan is a full-service plan that offers choice, flexibility, and maximum value through a VSP Network Provider. Please refer to pages 23 and 24 for an overview of the new VSP Choice Plan.

Coverage Tier ChangeWe will no longer have the Employee + 2 coverage tier. For 2021, the applicable coverage tiers will be Employee Only, Employee+1, and Family.

Tax-Free ChangesEffective January 1, 2021, the annual limit for tax-free spending health care accounts will be limited to $2,750. This is an increase from the current limit of $2,700.

Effective January 1, 2021, SwedishAmerican will also adopt the following changes as a result of the CARES Act:

• Over-the-counter medicines and drugs will no longer require a prescription to be reimbursed under the health care tax-free spending account.

• Over-the-counter menstrual care products (i.e. tampons, pads, liners, cups, sponges or similar products used by individuals with respect to menstruation or other genital tract secretions) will be considered eligible items for reimbursement under the health care tax-free spending account.



What’s New or Changing?

Online Threat Protection for your Devices

Multi-layered, advanced security helps protect against existing and emerging malware threats to your devices, and help protect your private and financial information when you go online.

Parental Controls Help your kids explore, learn, and enjoy their connected world safely on their PCs, smartphones, and tablets.

Password ManagerNorton Password Manager provides the tools you need to create, store, and manage every password, your credit card information and other credentials online – safely and securely in your very own encrypted, cloud-based vault.

Secure Cloud Backup Store and protect important files and documents on your PC as a preventative measure to data loss due to hard drive failures, stolen device and even ransomware.

LifeLock Plan ChangesLifeLock has merged with the antivirus company, Norton, to form Norton LifeLock. The merger has created an opportunity for benefit plan enhancements as well as a premium reduction in the Ultimate Plan. With the merger, the LifeLock Plan names have changed. The LifeLock Elite Plan is now LifeLock with Norton Benefit Essential and the LifeLock Ultimate Plan is now LifeLock with Norton Benefit Premier. All previous LifeLock benefits remain with the exception of court scanning. Plan enhancements include the following:



Review this Personal Solutions Enrollment Guide for important information that will help you choose the right benefits for you and your family. To ensure your benefit selections continue to meet your needs, you should review all of your options and costs and make appropriate changes or selections.

We will have a passive enrollment this year, meaning that most of your elections will automatically carry forward for 2021. Tax-free spending elections and Annual Leave Payout elections will not automatically renew. You will be required to make an active election in these coverage categories. The default for these categories will be No Coverage.

You must make any new elections or any changes to your existing elections by November 15, 2020. Please refer to the chart below for details.

Benefit Category Coverage If You Do Not EnrollMedical, Prescription, Dental, Vision You will automatically be enrolled in the same or most similar plan option

available.Basic Life and Disability (both short-term & long-term) coverage

You will automatically be enrolled in your current coverage.

Voluntary Benefits (voluntary life, voluntary AD&D, group legal, identity theft, hospital indemnity, critical illness, and accident insurance)

You will automatically be enrolled in your current coverage.

Tax-Free Spending You will not be re-enrolled. Your participation will end on the last day of current plan year (December 31st) and you will not be able to make contributions for 2021,

Annual Leave Payout You will not be re-enrolled. You will be defaulted to 0 days for 2021.

It’s Time to Enroll in Benefits

Note: Certain qualifying life events (as defined by the IRS), will allow you to make mid-year changes to your enrollment under the Personal Solutions Plan. Any changes in your elections must be consistent with your change in status or they will not be allowed (i.e. birth of a child – can add newborn to any coverages in force, but you cannot enroll for coverage as a result of the birth if you were not previously enrolled.). Contact Human Resources for information on qualifying life events.



I use my phone for everything I prefer to use my computer I feel more comfortable talking to someone

The MyChoiceTM Mobile App is perfect for your lifestyle.

www.mysahsbenefits.com is your go-to option.

Give the SwedishAmerican Benefits Center a call.

Download the app from your device’s app store, then log on to

www.mysahsbenefits.com to get the one-time access code

you’ll need to begin.

Login with your username and password or if you’re enrolling for the first time,

click register as a new user.

If you have questions or need moresupport, contact the SwedishAmerican

Benefits Center at833-955-1184 Monday through Friday

from 8 a.m. – 7 p.m. CT for enrollment support

Tip:Be sure to print a copy of

your benefits summary after enrolling.

Enrolling for BenefitsThree Easy Ways to Enroll in Your SwedishAmerican Personal Solutions Benefits You have several options for enrolling in your benefits. Select the option that best describes you.


EnrollingWhat you Need to Know My Medical My Wellness My Tax-free Spending My Life Insurance My Voluntary Benefits My Contacts



Need help or have questions about your enrollment?Chat with SofiaSM, your online personal benefits assistant. She’s available 24/7 to answer your benefits questions, whether you are using the mobile app or the website. You can access Sofia by clicking on the Chat button on the homepage of www.mysahsbenefits.com.

If you have any questions while enrolling at www.mysahsbenefits.com, a SwedishAmerican Benefits Service Center Advocate can log on with you to walk you through the enrollment process in real-time and answer any questions.

The SwedishAmerican Benefits Service Center team is available to help you Monday-Friday from 8 a.m.-7 p.m. Central Time at 833-955-1184.

Enrolling for Benefits

by

SM

Hello. I’m Sofia.What can I help you with today?





*Note: SwedishAmerican Health System’s health insurance plans exclude spouses from health insurance coverage if the spouse is eligible for coverage with his/her employer. Spouses can only be covered under SwedishAmerican’s health plan if the spouse is (1) unemployed, self-employed, or retired, or (2) not eligible for coverage through his/her employer. You will attest to this information online during the enrollment process.

Dependents You can cover eligible dependents under your SwedishAmerican Personal Solutions plans. Eligible dependents may include those noted below. Please check with HR to determine dependent eligibility.

Your spouse (same or opposite sex)*

Your children (up to age 26) include:• Biological or adopted children• Stepchildren• Children for whom you are legal guardian• Disabled child of any age who is mentally or physically handicapped and incapable of self-support.

(Additional criteria must be met – please contact Human Resources)

Your child or spouse who is subject to a qualified medical child support order.

Who You Can Cover



Who You Can CoverDependent Verification The Plan requires dependent eligibility verification (DEV) for any dependents that will be covered under the Personal Solutions benefit plans. Acceptable documentation may include, but is not limited to the following: marriage license/certificate, birth certificate, tax return, court order, etc. Note: If your spouse is eligible for coverage through his/her employer, he/she is not eligible for health coverage under the Personal Solutions plan. You must verify your spouse’s eligibility before we can cover him/her under the Personal Solutions plan.

*Note: Any misrepresentation of a dependent’s eligibility for insurance will result in progressive disciplinary action, up to and including termination of employment. Progressive discipline guidelines are outlined in Human Resources Policy #10-951.241, titled Employee Performance Expectations.

Cost of Coverage You and SwedishAmerican both contribute to the cost of your total benefits coverage. For many benefits, the company pays either the full cost or a portion of the cost. You can see what the bi-weekly (per pay period) cost for each benefit online or on the MyChoice Mobile App.

How to Enroll Once you’re ready to enroll, log onto www.mysahsbenefits.com and login with your user name and password. If you are enrolling for the first time, choose “Register” to set up your username, password, and answer security questions. Our company key is SAHS. Then choose “Start Here” and follow the instructions.

Don’t remember your username or password, just click on the “Forgot your user name or password?” link.

You can also use the MyChoice Mobile App to enroll and manage your benefits.

Simply download it from your device’s app store. Go to www.mysahsbenefits.com, login (or register if first-time user) and click Get Access Code on the home page under the MyChoice Mobile App icon. Follow the app’s directions to review your options and make your choices.

Make a change for a qualifying event If you have a qualifying event during the year, you may be able to make changes to your insurance elections prior to the next open enrollment period. Please contact the Human Resources department for any questions on qualifying life event changes. Any coverage changes must be made within 60 days of the qualifying event, and coverage changes must be consistent with the event. For example, you cannot change from the 80 Plan to the 80HD Plan due to the loss of a dependent. Documentation of the qualifying event will be required.





Medical and Prescription CoverageThe Personal Solutions Plan offers a choice of medical plan options—the 80 Plan, the 80HD Plan, and the Wrap Plan. Prescription coverage is bundled with the 80 Plan and the 80HD Plan option. Prescription coverage is not offered with the Wrap Plan.

EligibilityThe 80 Plan, the 80HD Plan, and the Wrap Plan are available to associates classified in one of the following employee types: OFCR, EXEC, PHYS,FT40, FT36, PT32, PT20, PTMD, or WKND.

You should review such things as your medical history, your comfort with paying out-of-pocket expenses, your anticipated medical care over the next year, and your eligibility for other employer sponsored health insurance (i.e. through a spouse’s plan or other employer’s plan) to determine which option might be the best for your situation.

MY MEDICAL AND PRESCRIPTION

Stay in-network and saveUsing in-network providers will save you

money because they have agreed to charge only up to a negotiated fee.

Out-of-network providers can charge whatever they want, which could be

more than the plan allows. In addition to higher co-insurance, you may have to pay the difference between what

the plan pays and the provider charges. You could end up paying a

lot more for the same services.


My MedicalWhat you Need to Know Enrolling My Wellness My Tax-free Spending My Life Insurance My Voluntary Benefits My Contacts

My MedicalThe 80 and the 80HD PlansHere’s an overview of the 80 Plan and the 80HD Plan.

80 Plan 80HD PlanTier 1

(SwedishAmerican)Tier 2

(In-Network)*Tier 3

(Non-Network)Tier 1


(In-Network)*Tier 3

(Non-Network)Preventive care $0 Co-Pay Deductible/70% Deductible/50% $0 Co-Pay Deductible/70% No CoverageOffice visits (PCP/Urgent Care) $25 Co-Pay Deductible/70% Deductible/50% Deductible/80% Deductible/70% No Coverage

Office visits (Specialist) $40 Co-Pay Deductible/70%* Deductible/50% Deductible/80% Deductible/70%* No Coverage

Office visits (Chiropractor)

Plan reimburses $50 per visit to an annual maximum

benefit of $500


benefit of $500


benefit of $500


benefit of $500


benefit of $500


benefit of $500

Annual deductibleIndividual $600 $1,000* $1,650 $1,650 $3,200* No CoverageFamily $1,100 $1,850* $3,150 $3,200 $6,250* No CoverageOut-of-pocket maximum (Once you reach the out-of-pocket maximum, eligible expenses are covered at 100% for the rest of the year)Individual $2,100 $4,100* $7,100* $2,100 $4,100* No CoverageFamily $4,100 $8,100* $14,100 $4,100 $8,100* No Coverage

New for 2021

*Note: If care cannot be provided at SwedishAmerican, the Tier 1 reimbursement level may apply. Prior authorization is required.



80 Plan 80HD Plan

Tier 1 (SwedishAmerican)

Tier 2(In-Network)*

Tier 3(Non-Network)

Tier 1 (SwedishAmerican)

Tier 2(In-Network)*

Tier 3(Non-

Network)

Inpatient HospitalDeductible/80% plus

$200 Co-Pay per admission

Deductible/70%* plus $200 Co-Pay per admission*

Deductible/50% plus $200 Co-Pay

per admission

Deductible/80% plus $200 Co-Pay per

admission


No Coverage

Inpatient Mental Health, Chemical Dependency & Eating Disorder


admission



per admission


admission


No Coverage

Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited No Coverage

Tip: Before enrolling, check to see if your primary doctor, any specialists you see regularly, and

your local hospital are considered in-network.


The 80 and the 80HD Plans (continued)My Medical



80 Plan 80HD PlanTier 1


(In-Network)*Tier 3

(Non-Network)Tier 1


(In-Network)*Tier 3

(Non-Network)Outpatient Diagnostic Services (i.e. x-ray and labs)

Deductible/80% Deductible/70%* Deductible/50% Deductible/80% Deductible/70%* No Coverage

Outpatient Surgery Deductible/80% Deductible/70%* Deductible/50% Deductible/80% Deductible/70%* No CoverageOutpatient Mental Health, Chemical Dependency & Eating Disorder

Deductible/80% Deductible/70%* Deductible/50% Deductible/80% Deductible/70%* No Coverage

Emergency room Note: Services that can be more appropriately performed in the physician office or urgent care setting will not be covered in the ER


per visit.Note: Co-Pay will be

waived if admitted to hospital


per visit.Note: Co-Pay will be waived if admitted to

hospital



hospital


per visit.Note: Co-Pay will be

waived if admitted to hospital



hospital


per visit. Note: Co-Pay will be waived if admitted to

hospital.Emergency Ambulance ServiceNote: Ambulance services are covered only to/from a hospital in case of emergency or life-threatening situation.

Deductible/80% Deductible/80%* Deductible/80% Deductible/80% Deductible/80% Deductible/80%

The 80 and the 80HD Plans (continued)


New for 2021

My Medical



Prescription Drug Coverage Prescription drug coverage is often as important to you as your health insurance. Both the 80 Plan and the 80HD Plan options include prescription drug coverage. Our prescription plan coverage offers you affordable prescription drug coverage and a full range of prescription drug services.

Formulary Utilization A formulary is a listing of brand name drugs selected for their cost effectiveness.

Retail Service Available at local Pharmacies (Walgreens is excluded.)

Contracted Pharmacies - Utilize any Elixir contracted pharmacy with the exception of Walgreens. Please visit www.envisionrx.com for a listing of contracted pharmacies.

My PrescriptionSwedishAmerican In-House Retail Pharmacy Prescriptions filled at the in-house retail pharmacy will have lower copays than those filled at other contracted pharmacy locations. Note: Specialty medications will be required to be filled through the SwedishAmerican pharmacy. In the event that a specialty medication is not available through the SwedishAmerican pharmacy, members will then be required to use the current specialty pharmacy, Orchard.

Free Maintenance Medications Available at any contracted Elixir pharmacy for ten select maintenance prescription medications.

Mail Service Available through our pharmacy benefit manager’s mail service facility for long-term and maintenance prescriptions.

Out-of-Pocket Maximums Both prescription plans have an out-of-pocket maximum of $1,500 for single coverage and $2,700 for family coverage.

SwedishAmerican Medication Management Clinic for Specialty Medications A clinic created to provide general medication education, copay assistance, and medication administration education, while leveraging benefits and resources available to assist you and the plan in cost savings.

Tip: Consider generic

prescriptions when possible to save both you & the plan money. Always consent with

your physician regarding changing to a generic

prescription. Personal Solutions Flexible Benefits Plan Enrollment Guide | 16


http://www.envisionrx.com

Prescription Plan Components: The Medication Management Clinic SwedishAmerican offers a medication management clinic for members who take a specialty medication. The clinic will provide specially trained pharmacists who are available to members. These pharmacists can help members optimize their medication regimens and can provide general medication education, copay assistance, and medication administration education.

Members who take specialty medication prescriptions must schedule a visit with the medication management clinic. There will not be a charge for the medication management clinic visit. Specialty medication prescriptions must be filled at the SwedishAmerican specialty pharmacy.

My PrescriptionHow the Program Works• Members taking a specialty medication

must see their regular physician for their medical and prescription care needs.

• Members will schedule a visit with the SwedishAmerican medication management clinic.

• Members will not incur a copay or any cost for their visit to the SwedishAmerican medication management clinic.

• Members fill their specialty medications through the SwedishAmerican specialty pharmacy.

• Members pay the applicable specialty prescription copay.

Note: Certain specialty prescription medications are considered limited distribution drugs which means not all pharmacies can access the medication for distribution. If you take one of these medications, you will not be able to fill your specialty medication at the SwedishAmerican specialty pharmacy and the normal specialty copay would apply.



Hint:If you take a similar medication to those listed

above and would like to take advantage of this benefit, please consult your physician to

determine the appropriateness of changing to one of the medications listed on the left.

Prescription Plan Components: 10 Free Medications

SwedishAmerican Pharmacy Benefit – 10 Free Medications

The SwedishAmerican pharmacy benefit plan allows you to fill 10 medications free of charge. These medications can be filled at any contracted Elixir pharmacy with a $0 copay.

The ten medications offered are as follows (in generic form):• Zocor• Prozac• Celexa• Vasotec• Claritin• Omeprazole• Glucophage• Norvasc• Paxil• Zoloft

Prescription Plan Components: Contraceptive Coverage

SwedishAmerican covers the following generic prescription contraceptive methods with a $0 copay: oral contraceptives, patch and vaginal contraceptives, emergency contraceptives, injectable, diaphragms, spermicides, sponges, and cervical caps.

Note: The plan will only cover generics with a $0 Co-Pay.

My Prescription



Prescription Plan Overview Here’s an overview of the prescription coverage that is bundled with the 80 Plan and the 80HD Plan. Note: Walgreens pharmacies will not be covered under the prescription plan in 2021.

SAH Retail Pharmacy Elixir Contracted Retail Pharmacies

Prescription deductible

Individual Deductible (does not apply to generics) $100 per person $100 per person

Out-of-pocket maximum*

Individual $1,500 $1,500

Family $2,700 $2,700

30-day supply

Generic $5.00 copay $25.00 copay

Brand Name Formulary $12.50 copay $40.00 copay

Non-Formulary $22.50 copay $60.00 copay

90-Day Supply (Mail Order through Elixir) Generic

Brand Name Formulary N/A $72.50 copay

Non-Formulary N/A $122.50 copay

Other Prescription Categories

Contraceptive Coverage (Oral contraceptives, injectable, diaphragms, spermicides, sponges, and cervical cap in generic form only) $0 copay $0 copay

10 Maintenance Medications in Generic Form (Zocor, Prozac, Celexa, Vasotec, Omeprazole, Claritin, Glucophage, Norvasc, Paxil, or Zoloft in generic form only) $0 copay $0 copay

Specialty Medication

Must be filled at SwedishAmerican Specialty Pharmacy ANDMember must have a visit with SwedishAmerican Medication Management

Clinic20% to maximum copay of $125.00 for a 30-day supply OR

20% to maximum copay of $200.00 for a 90-day supply

Note: If you take a specialty medication that cannot be filled through the SwedishAmerican specialty pharmacy because it is considered a limited distribution medication, you will need to obtain prior authorization and a specialty copay of 20% to a maximum of $275 or a 30-day supply or 20% to a maximum copay of $575 for a 90-day supply will be applied.Personal Solutions Flexible Benefits Plan Enrollment Guide | 19


The Wrap Plan (Medical Reimbursement Plan)Associates who enroll in the Wrap Plan are also required to have other employer sponsored group medical plan coverage through their spouse or another place of employment.

The Wrap Plan (medical reimbursement plan) will reimburse you 100% of reasonable and customary charges for deductibles, co-insurance, and copays for covered services you incur under another medical, prescription, dental, or vision plan, to a maximum benefit of $3,500 per covered member per calendar year.

You and your covered dependents are not required to use Tier 1 (SwedishAmerican) or the in-network (Tier 2) of plan providers. Additionally, this plan will provide you with the wellness dollar benefit.

To simplify coordination of benefits questions with your primary insurance plan, please refer to this plan as a medical reimbursement plan. The Wrap Plan should not be referred to or listed as other health insurance coverage with your primary insurance plan.

*Note: Non-covered expenses under your primary insurance plan will not be covered under the Wrap Plan.

MY MEDICAL – WRAP PLAN



Personal Solutions offers dental coverage for you and your eligible dependents.

My Dental EligibilityDental coverage is available to associates classified in one of the following employee types: OFCR, EXEC, PHYS, FT40, FT36, PT32, PT20, PTMD, or WKND.

Preferred PPO Dental NetworkOur dental plan has a preferred PPO dental network. The network has two categories: Delta Dental PPO and Delta Dental Premier. You may choose a provider from either network to benefit from network discounts and savings. Our dental network is a passive network, meaning you can still use the dental provider of your choice and get the same benefit to which you’re accustomed.

The PPO AdvantageIf you choose and utilize a network dental provider, there will be preferred discounts, and you will not be subject to reasonable & customary reductions. By choosing and using a network dental provider, both you and the plan save money.

Enhanced Benefits ProgramThe SwedishAmerican dental plan includes an enhanced benefits program which takes advantage of the emerging science of evidence-based dentistry and integrates medical and dental care. This program offers additional prophylaxis (general cleanings) or periodontal maintenance to members who have specific health conditions including diabetes, pregnancy, periodontal disease, high-risk cardiac conditions, kidney failure/undergoing dialysis, suppressed immune systems due to HIV positive status, organ transplant, and/or stem cell (bone marrow) transplant, cancer-related chemotherapy and/ or radiation, or those at risk for oral cancer. You or your dentist must enroll yourself or your covered family member in this program to be eligible for the additional benefits. You may enroll by calling Delta Dental at 1-800-236-3712.



MY DENTAL PLAN OVERVIEWHere’s an overview the dental plan coverage.

Coverage

Annual Deductible $75 per person$150 per family

Wellness/Preventive Care(Oral exams, cleaning, bitewing, x-rays (1x/year), fluoride treatments, emergency treatment, sealants)

Deductible does not apply100% of R&C

Basic Restorative(Full mouth x-rays, periapical x-rays, fillings, extractions, root canals, consultations, non-surgical periodontics)

Deductible applies80% of R&C

Major Restorative(Bridges, crowns, dentures, and repair, periodontal & oral surgery, general anesthesia, implants)

Deductible applies50% of R&C

Annual Plan Maximum (Note: Wellness/preventive services do not apply to annual plan maximum) $2,000

Orthodontia (For dependent children only) Deductible applies50% of R&C

Lifetime Orthodontic Maximum $1,500

Pre-Treatment Estimate Required $300+ Treatment Plans

New for 2021



Personal Solutions offers vision coverage for you and your eligible dependents through the VSP Choice Plan. Coverage includes routine vision exams and necessary eyeglasses including frames or contact lenses.

The Vision Plan is available to associates classified in one of the following employee types: OFCR, EXEC, PHYS, FT40, FT36, PT32, PT20, PTMD, or WKND.

My VisionProvider ChoiceVSP contracts with doctors nationally and has the largest independent doctor network in the country, so you are sure to find a practice close to you. You are not required to use a VSP network physician, but you will get the most from your vision benefits if you stay in-network.

How to File a Vision ClaimWhen you visit a VSP network doctor, there are no claim forms to submit. If you choose to see an out-of-network provider, you will have to submit a claim form and include any itemized receipts.

Here is an overview of the vision benefits.

Things To ConsiderDo you or your dependents have a need for routine eye care? (i.e., eyeglasses or contacts)If your annual vision expenses are lower than the annual cost of vision coverage, you may want to set aside dollars in a Health Care Tax-Free Spending Account instead of enrolling in the Vision Plan.

Benefits Through a VSP Network ProviderEye Exam • Comprehensive WellVision Exam covered in full (less exam copay of $10)

• Routine retinal screening covered after a no more than $39 copayLenses • Glass or plastic single vision, lined bifocal, lined trifocal, or lenticular lenses are covered in full (less a materials copay of $20)Lens Enhancements

• Most popular lens enhancements are covered after a copay, saving members an average of 30%Lens Enhancement Single Vision MultifocalAnti-reflective coating $41 $41Polycarbonate-Adult $31 $35Polycarbonate-Children Covered CoveredStandard Progressive N/A CoveredPhotochromic $75 $75Scratch-resistant coating $17 $17



Benefits Through a VSP Network Provider

Frame • Frames covered in full up to the retail allowance of $150• Members who select a featured frame brand, including Anne Klein, bebe, Calvin Klein, Flexon, Lacoste, Nike,

Nine West and more, will receive an extra $20 toward their frame allowance (Featured frame brands subject to change).

• 20% off any amount above the retail allowance.• Members can choose from virtually any frame on the market.

Additional Pairs of Glasses

• Within 12 months of exam: 20% off unlimited additional pairs of prescription glasses and/or non-prescription sunglasses from any VSP doctor.

Elective Contact Lenses

• Contact lens exam (fitting and evaluation): Standard and Premium fits are covered in full after copay. Member receives 15% off contact lens exam services and member’s copay will never exceed $60.00

• Prescription contact lens materials are covered in full up to the retail allowance of $150 (in lieu of frame & lenses).

• Members can choose from any available prescription contact lens materials.

VSP Diabetic EyeCare Plus Program

• Additional coverage for members with diabetic eye disease, glaucoma, or age-related macular degeneration.• $20 copay per visit.

VSP Laser Vision Care Program

• Discounts average 15-20% off or 5% off a promotional offer for laser surgery, including PRK, LASIK, Custom LASIK, and IntraLase

• (Discounts are only available from VSP-contracted facilities. Also custom LASIK coverage only available using wavefront technology with the microkeratome surgical device, other LASIK procedures may be performed at an additional cost to the member)

Low Vision • Pre-approved low vision supplemental testing covered every two years• 75% coverage for approved low vision aids, up to $1,000 (less any amount paid for supplemental testing) every two

years.

Out-of-Network Schedule

• VSP offers a generous reimbursement schedule for services from other providersExam $45Lenses: Single vision $30Lined bifocal $50Lined trifocal $65Frame $70Elective contact lenses $105 (in lieu of lenses and frame)



Wellness DollarsThe wellness dollars will continue to be a component of our health insurance plans. Associates carrying one of the health insurance options may be reimbursed up to $100 (total) per calendar year for the purchase of approved, wellness related products or services. Wellness dollars must be used to support associate wellness activities in the areas of nutrition, physical activity, stress management, or group support.

Note: The wellness dollar benefit is administered by Benefit Planning Consultants (BPC).

My Wellness

Tip: To receive reimbursement for wellness dollars simply mail or fax your prepaid,

detailed receipt along with a wellness dollar

reimbursement form to:

BPCPO Box 7500

Champaign, IL 61882Phone: 877-272-8880

Fax: 877-760-7076

Eligible products and services:• Bicycle• Blood Pressure Monitor• Books• CD’s • Classes (Fitness, Nutrition, Stress,

Yoga)• Complementary Therapies• Weight Loss Hypnotherapy• Wii Fit• Health Coaching (BetterLife Wellness)• Heart Monitor• Event Registration Fees (Approved

events – races, walks, etc)• Free Weights• Health Club Membership• Massage Therapy• NEW Fitness Equipment• Orthotics• Support Groups• Tapes• Videos• Weight Loss Counseling Weight Scales• Electric Toothbrushes• Body Mass Index Scale• BetterLife Wellness Health Coaching


My WellnessWhat you Need to Know Enrolling My Medical My Tax-free Spending My Life Insurance My Voluntary Benefits My Contacts

Tax-Free Spending Accounts Tax-free spending accounts allow you to set aside money from your paycheck before it’s taxed to pay for certain healthcare and dependent care expenses. Participation is voluntary. It is your decision to participate or not.

My Tax-Free Spending

Health Care Spending Account If you decide to open a Health Care Spending Account, you can contribute up to $2,750 per year to your account. Your contributions are deducted on a pre-tax basis from your pay in equal installments each pay period and deposited in your account. You can use tax-free dollars in your account to reimburse yourself for:

• Out-of-pocket expenses such as deductibles, copays, co-insurance, and amounts over reasonable and customary (R&C) and plan limits.

• Other eligible expenses that may not be covered by your medical, dental, or vision plans (i.e., hearing aids, eyeglasses, prescription sunglasses, contacts, and orthodontia).

Coverage for Over-the-Counter (OTC) MedicationsAs of January 1, 2021, SwedishAmerican will adopt the following changes as a result of the CARES Act:

• Over-the-counter medicines and drugs will no longer require a prescription to be reimbursed under the health care tax-free spending account.

• Over-the-counter menstrual care products (i.e. tampons, pads, liners, cups, sponges or similar products used by individuals with respect to menstruation or other genital tract secretions) will be considered eligible items for reimbursement under the health care tax-free spending account.

Please keep this criteria in mind when making your tax-free election.


My Tax-free SpendingWhat you Need to Know Enrolling My Medical My Wellness My Life Insurance My Voluntary Benefits My Contacts

My Tax-Free SpendingDependent Care Spending AccountIf you decide to open a Dependent Care Spending Account, you can contribute up to $5,000 per year to your account. Your contributions are deducted on a pre-tax basis from your pay in equal installments each pay period and deposited into your account. You can use tax-free dollars in your account to reimburse yourself for:

• Expenses to care for your dependents under age 13 or a disabled adult who is physically or mentally incapable of self-care.

• Dependent care can be in or out of your home or in a licensed daycare facility (Note: Pre-school is an eligible expense; however expenses for Kindergarten and above are not eligible.)

Be sure to get the taxpayer ID number of your day care center or the Social Security number of your caregiver. You will need this information to be reimbursed.

How TFSA’s Work–Use It or Lose it!When you participate in one or both of the TFSA’s:• You pay no federal or state income

taxes or Social Security taxes on the money you contribute to your account(s).

• You are issued a Debit Card, which is linked to your TFSA account(s).

• Your Debit Card can be used to pay for eligible expenses at the time an expense is incurred (no waiting for reimbursement).

• You must submit receipts for all debit card transactions.

• You can pay eligible expenses with cash or check and file a claim to be reimbursed from your TFSA account(s).

• You can file claims for 2020 expenses until March 31, 2021. After this deadline, any dollars left in either TFSA account will be forfeited.


My Tax-free SpendingWhat you Need to Know Enrolling My Medical My Wellness My Life Insurance My Voluntary Benefits My Contacts

Basic/Provided Life Insurance with AD&DSwedishAmerican automatically provides basic life and accidental death and dismemberment (AD&D) coverage to all associates eligible for Personal Solutions benefits. The basic life insurance benefit provided is dependent upon your employee type. The following chart summarizes the basic life benefits:

My Life Insurance

Tip: Remember to update beneficiaries at www.mysahsbenefits.com for

Life Insurance and AD&D.

Employee Type BenefitFull-Time Employees 1.5 x Covered EarningsPart-Time Employees 1.0 x Covered EarningsExecutives 2.0 x Covered EarningsPhysicians $50,000 Policy


What you Need to Know Enrolling My Medical My Wellness My Tax-free Spending My Voluntary Benefits My ContactsMy Life Insurance

Voluntary Life InsuranceYou may purchase voluntary life insurance for yourself, your spouse, and your eligible children. Note: For terms of this insurance contract, eligible children are defined by the voluntary life insurance carrier to be unmarried children to age 26 years. You must enroll for employee voluntary coverage in order to cover your spouse or children.

The voluntary life insurance coverage is portable (able to be continued) after termination of employment; however, if you are at normal retirement age as defined by Social Security, the coverage is not portable.

During open enrollment you can:

• Increase your life insurance coverage (May be subject to evidence of insurability)• Enroll for voluntary life coverage (Subject to evidence of insurability)• Decrease your life insurance coverage

The table below summarizes your voluntary life insurance options:

My Life InsuranceEvidence of InsurabilityThe Life insurance carrier may require evidence of insurability (EOI) before providing coverage. You will be prompted to complete EOI, if applicable, during your online enrollment.

Employee Coverage Spousal Coverage Children’s Coverage

Coverage Amounts Available in $10,000 units (see maximum amount below)

Available in $5,000 units (see maximum amount below)

Available in amounts of $1,000; $5,000; or $10,000

Minimum Amount $20,000 $10,000 $1,000

Maximum Amount 5 times salary or $300,000 (whichever is less)

100% of the employee’s voluntary coverage amount, not to exceed an overall maximum coverage

limit of $250,000$10,000



Voluntary Accidental Death & Dismemberment (AD&D)

You may purchase personal accident insurance for yourself, your spouse, and your eligible children. Note: For terms of this insurance contract, eligible children are defined by the voluntary life insurance carrier to be unmarried children to age 26. You must enroll for employee voluntary coverage in order to cover your spouse or children.

During open enrollment you can:

• Enroll for personal accident insurance• Increase your personal accident insurance• Decrease your personal accident insurance

The table below summarizes your personal accident insurance options:

My Life Insurance

Employee Coverage Spousal Coverage Children’s Coverage

Coverage AmountsAvailable in $10,000units (see maximum

amount below)

Available in $5,000units (see maximum

amount below)

Available in amountsof $1,000; $5,000; or

$10,000Minimum Amount $20,000 $10,000 $1,000

Maximum Amount 5 times salary or $300,000 (whichever is less)

50% of the employee’s voluntary AD&D coverage amount $10,000


My Life InsuranceWhat you Need to Know Enrolling My Medical My Wellness My Tax-free Spending My Voluntary Benefits My Contacts

EligibilityDisability coverage is available to all active, regular full-time, and part-time thirty-two associates that are regularly scheduled and working at least 64 hours per two-week period, and are classified in one of the following employee types: OFCR, EXEC, FT40, FT36, or PT32.

Short-Term and Long-Term DisabilitySwedishAmerican automatically provides short-term and long-term disability coverage to all eligible associates. Disability benefits are effective the first of the month following 90 days of employment for new hires. For existing employees who change status and become eligible for short-term disability benefits, these benefits will become effective on the first of the month following 90 days after transitioning to the new, benefited position. Note: The short-term disability plan has a pre-existing condition exclusion.

The disability plans replace a percentage of your eligible regular pay during a period of disability. The disability plans utilize case management services. You must cooperate with the case management programs to receive benefits under the plans. Short-term disability benefits are based on seniority, and the plan pays short-term disability benefits in accordance with national disability guideline durations.

The following chart summarizes the disability benefits:

My Disability CoverageShort-Term Disability Benefits and Temporary Work AssignmentsSwedishAmerican has an early return to work program. Under this program, we try to accommodate associates in temporary work assignments within the Health System when they (1) are placed on temporary work restrictions due to a medical illness or injury or (2) return from a leave of absence with temporary work restrictions.

Our short-term disability benefits coordinate with our return to work program. If you have temporary work restrictions and you are offered a temporary work assignment within your restrictions and you refuse the assignment, short-term disability benefits may end.

Important Notes• We will automatically enroll you for

this benefit (if eligible).• SwedishAmerican provides short and

long-term disability benefits at no cost to you.

• Contact Human Resources to initiate a claim for disability benefits or to initiate a Leave of Absence.

Seniority Short-Term Disability Long-Term Disability

Less than 5 years of service 60% Coverage 60% Coverage

5 or more years of service 75% Coverage 60% Coverage



Group Legal CoverageSwedishAmerican offers group legal benefits through the MetLaw plan. This plan gives you and eligible family members quick, easy, and affordable access to qualified attorneys.The MetLaw plan is a comprehensive legal plan, providing complete representation for many personal legal services, for a fee of $8.31 per pay. Plan attorneys are available for telephone advice and office consultations.Coverage categories include: estate planning documents, financial matters, real estate matters, elder law matters, family law, traffic offenses, document preparation, immigration assistance, juvenile court defense, consumer protection, defense of civil lawsuits, and personal property protection. Additional information is available online at: www.legalplans.com (enter password GETLAW) or contact the Client Service Center at 1-800-821-6400.

LifeLockSwedishAmerican offers LifeLock to help safeguard you and your family against identity theft. SwedishAmerican

My Voluntary Benefitsoffers a choice of two LifeLock identify theft plans.

LifeLock with Norton Benefit Essential (Formerly LifeLock Elite)This plan includes searching millions of transactions per second every day for potential threats to your identity and to financial assets. The plan also includesscanning for misuse of your social security number, and change of address for use of your identity to commit crimes.

LifeLock with Norton Benefit Premier (Formerly LifeLock Ultimate)This plan includes all services in the LifeLock Norton Benefit Essential plan plus enhanced services for bank account applications and takeover alerts, online credit reports and credit scores.

Group Auto and Home Insurance SwedishAmerican partners with LibertyMutual to offer you the coverage you need to protect your home, automobile or other vehicle, personal property, and other assets. Please contact Liberty Mutual at 1-815-633-1070 ext. 56895 for a free quote.

3 facts about supplemental health insuranceUse it how you need Benefit payments can be used to cover health insurance deductibles. In fact, payments can be used for whatever purpose the beneficiary chooses. That’s because unlike medical health insurance, these plans are not tied to specific services. Instead, they pay claims for specified events such as strokes, accidents, or heart attacks.

Great for familiesFamily coverage can offer relief when a parent or spouse must take unplanned time off work to tend to the care of a spouse or child who has been hospitalized.

It’s affordableUnexpected hospital expenses can place unexpected pressure on your finances. Supplemental health coverage plans can help ease the financial burden.

The monthly premium for supplemental coverage for young, healthy employees is about the same as the cost of a sandwich. Premiums increase as policyholders age and add family members.


My Voluntary BenefitsWhat you Need to Know Enrolling My Medical My Wellness My Tax-free Spending My Life Insurance My Contacts

http://www.legalplans.com

Allstate Voluntary Benefits (Accident, Critical Illness, and Hospital Indemnity)Life has a way of hitting you with unexpected expenses. That’s why Allstate grants you access to several supplemental benefits. These supplemental plans are designed to protect you and your family from the financial impact of a critical illness, injury, or hospital stay.

Here’s an overview of the different kinds of coverage available to you.

My Voluntary Benefits

Accident Insurance Critical Illness Insurance Hospital Indemnity Insurance

What it isVarious benefits help cover costs

associated with accidental injuries. Pays in addition to other insurance.

Lump sum payment to help cover expenses associated with certain

serious illnesses. Pays in addition to other insurance.

Daily benefits help cover out of pocket costs related to hospital stays. Pays in

addition to other insurance.

What it covers

Urgent Care/ERDiagnostic exams

FracturesDislocationsAmbulanceAnd more

Invasive cancerSkin CancerHeart attack

StrokeKidney failure

Organ TransplantAnd more

Inpatient hospital staysIntensive care

How it works You select from two coverage tiers.

You select from two coverage amounts for yourself. You can elect 100% of your

coverage amount for spouse and 50% for children.

You select from two coverage tiers.

What it pays Variable payout(s), based upon medical care received. A lump sum payment upon diagnosis. A lump sum payment based on days of

confinement.Who it pays Paid directly to you. Money can be applied wherever you need it most.


My Voluntary BenefitsWhat you Need to Know Enrolling My Medical My Wellness My Tax-free Spending My Life Insurance My Contacts

MY ContactSWhat Who Website/Mobile App Phone/Fax

General benefits questions SwedishAmerican Benefits Center www.mysahsbenefits.com Phone: 1-833-955-1184

Medical Plan (For 80 Plan & 80HD Plan) Quartz www.quartzaso.com Phone: 1-800-805-0693

Fax: 1-608-643-5230

Medical Plan & Wellness Dollars (Wrap Plan)

Benefit Planning Consultants (BPC) www.bpcinc.com Phone: 1-877-272-8880

Fax: 1-877-760-7076

Prescription Elixir www.envisionrx.com Phone: 1-800-361-4542

Dental Delta Dental of Wisconsin www.deltadentalwi.com Phone: 1-800-236-3712

Vision VSP www.visionbenefits.vsp.com Phone: 1-800-877-7195

Tax-Free Spending Benefit Planning Consultants (BPC) www.bpcinc.com Phone: 1-877-272-8880

Fax: 1-877-760-7076

Group Legal Hyatt Legal Plans www.metlaw.com Phone: 1-800-821-6400

Identity Theft Lifelock www.lifelock.com Phone: 1-866-917-2555

Accident insurance, Critical Illness insurance, or Hospital Indemnity insurance

Allstate

www.allstatebenefits.com/mybenefits

Information needed to register on the website includes: SSN, Zip Code, Birthdate

Customer Service: 1-866-709-3877 Claims Customer Service:

1-800-348-4489


My ContactsWhat you Need to Know Enrolling My Medical My Wellness My Tax-free Spending My Life Insurance My Voluntary Benefits


http://www.quartzaso.com

http://www.bpcinc.com

http://www.envisionrx.com

http://www.deltadentalwi.com

http://www.visionbenefits.vsp.com

http://www.bpcinc.com

http://www.metlaw.com

http://www.lifelock.com

http://www.allstatebenefits.com/mybenefits

http://www.allstatebenefits.com/mybenefits

Flexible Benefits Plan 2021Enrollment Guide · 2020. 11. 2. · Auto and Home Insurance 32 Allstate...

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