Welcome to Montefiore’s

Benefits Program!

For Your Benefit

Montefiore’s Benefits Program

• Healthcare

• Flexible Spending Accounts

• Life & Accident Insurance

• Disability

Who Is Eligible?

• You

• Your Family Members

–Spouse

–Children – up through age 26

Healthcare• Medical

• Vision

• Dental

Medical• MonteCare EPO

• MonteCare PPO

• Decline Coverage

• You & Montefiore share the premium cost of coverage

Provider NetworkMONTECARE EPO MONTECARE PPO

Coverage In-network Only In-network/Out-of-network

In-network Providers

• Hospitals and Other

Facilities

Empire BlueCard PPO and Montefiore Network (including Moses, Weiler, Wakefield,

Westchester Square, The Children’s Hospital at Montefiore, Montefiore Mount

Vernon Hospital, Montefiore New Rochelle Hospital, White Plains Hospital,

Montefiore Ambulatory Surgical Facilities, Montefiore Imaging Center, Montefiore

Department of Radiology, Advanced Endoscopy Center and NY GI Center)

• Physicians, Therapists

and Counseling for

Mental Health and

Substance Abuse

• Montefiore Integrated Provider Association (MIPA)

•Montefiore Behavioral Care Integrated Provider Association (MBCIPA)

•Empire BlueCard PPO Network

• Empire Behavioral Health Network

• Laboratories Quest Laboratories, LabCorp and any hospital laboratory participating in the Empire

BlueCard PPO and Montefiore Network (including Moses, Weiler, Wakefield,

Westchester Square, The Children’s Hospital at Montefiore, Montefiore Mount

Vernon Hospital, Montefiore New Rochelle Hospital, White Plains Hospital)

Your Share of the Cost- MONTECARE EPO MONTECARE PPO

Montefiore Network

Empire BlueCard

PPO NetworkOut-of-network

Montefiore Network

Empire BlueCard

PPO Network Out-of-network

Individual/Family Deductible None $500/$1,000 Not covered None $200/$400 $1,000/$2,500

Individual/Family Out-of-pocket Maximum

$5,350/$10,700 Not covered $5,350/$10,700 $6,000/$17,500

Physician (Primary Care or Specialist)

$15 copay/visit 20%* Not covered $15 copay/visit 10%* 30%*

Hospital – Pre-certified $0 20%* Not covered; except in an emergency

$0 $1,000 copay 30%* after $1,000 copay

Outpatient Surgery $0 20%* Not covered $0 $500 copay 30%*

MRI, MRA, CAT Scan, PET or Nuclear Cardiology

$0 20%* Not covered $0 $250 copay 30%*

Emergency Room (copay waived if admitted)

$100 copay $100 copay $100 copay $100 copay $100 copay $100 copay

* after deductible

Prescription Drugs

GenericPreferred

(Formulary)Non-preferred

(Non-formulary) Specialty

Montefiore Outpatient Pharmacies

• 30-day supply* $0 $20 copay You pay 100% of the discounted cost

$20 copay

• 90-day supply** $0 $40 copay You pay 100% of the discounted cost

$40 copay

Express Scripts

• Participating Retail Pharmacy (up to a 30-day supply )

$15 copay $45 copay You pay 100% of the discounted cost

$100 copay

• Home Delivery Pharmacy Service

o 30-day supply* $15 copay $45 copay You pay 100% of the discounted cost

$100 copay

o 90-day supply** $30 copay $90 copay You pay 100% of the discounted cost

$150 copay

* new prescriptions for chronic and seasonal allergy medications** refills and all other prescriptions

Care Guidance• Health & Lifestyle Assistance

–Recovering from illness/injury

–Managing chronic condition

–Transitioning from inpatient care

• Voluntary, Confidential, Free

Vision• Spectera Vision Plan

–Low Option

–High Option

–You pay 100% of the premium cost

• Empire BlueCross BlueShield

oSpecialOffers

Dental

DHMO Preventive & Diagnostic

DPPO

Dentists Use DHMO dentist Use any dentist Use any dentist

Individual Annual Deductible None None $100 (does not apply to Preventive Care)

Annual Maximum Benefits (for each covered person)

None None $1,500/$2,500 if you use a Montefiore dentist

Preventive and Diagnostic Services

$0 $0 $0

Basic Services $0 Not covered 20%1 coinsurance after deductible

Major Services 30%1 coinsurance Not covered 50%1 coinsurance after deductible

Orthodontics 50%1 coinsurance Not covered 20%1 coinsurance after deductible

Lifetime Orthodontic Maximum None None $2,000

1 Based on DPPO contracted fee schedules

Dental•First year, you pay 100% of the premium cost

• After 1 year

- Cigna DHMO – You pay 100% of the premium cost

- Preventive & Diagnostic – Montefiore pays 100% of the premium cost

- DPPO – You and Montefiore share the premium cost

Flexible Spending Account

• Before-tax Contributions

• Pay Eligible Expenses from Account

• No Taxes on Withdrawals

• You Save What You Don’t Pay in Taxes

Healthcare FSA• Eligible Expenses

–Deductibles, coinsurance, copayments

–Amounts above R & C limits

–Healthcare expenses for which you pay part or all of the cost

• Ineligible Expenses

–Cosmetic surgery

–Electrolysis

–Teeth whitening

Dependent Care FSA• Eligible Expenses

–Day care in or outside your home

–Before/After school care, Pre-school, Nursery school

–Summer Day Camp

• Ineligible Expenses

–Household services

– Institutional Care

–Overnight summer camp

–Weekend or “evening out” babysitting

FSA Accounts• Maximum Annual Contribution

–$2,550 Healthcare Account

–$5,000 Dependent Care Account

• Forfeit Unused Amounts

• Healthcare Debit Card Convenience

• Pay Me Back Claim Forms

Life Insurance• Basic

– 1X Salary (up to $250,000) or $50,000 (Opt Down)

– After 1 year Montefiore pays 100% of the premium cost

• Supplemental

– 1X – 7X Salary (up to $750,000)

– Evidence of Insurability

– You pay 100% of the premium cost

• Business Travel Accident

oMontefiore pays 100% of the premium cost

AD&D• Basic

o1X Salary (up to $250,000)

After 1 year Montefiore pays 100% of the premium cost

• Supplemental

o1X – 7X Salary (up to $750,000)

You pay 100% of the premium cost

Dependent Life Insurance

• Option 1

–$10,000 for your spouse

–$5,000 for each child

• Option 2

–$20,000 for your spouse

–$10,000 for each child

•You pay 100% of the premium cost

Short-term Disability• Paid Sick Leave – accrued sick time

o100% base salary

• New York State Disability

o50% base salary, $170/week maximum

• Montefiore Supplementary Sick Pay

o2/3 base salary, maximum weekly benefits apply

Long-term Disability• Mandatory Basic LTD

–60% predisability earnings

–Maximum monthly benefits based on position

•You pay 100% of the premium cost

ForAnnual

Salary ThresholdMaximum Monthly Basic LTD Benefit

Maximum MonthlyBasic and Buy-up LTD Benefit

Executives/Faculty $120,000 $6,000/month $6,000/month Basic

$9,000/month Buy-up

$15,000/month Combined

Exempt/Non-Exempt $60,000 $3,000/month $3,000/month Basic

$2,000/month Buy-up

$5,000/month Combined

Buy-up LTD

Group Legal Services• You pay 100% of the premium cost

• Network of Participating Attorneys

• Legal Services

oConsumer protection

oEstate planning

oFamily law

oReal estate

Commuter Benefits• Mass Transit – Buses, Subways, Commuter

Railroads, Ferry Boats, Van pool

•Parking

www.MyMonteBenefits.com

www.MonteBenefits.com or 888.860.6166

What happens if I don’t enroll?

• MonteCare EPO

–Single coverage

• Preventive & Diagnostic Dental Care

–Single coverage

• Basic Life and AD&D Insurance

• Mandatory Basic LTD

Welcome to

Montefiore’s Benefits Program!