2022 Everise Executives Benefits Guide

2022 Everise Benefit & Enrollment Guide
Executive Guide Everise 2022 Benefit & Enrollment Guide
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2022 Everise Benefit & Enrollment Guide

Everise 2022 Benefit & Enrollment Guide
WHAT’S INSIDE
2022 Employee Benefits .......................4
How To Enroll ................. ......................5
Eligibility ...............................................6
Medical .................................................8
Prescriptions ......................................11
Minimum Essential Coverage ..............16
Dental .................................................17
Vision ..................................................20
Rates ...................................................24
Health Savings Accounts .....................25
Flexible Spending Accounts .................26
Basic & Voluntary Life w/AD&D ...........28
EAP For All Employees .........................30
Disability .............................................31
LifeTime Benefit Term ........................33
Critical Illness ......................................36
Accident Insurance .............................37
Hospital Indemnity ..............................38
Legal Plan ............................................42
Pet Insurance .......................................43
401 K ....................................................44
Contacts ..............................................45
Federal Notices ...................................46
2022 Employee Benefits

Welcome to Everise! As a full-time, active employee, you are eligible to participate in a competitive benefit
program. Details are enclosed.
Scheduling Your Enrollment
All enrollments are scheduled through Everise's Enrollment Support Call-Center. As a new employee you will get
a New Hire welcome text message from Everise’s Enrollment Support Team inviting you to schedule your
enrollment session with our Enrollment Support Call Center. All of our benefits are enrolled through this call
center and during your session they will guide you through your Everise benefits step-by-step. At the end of
your session, you will receive an email confirmation of all your new benefits. Once you complete your elections,
your selections will be sent to the carriers to enroll you (and any dependents). Any benefits you enroll in will be
effective on the first of the month after you have been employed with Everise for 60 days. Your enrollment will
take 5-7 business days to complete with the carriers administering the benefits.
Should you have additional questions, need clarification on any benefits, our Enrollment Support Team will be
available to assist you and throughout the year. You can connect with them via email:
EnrollmentSupport@benefitsallin.com or through our dedicated support line: 1-800-518-8960.
If you need help obtaining ID cards or help with any of the carriers regarding your claims or eligibility, please
contact Paul Global Benefits.
You can reach Paul Global Benefits via email: everisemembersupport@pbgdirect.com
How To Enroll
You will enroll in your new ďĞŶĞĨŝƚƐthrough a live Enrollment Support Call-Center. ǀĞƌŝƐĞ has partnered with
ĞŶĞĨŝƚƐůů/Ŷ, a risk management based education and enrollment solutions firm, that specializes in decision
support, to offer ŶƌŽůůŵĞŶƚ^ƵƉƉŽƌƚ "where you are" through their call center.
This enrollment solution will provide each of you with an opportunity to navigate through your individual needs
and customize your choices with a licensed expert. We think that talking to an actual person can go a long way
when discussing your plans for you and your family's future, so we're excited to present this opportunity!
With Enrollment Support We Are Providing: Enrolling is simple.

Access To Education How To Schedule Your Appointment
EnjoǇŽŶĞͲŽŶͲŽŶĞŝŶĚŝǀŝĚƵĂů sessions that are geared Scan the QR Code below with the camera on your
to: phone & tap the notification when it pops up OR
• Walk you through your benefits at a deeper follow this link: https://txt.so/dyI99c
level 1. Enter your information
• Review each benefit offering with you 2. Choose your appointment
• Allow time to ask questions and broaden your 3. Confirm the time and date
knowledge on the benefits available to you
Personal Connection
Schedule your individual session to have one one one
time with a licensed specialist who will:
• Answer your direct questions
• Clarify all your individual pricing and plan
options
• Complete your enrollment for you
Ongoing Support
You can connect with the Enrollment Support Team
whenever you need assistance:
• For Live Response: 1-800-518-8960 Be Prepared To Enroll:
• Email Support:
• You will receive a direct call at the time of your
EnrollmentSupport@benefitsallin.com
appointment from 1-800-518-8960
• Have your dependent and beneficiary information
on hand to provide during your enrollment session:
• For Dependents:
o Date of Birth
o Social Security Number
• Take time to think about who you want to list as
your beneficiary for your Basic Life that is provided
by Everise. You can add more than one beneficiary
if needed.
Benefits Eligibility
Eligibility Qualifying Life Events
All full-time employees who are working 30 hours per Elections made as a new hire or during open enrollment
week are eligible to enroll. are effective until the following year's open enrollment.
The only other time you can make a change to your
Eligible Dependents
elections is if you experience a Qualifying Life Event. If
Medical, dental, vision and voluntary benefits are
you experience a Qualifying Life Event, please reach out
available for you and your eligible dependents.
to enrollmentsupport@benefitsallin to assist you. You
Family members who are eligible for the benefits
must provide supporting documentation at the time of
described in this guide include: legal spouses,
your call.
domestic partners*, dependent children to age 26
including step-children and children of domestic
Qualifying Life Events include:
partners, children under legal guardianship, children
covered under a qualified medical child support order • A change in marital status
and any child meeting the criteria who is over the age • A change in eligible dependents
of 26 and legally incapacitated prior to age 26 while • A change in employment status that affects
covered under the plan. eligibility for coverage
• A gain or loss over a dependent's eligibility
When Can I Enroll?
• A court order
As a new hire of Everise, you become eligible for
• A gain or loss of insurance coverage.
benefits on the first of the month following 60 days
of continuous employment. You will receive an
invitation to schedule your enrollment session 30
days prior to your effective date. Employees are
automatically enrolled in the Retirement Savings
401(k) account on the first of the month following 3
full months of service.
Making The Most Of Your Benefits

Helping you and your family members stay healthy Be Ready For The Doctor
and making sure that you use your benefits program To get the most out of your doctor visit, being
to its best advantage is Everise's goal in offering this organized and having a plan helps.
program. Here are a few things to keep in mind as you Bring the following with you:
make your choices. • Your Plan ID Card
• A list of your current medications
Paying For Your Benefits • A list of what you want to discuss with your
By giving you benefit options, Everise allows you to doctor
make benefit choices that work to meet your Using The Emergency Room
individual needs and also the needs of your family. Did you know that most Emergency Room visits are
Some benefits are provided to you at not cost, others unnecessary? Use them only in a true emergency.
have a shared cost between you and Everise and Otherwise, call your doctor or use your Telemedicine
others are paid for by you at a discounted group rate. benefit or go to an urgent care clinic. You will save a
The chart below will help you understand who lot of money and time.
contributes to each benefit.
Be Med-Wise
Stay Well! Always follow your doctor and pharmacist's
Harder than it sounds, of course, but many health instructions when taking medications. You can
problems are avoidable. Take action - from eating well worsen your condition by not taking your
to getting enough exercise and sleep. Taking care of medication or by skipping doses. If your medication
yourself avoids a lot of potential problems. is making you feel worse, contact your doctor
immediately.
Benefit Who Pays
Medical / Prescription Everise & You
Health Savings Account You
Flexible Spending Account You
Dental You
Vision You
EAP Everise
Basic Life & AD&D Everise
Voluntary Term Life & AD&D You
Short Term Disability You
Lifetime Benefit Term You
Accident Insurance You
Critical Illness Insurance You
Hospital Indemnity Insurance You
MetLaw Legal Plan You
UnitedHealthcare Medical Plans

Everise offers you a choice of comprehensive medical plans to assist you in providing excellent medical care for
you and your family. UnitedHealthcare (UHC) is your provider for four of your options. The medical plans offer
the UnitedHealthcare network of providers that have met the credentialing standards of UHC. You may locate
these providers by visiting www.myuhc.com.
As a participant, you may choose to use in-network or out-of-network providers. By utilizing the network for
provider services, you have the added advantage of negotiated pricing which can save you and the plan money.
The chart below provides a side-by-side comparison of the two medical plans when services are provided by an in
or out-of-network provider.
With the following: What is the process that I have to follow if I need to visit a UHC Network Provider? You will
first have to go online to locate a Provider that is in your area and participating in the UHC network. The website
that gives you this information is www.myuhc.com or you can call customer service at 1-866-633-2446. You will
need to register and create a user name and ID if it is your first time accessing the website.
You would then call the providers office to make an appointment. Do let them know the carrier is
UnitedHealthcare.
You will need to register and create a user name and ID if it is your first time accessing the website.
Once you have chosen a Provider, you will call his/her office and make an appointment. The staff will ask you
for your insurance information. You will provide them with the Member ID Number that is listed on your ID
Card.
Phone Number to Verify UHC Coverage: 1-866-633-2446

Medical coverage provides you with benefits that help keep you healthy like preventive care
screenings and access to urgent care. It also provides important financial protection if you have a
serious medical condition. UnitedHealthcare medical plans are administered on a Calendar year
basis. Your deductible will reset on January 1st each year.
UnitedHealthcare Choice Plus Buy Up

Plan Features In Network Out Of Network
Individual Deductible $1,500 $5,000
Family Deductible $3,000 $10,000
Individual Out Of Pocket Maximum $5,000 $10,000
Family Out Of Pocket Maximum $10,000 $20,000
Coinsurance 20% 50%
Office Visit Co-Pay $25 50%
Specialist Co-Pay - Premium Designated $25 50%
Specialist Co-Pay - Non Premium Designated $50 50%
Hospitalization 20% 50%
Emergency Room $250 Co-Pay Then 20% $250 Co-Pay Then 20%
Urgent Care $75 50%
UnitedHealthcare Choice Plus Base Plan

Plan Features In Network Out Of Network
Coinsurance 30% 50%
Office Visit Co-Pay $30 50%
Specialist Co-Pay - Premium Designated $30 50%
Specialist Co-Pay - Non Premium Designated $60 50%
Hospitalization 30% 50%
Emergency Room $250 Co-Pay Then 30% $250 Co-Pay Then 30%
Urgent Care $75 50%
Everise
20222022 Benefit
Benefit & Enrollment
& Enrollment Guide
Guide

UnitedHealthcare medical plans are administered on a Calendar year basis. Your deductible will
reset on January 1st each year.
UnitedHealthcare Choice Plus HSA Plan Plan

Benefits In Network Out Of Network
Coinsurance 20% 50%
Office Visit Co-Pay Deductible & Coinsurance 50%
Specialist Co-Pay Deductible & Coinsurance 50%
Hospitalization Deductible & Coinsurance 50%
Emergency Room Deductible & Coinsurance Deductible & Coinsurance
Urgent Care Deductible & Coinsurance 50%
UnitedHealthcare Bronze HSA Plan

Plan Benefits In Network Out Of Network
Individual Out Of Pocket Maximum Family $6,400 $20,000
Out Of Pocket Maximum $12,800 $40,000
Coinsurance 20% 50%
Office Visit Co-Pay Deductible & Coinsurance 50%
Specialist Co-Pay Deductible & Coinsurance 50%
Hospitalization Deductible & Coinsurance 50%
Emergency Room Deductible & Coinsurance Deductible & Coinsurance
Urgent Care Deductible & Coinsurance 50%
Hospital Indemnity Coverage for UHC Health Insurance Members

Everise provides executives with a Hospital Indemnity Plan when they enroll in one of the UnitedHealthcare
Medical Plans. You will be automatically enrolled into the Hospital Indemnity plan to match the tier of insurance
you choose. Example: If you enroll in a family plan, Everise will provide this coverage for your covered family
members also.
Provided by Chubb, this Hospital Indemnity Insurance offers you financial protection that covers you during a
hospital stay. No one plans for hospital stays, but if you if you are hospitalized this plan helps you by providing
benefits that can be used towards the out-of-pocket costs associated with hospital admission and confinement.
Hospital Indemnity Benefits Include:

• Initial Hospital Confinement Benefit - $1,000 is payable for the first day of hospital confinement per plan
year, per covered family member.
• Additional Hospital Confinement Benefit - $100 per day is payable for the 2nd through 30th day of Hospital
Confinement, limited to 29 days per plan year, per covered family member.
• Intensive Care Unit Benefit - $200 per day is payable for up to 30 days per plan year and is paid in addition
to any of the Hospital Confinement benefits paid.
Easy to Qualify -
• No health questions are asked or health exam required.
• Minimize Financial Exposure - Provides cash to help pay for out-of-pocket expenses resulting from a
hospitalization.
• No Pre-existing Conditions - Benefits are paid regardless of pre-existing conditions (no coverage for
pregnancy and childbirth when conception occurred prior to an employee's effective date).
• No Benefit Coordination - Chubb Hospital Indemnity benefits are paid regardless of any other medical
coverage.
Executive
Only
Benefit
Understanding How UHC Covers Prescriptions

The UnitedHealthCare Prescription List (PDL) is a list of medications that are covered by the plan. You
can review that list here: Your 2022 UHC Prescription Drug List
• Medications are placed into tiers that represent the cost you pay out-of-pocket
• Choosing medications in lower tiers may save you money
Tier One Tier Two Tier Three

• Lower-cost medications • Midrange cost • Higher cost
• Highest overall value • Good overall value • Lowest overall value
• Generics, some brands • Mix of brands & generics • Mostly brands
Tier One Tier Two Tier Three

Choice Plus Buy Up $10 Retail/$15 Mail Order $30 Retail/$75 Mail Order $50 Retail/$125 Mail Order
Choice Plus Base $15 Retail/$37.50 Mail Order $40 Retail/$100 Mail Order $75 Retail/$187/50 Mail Order
Choice Plus HSA $10 Retail/$25 Mail Order* $35 Retail/$87.50 Mail Order* $60 Retail/$150 Mail Order*
Bronze HSA $10 Retail/$25 Mail Order* $35 Retail/$87.50 Mail Order* $60 Retail/$150 Mail Order*
*After Deductible
Important Medical Coverage Information & Rules

Important Note: Prior Authorization - Requires your doctor to tell
When choosing your medical plan, UnitedHealthcare why you are taking a medication
it is very important to understand to how it may be covered by your plan. To start
that with the HSA plans you must the process, talk to your doctor or call the number
reach your deductible before your on your ID card.
plan starts to pay for your
Supply Limits - A supply limit is the largest
medication.
quantity of medication covered per co-payment or
in a defined time period. Based on FDA guidelines
for medication dosage, clinical guidelines or usage
patterns.
Step Therapy -
• Step 1 Medications - Proven to be clinically
similar and effective.
• Step 2 Medications - Treats same condition
but may cost more.
Employee Assistance Program (EAP) for UHC Members Only
When life gets

challenging,
you’ve got caring,
confidential help.
If you need guidance navigating mental
health, financial or legal concerns, take
advantage of the Employee Assistance
Program (EAP) for 24/7 support — at no
extra cost.
It’s good to know you’re not alone.

Reaching out to an EAP consultant is a good first step.
They’re trained to understand your concerns so they
can connect you with the consultant or service best able
to help you:
• Address depression, anxiety or substance use One call puts you in touch
issues.
with a clinician, counselor,
• Improve relationships at home or work. mediator, lawyer or
• Manage stress. financial adviser who could
• Work through emotional issues or grief. help change your life for the
• Assistance with legal and financial concerns. better.
Call the member phone number on your health plan ID card and ask to
speak to an EAP consultant. Or, contact EAP directly 24/7 at
1-888-887-4114.
2022 Benefit & Enrollment Guide
UHC Member Telemedicine
Visit with a doctor

24/7 — whenever,
wherever
With 24/7 Virtual Visits, you can connect to a
doctor by phone or video1 through myuhc.com®
or the UnitedHealthcare® app.
A convenient and faster way to get care

$
49
Doctors can treat a wide range of health conditions - including many of the
same conditions as an emergency room (ER) or urgent care - and may even
prescribe medications, if needed. With a UnitedHealthcare plan, your cost cost
for a 24/7 Virtual Visit is usualy $49 or less.
An estimated 25% of ER
visits could be treated
Consider 24/7 Virtual Visits for these common conditions:
with a 24/7 Virtual Visit —
• Allergies • Flu • Sore throats bringing a potential
• Bronchitis • Headaches/migraines • Stomachaches $2,000 4 cost down to $49.
• Eye infections • Rashes • and more
Get started Sign in at myuhc.com/virtualvisits | Call 1-855-615-8335

Download the UnitedHealthcare app
1 Data rates may apply.
2 Certain prescriptions may not be available, and other restrictions may apply.
3 The Designated Virtual Visit Provider’s reduced rate for a 24/7 Virtual Visit is subject to change at any time.
4 Average allowed amounts charged by UnitedHealthcare Network Providers are not tied to a specific condition or treatment. Actual payments may vary depending upon benefit coverage. Estimated Urgent Care savings are
based on $131 difference between average Urgent Care visit cost of $180 and Virtual Visit cost of $49; $2,000.00 difference between the average Emergency Room visit and the average urgent care visit. The information and
estimates provided are for general informational and illustrative purposes only and is not intended to be nor should be construed as medical advice or a substitute for your doctor’s care. You should consult with an appropriate
health care professional to determine what may be right for you. In an emergency, call 911 or go to the nearest emergency room.
The UnitedHealthcare® app is available for download for iPhone® or Android®. iPhone is a registered trademark of Apple, Inc. Android is a registered trademark of Google LLC.
24/7 Virtual Visits phone and video chat with a doctor are not an insurance product, health care provider or a health plan. Unless otherwise required, benefts are available only when services are delivered through a Designated
Virtual Network Provider. 24/7 Virtual Visits are not intended to address emergency or life-threatening medical conditions and should not be used in those circumstances. Services may not be available at all times, or in all
locations, or for all members. Check your beneft plan to determine if these services are available.
Insurance coverage provided by or through UnitedHealthcare Insurance Company or its afliates. Administrative services provided by United HealthCare Services, Inc. or their afliates. Health Plan coverage provided by or through a
UnitedHealthcare company.
B2C EI211092682.0 10/21 © 2021 United HealthCare Services, Inc. All Rights Reserved. 21-1091322-A
Frequently Asked Questions

What types of Physicians are considered Primary What is the Out-of-Pocket maximum?
Care Physicians? The Out-of-Pocket is the maximum amount you will
Primary Care Physicians are general practitioners, pay in a calendar year for eligible charges before the
internal medicine doctors, and family practitioners, plan starts paying 100% of the benefit. For example:
pediatricians for children and obstetricians and If you are enrolled in an employee only Buy-Up Plan,
gynecologists for women. All other physicians are your maximum network Out-of-Pocket per calendar
considered specialists except chiropractors. year will be $5,000 (this includes your deductible,
Do I send the bills directly to UnitedHealthcare? any co-pays and co-insurance).
If the doctor is part of the network, he or she will send How do I obtain my prescription drugs?
your bill(s) directly to UnitedHealthcare for payment. You can obtain your prescription drugs in two ways. If
You will be responsible for your share of the cost each you utilize a retail network pharmacy. You can also
time you visit the doctor. Should you encounter any obtain your prescription at retail network pharmacy,
issues regarding your claim or have any questions your Co-pay will vary depending on the plan you have
understanding the explanation of benefits (EOB) chosen. You can only get a 30-day supply of your
Review “What is an explanation of benefits?” from prescription at the retail level. Present your medical
UHC or please contact UHC directly at the 1-800 # on ID card to the pharmacist and he/she will take care of
the back of your ID card. If your doctor is not a part of the rest.
the network, your doctor may not be willing to file the
If you are on maintenance drugs (drugs that you will
claims for you. In such a case, you will need to file your
be taking over a long period of time), you may want
claims directly with UHC. Send claim forms to the
to utilize the Optum mail-order program. Under the
address listed on the back of your ID card.
mail-order program, you can obtain a 90-day supply
What is the office visit Co-pay? at the retail cost. Follow this link for instructions:
An office visit co-pay is the dollar amount you pay at
What are Formulary and Non-Formulary
each doctor’s office visit. Co-pays will vary depending
prescription drugs?
on the plan you have chosen and the type of doctor
Certain brand name drugs are selected as Formulary
you are seeing. The amount of co-pay that you have to
Brand Drugs due to deeper discount arrangements
pay is indicated on your ID card.
between the pharmacy benefit manager and the
What is the Co-insurance amount? pharmaceutical company. Other brand name drugs
The Coinsurance is the portion you pay after satisfying where the discounts negotiated are not as favorable
the deductible for services rendered outside the are designated as Non-Formulary Brand drugs. You
doctor’s office (such as Outpatient Procedures, will want to ask your physician to review the
Inpatients Procedures, Radiology, Labs etc). Example: Formulary Brand prescription drug list as these
Your coinsurance is 20% if you are enrolled in the Buy- medications have a lower co-pay, which means they
Up Plan, if you utilize Non-Network providers, your will cost you less money than the Formulary Brand
coinsurance is 50%. prescription drugs.
For example: You are enrolled in the Buy-Up Plan and
your network provider submits a bill to UHC for $100. Access a new prescription
After discounting the bill, $80 is allowed. UHC pays the mail order form by clicking
claim at 80% and sends your provider a check for $64. the icon.
You are now responsible for your 20% co-insurance or
$16 dollars.
Frequently Asked Questions

What is the process for submitting claims for What is an explanation of benefits?
reimbursement for prescription drugs? An explanation of benefits is your assurance that the
If for some reason you need to purchase a provider you visited has submitted their bill to UHC
prescription and you have not yet received for payment. It details:
your health ID card, you may choose to fill your
• Who the provider of services was that submitted
prescription and pay the full cost. If you return to the
the bill
pharmacy within 5-7 days from the original date your
• What services were rendered and the charges for
prescription was filled, the pharmacist can re- their services
adjudicate the prescription & reimburse you directly • Most importantly, how UHC settled the bills
for all but your applicable co-pay. If too much time
A provider usually submits their bills within 30-60 days
has passed since you filled your prescription, you will
of the date services are rendered. If you would like to
need to mail the bill with a copy of your health ID card
follow up to ensure your bill has been submitted, you
to the address indicated for UHC on your health ID
should call UnitedHealthcare at 1-866-633-2446.
card. No claim form is necessary to request a
reimbursement. What is the process that I have to follow if I visit a
Dentist or Orthodontist?
When can I change my medical plan option?
You can visit any dentist you choose but you can save
Once you have made your election for the year, you
money if you utilize a UnitedHealthcare
can only change your plan option during the Annual
Dental in-network provider. You can locate a network
Enrollment period. The only other time you can
provider by going to myuhc.com or call
change plans is if a “Life Change Event’ has occurred.
UnitedHealthcare Dental at 1-877-816-3596.
What is a Life Change Event?
Your policy number for UHC Dental is 921157.
A change in your situation — like getting married,
having a baby, or losing health coverage — that can What is the process that I have to follow if I visit a
make you eligible for a Special Enrollment Period, Vision Practitioner?
allowing you to enroll in health insurance outside the You can visit an ophthalmologist or optometrist
yearly Open Enrollment Period. Please reach out to of your choice, but you can save money if you
enrollmentsupport@benefitsallin.com to initiate a utilize a UnitedHealthcare provider. You may find the
life event. providers at myuhcvision.com or 1-800-638-3120.
Treatment of any disease affecting the eye is generally
When can I add my dependent(s) to the plan?
covered under the medical plan.
You can add your dependent(s) within 30 days
of your hire date, at annual enrollment or if you Your policy number for UHC Vision is 921157.
experience a Family Status Change as defined by the
Internal Revenue Service (IRS). To review a list of Who can assist me if I have questions?
Qualifying Life Events, see page 6; "Benefits Any questions regarding your benefits or the bills you
Eligibility". have incurred can be directed to UHC Administrators.
Paul Global Benefits can also help if you have difficulty
IMPORTANT NOTE: with a bill, provider’s office, UHC or need clarification
All requests for coverage and/or a change of on how your claim was processed. If you would like to
coverage must be received within 30 days of have a bill or an explanation of benefits reviewed,
being eligible or your opportunity to make a please email to Paul Global Benefits at
change will be forfeited. everisemembersupport@pgbdirect.com Please allow
24-48 hours for a response.
13
Everise 2022
2022 Benefit
Benefit && Enrollment
Enrollment Guide
Guide
KBA Minimum Essential Coverage (MEC) Plan

The MEC plan is offered through Key Benefits Administrators. The MEC Preventive Plan offers preventive
coverage only and meets the essential coverage requirements of the Affordable Care Act. If you wish to
have additional coverage to offset the cost of a hospital stay (including maternity), consider electing the
Hospital Indemnity Insurance. When you enroll in this medical plan, Everise also pays for your
Telemedicine coverage. The KBA Open Access Network allows you to seek care and treatment for any
provider you choose so there is not an out-of-network cost.
Key Benefits
BenefitsAdministrators
Administrators- -Minimum
MinimumEssential
Essential Coverage
Coverage (MEC) Group ID - M500578
(MEC)
Covered Benefit In-Network Only
Deductible (Single/Family) $0/$0
Coinsurance 100%
Out-Of-Pocket Maximum (Single/Family) N/A
PPO Network Open Access Solution
ACA Required Preventive Care Benefits Covers 100% of required preventive and wellness
Physician & Specialist Office Visit 8 visits covered at 100% for sickness and injury
Prescription Benefit
Tier 1 (Generic) $10 copay then plan pays 100%
Tier 2 (Preferred Brand) $50 copay or 50% coinsurance whichever is greater
Tier 3 Comprehensive Discount Card
Monthly Maximum $250 Individual/$500 Family Monthly Maximum
MEC Member Telemedicine - First Stop Health

Everise employees who enroll in the KBA MEC Plan receive access to telemedicine through First Stop
Health. This benefit is provided by Everise for KBA MEC Plan members so there are no fees or copays
included with the telemedicine. This gives KBA MEC Plan members access to talking to a doctor via
phone or video for treatment for a wide variety of health concerns such as sore throat, cough, sinus
infection, skin rash, eye infection, earache, urinary tract infection, aches and pains, medical questions
and medication refills. Doctors can write prescriptions when needed, however prescription costs are
applicable to your MEC plan.
Accessing Telemedicine:
• Members can request a telemedicine visit by calling 1-888-691-7867 or can register online at
www.fshealth.com.
• Users will have the option to choose their preferred method of telemedicine visit (phone or video),
unless state law or regulation requires a particular method.
• There are no limits on the number of calls members can make to physicians.
14
UnitedHealthcare Dental Options - Standard Plan

Regular dental exams are an important part of maintaining your overall health. These exams can help you
and your dentist detect problems in their early stages when treatment is less expensive and manageable.
Keeping your teeth and gums clean and healthy will help prevent most tooth decay and periodontal disease.
Everise offers two dental plans through UnitedHealthcare. Our Dental Plan(s) are administered on a policy
year, this means your deductible and annual year maximum will reset on April 1 each year.
DENTAL INSURANCE - STANDARD PLAN NON-ORTHODONTICS ORTHODONTICS

UHC 30100 / VOLUNTARY PPO 30 NETWORK NON-NETWORK NETWORK NON-NETWORK
Individual Annual Deductible $25 $25 $0 $0
Family Annual Deductible $75 $75 $0 $0
Maximum $1,500 per $1,500 per $1,500 per $1,500 per
(the sum of all Network and Non-Network person per person per person per person per
benefits will not exceed Annual maximum) Plan Year Plan Year Lifetime Lifetime
New enrollee’s waiting period None
Annual deductible applies to preventive and diagnostic services No (In Network) No (Out Network)
Annual Deductible Applies to Orthodontic Services No
Orthodontic Eligibility Requirement Adult & Child
Orthodontic Max $1,500 Lifetime Max Per Insured
COVERED SERVICES* NETWORK NON-NETWORK BENEFIT GUIDELINES
PLAN PAYS** PLAN PAYS***
DIAGNOSTIC SERVICES
Periodic Oral Evaluation 100% 100% See Exclusions and Limitations
Radiographs 100% 100% section for benefit guidelines.
Lab and Other Diagnostic Tests 100% 100%
PREVENTIVE SERVICES
Prophylaxis (Cleaning) 100% 100% See Exclusions and Limitations
Fluoride Treatment (Preventive) 100% 100% section for benefit guidelines.
Sealants 100% 100%
Space Maintainers 100% 100%
BASIC SERVICES
Restorations (Amalgams or Composite) 80% 80% See Exclusions and Limitations
Emergency Treatment/General Services 80% 80% section for benefit guidelines.
Simple Extractions 80% 80%
Oral Surgery (incl. surgical extractions) 80% 80%
Periodontics 80% 80%
Endodontics 80% 80%
MAJOR SERVICES
Inlays/Onlays/Crowns 50% 50% See Exclusions and Limitations
Denturesand Removable Prosthetics 50% 50% section for benefit guidelines.
Fixed Partial Dentures (Bridges) 50% 50%
Implants 50% 50%
ORTHODONTIC SERVICES
Diagnose or correct misalignment of the teeth or 50% 50%
bite
*For further details please refer to Benefit Summary Description.
Everise 2022
2022 Benefit
Benefit && Enrollment
Enrollment Guide
Guide
UnitedHealthcare Dental Options - Buy Up Plan

UnitedHealthcare Insurance Company (30100)® Dental Plan
NON-ORTHODONTICS ORTHODONTICS
NETWORK NON-NETWORK NETWORK NON-NETWORK
Individual Annual Deductible $25 $25 $0 $0
Family Annual Deductible $75 $75 $0 $0
Maximum $2,500 per $2,500 per $2,500 per $2,500 per
(the sum of all Network and Non-Network person per person per person per person per
benefits will not exceed Annual maximum) Calendar Year Calendar Year Lifetime Lifetime
New enrollee’s waiting period None
Annual deductible applies to preventive and diagnostic services No (In Network) No (Out Network)
Annual Deductible Applies to Orthodontic Services No
Orthodontic Eligibility Requirement Adult & Child
Orthodontia Max $2,000 Lifetime Max Per Insured
COVERED SERVICES* NETWORK NON-NETWORK BENEFIT GUIDELINES
PLAN PAYS** PLAN PAYS***
DIAGNOSTIC SERVICES
Periodic Oral Evaluation 100% 100% See Exclusions and Limitations
Radiographs 100% 100% section for benefit guidelines.
Lab and Other Diagnostic Tests 100% 100%
PREVENTIVE SERVICES
Prophylaxis (Cleaning) 100% 100% See Exclusions and Limitations
Fluoride Treatment (Preventive) 100% 100% section for benefit guidelines.
Sealants 100% 100%
Space Maintainers 100% 100%
BASIC SERVICES
Restorations (Amalgams or Composite) 90% 90% See Exclusions and Limitations
Emergency Treatment/General Services 90% 90% section for benefit guidelines.
Simple Extractions 90% 90%
Oral Surgery (incl. surgical extractions) 90% 90%
Periodontics 90% 90%
Endodontics 90% 90%
MAJOR SERVICES
Inlays/Onlays/Crowns 60% 60% See Exclusions and Limitations
Denturesand Removable Prosthetics 60% 60% section for benefit guidelines.
Fixed Partial Dentures (Bridges) 60% 60%
Implants 60% 60%
ORTHODONTIC SERVICES
Diagnose or correct misalignment of the teeth or 50% 50%
bite
*For further details please refer to Benefit Summary Description.
UnitedHealthcare (UHC) Dental Plan Frequently Asked Questions

Will I get a UnitedHealthcare dental ID card? Can I ask UHC to add my dentist to the network?
All new members can print their ID card anytime at If you want your dentist to be part of the network,
myuhc.com. Your card will only list your name, but visit myuhc.com and fill out the provider
everyone on your plan should use the card. Be sure nomination form. Or call customer care at the
to bring it with you each time you see the dentist. number on your ID card.
How do I make an appointment? Call your dentist I started dental work when I had a different
to make an appointment. Let the dental office know insurance plan. What happens now? Your old plan
you have a UHC dental plan and show your dental ID should pay for any dental work that was started
card at your appointment. until it's finished. On your dental bill, if the date you
How do I check on a claim? To check on a claim, log received care is before you switched to UHC,
in to your member website at myuhc.com or call submit a claim to your old plan. (In some cases,
the toll-free customer care number on your ID card. depending on what your old plan covered, you may
The automated system is available 24 hours a day, 7 need to pay the bill.) UHC will handle any dental
days a week. care you receive after your coverage effective date.
Do I need to see a dentist in the network? You will What happens if I switch to UHC when I have
get discounts and save money when you see a braces? If you switch dental plans when you have
dentist in the network. Your out-of-pocket costs will braces, your new UHC plan will pay for your care on
almost always be higher if you see a dentist outside a prorated basis. Your coverage will depend on the
the network. time left in your treatment plan and your benefit
level.
Does UHC pay out-of-network dentists directly?
UHC pays all dentists directly. UHC can't require How do I submit a claim? In most cases, your
out-of network dentists to accept payments, but dentist will submit your claim for you. If you need
most do. to submit a claim, send it to the address listed on
your ID card:
How can I find a dentist in the network? It's easy!
UnitedHealthcare
You have 2 options:
Attn: Claims Unit
• Log in to myuhc.com and use the Find a P.O. Box 30567
Dentist tool. You'll see a list of dentists who Salt Lake City, UT 54130-0567
are part of your network. (If you don't log in to
the member website, you can still use the
search tool, but you have to chose your
network from the list.
• Call the customer care number on your ID
card. If a network dental provider is not
available within a reasonable distance, you
may be referred to an ot-of-network provider.
Please see your official dental plan documents
for all of the details about your plan coverage.
UnitedHealthcare Vision Benefit Summary - Base

Powered by Spectera Eyecare Networks / Plan V1406
Customer Service and Provider Locator: (800) 638-3120 myuhcvision.com
United Healthcare vision has been trusted for more than 50 years to deliver affordable, innovative vision care
solutions to the nation’s leading employers through experienced, customer-focused people and the nation’s
most accessible, diversified vision care network.
EXAM WITH MATERIALS

BENEFIT FREQUENCY
Comprehensive Exam(s) Once every 12 months
Eyeglass Lenses Once every 12 months
Frames Once every 12 months
Contact Lenses instead of Eyeglasses Once every 12 months
IN-NETWORK SERVICES
COPAYS
Exam(s) $ 10.00
Eyeglasses (lenses and frame) $ 25.00
Contact lenses instead of Eyeglasses $ 25.00
FRAME BENEFIT (for frames that exceed the allowance, an additional 30% discount may be applied to the overage)¹
Private Practice Provider $130.00 retail frame allowance
Retail Chain Provider $130.00 retail frame allowance
LENS OPTIONS
Standard Scratch-resistant Coating,Polycarbonate Lenses for Dependent Children (up to age 19) — covered in full. Contact Lens
Benefit² (Formulary contact lenses refer to contact lenses available on our formulary contact list. Contact lenses not on this list
are referred to as Non-Formulary. A copy of the list can be found at myuhcvision.com).
Formulary contact lenses If you choose disposable contacts, up to 4 boxes are included
The fitting/evaluation fees, contact lenses, and up to two when obtained from an in-network provider.
follow-up visits are covered in full after copay.
Non-Formulary contact lenses $105.00
An allowance is applied toward the purchase of contact lenses
outside the Formulary. Contact lens copay is waived.
Necessary contact lenses 3 Covered in full after copay (if applicable).
CHILDREN’S AND MATERNITY EYE CARE BENEFIT
Members age 0-12 and members pregnant or breastfeeding are eligible for a 2nd exam. Members age 0-12 and members
pregnant or breastfeeding are also eligible for a replacement frame and lenses if they have a prescription change of 0.5 diopter
or more. The 2nd exam and replacement benefits are the same as the initial exam, frame and lens benefits.
OUT-OF-NETWORK REIMBURSEMENTS (Copays do not apply)

Exam(s) Up to $40.00
Frames Up to $45.00
Single Vision Lenses Up to $40.00
Lined Bifocal and Progressive Lenses Up to $60.00
Lined Trifocal Lenses Up to $80.00
Lenticular Lenses Up to $80.00
Elective Contacts instead of Eyeglasses Up to $200.00
Necessary Contacts instead of Eyeglasses Up to $210.00
DISCOUNTS
Laser VIsion
UnitedHealthcare has partnered with QualSight LASIK, the largest LASIK manager in the United States, to provide our members with access to discounted laser
vision correction providers. Member savings represent up to 35% off the national average price of Traditional LASIK. Contracted prices start at $945 per eye for
Traditional LASIK and $1,395 per eye for Custom LASIK. Discounts are also provided on newer technologies such as Custom Bladeless (all laser) LASIK. For more
information, visit myuhcvision.com.
Additional Material
At a participating in-network provider you will receive up to a 20% discount on an additional pair of eyeglasses or contact lenses. This program is available after
your vision benefits have been exhausted. Please note that this discount shall not be considered insurance, and that UnitedHealthcare shall neither pay nor
reimburse the provider or member for any funds owed or spent. Additional materials do not have to be purchased at the time of initial material purchase.
Hearing Aids
As a UnitedHealthcare vision plan member, you can save on custom-programmed hearing aids when you buy them from UnitedHealthcare Hearing. To find
out more go to UHCHearing.com. When placing your order use promo code MYVISION to get the special price discount.
UnitedHealthcare Vision Benefit Summary - Buy-Up Option

Powered by Spectera Eyecare Networks / Plan VH416
Customer Service and Provider Locator: (800) 638-3120 myuhcvision.com
United Healthcare vision has been trusted for more than 50 years to deliver affordable, innovative vision care
solutions to the nation’s leading employers through experienced, customer-focused people and the nation’s
most accessible, diversified vision care network.
EXAM WITH MATERIALS

BENEFIT FREQUENCY
Comprehensive Exam(s) Once every 12 months
Eyeglass Lenses Once every 12 months
Frames Once every 12 months
Contact Lenses instead of Eyeglasses Once every 12 months
IN-NETWORK SERVICES
COPAYS
Exam(s) $ 10.00
Eyeglasses (lenses and frame) $ 10.00
Contact lenses instead of Eyeglasses $ 10.00
FRAME BENEFIT (for frames that exceed the allowance, an additional 30% discount may be applied to the overage)¹
Private Practice Provider $200.00 retail frame allowance
Retail Chain Provider $200.00 retail frame allowance
LENS OPTIONS
Standard Scratch-resistant Coating,Polycarbonate Lenses for Dependent Children (up to age 19) — covered in full. Contact
Lens Benefit (Formulary contact lenses refer to contact lenses available on our formulary contact list. Contact lenses not on
this list are referred to as Non-Formulary. A copy of the list can be found at myuhcvision.com).
Formulary contact lenses
If you choose disposable contacts, up to 4 boxes are
The fitting/evaluation fees, contact lenses, and up to two
included when obtained from an in-network provider.
follow-up visits are covered in full after copay.
Non-Formulary contact lenses $105.00
An allowance is applied toward the purchase of contact lenses
outside the Formulary. Contact lens copay is waived.
Necessary contact lenses Covered in full after copay (if applicable).
CHILDREN’S AND MATERNITY EYE CARE BENEFIT
Members age 0-12 and members pregnant or breastfeeding are eligible for a 2nd exam. Members age 0-12 and members
pregnant or breastfeeding are also eligible for a replacement frame and lenses if they have a prescription change of 0.5 diopter
or more. The 2nd exam and replacement benefits are the same as the initial exam, frame and lens benefits.
OUT-OF-NETWORK REIMBURSEMENTS (Copays do not apply)

Exam(s) Up to $40.00
Frames Up to $45.00
Single Vision Lenses Up to $40.00
Lined Bifocal and Progressive Lenses Up to $60.00
Lined Trifocal Lenses Up to $80.00
Lenticular Lenses Up to $80.00
Elective Contacts instead of Eyeglasses Up to $200.00
Necessary Contacts instead of Eyeglasses Up to $210.00
DISCOUNTS
Laser VIsion
UnitedHealthcare has partnered with QualSight LASIK, the largest LASIK manager in the United States, to provide our members with access to discounted laser
vision correction providers. Member savings represent up to 35% off the national average price of Traditional LASIK. Contracted prices start at $945 per eye for
Traditional LASIK and $1,395 per eye for Custom LASIK. Discounts are also provided on newer technologies such as Custom Bladeless (all laser) LASIK. For more
information, visit myuhcvision.com.
Additional Material
At a participating in-network provider you will receive up to a 20% discount on an additional pair of eyeglasses or contact lenses. This program is available after
your vision benefits have been exhausted. Please note that this discount shall not be considered insurance, and that UnitedHealthcare shall neither pay nor
reimburse the provider or member for any funds owed or spent. Additional materials do not have to be purchased at the time of initial material purchase.
Hearing Aids
As a UnitedHealthcare vision plan member, you can save on custom-programmed hearing aids when you buy them from UnitedHealthcare Hearing. To find
out more go to UHCHearing.com. When placing your order use promo code MYVISION to get the special price discount.
Medical, Dental & Vision Bi-Weekly Rates

• The rates below show how much your medical, dental and vision rates are per paycheck. It's important
to know that these are your bi-weekly rates.
• In order for you to enroll your dependents, you must be enrolled.
• UnitedHealthcare Medical plans are administered on a Calendar Year basis. This means your deductible
resets on January 1st each year.
• Your UnitedHealthcare deductible accrues from January 1 to December 31 each calendar year.
• When you enroll in a medical plan, you will receive an identification card in the mail, be sure to confirm
your address during your enrollment. If you have family coverage you will receive two cards.
MEDICAL PLAN BUY-UP BASE HSA BRONZE MEC

TIER PLAN PLAN PLAN HSA PLAN
Employee Only $136.62 $109.47 $60.46 $67.85 $11.54
Employee & Spouse $373.85 $323.83 $216.45 $440.61 $41.11
Employee & Child(ren) $285.23 $243.96 $158.99 $343.80 $35.69
Family $546.92 $446.34 $296.30 $630.03 $59.08
DENTAL PLAN TIER BASE PLAN BASE PLAN TX* BUY-UP PLAN
Employee Only $11.40 $10.42 $16.97

Employee & Spouse $33.45 $30.57 $49.82
Employee & Child(ren) $33.45 $30.57 $49.82
Family $37.76 $34.51 $56.24
VISION PLAN TIER BASE PLAN BUY-UP PLAN
Employee Only $2.77 $3.92
Employee & Spouse $4.46 $6.31
Employee & Child(ren) $4.46 $6.31
Family $7.97 $11.28

Health Savings Accounts (HSA)

If you enroll in one of the UnitedHealthcare HSA Medical Plans, you will have access to a Health Savings
Account. An HSA helps you save pre-tax dollars for use on health expenses now or in the future. The account is
yours, even if you change plans in the future, and the balance rolls over each year, accumulating interest
tax-free. Your Health Savings Account is administered by Optum Bank.
Your Medical Plan & HSA Working Together:
• When you go to the Doctor or Pharmacy, you pay the full discounted cost of care (other than preventive
care) until you reach the deductible.
• Once you reach the deductible, the plan shares the cost of care through coinsurance.
• You can contribute pre-tax dollars through payroll deductions up to the 2022 IRS Limits.
• All funds remaining in your HSA after the end of the plan year roll over. That allows you to continue saving
for longer-term health care expenses, including your health care needs in retirement.
• Eligible individuals, 55 or older, can contribute an additional catch-up contribution of $1,000 per year.
Three Reasons To Love An HSA:
1. It's all yours. You own, manage and control the account. Unused funds earn interest and roll over from
year to year. You can keep the account for as long as you want, even if you are no longer with Everise.
2. It saves you money. You get triple tax advantages. Any contributions you make are automatically
deducted from your paychecks pre-taxed, which lowers your taxable income. The funds in your account
earn interest over time, tax-free. The funds you use continue to be tax-free as long as you use them for
eligible expenses. (See IRS publication 502 for a full list.)
3. You can use it when you want to. You can use your HSA to pay for things you need today or save it
to build a financial nest egg for the future - even for retirement. If you don't use it, you don't lose it.
How does an HSA work? Three ways your HSA helps you save.
• Money deposited is not taxed.
• Interest earned is not taxed
Deposit money into your HSA. • Money withdrawn from your HSA to pay for
qualified medical expenses is not taxed.
What counts as a qualified medical expense

(QME)? Check the list here:
Save on taxes
Use your HSA to pay for

qualified medical
expenses
Invest your savings in

mutual funds, if you choose. Find out by using the QME tool on
optumbank.com (for Optum HSA subscribers)
Flexible Spending Accounts (FSA)

Flexible Spending Accounts All expenses must be incurred before March 3st and
submitted no later than June 30th.
FSA’s provide you with an important tax advantage that
Elections are for the calendar year unless an allowable
can help you pay health care and dependent
Family Status Change occurs and you properly notify
care expenses on a pre-tax basis. By anticipating your
Human Resources within 30 days of the event.
family’s health care and dependent care costs for the
next year, you can actually lower your taxable
income. The annual maximum allowed for Health
Dependent Care Reimbursement Account
Care Reimbursement Account (HCRA) is $2,850 per You may use pre-tax dollars towards IRS qualified
calendar year. The annual maximum allowed for the dependent care expenses:
Dependent Care Reimbursement Account (DCRA) is the • The cost of child or adult dependent care
lesser of $5,000 (if you are married filing a joint return
• The cost for an individual to provide care either
or you are head of a household) or $2,500 (if you are
in or out of your house
married filing separate returns). Due to tax laws,
benefits provided to Domestic Partners are • Nursery schools and preschools (excluding
not eligible for reimbursement under this program. kindergarten)
FSA funds may be used for expenses such as: Whether you’re a single person, single parent, part of
a dual-income household, or a family with a non-
• Hearing services, including hearing aids and working spouse, this Plan may provide you with
batteries
additional benefits and more take- home pay.
• Vision services, including contact lenses,
contact lens solution, eye examinations, and Remember: You have 100% of every dollar you
eyeglasses put in your FSA account to spend for FSA eligible
• Dental services and orthodontia expenses. You could lose 35.65% of every after-tax
• Chiropractic services dollar you spend to pay for expenses that would
• Acupuncture otherwise be FSA eligible. Actual savings are based on
• Prescription contraceptives your personal tax rates and for purposes of these
• Prescribed over the counter medications discussions we have used 28% Federal Income Tax
Additional FSA Information plus 7.65% SS/Medicare.
You may only enroll in an FSA if you are enrolled in Additional DFSA Information
one of Everise's PPO plans. Funds are used for dependent children up to age 13 or
Your entire contribution is available at the beginning elderly day care. Must be IRS eligible dependents.
of the plan year. Funds are available as they're deducted from your
Your funds can be use by you, your spouse, child(ren) paycheck and added to your account.
to age 26 or a tax dependent who is permanently and The IRS annual dependent care FSA pretax
totally disabled. contribution limit is $5,000 per family.
The IRS requires the FSA plan to be subject to the To use your funds, you must be working. If you are
Use It or Lose It Rule. This means that whatever you married, your spouse must either be working, looking
deposit into this account must be used within the for work, be a full-time student or incapable of self-
plan year or you will lose the remaining balance. care.
Reimbursement for Incurred Expenses

Everise's Flexible Spending Accounts are administered by Optum Bank. When you enroll in a Flexible Spending
Account, you will receive an Optum Bank Debit Mastercard in the mail. You can use the the Optum Bank Debit
Mastercard and swipe card at the time of service like you would any credit/debit card. Optum will take care of
paying your provider and deducting money from your FSA account. In certain cases, you may need to submit
documentation relating to your purchase(s). You can also register with Optum to manage your account by
following this link: Optum Website
If you are enrolled in the Dependent Care FSA, remember to download the Optum Bank mobile app for your
iOS or Android device. It's a secure app tat lets you view your balance and payments, upload photos of
documentation and contact customer service.
Important Note About Over the Counter Drugs:
Effective 1/1/2011 distributions from health FSAs will be allowed to reimburse the cost of over-the-counter
medicines or drugs only if they are purchased with a prescription. This new rule does not apply to
reimbursements for the cost of insulin and a limited list of items, which will continue to be permitted, even
if purchased without a prescription.
Can I still use my benefits debit card to purchase a prescribed OTC?
The answer is no because of the doctor’s prescription requirement. You will need to purchase OTC drugs
using another form of payment and then submit a reimbursement request along with the doctor’s
prescription for the purchased OTC drug to our plan administrator, Optum.
Executive Basic Life and AD&D Insurance

Benefits Administered by Lincoln Financial Group
Everise provides and pays for an enhanced executive Basic Life and AD&D insurance coverage for all full-
time employees in your job class. You are eligible for benefits equaling 1 times your Annual Earnings as of
your date of hire. If you have loved ones who depend on your income for support, having Life and
Accidental Death and Dismemberment (AD&D) insurance can help protect your family's financial security.
Employer Paid Enhanced Basic Term Life and AD&D for Executives
Basic Life and AD&D Benefit 3X Annual Salary to a maximum of $1,500,00.000
Evidence of Insurability Benefit Amounts over $750,000 require you to complete EOI*
*Evidence of Insurability (EOI) - if 3X your annual salary exceeds $750,000, Lincoln Financial Group requires
you to complete this form and return it to your human resource department. Everise still provides the benefit
for you, but the provider's guidelines require this extra step. If you do not complete your form and return it in
a timely manner, your benefit will resume a maximum of $750,000 without additional response. Download
the on-line instructions here: Lincoln EOI Instructions
Voluntary Life and AD&D Insurance
Everise also provides the opportunity for executives to supplement the Basic Life and AD&D insurance by
purchasing Voluntary Life insurance. Voluntary Life insurance is available for you to purchase for yourself and/
or you may purchase voluntary life insurance for your spouse or Domestic Partner and your child(ren). When
you enroll yourself and/or your dependents in this benefit, you pay the full cost through payroll deductions on
an after-tax basis. Upon termination of employment, you will have the option of taking these benefits with
you in the form of conversion or porting of your coverage.
Lincoln Financial Voluntary Life & ADD Rates

Benefit Amount Maximum Guaranteed Issue Amount
Lesser of 5 Times Salary
Employee Units of $10,000 or $500,000
$250,000
$125,000 not to exceed 50% of the

Spouse Units of $5,000 $30,000
employee benefit
Units of $2,000 with a
Children minimum of $10,000
$20,000 All Amounts
Monthy Cost of Coverage

Age Employee Cost per Spouse Cost per Age Employee Cost per Spouse Cost per
$1,000 $1,000 $1,000 $1,000
0-19 $0.122 $0.122 60-64 $0.872 $0.872
20-24 $0.122 $0.122 65-69 $1.612 $1.612
25-29 $0.122 $0.122 70-74* $3.872 $1.240
30-34 $0.142 $0.142 75-79* $3.872 $1.240
35-39 $0.167 $0.167 80-84* $3.872 $1.240
40-44 $0.182 $0.182 85-89* $3.872 $1.240
45-49 $0.252 $0.252 90-94* $3.872 $1.240
50-54 $0.342 $0.342 95-99* $3.872 $1.240
55-59 $0.592 $0.592
*If an employee initially becomes insured after attaining age 70 the benefit is subject to a maximum of
$50,000.
Important Plan Information:

• Child Cost is $2.00 per month for $10,000 regardless of the number of children.
• Actual per pay period premiums may differ due to rounding, The rates above reflect the total cost. All
spouse rates are based upon employee age. Rates vary by age and my be subject to change in the future.
• Benefits will reduce based on age as follows:
o 35% at age 65
o Additional 25% of original amount at age 70
o Additional 15% of original amount at age 75
How to Calculate Your Monthly Cost

Step 1: Use the chart above to find your Monthly rate based on your age, as of your effective year.
Step 2: Multiply this rate by your desired coverage, per $1,000. Reference the table above to find the
appropriate rate amount for employee and/or dependents,
Step 3: The result is the Monthly cost.
Employee Assistance Program for Employees
The resources you

need to meet life’s
challenges
EmployeeConnect offers professional, confidential services to help you and your loved ones improve
your quality of life.
In-person Unlimited 24/7 Online

Guidance Assistance Resources
Some matters are best resolved by You and your family can access the EmployeeConnectSM offers
meeting with a professional in person. following services anytime — online, on the a wide range of information and
With EmployeeConnectSM, you and your mobile app or with a toll-free call: resources you can research and access
family get: • Information and referrals on family on your own. Expert advice
• In-person help for short-term matters, such as child and elder care, and support tools are just
issues(up to five sessions with a pet care, vacation planning, moving, a click away when you visit
counselor per persone, per issue, car buying, college planning and GuidanceResources.com or download
per year) more the GuidanceNowSM mobile app. You’ll
• In-person consultations with • Legal information and referrals for find:
network lawyers, including one family law, estate planning, • Articles and tutorials
free 30-minute in-person consumer and civil law • Videos
consultation per legal issue, and • Financial guidance on household • Interactive tools, including financial
25% off subsequent meetings budgeting and short-and long-term calculators, budgeting worksheets
planning and more
EmployeeConnectSM
EmployeeConnect SM
EMPLOYEE ASSISTANCE PROGRAM SERVICES
EMPLOYEE ASSISTANCE PROGRAM SERVICES To find out more:
Confidential help 24 hours a day, seven days a week for Visit GuidanceResources.com
employees and their family members. Get help with: username: LFGSupport password: LFGSupport1
Download the GuidanceNowSM mobile app
Family Emotional Relationships Call 888-628-4824
Parenting Legal Stress
Addictions Financial


Executive Short-Term Disability Benefit

These benefits are administered by Lincoln Financial Group
Short-Term Disability Income Benefit
Everise provides all full-time executive employees with a Short-Term Disability income benefit. Disability
benefits are an important part of your employee benefit program and can provide a source of income should
you become disabled. Benefits received under the disability programs are subject to taxation. Employees
receiving workers’ compensation benefits are not eligible to receive short-term disability benefits.
Your Short-Term Disability Benefit
GROSS-WEEKLY MAXIMUM GROSS- BENEFIT WAITING MAXIMUM BENEFIT

BENEFIT WEEKLY BENEFIT PERIOD PERIOD
66.7% of your weekly $2,500 • 7 Days Accident • 12 weeks for Accident

covered earnings • 7 Days Sickness • 12 weeks for Sickness
WHAT DEFINES A DISABILITY? HOW IT WORKS:

If you don’t get a paycheck what happens to… • Your benefit amount is automatically calculated
• Your house at 66.7% of your weekly earnings.
• Bills • It’s cost efficient and paid through payroll
• Groceries deduction
• Car/gas • At time of injury or illness, file a claim.
If you become injured or sick and you cannot work, • Your benefit is paid directly to you at home.
this coverage pays a portion of your paycheck for a PRE-EXISTING CONDITIONS
period of time • If you have a medical condition that begins
A disability can be: before your coverage takes effect, and you
• Broken leg have received treatment for that condition
• Recovering after surgery within the 3 months leading up to your
coverage start date, you will not be eligible for
• Pregnancy
benefits for that specific condition until you
• Back and joint disorders have been covered by the plan for 12 months.
• Short term illness
Lincoln Financial Customer Service Line - 1-800-423-2765

Executive Long-Term Disability Benefit

These benefits are administered by Lincoln Financial Group
Long-Term Disability Income Benefit
Everise provides all full-time executive employees with a Long-Term Disability income benefit. Long-Term
Disability Insurance is important to have in place and is intended to maintain income replacement if your
condition keeps you out of work past the end of your short-term disability benefit period, even to retirement,
depending on your disability. Benefits received under the disability programs are subject to taxation. Employees
receiving workers’ compensation benefits are not eligible to receive short-term disability benefits.
Long-Term Disability Benefit

Employer Paid Long-Term Disability Benefit
Monthly Benefit 66.7% of Monthly Salary, to a max of $10,000 per month
Max Monthly Amount 24 Months
Benefit Waiting Period 90 Days
Max Benefit Period To Age 65 or SNRA*, whichever is later
Important Definitions
*SSRN - Social Security Normal Retirement Age
Elimination Period
• This is the number of days you must be disabled before you can collect disability benefits
• The elimination period can be met through either total disability (out of work entirely) or partial
disability (working with a reduced schedule or performing different types of duties).
Coverage Period for Your Job Class
• This is the coverage period for the trade or profession in which you were employed at the tine of your
disability (also known as your own occupation).
• You may be eligible to continue receiving benefits if your disability prohibits you from any occupation
for which you are reasonably suited through your training, education and experience. In this case, your
benefits may extend through the end of your maximum benefit period.
Maximum Benefit Period
• This is the total amount of time you may be eligible to collect disability benefits. (also known as the
benefit duration).
• Benefits are limited to 24 months for mental illness, 24 months for substance abuse. See contract for
detail on other specified illnesses.
LifeTime Benefit Term

These benefits are administered by Chubb
Your Permanent Life Option With Access to Long Term Care.

LifeTime Benefit Term helps protect you and your family if you were no longer able to provide form them.
Your family can receive cash benefits paid directly to them upon your death that they can use to help cover
expenses like mortgage payments, credit card debt, childcare, college tuition and other household expenses.
Cash benefits can also be paid directly to you while you are living for long-term care expenses.
As Life Insurance
All Everise employees are offered up to $150,000 in life insurance coverage without answering any
underwriting questions or completing a health questionnaire during this initial offer. Coverage is also available
for your family.
For Long Term Care* (LTC)
If you become chronically ill, the long-term care rider will pay you 4% of your death benefit each month you
receive long term care. You can use this money any way you choose, and your life insurance premiums will be
waived. The long-term care benefit is included in your policy.
Restoration of Your Death Benefit
This rider restores your life coverage to not less than 50% of the death benefit on which your long-term care
benefits were based, not to exceed $50,000. This rider assures there will be a death benefit available for your
beneficiary until you reach age 121.
Terminal Illness Coverage
After your coverage has been in force for two years, you can receive 50% of your death benefit, up to
$100,000, if you are diagnosed as terminally ill.
Extension of Benefits
Once the full death benefit has been paid in advance for long-term care, payments can be extended.
Extension of benefits may extend the same monthly LTC benefit for up to an additional 25 months, doubling
the value.
How The Life with Long-Term Care Plan Works:
When an employee decides to protect their family with Chubb's LifeTime Benefit Term policy, there are
several ways it can work for them. Employees don't have to make any decisions on how they use their
benefits until they need them. Here is an example of how Life Insurance with Long-Term Care provides for an
employee and their family, using a life insurance benefit amount of $150,000.
LifeTime Benefit Term Eligibility For New Hires

Employees:
• Actively employed working at least 30 hours per week
• Ages 19 through 79
• Service wait period for benefit eligibility: 90 days
Issue Type Issue Age Maximum Benefit Amount
Guaranteed Issue 19 through 70 $100,000
Conditional Guaranteed Issue 19 through 70 $150,000
Simplified Issue 19 through 70 $225,000
Spouse:
• Includes legally married spouse, domestic partner and civil union partner
• Ages 19 through 70
Issue Type Issue Age Maximum Benefit Amount
Conditional Guaranteed Issue 19 through 70 $75,000
Children:
• Ages 15 days through 25 years
Type of Coverage Issue Age Maximum Benefit Amount
Child Term Rider 15 days - 25 years $25,000
LifeTime Benefit Term Certificate 15 days - 18 years $25,000

19 through 25 The amount $3/week will purchase
Plan Features
• Permanent and Guaranteed Renewable
Coverage cannot be canceled as long as premiums are paid as due.
• Full Portability
Employees can keep their coverage at the same rate if they change jobs or retire.
• Level Premium
Life insurance premium will never increase and are guaranteed through age 100. After age 100 no
premium is due.
LifeTime Benefit Term Sample Monthly Rates

These benefits are administered by Chubb
These are sample monthly rates. To estimate your cost per pay period, follow these steps:
Step 1: Use the chart below to find your Monthly rate based on your age, as of your effective year.
Step 2: Multiply this rate by 12 and divide by 26 pay periods.
Step 3: The result is your estimated cost per pay period.
Iss Age 10,000 25,000 50,000 75,000 100,000 125,000 150,000 225,000
19 N/A N/A 23.04 34.56 46.08 57.60 69.12 103.68
20 N/A N/A 23.62 35.44 47.25 59.06 70.87 106.31
21 N/A N/A 24.08 36.12 48.16 60.21 72.25 108.37
22 N/A N/A 24.50 36.75 49.00 61.25 73.50 110.25
23 N/A N/A 25.00 37.50 50.00 62.50 75.00 112.50
24 N/A N/A 25.54 38.31 51.08 63.85 76.62 114.93
25 N/A 13.04 26.08 39.12 52.16 65.21 78.25 117.37
26 N/A 13.46 26.92 40.37 53.83 67.29 80.75 121.12
27 N/A 13.96 27.92 41.87 55.83 69.79 83.75 125.62
28 N/A 14.50 29.00 43.50 58.00 72.50 87.00 130.49
29 N/A 15.02 30.04 45.06 60.08 75.10 90.12 135.18
30 N/A 15.56 31.12 46.69 62.25 77.81 93.37 140.06
31 N/A 16.21 32.42 48.62 64.83 81.04 97.25 145.87
32 N/A 16.94 33.87 50.81 67.75 84.68 101.62 152.43
33 N/A 17.67 35.33 53.00 70.66 88.33 106.00 158.99
34 N/A 18.50 37.00 55.50 74.00 92.50 111.00 166.49
35 N/A 19.37 38.75 58.12 77.50 96.87 116.25 174.37
36 N/A 20.45 40.90 61.35 81.80 102.25 122.70 184.04
37 N/A 21.59 43.17 64.76 86.35 107.93 129.52 194.28
38 N/A 22.79 45.57 68.36 91.15 113.93 136.72 205.08
39 N/A 24.07 48.14 72.21 96.28 120.35 144.42 216.63
40 N/A 25.39 50.79 76.18 101.58 126.97 152.37 228.55
41 N/A 26.84 53.67 80.51 107.35 134.18 161.02 241.53
42 N/A 28.32 56.64 84.96 113.28 141.60 169.92 254.88
43 N/A 29.91 59.81 89.72 119.63 149.54 179.44 269.16
44 N/A 31.58 63.16 94.73 126.31 157.89 189.47 284.20
45 13.36 33.39 66.79 100.18 133.58 166.97 200.37 300.55
46 14.29 35.72 71.43 107.15 142.86 178.58 214.29 321.44
47 15.33 38.33 76.66 114.98 153.31 191.64 229.97 344.95
48 16.45 41.13 82.26 123.38 164.51 205.64 246.77 370.15
49 17.62 44.05 88.10 132.16 176.21 220.26 264.31 396.47
50 18.96 47.39 94.79 142.18 189.58 236.97 284.36 426.55
51 20.21 50.53 101.06 151.59 202.13 252.66 303.19 454.78
52 21.55 53.88 107.75 161.63 215.51 269.39 323.26 484.89
53 22.98 57.45 114.90 172.36 229.81 287.26 344.71 517.07
54 24.53 61.32 122.64 183.96 245.27 306.59 367.91 551.87
55 26.20 65.50 130.99 196.49 261.99 327.49 392.98 589.48
56 25.68 64.21 128.42 192.63 256.84 321.05 385.26 577.89
57 27.78 69.44 138.89 208.33 277.77 347.22 416.66 624.99
58 29.98 74.95 149.89 224.84 299.79 374.74 449.68 674.52
59 32.31 80.76 161.53 242.29 323.05 403.82 484.58 726.87
60 34.77 86.93 173.87 260.80 347.74 434.67 521.60 782.41
61 37.85 94.63 189.25 283.88 378.50 473.13 567.75 851.63
62 41.06 102.65 205.30 307.95 410.60 513.25 615.90 923.85
63 44.46 111.15 222.31 333.46 444.62 555.77 666.92 1,000.38
64 48.00 119.99 239.98 359.97 479.96 599.96 719.95 1,079.92
65 51.72 129.31 258.61 387.92 517.23 646.54 775.84 1,163.77
66 57.48 143.70 287.41 431.11 574.81 718.51 862.22 1,293.32
67 63.56 158.89 317.78 476.67 635.56 794.45 953.34 1,430.01
68 69.97 174.93 349.86 524.79 699.72 874.65 1,049.58 1,574.37
69 76.75 191.87 383.73 575.60 767.47 959.34 1,151.20 1,726.81
70 83.98 209.95 419.90 629.85 839.80 1,049.75 1,259.70 1,889.55
Critical Illness Insurance

This benefit is administered by Chubb
When a critical illness happens your health insurance plan may cover a lot of your medical and hospital
expenses but not everything. If you and your family need extra protection that closes the financial gap and
helps you manage expenses such as:
• Out-of-Pocket Medical Costs - deductibles, copays, coinsurance, prescriptions and medical travel
• Everyday Costs - rent or mortgage payments, credit card debit, car payments, household necessities and
savings for college & retirement
• Recovery Cost - loss of family income, rehabilitation and childcare or parent care
Would a Check for $20,000 help?

Chubb Critical Illness pays you cash immediately. Upon diagnosis of a covered condition, Chubb sends a
lump sum check directly to you. You can use your cash benefit however you choose - to help with your
everyday living expenses, pay your out-of-pocket medical costs or replace lost income. Your benefit is paid in
full regardless of any other insurance you may have.
Here's How It Works
When you are diagnosed with a covered condition after the certificate effective date, submit your claim and
Chubb will quickly send you a check. It's that simple. You can use your money however you choose.
Critical illness benef it summary continued on the next page.

Critical Illness Summary of Benefits

Help with a life-changing health event. Pays a lump-sum benefit directly to you in the event you are
diagnosed with a covered critical illness such as cancer, heart attack or stroke. What you do with the payment
is up to you. It can be used for expenses beyond direct medical costs. It can help provide financial relief so
you can focus on getting better.
Benefit Details
• Lump-sum benefit is paid upon the diagnosis of a covered condition – $10,000 $20,000 or $30,000
• Covered Diagnosis Include:
• Invasive cancer • Dismemberment • Loss of Sight,

• Breast Cancer* • Stroke Speech and
• Coronary artery Hearing
• Carcinoma in situ*
obstruction* • Major Organ
• Skin cancer ($250) Failure
• End Stage Renal
• Heart Attack • Paralysis
Failure
• Additional Covered Childhood Diagnosis Include:
• Autism • Cystic Fibrosis • Muscular

• Cerebral Palsy • Down Syndrome Dystrophy
• Congenital • Gaucher Disease • Sickle Cell
Birth Defects • Type 1 Diabetes Disease
• No Lifetime Maximum - If you get sick again with the same or different condition, you're still covered.
There is no total maximum benefit amount to worry about. Different covered conditions need to be
diagnosed at least 6 months apart.
• Recurrence Benefit - Once Chubb pays a Critical Illness benefit for Aneurysm (Cerebral or Aortic),
Benign Brain Tumor, Coma, Coronary Artery Obstruction, Heart Attack, Major Organ Failure, Sever
Burns, Stroke or Sudden Cardiac Arrest, and there is a recurrence, you can receive 50% of your Face
Amount, as long as you were treatment free for at least 6 months. For a recurrence of Cancer,
including Carcinoma In Situ, you can receive 100% of your Face Amount, as long as you were
treatment free for 12 months and in complete remission.
• Enhanced Breast Cancer Benefit - If you're diagnosed with breast cancer, including carcinoma in situ,
this benefit will pay your full face amount.
• Occupational Package - Chubb pays benefits if you are infected with HIV, Hepatitis B, C or D from an
accidental needle stick at work. You will receive 100% of your benefit amount.
• Wellness Benefit - Be proactive with preventive care! This benefit pays you $100 for undergoing a
health screening test.
• Advocacy Benefits - Personal and confidential assistance from professionals. The plan also gives you
access to Best Doctors to assist with finding the best doctor, an "Ask The Expert" Hotline and diagnosis
and treatment advice.
Chubb Critical Illness Rates

Employee Paid Guaranteed Issue Level: $30,000
Employee Per Pay Period Age Banded Rates
Cost Per Pay Period for $10,000 in Coverage
Ee 10,000 10,000 10,000 10,000 10,000 10,000 10,000 10,000

Sp 5,000 5,000 5,000 5,000
Ch 2,500 2,500 2,500 2,500
Issue Ee Ee Ee+Sp Ee+Sp Ee+Ch Ee+Ch Ee+Fam Ee+Fam
Age NT TB NT TB NT TB NT TB
18-24 2.78 3.41 4.84 5.77 2.78 3.41 4.84 5.77
25-29 2.95 3.82 5.09 6.40 2.95 3.82 5.09 6.40
30-34 3.74 5.15 6.27 8.39 3.74 5.15 6.27 8.39
35-39 4.61 6.90 7.58 11.01 4.61 6.90 7.58 11.01
40-44 5.98 9.51 9.64 14.93 5.98 9.51 9.64 14.93
45-49 7.73 12.63 12.25 19.61 7.73 12.63 12.25 19.61
50-54 9.72 16.41 15.24 25.28 9.72 16.41 15.24 25.28
55-59 12.42 20.56 19.29 31.51 12.42 20.56 19.29 31.51
60-64 15.54 24.34 23.97 37.18 15.54 24.34 23.97 37.18
65-69 17.32 25.34 26.65 38.67 17.32 25.34 26.65 38.67
70+ 29.99 40.00 45.65 60.67 29.99 40.00 45.65 60.67
As a new hire, the Critical Illness Plan is available to you for up to $30,000 in coverage without any
health questions. You can use the illustration above to calculate the cost per pay period for $10,000,
$20,000 or $30,000 in coverage.
Here is the key:

Ee - Employee Only
Ee + Sp = Employee & Spouse
Ee + Ch - Employee & Child(ren)
NT - Non Tobacco User
TB - Tobacco User
Example: John Smith is 35 years old, does not use tobacco and wants to cover his family at a face
amount of $30,000.
His cost per pay period in the illustration above is $7.58 per pay period for $10,000.
$7.58 X 3 ($10,000 benefit X 3 = $30,000 benefit) = $22.74 per pay period for $30,000 benefit.
Accident Insurance
This benefit is administered by Chubb.
Chubb Accident provides coverage if you are accidentally injured and need treatment, whether you go to a
physician's office, urgent care center, emergency room or use telemedicine services. There are no restrictions
on how your money can be used. All benefits are paid directly to you.
Benefit Features:
• Guaranteed Issue - No medical history is required for coverage to be issued.
• Renewable - Coverage is automatically renewed as long as you are an eligible employee, your premiums
are paid as due and the policy is in force.
• Portable - You can keep your coverage even if you change jobs or retire without a change in cost.
• Family Coverage - You can insure yourself, your spouse and your children. You can include your children
and dependent grandchildren through age 26.
• HSA Compatible - You can have this coverage even if you have a Health Savings Account.
Accident Insurance Benefits Also Include:
• Sports Package - Chubb will increase your benefit 24%, up to $1,000 per person per year, for injuries
resulting from participating in organized sports.
• Rehabilitation Package - chubb pays cash benefits for admission, daily confinement and recovery.
Whether you're released to a Rehabilitation Center following a hospital stay or you recover at home,
Chubb pays a daily recovery benefit to help with your transition. They also pay a benefit for residence/
vehicle modification, and therapy (including physical, occupational and speech).
TIER PREMIUM PER PAY PERIOD

Employee $3.48
Employee & Spouse $5.34
Employee & Child(ren) $6.89
Family $8.57
Hospital Indemnity Insurance

Chubb's Hospital Indemnity Insurance offers you financial protection that covers you during a hospital stay. No
one plans for hospital stays, but if you if you are hospitalized this plan helps you by providing benefits that can
be used towards the out-of-pocket costs associated with hospital admission and confinement.
Hospital Confinements Are Expensive

The rising costs of healthcare, along with rising health plan deductible can cause financial hardship. Costs from
an unforeseen or even a planned hospital visit can add up quickly, such as:
• Deductibles • Prescriptions
• Copays • Out-of-pocket expenses
• Co-insurance
Hospital Indemnity Benefits Include:

Initial Hospital Confinement Benefit - Depending on which plan you choose, either $500 or $1,000 is payable for
the first day of hospital confinement per plan year, per covered family member.
Additional Hospital Confinement Benefit - $100 per day is payable for the 2nd through 30th day of Hospital
Confinement, limited to 29 days per plan year, per covered family member.
Intensive Care Unit Benefit - $200 per day is payable for up to 30 days per plan year and is paid in addition to any
of the Hospital Confinement benefits paid.
Hospital Indemnity Insurance Benefits

Chubb Makes It Easy

• Easy to Qualify - No health questions are asked or health exam required.
• Minimize Financial Exposure - Provides cash to help pay for out-of-pocket expenses resulting from a
hospitalization.
• No Pre-existing Conditions - Benefits are paid regardless of pre-existing conditions (no coverage for
pregnancy and childbirth when conception occurred prior to an employee's effective date).
• No Benefit Coordination - Chubb Hospital Indemnity benefits are paid regardless of any other medical
coverage.
• Spouse and Child(ren) Coverage Available - Extend Chubb Hospital Indemnity coverage to members of
your family.
• Guaranteed Renewable - Your coverage cannot be canceled as long as premiums are paid.
More Information About The Coverage:

Hospital Indemnity Insurance coverage provides a benefit according to the schedule below when a covered
member incurs a Hospital stay resulting from a Covered Injury or Covered Illness. The benefit amounts shown
in this summary will be paid regardless of the actual expenses incurred and are paid on a per day basis unless
otherwise specified. Benefits are only payable when all policy terms and conditions are met. Please read all
the information in this summary to understand the terms, conditions, state variations, exclusions and
limitations applicable to these benefits. See your Certificate of Insurance for more information.
Plan 1 Plan 2
Employee $4.42 $6.01
Employee + Spouse/Domestic Partner 9.80 $19.98
Employee + Child(ren) $8.35 $12.52
Employee + Family $13.45 $26.49
Hospitalization Benefits Plan 1 Plan 2

Hospital Admission Benefit $500 $1,000
Additional Hospital Confinement

$100 $100
2nd day through 30th day, max 30 days per plan year, per insured
Intensive Care Unit
$100 $200
Max 30 days per plan year, per insured
MetLaw Legal Plan

This benefit is administered by MetLife.
Why MetLaw makes sense. Having an experienced attorney when you need one may cost less
than you think.
Navigating through some of life’s important moments MetLaw covers the most common personal legal
such as buying a home, creating a will, or defending a matters including:
civil litigation matter can be overwhelming, especially • Estate planning documents, including wills and
if you can’t find an attorney that meets your needs or trusts
your budget. Now you can take advantage of MetLaw, • Real estate matters
a legal services plan from Hyatt Legal Plans, a MetLife • Identity theft defenses
company, to get convenient access to comprehensive • Financial matters, such as debt-collection
legal services at an affordable cost. defenses
Your choice of experienced attorneys. • Traffic offenses
With MetLaw, you can access a network of local • Document reviews
credentialed Network Attorneys who have an average • Family law, including adoptions and name
of 25 years of experience. You can also choose to work changes
with an out-of-network attorney and may be • Advice and consultation on personal legal
reimbursed according to a set fee schedule. matters
How do I use the plan?
Low monthly cost for unlimited use.
No matter how many times throughout the year you It’s easy – Simply access the member site or call
use the services of a Network Attorney for covered MetLaw's Client Service Center at 800-821-6400 from
legal matters, all you pay is your monthly premium, no 8:00 am - 8:00 pm EST/EDT, Monday - Friday.
copays — no deductibles. For the same cost as finding After signing in, you may:
an attorney on your own for one legal matter, you get • Review covered services and see complete
full service on an unlimited number of the most benefit definitions.
common personal legal matters by telephone or in- • Find an attorney near you using the Attorney
person regardless of how long it takes. Locator.
• Get a case number by clicking on “Obtain Case
Number.”
• Contact the network attorney of your choice and
reference your case number when making an
appointment.
$9 per pay period covers an employee and their family.
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My Pet Protection
This benefit is administered by Nationwide.
Nationwide® pet insurance provides coverage for veterinary expenses related to accidents and illnesses.
Policies are available for dogs, cats, birds, reptiles and other exotic pets.
Optional wellness coverage is also available for dogs and cats, providing reimbursement for the preventive
care necessary to keep them healthy year after year.
My Pet Protection pet insurance plans now feature more choices and more flexibility
 Get cash back on eligible vet bills  Use any vet, anywhere
Choose from three levels of reimbursement: No networks, no pre-approvals
90%, 70% or 50%*  Optional wellness coverage available
 Available exclusively for employees Includes spay/neuter, dental
These plans aren’t available to the general cleaning, exams, vaccinations and
public more
 Same price for pets of all ages
Your rate won’t go up because your pet had
a birthday
Choose the reimbursement level that fits your needs.
Problems such as upset stomach are among the most common reasons dogs and cats go to the vet.
The average cost for this kind of visit is $424. Here’s how My Pet Protection would cover the bill.*
90% 70% 50%

reimbursement reimbursement reimbursement
$381 $296 $212

reimbursement reimbursement reimbursement
You pay: $43 You pay: $128 You pay: $212

Nationwide pays: Nationwide pays: Nationwide pays:
$381 $296 $212
Examples reflect reimbursement after $250 annual deductible has been fulfilled.
How To Apply For A Policy:
Choose from two easy ways to sign up:

1. Call 877-738-7874 and tell the pet insurance specialist that you work for Everise. You'll receive
preferred pricing on your base pet policy.
2. Visit: https://benefits.petinsurance.com/everise to enroll online. The rates will include your preferred
pricing.
401 (k)
This benefit is administered by One America.
Employees are automatically enrolled in the Retirement Savings 401(k) account on the first of the month
following 3 full months of service. For more information on the automatic enrollment and benefit features
please scan the applicable QR code or follow the links listed below.
Benefit Documents:
Automatic Enrollment Notice Self Enrollment Instructions Summary Plan Description

Click HERE or scan below Click HERE or scan below Click HERE or scan below
Participant Fee Disclosure Annual QDIA Notice

Click HERE or scan below Click HERE or scan below
Contacts
Refer to the contact list when you need to reach one of your benefit vendors. For general information or
enrollment contact our Enrollment Support Team at EnrollmentSupport@benefitsallin.com.
Benefit Who To Call Email/Website Phone Number

UHC Medical & RX PPO UnitedHealthcare www.myuhc.com 1-866-613-2446
UHC Medical & RX HSA UnitedHealthcare www.myuhc.com 1-866-314-0335
UHC Dental Plans UnitedHealthcare www.myuhc.com 1-877-816-3596
UHC Vision Plans UnitedHealthcare www.myuhcvision.com 1-800-638-3120
UHC Member Telemedicine UnitedHealthcare myuhc.com/virtualvisits 1-855-615-8335
UHC Member EAP* UnitedHealthcare 1-888-887-4114
MEC Plan Key Benefit Administrators www.kbasolutions.com 1-877-851-0906
MEC Member Telemedicine First Stop Health www.fshealth.com. 1-888-691-7867

Health Savings Accounts Optum Bank www.optumbank.com 1-800-731-9361
Flexible Spending Accounts Optum Bank www.optumbank.com 1-800-243-5543

Life and Disability Lincoln Financial Group www.lincolnfinancial.com 1-800-423-2765
Lifetime Benefit Term Chubb csmail@gotoservice.chubb.com 1-855-241-9891

Accident, Critical Illness,
Hospital Indemnity Chubb csmail@gotoservice.chubb.com 1-800-544-9382
Coverage
Legal Plan MetLaw www.legalplans.com 1-800-821-6400
401(k) Plan OneAmerica www.oneamerica.com/login 1-800-249-6269
Pet Insurance Nationwide www.petinsurance.com 1-800-738-7874
Enrolling is simple.
How To Schedule Your Appointment
Scan the QR Code with the camera on your phone & tap the notification when i
t pops up OR follow this link: https://txt.so/dyI99c
1. Enter your information
2. Choose your appointment
3. Confirm the time and date
Federal Notices
Women’s Health and Cancer Rights Act of 1998
Notice to Participants
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s
Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits,
coverage will be provided in a manner determined in consultation with the attending physician and the patient,
for:
• All stages of reconstruction of the breast on which the mastectomy was performed;
• Surgery and reconstruction of the other breast to produce a symmetrical
appearance;
• Prostheses; and
• Treatment of physical complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same deductibles and co-insurance applicable to other medical
and surgical benefits provided under this plan. Please review your group health summary plan description for
details of the Plan’s deductible and co-payment requirements for mastectomies.
Marketplace Coverage Options and Your Health Coverage

Health Coverage Reminder
The Patient Protection and Affordable Care Act (PPACA) requires most individuals to have minimum
essential health coverage or pay a penalty. You may obtain coverage through your employer or through
the Marketplace. Visit www.HealthCare.gov for Marketplace information.
REMINDER: You may only purchase insurance through the Marketplace if you experience a qualifying
event OR during Open Enrollment. The Federal Marketplace Open Enrollment dates are from November 15
through February 15.
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your
employer, your state may have a premium assistance program that can help pay for coverage, using funds from
their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be
eligible for these premium assistance programs but you may be able to buy individual insurance coverage
through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact
your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your
dependents might be eligible for either of these programs, contact your State Medicaid or CHIP
office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your
state if it has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under
your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already
enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of
being determined eligible for premium assistance. If you have questions about enrolling in your employer plan,
contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer health plan
premiums. The following list of states is current as of October 15, 2021. Contact your State for more
information on eligibility.
ALABAMA – Medicaid ALASKA – Medicaid
Website: http://myalhipp.com/ The AK Health Insurance Premium Payment Program Website:
Phone: 1-855-692-5447 http://myakhipp.com/
Phone: 1-866-251-4861
Email: CustomerService@MyAKHIPP.com
Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
ARKANSAS – Medicaid CALIFORNIA – Medicaid

Website: http://myarhipp.com/ Website: Health Insurance Premium Payment (HIPP) Program
Phone: 1-855-MyARHIPP (855-692-7447) http:/dhcs.ca.gov/hipp Phone: 916-445-8322
Email: hipp@dhcs.ca.gov
COLORADO – Health First Colorado (Colorado’s Medicaid Program) &

FLORIDA – Medicaid
Child Health Plan Plus (CHP+)
Health First Colorado Website: Website: https://www.flmedicaidtplrecovery.com/
https://www.healthfirstcolorado.com/ flmedicaidtplrecovery.com/ hipp/index.html
Health First Colorado Member Contact Center: Phone: 1-877-357-3268
1-800-221-3943/ State Relay 711
CHP+:
https://www.colorado.gov/pacific/hcpf/child-health-plan-plus CHP+ Customer
Service: 1-800-359-1991/ State Relay 711 Health Insurance Buy-In Program
(HIBI): https://www.colorado.gov/pacific/hcpf/health-insurance-buy-program
HIBI Customer Service: 1-855-692-6442
GEORGIA – Medicaid INDIANA – Medicaid

Website: https://medicaid.georgia.gov/health-insurance- premium- Healthy Indiana Plan for low-income adults 19-64
payment-program-hipp Website: http://www.in.gov/fssa/hip/
Phone: 678-564-1162 ext 2131 Phone: 1-877-438-4479
All other Medicaid
Website: https://www.in.gov/medicaid/ Phone 1-800-457-4584
IOWA – Medicaid and CHIP (Hawki) KANSAS – Medicaid

Medicaid Website: https://dhs.iowa.gov/ime/members Website: https://www.kancare.ks.gov/
Medicaid Phone: 1-800-338-8366 Phone: 1-800-792-4884
Hawki Website: http://dhs.iowa.gov/Hawki
Hawki Phone: 1-800-257-8563
HIPP Website: https://dhs.iowa.gov/ime/members/medicaid-a- to-z/hipp
HIPP Phone: 1-888-346-9562
KENTUCKY – Medicaid LOUISIANA – Medicaid

Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp
Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)
Phone: 1-855-459-6328
Email: KIHIPP.PROGRAM@ky.gov
KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx Phone:
1-877-524-4718
Kentucky Medicaid Website: https://chfs.ky.gov
MAINE – Medicaid MASSACHUSETTS – Medicaid and CHIP
Enrollment Website: https://www.maine.gov/dhhs/ofi/applications- Website: https://www.mass.gov/info-details/masshealth-premium-
forms assistance-pa
Phone: 1-800-442-6003 TTY: Maine relay 711 Phone: 1-800-862-4840
Private Health Insurance Premium Webpage:
https://www.maine.gov/dhhs/ofi/applications-forms Phone:
800-977-6740 TTY: Maine relay 711
MINNESOTA – Medicaid MISSOURI – Medicaid
Website: https://mn.gov/dhs/people-we-serve/children-and- families/health- Website:
care/health-care-programs/programs-and- services/other-insurance.jsp http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone:
Phone: 1-800-657-3739 573-751-2005
MONTANA – Medicaid NEBRASKA – Medicaid

Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Website: http://www.ACCESSNebraska.ne.gov
Phone: 1-800-694-3084 Phone: 1-855-632-7633
Lincoln: 402-473-7000
Omaha: 402-595-1178
NEVADA – Medicaid NEW HAMPSHIRE – Medicaid
Medicaid Website: http://dhcfp.nv.gov Medicaid Website: https://www.dhhs.nh.gov/oii/hipp.htm
Phone: 1-800-992-0900 Phone: 603-271-5218
Toll free number for the HIPP program: 1-800-852-3345, ext 5218
NEW JERSEY – Medicaid & CHIP NEW YORK – Medicaid
Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/ Website: https://www.health.ny.gov/health_care/medicaid/
clients/medicaid/ Phone: 1-800-541-2831
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
NORTH CAROLINA – Medicaid NORTH DAKOTA – Medicaid
Website: https://medicaid.ncdhhs.gov/ Website:
Phone: 919-855-4100 http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 1-844-854-4825
OKLAHOMA – Medicaid & CHIP OREGON – Medicaid
Website: http://www.insureoklahoma.org Website: http://healthcare.oregon.gov/Pages/index.aspx http://
Phone: 1-888-365-3742 www.oregonhealthcare.gov/index-es.html
Phone: 1-800-699-9075
PENNSYLVANIA – Medicaid RHODE ISLAND – Medicaid & CHIP
Website: https://www.dhs.pa.gov/Services/Assistance/Pages/HIPP- Website: http://www.eohhs.ri.gov/
Program.aspx Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)
Phone: 1-800-692-7462
SOUTH CAROLINA – Medicaid SOUTH DAKOTA – Medicaid
Website: https://www.scdhhs.gov Website: http://dss.sd.gov
Phone: 1-888-549-0820 Phone: 1-888-828-0059
TEXAS – Medicaid UTAH – Medicaid & CHIP
Website: http://gethipptexas.com/ Medicaid Website: https://medicaid.utah.gov/
Phone: 1-800-440-0493 CHIP Website: http://health.utah.gov/chip
Phone: 1-877-543-7669
VERMONT– Medicaid VIRGINIA – Medicaid & CHIP
Website: http://www.greenmountaincare.org/ Website: https://www.coverva.org/en/famis-select https://
Phone: 1-800-250-8427 www.coverva.org/en/hipp
Medicaid Phone: 1-800-432-5924
CHIP Phone: 1-800-432-5924
WASHINGTON – Medicaid WEST VIRGINIA – Medicaid
Website: https://www.hca.wa.gov/ Website: http://mywvhipp.com/
Phone: 1-800-562-3022 Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
WISCONSIN – Medicaid & CHIP WYOMING – Medicaid
Website: Website: https://health.wyo.gov/healthcarefin/medicaid/programs-and-
https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm eligibility/
Phone: 1-800-362-3002 Phone: 1-800-251-1269
To see if any other states have added a premium assistance program since October 15, 2021, or for more
information on special enrollment rights, contact either:
U.S. Department of Labor U.S. Department of Health and Human Services

Employee Benefits Security Administration Centers for Medicare & Medicaid Services
www.dol.gov/agencies/ebsa www.cms.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565
Paperwork Reduction Act Statement Notice of Privacy Practices

According to the Paperwork Reduction Act of 1995 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION
(Pub. L. 104-13) (PRA), no persons are required to respond ABOUT YOU MAY BE USED AND DISCLOSED AND HOW
to a collection of information unless such collection displays YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
a valid Office of Management and Budget (OMB) control REVIEW IT CAREFULLY.
number. The Department notes that a Federal agency This Notice is effective as of January 1, 2011 and shall
cannot conduct or sponsor a collection of information remain in effect until you are notified of any changes,
unless it is approved by OMB under the PRA, and displays modifications or amendments. This Notice applies to
a currently valid OMB control number, and the public is not health information the Everise UnitedHealth Network
required to respond to a collection Options PPO Medical, Dental and Vision Benefit Plan
of information unless it displays a currently valid OMB (referred to herein as the “Plan” OR collectively referred
control number. See 44 U.S.C. 3507. Also, notwithstanding to herein as the “Plan”) creates or receives about you. You
any other provisions of law, no person shall be subject to may receive notices about your medical information and
penalty for failing to comply with a collection of information how it is handled by other plans or insurers. The Health
if the collection of information does not display a currently Insurance Portability and Accountability Act of 1996, as
valid OMB control number. See 44 U.S.C. 3512. amended (“HIPAA”), mandated the issuance of regulations
The public reporting burden for this collection of to protect the privacy of individually identifiable health
information is estimated to average approximately seven information, which were issued at 45 CFR Parts 160
minutes per respondent. Interested parties are encouraged through 164 (the
to send comments regarding the burden estimate or any “Privacy Regulations”). As a participant or beneficiary of
other aspect of this collection of information, including the Plan, you are entitled to receive a notice of the Plan’s
suggestions for reducing this burden, to the U.S. privacy procedures with respect to your health
Department of Labor, Employee Benefits Security information that is created or received by the Plan (your
Administration, Office of Policy and Research, Attention: “Protected Health Information” or “PHI”). This Notice is
PRA Clearance Officer, 200 Constitution Avenue, N.W., intended to inform you about how the Plan will use or
Room N-5718, Washington, DC 20210 or email disclose your PHI, your privacy rights with respect to the
ebsa.opr@dol.gov and reference the OMB Control Number PHI, the Plan’s duties with respect
1210-0137. to your PHI, your right to file a complaint with the Plan or
OMB Control Number 1210-0137 (expires 1/31/2023) with the Secretary of the U.S. Department of Health and
Human Services (“HHS”) and the office to contact for
HIPAA Special Enrollment Rights Notification further information about the Plan’s privacy practices.
If you are declining enrollment for yourself or your How the Plan Will Use or Disclose Your PHI
dependents (including your spouse) because of other health
Other than the uses or disclosures discussed below, any
insurance or group health plan coverage, you may be able
use or disclosure of your PHI will be made only with your
to enroll yourself and your dependents in this plan if you or
written authorization. Any authorization by you must be in
your dependents lose eligibility for that other coverage (or if
writing. You will receive a copy
the employer stops contributing toward you or your
of any authorization you sign. You may revoke your
dependents’ other coverage). However, you must request
authorization in writing, except your revocation cannot be
enrollment within 30 days after you or your dependents’
effective to the extent the Plan has taken any action
other coverage ends (or after the employer stops
relying on your authorization for disclosure. Your
contribution toward the other coverage).
authorization may not be revoked if your authorization
In addition, if you have a new dependent as a result of marriage, was obtained as a condition for obtaining insurance
birth, adoption, or placement for adoption, you may be able to coverage and any law provides the insurer with the right
enroll yourself and your dependents. However, you must to contest a claim under the policy or the policy itself
request enrollment within 30 days after the marriage, birth, provides such right.
adoption, or placement
When using or disclosing PHI or when requesting PHI from
for adoption. You can reach Paul Global Benefits via email:
another covered entity, the Plan will make reasonable
everisemembersupport@pgbdirect.com
efforts not to use, disclose or request more than the
minimum amount of PHI necessary to accomplish the
intended purpose of the use, disclosure or request, taking
into consideration practical and technological limitations.
However, the minimum necessary standard will not apply The Plan is prohibited from using or disclosing your PHI
in the following situations: that is genetic information for underwriting purposes.
• disclosures to or requests by a health care provider The following use and disclosure of your PHI may only be
for treatment; made by the Plan with your written authorization or by
providing you with an opportunity to agree or object to
• uses or disclosures made to the individual;
the disclosure:
• disclosures made to HHS;
To Individuals Involved in Your Care. The Plan is
• uses or disclosures that are required by law; permitted to disclose your PHI to your family members,
• uses or disclosures that are required for the Plan’s other relatives and your close personal friends if:
compliance with legal regulations; and • the information is directly relevant to the family or
• uses and disclosures made pursuant to a valid friend’s involvement with your care or payment for
authorization. that care; and
• you have either agreed to the disclosure or have
The following uses and disclosures of your PHI may be
been given an opportunity to object and have not
made by the Plan:
objected.
For Payment.
The following uses and disclosures of your PHI may be
Your PHI may be used or disclosed to obtain payment, made by the Plan without your authorization or without
including disclosures for coordination of benefits paid with providing you with an opportunity to agree or object to the
other plans disclosure:
and medical payment coverages, disclosures
For Appointment Reminders.
for subrogation in order for the Plan to pursue recovery of
benefits paid from parties who caused or contributed to Your PHI may be used so that the Plan, or one of its
the injury or illness, disclosures to determine if the claim contracted service providers, may contact you to provide
for benefits are covered under the Plan, are medically appointment reminders, information on treatment
necessary, experimental alternatives, or other health related benefits and services
or investigational, and disclosures to obtain reimbursement that may be of interest to you, such as case management,
under insurance, reinsurance, disease management, wellness programs, or employee
stop loss or excessive loss policies providing assistance programs.
reimbursement for the benefits paid under the Plan on To the Plan Sponsor.
your behalf. Your PHI may be disclosed to other health
plans maintained by the Plan sponsor for any of the PHI may be provided to the sponsor of the Plan provided
purposes described above. that the sponsor has certified that this PHI will not be used
for any other benefits, employee benefit plans or
For Treatment. employment- related activities.
Your PHI may be used or disclosed by the Plan for purposes When Required by Law.
of treating you. One example would be if your doctor
requests information on what other drugs you are The Plan may also be required to use or disclose your PHI
currently receiving during the course of treating you. as required by law. For example, the law may require
reporting of certain types of wounds or a disclosure to
For the Plan’s Operations. comply with a court order, a warrant, a subpoena, a
Your PHI may be used as part of the Plan’s health care summons, or a grand jury subpoena received by the Plan.
operations. Health care operations include quality For Workers’ Compensation.
assurance, underwriting and premium rating to obtain
renewal coverage, and other activities that are related to The Plan may disclose your PHI as authorized by and to the
creating, renewing, or replacing the contract of health extent necessary to comply with laws relating to workers’
insurance or health benefits or securing or placing a compensation or other similar programs, established by
contract for reinsurance of risk, including stop loss law, that provide benefits for work-related injuries or
insurance, reviewing the competence and qualification of illnesses without regard to fault.
health care providers and conducting cost management
and quality improvement activities, and customer service
and resolution of internal grievances.
For Public Health Activities. For Other Law Enforcement Purposes.

When permitted for purposes of public health activities, The Plan may disclose your PHI for other law enforcement
including when necessary to report product defects, to purposes, including for the purpose of identifying or
permit product recalls and to conduct post-marketing locating a suspect, fugitive, material witness or missing
surveillance. Your PHI may also be used or disclosed if you person. Disclosures for law enforcement purposes include
have been exposed to a communicable disease or are at disclosing information about
risk of spreading a disease or condition, if authorized or an individual who is or is suspected to be a victim
required by law. of a crime, but only if the individual agrees to the
disclosure, or the Plan is unable to obtain the individual’s
To Report Abuse, Neglect or Domestic Violence.
agreement because of emergency circumstances.
When authorized or required by law to report information Furthermore, the law enforcement official must represent
about abuse, neglect or domestic violence to public that the information is not intended to be used against the
authorities if there exists a reasonable belief that you may individual, the immediate law enforcement activity would
be a victim of abuse, neglect or domestic violence. In such be materially and adversely affected by waiting to obtain
case, the Plan will promptly inform you that such a the individual’s agreement, and disclosure is in the best
disclosure has been or will be made unless that notice interest of the individual as determined by the exercise of
would cause a risk of serious harm. For the purpose of the Plan’s best judgment.
reporting child abuse or neglect, the Plan is not required to
inform the minor that such a disclosure has been or will be To a Coroner or Medical Examiner.
made. Disclosure may generally be made to the minor’s When required to be given to a coroner or medical
parents or other representatives, although there may be examiner for the purpose of identifying a deceased person,
circumstances under federal or state law when the parents determining a cause of death or other duties as authorized
or other representatives may not be given access to a or required by law. Also, disclosure is permitted to funeral
minor’s PHI. directors, consistent with applicable law, as necessary to
carry out their duties with respect to the decedent.
For Public Health Oversight Activities.
For Research.
The Plan may disclose your PHI to a public health oversight
agency for oversight activities authorized or required by The Plan may use or disclose PHI for research, subject to
law. This includes uses or disclosures in civil, administrative certain conditions.
or criminal investigations; inspections; licensure or To Prevent or Lessen a Serious and Imminent Threat.
disciplinary actions (for example, to investigate complaints When consistent with applicable law and standards of
against providers); and other activities necessary for ethical conduct, if the Plan, in good faith, believes the use
appropriate oversight of government benefit programs (for or disclosure is necessary to prevent or lessen a serious
example, to investigate Medicare or Medicaid fraud). and imminent threat to the health or safety of a person or
For Judicial or Administrative Proceedings. the public and the disclosure is to a person reasonably able
to prevent or lessen the threat, including the target of the
The Plan may disclose your PHI when required for judicial
threat.
or administrative proceedings. For example, your PHI may
be disclosed in response to a subpoena or discovery State Privacy Laws.
request provided certain conditions are met. One of those Some of the uses or disclosures described in this Notice
conditions is that satisfactory assurances must be given to may be prohibited or materially limited by other applicable
the Plan that the requesting party has made a good faith state laws to the extent such laws are more stringent than
attempt to provide written notice to you, and the notice the Privacy Regulations. The Plan shall comply with
provided sufficient information about the proceeding to any applicable state laws that are more stringent when
permit you to raise an objection and no objections were using or disclosing your PHI for any purposes described by
raised or any raised were resolved in favor of disclosure by this Notice.
the court or tribunal.
Your Privacy Rights With Respect To PHI

Right to Request Restrictions on PHI Uses and You or your personal representative will be required to
Disclosures complete a form to request access to the PHI in your
designated record set. If access is denied, you or your
You may request the Plan to restrict uses and disclosures of
personal representative will be provided with a written
your PHI to carry out treatment, payment or health care
denial setting forth the basis for the denial, a statement of
operations, or to restrict uses and disclosures to family
your review rights, a description of how you may exercise
members, relatives, friends or other persons identified by you
those review rights and a description of how you may
who are involved in your care or payment for your care.
complain to HHS.
The Plan is required to comply with your request if:
Right to Amend
(1) the disclosure is to a health care plan for purposes of
carrying out payment or health care operations, and You have the right to request the Plan to amend your PHI
or a record about you in a designated record set for as long
(2) the PHI pertains solely to a health care item or service for as the PHI is maintained in the designated record set. If the
which the health care provider involved has already been paid request is denied in whole or part, the Plan must provide
in full. Otherwise, the Plan is not required to agree to your you with a written denial that explains the basis for the
request. The Plan will accommodate reasonable requests to denial. You or your personal representative may then
receive communications of PHI by alternative means or at submit a written statement disagreeing with the denial and
alternative locations. You or your personal representative will have that statement included with any future disclosures of
be required to complete a form to request restrictions on your PHI.
uses and disclosures of your PHI.
You or your personal representative will be required to
Right to Inspect and Copy PHI complete a form to request amendment of the PHI in your
You have a right to inspect and obtain a copy of your PHI designated record set. You must make requests for
contained in a “designated record set,” for as long as the amendments in writing and provide a reason to support
Plan maintains the PHI, other than psychotherapy notes your requested amendment.
and any information compiled in reasonable anticipation of Right to Receive an Accounting of PHI Disclosures
or for the use of civil, criminal, or administrative actions or
At your request, the Plan will also provide you with an
proceedings or PHI that is maintained by a covered entity
accounting of disclosures by the Plan of your PHI during the
that is a clinical laboratory. Psychotherapy notes are
six years prior to the date of your request. However, such
separately filed notes about your conversations with your
accounting need not include PHI disclosures made:
mental health professional during a counseling session.
Psychotherapy notes do not include summary information (1) to carry out treatment, payment or health care
about your mental health treatment. To the extent that the operations;
Plan uses or maintains an electronic health record, you (2) to individuals about their own PHI;
have a right to obtain a copy of your PHI from the Plan in (3) pursuant to a valid authorization;
an electronic format. In addition, you may direct the Plan (4) incident to a use or disclosure otherwise permitted or
to transmit a copy of your PHI in such electronic format required under the Privacy Regulations;
directly to an entity or person designated by the individual. (5) as part of a limited data set; or
A “designated record set” includes the medical records and (6) prior to the date the Privacy Regulations were effective
billing records about individuals maintained by or for a for the Plan on April 14, 2004. If you request more than one
covered health care provider; enrollment, payment, billing, accounting within a 12-month period, the Plan will charge a
claims adjudication and case or medical management reasonable, cost-based fee for each subsequent accounting.
record systems maintained by or for the Plan; or other Right to Receive Confidential Communications
information used in whole or in part by or for the Plan to You have the right to request to receive confidential
make decisions about individuals. Information used for communications of your PHI. This may be provided to you
quality control or peer review analyses and not used to by alternative means or at alternative locations if you
make decisions about individuals is not in the designated clearly state that the disclosure of all or part of the
record set. information could endanger you.
Right to Receive a Paper Copy of This Notice Upon Your Right to File a Complaint
Request You have the right to file a complaint with the Plan or HHS
To obtain a paper copy of this Notice, contact the Privacy if you believe that your privacy rights have been violated.
Official at the address and telephone number set forth in You may file a complaint with the Plan by filing a written
the Contact Information section below. notice with the Complaint Official, describing when you
believe the violation occurred, and what you believe the
A Note About Personal Representatives
violation was. You will not be retaliated against for filing a
You may exercise your rights through a personal complaint.
representative. Your personal representative will be
required to produce evidence of his or her authority to act Contact Information
on your behalf before that person will be given access to If you have any questions or complaints, please contact:
your PHI or allowed to take any action for you. Proof of
such authority may take one of the following forms: UHC
P.O.BOX 7401111, Atlanta,
• a power of attorney for health care purposes, GA, 30374-0111
notarized by a notary public; 1-877-844-0280
• a court order of appointment of the person as the
If you are concerned that we have violated your privacy
conservator or guardian of the individual; or
rights, or you disagree with a decision we made about
• an individual who is the parent of a minor child. access to your records, you may contact the person listed
The Plan retains discretion to deny access to your PHI to a above. You also may send a written complaint to the U.S.
personal representative to provide protection to those Department of Health and Human Services — Office of Civil
vulnerable people who depend on others to exercise their Rights. The person listed above can provide you with the
rights under these rules and who may be subject to abuse appropriate address upon request or you may visit
or neglect. This also applies to personal representatives of www.hhs.gov/ocr for further information.
minors. MEDICARE PART D- ELIGIBLE EMPLOYEES AND
The Plan’s Duties With Respect to Your PHI DEPENDENTS
The Plan has the following duties with respect to your PHI: Important Notice from Everise About Your Prescription
Drug Coverage and Medicare
The Plan is required by law to maintain the privacy of PHI
and provide individuals with notice of its legal duties and Please read this notice carefully and keep it where you
privacy practices with respect to the PHI. can find it. This notice has information about your current
prescription drug coverage with Everise and about your
The Plan is required to abide by the terms of the notice options under Medicare’s prescription drug coverage. This
that are currently in effect. information
The Plan reserves the right to make amendments or can help you decide whether or not you want to join a
changes to any and all of its privacy policies and practices Medicare drug plan. If you are considering joining, you
described in this Notice and to apply such changes to all should compare your current coverage, including which
PHI the Plan maintains. Any PHI that the Plan previously drugs are covered at what cost, with the coverage and costs
received or created will be subject to such revised policies of the plans offering Medicare prescription drug coverage in
and practices and the Plan may make the changes your area. Information about where you can get help to
applicable to all PHI it receives or maintains. Any revised make decisions about your prescription drug coverage is at
version of this Notice will be distributed within 60 days of the end of this notice.
the effective date of any material change to the uses or There are two important things you need to know about
disclosures, the individual’s rights, the duties of the Plan or your current coverage and Medicare’s prescription drug
other privacy practices stated in this Notice. 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.
2. All Medicare drug plans provide at least a standard level For example, if you go nineteen months without creditable
of coverage set by Medicare. Some plans may also offer coverage, your premium may consistently be at least 19%
more coverage for a higher monthly premium. has higher than the Medicare base beneficiary premium. You
determined that the prescription drug coverage offered by may have to pay this higher premium (a penalty) as long as
the Everise Medical Plan is, on average for all plan you have Medicare prescription drug coverage. In addition,
participants, expected to pay out as much as standard you may have to wait until the following October to join.
Medicare prescription drug coverage pays and is therefore
considered Creditable Coverage. Because your existing For More Information About This Notice Or Your
coverage is Creditable Coverage, you can keep this coverage Current Prescription Drug Coverage…
and not pay a higher premium (a penalty) if you later decide Contact the person listed below for further information.
to join a Medicare drug plan. NOTE: You’ll get this notice each year. You will also get it
When Can You Join A Medicare Drug Plan? before the next period you can join a Medicare drug plan,
and if this coverage through Everise changes. You also may
You can join a Medicare drug plan when you first become request a copy of this notice at any time.
eligible for Medicare and each year from October 15th to
December 7th. For More Information About Your Options Under
However, if you lose your current creditable prescription Medicare Prescription Drug Coverage…
drug coverage, through no fault of your own, you will also be More detailed information about Medicare plans that offer
eligible for a two (2) month Special Enrollment Period prescription drug coverage is in the “Medicare & You”
(SEP) to join a Medicare drug plan. handbook. You’ll get a copy of the handbook in the mail
What Happens To Your Current Coverage If You every year from Medicare. You may also be contacted
directly by Medicare drug plans.
Decide to Join A Medicare Drug Plan?
If you decide to join a Medicare drug plan, your current For more information about Medicare prescription drug
Everise coverage may be affected. Your current coverage coverage:
pays for other health expenses • Visit www.medicare.gov
in addition to prescription drugs. If you enroll in
a Medicare prescription drug plan, you and your eligible • Call your State Health Insurance Assistance Program (see
dependents will still be eligible to receive the inside back cover of your copy of the “Medicare &
all of your current health and prescription drug benefits. You” handbook for their telephone number) for
personalized help.
Special rules do apply when you are covered by this Plan and
by Medicare. Generally, this Plan • Call 1-800-MEDICARE (1-800-633-4227). TTY users
is a Primary Plan if you are an active Employee, should call 1-877-486-2048.
and Medicare is a Primary Plan if you are a retired Employee. If you have limited income and resources, extra help
If you do decide to join a Medicare drug plan and drop your paying for Medicare prescription drug coverage is available.
current Everise coverage, be aware that you and your For information about this extra help, visit Social Security on
dependents may not be able to get your Everise coverage the web at www.socialsecurity.gov, or call them at
back. 1-800-772-1213 (TTY 1-800-325-0778).
When Will You Pay A Higher Premium (Penalty) To Remember: Keep this Creditable Coverage notice. If you
Join A Medicare Drug Plan? decide to join one of the Medicare drug plans, you may
You should also know that if you drop or lose your current be required to provide a copy of this notice when you
coverage with Everise and don’t join a Medicare drug plan join to show whether or not you have maintained
within 63 continuous days after your current coverage ends, creditable coverage and, therefore, whether or not you
you may pay a higher premium (a penalty) to join a Medicare are required to pay a higher premium (a penalty).
drug plan later.
Date: January 1, 2021
If you go 63 continuous days or longer without creditable
prescription drug coverage, your monthly premium may go You can reach Paul Global Benefits via email:
up by at least 1% of the Medicare base beneficiary premium everisemembersupport@pgbdirect.com
per month for every month that you did not have that
coverage.

2022 Everise Executives Benefits Guide

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2022 Everise Executives Benefits Guide

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2022 Everise Benefit & Enrollment Guide

Executive Guide Everise 2022 Benefit & Enrollment Guide

2022 Everise Benefit & Enrollment Guide

2022 Employee Benefits

With Enrollment Support We Are Providing: Enrolling is simple.

Making The Most Of Your Benefits

UnitedHealthcare Medical Plans

UnitedHealthcare Medical Plans

UnitedHealthcare Choice Plus Buy Up

UnitedHealthcare Choice Plus Base Plan

UnitedHealthcare Medical Plans

UnitedHealthcare Choice Plus HSA Plan Plan

UnitedHealthcare Bronze HSA Plan

Hospital Indemnity Coverage for UHC Health Insurance Members

Hospital Indemnity Benefits Include:

Understanding How UHC Covers Prescriptions

Tier One Tier Two Tier Three

Tier One Tier Two Tier Three

Important Medical Coverage Information & Rules

Employee Assistance Program (EAP) for UHC Members Only

When life gets

It’s good to know you’re not alone.

UHC Member Telemedicine

Visit with a doctor

A convenient and faster way to get care

Get started Sign in at myuhc.com/virtualvisits | Call 1-855-615-8335

Frequently Asked Questions

Frequently Asked Questions

KBA Minimum Essential Coverage (MEC) Plan

MEC Member Telemedicine - First Stop Health

UnitedHealthcare Dental Options - Standard Plan

DENTAL INSURANCE - STANDARD PLAN NON-ORTHODONTICS ORTHODONTICS

UnitedHealthcare Dental Options - Buy Up Plan

UnitedHealthcare (UHC) Dental Plan Frequently Asked Questions

UnitedHealthcare Vision Beneﬁt Summary - Base

EXAM WITH MATERIALS

CHILDREN’S AND MATERNITY EYE CARE BENEFIT

OUT-OF-NETWORK REIMBURSEMENTS (Copays do not apply)

UnitedHealthcare Vision Beneﬁt Summary - Buy-Up Option

EXAM WITH MATERIALS

OUT-OF-NETWORK REIMBURSEMENTS (Copays do not apply)

Medical, Dental & Vision Bi-Weekly Rates

MEDICAL PLAN BUY-UP BASE HSA BRONZE MEC

Employee Only $136.62 $109.47 $60.46 $67.85 $11.54

Employee & Spouse $373.85 $323.83 $216.45 $440.61 $41.11

Employee & Child(ren) $285.23 $243.96 $158.99 $343.80 $35.69

Family $546.92 $446.34 $296.30 $630.03 $59.08

Employee Only $11.40 $10.42 $16.97

VISION PLAN TIER BASE PLAN BUY-UP PLAN

Employee Only $2.77 $3.92

Employee & Spouse $4.46 $6.31

Employee & Child(ren) $4.46 $6.31

Family $7.97 $11.28

Health Savings Accounts (HSA)

What counts as a qualiﬁed medical expense

Use your HSA to pay for

Invest your savings in

Flexible Spending Accounts (FSA)

Reimbursement for Incurred Expenses

Executive Basic Life and AD&D Insurance

Lincoln Financial Voluntary Life & ADD Rates

$125,000 not to exceed 50% of the

Monthy Cost of Coverage

Important Plan Information: