ALL EMPLOYEES MUST TAKE ACTION BEFORE NOVEMBER 30, 2016.

Enrollment in COOK employee health and life insurance benefits for 2017 begins November 1st. You must go online to www.mycookgroupbenefits.com to make your 2017 benefit plan elections. The deadline to enroll for your 2017 benefits is November 30, 2016. If you do not go online and submit your benefit choices by this deadline, you (and your dependents) will not have these benefits with COOK for 2017. As a reminder, you will need the social security numbers and birth dates for your dependents to complete the enrollment process unless you are not making any changes from the previous year. See the enclosed 2017 Online Benefit Enrollment Instructions for more details.

If you do not wish to enroll in benefits for 2017, you will need to decline benefits at www.mycookgroupbenefits.com.

COOK continually evaluates benefit plans and their costs to ensure the plan options are competitive and provide overall financial security and value for COOK employees and their family members. COOK is pleased to announce changes to the COOK Health Plan options and the addition of several new benefits for 2017.

CHANGES TO ALL COOK HEALTH PLAN OPTIONS (EFFECTIVE JANUARY 1, 2017)

Vision Plan - Exams and Eyeglass Lenses Covered Annually

The new enhanced COOK vision benefits allow you to use the Anthem Blue View provider network for discounts on vision products and services. You can also go to any vision provider and receive out-of-network benefits. See attached summary.

New Hearing Aid Benefit

The COOK Health Plan will pay $3,000 per person every five calendar years for hearing aid products and supplies. Eligible charges are applied to the medical deductible and covered at 80% in-network. See attached summary.

Screening CT Colonography

The CT Colonography has emerged as another screening tool for colon cancer in people who are at average risk for the disease. This new preventive service is covered by the COOK Health Plan in-network at 100% every 5 years for participants age 50 and over.

Dependent Care Flexible Spending Account (DCFSA)

Using a DCFSA is an excellent way to pay for dependent care expenses and lower your taxable income. You save by having money deducted from your pay pretax and deposited in a DCFSA to pay for eligible child care or elder care expenses. Reimbursements for these expenses from the DCFSA are tax free. See attached summary.

Limited Purpose Health Flexible Spending Account (LPHFSA) Option

For 2017, there will be two tax advantage HFSA options to choose from - the current General Purpose Health Flexible Spending Account (GPHFSA) and a new Limited Purpose Health Flexible Spending Account (LPHFSA). The LPHFSA is the option to elect if you have a spouse who is covered by a high deductible health plan and Health Savings Account (HSA) through their employer. Per IRS regulations, coverage in a GPHFSA is disqualifying coverage for a spouse to make or receive contributions to their HSA. The LPHFSA works just like the GPHFSA, but is limited to only reimbursing out-of-pocket dental and vision expenses and some preventive expenses. By limiting reimbursements to dental and vision expenses, your spouse remains eligible to participate in their employer’s HSA. See attached summary.

2017 EMPLOYEE BENEFITS OPEN ENROLLMENTNovember 1 – 30, 2016

CMI-Q30466-EN

HEALTH FLEXIBLE SPENDING ACCOUNT (HFSA)

Information for General Purpose and Limited Purpose HFSA OptionsYou may want to enroll in one of the HFSA options COOK is offering for 2017 and take advantage of the benefits listed below:

• A HFSA allows you to pay for out-of-pocket health care expenses including copayments, deductibles and coinsurance with pretax dollars and be reimbursed tax free.

• You have immediate access to your annual election on January 1, 2017.

• The annual HFSA maximum is $2,500.

• You are eligible to participate in a HFSA even if you are not enrolled in a COOK Health Plan option.

• You can only enroll in one HFSA option.

IMPORTANT: The last day (date of service) you can incur claims towards your 2017 GPHFSA or LPHFSA is December 31, 2017.However, you will have until March 31, 2018 to submit 2017 claims to the COOK Insurance Department for reimbursement. Funds remaining in a 2017 GPHFSA or LPHFSA after March 31, 2018 are forfeited.

Are You Making the Most of Your COOK Employee Benefits?Make certain to take full advantage of the benefits COOK offers because doing so can save you thousands of dollars in taxes. You get tax breaks on out-of-pocket health care expenses by contributing to a HFSA and now you can get additional tax breaks on day care and elder care expenses by contributing to a DCFSA. Don’t forget the tax breaks on the money you contribute to the COOK Profit Sharing 401k Plan. Make certain you are contributing at least 4% of your pay to the COOK Profit Sharing 401(k) Plan to maximize the 4% company match. All these benefits add up to significant tax savings over time.

New Health Plan ID CardYou will receive two new COOK Health Plan ID cards mailed to your home. In addition to the Anthem network information on the ID card, you will find contact and claim processing information for Delta Dental and TrueScripts.

2017 COOK Health Plan Employee Premiums

The partnerships with Anthem, TrueScripts, and Delta Dental have provided favorable discounts which have saved employees money and allowed COOK to only increase premiums by 4% even though projected increases in health care spending for the next year is 6%. COOK Health Plan employee premium rates include medical, dental, vision and prescription drug benefits. Employee premiums by pay period for 2016 and 2017 are shown in the tables below

Traditional & Clinic Plan Premiums

Weekly Bi-weekly Monthly

2016 2017 2016 2017 2016 2017

Employee Only $15.72 $16.35 $31.45 $32.71 $68.14 $70.87

Employee + Spouse $77.38 $80.47 $154.75 $160.94 $335.30 $348.71

Employee + Child(ren) $51.67 $53.73 $103.33 $107.47 $223.89 $232.85

Family $100.33 $104.34 $200.66 $208.69 $434.77 $452.16

Castlight: COOK’s Healthcare Shopping Tool

Castlight is a personalized healthcare shopping tool that allows you to shop for medical services based on cost, quality, and convenience. If you haven’t already registered with Castlight, you can register during open enrollment on the benefits enrollment system or you can register anytime by visiting Castlight’s website: www.mycastlight.com/cook. Castlight is provided free of charge to employees and their covered family members who are enrolled in the COOK Traditional or Clinic Plans that use the Anthem Blue Card PPO network.

ADDITIONAL INFORMATION

Anthem Employee Assistance Program

This is a reminder that the Anthem Employee Assistance Program is available to COOK employees and family members who need help meeting the demands and stresses of everyday life. Enrollment in the EAP or COOK Health Plan is not required. To talk with an EAP staff member 24/7 just call 1.800.865.1044 or visit www.anthemEAP.com and enter “COOK”.

Update Your Life Insurance and Profit Sharing Plan Beneficiaries

Remember to update your life insurance beneficiary with Prudential by logging on to Prudential’s website at www.prudential.com/mybenefits. You will need the COOK company control number, which is 50318. You can update your life insurance beneficiary at any time (not just during open enrollment) on the website.

You can update your COOK Profit Sharing 401(k) Plan beneficiary by logging on to Fidelity’s website at www.401k.com. Click on “Profile” and then click on “Beneficiary” to access the beneficiary update screen. You can also call Fidelity at 1.800.835.5091 and request a beneficiary designation form to complete and send back to Fidelity

COOK Group Long Term Care Insurance Program

COOK offers voluntary long term care insurance to full-time employees and to the employees’ spouses, parents, grandparents and children. Employees and eligible family members can apply at any time, not just during open enrollment. Contact Genworth at 1.800.416.3624 or visit www.genworth.com/groupltc for more information or to enroll. If visiting the website use Group ID “Cook” and Access Code “groupltc.” If you are already enrolled in long term care insurance you do not need to enroll again.

Benefits Fair

If you have questions about your employee benefits, representatives from Anthem, Castlight, Prudential, Fidelity, Delta Dental, and COOK Insurance Department will be at various COOK locations during open enrollment to provide assistance. Raymond Evans in COOK Medical’s Human Resources Department will be available at several locations to help you with questions about Castlight, Medicare, Medicaid, Social Security and other government health insurance programs. Employees who have questions and do not get the opportunity to meet with a representative should contact the COOK Insurance Department at 1.800.593.2080 or COOK Group Benefits Coordinator at 1.800.468.1379, ext. 102356 for assistance.

Your local human resources department will provide the dates and times the representatives will be at various COOK locations. Please contact your local human resources department or the contacts listed below if you have any questions concerning your 2017 employee benefit options or the online enrollment process.

For assistance contact:

Local Human Resources Department

COOK Insurance Department – 1.800.593.2080

COOK Group Benefits Coordinator (Jed Ehret) – 1.800.468.1379, ext. 102356

COOK Member Engagement Specialist (Raymond Evans) – 1.800.468.1379, ext. 102847

Attachments:

Vision Plan Summary

Hearing Aid Benefits Summary

Dependent Care Flexible Spending Account Summary

Dependent Care Flexible Spending Account FAQ

Limited Purpose Health Flexible Spending Account Summary

2017 COOK Health Plan Summary of Benefits and Coverage

2017 Online Enrollment Instructions

Women’s Cancer Rights Notice

Medicare Prescription Drug Notice

Medicaid Children’s Health Insurance Notice

Notice of Privacy Practices

Your Blue View Vision network

Blue View Vision offers you one of the largest vision care networks in the industry, with a wide selection of experienced ophthalmologists, optometrists, and opticians. Blue View Vision’s network also includes convenient retail locations, many with evening and weekend hours, including 1-800-CONTACTS, LensCrafters®, Sears OpticalSM, Target Optical®, JCPenney® Optical and most Pearle Vision® locations. Best of all – when you receive care from a Blue View Vision participating provider, you can maximize your benefits and money-saving discounts.

Out-of-network: If you choose to, you may receive covered benefits outside of the Blue View Vision network. Just pay in full at the time of service, obtain an itemized receipt, and file a claim for reimbursement of your out-of-network allowance. In-network benefits and discounts will not apply.

YOUR BLUE VIEW VISION PLAN AT-A-GLANCE

VISION PLAN BENEFIT IN-NETWORK OUT-OF-NETWORK

Routine eye exam Once every calendar year. • $0 copay, then covered in full • $42 allowance

Eyeglass framesOnce every two calendar years you may select an eyeglass frame and receive an allowance toward the purchase price.

• $200 allowance, then 20% off any remaining balance • $42 allowance

Eyeglass lenses (Standard)Once every calendar year you may receive any one of the following lens options:

• Standard plastic single vision lenses (1 pair)

• Standard plastic bifocal lenses (1 pair)

• Standard plastic trifocal lenses (1 pair)

• $0 copay, then covered in full

• $0 copay, then covered in full

• $0 copay, then covered in full

• $40 allowance

• $60 allowance

• $80 allowance

Eyeglass lens enhancementsWhen obtaining covered eyewear from a Blue View Vision provider, you may add any of the following lens enhancements at no extra cost.

• Transitions Lenses (for a child under age 19)

• Standard Polycarbonate (for a child under age 19)

• Factory Scratch Coating

• $0 after eyeglass lens copay

• $0 after eyeglass lens copay

• $0 after eyeglass lens copay

No allowance on lens enhancements when obtained out-of-network

Contact lensesOnce every calendar year. Prefer contact lenses over glasses? You may choose contact lenses instead of eyeglass lenses and receive an allowance toward the cost of a supply of contact lenses.

• Elective Conventional Lenses; or

• Elective Disposable Lenses; or

• Non-Elective Contact Lenses

• $105 allowance

• $105 allowance

• $210 allowance

• $200 allowance, then 15% off any remaining balance

• $200 allowance (no additional discount)

• Covered in fullYour contact lens allowance can only be applied toward the first purchase of contacts you make during a benefit period. Any unused amount remaining cannot be used for subsequent purchases made during the same benefit period, nor can any unused amount be carried over to the following benefit period.

EXCLUSIONS & LIMITATIONS (not a complete list)

Combined Offers. Not combined with any offer, coupon, or in-store advertisement.

Excess Amounts. Amounts in excess of covered vision expense.

Sunglasses. Sunglasses and accompanying frames.

Safety Glasses. Safety glasses and accompanying frames.

Not Specifically Listed. Services not specifically listed in this plan as covered services.

Lost or Broken Lenses or Frames. Any lost or broken lenses or frames are not eligible for replacement unless the insured person has reached his or her normal service interval as indicated in the plan design.

Non-Prescription Lenses. Any non-prescription lenses, eyeglasses or contacts. Plano lenses or lenses that have no refractive power.

Orthoptics. Orthoptics or vision training and any associated supplemental testing.

VISION PLAN SUMMARY

OPTIONAL SAVINGS AVAILABLE FROM IN-NETWORK PROVIDERS ONLYIN-NETWORK MEMBER COST

(AFTER ANY APPLICABLE COPAY)

Retinal Imaging - at member’s option can be performed at time of eye exam Not more than $39

Eyeglass lens upgradesWhen obtaining eyewear from a Blue View Vision provider, you may choose to upgrade your new eyeglass lenses at a discounted cost. Eyeglass lens copayment applies.

• Transitions lenses (Adults)

• Standard Polycarbonate (Adults)

• Tint (Solid and Gradient)

• UV Coating

• Progressive Lenses1

• Standard

• Premium Tier 1

• Premium Tier 2

• Premium Tier 3

• Anti-Reflective Coating2

• Standard

• Premium Tier 1

• Premium Tier 2

• Other Add-ons and Services

$75

$40

$15

$15

$65

$85

$95

$110

$45

$57

$68

20% off retail price

Additional Pairs of EyeglassesAnytime from any Blue View Vision network provider

• Complete pair

• Eyeglass materials purchased separately

40% off retail price

20% off retail price

Eyewear Accessories • Items such as non-prescription sunglasses, lens cleaning supplies, contact lens solutions, eyeglass cases, etc.

20% off retail price

Contact lens fit and follow-upA contact lens fitting and up to two follow-up visits are available to you once a comprehensive eye exam has been completed.

• Standard contact lens fitting3

• Premium contact lens fitting4

Up to $55

10% off retail price

Conventional Contact Lenses • Discount applies to materials only 15% off retail price

Laser vision correction surgery

LASIK refractive surgery

• Discount per eye For more information, go to anthem.com/specialoffers and select vision care.

Members can take advantage of savings opportunities from dozens of vendors on a variety of products and services, including LASIK vision surgery, hearing services and aids, wellness products, weight loss programs, fitness memberships, elder care services, 1-800-Contacts* and much more.1 Please ask your provider for his/her recommendation as well as the progressive brands by tier.2 Please ask your provider for his/her recommendation as well as the coating brands by tier.3 A standard contact lens fitting includes spherical clear contact lenses for conventional wear and planned replacement. Examples include but

are not limited to disposable and frequent replacement. 4 A premium contact lens fitting includes all lens designs, materials and specialty fittings other than standard contact lenses. Examples include

but are not limited to toric and multifocal.

OUT-OF-NETWORK

If you choose an out-of-network provider, please complete an out-of-network claim form available in your local HR department or on the www.cookmedicalclaims.com website submit it along with your itemized receipt to the fax number, email address, or mailing address below. When visiting an out-of-network provider, discounts do not apply and you are responsible for payment of services and/or eyewear materials at the time of service.

To Fax: 866-293-7373To Email: oonclaims@eyewearspecialoffers.comTo Mail: Blue View Vision

Attn: OON ClaimsP.O. Box 8504 Mason, OH 45040-7111

Blue View Vision is for routine eye care only. If you need medical treatment for your eyes, visit a participating eye care physician from your medical network. If you have questions about your benefits or need help finding a provider, visit anthem.com or call us at 1-866-723-0515.

This is a primary vision care benefit intended to cover only routine eye examinations and corrective eyewear. Benefits are payable only for expenses incurred while the group and insured person’s coverage is in force.

This information is intended to be a brief outline of coverage. All terms and conditions of coverage, including benefits and exclusions, are contained in the plan document, which shall control in the event of a conflict with this overview. Discounts referenced are not covered benefits under this vision plan and therefore are not included in the plan document. Frame discounts may not apply to some frames where the manufacturer has imposed a no discount policy on sales at retail and independent provider locations. Discounts are subject to change without notice. This benefit overview is only one piece of your entire enrollment package.

Transitions and the swirl are registered trademarks of Transitions Optical, Inc. Photochromic performance is influenced by temperature, UV exposure and lens material. Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Ohio: Community Insurance Company. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are the registered marks of the Blue Cross and Blue Shield Association. 7/12

OPTIONAL SAVINGS AVAILABLE FROM IN-NETWORK PROVIDERS ONLY In-network Member Cost (after any applicable copay)

Retinal Imaging - at member’s option can be performed at time of eye exam Not more than $39 Eyeglass lens upgrades

When obtaining eyewear from a Blue View Vision provider, you may choose to upgrade your new eyeglass lenses at a discounted cost. Eyeglass lens copayment applies.

£   lenses (Adults) £   Standard Polycarbonate (Adults) £   Tint (Solid and Gradient) £   UV Coating £   Progressive Lenses1

£   Standard £   Premium Tier 1 £   Premium Tier 2 £   Premium Tier 3

£   Anti-Reflective Coating2 £   Standard £   Premium Tier 1 £   Premium Tier 2

£   Other Add-ons and Services

$75 $40 $15 $15

$65 $85 $95

$110

$45 $57 $68

20% off retail price

Additional Pairs of Eyeglasses Anytime from any Blue View Vision network provider

£   Complete Pair £   Eyeglass materials purchased separately

40% off retail price 20% off retail price

Eyewear Accessories £   Items such as non-prescription sunglasses, lens cleaning supplies, contact lens solutions, eyeglass cases, etc.

20% off retail price

Contact lens fit and follow-up A contact lens fitting and up to two follow-up visits are available to you once a comprehensive eye exam has been completed.

£   Standard contact lens fitting3 £   Premium contact lens fitting4

Up to $55

10% off retail price

Conventional Contact Lenses £   Discount applies to materials only 15% off retail price

Laser vision correction surgery LASIK refractive surgery

£   Discount per eye

For more information, go to anthem.com/specialoffers

and select vision care. Members can take advantage of savings opportunities from dozens of vendors on a variety of products and services, including LASIK vision surgery, hearing services and aids, wellness products, weight loss programs, fitness memberships, elder care services, *and much more.

1 Please ask your provider for his/her recommendation as well as the progressive brands by tier. 2 Please ask your provider for his/her recommendation as well as the coating brands by tier.

3 A standard contact lens fitting includes spherical clear contact lenses for conventional wear and planned replacement. Examples include but are not limited to disposable and frequent replacement. 4 A premium contact lens fitting includes all lens designs, materials and specialty fittings other than standard contact lenses. Examples include but are not limited to toric and multifocal.

OUT-OF-NETWORK If you choose an out-of-network provider, please complete an out-of-network claim form available in your local HR department or on the www.cookmedicalclaims.com website submit it along with your itemized receipt to the fax number, email address, or mailing address below. When visiting an out-of-network provider, discounts do not apply and you are responsible for payment of services and/or eyewear materials at the time of service.

To Fax: 866-293-7373 To Email: oonclaims@eyewearspecialoffers.com To Mail: Blue View Vision

Attn: OON Claims P.O. Box 8504 Mason, OH 45040-7111

Blue View Vision is for routine eye care only. If you need medical treatment for your eyes, visit a participating eye care physician from your medical network. If you have questions about your benefits or need help finding a provider, visit anthem.com or call us at 1-866-723-0515. This is a primary vision care benefit intended to cover only routine eye examinations and corrective eyewear. Benefits are payable only for expenses incurred while the group and insured person’s coverage is in force. This information is intended to be a brief outline of coverage. All terms and conditions of coverage, including benefits and exclusions, are contained in the plan document, which shall control in the event of a conflict with this overview. Discounts referenced are not covered benefits under this vision plan and therefore are not included in the plan document. Frame discounts may not apply to some frames where the manufacturer has imposed a no discount policy on sales at retail and independent provider locations. Discounts are subject to change without notice. This benefit overview is only one piece of your entire enrollment package.

Effective January 1, 2017

This benefit covers medically necessary hearing aids when ordered or purchased as a result of a written recommendation from an otolaryngologist or state certified audiologist.

What is Covered?

• Hearing aids (monaural or binaural) including ear mold(s).

• Hearing aid instrument, batteries, cords and other ancillary equipment.

What is NOT Covered?

• Charges for a hearing aid which exceeds specifications prescribed for the correction of the hearing loss.

• Surgically implanted hearing devices (i.e. cochlear implants, audient bone conduction devices). Medically necessary surgically implanted hearing devices may be covered under the COOK Health Plan’s medical benefits for prosthetic devices.

• Charges for a hearing aid which is not medically necessary

Hearing Aid Benefits

• The COOK Health Plan pays a maximum of $3,000 per person every 5 years for hearing aids and supplies.

• Network Benefits - Plan pays 80% after medical plan deductible. Charges apply to the annual out-of-pocket maximum. For network benefits you must use Blue Cross Blue Shield National Blue Card PPO network providers. Employees in Pennsylvania must use the FirstHealth providers for network benefits.

• Out-of-Network Benefits - Plan pays 60% after medical plan deductible. Charges do not apply to annual out-of-pocket maximum. Use any qualified provider.

This Summary of Benefits is a brief overview. Refer to you Cook Health Plan booklet for more details.

COOK HEALTH PLAN HEARING AID BENEFIT SUMMARY

Effective January 1, 2017

A DCFSA is a great way to pay dependent care expenses and lower your taxable income. It can be used to pay a child’s day care expenses or to pay custodial expenses for a disabled spouse or grandparent. The expenses must be incurred so you (and your spouse) can work. If you have a stay at home spouse, you should not enroll in a DCFSA.

How Does the DCFSA Work?

• Elect your DCFSA during open enrollment or during new hire open enrollment period.

• Contribute up to $5,000 maximum per year per family if your tax filing status is “married and filing jointly” and $2,500 maximum per year if tax filing is “married and filing single.” Minimum contribution amount is $100.

• Contributions are pre-tax; reimbursements are tax free.

• No advanced funding. You can only be reimbursed for funds in your DCFSA at the time you claim them.

• Reimbursements are processed on the Monday following each of your regular pay periods.

• Debit card and direct deposit available.

• “Use it or lose it.” Your DCFSA must be used for services incurred on or before December 31 of plan year. Funds remaining in your DCFSA after March 31 of the following plan year will be forfeited.

• Changes to a DCFSA election amount allowed outside of open enrollment with qualified IRS status change. The change must be consistent with the event.

• COOK Insurance Department processes your claims.

Qualifying Dependents

• A tax dependent of yours who is under age 13.

• A tax dependent of yours, such as a spouse or elderly parent, who is physically or mentally incapable of self-care and has the same principal residence as you.

Examples of Eligible DCFSA Expenses

• Before and after school care.

• Baby sitter in your home or outside your home. Provider cannot be an IRS tax dependent.

• Summer day camp for child.

• Expenses for licensed day care, preschool, and nursery school.

• Elder day care expenses.

Examples of Ineligible Expenses

• Payments to a spouse or to a person you or your spouse can claim as a dependent on IRS tax filings.

• Day care for child age 13 or older.

• Education fees/tuition/enrichment classes/summer school/overnight camps.

• Nursing home/long term care expenses.

• Meals, supplies, transportation costs.

This Summary of Benefits is a brief overview. Refer to you Cook Health Plan booklet for more details.

DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (DCFSA)

What is a DCSA?

A DCFSA creates a tax break for dependent child care or day care expenses for children under age 13 or for children of any age who require custodial care because they are physically or mentally incapable of self-care. Additionally, it can be used for custodial day care for a disabled spouse or elderly parents who are considered an Internal Revenue Service (IRS) tax dependent and require someone to come into the home to assist with day-to-day living.

How do I save money on day care expenses?

You direct a portion of your pay into an account every regular pay period to pay for dependent care expenses. The money that you direct into a DCFSA is before taxes and reimbursements from the account are not taxed. You can use this account throughout the calendar year to pay dependent care expenses so you and, if married, your spouse can work. If you have a stay-at-home spouse you should not enroll in a DCFSA.

How do I enroll in a DCFSA?

You can enroll in a DCFSA during COOK’S annual open enrollment period. You cannot change your DCFSA election amount outside of open enrollment without experiencing a qualified IRS status change such as loss of a job or birth of a child. You can also enroll outside of open enrollment if you experience a qualified IRS status change.

Can my DCFSA contribution amount be changed?

You cannot change your DCFSA contribution amount outside of open enrollment without a qualified IRS status change.

How do I decide how much money to contribute to a DCFSA?

Estimate your day care expenses for the entire calendar year and take into consideration any school holidays, breaks or summer vacations. Before and after school expenses are allowable as well as some summer day camps. The maximum annual deduction is $5,000 per family if tax filing status is “married and filing jointly” and $2,500 if tax filing status is “married and filing separately.” The minimum contribution is $100.

What happens to unused funds in my DCFSA after the end of the year?

“Use it or lose it.” All funds in your DCFSA must be used for services incurred on or before December 31st of the plan year. You have until March 31st of the following plan year to submit claims for reimbursement from the prior year. Funds left in your account after March 31st of the following plan year are forfeited.

What happens if I stop working at COOK?

Your DCFSA contributions will stop. Expenses for dependent care expenses incurred after your termination date are not eligible for reimbursement. You have 60 days from your termination date to submit claims for services incurred on or before your termination date with COOK. Funds remaining in your account after 60 days will be forfeited.

If my spouse has a DCFSA, can we both contribute $5,000 each?

No. Your combined maximum contribution per family per calendar year is $5,000 or $2,500 for each account.

If I pay my 16-year old daughter to watch my 8-year old son after school, can I be reimbursed for payments made to my daughter?

No. You cannot be reimbursed for paying an older sibling that you (or your spouse) can claim as a dependent on your IRS tax filing. You also cannot be reimbursed for payments made to a child who is younger than age 19 at the end of the plan year.

If I have a DCFSA, do I need to report anything on my tax return at the end of the year?

Yes. You must list all people or organizations that provided care to your child or elderly dependent. You do this by filing Form 2441 – Child and Dependent Care Expenses along with Form 1040 (or Schedule 2 for Form 1040A).

If I have a DCFSA, can I claim the dependent care credit on my tax return?

No. You cannot claim any other tax benefit for the tax-free money you get under this DCFSA. Talk with your tax advisor for more details.

If I put $400 each month in my DCFSA and my actual expenses are $500 per month, should I submit a claim for $400 or  500?

You should submit a claim for the actual expense amount which is $500. If you have $500 in you DCFSA, you will be reimbursed for that amount. If not, the rest will be put on hold and reimbursed on the next reimbursement cycle when funds are in your account.

DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (DCFSA) FREQUENTLY ASKED QUESTIONS

Can I pay for dependent care expenses with a debit card?

The DCFSA comes with a debit card for you to use to pay for dependent care expenses. You can only swipe the debit card for the amount that is in your account at that time; otherwise, the entire transaction will be declined.

How can I keep track of my DCFSA activity?

Your account information can be viewed anytime by logging on to www.cookmedicalclaims.com.

You can view your current balance, claim status, and reimbursement history. You can also contact the COOK Insurance Department at 800.593.2080 for this information. You will need your COOK Health Plan ID number to log on to the www.cookmedicalclaims.com website.

How do I file a dependent care claim?

Claims for reimbursement can be filed manually. You pay for the dependent care services and send in the receipt along with a Dependent Care Claim Form to the COOK Insurance Department. Your child’s day care or elder care provider’s current Tax ID or SSN will also be required. Claims forms are available in your local HR office or on www.cookmedicalclaims.com website.

When are dependent care claims reimbursed?

Your reimbursement will be processed on the Monday following each of your payroll contributions until the end of the year. Reimbursement checks will be mailed to your home unless you have signed up for direct deposit.

How can I be reimbursed for re-incurring dependent care expenses?

COOK offers a time-saving re-incurring Dependent Care Claim Form that can be found online at www.cookmedicalclaims.com. This form saves you time as it only needs to be completed once at the beginning of each new plan year. No further dependent care claim submissions will be required by you for that plan year. Please keep in mind that you must submit a new claim form each plan year. The form must be signed and dated by your day care provider. Your child’s day care provider’s current Tax ID or SSN will also be required.

Is direct deposit an option?

Yes. To receive the reimbursement faster, send along a Direct Deposit Enrollment Form which can also be found online at www.cookmedicalclaims.com or in your local human resources office. Your reimbursement will be deposited in your bank account the next business day after Monday’s weekly check cycle following your DCHFSA payroll contribution.

DCFSA TAX SAVINGS EXAMPLES:

A DCFSA offers a better way to manage dependent care expenses and realize more tax savings. Your actual savings is based upon several factors including income, IRS filing status, tax bracket, the amount of income taxes you pay, and yearly dependent care expenses.

IRS 2016 Tax Tables 15% Tax Bracket

Example 1: Single with 2 children With DCFSA Without DCF

Taxable Income before DCFSA ContributionDCFSA Pre-Tax Contributions from PayrollTaxable IncomeEstimated Federal/State/County WithholdingEstimated Social Security Tax -7.65%Dependent Care ExpensesTax Credit for Dependent Care ExpensesTake Home PayTax Savings

$40,000($2,500)$37,500($6,809)($2,869)($2,500) —

$27,822$126

$40,000 —$40,000($7,294)($3,060) —$550

$27,696

Example 2: Married with 2 children With DCFSA Without DCF

Taxable Income before DCFSA ContributionDCFSA Pre-Tax Contributions from PayrollTaxable IncomeEstimated Federal/State/County WithholdingEstimated Social Security Tax -7.65%Dependent Care ExpensesTax Credit for Dependent Care ExpensesTake Home PayTax Savings

$40,000($5,000)$35,000($5,861)($2,678) — —

$26,462$252

$40,000 —$40,000($6,831)($3,060)($5,000)$1,100

$26,210

Effective January 1, 2017

What is a LPHFSA?

The new LPHFSA option works like the current General Purpose HFSA, but tax free reimbursements are limited to out-of-pocket dental and vison care expenses and some preventive care expenses. It cannot be used for the reimbursement of out-of-pocket medical expenses.

Why Would I Choose the LPHFSA?

The LPHFSA gives an employee who has a spouse covered by a Health Savings Account (HSA) through their employer a HFSA option. According to Internal Revenue Service Regulations, a person covered by a General Purpose HFSA is not eligible to participate in a HSA, but can enroll in a LPHFSA.

How Does it Work?

• Contribute up to $2,500 per calendar year into a LPHFSA to pay for eligible out-of-pocket dental and vision expenses. Cannot use for medical expenses.

• Elect your LPHFSA during open enrollment.

• Contributions are pretax.

• Reimbursements are tax free.

• Cook Insurance Dept. processes your claims.

• Debit card and direct deposit available.

• Use it or lose it – LPHFSA must be used for services incurred on or before December 31 of the plan year. Funds remaining in your LPHFSA after March 31 of the following calendar year are forfeited.

• Changes to a LPHFSA election amount allowed outside of open enrollment with qualified IRS status change.

Examples of Eligible Expenses

• Eligible out of pocket dental expenses for cleanings, x-rays, filings, crowns, orthodontia, dentures, and eligible dental expenses that exceed plan maximums.

• Eligible out-of-pocket vision expenses for exams, screening tests, eyeglasses, contact lenses, LASIK surgery and eligible vision expenses that exceed plan maximums.

Examples of Ineligible LPHFSA Expenses

• Medical expenses including deductibles, copays, and coinsurance

• Health plan premiums

• Cosmetic medical and dental procedures

• Over the counter medicines

This Summary of Benefits is a brief overview. Refer to your Cafeteria Plan booklet for more details.

LIMITED PURPOSE HEALTH FLEXIBLE SPENDING ACCOUNT (LPHFSA)

       1  of  8

 

Coo

k  Medical    

   

Coo

k  Group

 Health

 Plan:  Clinic  Plan  (CP)  Option                                                                                            Period:  01/01/2017  –  12/31/2017  

Summary  of  Benefits  and

 Coverage:  What  this  Plan  Covers  &  What  it  Costs  

Coverage  for:  Employee  &  Child(ren),  Family|  P

lan  Type:  P

PO  

Que

stio

ns: C

all 1

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.593

.208

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w.c

ookm

edic

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ut a

ny o

f the

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erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

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ary.

You

can

vie

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all 1

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est a

cop

y.

Thi

s is

onl

y a

sum

mar

y. If

you

wan

t mor

e de

tail

abou

t you

r cov

erag

e an

d co

sts,

you

can

get t

he c

ompl

ete

term

s in

the

polic

y or

pla

n do

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ent a

t w

ww

.coo

kmed

ical

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ms.

com

or b

y ca

lling

1-8

00-5

93-2

080.

Impo

rtan

t Que

stio

ns

Ans

wer

s

Wha

t is

the

over

all

dedu

ctib

le?

$500

per

indi

vidu

al a

nd $

1,00

0 pe

r fam

ily fo

r in-

netw

ork

serv

ices

. S

epar

ate

dedu

ctib

les (

$500

per

in

divi

dual

and

$1,

000

per f

amily

) fo

r out

-of-

netw

ork

serv

ices

. No

mor

e th

an $

500

per p

erso

n co

unts

tow

ards

the

fam

ily

dedu

ctib

le. I

n-ne

twor

k pr

even

tive

care

, clin

ic la

b w

ork,

den

tal a

nd

visio

n ca

re, a

nd p

resc

riptio

n dr

ugs

are

not s

ubje

ct to

thes

e de

duct

ible

s. D

enta

l and

visi

on

care

, pre

scrip

tion

drug

s, co

paym

ents

, sec

ond

or th

ird

surg

ical

opi

nion

s , an

d no

n-co

vere

d se

rvic

es c

anno

t be

used

to

satis

fy th

e de

duct

ible

s.

You

mus

t pay

all

the

cost

s up

to th

e de

duct

ible

am

ount

bef

ore

this

plan

beg

ins t

o pa

y fo

r cov

ered

se

rvic

es y

ou u

se. T

he d

educ

tible

star

ts o

ver J

anua

ry 1

of e

ach

year

. See

the

char

t sta

rting

on

page

3

for h

ow m

uch

you

pay

for c

over

ed se

rvic

es a

fter y

ou m

eet t

he d

educ

tible

.

Are

ther

e ot

her

dedu

ctib

les

for s

peci

fic

serv

ices

?

Yes

. The

re is

a $

300

fam

ily

dedu

ctib

le fo

r pre

scrip

tion

drug

ex

pens

es.

Ther

e ar

e no

oth

er

spec

ific

dedu

ctib

les.

You

mus

t pay

all

the

cost

s for

the

serv

ices

up

to th

e sp

ecifi

c de

duct

ible

am

ount

bef

ore

this

plan

be

gins

to p

ay fo

r the

serv

ices

.

Is th

ere

an o

ut-o

f-po

cket

lim

it on

my

expe

nses

?

Yes

. For

net

wor

k pr

ovid

ers,

ther

e is

an o

ut-o

f-po

cket

lim

it of

$2,

000

per i

ndiv

idua

l and

$4,

000

per

fam

ily. T

here

is n

o lim

it fo

r out

-of

-net

wor

k pr

ovid

ers.

The

out-o

f-po

cket

lim

it is

the

mos

t you

cou

ld p

ay d

urin

g a

cale

ndar

yea

r for

you

r sha

re o

f the

cos

ts

of c

over

ed se

rvic

es. T

his l

imit

help

s you

pla

n fo

r hea

lth c

are

expe

nses

. The

re's

no li

mit

on h

ow

muc

h yo

u ca

n pa

y du

ring

a ca

lend

ar y

ear f

or y

our s

hare

of t

he c

ost o

f out

-of-

netw

ork

cove

red

serv

ices

.

       2  of  8

 

Coo

k  Medical    

   

Coo

k  Group

 Health

 Plan:  Clinic  Plan  (CP)  Option                                                                                            Period:  01/01/2017  –  12/31/2017  

Summary  of  Benefits  and

 Coverage:  What  this  Plan  Covers  &  What  it  Costs  

Coverage  for:  Employee  &  Child(ren),  Family|  P

lan  Type:  P

PO  

Que

stio

ns: C

all 1

.800

.593

.208

0 or

visi

t us a

t ww

w.c

ookm

edic

alcl

aim

s.co

m.

 If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

vie

w th

e G

loss

ary

at w

ww

.coo

kmed

ical

clai

ms.

com

or c

all 1

.800

.593

.208

0 to

requ

est a

cop

y.

Wha

t is

not i

nclu

ded

in

the

out-

of-p

ocke

t lim

it?

Prem

ium

s, ba

lanc

e bi

lled

char

ges

(unl

ess b

alan

ce b

illin

g is

proh

ibite

d ), h

ealth

car

e th

is pl

an

does

n't c

over

, adu

lt de

ntal

, visi

on,

fam

ily p

lann

ing,

out

-of-

netw

ork

char

ges,

amou

nts r

eim

burs

ed

unde

r the

pre

scrip

tion

drug

sp

ecia

lty c

are

prog

ram

, and

pe

nalti

es fo

r fai

lure

to o

btai

n pr

eaut

horiz

atio

n .

Eve

n th

ough

you

pay

thes

e ex

pens

es, t

hey

do n

ot c

ount

tow

ard

the

out-o

f-po

cket

lim

it.

Is

ther

e an

ove

rall

annu

al

limit

on w

hat t

he p

lan

pays

?

No.

Th

e ch

art s

tarti

ng o

n pa

ge 3

des

crib

es a

ny li

mits

on

wha

t the

pla

n w

ill p

ay fo

r spe

cific

cove

red

serv

ices

, suc

h as

off

ice

visit

s.

Doe

s th

is p

lan

use

a ne

twor

k of

pro

vide

rs?

Yes

. See

ww

w.an

them

.com

or c

all

Ant

hem

’s Pr

ovid

er L

ocat

or

tele

phon

e nu

mbe

r 1.

800.

810.

2583

. You

can

also

cal

l C

ook

Insu

ranc

e D

ept.

1-80

0-59

3-20

80 fo

r ass

istan

ce fi

ndin

g ne

twor

k pr

ovid

ers.

If y

ou u

se a

net

wor

k do

ctor

or o

ther

hea

lth c

are

prov

ider

, thi

s pla

n w

ill p

ay so

me

or a

ll of

the

cost

s of

cov

ered

serv

ices

. Be

awar

e, y

our n

etw

ork

doct

or o

r hos

pita

l may

use

an

out-o

f-ne

twor

k pr

ovid

er

for s

ome

serv

ices

. Pla

ns u

se th

e te

rms “

netw

ork,

” “p

refe

rred

,” o

r “pa

rtici

patin

g” fo

r pro

vide

rs in

th

eir n

etw

ork.

See

the

char

t sta

rting

on

page

3 fo

r how

this

plan

pay

s diff

eren

t kin

ds o

f pro

vide

rs.

Do

I ne

ed a

refe

rral

to s

ee

a sp

ecia

list?

N

o.

You

can

see

the

spec

ialis

t you

cho

ose

with

out p

erm

issio

n fr

om th

is pl

an.

Are

ther

e se

rvic

es th

is

plan

doe

sn’t

cove

r?

Yes

. T h

e se

rvic

es th

is pl

an d

oesn

't co

ver a

re li

sted

on

page

5. S

ee y

our b

enef

its b

ookl

et o

r pla

n m

anua

l fo

r add

ition

al in

form

atio

n ab

out e

xclu

ded

serv

ices

.

OM

B Co

ntro

l Num

bers

154

5-22

29,

1210

-014

7, a

nd 0

938-

1146

Rele

ased

on

Apr

il 23

, 201

3 (c

orre

cted

)

       3  of  8

 

Coo

k  Medical    

   

Coo

k  Group

 Health

 Plan:  Clinic  Plan  (CP)  Option                                                                                            Period:  01/01/2017  –  12/31/2017  

Summary  of  Benefits  and

 Coverage:  What  this  Plan  Covers  &  What  it  Costs  

Coverage  for:  Employee  &  Child(ren),  Family|  P

lan  Type:  P

PO  

Que

stio

ns: C

all 1

.800

.593

.208

0 or

visi

t us a

t ww

w.c

ookm

edic

alcl

aim

s.co

m.

 If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

vie

w th

e G

loss

ary

at w

ww

.coo

kmed

ical

clai

ms.

com

or c

all 1

.800

.593

.208

0 to

requ

est a

cop

y.

•  C

opay

men

ts a

re fi

xed

dolla

r am

ount

s (fo

r exa

mpl

e, $

15) y

ou p

ay fo

r cov

ered

hea

lth c

are,

usu

ally

whe

n yo

u re

ceiv

e th

e se

rvic

e. •  

Coi

nsur

ance

is yo

ur sh

are

of th

e co

sts o

f a c

over

ed se

rvic

e, c

alcu

late

d as

a p

erce

nt o

f the

allo

wed

am

ount

for t

he se

rvic

e. F

or e

xam

ple,

if th

e pl

an’s

allo

wed

am

ount

for a

n ov

erni

ght h

ospi

tal s

tay

is $1

,000

, you

r coi

nsur

ance

pay

men

t of 2

0% w

ould

be

$200

. Th

is m

ay c

hang

e if

you

have

n’t m

et y

our

dedu

ctib

le.

•  Th

e am

ount

the

plan

pay

s for

cov

ered

serv

ices

is b

ased

on

the

allo

wed

am

ount

. If a

n ou

t-of-

netw

ork

prov

ider

cha

rges

mor

e th

an th

e al

low

ed a

mou

nt,

you

may

hav

e to

pay

the

diff

eren

ce. F

or e

xam

ple,

if a

n ou

t-of-

netw

ork

hosp

ital c

harg

es $

1,50

0 fo

r an

over

nigh

t sta

y an

d th

e al

low

ed a

mou

nt is

$1,

000,

yo

u m

ay h

ave

to p

ay th

e $5

00 d

iffer

ence

. (Th

is is

calle

d ba

lanc

e bi

lling

.) •  

This

plan

may

enc

oura

ge y

ou to

use

net

wor

k pr

ovid

ers

by c

harg

ing

you

low

er d

educ

tible

s, c

opay

men

ts a

nd c

oins

uran

ce a

mou

nts.

Com

mon

M

edic

al E

vent

Se

rvic

es Y

ou M

ay N

eed

You

r Cos

t If Y

ou

Use

an

In

-net

wor

k Pr

ovid

er

You

r Cos

t If Y

ou

Use

an

O

ut-o

f-ne

twor

k Pr

ovid

er

Lim

itatio

ns &

Exc

eptio

ns

If y

ou v

isit

a he

alth

ca

re p

rovi

der’s

offi

ce

or c

linic

Prim

ary

care

visi

t to

treat

an

inju

ry o

r illn

ess

$15

co-p

ay p

er v

isit

Not

cov

ered

C

o-pa

y co

vers

lab

wor

k, m

inor

surg

ery

and

x-ra

ys in

phy

sicia

n's o

ffic

e

Spec

ialis

t visi

t $1

5 co

-pay

per

visi

t 40

% c

oins

uran

ce

Co-

pay

does

not

cov

er la

b w

ork,

min

or

surg

ery

and

x-ra

ys in

phy

sicia

n's o

ffic

e.

Oth

er p

ract

ition

er o

ffic

e vi

sit

20%

coi

nsur

ance

for

chiro

prac

tor

40%

coi

nsur

ance

Li

mite

d to

20

chiro

prac

tor v

isits

per

pe

rson

per

cal

enda

r yea

r. Pr

even

tive

care

/scr

eeni

ng/i

mm

uniz

atio

n N

o ch

arge

40

% c

oins

uran

ce

Non

e.

If y

ou h

ave

a te

st

Dia

gnos

tic te

st (x

-ray

, blo

od w

ork)

20

% c

oins

uran

ce

40%

coi

nsur

ance

N

one.

Imag

ing

(CT/

PET

scan

s, M

RIs)

20

% c

oins

uran

ce

40%

coi

nsur

ance

N

one.

If

you

nee

d dr

ugs

to

trea

t you

r illn

ess

or

cond

ition

M

ore

info

rmat

ion

abou

t pr

escr

iptio

n dr

ug

cove

rage

is a

vaila

ble

at

ww

w.c

ookm

edic

alcl

aim

s.co

m

Gen

eric

dru

gs

20%

coi

nsur

ance

20

% c

oins

uran

ce

50%

coi

nsur

ance

if d

rug

avai

labl

e in

ne

twor

k, b

ut p

urch

ased

out

-of-

netw

ork.

Se

para

te $

300

annu

al fa

mily

ded

uctib

le.

$100

coi

nsur

ance

max

imum

for 3

0 da

y su

pply

. Pr

efer

red

bran

d dr

ugs

20%

coi

nsur

ance

20

% c

oins

uran

ce

N

on-p

refe

rred

bra

nd d

rugs

20

% c

oins

uran

ce

20%

coi

nsur

ance

Spec

ialty

dru

gs

20%

coi

nsur

ance

20

% c

oins

uran

ce

If

you

hav

e ou

tpat

ient

su

rger

y Fa

cilit

y fe

e (e

.g.,

ambu

lato

ry su

rger

y ce

nter

) 20

% c

oins

uran

ce

40%

coi

nsur

ance

Pr

eaut

horiz

atio

n re

quire

d fo

r mos

t ou

tpat

ient

surg

erie

s or t

he su

rger

ies a

re

not c

over

ed.

       4  of  8

 

Coo

k  Medical    

   

Coo

k  Group

 Health

 Plan:  Clinic  Plan  (CP)  Option                                                                                            Period:  01/01/2017  –  12/31/2017  

Summary  of  Benefits  and

 Coverage:  What  this  Plan  Covers  &  What  it  Costs  

Coverage  for:  Employee  &  Child(ren),  Family|  P

lan  Type:  P

PO  

Que

stio

ns: C

all 1

.800

.593

.208

0 or

visi

t us a

t ww

w.c

ookm

edic

alcl

aim

s.co

m.

 If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

vie

w th

e G

loss

ary

at w

ww

.coo

kmed

ical

clai

ms.

com

or c

all 1

.800

.593

.208

0 to

requ

est a

cop

y.

Com

mon

M

edic

al E

vent

Se

rvic

es Y

ou M

ay N

eed

You

r Cos

t If Y

ou

Use

an

In

-net

wor

k Pr

ovid

er

You

r Cos

t If Y

ou

Use

an

O

ut-o

f-ne

twor

k Pr

ovid

er

Lim

itatio

ns &

Exc

eptio

ns

Phys

icia

n/su

rgeo

n fe

es

20%

coi

nsur

ance

40

% c

oins

uran

ce

Prea

utho

rizat

ion

requ

ired

for m

ost

outp

atie

nt su

rger

ies o

r the

surg

erie

s are

no

t cov

ered

.

If y

ou n

eed

imm

edia

te

med

ical

atte

ntio

n

Em

erge

ncy

room

serv

ices

$1

00 c

o-pa

y; 2

0%

coin

sura

nce

$100

co-

pay,

20%

co

insu

ranc

e N

one.

Em

erge

ncy

med

ical

tran

spor

tatio

n 20

% c

oins

uran

ce

20%

coi

nsur

ance

N

one.

Urg

ent c

are

$50

co-p

ay; 2

0%

coin

sura

nce

$50

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ay; 2

0%

coin

sura

nce

Non

e.

If y

ou h

ave

a ho

spita

l st

ay

Faci

lity

fee

(e.g

., ho

spita

l roo

m)

20%

coi

nsur

ance

40

% c

oins

uran

ce

Prea

utho

rizat

ion

requ

ired

for c

over

age.

Ph

ysic

ian/

surg

eon

fee

20%

coi

nsur

ance

40

% c

oins

uran

ce

Prea

utho

rizat

ion

requ

ired

for c

over

age.

If y

ou h

ave

men

tal

heal

th, b

ehav

iora

l he

alth

, or s

ubst

ance

ab

use

need

s

Men

tal/

Beha

vior

al h

ealth

out

patie

nt se

rvic

es

$15

co-p

ay p

er o

ffic

e vi

sit; 2

0%

coin

sura

nce

for

addi

tiona

l ser

vice

s

40%

coi

nsur

ance

N

one.

Men

tal/

Beha

vior

al h

ealth

inpa

tient

serv

ices

20

% c

oins

uran

ce

40%

coi

nsur

ance

Pr

eaut

horiz

atio

n re

quire

d fo

r cov

erag

e.

Subs

tanc

e-us

e di

sord

er o

utpa

tient

serv

ices

$15

co-p

ay p

er o

ffic

e vi

sit; 2

0%

coin

sura

nce

for

addi

tiona

l ser

vice

s

40%

coi

nsur

ance

N

one.

Subs

tanc

e-us

e di

sord

er in

patie

nt se

rvic

es

20%

coi

nsur

ance

40

% c

oins

uran

ce

Prea

utho

rizat

ion

requ

ired

for c

over

age.

If y

ou a

re p

regn

ant

Pren

atal

and

pos

tnat

al c

are

20%

coi

nsur

ance

40

% c

oins

uran

ce

Non

e.

Del

iver

y an

d al

l inp

atie

nt se

rvic

es

20%

coi

nsur

ance

40

% c

oins

uran

ce

Non

e.

       5  of  8

 

Coo

k  Medical    

   

Coo

k  Group

 Health

 Plan:  Clinic  Plan  (CP)  Option                                                                                            Period:  01/01/2017  –  12/31/2017  

Summary  of  Benefits  and

 Coverage:  What  this  Plan  Covers  &  What  it  Costs  

Coverage  for:  Employee  &  Child(ren),  Family|  P

lan  Type:  P

PO  

Que

stio

ns: C

all 1

.800

.593

.208

0 or

visi

t us a

t ww

w.c

ookm

edic

alcl

aim

s.co

m.

 If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

vie

w th

e G

loss

ary

at w

ww

.coo

kmed

ical

clai

ms.

com

or c

all 1

.800

.593

.208

0 to

requ

est a

cop

y.

Com

mon

M

edic

al E

vent

Se

rvic

es Y

ou M

ay N

eed

You

r Cos

t If Y

ou

Use

an

In

-net

wor

k Pr

ovid

er

You

r Cos

t If Y

ou

Use

an

O

ut-o

f-ne

twor

k Pr

ovid

er

Lim

itatio

ns &

Exc

eptio

ns

If y

ou n

eed

help

re

cove

ring

or h

ave

othe

r spe

cial

hea

lth

need

s

Hom

e he

alth

car

e 20

% c

oins

uran

ce

40%

coi

nsur

ance

Pr

eaut

horiz

atio

n re

quire

d fo

r cov

erag

e.

Reha

bilit

atio

n se

rvic

es

20%

coi

nsur

ance

40

% c

oins

uran

ce

Non

e.

Hab

ilita

tion

serv

ices

20

% c

oins

uran

ce

40%

coi

nsur

ance

N

one.

Sk

illed

nur

sing

care

20

% c

oins

uran

ce

40%

coi

nsur

ance

N

one.

Dur

able

med

ical

equ

ipm

ent

20%

coi

nsur

ance

40

% c

oins

uran

ce

Som

e eq

uipm

ent m

ust b

e pr

eaut

horiz

ed

for c

over

age.

H

ospi

ce se

rvic

e 20

% c

oins

uran

ce

40%

coi

nsur

ance

N

one.

If y

our c

hild

nee

ds

dent

al o

r eye

car

e

Eye

exa

m

No

char

ge

See

limita

tions

and

ex

cept

ions

Out

-of-

netw

ork

- $42

tota

l allo

wan

ce fo

r an

ann

ual e

xam

and

$40

/$60

/$80

ann

ual

allo

wan

ce fo

r sta

ndar

d sin

gle/

bifo

cal/

trifo

cal l

ense

s. $

42

allo

wan

ce fo

r fra

mes

eve

ry 2

yea

rs.

Gla

sses

N

o ch

arge

Se

e lim

itatio

ns a

nd

exce

ptio

ns

In-n

etw

ork

- $20

0 al

low

ance

for f

ram

es

ever

y 2

year

s. D

enta

l che

ck-u

p N

o ch

arge

N

o ch

arge

Tw

o pe

r cal

enda

r yea

r.

Exc

lude

d Se

rvic

es &

Oth

er C

over

ed S

ervi

ces:

Serv

ices

You

r Pla

n D

oes

NO

T C

over

(Thi

s is

n’t a

com

plet

e lis

t. C

heck

you

r pol

icy

or p

lan

docu

men

t for

oth

er e

xclu

ded

serv

ices

.)

•  A

cupu

nctu

re

•  Lo

ng-te

rm c

are

•  N

on-e

mer

genc

y ca

re w

hen

trave

ling

outs

ide

the

U.S

.

•  Ro

utin

e fo

ot c

are

•  W

eigh

t los

s pro

gram

s

Oth

er C

over

ed S

ervi

ces

(Thi

s is

n’t a

com

plet

e lis

t. C

heck

you

r pol

icy

or p

lan

docu

men

t for

oth

er c

over

ed s

ervi

ces

and

your

cos

ts fo

r the

se s

ervi

ces.

)

•  C

hiro

prac

tic c

are

•  C

osm

etic

surg

ery

to re

pair

an in

jury

or c

onge

nita

l de

form

ity o

r to

rest

ore

norm

al b

ody

func

tion

•  Ba

riatri

c su

rger

y

•  D

enta

l car

e (a

dult)

•  In

ferti

lity

treat

men

t

•  Pr

ivat

e du

ty n

ursin

g

•  Ro

utin

e ey

e ca

re (a

dult)

•  H

earin

g ai

ds

       6  of  8

 

Coo

k  Medical    

   

Coo

k  Group

 Health

 Plan:  Clinic  Plan  (CP)  Option                                                                                            Period:  01/01/2017  –  12/31/2017  

Summary  of  Benefits  and

 Coverage:  What  this  Plan  Covers  &  What  it  Costs  

Coverage  for:  Employee  &  Child(ren),  Family|  P

lan  Type:  P

PO  

Que

stio

ns: C

all 1

.800

.593

.208

0 or

visi

t us a

t ww

w.c

ookm

edic

alcl

aim

s.co

m.

 If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

vie

w th

e G

loss

ary

at w

ww

.coo

kmed

ical

clai

ms.

com

or c

all 1

.800

.593

.208

0 to

requ

est a

cop

y.

You

r Rig

hts

to C

ontin

ue C

over

age:

If

you

lose

cov

erag

e un

der

the

plan

, the

n, d

epen

ding

upo

n ci

rcum

stan

ces,

Fede

ral a

nd S

tate

law

s m

ay p

rovi

de p

rote

ctio

ns th

at a

llow

you

to k

eep

heal

th c

over

age.

Any

su

ch ri

ghts

may

be

limite

d in

dur

atio

n an

d w

ill re

quire

you

to p

ay a

pre

miu

m, w

hich

may

be

signi

fican

tly h

ighe

r tha

n th

e pr

emiu

m y

ou p

ay w

hile

cov

ered

und

er th

e pl

an.

Oth

er li

mita

tions

on

your

righ

ts to

con

tinue

cov

erag

e al

so a

pply

. Fo

r m

ore

info

rmat

ion

on y

our

right

s to

con

tinue

cov

erag

e, c

onta

ct th

e pl

an a

t 1-8

00-5

93-2

080.

Y

ou m

ay a

lso c

onta

ct y

our

stat

e in

sura

nce

depa

rtmen

t, an

d th

e U

.S.

Dep

artm

ent

of L

abor

’s E

mpl

oyee

Ben

efits

Sec

urity

Adm

inist

ratio

n at

1-8

66-4

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272

or w

ww

.dol

.gov

/ebs

a/he

alth

refo

rm,

or t

he U

.S.

Dep

artm

ent

of H

ealth

and

H

uman

Ser

vice

s at 1

-877

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3 ex

t. 61

656

or w

ww

.cci

io.c

ms.g

ov.

You

r Grie

vanc

e an

d A

ppea

ls R

ight

s:

If y

ou h

ave

a co

mpl

aint

or a

re d

issat

isfie

d w

ith a

den

ial o

f cov

erag

e fo

r cla

ims u

nder

you

r pla

n, y

ou m

ay b

e ab

le to

app

eal o

r file

a g

rieva

nce.

For

que

stio

ns a

bout

you

r rig

hts,

this

notic

e, o

r ass

istan

ce, y

ou c

an c

onta

ct: C

ook

Gro

up H

ealth

Pla

n A

dmin

istra

tor,

Coo

k G

roup

Inco

rpor

ated

, P.O

. Box

160

8 Bl

oom

ingt

on, I

N 4

7402

, 1.

800.

593.

2080

or D

epar

tmen

t of L

abor

, Em

ploy

ee B

enef

its S

ecur

ity A

dmin

istra

tion

at 1

.866

.444

.EBS

A(3

272)

or w

ww

.dol

.gov

/ebs

a/he

alth

refo

rm.

Doe

s th

is C

over

age

Prov

ide

Min

imum

Ess

entia

l Cov

erag

e?

The

Aff

orda

ble

Car

e A

ct re

quire

s mos

t peo

ple

to h

ave

heal

th c

are

cove

rage

that

qua

lifie

s as “

min

imum

ess

entia

l cov

erag

e.”

Thi

s pl

an o

r pol

icy

does

pro

vide

m

inim

um e

ssen

tial c

over

age.

L

angu

age

Acc

ess

Serv

ices:    

Span

ish (E

spañ

ol):

Para

obt

ener

asis

tenc

ia e

n E

spañ

ol, l

lam

e al

1.8

00.4

68.1

379.

C

hine

se (中文

): 如果需要中文的帮助，请拨打这个号码

1.8

00.4

68.1

379.

D

oes

this

Cov

erag

e M

eet t

he M

inim

um V

alue

Sta

ndar

d?

The

Aff

orda

ble

Car

e A

ct e

stab

lishe

s a m

inim

um v

alue

stan

dard

of b

enef

its o

f a h

ealth

pla

n. T

he m

inim

um v

alue

stan

dard

is 6

0% (a

ctua

rial v

alue

). T

his

heal

th

cove

rage

doe

s m

eet t

he m

inim

um v

alue

sta

ndar

d fo

r the

ben

efits

it p

rovi

des.

––––

––––

––––

––––

––––

–To s

ee ex

ample

s of h

ow th

is pla

n mi

ght c

over

costs

for a

samp

le me

dical

situa

tion,

see t

he n

ext p

age.–

––––

––––

––––

––––

––––

–

       7  of  8

 

Coo

k  Medical    

 Coo

k  Group

 Health

 Plan:  Clinic  Plan  (CP)  Option                                                                                            Period:  01/01/2016  –  12/31/2016  

Summary  of  Benefits  and

 Coverage:  What  this  Plan  Covers  &  What  it  Costs  

Coverage  for:  Employee  &  Child(ren),  Family|  P

lan  Type:  P

PO  

Que

stio

ns: C

all 1

.800

.593

.208

0 or

visi

t us a

t ww

w.c

ookm

edic

alcl

aim

s.co

m.

 If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

vie

w th

e G

loss

ary

at w

ww

.coo

kmed

ical

clai

ms.

com

or c

all 1

.800

.593

.208

0 to

requ

est a

cop

y.

Having  a  baby

(n

orm

al d

eliv

ery)

Managing  type  2  diabetes

(rout

ine

mai

nten

ance

of

a w

ell-c

ontro

lled

cond

ition

)

Abo

ut th

ese

Cov

erag

e E

xam

ples

: Th

ese

exam

ples

show

how

this

plan

mig

ht c

over

m

edic

al c

are

in g

iven

situ

atio

ns. U

se th

ese

exam

ples

to

see,

in g

ener

al, h

ow m

uch

finan

cial

pro

tect

ion

a sa

mpl

e pa

tient

mig

ht g

et if

they

are

cov

ered

und

er

diff

eren

t pla

ns.

n A

mou

nt o

wed

to p

rovi

ders

: $7,

540

n P

lan

pays

$5,

080

n P

atie

nt p

ays

$2,4

60

Sa

mpl

e ca

re c

osts

: H

ospi

tal c

harg

es (m

othe

r)

$2,7

00

Rout

ine

obst

etric

car

e $2

,100

H

ospi

tal c

harg

es (b

aby)

$9

00

Ane

sthe

sia

$900

La

bora

tory

test

s $5

00

Pres

crip

tions

$2

00

Radi

olog

y $2

00

Vac

cine

s, ot

her p

reve

ntiv

e $4

0 T

otal

$7

,540

Pa

tient

pay

s:

Ded

uctib

les

$1,2

00

Cop

ays

$0

Coi

nsur

ance

$1

260

Lim

its o

r exc

lusio

ns

$0

Tot

al

$2,4

60

n A

mou

nt o

wed

to p

rovi

ders

: $5,

400

n P

lan

pays

$3,

750

n P

atie

nt p

ays

$1,6

50

Sa

mpl

e ca

re c

osts

: Pr

escr

iptio

ns

$2,9

00

Med

ical

Equ

ipm

ent a

nd S

uppl

ies

$1,3

00

Off

ice

Visi

ts a

nd P

roce

dure

s $7

00

Edu

catio

n $3

00

Labo

rato

ry te

sts

$100

V

acci

nes,

othe

r pre

vent

ive

$100

T

otal

$5

,400

Pa

tient

pay

s:

Ded

uctib

les

$800

C

opay

s $9

0 C

oins

uran

ce

$760

Li

mits

or e

xclu

sions

$0

T

otal

$1

,650

This  is    

not  a  cost  

estim

ator.    

Don

’t us

e th

ese

exam

ples

to

estim

ate

your

act

ual c

osts

und

er

this

plan

. The

act

ual c

are

you

rece

ive

will

be

diff

eren

t fro

m

thes

e ex

ampl

es, a

nd th

e co

st o

f th

at c

are

will

also

be

diff

eren

t.

See

the

next

pag

e fo

r im

porta

nt

info

rmat

ion

abou

t the

se

exam

ples

.  

       8  of  8

 

Coo

k  Medical    

 Coo

k  Group

 Health

 Plan:  Clinic  Plan  (CP)  Option                                                                                            Period:  01/01/2016  –  12/31/2016  

Summary  of  Benefits  and

 Coverage:  What  this  Plan  Covers  &  What  it  Costs  

Coverage  for:  Employee  &  Child(ren),  Family|  P

lan  Type:  P

PO  

Que

stio

ns: C

all 1

.800

.593

.208

0 or

visi

t us a

t ww

w.c

ookm

edic

alcl

aim

s.co

m.

 If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

vie

w th

e G

loss

ary

at w

ww

.coo

kmed

ical

clai

ms.

com

or c

all 1

.800

.593

.208

0 to

requ

est a

cop

y.

Que

stio

ns a

nd a

nsw

ers

abou

t the

Cov

erag

e E

xam

ples

: W

hat a

re s

ome

of th

e as

sum

ptio

ns b

ehin

d th

e C

over

age

Exa

mpl

es?

•  C

osts

don

’t in

clud

e pr

emiu

ms.

•  

Sam

ple

care

cos

ts a

re b

ased

on

natio

nal

aver

ages

supp

lied

by th

e U

.S. D

epar

tmen

t of

Hea

lth a

nd H

uman

Ser

vice

s, an

d ar

en’t

spec

ific

to a

par

ticul

ar g

eogr

aphi

c ar

ea o

r he

alth

pla

n.

•  Th

e pa

tient

’s co

nditi

on w

as n

ot a

n ex

clud

ed o

r pr

eexi

stin

g co

nditi

on.

•  A

ll se

rvic

es a

nd tr

eatm

ents

star

ted

and

ende

d in

the

sam

e co

vera

ge p

erio

d.

•  Th

ere

are

no o

ther

med

ical

exp

ense

s for

any

m

embe

r cov

ered

und

er th

is pl

an.

•  O

ut-o

f-po

cket

exp

ense

s are

bas

ed o

nly

on

treat

ing

the

cond

ition

in th

e ex

ampl

e.

•  Th

e pa

tient

rece

ived

all

care

from

in-n

etw

ork

prov

ider

s. I

f the

pat

ient

had

rece

ived

car

e fr

om o

ut-o

f-ne

twor

k pr

ovid

ers,

cos

ts w

ould

ha

ve b

een

high

er.

Wha

t doe

s a

Cov

erag

e E

xam

ple

show

?

For e

ach

treat

men

t situ

atio

n, th

e C

over

age

Exa

mpl

e he

lps y

ou se

e ho

w d

educ

tible

s,

copa

ymen

ts, a

nd c

oins

uran

ce c

an a

dd u

p. It

al

so h

elps

you

see

wha

t exp

ense

s mig

ht b

e le

ft up

to

you

to p

ay b

ecau

se th

e se

rvic

e or

trea

tmen

t isn

’t co

vere

d or

pay

men

t is l

imite

d.

Doe

s th

e C

over

age

Exa

mpl

e pr

edic

t my

own

care

nee

ds?

û N

o. T

reat

men

ts sh

own

are

just

exa

mpl

es. T

he

care

you

wou

ld re

ceiv

e fo

r thi

s con

ditio

n co

uld

be d

iffer

ent b

ased

on

your

doc

tor’s

adv

ice,

yo

ur a

ge, h

ow se

rious

you

r con

ditio

n is,

and

m

any

othe

r fac

tors

. D

oes

the

Cov

erag

e E

xam

ple

pred

ict m

y fu

ture

ex

pens

es?

ûN

o. C

over

age

Exa

mpl

es a

re n

ot c

ost e

stim

ator

s. Y

ou c

an’t

use

the

exam

ples

to e

stim

ate

cost

s fo

r an

actu

al c

ondi

tion.

The

y ar

e fo

r co

mpa

rativ

e pu

rpos

es o

nly.

You

r ow

n co

sts

will

be

diff

eren

t dep

endi

ng o

n th

e ca

re y

ou

rece

ive,

the

pric

es y

our p

rovi

ders

cha

rge,

and

th

e re

imbu

rsem

ent y

our h

ealth

pla

n al

low

s.

Can

I u

se C

over

age

Exa

mpl

es to

com

pare

pl

ans?

üY

es. W

hen

you

look

at t

he S

umm

ary

of B

enef

its

and

Cov

erag

e fo

r oth

er p

lans

, you

’ll fi

nd th

e sa

me

Cov

erag

e E

xam

ples

. Whe

n yo

u co

mpa

re

plan

s, ch

eck

the

“Pat

ient

Pay

s” b

ox in

eac

h ex

ampl

e. T

he sm

alle

r tha

t num

ber,

the

mor

e co

vera

ge th

e pl

an p

rovi

des.

Are

ther

e ot

her c

osts

I s

houl

d co

nsid

er w

hen

com

parin

g pl

ans?

üY

es. A

n im

porta

nt c

ost i

s the

pre

miu

m y

ou

pay.

Gen

eral

ly, t

he lo

wer

you

r pre

miu

m, t

he

mor

e yo

u’ll

pay

in o

ut-o

f-po

cket

cos

ts, s

uch

as

copa

ymen

ts, d

educ

tible

s, a

nd c

oins

uran

ce.

You

shou

ld a

lso c

onsid

er c

ontri

butio

ns to

ac

coun

ts su

ch a

s hea

lth sa

ving

s acc

ount

s (H

SAs)

, fle

xibl

e sp

endi

ng a

rran

gem

ents

(FSA

s)

or h

ealth

reim

burs

emen

t acc

ount

s (H

RAs)

that

he

lp y

ou p

ay o

ut-o

f-po

cket

exp

ense

s.

       1  of  9

 

Cook  Medical    

   

Cook  Group  Health  Plan:  Traditional  Plan  (TP)  Option                                                        Coverage  Period:  01/01/2017  –  12/31/2017  

Summary  of  Benefits  and  Coverage:  What  this  Plan  Covers  &  What  it  Costs  

Coverage  for:  Employee  &  Child(ren),  Family|  Plan  Type:  PPO  

Que

stio

ns: C

all 1

.800

.593

.208

0 or

visi

t us a

t ww

w.c

ookm

edic

alcl

aim

s.co

m.

 If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

vie

w th

e G

loss

ary

at w

ww

.coo

kmed

ical

clai

ms.

com

or c

all 1

.800

.593

.208

0 to

requ

est a

cop

y.

 

 This  is  only  a  summary.  If

you

wan

t mor

e de

tail

abou

t you

r cov

erag

e an

d co

sts,

you

can

get t

he c

ompl

ete

term

s in

the

polic

y or

pla

n do

cum

ent a

t w

ww

.coo

kmed

ical

clai

ms.

com

or b

y ca

lling

1-8

00-5

93-2

080.

 

 

Important  Questions  

Answers  

Wha

t is

the

over

all

dedu

ctib

le?

$500

per

indi

vidu

al a

nd $

1,00

0 pe

r fa

mily

for i

n-ne

twor

k se

rvic

es.

Sepa

rate

ded

uctib

les (

$500

per

in

divi

dual

and

$1,

000

per f

amily

) fo

r out

-of-

netw

ork

serv

ices

. No

mor

e th

an $

500

per p

erso

n co

unts

to

war

ds th

e fa

mily

ded

uctib

le. I

n-ne

twor

k pr

even

tive

care

, den

tal o

r vi

sion

care

, and

pre

scrip

tion

drug

s ar

e no

t sub

ject

to th

ese

dedu

ctib

les .

Den

tal a

nd v

ision

car

e,

pres

crip

tion

drug

s, co

paym

ents

, se

cond

or t

hird

surg

ical

opi

nion

s, an

d no

n-co

vere

d se

rvic

es c

anno

t be

use

d to

satis

fy th

e de

duct

ible

s.

You

mus

t pay

all

the

cost

up

to th

e de

duct

ible

am

ount

bef

ore

this

plan

beg

ins t

o pa

y fo

r cov

ered

se

rvic

es y

ou u

se. T

he d

educ

tible

star

ts o

ver J

anua

ry 1

of e

ach

year

. See

the

char

t sta

rting

on

page

3

for h

ow m

uch

you

pay

for c

over

ed se

rvic

es a

fter y

ou m

eet t

he d

educ

tible

.

Are

ther

e ot

her

dedu

ctib

les

for s

peci

fic

serv

ices

?

Yes

. The

re is

a $

300

fam

ily

dedu

ctib

le fo

r pre

scrip

tion

drug

ex

pens

es. T

here

are

no

othe

r sp

ecifi

c de

duct

ible

s.

You

mus

t pay

all

the

cost

s for

the

serv

ices

up

to th

e sp

ecifi

c de

duct

ible

am

ount

bef

ore

this

plan

be

gins

to p

ay fo

r the

serv

ices

.

Is th

ere

an o

ut-o

f-po

cket

lim

it on

my

expe

nses

?

Yes

. For

net

wor

k pr

ovid

ers,

ther

e is

an o

ut-o

f-po

cket

lim

it of

$2,

000

per i

ndiv

idua

l and

$4,

000

per

fam

ily. T

here

is n

o lim

it fo

r out

-of-

netw

ork

prov

ider

s.

The

out-o

f-po

cket

lim

it is

the

mos

t you

cou

ld p

ay d

urin

g a

cale

ndar

yea

r for

you

r sha

re o

f the

cos

ts

of c

over

ed se

rvic

es. T

his l

imit

help

s you

pla

n fo

r hea

lth c

are

expe

nses

. The

re's

no li

mit

on h

ow

muc

h yo

u ca

n pa

y du

ring

a ca

lend

ar y

ear f

or y

our s

hare

of t

he c

ost o

f out

-of-

netw

ork

cove

red

serv

ices

.

Wha

t is

not i

nclu

ded

in

the

out-

of-p

ocke

t lim

it?

Prem

ium

s, ba

lanc

e bi

lled

char

ges

( u

nles

s bal

ance

bill

ing

is pr

ohib

ited)

, hea

lth c

are

this

plan

do

esn'

t cov

er, a

dult

dent

al, v

ision

, fa

mily

pla

nnin

g, o

ut-o

f-ne

twor

k ch

arge

s, am

ount

s rei

mbu

rsed

un

der t

he p

resc

riptio

n dr

ug

Eve

n th

ough

you

pay

thes

e ex

pens

es, t

hey

do n

ot c

ount

tow

ard

the

out-o

f-po

cket

lim

it.

       2  of  9

 

Cook  Medical    

   

Cook  Group  Health  Plan:  Traditional  Plan  (TP)  Option                                                        Coverage  Period:  01/01/2017  –  12/31/2017  

Summary  of  Benefits  and  Coverage:  What  this  Plan  Covers  &  What  it  Costs  

Coverage  for:  Employee  &  Child(ren),  Family|  Plan  Type:  PPO  

Que

stio

ns: C

all 1

.800

.593

.208

0 or

visi

t us a

t ww

w.c

ookm

edic

alcl

aim

s.co

m.

 If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

vie

w th

e G

loss

ary

at w

ww

.coo

kmed

ical

clai

ms.

com

or c

all 1

.800

.593

.208

0 to

requ

est a

cop

y.

spec

ialty

car

e pr

ogra

m a

nd

pena

lties

for f

ailu

re to

obt

ain

prea

utho

rizat

ion.

Is th

ere

an o

vera

ll an

nual

lim

it on

wha

t the

pla

n pa

ys?

No.

Th

e ch

art s

tarti

ng o

n pa

ge 3

des

crib

es a

ny li

mits

on

wha

t the

pla

n w

ill p

ay fo

r spe

cific

cove

red

serv

ices

, suc

h as

off

ice

visit

s.

Doe

s th

is p

lan

use

a ne

twor

k of

pro

vide

rs?

Yes

. See

ww

w.an

them

.com

or c

all

Ant

hem

’s Pr

ovid

er L

ocat

or

tele

phon

e nu

mbe

r 1.8

00.8

10.2

583.

Y

ou c

an a

lso c

all C

ook

Insu

ranc

e D

ept.

1-80

0-59

3-20

80 fo

r as

sista

nce

findi

ng n

etw

ork

prov

ider

s.

If y

ou u

se a

net

wor

k do

ctor

or o

ther

hea

lthca

re p

rovi

der,

this

plan

will

pay

the

cost

of c

over

ed

serv

ices

. Be

awar

e, y

our n

etw

ork

doct

or o

r hos

pita

l may

use

an

out-o

f-ne

twor

k pr

ovid

er fo

r som

e se

rvic

es. P

lans

use

the

term

s of “

netw

ork,

” “p

refe

rred

,” o

r “pa

rtici

patin

g” fo

r pro

vide

rs in

thei

r ne

twor

k. S

ee th

e ch

art o

n pa

ge 3

for h

ow th

is pl

an p

ays f

or d

iffer

ent k

inds

of p

rovi

ders

.

Do

I ne

ed a

refe

rral

to s

ee

a sp

ecia

list?

N

o.

You

can

see

the

spec

ialis

t you

cho

ose

with

out p

erm

issio

n fr

om th

is pl

an.

Are

ther

e se

rvic

es th

is

plan

doe

sn’t

cove

r?

Yes

. So

me

of th

e se

rvic

es th

is pl

an d

oesn

't co

ver a

re li

sted

on

page

5. S

ee y

our b

enef

its b

ookl

et o

r pla

n m

anua

l for

add

ition

al in

form

atio

n ab

out e

xclu

ded

serv

ices

.  

OM

B Co

ntro

l Num

bers

154

5-22

29, 1

210-

0147

, and

093

8-11

46

Rele

ased

on

Apr

il 23

, 201

3 (c

orre

cted

)

       3  of  9

 

Cook  Medical    

   

Cook  Group  Health  Plan:  Traditional  Plan  (TP)  Option                                                        Coverage  Period:  01/01/2017  –  12/31/2017  

Summary  of  Benefits  and  Coverage:  What  this  Plan  Covers  &  What  it  Costs  

Coverage  for:  Employee  &  Child(ren),  Family|  Plan  Type:  PPO  

Que

stio

ns: C

all 1

.800

.593

.208

0 or

visi

t us a

t ww

w.c

ookm

edic

alcl

aim

s.co

m.

 If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

vie

w th

e G

loss

ary

at w

ww

.coo

kmed

ical

clai

ms.

com

or c

all 1

.800

.593

.208

0 to

requ

est a

cop

y.

 •  C

opay

men

ts a

re fi

xed

dolla

r am

ount

s (fo

r exa

mpl

e, $

15) y

ou p

ay fo

r cov

ered

hea

lth c

are,

usu

ally

whe

n yo

u re

ceiv

e th

e se

rvic

e. •  

Coi

nsur

ance

is yo

ur sh

are

of th

e co

sts o

f a c

over

ed se

rvic

e, c

alcu

late

d as

a p

erce

nt o

f the

allo

wed

am

ount

for t

he se

rvic

e. F

or e

xam

ple,

if th

e pl

an’s

allo

wed

am

ount

for a

n ov

erni

ght h

ospi

tal s

tay

is $1

,000

, you

r coi

nsur

ance

pay

men

t of 2

0% w

ould

be

$200

. Th

is m

ay c

hang

e if

you

have

n’t m

et y

our

dedu

ctib

le.

•  Th

e am

ount

the

plan

pay

s for

cov

ered

serv

ices

is b

ased

on

the

allo

wed

am

ount

. If a

n ou

t-of-

netw

ork

prov

ider

cha

rges

mor

e th

an th

e al

low

ed a

mou

nt,

you

may

hav

e to

pay

the

diff

eren

ce. F

or e

xam

ple,

if a

n ou

t-of-

netw

ork

hosp

ital c

harg

es $

1,50

0 fo

r an

over

nigh

t sta

y an

d th

e al

low

ed a

mou

nt is

$1,

000,

yo

u m

ay h

ave

to p

ay th

e $5

00 d

iffer

ence

. (Th

is is

calle

d ba

lanc

e bi

lling

.) •  

This

plan

may

enc

oura

ge y

ou to

use

net

wor

k pr

ovid

ers

by c

harg

ing

you

low

er d

educ

tible

s, c

opay

men

ts a

nd c

oins

uran

ce a

mou

nts.

  Com

mon    

Medical  Event  

Services  You  May  Need  

Your  Cost  If  You  

Use  an    

In-­network  

Provider  

Your  Cost  If  You  

Use  an    

Out-­of-­network  

Provider  

Limitations  &  Exceptions  

If y

ou v

isit

a he

alth

ca

re p

rovi

der’s

offi

ce

or c

linic

Prim

ary

care

visi

t to

treat

an

inju

ry o

r illn

ess

$15

co-p

ay p

er v

isit

40%

coi

nsur

ance

C

o-pa

y do

es n

ot c

over

lab

wor

k, m

inor

su

rger

y an

d x-

rays

in p

hysic

ian'

s off

ice.

Spec

ialis

t visi

t $1

5 co

-pay

per

visi

t 40

% c

oins

uran

ce

Co-

pay

does

not

cov

er la

b w

ork,

min

or

surg

ery

and

x-ra

ys in

phy

sicia

n's o

ffic

e.

Oth

er p

ract

ition

er o

ffic

e vi

sit

20%

coi

nsur

ance

for

chiro

prac

tor

40%

coi

nsur

ance

fo

r chi

ropr

acto

r Li

mite

d to

20

chiro

prac

tor v

isits

per

pe

rson

per

cal

enda

r yea

r.

Prev

entiv

e ca

re/s

cree

ning

/im

mun

izat

ion

No

char

ge

40%

coi

nsur

ance

N

one.

If y

ou h

ave

a te

st

Dia

gnos

tic te

st (x

-ray

, blo

od w

ork)

20

% c

oins

uran

ce

40%

coi

nsur

ance

N

one.

Im

agin

g (C

T/PE

T sc

ans,

MRI

s)

20%

coi

nsur

ance

40

% c

oins

uran

ce

Non

e.

If y

ou n

eed

drug

s to

tr

eat y

our i

llnes

s or

co

nditi

on

Mor

e in

form

atio

n ab

out

pres

crip

tion

drug

co

vera

ge is

ava

ilabl

e at

w

ww

.coo

kmed

ical

clai

ms.

com

.

Gen

eric

dru

gs

20%

coi

nsur

ance

20

% c

oins

uran

ce

Pref

erre

d br

and

drug

s 20

% c

oins

uran

ce

20%

coi

nsur

ance

Se

para

te $

300

annu

al fa

mily

ded

uctib

le.

$100

coi

nsur

ance

max

imum

for 3

0-da

y su

pply

. N

on-p

refe

rred

bra

nd d

rugs

20

% c

oins

uran

ce

20%

coi

nsur

ance

Spec

ialty

dru

gs

20%

coi

nsur

ance

20

% c

oins

uran

ce

If y

ou h

ave

outp

atie

nt

surg

ery

Faci

lity

fee

(e.g

., am

bula

tory

surg

ery

cent

er)

20%

coi

nsur

ance

40

% c

oins

uran

ce

Prea

utho

rizat

ion

requ

ired

for m

ost

outp

atie

nt su

rger

ies o

r the

surg

erie

s are

no

t cov

ered

.

       4  of  9

 

Cook  Medical    

   

Cook  Group  Health  Plan:  Traditional  Plan  (TP)  Option                                                        Coverage  Period:  01/01/2017  –  12/31/2017  

Summary  of  Benefits  and  Coverage:  What  this  Plan  Covers  &  What  it  Costs  

Coverage  for:  Employee  &  Child(ren),  Family|  Plan  Type:  PPO  

Que

stio

ns: C

all 1

.800

.593

.208

0 or

visi

t us a

t ww

w.c

ookm

edic

alcl

aim

s.co

m.

 If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

vie

w th

e G

loss

ary

at w

ww

.coo

kmed

ical

clai

ms.

com

or c

all 1

.800

.593

.208

0 to

requ

est a

cop

y.

Com

mon    

Medical  Event  

Services  You  May  Need  

Your  Cost  If  You  

Use  an    

In-­network  

Provider  

Your  Cost  If  You  

Use  an    

Out-­of-­network  

Provider  

Limitations  &  Exceptions  

Phys

icia

n/su

rgeo

n fe

es

20%

coi

nsur

ance

40

% c

oins

uran

ce

Prea

utho

rizat

ion

requ

ired

for m

ost

outp

atie

nt su

rger

ies o

r the

surg

erie

s are

no

t cov

ered

.

If y

ou n

eed

imm

edia

te

med

ical

atte

ntio

n

Em

erge

ncy

room

serv

ices

$1

00 c

o-pa

y; 2

0%

coin

sura

nce

$100

co-

pay;

20%

co

insu

ranc

e N

one.

Em

erge

ncy

med

ical

tran

spor

tatio

n 20

% c

oins

uran

ce

20%

coi

nsur

ance

N

one.

Urg

ent c

are

$50

co-p

ay; 2

0%

coin

sura

nce

$50

co-p

ay; 2

0%

coin

sura

nce

Non

e.

If y

ou h

ave

a ho

spita

l st

ay

Faci

lity

fee

(e.g

., ho

spita

l roo

m)

20%

coi

nsur

ance

40

% c

oins

uran

ce

Prea

utho

rizat

ion

requ

ired

for c

over

age.

Ph

ysic

ian/

surg

eon

fee

20%

coi

nsur

ance

40

% c

oins

uran

ce

Prea

utho

rizat

ion

requ

ired

for c

over

age.

If y

ou h

ave

men

tal

heal

th, b

ehav

iora

l he

alth

, or s

ubst

ance

ab

use

need

s

Men

tal/

Beha

vior

al h

ealth

out

patie

nt se

rvic

es

$15

co-p

ay p

er o

ffic

e vi

sit; 2

0%

coin

sura

nce

for

addi

tiona

l ser

vice

s

40%

coi

nsur

ance

N

one.

Men

tal/

Beha

vior

al h

ealth

inpa

tient

serv

ices

20

% c

oins

uran

ce

40%

coi

nsur

ance

Pr

eaut

horiz

atio

n re

quire

d fo

r cov

erag

e.

Subs

tanc

e-us

e di

sord

er o

utpa

tient

serv

ices

$15

co-p

ay p

er o

ffic

e vi

sit; 2

0%

coin

sura

nce

for

addi

tiona

l ser

vice

s

40%

coi

nsur

ance

N

one.

Subs

tanc

e-us

e di

sord

er in

patie

nt se

rvic

es

20%

coi

nsur

ance

40

% c

oins

uran

ce

Prea

utho

rizat

ion

requ

ired

for c

over

age.

If y

ou a

re p

regn

ant

Pren

atal

and

pos

tnat

al c

are

20%

coi

nsur

ance

40

% c

oins

uran

ce

Non

e.

Del

iver

y an

d al

l inp

atie

nt se

rvic

es

20%

coi

nsur

ance

40

% c

oins

uran

ce

Non

e.

       5  of  9

 

Cook  Medical    

   

Cook  Group  Health  Plan:  Traditional  Plan  (TP)  Option                                                        Coverage  Period:  01/01/2017  –  12/31/2017  

Summary  of  Benefits  and  Coverage:  What  this  Plan  Covers  &  What  it  Costs  

Coverage  for:  Employee  &  Child(ren),  Family|  Plan  Type:  PPO  

Que

stio

ns: C

all 1

.800

.593

.208

0 or

visi

t us a

t ww

w.c

ookm

edic

alcl

aim

s.co

m.

 If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

vie

w th

e G

loss

ary

at w

ww

.coo

kmed

ical

clai

ms.

com

or c

all 1

.800

.593

.208

0 to

requ

est a

cop

y.

Com

mon    

Medical  Event  

Services  You  May  Need  

Your  Cost  If  You  

Use  an    

In-­network  

Provider  

Your  Cost  If  You  

Use  an    

Out-­of-­network  

Provider  

Limitations  &  Exceptions  

If y

ou n

eed

help

re

cove

ring

or h

ave

othe

r spe

cial

hea

lth

need

s

Hom

e he

alth

car

e 20

% c

oins

uran

ce

40%

coi

nsur

ance

Pr

eaut

horiz

atio

n re

quire

d fo

r cov

erag

e Re

habi

litat

ion

serv

ices

20

% c

oins

uran

ce

40%

coi

nsur

ance

N

one.

H

abili

tatio

n se

rvic

es

20%

coi

nsur

ance

40

% c

oins

uran

ce

Non

e.

Skill

ed n

ursin

g ca

re

20%

coi

nsur

ance

40

% c

oins

uran

ce

Non

e.

Dur

able

med

ical

equ

ipm

ent

20%

coi

nsur

ance

40

% c

oins

uran

ce

Som

e eq

uipm

ent m

ust b

e pr

eaut

horiz

ed

for c

over

age.

H

ospi

ce se

rvic

e 20

% c

oins

uran

ce

40%

coi

nsur

ance

N

one.

If y

our c

hild

nee

ds

dent

al o

r eye

car

e

Ann

ual e

ye e

xam

N

o ch

arge

Se

e lim

itatio

ns a

nd

exce

ptio

ns

Out

-of-

netw

ork

- $42

tota

l allo

wan

ce fo

r an

ann

ual e

xam

and

$40

/$60

/$80

ann

ual

allo

wan

ce fo

r one

pai

r of s

tand

ard

singl

e/bi

foca

l/tri

foca

l len

ses.

$42

al

low

ance

for f

ram

es e

very

2 y

ears

.

Eye

glas

ses

No

char

ge

See

limita

tions

and

ex

cept

ions

In

-net

wor

k - $

200

allo

wan

ce fo

r fra

mes

ev

ery

2 ye

ars.

Den

tal c

heck

-up

No

char

ge

No

char

ge

Tw

o pe

r cal

enda

r yea

r

Excluded  Services  &  Other  Covered  Services:  

Services  Your  Plan  Does  NOT  Cover  (T

his

isn’

t a c

ompl

ete

list.

Che

ck y

our p

olic

y or

pla

n do

cum

ent f

or o

ther

exc

lude

d se

rvic

es.)  

•  A

cupu

nctu

re

•  Lo

ng-te

rm c

are

•  N

on-e

mer

genc

y ca

re w

hen

trave

ling

outs

ide

the

U.S

.

•  Ro

utin

e fo

ot c

are

•  W

eigh

t los

s pro

gram

s

 

       6  of  9

 

Cook  Medical    

   

Cook  Group  Health  Plan:  Traditional  Plan  (TP)  Option                                                        Coverage  Period:  01/01/2017  –  12/31/2017  

Summary  of  Benefits  and  Coverage:  What  this  Plan  Covers  &  What  it  Costs  

Coverage  for:  Employee  &  Child(ren),  Family|  Plan  Type:  PPO  

Que

stio

ns: C

all 1

.800

.593

.208

0 or

visi

t us a

t ww

w.c

ookm

edic

alcl

aim

s.co

m.

 If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

vie

w th

e G

loss

ary

at w

ww

.coo

kmed

ical

clai

ms.

com

or c

all 1

.800

.593

.208

0 to

requ

est a

cop

y.

Oth

er C

over

ed S

ervi

ces

(Thi

s is

n’t a

com

plet

e lis

t. C

heck

you

r pol

icy

or p

lan

docu

men

t for

oth

er c

over

ed s

ervi

ces

and

your

cos

ts fo

r the

se s

ervi

ces.

)

•  Ba

riatri

c su

rger

y

•  C

hiro

prac

tic c

are

•  C

osm

etic

surg

ery

to re

pair

an in

jury

or c

onge

nita

l de

form

ity o

r to

rest

ore

norm

al b

ody

func

tion

•  D

enta

l car

e (a

dult)

•  I n

ferti

lity

treat

men

t

•  Pr

ivat

e du

ty n

ursin

g

•  Ro

utin

e ey

e ca

re (a

dult)

•  H

earin

g ai

ds

You

r Rig

hts

to C

ontin

ue C

over

age:

If

you

lose

cov

erag

e un

der

the

plan

, the

n, d

epen

ding

upo

n ci

rcum

stan

ces,

Fede

ral a

nd S

tate

law

s m

ay p

rovi

de p

rote

ctio

ns th

at a

llow

you

to k

eep

heal

th c

over

age.

Any

su

ch ri

ghts

may

be

limite

d in

dur

atio

n an

d w

ill re

quire

you

to p

ay a

pre

miu

m, w

hich

may

be

signi

fican

tly h

ighe

r tha

n th

e pr

emiu

m y

ou p

ay w

hile

cov

ered

und

er th

e pl

an.

Oth

er li

mita

tions

on

your

righ

ts to

con

tinue

cov

erag

e al

so a

pply

. Fo

r m

ore

info

rmat

ion

on y

our

right

s to

con

tinue

cov

erag

e, c

onta

ct th

e pl

an a

t 1-8

00-5

93-2

080.

Y

ou m

ay a

lso c

onta

ct y

our

stat

e in

sura

nce

depa

rtmen

t, an

d th

e U

.S.

Dep

artm

ent

of L

abor

’s E

mpl

oyee

Ben

efits

Sec

urity

Adm

inist

ratio

n at

1-8

66-4

44-3

272

or w

ww

.dol

.gov

/ebs

a/he

alth

refo

rm,

or t

he U

.S.

Dep

artm

ent

of H

ealth

and

H

uman

Ser

vice

s at 1

-877

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3 ex

t. 61

656

or w

ww

.cci

io.c

ms.g

ov.

You

r Grie

vanc

e an

d A

ppea

ls R

ight

s:

If y

ou h

ave

a co

mpl

aint

or a

re d

issat

isfie

d w

ith a

den

ial o

f cov

erag

e fo

r cla

ims u

nder

you

r pla

n, y

ou m

ay b

e ab

le to

app

eal o

r file

a g

rieva

nce.

For

que

stio

ns a

bout

you

r rig

hts,

this

notic

e, o

r ass

istan

ce, y

ou c

an c

onta

ct: C

ook

Gro

up H

ealth

Pla

n A

dmin

istra

tor,

Coo

k G

roup

Inco

rpor

ated

, P.O

. Box

160

8, B

loom

ingt

on, I

N 4

7402

, 1.

800.

593.

2080

or D

epar

tmen

t of L

abor

, Em

ploy

ee B

enef

its S

ecur

ity A

dmin

istra

tion

at 1

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A(3

272)

or w

ww

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.gov

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a/he

alth

refo

rm.

Doe

s th

is C

over

age

Prov

ide

Min

imum

Ess

entia

l Cov

erag

e?

T he

Aff

orda

ble

Car

e A

ct re

quire

s mos

t peo

ple

to h

ave

heal

th c

are

cove

rage

that

qua

lifie

s as “

min

imum

ess

entia

l cov

erag

e.”

Thi

s pl

an o

r pol

icy

does

pro

vide

m

inim

um e

ssen

tial c

over

age.

D

oes

this

Cov

erag

e M

eet t

he M

inim

um V

alue

Sta

ndar

d?

The

Aff

orda

ble

Car

e A

ct e

stab

lishe

s a m

inim

um v

alue

stan

dard

of b

enef

its o

f a h

ealth

pla

n. T

he m

inim

um v

alue

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dard

is 6

0% (a

ctua

rial v

alue

). T

his

heal

th

cove

rage

doe

s m

eet t

he m

inim

um v

alue

sta

ndar

d fo

r the

ben

efits

it p

rovi

des.

Lan

guag

e A

cces

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rvic

es:

Span

ish (E

spañ

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Para

obt

ener

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tenc

ia e

n E

spañ

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lam

e al

1.8

00.4

68.1

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C

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1.8

00.4

68.1

379.

       7  of  9

 

Cook  Medical    

   

Cook  Group  Health  Plan:  Traditional  Plan  (TP)  Option                                                        Coverage  Period:  01/01/2017  –  12/31/2017  

Summary  of  Benefits  and  Coverage:  What  this  Plan  Covers  &  What  it  Costs  

Coverage  for:  Employee  &  Child(ren),  Family|  Plan  Type:  PPO  

Que

stio

ns: C

all 1

.800

.593

.208

0 or

visi

t us a

t ww

w.c

ookm

edic

alcl

aim

s.co

m.

 If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

vie

w th

e G

loss

ary

at w

ww

.coo

kmed

ical

clai

ms.

com

or c

all 1

.800

.593

.208

0 to

requ

est a

cop

y.

––––

––––

––––

––––

––––

––To

see e

xamp

les of

how

this

plan

migh

t cov

er cos

ts for

a sa

mple

medic

al sit

uatio

n, se

e the

nex

t pag

e.–––

––––

––––

––––

––––

–––

       8  of  9

 

Cook  Medical  

Cook  Group  Health  Plan:  Traditional  Plan  (TP)  Option    

Coverage  Period:  01/01/2017  –  12/31/2017    

Coverage  Exam

ples  

 Coverage  for:  Employee  &  Child(ren),  Family  |  Plan  Type:  PPO  

Que

stio

ns: C

all 1

.800

.593

.208

0 or

visi

t us a

t ww

w.c

ookm

edic

alcl

aim

s.co

m.

 If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

vie

w th

e G

loss

ary

at w

ww

.coo

kmed

ical

clai

ms.

com

or c

all 1

.800

.593

.208

0 to

requ

est a

cop

y.

Having  a  baby

(n

orm

al de

liver

y)

Managing  type  2  diabetes

(rout

ine

main

tena

nce

of

a w

ell-c

ontro

lled

cond

ition

)

About  these  Coverage  Exam

ples:  

Thes

e ex

ampl

es sh

ow h

ow th

is pl

an m

ight

cov

er

med

ical

car

e in

giv

en si

tuat

ions

. Use

thes

e ex

ampl

es

to se

e, in

gen

eral

, how

muc

h fin

anci

al p

rote

ctio

n a

sam

ple

patie

nt m

ight

get

if th

ey a

re c

over

ed u

nder

di

ffer

ent p

lans

.

        n  Amount  owed  to  providers:  $7,540  

n  Plan  pays  $5,080  

n  Patient  pays  $2,460  

 Sample  care  costs:  

Hos

pita

l cha

rges

(mot

her)

$2

,700

Ro

utin

e ob

stet

ric c

are

$2,1

00

Hos

pita

l cha

rges

(bab

y)

$900

A

nest

hesia

$9

00

Labo

rato

ry te

sts

$500

Pr

escr

iptio

ns

$200

Ra

diol

ogy

$200

V

acci

nes,

othe

r pre

vent

ive

$40

Tot

al

$7,5

40

Patient  pays:  

Ded

uctib

les

$1,2

00

Cop

ays

$0

Coi

nsur

ance

$1

,260

Li

mits

or e

xclu

sions

$0

T

otal

$2

,460

 

        n  Amount  owed  to  providers:  $5,400  

n  Plan  pays  $3,750  

n  Patient  pays  $1,650  

 Sample  care  costs:  

Pres

crip

tions

$2

,900

M

edic

al E

quip

men

t and

Sup

plie

s $1

,300

O

ffic

e V

isits

and

Pro

cedu

res

$700

E

duca

tion

$300

La

bora

tory

test

s $1

00

Vac

cine

s, ot

her p

reve

ntiv

e $1

00

Tot

al

$5,4

00

Patient  pays:  

Ded

uctib

les

$800

C

opay

s $9

0 C

oins

uran

ce

$760

Li

mits

or e

xclu

sions

$0

T

otal

$1

,650

       

This  is    

not  a  cost  

estim

ator.    

Don

’t us

e th

ese

exam

ples

to

estim

ate

your

act

ual c

osts

un

der t

his p

lan.

The

act

ual c

are

you

rece

ive

will

be

diff

eren

t fr

om th

ese

exam

ples

, and

the

cost

of t

hat c

are

will

also

be

diff

eren

t.

See

the

next

pag

e fo

r im

port

ant

info

rmat

ion

abou

t the

se

exam

ples

.  

       9  of  9

 

Cook  Medical  

Cook  Group  Health  Plan:  Traditional  Plan  (TP)  Option    

Coverage  Period:  01/01/2017  –  12/31/2017    

Coverage  Exam

ples  

 Coverage  for:  Employee  &  Child(ren),  Family  |  Plan  Type:  PPO  

Que

stio

ns: C

all 1

.800

.593

.208

0 or

visi

t us a

t ww

w.c

ookm

edic

alcl

aim

s.co

m.

 If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms u

sed

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

vie

w th

e G

loss

ary

at w

ww

.coo

kmed

ical

clai

ms.

com

or c

all 1

.800

.593

.208

0 to

requ

est a

cop

y.

Questions  and  answers  about  the  Coverage  Exam

ples:  

    What  are  som

e  of  the  assumptions  

behind  the  Coverage  Exam

ples?    

•  C

osts

don

’t in

clud

e pr

emiu

ms.

•  

Sam

ple

care

cos

ts a

re b

ased

on

natio

nal

aver

ages

supp

lied

by th

e U

.S. D

epar

tmen

t of

Hea

lth a

nd H

uman

Ser

vice

s, an

d ar

en’t

spec

ific

to a

par

ticul

ar g

eogr

aphi

c ar

ea o

r he

alth

pla

n.

•  Th

e pa

tient

’s co

nditi

on w

as n

ot a

n ex

clud

ed o

r pr

eexi

stin

g co

nditi

on.

•  A

ll se

rvic

es a

nd tr

eatm

ents

star

ted

and

ende

d in

the

sam

e co

vera

ge p

erio

d.

•  Th

ere

are

no o

ther

med

ical

exp

ense

s for

any

m

embe

r cov

ered

und

er th

is pl

an.

•  O

ut-o

f-po

cket

exp

ense

s are

bas

ed o

nly

on

treat

ing

the

cond

ition

in th

e ex

ampl

e.

•  Th

e pa

tient

rece

ived

all

care

from

in-n

etw

ork

prov

ider

s. I

f the

pat

ient

had

rece

ived

car

e fr

om o

ut-o

f-ne

twor

k pr

ovid

ers,

cos

ts w

ould

ha

ve b

een

high

er.

What  does  a  Coverage  Exam

ple  show?    

For e

ach

treat

men

t situ

atio

n, th

e C

over

age

Exa

mpl

e he

lps y

ou se

e ho

w d

educ

tible

s,

copa

ymen

ts, a

nd c

oins

uran

ce c

an a

dd u

p. It

al

so h

elps

you

see

wha

t exp

ense

s mig

ht b

e le

ft up

to

you

to p

ay b

ecau

se th

e se

rvic

e or

trea

tmen

t isn

’t co

vere

d or

pay

men

t is l

imite

d.

Does  the  Coverage  Exam

ple  predict  m

y  own  care  needs?

û N

o. T

reat

men

ts sh

own

are

just

exa

mpl

es. T

he

care

you

wou

ld re

ceiv

e fo

r thi

s con

ditio

n co

uld

be d

iffer

ent b

ased

on

your

doc

tor’s

adv

ice,

yo

ur a

ge, h

ow se

rious

you

r con

ditio

n is,

and

m

any

othe

r fac

tors

. Does  the  Coverage  Exam

ple  predict  m

y  future  expenses?

ûN

o. C

over

age

Exa

mpl

es a

re n

ot c

ost e

stim

ator

s. Y

ou c

an’t

use

the

exam

ples

to e

stim

ate

cost

s fo

r an

actu

al c

ondi

tion.

The

y ar

e fo

r co

mpa

rativ

e pu

rpos

es o

nly.

You

r ow

n co

sts

will

be

diff

eren

t dep

endi

ng o

n th

e ca

re y

ou

rece

ive,

the

pric

es y

our p

rovi

ders

cha

rge,

and

th

e re

imbu

rsem

ent y

our h

ealth

pla

n al

low

s.

Can  I  use  Coverage  Exam

ples  to  

compare  plans?

üY

es. W

hen

you

look

at t

he S

umm

ary

of B

enef

its

and

Cov

erag

e fo

r oth

er p

lans

, you

’ll fi

nd th

e sa

me

Cov

erag

e E

xam

ples

. Whe

n yo

u co

mpa

re

plan

s, ch

eck

the

“Pat

ient

Pay

s” b

ox in

eac

h ex

ampl

e. T

he sm

alle

r tha

t num

ber,

the

mor

e co

vera

ge th

e pl

an p

rovi

des.

Are  there  other  costs  I  should  consider  

when  comparing  plans?

üY

es. A

n im

porta

nt c

ost i

s the

pre

miu

m y

ou

pay.

Gen

eral

ly, t

he lo

wer

you

r pre

miu

m, t

he

mor

e yo

u’ll

pay

in o

ut-o

f-po

cket

cos

ts, s

uch

as

copa

ymen

ts, d

educ

tible

s, a

nd c

oins

uran

ce.

You

shou

ld a

lso c

onsid

er c

ontri

butio

ns to

ac

coun

ts su

ch a

s hea

lth sa

ving

s acc

ount

s (H

SAs)

, fle

xibl

e sp

endi

ng a

rran

gem

ents

(FSA

s)

or h

ealth

reim

burs

emen

t acc

ount

s (H

RAs)

that

he

lp y

ou p

ay o

ut-o

f-po

cket

exp

ense

s.

The online enrollment will take you through a series of easy to read screens to validate your personal information, add or delete dependents, and allow you to select your benefits for 2017.

For 2017, the online enrollment system offers you two ways to enroll in benefits:

1) If you don’t want to make any changes for 2017, you can use the “Quick Enrollment” screen to easily transfer your 2016 benefit elections into 2017.

2) If you need to make changes to your benefits for 2017, you must go through each benefit enrollment screen and make your individual benefit plan elections or declinations.

Whichever method you choose, please read the instructions on the enrollment screens before making your elections! The screens will display a per pay period cost for each selection and a cumulative 2017 cost per pay for all selections you have made up to that point. Selecting your benefits is a simple click of the button next to the plan best for you! If you choose not to elect a benefit, you must click on the “DECLINE” button. To save your elections at the end of the session make certain you click on the “SUBMIT ELECTION” button. “PRINT” and “SAVE” your 2017 Benefit Election Confirmation Statement. The internet address for the online benefits enrollment site is: www.mycookgroupbenefits.com

To begin your enrollment session:

1) You will need your 5 digit employee number. This can be found on your check stub. On the stub, your employee number is the last 5 numbers of the ID Number. A human resource representative can also help you determine your employee number.

2) The system will use your birth date as your temporary personal identification number (“PIN”) the first time you log into the system. The format of your birth date PIN is MMDDYY. If your birth date was May 10, 1955 you would enter 051055 in the system. You will then be asked to establish a new PIN that is different from your birth date, which should be used for all other times you use the system. However, you can continue to use your birth date as your new PIN.

ENROLLMENT SCREENS

Personal Information Screen

Please verify your personal information and make any changes in the non-shaded areas. Notify a human resource representative of any changes in the shaded areas. Make certain your home address is accurate.

Medical, Optional Term Life Insurance and Optional Accidental Death and Dismemberment Covered Dependents Screen

If you are enrolling your spouse and/or dependents in the COOK Health Plan (health plan), optional life insurance plan or the optional accidental death and dismemberment insurance plan, please have their social security numbers and birth dates handy before you begin your session. You will not be able to go to the next screen without this information. Make certain you click on the “DISK” symbol next to the dependent information you entered to ensure you have saved the information and enrolled your dependent.

Your spouse is NOT eligible for the COOK Health Plan if their employer offers health insurance, and the premium is less than $250 per month for single coverage. An ex- spouse cannot remain on the COOK Health Plan following a divorce unless the ex-spouse elects COBRA. It is your responsibility to notify the COOK Insurance Department within 30 days of a divorce and by the end of the month in which a son or daughter turns age 26.

Quick Enrollment Screen

The screen called “Quick Enroll “ allows you to make one click on “Elect 2017 Benefits the same as 2016” and you will be enrolled in the same benefits for 2017 that you had in 2015. This button is located at the bottom of the screen. Just click on it and you will be enrolled in the same health plan option, same health flexible spending account amount, the same optional term life insurance amount, the same accidental death and dismemberment insurance amount, and voluntary disability insurance options for 2017 that you had in 2015. New 2017 employee premiums will be highlighted in “red.”

2017 ONLINE BENEFITS ENROLLMENT INSTRUCTIONS

Health Care Flexible Spending Account (HFSA) Screen

The maximum annual election for your 2017 health flexible spending account is $2,500, and the minimum election is $100. You may elect this benefit, even if you are not participating in the health insurance. If you do not want to participate in a health flexible spending account for 2017, you must select “DECLINE” to continue. Your 2017 HFSA can only be used for out of pocket expenses incurred between January 1, 2017 and December 31, 2017.

You can also elect to have your health flexible spending account reimbursements deposited directly into your checking or savings account. Simply print off the Direct Deposit Form under Forms and Materials at the top of the screen, complete it, and mail it to the COOK Insurance Department. The address is on the form.

Optional Employee and Dependent Term Life Insurance Screen

Term life Insurance is optional. Keep in mind effective January 1, 2017 if your annual earnings are less than $50,000, you have $75,000 of company paid term life insurance coverage. If you annual earnings are $50,000 or more, you have company paid term life insurance coverage equal to 1.5 times annual earnings up to a maximum of $150,000.

If you are currently not enrolled in optional employee term life insurance and have not been denied coverage in the past, you can elect up to $40,000 with no evidence of insurability required. If you are increasing current coverage for more than $40,000, you must complete the Prudential Evidence of Insurability Form that pops up on the enrollment screen and be approved for your coverage election by Prudential. If you are electing new or additional coverage for your spouse, you must complete a Prudential Evidence of Insurability Form and be approved by Prudential.

Optional Accidental Death and Dismemberment Insurance Screen

Accidental death & dismemberment insurance is optional. Keep in mind if your annual earnings are less than $50,000, you have $75,000 of company paid accidental death and dismemberment insurance coverage. If your annual earnings are $50,000 or more, you have company paid accidental death and dismemberment coverage equal to 1.5 times annual earnings up to a maximum of $150,000.

Voluntary Long Term Disability Screen

If you are enrolling in the voluntary long term disability plan for the first time, you must fully complete and submit the Prudential Evidence of Insurability Form online that pops up during the enrollment process. Paper enrollment forms will not be accepted. Your Evidence of Insurability Form must be approved by Prudential which could take several weeks. If coverage is denied, any payroll deductions taken during the Evidence of Insurability approval process will be refunded.

Enrollment Preview Screen

Review your elections and make any necessary corrections then click “SUBMIT ELECTIONS” to process your 2017 benefit elections. Continue to the next screen. Note: You will have until the end of November to log back in and make changes to your 2017 benefit elections. Each time you log back in and make a change, you are required to re-elect all of your benefits and click “SUBMIT ELECTIONS” again. Your last benefits enrollment election is the one that will be used for 2017.

2017 Benefits Confirmation Screen

Print your 2017 Benefits Confirmation Statement and save it for future reference. Make sure you double-check all dependent information for accuracy. You may now log off. If you have not already registered for Castlight you can do it now by clicking “Castlight.” It requires you to provide an email address and create a password. After you print your 2017 Benefits Confirmation Statement promptly remove it from the printer as it contains your personal information.

Please contact your human resource representative if you have any questions about your benefits or the online enrollment process.

Because the COOK Group Health Plan (“Plan”) covers medical and surgical services for mastectomies, a federal law called the “Women’s Health and Cancer Rights Act of 1998” requires the Plan to also cover reconstructive surgery.

Therefore, if a participant or beneficiary of the Plan receives benefits in connection with a mastectomy and, in consultation with the patient’s attending physician, elects breast reconstruction in connection with the mastectomy, the Plan will cover the following services and supplies:

• Reconstruction of the breast on which the mastectomy has been performed

• Surgery and reconstruction of the other breast to produce a symmetrical appearance

• Prostheses

• The treatment of physical complications arising in all stages of mastectomy, including lymphedemas

Such coverage is, however, subject to the regular annual deductibles and coinsurance provisions of the Plan.

COOK GROUP HEALTH PLAN COVERAGE UNDER THE WOMEN’S HEALTH AND CANCER RIGHTS ACT

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

This notice has information about your current prescription drug coverage with the Cook Group Health Plan and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

IMPORTANT NOTICE FROM THE COOK GROUP HEALTH PLAN ABOUT YOUR PRESCRIPTION DRUG COVERAGE AND MEDICARE 2017

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

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

2. Cook Group has determined that the prescription drug coverage offered by the Cook Group Health Plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage.

Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

When Can You Join A Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide To Join A Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current Cook Group Health Plan coverage will not be affected. The Clinic Plan and Traditional Plan each have a prescription drug deductible of $300 per family per year. Generally, the Plan pays 80% of the cost of the drug and you pay the remaining 20% up to a $100 maximum for each 30-day supply. If you are a participant in the Clinic Plan and you do not purchase drugs from the Clinic pharmacy, then the Plan will pay only 50% of the cost of the drug. Brand name and generic drugs are covered by the Plan. There is no annual or lifetime maximum drug benefit. See pages 7-9 of the CMS Disclosure of Creditable Coverage To Medicare Part D Eligible Individuals Guidance available at https://www.cms.gov/Medicare/PrescriptionDrug-Coverage/CreditableCoverage/downloads/Updated_Guidance_02_15_07.pdf which outlines the prescription drug provisions/options that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D.

If you decide to join a Medicare drug plan and drop your current Cook Group Health Plan coverage, you and your dependents will be able to get this coverage back during open enrollment.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?

You should also know that if you drop or lose your current coverage with the Cook Group Health Plan and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without credible prescription drug coverage, your monthly premium may go up at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go 19 months without credible coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay the entire premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

CMS Form 10182-CC

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938–0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to-CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C-4–26–05, Baltimore, MD 21244–1850.2.

Updated April 1, 2011

Continued on reverse side

For More Information About This Notice Or Your Current Prescription Drug Coverage:

Contact the person listed below for further information or call the Cook Group Benefits Coordinator at 800.468.1379.

Note: You’ll get this notice each year before the next period you can join a Medicare drug plan, and if this coverage through the Cook Group Health Plan changes. You may also request a copy of this notice at any time.

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage

• Visit www.medicare.gov

• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help

• Call 800.MEDICARE (800.633.4227). TTY users should call 877.486.2048

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security’s website www.socialsecurity.gov, or call them at 800.772.1213 (TTY 800.325.0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and whether or not you are required to pay a higher premium (a penalty).

Date: January 20, 2016

Name of Entity/Sender: Cook Group Health Plan

Contact--Position/Office: Ms. Debbie Snyder

Address: P.O. Box 1029, Bloomington, IN 47402

Telephone Number: 812.355.2528 or 800.593.2080

CMS Form 10182-CC

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938–0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to-CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C-4–26–05, Baltimore, MD 21244–1850.2.

Updated April 1, 2011

Continued on reverse side

PREMIUM ASSISTANCE UNDER MEDICAID AND THECHILDREN’S HEALTH INSURANCE PROGRAM (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

IF YOU LIVE IN ONE OF THE FOLLOWING STATES, YOU MAY BE ELIGIBLE FOR ASSISTANCE PAYING YOUR EMPLOYER HEALTH PLAN PREMIUMS. THE FOLLOWING LIST OF STATES IS CURRENT AS OF JULY 31, 2016. CONTACT YOUR STATE FOR MORE INFORMATION ON ELIGIBILITY.

ALABAMA – Medicaid Website: www.myalhipp.com Phone: 855.692.5447

ALASKA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone 866.251.4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

ARKANSAS – Medicaid Website: http://myarhipp.com/ Phone: 855.MyARHIPP (855.692.7447)

COLORADO – Medicaid Medicaid Website: http://www.colorado.gov/hcpf Medicaid Customer Contact Center: 800.221.3943

FLORIDA – Medicaid Website: https://www.flmedicaidtplrecovery.com/hipp/ Phone: 877.357.3268

GEORGIA – Medicaid Website: : http://dch.georgia.gov/medicaid Click on “Health Insurance Premium Payment (HIPP)” Phone: 404.656.4507

INDIANA – Medicaid Healthy Indiana Plan for low income adults 19-64 Website: http://www.hip.in.gov Phone: 877.438.4479 All other Medicaid Website: http://www.indianamedicaid.com Phone: 800.403.0864

IOWA – Medicaid Website: www.dhs.state.ia.us/hipp Phone: 888.346.9562

KANSAS – Medicaid Website: http://www.kdheks.gov/hcf Phone: 785.296.3512

KENTUCKY – Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 800.635.2570

LOUISIANA – Medicaid Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 888.695.2447

MAINE – Medicaid Website: http://www.maine.gov/dhhs/ofi/public-assistance/ index.html Phone: 800.442.6003 TTY: Maine relay 711

MASSACHUSETTS – Medicaid and CHIP Website: http://www.mass.gov/MassHealth Phone: 800.462.1120

MINNESOTA – Medicaid Website: http://mn.gov/dhs/ma/ Phone: 800.657.3739

MISSOURI – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573.751.2005

MONTANA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 800.694.3084

NEBRASKA – Medicaid Website: http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/acessnebraska_index.aspx Phone: 855.632.7633

NEVADA – Medicaid Medicaid Website: http://dwss.nv.gov Medicaid Phone: 800.992.0900

NEW HAMPSHIRE – Medicaid Website: www.dhhs.nh.gov/oii/documents.hippapp.pdf Phone: 603.271.5218

NEW JERSEY – Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid Medicaid Phone: 609.631.2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 800.701.0710

NEW YORK – Medicaid Website: http://www.nyhealth.gov/health_care/medicaid Phone: 800.541.2831

NORTH CAROLINA – Medicaid Website: http://www.ncdhhs.gov/dma Phone: 919.855.4100

NORTH DAKOTA – Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid Phone: 844.854.4825

OKLAHOMA – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 888.365.3742

OREGON – Medicaid and CHIP Website: http://www.healthcare.oregon.gov/Pages/ index-aspx Website: http://www.oregonhealthcare.gov/index-es.html Phone: 800.699.9075

PENNSYLVANIA – Medicaid Website: http://www.dpw.pa.gov/hipp Phone: 800.692.7462

RHODE ISLAND – Medicaid Website: www.eohhs.ri.gov Phone: 401.462.5300

SOUTH CAROLINA – Medicaid Website: http://www.scdhhs.gov Phone: 888.549.0820

SOUTH DAKOTA – Medicaid Website: http://dss.sd.gov Phone: 888.828.0059

TEXAS – Medicaid Website: www.gethipptexas.com Phone: 800.440.0493

UTAH – Medicaid and CHIP Medicaid: http://health.utah.gov/medicaid CHIP: http://health.utah.gov/chip Phone: 877.543.7669

VERMONT– Medicaid Website: http://www.greenmountaincare.org Phone: 800.250.8427

VIRGINIA – Medicaid and CHIP http://www.coverva.org/programs_premium_assistance. cfm Medicaid Phone: 800.432.5924 CHIP Website: http://www.coverva.org/programs_premium_assistance. cfm CHIP Phone: 855.242.8282

WASHINGTON – Medicaid Website: http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-program Phone: 800.562.3022, ext. 15473

WEST VIRGINIA – Medicaid Website: http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/default.aspx Phone: 877.598.5820, HMS Third Party Liability

WISCONSIN – Medicaid & CHIP

Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 800.362.3002

WYOMING – Medicaid Website: https://wyequalitycare.acs-inc.com/ Phone: 307.777.7531

To see if any other states have added a premium assistance program since July 31, 2016, or for more information on special enrollment rights, contact either:

U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/ebsa 866.444.EBSA (3272)

U.S. Department of Health and Human Services Centers for Medicare and Medicaid Services www.cms.hhs.gov 877.267.2323, Menu Option 4, ext. 61565

OMB Control Number 1210-0137 (expires 10/31/2016)

Overview

This Notice of Privacy Practices is provided by the Cook Group (“Cook”), to participants of our Group Health Plan or Group Cafeteria Plan (“Health Plans”), and to patients who receive treatment at the Cook Family Health Center (“Health Center”) by healthcare staff or physicians. It describes how your health information (called “Protected Health Information” or “PHI”) may be collected, used and disclosed by the Health Plans and/or Health Center, as well as your rights in relation to that information. Please use the contact information contained in this Notice if you have any questions or would like to contact us.

How We Protect Your Privacy

The Cook Health Plans and the Health Center are required to comply with federal and state privacy, security and genetic information protection laws in connection with your health information. This means that they can collect and use your health information only for purposes that are allowed under those laws, and must take steps to safeguard your data in accordance with the legal requirements. With respect to the privacy of your genetic information, it also means that the Health Plans, the Health Center and the third parties assisting them (Business Associates or subcontractors) are specifically prohibited from using your genetic information for purposes of insurance underwriting (i.e., setting rates or insurance coverage terms based upon genetic data).

How We Use and Disclose Your Protected Health Information

This section describes the ways that the Health Plans and the Health Center may use and disclose your protected health information without first seeking written authorization from you. Please note that for any of these disclosures, only the minimum necessary information (i.e., that which is necessary and relevant) from your medical record is disclosed.

• Treatment Your information may be used or disclosed in connection with treatment, such as sharing relevant information with other healthcare providers involved in your care.

• Payment Your information may be used or disclosed in connection with obtaining payment for your healthcare services or administering your insurance coverage.

• Healthcare Operations Your information may be used or disclosed for certain types of approved administrative purposes, such as to conduct an audit.

• Outside Service Providers (Business Associates) Your information may be used or disclosed in connection with outside service providers (“Business Associates”) retained by the Health Plans or Health Center.

• Public Health Activities Your information may be used or disclosed in connection with public health activities that are authorized by law, such as to prevent or control disease, injury or disability.

• Health or Safety Your information may be used or disclosed to prevent or lessen a serious threat to your health or safety or that of the general public.

• Health Oversight Activities Your information may be used or disclosed in connection with government or regulatory oversight or compliance, such as to health authorities to report adverse events or product defects, to enable recalls or for similar safety reasons. It may also be accessible to agencies that evaluate billing or other legal or healthcare matters.

• Victims of Abuse, Neglect, or Domestic Violence Your information may be used or disclosed in connection with reporting to government agencies authorized by law to receive reports of abuse, neglect or domestic violence.

• Certain Limited Research Purposes Your information may be used or disclosed in connection with certain limited research purposes, as authorized by law.

• Workers Compensation Your information may be used or disclosed in connection with complying with workers’ compensation laws and regulations.

• Judicial, Administrative, Government and Legal Obligations Your information may be disclosed to the police, other law enforcement officials, or the government in connection with legal proceedings, compliance with a court order, or for other legal or judicial or law enforcement processes as authorized or required by law.

COOK GROUP HEALTH PLAN AND COOK GROUP CAFETERIA PLANNOTICE OF PRIVACY PRACTICES

Uses and Disclosures With Your Written Authorization

Other than the uses and disclosures described in this Notice, the Health Plans and Health Center may not use or disclose your information without your written authorization. This includes, for example, any proposed use or disclosure of your information for a marketing or sales purpose. You may revoke any such authorization in writing except to the extent that the Health Plans and Health Center have already taken action in reliance on your authorization.

Your Individual Rights

Right to Request Additional RestrictionsYou have the right to request additional restrictions on certain uses and disclosures of your PHI to carry out treatment, payment or healthcare operations functions as described in this Notice. For example, you can request that your PHI be disclosed to certain family members or others who may assist with your medical care, and not be disclosed to others. While the Health Plans and Health Center will consider all requests carefully, they are not always required to agree to the requested restriction. If they agree to honor your request, the Health Plans/Health Center will not use or disclose your personal health information in the way you specified unless the information is needed to provide emergency treatment. If they are required to disclose restricted information due to an emergency, they will request assurances from the service provider that the service provider will not further disclose your personal health information.

Right to Avoid Disclosures to Health Plans for Payment or Healthcare OperationsYou have the right to request that your PHI not be provided to the Health Plans and/or Health Center in situations where the disclosure (1) is related to payment or healthcare operations, and (2) you paid for the service in full yourself, without any insurance reimbursement. This right must generally be exercised in advance of any treatment, and there are certain requirements to do so. Please ask the Benefits Department or Health Center medical staff for additional information.

Right to Receive Confidential CommunicationsIn certain circumstances, you may ask to receive confidential communications of PHI in a manner outside of the Health Plans’ or Health Center’s normal procedures. While all reasonable requests will be carefully considered, those entities are regrettably not able to agree to all requests.

Right to Inspect and Obtain a Copy of Your Personal Health InformationYou may ask to inspect or to obtain a copy of your personal health information that is included in certain records maintained by the Health Plans or Health Center. Under limited circumstances, they may deny you access to a portion of your records. In addition, this right does not apply to certain types of information – psychotherapy notes; information that may be used in a civil, criminal, or administrative action or proceeding; and information that is not part of the records  they maintain. You have the right to request your information in electronic format, provided that it is maintained in that format.

Right to Amend Your RecordsYou have the right to ask the Health Plans and/or Health Center to amend your personal health information that is included in certain records that they maintain. If it is determined by authorized representatives of those entities that the record is inaccurate, and the law permits the Health Plans/Health Center to amend the record, they will amend it. If your doctor or another person created the information that you want to change, you should ask that person to amend the information.

Right to Receive an Accounting of DisclosuresUpon request, you may obtain an accounting of disclosures of your personal health information made by the Health Plans, the Health Center or their respective business associates. The accounting will not include disclosures made earlier than three years before the date of your request, and certain other disclosures that are excluded by law. If you request an accounting more than once during any 12-month period, you will be charged a reasonable fee for each accounting statement after the first one. If you request an accounting relating to disclosures by business associates, the Health Plans/Health Center will either provide you with such an accounting directly, or they may choose to provide you with the contact information for those business associates, such that you may request an accounting directly from them.

Right to be Notified of Security Breaches Involving Your InformationIn accordance with the federal and state breach notification laws and requirements, you have the right to receive notification in the event that the Health Plans, Health Center or their respective Business Associates or subcontractors suffer a security breach involving your personal information.

Right to Receive a Paper Copy of this NoticeYou may contact the Cook Benefits Department or the Health Center to obtain an additional copy of this Notice at any time.

Copying FeesYou may be charged a reasonable fee to cover costs related to copying or preparing your information, in connection with requests for copies of your health records.

Revisions to this Notice

The terms of this Notice may be changed from time to time. If so, the additional protections contained in the updated Notice terms may be made effective for all of your PHI maintained by the Health Plans/Health Center, including any information that was created or received before the new Notice was issued. If this Notice is revised, the revised notice will be promptly delivered to all enrollees.

Amendment to The Health Plans

This Notice is also intended to serve as an amendment to the Health Plans. It is also a summary of material modifications to update your summary plan descriptions for the Health Plans. To the extent of these changes, this summary of material modifications takes precedence over your summary plan descriptions. You may inspect copies of the Health Plan documents themselves during normal business hours by contacting the Cook Group Benefits Department. As always, the Health Plan sponsor retains the right to terminate the Health Plans at any time and may amend or otherwise modify the Health Plans at any time.

Complaints

If you believe the Health Plans or Health Center has violated your privacy rights, you may file a complaint with the Health Plans, Health Center, or with the U.S. Secretary of Health and Human Services. Complaints to the Health Plans or Health Center should be filed in writing with the Cook Global Privacy Office, P.O. Box. 1608, Bloomington, Indiana, 47402. The Health Plans and Health Center have put in place a process for handling all complaints. Cook Group also has a process for ensuring there is no retaliation against anyone who files a complaint based upon a legitimate belief that their privacy or security has been violated by these entities

Contact Information to Exercise Your Rights

If you want to exercise any of your rights from the Health Plans or Health Center as described in this Notice, the contact information is as follows:

CATEGORY EXAMPLES OF INFORMATION COOK DEPARTMENT CONTACT INFORMATION

Privacy Security • Privacy or security question

• Protection of genetic data

• Complaint

Cook Group Privacy Office

Megan J. CharlesworthPrivacy OfficerCook Group Health Plan TrustP.O. Box 1608Bloomington, Indiana 47402812.331.1025megan.charlesworth@cookgroup.com

Benefits Coverage

• Benefits question Cook Group Benefits Department

Cook Benefits DepartmentCook Group Health PlanCook Group Cafeteria PlanP.O. Box 1608Bloomington, Indiana 47402800.593.2080 or 812.355.2528

Changes Copies

• Individual access request

• Request for amendment

• Request for disclosures

• Change of address, name

• Copies of records

Cook Family Health Center

Cook Family Health Center402 North Rogers StreetBloomington, IN 47404812.330.9944

Contact Information to Exercise Your Rights

This Notice is effective as of July 31, 2016.