HAWAII BENEFITS GUIDE - PSEB€¦ · Supplemental Plans 19 Accidents, Critical Illness, Hospital ... dental, vision, and life insurance plans. Eligible dependents include: • Spouse

HAWAIIBENEFITS GUIDEJUNE 1, 2019 – MAY 31, 2020

Eligibility & Enrollment | 2

If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, Federal law gives you more choices about

your prescription drug coverage. See page 27 for more details.

This guide contains an overview of the PSEB benefit programs. Should any discrepancy arise between this guide and the official plan documents, the official plan documents will govern in all cases. Although we intend to continue this program, PSEB reserves the right to change and/or

terminate any portion of the benefit program at any time for any reason with or without notice. Participation in the benefit program does not give anyone the right to continued employment

with PSEB.

PSEB BENEFITS AT A GLANCE

As you review this guide, be on the look-out for this icon. While we

encourage you to review the full guide, this icon calls attention to changes or

required action steps.

TABLE OF CONTENTS

Eligibility & Enrollment 4Who Is Eligible? Qualifying Life EventsThe PSEB CollectiveActive Open Enrollment / Enrolling in UltiPro

Keeping You Healthy 7

Medical 8HMAA PPO

Prescriptions 10Express Scripts

Dental 11Aetna Basic Dental PPOAetna Enhanced Dental PPO

Vision 12VSP Choice Network

Protecting Your Income 13

Flexible Spending Accounts (FSA) 14Healthcare FSA (Navia)Dependent Care FSA (Navia)Commuter FSA (Navia)

Life Insurance 15Company-Paid Basic Life/AD&D (Cigna)Voluntary Life (Cigna)Voluntary AD&D (Cigna)

Disability Insurance 16Short-Term Disability (Cigna) Company-Paid Long-Term Disability (Cigna)Voluntary Long-Term Disability (Cigna)

Supplemental Plans 19Accidents, Critical Illness, Hospital (Aetna) Legal (Hyatt Legal)Identity Theft Protection (InfoArmor)

Supporting Your Life Beyond Work 21

Employee Assistance Program 22EAP (Cigna)

Associate Discount 23

Benefit Contacts 24

Required Legal Notices 26


Eligibility & Enrollment

GROUP 2* GROUP 3* GROUP 4*

x = Eligible For Benefit30 - 40 hours

30 - 39 hours

20 - 29 hours

Less than 20 hours

Keeping You Healthy

Medical x x x x

Prescriptions x x x x

Dental x x x x

Vision x x x x

Protecting Your Income

Flexible Spending Accounts x x x

Life Insurance (Company-paid) x x

Life Insurance (Voluntary Associate-paid) x x x x

Short-Term Disability (Statutory Hawaii) x x x x

Short-Term Disability (Company-paid over Statutory Plan) x x x

Long-Term Disability (Company-paid) x

Long-Term Disability (Voluntary Associate-paid) x x

Supplemental Plans (Voluntary Associate-paid) x x x

Supporting Your Life Beyond Work

Employee Assistance Program (EAP) x x x

Associate Discount x x x x x

You are eligible to enroll in a health benefits plan (Medical, Prescription, Dental, Vision, FSA) if you are a full-time associate working an average of 20 hours per week - OR - if you are a part-time associate working an average of 20-hours per week during your initial measurement period or the company’s standard measurement period. The measurement period is the time the company uses to track hours worked and determine if you have worked an average of 20 hours per week or more. If it has been deter-mined that you have worked an average of 20 hours or more during your measurement period, you are eligible to enroll in health benefits and receive coverage for up to 12 months while the company tracks your hours to determine eligibility for the next 12 months. You may also enroll eligible dependents including spouse, dependent children up to age 26, and dependent children past the age limit who cannot work to support themselves due to physical or mental disability.

Associate Eligibility

Eligibility for benefits is based on your position, full-time or part-time status, and average hours worked. The chart below outlines the benefit offerings available to PSEB associates.

* Eligible Associate Roles

• GROUP 2: District Managers

• GROUP 3: Store Managers**, FT Assistants

• GROUP 4: PT Assistants, Lead, Seasonal Sales Lead, Sales Associates

** Store Managers now receive Company-Paid LTD benefits

Waiver Required By State Law: If you choose not to enroll in

medical coverage with PSEB, due to other coverage, you are required to complete form

HC-5 Employee Notification to Employer every year. Visit The PSEB Collective to print a form.


Dependent Eligibility

Once you enroll yourself in coverage, you may also enroll your eligible dependents in medical, dental, vision, and life insurance plans.

Eligible dependents include:• Spouse• Dependent children up to age 26 (includes legally adopted and step-children)• Dependent children past the age limit who cannot work to support themselves due to physical or mental disability and meets carrier

requirements

We will perform periodic audits where you may be asked to submit the following documentation to verify dependent eligibility:• Marriage Certificate for your Legal Married Spouse• Birth Certificate for your Child(ren)

Misrepresentation of information, as it relates to a dependent’s relationship for eligibility, shall be considered grounds for disciplinary action, up to and including separation of employment. Qualifying Life Events

The benefits you elect will stay in place through May 31, 2020 unless you have a qualifying life event as defined by the IRS. In the case of a life event, contact the Benefits Team within 31 days of the event to confirm eligibility and discuss required action steps.

Examples of qualifying life events include:• Marriage• Divorce or legal separation• Addition of a dependent through birth or adoption• Death of a spouse, child, or covered dependent• Change in your or your spouse’s employment status, including the gain or loss of benefit eligibility• Dependent no longer meets the definition of an eligible dependent• Any other status changes permitted by law and consistent with plan administration

Introducing: The PSEB Collective

This guide provides an overview of benefit options, but there is much more to discover. Visit The PSEB Collective, our new benefits website at https://TheCollective.psebllc.com. This website is available on any internet-enabled device—at home or at work.

Active Open Enrollment

It’s Open Enrollment time at PSEB. This is your annual opportunity to enroll or decline benefits coverage. And this year it’s an Active Open Enrollment, which means that every eligible associate is required to enroll in or decline benefits before 8:59 pm PT / 11:59 pm ET on May 17, 2019. Submit your selections before the deadline or you will lose coverage on May 31, 2019.

Watch our What’s Changing Video for an overview of changes and action steps this Open Enrollment period:• Text “PSEB639” to 61759• Visit http://bit.ly/OEChanges

Action required! Submit your online enrollment by

May 17, 2019 or you will lose coverage on May 31, 2019.

Eligibility &Enrollment continued


Helpful Tips

Tips below are color coded in the image on the right.

1. Draft Button. A Draft button appears on the top of most enrollment screens. Select this button to save your progress and return later. Please ensure that you return and submit your elections prior to the deadline.

2. Current Coverage Box. A gray box will appear on the right margin of each screen to show your 2018-2019 elections. Click the arrow to expand the box so you may compare costs between current and future elections.

3. Decline Box. If you don’t want to enroll in coverage, select the “I decline plans” box. A selection is required on every screen. If you decline medical, dental, or vision coverage, you’ll be asked to provide feedback on what influenced your decision.

Enrolling In UltiPro

All associates now enroll in benefits online in UltiPro! And UltiPro is accessible from any internet enabled device—at home or work.

Quick Start Guide

Instructions below are color coded in the image on the right.

1. Visit http://n33.ultipro.com First time in UltiPro? Visit EB Net/The Lounge/PCH or contact your manager for log-in instructions.

2. Navigate to Menu in the top left corner of the Home Screen3. Navigate to the Myself tab4. Select Open Enrollment5. Follow the system prompts to work through the enrollment

process6. Once comfortable with your selections, hit the Submit button to

send your enrollment to the Associate Service Center7. Print your confirmation statement for your records

Watch our Enrolling in UltiPro video! Visit http://bit.ly/ULTIPRO19

or text PSEB520 to 61759

Enrolling on a Mobile Device

You may complete your Open Enrollment action steps from any internet-enabled device—from home or work. If you are accessing from a mobile device, hit the “View Desktop Version” link before logging in. Open Enrollment features are NOT available via the UltiPro App.

Eligibility & Enrollment continued

Keeping You Healthy | 7

Keeping You Healthy

Promoting a healthy lifestyle is what PSEB is all about. It’s at our core. It’s what we sell and how we live — at work and in our personal lives. That’s why PSEB offers associates important benefits such as medical, dental, and vision.


HMAA PPO

The Hawaii Medical Assurance Association (HMAA) PPO plan offers access to HMAA’s provider network. For both in and out-of-networkproviders, you must meet the annual deductible before the plan’s coinsurance begins.

With the PPO plan, you have a choice every time you need care. Your network physicians will submit claims for you. If you receive treatment from an out-of-network physician, they may require you to pay the entire amount at the time of service and then submit a claim for reimbursement.

You may choose to have your treatment provided by an in or out-of-network provider. However, you will have lower out-of-pocketcosts when care is received from an in-network physician.

Preventive Care

Coverage for specific preventive care services is free when you see an in-network provider. A list of preventive services is available at www.healthcare.gov/coverage/preventive-care-benefits.

Find a Doctor

Follow the instructions below to to see if your doctor is in-network or to find a new doctor:1. Visit www.hmaa.com2. Select “Find a Provider”3. Select “HWMG: Medical & Dental Providers in Hawaii”4. Follow the on-screen prompts to find a doctor in your area

Medical

Spousal Surcharge

In line with national healthcare trends, PSEB is implementing a spousal surcharge. Associates who choose to cover a spouse who has the option to elect healthcare coverage

through his/her own employer will pay a $46 surcharge per pay period. To help you determine if the surcharge applies to your situation, please review the following scenarios:

You will be subject to the SURCHARGE:• If your spouse is working at an employer who offers group

health insurance, but has declined that coverage and wants to remain on a PSEB medical plan.

• If your spouse is eligible and/or enrolled in Medicare, but is still actively working at their own employer, who offers group health insurance, and chooses PSEB medical plan coverage.

• If your spouse is offered coverage for any time period throughout the year with their employer, and you choose to continue their coverage on a PSEB medical plan.

You will NOT be subject to the SURCHARGE:• If your spouse works part-time and has no access to health

coverage through an employer sponsored plan.• If your spouse is eligible and/or enrolled in Medicare, and is not

actively working but is currently covered as a dependent on your PSEB medical plan.

• If your spouse is a retiree from another employer, but is not actively working.

• If your spouse is unemployed and has no access to health coverage through an employer sponsored plan.

• If your spouse is self-employed and has no access to health coverage through an employer sponsored plan.

You will be asked to attest to whether or not your covered spouse has declined benefits through his or her employer when you complete your online enrollment in UltiPro.


BENEFIT IN-NETWORK OUT-OF-NETWORK

Calendar Year DeductibleAssociate: $100

Associate + Dependent(s): $300Associate: $100

Associate + Dependent(s): $300

Calendar Year Out-of-Pocket Maximum Associate: $2,000Associate + Dependent(s): $6,000

Associate: $2,000Associate + Dependent(s): $6,000

Lifetime Maximum Unlimited Unlimited

Preventive Care No charge No charge

Office Visit (Primary (PCP) / Specialist)

$15 copay $15 copay

Maternity (Prenatal/Postnatal Services)

90% 90%

Diagnostic Lab Services 80% 80%

Urgent Care $25 copay $25 copay

Inpatient Hospitalization 80% 80%

Outpatient Surgery 80% 80%

Emergency Room 80% 80%

Ground Ambulance Air Ambulance

80%80% after deductible

80%80% after deductible

Mental Health (Outpatient) $15 copay $15 copay

Outpatient Short-Term Rehabilitative Therapy

80% after deductible 80% after deductible

BI-WEEKLY RATES

Associate Only $5.33

Associate + Spouse $71.20

Associate + Child(ren) $77.67

Associate + Family $100.33

HMAA PPO Plan


Prescriptions

Associates enrolled in the HMAA medical plan receive prescription coverage through OptumRX at no additional cost.

Short-Term Medications

A retail pharmacy should be used when filling prescriptions for short-term medications such as antibiotics. When filling a short-term prescription at a retail pharmacy, simply present your member ID card to the pharmacist. You will pay a copay based on the type of prescription and will receive a 30-day supply

Ask For Generic Drugs

Generic drugs have the same active ingredients, dosage, and strength as their brand name counterparts and can cost significantly less. Ask your physician if a suitable, alternative generic drug is available. If you do not use generic drugs when they are available, you will pay the difference between the cost of the generic and the brand name drug unless your doctor writes “dispense as written” on the prescription.

Long-Term Maintenance Medications

Maintenance medications are those you take regularly for ongoing conditions, such as high blood pressure, cholesterol levels, diabetes, asthma, and arthritis. You are encouraged to use the mail order program for long-term maintenance medications. When you use the home delivery mail order service, you will receive a 3-month supply for the cost of 2-months.

Ask your doctor to write a new prescription for your plan’s maximum days’ supply with refills up to 1 year, as appropriate. You may mail your prescriptions in or ask your doctor to call 808-941-4622 for fax instructions. If your order is faxed, your doctor will need your member ID number found on your member ID card.

BENEFIT RETAIL PHARMACY

SHORT-TERM DRUGS

MAIL ORDER

LONG-TERM DRUGS

Supply 30-Day Supply 90-Day Supply

Generic $12 copay or 20% if cost of drug exceeds $250

$24 copay or 20% if cost of drug exceeds $250 per 30 day supply

Preferred $24 copay or 20% if cost of drug exceeds $250


Non-Preferred $48 copay or 20% if cost of drug exceeds $250


Out-of-Pocket Maximum Associate: $5,350Associate + Dependent(s): $8,700

Associate: $5,350Associate + Dependent(s): $8,700


Dental

Aetna Dental Plans

Regular, professional dental care is an important part of maintaining your overall health. This year, PSEB is offering two options for dental coverage: the Basic Dental PPO Plan and the Enhanced PPO Plan. Both plans offer access to the same dental provider network, but they differ in the way they share costs with you. You may choose to visit in- or out-of-network providers and facilities on either plan, however, you will have lower out-of-pocket costs when care is received in-network.

The Basic PPO is a great plan for regular cleanings and fillings, whereas the Enhanced PPO plan offers expanded benefits including Orthodontia, Implants, and Bone Grafts.

Note: You will not receive an ID card for dental. Let your dentist’s office know you have Aetna and they will confirm your coverage with information like your name, Social Security number, and date of birth. If you would prefer to print an ID card, log on to www.aetna.com.

Out-of-Network Dentists

If you receive treatment from an out-of-network dentist, they may require you to pay the entire amount at the time of service and then you can submit a claim for reimbursement. If they charge more than the allowed amount, you will be responsible for anything over and above that amount.

Find an Aetna Network Dentist:

1. Visit www.aetna.com/docfind2. Continue as a guest or log in once you are enrolled in the plan3. Search for your provider using your home zip code or city4. Under ”Select a Plan,” choose Dental PPO/PDN with PPO II5. Select “Continue”6. Select “Dental Care” and find the type of provider you need

Plan Year: June 1 - May 31 BASIC PPO ENHANCED PPO

BI-W

EEK

LY

CO

NTR

IBU

TIO

NS Associate Only $10.19 $18.36

Associate + Spouse $20.39 $36.74

Associate + Child(ren) $18.35 $33.06

Associate + Family $30.59 $55.11

BEN

EFIT

S

Plan Year Deductible $100 Individual / $300 Family $50 Individual / $150 Family

Plan Year Maximum $1,000 $2,000

Preventive Services No charge No charge

Basic Services 60% 80%

Major Services 40% 50% Includes Implants & Bone Grafts

Orthodontia Adult and Child(ren)

N/A $50 lifetime deductible then 50% $1,500 lifetime maximum


Vision

Vision Service Plan (VSP) Choice Network

Whether or not your vision is 20/20, regular vision care is important for everyone. Vision coverage is offered through Vision Service Plan (VSP). VSP has one of the largest networks of private practicing optometrists, ophthalmologists, and opticians. You have the option to visit a VSP in-network doctor or an out-of-network doctor. However, your out-of-pocket costs will be higher if you visit an out-of-network doctor. When you visit a VSP network doctor, your provider will submit a claim on your behalf. If you elect to visit an out-of-network provider, you will be required to pay them in full at the time of service. You will then have to file a claim for reimbursement with VSP. VSP will then reimburse you up to the allowed amount under the out-of-network reimbursement schedule. You do not need an ID card. Simply call an in-network provider to schedule an appointment and be sure to tell them you are a VSP member. They can then verify your coverage. Visit www.vsp.com for a list of providers in the Choice Network. Special Discounts

VSP offers special discounts on a number of non-covered services, such as additional pairs of glasses, special lens options, and LASIK surgery. For more information visit www.vsp.com or call VSP Customer Service at 800-877-7195.

VSP VISION BI-WEEKLY CONTRIBUTIONS

Associate Only $3.87

Associate + Spouse $6.33

Associate + Child(ren) $5.70

Associate + Family $12.64

BENEFIT - Once every 12 months VSP CHOICE NETWORK OUT-OF-NETWORK REIMBURSEMENT

Exam $10 copay Up to $45

LensesSingle VisionLined BifocalLined Trifocal

No charge1

No charge1

No charge1

Up to $30Up to $50Up to $65

Frames $150 allowance Up to $70

Contact Lenses - In lieu of lenses & framesExam Contact Lenses

Up to $60 exam copay$130 allowance Up to $105 for contacts and the contact lens exam

1Less any applicable copay

Protecting Your Income | 13

Protecting Your Income

PSEB sees the importance of helping you protect your income during life events. That’s why medical

eligible associates are invited to enroll in an FSA to set aside pre-tax dollars to pay for healthcare,

dependent care, or commuting expenses. Additionally, eligible associates receive company-paid life

insurance, along with the option of buying voluntary life insurance for yourself, your spouse, and your

children. Short-term disability (STD) and long-term disability (LTD) benefits provide eligible associates

continued income beyond Paid Time Off for non-work-related illnesses or injury.


Flexible Spending Accounts

Did you know you can pay for out-of-pocket healthcare, dependent care, and commuter costs with pre-tax dollars? Flexible Spending Accounts allow you to set aside pre-tax contributions through payroll deduction to pay for eligible expenses. They also help reduce your taxable income and are easy to use with a point of sale debit card.

The money that you contribute to your FSA is deducted from your paycheck in equal amounts bi-weekly. Your contributions are deducted before Federal, State, and Social Security taxes are withheld from your pay.

Navia is our new FSA administrator. Claims incurred through May 31, 2019 may be submitted to WageWorks for reimbursement through August 31, 2019. Funds remaining after the August 31, 2019 deadline will be forfeited. Healthcare FSA

The Healthcare Flexible Spending Account allows you to pay for eligible healthcare expenses that are not covered by your medical, dental, and vision insurance plans with tax-exempt funds. Such expenses may include: deductibles, copays, coinsurance, and prescriptions. You may contribute up to $2,700 per plan year (plan year: June 1 - May 31).

Healthcare FSA Debit Card

The FSA Debit Card makes using your Healthcare FSA dollars quick and easy. The card deducts each payment directly from your FSA account. You may be asked to submit a copy of your detailed receipt as proof of an eligible expense. If you pay for your eligible expenses out-of-pocket, please submit a claim form to Navia with a copy of your receipt. Keep your receipts in case of an IRS audit. New Healthcare FSA debit cards will be issued. Your current WageWorks debit card will no longer work as of June 1, 2019.

Dependent Care FSA

The Dependent Care FSA is a great way for you to pay for eligible expenses related to the care and supervision of your child or elder dependent. Such expenses include: nursery schools, preschools, before- and after-school care, day camps, and eldercare. The maximum amount you may contribute is $5,000 annually or $2,500 if married and filing separately.

Commuter FSA

The Commuter FSA allows you to pay for eligible commuter expenses including parking, subway, train, ferry, and bus expenses. The maximum you may contribute is $265 per month.

Bellevue associates are eligible to either participate in the Commuter FSA OR to receive an ORCA Pass / on-site parking subsidy. Navia Online and Mobile App

Filing a claim has never been easier! Visit The PSEB Collective for information on how to register for an online Navia benefit account, as well as mobile app information.

IRS Rules

Flexible Spending Accounts have a “use it or lose it” rule. Any money that you set aside in your Healthcare, Dependent Care, or Commuter/Transit FSA that is not used or reimbursed for claims incurred during the plan year will be forfeited. Plan accordingly and do not contribute more than the amount you are sure you will use during the plan year. You have until August 31, 2020 to request reimbursement for claims incurred through May 31, 2020. Visit www.naviabenefits.com/participants/resources/expenses/ for a list of covered expenses.

Current Healthcare FSA Members: New Navia Healthcare FSA Debit Cards will be issued.

Discard your WageWorks FSA Debit Cards on June 1, 2019.


Basic Term Life Insurance

PSEB provides eligible associates with Basic Term Life Insurance at no extra cost to you, and enrollment is automatic. You are not required to take any action to participate. Life Insurance coverage amounts vary by Eligibility Group. See eligibility chart on page 4 to locate the Group into which you fall. • Group 1: $1,000,000 • Group 2: $150,000 • Group 3: 1 times your salary up to a maximum of $150,000 Benefits reduce to 65% at age 70 and 50% at age 75. Accidental Death and Dismemberment (AD&D) Insurance

If you are eligible for life insurance, your AD&D benefit is equal to the amount of your Basic Life Insurance benefit and is provided at no extra cost to you. Benefits reduce to 65% at age 70 and 50% at age 75. Enrollment in the AD&D plan is automatic. You are not required to take any action to participate.

Beneficiary Designation

You need to designate a beneficiary to receive your Basic Life and AD&D Insurance benefit in the event of your death. Designate a beneficiary as part of your online enrollment in UltiPro. You may add or edit beneficiaries at any time during the year by logging into your UltiPro account.

Life Insurance

Voluntary Term Life Insurance

Eligible associates may purchase additional Voluntary Term Life Insurance to cover yourself, your spouse, and your child(ren). If you enroll this Open Enrollment period, you may take advantage of the guaranteed issue amount and will not have to complete an Evidence of Insurability (EOI). If you do not enroll now, EOI requirements apply in the future. Associate Voluntary Term Life Insurance

You may elect coverage up to a maximum of 5 times your salary or $500,000; whichever is less. An Evidence of Insurability (EOI) will be required for any amounts greater than $250,000.

Benefits reduce to 65% at age 70 and 50% at age 75.

Associates are required to enroll themselves in Voluntary Term Life Insurance in order to add a spouse or child(ren) to coverage. Spouse Voluntary Term Life Insurance

You may elect coverage in amounts of $10,000, $25,000, $50,000, $75,000, $100,000 or $125,000 for your spouse. An Evidence of Insurability (EOI) will be required for any amounts greater than $50,000. Benefits reduce to 65% at age 70 and 50% at age 75. Child Voluntary Term Life Insurance

You may elect coverage in the amounts of $5,000 or $10,000 for your dependent child(ren) aged 6 months to age 26. A child under the age of 6 months is only eligible for $500 of life insurance. If more than one child is enrolled, all children are required to be enrolled in the same amount of coverage.

Designate your beneficiaries online in UltiPro when you complete your

Open Enrollment action steps.


Voluntary AD&D Insurance

New! Associates may enroll themselves and eligible spouse and/or child(ren)

in Voluntary AD&D Insurance.

Voluntary Accidental Death and Dismemberment (AD&D) Insurance

Eligible associates may purchase Voluntary Accidental Death and Dismemberment (AD&D) insurance to cover yourself, spouse of child(ren). Associate Voluntary AD&D Insurance

You may elect amounts of $100,000, $200,000, $300,000, $400,000, or $500,000.

Benefits reduce to 65% at age 70 and 50% at age 75.

Associates are required to enroll themselves in Voluntary AD&D Insurance in order to add a spouse or child(ren) to coverage. Spouse Voluntary AD&D Insurance

You may elect coverage in amounts of $50,000, $100,000, $150,000, $200,000, or $250,000 for your spouse up to a maximum of 50% of your voluntary AD&D amount. Benefits reduce to 65% at age 70 and 50% at age 75. Child Voluntary AD&D Insurance

You may elect coverage in the amounts of $5,000 or $10,000.

Beneficiary Designation

You need to designate a beneficiary to receive your AD&D Insurance benefit in the event of your death. Designate a beneficiary as part of your online enrollment in UltiPro. You may add or edit beneficiaries at any time during the year by logging into your UltiPro account.


Short Term Disability (STD) Insurance

Short-Term Disability (STD)

Short-term disability offers income protection should you be unable to work as a result of a non-work related illness or injury (including pregnancy, childbirth, or related medical condition). PSEB provides this coverage through Cigna at no extra cost to eligible associates. Enrollment in the Short-Term Disability plan is automatic. You are not required to take any action to participate.

Coordination With State Disability Programs

Hawaii associates are provided disability insurance benefits by a mandated state disability program.

STATE CARRIER MAXIMUM %

MAXIMUMBENEFIT

Hawaii Statutory Cigna 58% $632/week

PSEB STD for Groups 2 and 3

Cigna 60% $1,500/week

Benefit Coverage

Cigna STD coverage is provided for Group 2 and 3 associates. See eligibility chart on page 4 to locate the Group into which you fall. Cigna STD provides the difference between state disability and the maximum percentage allowed under the Cigna STD plan, which is up to 12 Weeks of coverage at 60% of your normal weekly earnings, up to $1,500 per week.

Waiting Periods

Cigna STD benefits will be available to eligible associates on the first of the month following 180 days of employment/eligibility.

There is a 7-day waiting period from the date of disability before benefits are paid.

Please contact the Benefits Team for more information regarding eligibility requirements.

PSEB STD benefit has changed to a maximum benefit of up to 12 weeks at 60% of your

normal weekly earnings, up to $1,500/week! Review the information below closely to

understand your coverage.


Company-Paid Long-Term Disability (LTD)

Long-term disability benefits are provided in situations where STD benefits have been exhausted and you are still unable to work.

PSEB provides this coverage through Cigna at no extra cost to eligible associates. Enrollment in the LTD plan is automatic for eligible associates. You are not required to take any action to participate.

Waiting Period

LTD benefits will be available to eligible associates on the first of the month following 180 days of employment/eligibility.


Benefit Coverage

Benefit coverage amounts vary by Eligibility Group as reflected in the chart below. See eligibility chart on page 4 to locate the Group into which you fall.

Voluntary Long-Term Disability (LTD)

Group 3 and eligible Group 4 associates may purchase Cigna Voluntary LTD coverage.

Waiting Period

LTD benefits will be available to eligible associates on the first of the month following 180 days of employment/eligibility.


Benefit Coverage

Benefit coverage for Group 3 and eligible Group 4 associates is 60% of your monthly salary to a maximum of $5,000 per month up to Social Security Normal Retirement Age (SSNRA).

Rates are based on your covered salary and age as shown in the chart below:

ASSOCIATE AGE (AS OF JUNE 1, 2019)

BI-WEEKLY RATE (PER $100 OF COVERAGE)

<30 $0.0249

30 - 39 $0.0554

40 - 44 $0.0988

45 - 49 $0.1292

50 - 54 $0.2077

55 - 59 $0.2862

60 - 64 $0.3877

65+ $0.5077

GROUP BENEFIT COVERAGE

1 66-2/3% of your monthly salary, up to a maximum of $17,000 per month up to SSNRA

2 60% of your monthly salary, up to a maximum of $15,000 per month up to SSNRA

Store Managers

60% of your monthly salary, up to a maximum of $15,000 per month up to SSNRA

Store Managers:We have added our Store Managers to the

PSEB-provided LTD Plan! Review the information below closely to

understand your new benefits!

Long Term Disability (LTD) Insurance


Supplemental Plans

Supplemental plans are designed to compliment your group medical plan. While you pay the full cost for this coverage, Aetna will pay you directly should you need to file a claim. Visit The PSEB Collective for more details on each plan.

Voluntary Accident, Hospital and Critical Illness Plans

We understand that medical costs and other life expenses can pop up suddenly, and sometimes when you can least afford them. With voluntary insurance benefits from Aetna, you can prepare for the unexpected. Coverage can help pay for some of your medical costs, such as deductibles and coinsurance. It can also help for everyday expenses, including your mortgage, groceries, and utility bills.

Coverage options include Accident, Hospital Indemnity, and Critical Illness. Read more below.

Accident: Provides cash benefits to help cover out-of-pocket costs, such as deductibles or coinsurance, lodging, transportation, day care, utility bills, or whatever else is needed as a result of a covered accident. Two plan options are available. Both plans offer similar coverage, but Plan 2 offers richer benefits.

Bi-Weekly Rate Plan 1 Plan 2

Associate $2.35 $3.64




Hospital Indemnity: Provides fixed payments for out-of-pocket medical and non-medical expenses related to a covered inpatient hospital stay. Two plan options are available. Both plans offer similar coverage, but Plan 2 offers richer benefits.

Bi-Weekly Rate Plan 1 Plan 2





Critical Illness: Helps you pay out-of-pocket costs that come with a covered critical illness such as heart attack, stroke, major organ failure, or cancer. Coverage is available for up to $10,000 in benefit coverage for Associates. Once you’ve enrolled yourself, you may also add up to a $5,000 benefit for a Spouse or Child(ren).

NON-TOBACCO USER BI-WEEKLY RATES

AGE ASSOCIATEASSOCIATE

+ SPOUSE

ASSOCIATE

+ CHILD(REN)

ASSOCIATE

+ FAMILY

<20 $1.21 $1.96 $1.21 $1.96

20-24 $1.37 $2.19 $1.37 $2.19

25-29 $1.58 $2.52 $1.58 $2.52

30-34 $1.87 $2.95 $1.87 $2.95

35-39 $2.32 $3.63 $2.32 $3.63

40-44 $3.12 $4.82 $3.12 $4.82

45-49 $4.41 $6.76 $4.41 $6.76

50-54 $6.50 $9.90 $6.50 $9.90

55-59 $9.38 $14.22 $9.38 $14.22

60-64 $12.93 $19.55 $12.93 $19.55

65-69 $17.11 $25.83 $17.11 $25.83

70-74 $20.70 $31.20 $20.70 $31.20

TOBACCO USER BI-WEEKLY RATES

AGE ASSOCIATEASSOCIATE

+ SPOUSE

ASSOCIATE

+ CHILD(REN)

ASSOCIATE

+ FAMILY

<20 $1.64 $2.58 $1.64 $2.58

20-24 $1.91 $2.98 $1.91 $2.98

25-29 $2.27 $3.52 $2.27 $3.52

30-34 $2.76 $4.26 $2.76 $4.26

35-39 $3.52 $5.40 $3.52 $5.40

40-44 $4.86 $7.41 $4.86 $7.41

45-49 $7.03 $10.68 $7.03 $10.68

50-54 $10.56 $15.96 $10.56 $15.96

55-59 $15.42 $23.26 $15.42 $23.26

60-64 $21.39 $32.22 $21.39 $32.22

65-69 $28.44 $42.80 $28.44 $42.80

70-74 $34.48 $51.86 $34.48 $51.86


Legal

Finding an affordably priced lawyer for the most common personal legal matters can be a challenge. That’s why PSEB offers associates the chance to enroll in Hyatt Legal coverage to provide representation for you, your spouse, and dependents $7.62 bi-weekly. In-network providers provide advice and consultation without deductibles, copays, or claim forms on topics such as money matters, home & real estate, estate planning, family & personal issues, civil lawsuits, elder-care issues, and vehicle & driving matters.

Identity Theft Protection

InfoArmor leads the identity theft protection industry with PrivacyArmor, a proactive monitoring service that alerts you at the first sign of fraud. Get alerts for credit inquiries, accounts opened in your name, unsavory content on your social media accounts, compromised credentials, and financial transactions. Enrolling your family extends that protection to anyone in your household.

In the event of fraud, you don’t have to figure out what to do — or even do it. PrivacyArmor’s dedicated Privacy Advocates fully manage and restore your identity, and their $1 million identity theft insurance policy covers any fees for identity restoration.

Bi-Weekly Rate PrivacyArmor PrivacyArmor Plus



Supplemental Plans continued

Supporting Your Life Beyond Work | 21

Supporting Your Life Beyond Work

PSEB offers a comprehensive Employee Assistance Program (EAP) and a generous Associate

Discount to support your life beyond work!


Employee Assistance Program (EAP)

Employee Assistance Program

Life is full of challenges and sometimes balancing it is difficult. PSEB is proud to provide a program dedicated to supporting the emotional health and well-being of our Associates and their families.

Administered by Cigna, the Employee Assistance Program (EAP), is a confidential program for you, your family, and all household members. The services are offered to all benefits-eligible associates at no extra cost. Cigna Life Assistance provides a toll-free number with 24-hour assistance, 365 days a year.

Here are just a few of the many services available:

• Free counselling sessions: up to 3 in-person visits per issue for you and your dependents, as well as other family members, on topics such as stress, emotions, workplace issues, financial needs, legal needs, and other health issues.

• Expert assessment and advice: Professional counsellors available by phone 24 hours a day, 7 days a week on a variety of issues, including mental health and substance abuse.

• Adult/elder support services: Help with retirement planning, care giving and housing options, chronic illness support, transportation and meal services, and senior activity groups.

• Child/parenting support services: Information and consulting on parenting questions; resources for parenting classes, day care, summer camps, adoption, and sick-child care.

Help when you need it!The EAP is there for you and your family 24x7

at 800-538-3543 or online at www.cignalap.com


Associate Discount

Associate Discount

Yet another way PSEB supports your lifestyle is through our generous associate discount. Associates and their eligible dependents receive a discount of 30-50% off full priced products at Eddie Bauer and PacSun—a leading benefit in the retail industry! For additional information, including discount codes and the full policy, visit EB Net, The Lounge, PCH, or UltiPro.

Benefit Contacts | 24

Benefit Contacts

Benefit Contacts | 25

Benefit Contacts

BENEFIT CARRIER CONTACT WEBSITE

PSEB Benefits Team n/a866-989-6958, #2

[email protected]://TheCollective.psebllc.com

https://n33.ultipro.com

MedicalHMAA PPO

HMAA 800-621-6998 www.hmaa.com

PrescriptionsOptumRX 808-941-4622 www.optumrx.com

DentalBasic PPOEnhanced PPO

Aetna 877-238-6200 www.aetna.com

VisionChoice Network

Vision Service Plan (VSP)

800-877-7195 www.vsp.com

Flexible Spending Account (FSA)Healthcare FSADependent Care FSACommuter FSA

Navia Benefits 800-669-3539 www.naviabenefits.com

Life Insurance/AD&DCompany-Paid Basic Life/AD&DVoluntary LifeVoluntary AD&D

Cigna 800-362-4462 www.cigna.com

DisabilityShort-Term DisabilityLong-Term DisabilityVoluntary Long-Term Disability

Cigna 800-362-4462 www.cigna.com

Supplemental PlansAccidentCritical IllnessHospital

Aetna 800-607-3366 www.aetna.com

Supplemental PlansLegal

Hyatt Legal 800-821-6400 www.legalplans.com

Supplemental PlansIdentity Theft Protection

InfoArmor 800-789-2720 www.myprivacyarmor.com

Employee Assistance Plan (EAP) Cigna 800-538-3543 www.cignalap.com

Required Legal Notices | 26

Required Legal Notices


CERTIFICATE OF CREDITABLE PRESCRIPTION DRUG COVERAGE

IMPORTANT NOTICE FROM PSEB LLC ABOUT YOUR PRESCRIPTION DRUG COVERAGE AND MEDICARE

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with PSEB LLC 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. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Your company has determined that the prescription drug coverage offered by Aetna is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. WHEN CAN YOU JOIN A MEDICARE DRUG PLAN?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. WHAT HAPPENS TO YOUR CURRENT COVERAGE IF YOU DECIDE TO JOIN A MEDICARE DRUG PLAN?

If you decide to join a Medicare drug plan, your current coverage may be affected. Your current coverage pays for other health expenses in addition to prescription drugs. If you enroll in a Medicare prescription drug plan, you and your eligible dependents may still be eligible to receive all of your current health and prescription drug benefits. If you do decide to join a Medicare drug plan and drop your current company coverage, be aware that you and your dependents may be able to get this coverage back by enrolling back into the company benefit plan during the Open Enrollment period under the company benefit plan.

SUMMARY OF BENEFITS & COVERAGE (SBC) DOCUMENTS

SBC DOCUMENTS ARE AVAILABLE ONLINE

Required Summary of Benefits & Coverage documents may be found online at https://TheCollective.psebllc.com. Paper copies are also available, free of charge, by contacting the Benefits Team at [email protected] or 866-989-6958, option #2.


CERTIFICATE OF CREDITABLE PRESCRIPTION DRUG COVERAGE

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 company and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. FOR MORE INFORMATION ABOUT THIS NOTICE OR YOUR CURRENT PRESCRIPTION DRUG COVERAGE…

Contact the person listed below for further information. Note: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through the company changes. You also may request a copy of this notice at any time. FOR MORE INFORMATION ABOUT YOUR OPTIONS UNDER MEDICARE PRESCRIPTION DRUG COVERAGE…

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’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 on the web at www.socialsecurity.gov, or call them at 800.772.1213 (TTY 800.325.0778).

• Date: June 1, 2019

• Name of Entity/Sender: PSEB LLC

• Contact - Position/Office: Benefits Team

• Address: 10401 NE 8th Street, Ste 500 Bellevue, WA 98004

• Phone Number: 866989.6958, option #2


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

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1.877.KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1.866.444.EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2019. Contact your State for more information on eligibility.

ALABAMA – MedicaidWebsite: http://myalhipp.com/ Phone: 1.855.692.5447

ALASKA – MedicaidThe AK Health Insurance Premium Payment Program Website: http://myakhipp.com/Phone: 1.866.251.4861Email: [email protected] Medicaid Eligibility:http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

ARKANSAS – MedicaidWebsite: http://myarhipp.com/Phone: 1.855.MyARHIPP (855.692.7447)

COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+)Health First Colorado Website: https://www.healthfirstcolorado.com/Health First Colorado Member Contact Center: 1.800.221.3943/ State Relay 711CHP+: Colorado.gov/HCPF/Child-Health-Plan-PlusCHP+ Customer Service: 1.800.359.1991/State Relay 711

FLORIDA – MedicaidWebsite: http://flmedicaidtplrecovery.com/hipp/ Phone: 1.877.357.3268

GEORGIA – MedicaidWebsite: www.medicaid.georgia.govClick on Health Insurance Premium Payment (HIPP) Phone: 404.656.4507

INDIANA – MedicaidHealthy Indiana Plan for low-income adults 19-64Website: http://www.in.gov/fssa/hip/Phone: 1.877.438.4479All other MedicaidWebsite: http://www.indianamedicaid.com Phone 1.800.403.0864

IOWA – MedicaidWebsite: https://dhs.iowa.gov/hawk-iPhone: 1.800.257.8563 KANSAS – MedicaidWebsite: http://www.kdheks.gov/hcf/ Phone: 1.785.296.3512

KENTUCKY – MedicaidWebsite: https://chfs.ky.govPhone: 1.800.635.2570

LOUISIANA – MedicaidWebsite: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1.888.695.2447

MAINE – MedicaidWebsite: http://www.maine.gov/dhhs/ofi/public-assistance/index.htmlPhone: 1.800.442.6003TTY: Maine relay 711

MASSACHUSETTS – Medicaid and CHIPWebsite: http://www.mass.gov/eohhs/gov/departments/masshealth/Phone: 1.800.862.4840


PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) - CONTINUED

MINNESOTA – MedicaidWebsite: https://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/other-insurance.jspPhone: 1.800.657.3739 or 651-431-2670

MISSOURI – MedicaidWebsite: https://www.dss.mo.gov/mhd/participants/pages/hipp.htmPhone: 573.751.2005

MONTANA – MedicaidWebsite: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPPPhone: 1.800.694.3084

NEBRASKA – MedicaidWebsite: http://www.ACCESSNebraska.ne.gov Phone: 855.632.7633Lincoln: 402.473.7000Omaha: 402.595.1178

NEVADA – MedicaidMedicaid Website: https://dhcfp.nv.gov Medicaid Phone: 1.800.992.0900

NEW HAMPSHIRE – MedicaidWebsite: https://www.dhhs.nh.gov/oii/hipp.htmPhone: 603.271.5218Toll-Free: 1-800-852-3345, ext 5218

NEW JERSEY – Medicaid and CHIPMedicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/Medicaid Phone: 609.631.2392CHIP Website: http://www.njfamilycare.org/index.htmlCHIP Phone: 1.800.701.0710

NEW YORK – MedicaidWebsite: https://www.health.ny.gov/health_care/medicaid/ Phone: 1.800.541.2831

NORTH CAROLINA – MedicaidWebsite: https://dma.ncdhhs.gov/ Phone: 919.855.4100

NORTH DAKOTA – MedicaidWebsite: http://www.nd.gov/dhs/services/medicalserv/medicaid/Phone: 1.844.854.4825

OKLAHOMA – Medicaid and CHIPWebsite: http://www.insureoklahoma.orgPhone: 1.888.365.3742

OREGON – MedicaidWebsite: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.htmlPhone: 1.800.699.9075

PENNSYLVANIA – MedicaidWebsite: http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htmPhone: 1.800.692.7462

RHODE ISLAND – MedicaidWebsite: http://www.eohhs.ri.gov/ Phone: 855.697.4347

SOUTH CAROLINA – MedicaidWebsite: https://www.scdhhs.gov Phone: 1.888.549.0820

SOUTH DAKOTA - MedicaidWebsite: http://dss.sd.gov Phone: 1.888.828.0059

TEXAS – MedicaidWebsite: http://gethipptexas.com/ Phone: 1.800.440.0493

UTAH – Medicaid and CHIPMedicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1.877.543.7669

VERMONT– MedicaidWebsite: http://www.greenmountaincare.org/ Phone: 1.800.250.8427

VIRGINIA – Medicaid and CHIPMedicaid Website: http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1.800.432.5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfmCHIP Phone: 1.855.242.8282

WASHINGTON – MedicaidWebsite: http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-programPhone: 1.800.562.3022 ext. 15473

WEST VIRGINIA – MedicaidWebsite: http://mywvhipp.com/Toll-free phone: 1.855.MyWVHIPP (1.855.699.8447)


PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) - CONTINUED

WISCONSIN – Medicaid and CHIPWebsite: https://health.wyo.gov/healthcarefin/medicaid/Phone: 1.800.362.3002

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

To see if any other states have added a premium assistance program since January 31, 2019, or for more information on special enrollment rights, contact either: U.S. Department of Labor Associate Benefits Security Administration dol.gov/agencies/ebsa 866.444.EBSA (3272) U.S. Department of Health & Human Services Centers for Medicare & Medicaid Services cms.hhs.gov 877.267.2323 (Menu Option 4, Ext. 61565)

WOMEN’S HEALTH & CANCER RIGHTS ACT NOTICESIf you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (“WHCRA”). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: • All states of reconstruction of the breast on which the mastectomy was performed; • Surgery and reconstruction of the other breast to produce a symmetrical appearance; • Prostheses; and • Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under the plan. Therefore, the following deductibles and coinsurance apply: If you would like more information on WHCRA benefits, call your plan administrator at 866-989-6958, option #2. Federal law (Newborns’ and Mothers’ Health Protection Act of 1996) prohibits the plan from limiting a mother’s or newborn’s length of stay to less than 48 hours for a normal delivery or 96 hours for a cesarean delivery or from requiring the provider to obtain pre-authorization for a stay of 48 hours or 96 hours, as appropriate. However, federal law generally does not prohibit the attending provider, after consultation with the mother, from discharging the mother or her newborn earlier than 48 hours for normal delivery or 96 hours for cesarean delivery.

NON-TOBACCO USER DISCOUNT DISCLOSURE PSEB LLC is committed to helping you achieve your best health. The non-tobacco user discount is available to all eligible associates. If you think you might be unable to meet a standard for the discount, you might qualify for an opportunity to earn the same reward by different means. Contact the Benefits Team at [email protected] or 866-989-6958, option #2 and we will work with you (and if you wish with your doctor) to find a wellness program with the same reward that is right for you in light of your health status.


STATEMENT OF ERISA RIGHTS

As a participant in the Plan, you are entitled to certain rights and protections under the Associate Retirement Income Security Act of 1974 (“ERISA”). ERISA provides that all participants shall be entitled to:

• Examine, without charge, at the Plan Administrator’s office and at other specified locations, the documents governing the plan, including the insurance contract and a copy of the latest annual report (Form 5500 Series) if any filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Associate Benefits Security Administration.

• Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the plan, including insurance contracts, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The Plan Administrator may make a reasonable charge for the copies.

• Receive a summary of the Plan’s annual financial report, if any. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report, if any.

You have a right to continue healthcare coverage for yourself, spouse, or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review the summary plan description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights. In addition to creating rights for participants, ERISA imposes duties upon the people who are responsible for operation of the Plan. These people, called “fiduciaries” of the Plan, have a duty to operate the Plan prudently and in the interest of you and other Plan participants and beneficiaries. Fiduciaries who violate ERISA may be removed and required to make good any losses they have caused the Plan. No one, including the Company or any other person, may fire you or discriminate against you in any way to prevent you from obtaining welfare benefits or exercising your rights under ERISA. If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.

Under ERISA, there are steps you can take to enforce these rights. For instance, if you request a copy of plan documents or the latest annual report from the Plan Administrator and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for benefits, which is denied or ignored, in whole or in part, and you have exhausted the claims procedures available to you under the Plan (see your plan document or summary plan description for more detail), you may file suit in a state or Federal court. In addition, if you disagree with the plan’s decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court. If it should happen that Plan fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. If you have any questions about your Plan, you should contact the Plan Administrator. If you have any questions about this statement, or your rights under ERISA, or if you need assistance or information regarding your rights under HIPAA, you should contact the nearest office of the Associate Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Associate Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Associate Benefits Security Administration.


HIPAA NOTICE OF PRIVACY PRACTICESProtecting Your Health Information Privacy Rights

PSEB LLC is committed to the privacy of your health information. The administrators of the PSEB Health and Welfare Plan (the “Plan”) use strict privacy standards to protect your health information from unauthorized use or disclosure. The Plan’s policies protecting your privacy rights and your rights under the law are described in the Plan’s Notice of Privacy Practices. You may receive a copy of the Notice of Privacy Practices by contacting [email protected] or 866-989-6958, option #2. The notice also is available on-line at https://thecollective.psebllc.com/legal-notices/.

HIPAA SPECIAL ENROLLMENT RIGHTSNotice of Your HIPAA Special Enrollment Rights

A federal law called HIPAA requires that we notify you about an important provision in the plan - your right to enroll in the plan under its “special enrollment provision” if you acquire a new dependent, or if you decline coverage under this plan for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons. Loss of Other Coverage (Excluding Medicaid or a State Children’s Health Insurance Program)

If you decline enrollment for yourself or for an eligible dependent (including your spouse) while other health insurance or group health plan coverage is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). Loss of Coverage for Medicaid or a State Children’s Health Insurance Program

If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under a state children’s health insurance program is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or your dependents’ coverage ends under Medicaid or a state children’s health insurance program. New Dependent by Marriage, Birth, Adoption, or Placement for Adoption

If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your new dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. Eligibility for Medicaid or a State Children’s Health Insurance Program

If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state children’s health insurance program with respect to coverage under this plan, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days after your or your dependents’ determination of eligibility for such assistance. To request special enrollment or to obtain more information about the plan’s special enrollment provisions, contact the Benefits Team at [email protected] or 866-989-6958, option #2.

This brochure was prepared for you by:

This booklet gives you an overview of the main features of your benefit plans. The plans are administered according to legal plan documents and insurance contracts. Although we’ve tried to summarize the provisions

of these legal documents clearly and accurately, if any information presented here conflicts with the legal documents, the legal documents

will govern.

For more detailed information on the plans and your legal rights under the plans, be sure to read the summary plan descriptions or request a copy of the plan documents. All benefit plans are subject to change from time to time and PSEB reserves the right to amend or cancel any benefits

described in this booklet, with or without notice.

This document does not guarantee any benefits.

File: PSEB 2018

Documents

HAWAII BENEFITS GUIDE - PSEB€¦ · Supplemental Plans 19 Accidents, Critical Illness, Hospital ... dental, vision, and life insurance plans. Eligible dependents include: • Spouse