2013 Benefit Enrollment Guide - Troy University

2013 Benefit Enrollment Guide
an overview of your employee benefits for the 2013 plan year

Welcome to your 2013 Benefits Guide.
Please review this Benefits Enrollment Guide carefully before making benefit elections for the 2013 Plan Year.
Introduction.....................................................................................1
Enrollment.......................................................................................2
Healthcare Benefits.........................................................................3
Disability..........................................................................................8
Life Insurance..................................................................................8
Voluntary Life Insurance.................................................................9
Employee Assistance Program..................................................... 10
Travel Assistance.......................................................................... 11
Health Reimbursement Account................................................... 12
Flexible Spending.......................................................................... 13
Retirement..................................................................................... 15
Important Notices..........................................................................16
Summary of Benefits & Costs (SBC)............................................ 19
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 2

introduction
Enrollment
Current Employees
You may add, drop or make changes to your benefits for 2013 during our
Annual Enrollment period, November 12, 2012 – November 26, 2012. Your
choices will become effective January 1, 2013.
If you do not make any elections or changes during Annual Enrollment,
your benefit elections as of December 31, 2012 will automatically continue
for plan year 2013, except for your Flexible Spending Accounts (FSA). You
must enroll and make a new Health and/or Dependent Care FSA election
for the 2013 plan year.
New Hires
Benefits are effective on your date of hire. You have 30 days from your
date of hire to complete your enrollment. Enrollment instructions are
located on page 2 of this guide.
Eligibility
Troy University benefits are effective on the date of hire for all full time
eligible employees. You must complete your enrollment in order for
benefits to go into effect. Benefits will end at midnight on the date an
employee resigns, retires or is no longer an employee of Troy University.
Employees who are married and their spouse also works for Troy
University cannot be covered as an employee and as a dependent.
Dependent children may only be covered as a dependent under one
parent and not both. Double coverage is not allowed.
Contact Information
The Enrollment Center
Customer Service: 866-688-9727
International callers: 1-706-645-8355
Website: troyuniversity.empowHR.com
Medical, Dental, Prescription Drugs
Blue Cross Blue Shield of Alabama (BCBSAL)
Customer Service: 1-800-292-8868
Website: www.bcbsal.org
Mental Health and Substance Abuse
Customer Service: 1-800-245-1150
Website: www.behavioralhealthsystems.com (login: Troysu)
FSA and HRA
Flex Corp
Customer Service: 205-995-1222
Website: www.flexcorp.com
Teachers’ Retirement System
Defined Benefit Plan 401(a)
Customer Service: 877-517-0020
Website: www.rsa-al.gov
BlueCard Worldwide
Service Center: 1-800-810-2583 or collect at 1-804-673-1177
Important Note
To enroll in your benefits, you will be required to go online or call
The Enrollment Center. If you have changes during the plan
year, you will need to contact The Enrollment Center via
telephone at 866-688-9727.
You are able to make changes to your demographic
information or beneficiary designations at any time
throughout the year.
Demographic changes include:
• Address update
• Name update (requires proof of
a current Social Security card)
• Contact number update
Benefit changes are not allowed during the plan year,
unless you have a “qualifying life event.”
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 1

enrollment
Preparing for On-Line or
Telephonic Enrollment
Please take the time to review this enrollment guide. It contains
important information about your benefits and the deductions that
will be taken from your paycheck. You have been given examples
of payroll deductions throughout the enrollment guide. By
reviewing this information in advance, you will have the opportunity
to decide which benefits are the most important to you.
• Changes made during Annual Enrollment are effective
January 1, 2013 (except for policies and/or amounts that
require the approval of underwriters).
• Verify that changes have been processed. Review
your Earnings Statement to confirm that your enrollments
and deductions are correct.
• If you notice an error on your Earnings Statement,
contact Human Resources or The Enrollment Center.
Please note that this guide is a general summary of your benefits.
For specific details, you may refer to each carrier’s summary plan
description which is available at troyuniversity.empowHR.com.
Every effort has been made to ensure that this booklet accurately
represents the benefits. However, if there are any discrepancies
between the terms in this booklet and the terms in the plan
document, the plan document will prevail.
Some Information You Will Need
Please have the following information ready when enrolling:
• Your name, date of birth and Social Security Number
• The name(s), date(s) of birth and Social Security Number(s)
of your dependent children up to age 26. Dependent children
include your natural children, adopted children, stepchildren
and children for whom you have legal guardianship.
• The name, date of birth and Social Security Number of
your spouse (if applicable)
• Your current address. This will also ensure that both your ID
cards and other important benefit information are sent to the
correct address.
• The full name and relationship of your beneficiary
(Your beneficiary must be at least 18 years old or you
will be required to name a guardian for him or her.)
How to Enroll On-line
You may make your benefit elections and enroll online. Your
enrollment is confidential and secure. To enroll online, just follow
these simple steps:
1. To begin your enrollment, go to troyuniversity.empowHR.com.
Do not include “www”.
2. Enter your personal User ID which is the first initial of your
first name and your full last name and the last four digits
of your Social Security Number (for example, Tina Smith =
tsmith6789). Do not use spaces or suffixes.
3. Enter your personal password which is your full Social
Security Number (no spaces or dashes).
4. You will be asked to select a new password after your initial
login. Please keep this information in a secure location for
future access.
5. Read the instructions and click OPEN ENROLLMENT at the
bottom of the screen to begin enrollment.
6. Enter Spouse and Dependent children information by choosing
add or edit dependent on your verify information screen.
7. Click Next at the bottom of the screen once all dependents
are entered into the system.
8. Make your benefit elections from the benefits offered by clicking
the appropriate circle on the screen for that benefit. You will click
Next at the bottom of the screen to move to the next benefit plan.
9. You may “elect” or “decline” coverage by clicking the
appropriate box. Some coverages may require you to input
a dollar amount (for example, Voluntary Life and Flexible
Spending Accounts) or select one of several options.
10. After completing all of the benefit sections, click the I have
completed my online enrollment and agree to benefits
presented button to securely process your form.
11. If you are unable to complete your form in its entirety, you may
click the Print and Save in your File Cabinet button to save
your data and complete at a later time. All enrollments must be
completed by midnight prior to your effective date or the last
day of your company’s annual enrollment period.
12. Upon submitting your enrollment form, you will receive a
Confirmation Page. Please print a copy of this page for your records.
13. To complete a saved enrollment or make changes to an
existing enrollment, simply use your personal User ID and
password from your confirmation screen to access and make
edits to your selections.
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 2

Healthcare Benefits
Medical (Blue Cross Blue Shield of AL)
Make the Most of Your Network-Based Healthcare Plans
Blue Cross Blue Shield of Alabama has contracted with a network of
providers, including physicians, hospitals and other types of providers.
In order to receive the highest level of benefits and pay the least
amount out of your pocket, you need to access care from the providers
who have elected to be part of the network.
This plan allows you to seek care from a provider who is not in the
network. Just remember that if you make this choice, you will be
required to pay a larger portion of the expenses out of your pocket,
and the expenses may be subject to the Reasonable and Customary
charging pattern for the area. This could also result in a greater outof-pocket
expense for you. We want you to get the most from your
healthcare plan. Please log on to www.bcbsal.org for any additional
information about Blue Cross Blue Shield of Alabama.
Important Note: Effective 1-1-2013, a tobacco
certification form is required for Troy University
employees enrolled in the Group Medical Plan.
Employees and their covered dependents that
are tobacco users will be charged a tobacco
surcharge of $19 dollars per month in addition
to their insurance premiums. Tobacco users
are defined as an individual who uses any
form of tobacco regardless of the method and/
or frequency of use. Employees who do not
complete the Tobacco Certification Form will be
charged the Tobacco User Surcharge.
2013 Health and Dental Insurance Benefits Cost
Monthly
Bi-Weekly
Less than $30,000 Salary $30,000 Salary and over Less than $30,000 Salary $30,000 Salary and over
Employee $95.26 $142.88 $47.63 $71.44
Family $213.54 $320.30 $106.77 $160.15
Note: 2013 rates cover medical, dental, prescription and Behavioral Health benefits.
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 3

Healthcare Benefits
Medical (Blue Cross Blue Shield of AL)
Medical Summary of Benefits
PPO Plan Benefits In-Network Out-of-Network Out-of-Area
Office Visits $25 PCP / $40 Specialist 70% after deductible 80% after deductible
Hospital Services
Inpatient
Outpatient Surgery &
Emergency Service
Preventive Care Services
Routine Well Child Care
Routine Immunizations
Physicians Services
In-Hospital Visits,
Surgery, Anesthesia,
Diagnostic X-rays & Lab
Services for treatment
in the Emergency Room
Other Covered Services
Durable Medical Equipment,
Physical Therapy,
Ambulance Service
$300 deductible per admission,
100% after deductible
$950 deductible per admission, $50
copay per day, 80% after deductible
80% after deductible
$125 copay, 100% after copay $300 copay, 100% after copay 80% after deductible
$25 copay; 100% after copay
100% of allowed amount;
no deductible or copay
No deductible;
100% of allowed amount
Covered only when provided by
Primary Care Physician
Covered only when provided by
Primary Care Physician
Covered only when provided by
Primary Care Physician
Covered only when provided by
Primary Care Physician
70% after deductible 80% after deductible
$40 copay, then 100% 70% after deductible 80% after deductible
80% after deductible 70% after deductible 80% after deductible
Chiropractic Services
80% after Ded,
limit 12 visits per year
or $400 a year
Not Covered
80% after Ded,
limit 12 visits per year
or $400 a year
Deductibles $500 Individual / $1,500 Family $500 Individual / $1,500 Family $500 Individual / $1,500 Family
Out-of-Pocket Maximum $400 Individual / No family max $400 Individual / No family max $400 Individual / No family max
Mental Health and Substance Abuse
Behavioral Health Systems (BHS) specializes in managing mental
health and substance abuse benefits. BHS has a preferred
provider network of credentialed mental health care providers.
Benefits are available to all persons enrolled and eligible under a
Troy University-sponsored medical plan. To qualify for coverage,
you must be pre-certified and referred through Behavioral Health
Systems. It is your responsibility to make sure that approval is
received from BHS before you are treated. If you do not receive
approval, no benefits will be paid.
To Access Benefits: Call 1-800-245-1150 or visit their website
at www.behavioralhealthsystems.com. Member login is Troysu.
Prescription Drugs
Prescription Drugs (Blue Cross Blue Shield of AL)
Deductible
Individual
No deductible
Family
No deductible
Retail Co-payments
Generic $10.00
Preferred $35.00
Non Preferred $50.00
Mail Order Co-payments
(90 day supply)
Generic $20.00
Preferred $70.00
Non Preferred $100.00
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 4

Healthcare Benefits
Pre-Tax Cafeteria Plan (Section 125)
Troy University provides its employees with the option of having
certain benefit premiums payroll deducted on a pre-tax basis. You
may choose to have your health, dental, flexible spending, and
some voluntary coverage deducted from your check on a pre-tax
basis (section 125).
A Cafeteria Plan is an employee benefits program designed to
take advantage of Section 125 of the Internal Revenue Code. A
Cafeteria Plan allows employees to pay certain qualified expenses
(such as health insurance premiums) on a pre-tax basis, thereby
reducing their total taxable income and increasing their spendable/
take-home income. Funds set aside in Flexible Spending Accounts
(FSAs) are not subject to federal, state, or Social Security taxes.
It is important to know that under the pre-tax option once you make
your benefit election you cannot change that election unless you
have a qualified life event, such as marriage, birth, divorce, or loss
of other coverage. The reduction also lowers the salary on which
Social Security benefits are calculated. While the actual impact on
the benefit calculation is typically very minor, if you are concerned
and you are close to beginning a Social Security benefit, you may
wish to consider waiving the Section 125 Plan.
About Qualifying Events
Changes to benefits for which you elect to have your premiums
deducted on a pre-tax basis are NOT allowed during the plan year,
except for a “qualifying life event.” Qualifying life events that could
result in changes to your coverage include:
• marriage or divorce
• birth or adoption of a child
• death of a dependent
• Medicare entitlement
• loss of coverage
If you have a qualifying life event, you must notify The Enrollment
Center and provide the necessary documentation within
30 days of the event. If you do not do so, you must wait until
the next Annual Enrollment.
Example of Employee Savings
Cafeteria Plan Waived
(premiums deducted post-tax)
Cafeteria Plan Elected
(premiums deducted pre-tax)
Employee Gross Pay $2,000 $2,000
Medical Premiums $0 $142.88
Taxable Income $2,000 $1,857.12
Tax Rate 25% 25%
Taxes Withheld $500 $464.28
Employee Net Pay $1,500 $1,392.84
Medical Premiums $148.88 0
Take Home Pay $1,351.12 $1,392.84
An employee who elected pre-tax cafeteria plan option paid less tax and took home more pay.
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 5

Healthcare Benefits
Dental (Blue Cross Blue Shield of AL)
In- Network and Out-of-Network
Dental Coinsurance Covered Procedures
80% Basic Services
• Routine oral examinations (two per calendar year)
• Routine Cleanings (two per calendar year)
• Topical applications of fluoride (children
through age 18, 2x per calendar year)
• Space maintainers (through age 18)
• Dental X-rays (full mouth 1x during any 36
months in a row, Bitewing 2x in a calendar year)
• Sealants*
Dental Benefits are available to you and your eligible family
members to cover routine care, such as exams, x-rays and
cleanings, fillings, and periodontal care.
Orthodontia is not included. Under the BCBS of AL Plan, you
can go to the dental provider within the Dental PPO Network.
If you choose to go to an out-of-network provider, the same
percentages will be paid, but you will be responsible for any
Reasonable or Customary charges.
Dental Summary of Benefits
Dental Expenses
Plan pays after deductible
Basic Services 80%
Supplemental Services 80%
Periodontic Services 80%
Annual Maximum
$1,000 per covered person
Deductible
Individual $25.00
Family
$75.00
(Three $25 deductibles per family maximum)
• Fillings*
• Simple tooth extractions
• Repairs to removable dentures
*Refer to SPD for limitations
80% Supplemental Services
• Oral surgery – tooth extractions and impacted
teeth and to treat mouth abscesses
• General anesthesia
• Treatment of the root tip of the tooth including its removal
80% Periodontic Services
• Periodontic exams 2x each 12 months
• Removal of diseased gum tissue and reconstructing gums
• Removal of diseased bone
• Reconstruction of gums and mucous membranes by surgery
• Removing plague and calculus below the gum line for
periodontal disease
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 6

Healthcare Benefits
BlueCard Worldwide ®
Healthcare coverage wherever you go.
To take advantage of the BlueCard Worldwide Program, whether
you are traveling or living abroad, please follow these steps:
1. Before you leave, contact your Blue Plan for coverage details.
Coverage outside the United States may be different.
2. Always carry your current Blue SM ID card.
3. In an emergency, go directly to the nearest hospital.
4. If you need to locate a doctor or hospital, or need medical
assistance services, call the BlueCard Worldwide Service
Center at 1-800-810-BLUE (2583) or call collect at
1-804-673-1177, 24 hours a day, seven days a week.
An assistance coordinator, in conjunction with a medical
professional, will arrange a physician appointment or
hospitalization, if necessary.
5. Call the BlueCard Worldwide Service Center at 1-800-810-2583
or collect at 1-804-673-1177 when you need inpatient care. In
most cases, you should not need to pay upfront for inpatient care
at BlueCard Worldwide hospitals except for the out-of-pocket
expenses (noncovered services, deductible, copayment
and coinsurance) you normally pay. The hospital should
submit your claim on your behalf. In addition to contacting
the BlueCard Worldwide Service Center, call your Blue Plan
for precertification or preauthorization. Refer to the phone
number on the back of your Blue ID card. Note: this number
is different from the phone number listed above.
6. You may need to pay upfront for care received from a doctor
and/or hospital. Then complete a BlueCard Worldwide
International claim form and send it with the bill(s) to the
BlueCard Worldwide Service Center (the address is on the
form). The claim form is available from your Blue Plan, online
at www.BCBS.com/bluecardworldwide, or the BlueCard
Worldwide Service Center.
To file a claim please do the following:
1. If the BlueCard Worldwide Service Center arranged
your hospitalization, the hospital will file the claim for
you. You will need to pay the hospital for the out-ofpocket
expenses you normally pay.
2. For outpatient and doctor care, or inpatient care not
arranged through the BlueCard Worldwide Service
Center, you will need to pay the healthcare provider
and submit a BlueCard Worldwide International
claim form with original bills to the BlueCard
Worldwide Service Center.
3. International claim forms are available from your Blue
Plan, the Service Center or online at www.bcbs.com/
bluecardworldwide.
BlueCard Worldwide Service Center:
1-800-810-2583 or collect:1-804-673-1177
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 7

Disability & Life Insurance
Long Term Disability (Standard Insurance)
Long Term Disability, or LTD, is a benefit paid to replace a portion
of your income for a long period of time. Full-time Troy University
employees are eligible for LTD after completing one year of fulltime
employment at no cost to the employee.
Long Term Disability Summary of Benefits
Benefit Amount
60% of Basic Earnings
Maximum Monthly Benefit $6000
Benefits Begin
After 180 consecutive days
of any one period of disability
Age When Disabled
Prior to Age 63
Age 63
Age 64
Age 65
Age 66
Age 67
Age 68
Age 69 and over
Maximum Duration of Benefits
Benefits Payable
To Normal Retirement Age or 42 months, if greater
To Normal Retirement Age or 36 months, if greater
To Normal Retirement Age or 30 months, if greater
24 Months
21 Months
18 Months
15 Months
12 Months
Basic Life and AD&D Insurance
(Standard Insurance)
Troy University provides all full-time employees with Basic Life
and Accidental Death and Dismemberment coverage equal to one
times annual salary up to the maximum of $100,000 at no cost to
the employee.
You are not subject to any copay charge and your life insurance
coverage will end when you terminate employment or retire.
Age reduction will apply commencing at age 60 for Standard Life
Insurance and AD&D.
Employees hired before September 1, 1991 are
grandfathered and will need to contact Human
Resources for their life insurance benefit.
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 8

Voluntary Life Insurance
Voluntary Term Life (Standard Insurance)
If you have thought about
increasing the protection you
presently provide your family
through life insurance coverage,
you may want to consider the
Voluntary Term Life program. All
full-time employees are eligible
at the group rates.
This program allows you to select coverage from a minimum of
$10,000 to a maximum of $300,000 in increments of $10,000.
Guarantee issue amount is $200,000 with no medical questions
asked if coverage is taken at initial employment.
Coverage amounts in excess of $200,000 will require completion
of a medical underwriting form and approval by underwriting.
Employees who decline coverage at initial employment must submit
evidence of insurability if electing coverage after initial eligibility or
if an insured employee wishes to increase the amount of coverage
after initial eligibility. Any coverage after initial eligibility or increase
in coverage will take effect only after approval by underwriting.
Coverage will be effective the first day of the month following your
employment date and after payroll deduction of applicable premium.
Benefit Reductions: Your insurance, if in place prior to age 65,
will reduce to 65% of coverage at age 65 and to 50% at age 70.
Note: Employees will need to contact Human Resources for any
changes to Voluntary Term Life.
Employee
Spouse
Child(ren)
Voluntary Term Life Benefits
Benefit Minimum $10,000 in increments of $10,000
Benefit Maximum $300,000
Guarantee Issue $200,000
Benefit Amount $10,000 (not to exceed 100% of employee’s amount)
Benefit Maximum $50,000
Guarantee Issue
$50,000 for spouses under 60
No guarantee issue for spouses 60+
Aged 14 days
to 6 months
$500 per child
Aged 6 months
to 26 years
Guarantee Issue $10,000
Increments of $1,000
($10,000 maximum)
Rate Table For Employee And Spouse*
Age Bracket
Rate
< 29 $0.05
30-34 $0.08
35-39 $0.10
40-44 $0.15
45-49 $0.26
50-54 $0.39
55-59 $0.68
60-64 $1.03
65-69 $1.84
*Dependent Child Rate: $0.14 per $1000.
Sample Voluntary Term Life Rates
Employee And Spouse Sample Monthly Rates
Amount of coverage elected Age 20 Age 35 Age 40 Age 50 Age 60
$20,000 $1.00 $2.00 $3.00 $7.80 $20.60
$30,000 $1.50 $3.00 $4.50 $11.70 $30.90
$40,000 $2.00 $4.00 $6.00 $15.60 $41.20
$50,000 $2.50 $5.00 $7.50 $19.50 $51.50
Dependent Child(ren) Rates
*The Child Voluntary Term Life Insurance has a flat rate, so it will remain the same for multiple children.
$0.14 per $1,000 of coverage
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 9

Employee Assistance Program
Employee Assistance Program (Standard Insurance)
All Troy University employees covered by the Long Term Disability policy will have access
to Horizon Health (you do not have to be enrolled on the medical plan to be eligible for
these benefits).
The Horizon Health Employee Assistance Program (EAP) offers support, guidance and
resources that can help you resolve personal issues and meet life’s challenges. This
service is provided at no additional cost to you by Troy University, in connection with your
Group Long Term Disability coverage from The Standard.
To access the Horizon Health EAP, please call 888-293-6948 or visit
www.horizoncarelink.com. Horizon Health EAP is always ready to assist you.
HorizonCareLink SM
1. Enter this address in
your Web browser:
www.horizoncarelink.com
2. Enter standard as the
login ID (in all lowercase
letters) when prompted.
3. Enter password: eap4u
when prompted.
Note: It is a violation of your
company’s contract to share this
information with individuals who
are not eligible for this service.
The Horizon Health EAP can
help you with all of the following:
• Child care and elder care
• Alcohol and drug abuse
• Life improvement
• Difficulties in relationships
• Stress and anxiety with work or family
• Depression
• Personal achievement
• Emotional well-being
• Financial and legal concerns
• Grief and loss
• Identity theft and fraud resolution
The program is available 24 hours a day,
every day, to you and members of your
household. You’ll receive up to three faceto-face
counseling sessions per issue.
WorkLife Services
WorkLife services can save you countless
hours by researching and providing
referrals for important issues such as:
• Child care and elder care
• Education
• Adoption
• Pet care
• Daily living
• Travel
Confidential Advice
Your calls and all counseling services are
completely confidential. Information will be
released only with your permission or as
required by law.
This EAP service is provided through an
arrangement with Horizon Behavioral
Services, Inc., which is not affiliated with
The Standard. The EAP service is not an
insurance product.
The Standard is a marketing name for
StanCorp Financial Group, Inc. and
subsidiaries. Insurance products are
offered by Standard Insurance Company
of Portland, Ore. in all states except
New York, where insurance products are
offered by The Standard Life Insurance
Company of New York of White Plains, N.Y.
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 10

travel assistance
MEDEX ® Travel Assist (Standard Insurance)
MEDEX ® Travel Assist helps you cope with emergencies when you
travel more than 100 miles from home or internationally for trips
of up to 180 days. MEDEX ® Travel Assist can also help you with
non-emergencies, such as planning your trip.
You do not have to enroll. As a participant in Troy University’s
Group Life Insurance coverage from The Standard, you and
your family members are automatically covered. All services are
provided by MEDEX ® Assistance Corporation and are available
24 hours a day, every day.
In the U.S., Canada, Puerto Rico, U.S. Virgin
Islands, and Bermuda, call 800-527-0218. In
other locations worldwide, call +1-410-453-6330
collect. You can also reach MEDEX Travel Assist
at operations@medexassist.com.
MEDEX ® Travel Assist offers the following services:
• Pre-trip Assistance including passport, visa, weather and
currency exchange information, health hazards advice and
inoculation requirements
• Medical Assistance Services including locating medical
care providers and interpreter services
• Travel Assistance Services including emergency ticket,
credit card and passport replacement assistance, funds
transfer assistance and missing baggage assistance
• Legal Assistance Services including locating a local
attorney, consular officer or bail bond services
• Emergency Transportation Services including arranging
and paying for emergency evacuation to the nearest adequate
medical facility and medically-necessary repatriation to the
employee’s home, including repatriation of remains*
• Personal Security Services including evacuation and
logistical arrangements in the event of political unrest, social
instability, weather conditions, health or environmental hazards
* Emergency Transportation Services arranged and provided by MEDEX® are covered up
to a Combined Single Limit of $1,000,000. Related medical services, medical supplies
and a medical escort are covered where applicable and necessary.
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 11

health reimbursement account
Health Reimbursement Account
A major component of Troy University’s employee benefit package
is a Health Reimbursement Account—a type of benefit that covers
common expenses most households incur on a routine basis.
What Is A “Health Reimbursement Account”
A Health Reimbursement Account (HRA) is an account funded
by Troy University that will reimburse YOU for eligible medical
expenses not otherwise covered by the Troy University health plan.
You may submit claims for reimbursement for any expenses that
you incur, as well as expenses for your spouse or any other tax
dependent. Examples of eligible expenses are orthodontia, vision
care, Lasik surgery, etc. If you have any unused funds in your
HRA at the end of the year, there is no need to worry because the
balance, up to $3,000 for family coverage and $1,500 for individual
coverage, will roll forward into the next plan year.
How Does HRA Work
You will need to file all claims with Flexible Corporate Plans.
Health Reimbursement claim forms can be downloaded at
www.flexcorp.com and submitted to FlexCorp with a copy of the
receipt or documentation of expense incurred.
Each year you are enrolled in the health insurance plan, you will
have the opportunity to accrue monies to add to your HRA for the
next year. By the end of March, employees will receive a statement
from FlexCorp showing their new balance for the plan year.
Please contact Flexible Corporate Plans by phone at 205-995-1222
or visit www.flexcorp.com if you need your pin number or to view
your personal account.
Plan Provisions:
• Your HRA account will be available to reimburse your
expenses during your second year of participation in the
Troy University health plan.
• To earn HRA funds, a beginning balance of $1,500 for family
coverage or $750 for single coverage is reduced by your
claims paid during your first year on the health plan.
• New employees or employees enrolling in the Troy University
health plan after January 1st of each year will have their
HRA contribution prorated based on the number of months
remaining in that year.
• 75% of any amount not used for your current year plan
will be carried forward and added to any previous year
balances in your HRA.
• You must maintain coverage in the Troy University
health plan to be eligible for HRA.
• Plan year begins on January 1st and ends on December 31st.
• HRA’s are capped at $3,000 for family coverage and
$1,500 for individual coverage per plan year.
Eligible Expenses:
• Orthodontia & major dental expenses above plan limits
• Lasik surgery
• Co-insurance amounts required by the plan
• Vision care
• Other expenses allowed under IRS Code Sec. 213(d)
Ineligible Expenses
• Insurance Deductibles
• Co-payments
• OTC medications
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 12

flexible spending
Flexible Spending Accounts (Flex Corp)
Want an easy way to save money Whether you are married with
kids, single with no children, a single parent, or any other lifestyle
status, a Flexible Spending Account can save you money.
A FSA is actually comprised of two accounts:
• A Health Care Account for health care reimbursement
• A Dependent Care Account for child or elder care reimbursement
How FSAs Save You Money
FSAs allow you to set aside before-tax dollars to cover qualified
expenses that you would normally pay out of your pocket with
after-tax dollars. You pay no federal income, state income or Social
Security taxes on the money you place in your FSA. With just a little
planning, you can increase your net pay.
*Please note that any expense reimbursed through your FSA is not
eligible to be claimed as a deduction or credit on your tax return.
How FSAs Work
First, estimate what your out-of-pocket health care and child/elder
care expenses will be for the year. Based on your estimate, you will
then specify the amount of dollars you want to contribute to your
FSA for the year. For 2013, you may contribute up to $2,500 to your
Health Care Account and $5,000 to your Dependent Care Account.
Once you begin depositing money into your FSA, you can start
getting reimbursed for eligible expenses. You can be reimbursed up
to the full amount of your annual Health Care Account contribution,
regardless of the amount you have deposited in your account. For
your Dependent Care Account, you can be reimbursed up to the
amount you have deposited.
Please visit www.flexcorp.com for a video about Flexible
Spending. Click on “Participants,” then “Welcome Center.” On
the Welcome Center page, click on “Employee Presentation.”
And, don’t forget about your Flex Card!
You can use your Flex Card at approved providers to instantly
access your account. It allows you to pay for eligible expenses
and services at the point of service by automatically deducting
the amount from your FSA. No hassle and no waiting! Plus, you
can view your account activity and balance any time on-line at
www.flexcorp.com by clicking on Participants and Online Access.
Frequently Asked Questions about FSA
Who is eligible to participate in the FSA plan All full-time
employees who work at least 40 hours per week are eligible to
participate in the plan immediately upon hire.
What is a Dependent Care Spending Account A Dependent
Care Flexible Spending Account is used to pay for eligible
dependent care expenses such as child care for children under
age 13 or day care for anyone who you claim as a dependent
on your Federal tax return who is physically or mentally
incapable of self-care so that you (and your spouse, if you are
married) can work, look for work, or attend school full time.
What qualifies as an eligible expense under a Health Care
FSA or a Dependent Care Spending Account Check the
following page for eligible expenses.
What if I do not use all the money in my account by the end of
the year The Plan starts on January 1st of each year and ends
on December 31st. According to IRS guidelines, any unused funds
will be lost. Troy University gives you a grace period, which gives
you until March 31st to file your claims. After that date, claims will
no longer be accepted for the previous plan year.
What happens if I terminate If you terminate employment with
the company and you still have money that you have contributed
in your medical reimbursement account, you may elect, through
COBRA, to continue to access those monies for expenses
incurred after your termination date through the end of the plan
year as long as you continue to make your COBRA payments.
Reminder
Regardless of plan year, the only acceptable form
of documentation for reimbursement for OTC drugs
and medicines is a doctor’s prescription, as regulated
by state law. Insulin, medial devices (crutches, blood
sugar monitors, etc.) and items such as bandages,
contact lens solution, denture bond, etc. remain
eligible and will not require a doctor’s prescription.
The new rule applies to all tax-advantaged health
care accounts, including Flexible Spending Accounts
(FSAs), Health Savings Accounts (HSAs), Health
Reimbursement Arrangements (HRAs) and Archer
Medical Savings Accounts (Archer MSAs).
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 13

flexible spending
Eligible and Ineligible FSA Expenses
Eligible Expenses
• Health Care/Medical
• Prescription Birth Control
• Prescription Drugs
• Obstetric Services
• Mid-Wife Expenses
• OB/GYN Exams
• OB/GYN Prepaid
• Maternity Fees
(reimbursable after date of birth)
• Practitioners
• Allergist
• Chiropractor
• Christian Science
• Dermatologist
• Homeopath
• Naturopathy
• Osteopath
• Physician
• Psychiatrist
• Psychologist
• Other Medical
Treatments/ Procedures
• Acupuncture
• Alcoholism (inpatient treatment)
• Ambulance Services
• Arches/Orthopedic Shoes
• Contraceptives
• Counseling
• Crutches
• Guide Dog (for visually/
hearing impaired person)
• Hearing Aids & Batteries
• Hospital Bed
• Learning Disabilities
(Special school/teacher)
• Medical Alert
Bracelet or Necklace
• Oxygen Equipment
• Prescribed Medical
and Exercise
• Prosthesis
• Splints/Casts
• Support Hose (if medically necessary)
• Syringes
• Transportation Expenses
(essential to medical care)
• Wheelchair
• Wigs (hair loss due to disease)
• Vision Services
• Eye Examinations
• Eyeglasses
• Contact Lenses
• Prescription Sunglasses
• Laser Eye Surgery
• Ophthalmologist
• Optometrist
• Artificial Eye
• Radial Keratotomy
• Drug Addiction
• Hearing Exams
• Hospital Services
• Infertility
• In vitro Fertilization
• Norplant Insertion or Removal
• Patterning Exercises
• Physical Examination
(not employment related)
• Physical Therapy
• Pregnancy Tests
• Smoking Cessation Programs
• Speech Therapy
• Sterilization
• Transplants (includes organ donor)
• Treatment for Handicapped
• Vaccinations/ Immunizations
• Vasectomy
• Well Baby Care
• Other Medical Equipment
• Abdominal/Back Supports
• Dental Services
• Crowns/Bridges
• Dental X-Rays
• Dentures
• Exams/Teeth Cleaning
• Extractions
• Fillings
• Gum Treatment
• Oral Surgery
• Orthodontia/Braces
• Insurance - Related Items
• Co-pay Amounts
• Deductibles
• Pre-existing Condition
• Private Hospital Room
• Lab Exams/Tests
• Blood Test
• Cardiographs
• Diagnostics
• Laboratory Fees
• Metabolism Tests
• Spinal Fluid Tests
• Urine/Stool Analyses
• X-Rays
• Medications
• Aspirin, if plan allows
• Insulin
• Nicotine Gum or
Patches, if plan allows
Ineligible Expenses
The IRS does not allow the following expenses to be reimbursed under the Health Care Reimbursement Account. Expenses to promote
general health are not eligible expenses. This is not an inclusive listing.
• Breast Pumps
• Calcium Supplements
• Canceled Appointment Fees
• Contact Lens Insurance
• Cosmetic Surgery/Procedures
• Custom Fitovers (clip ons)
• Dancing Lessons
• Diaper Service
• Discounted Fees/Write-offs
• Electrolysis
• Exercise Equipment
• Eyeglass Insurance
• Fitness Programs
• Hair Loss Medication
• Hair Transplants
• Health Club Dues
• Herbs & Herbal Medicines
• Homeopathic Drugs
• Illegal Operations or
Treatment
• Insurance Premiums
• Lamaze Class
• Marriage Counseling
• Massage Therapy
• Maternity Clothes
• Personal Trainer
• Prescription Drug Discount
Program Premiums
• Retin-A
• Rogaine
• Special Foods
(cost difference of common product)
• Student Health Fee
• Swimming Lessons
• Tattoo Removal
• Teeth Whitening/Bleaching
• Toiletries, Toothpaste, etc.
• Varicose Vein Treatment
• Veneers
*This list is not meant to be all-inclusive. Other expenses not specifically mentioned may also qualify. For additional
information, please refer to IRS Publication 502 Medical and Dental Expenses that are www.irs.gov/pub/irs-pdf/p502.pdf.
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 14

etirement
Mandatory Retirement Plan
Teachers’ Retirement System Defined Benefit Plan 401(a)
As a condition of employment with Troy University, all eligible
employees are required to join the Retirement Systems of Alabama.
This program provides allowances for eligible members in accordance
with the plan or option the member designates at the time for
retirement. All contributions to the retirement systems are tax deferred
for federal income tax purposes until retirement or withdrawal from the
plan. For additional information visit www.rsa-al.gov.
Designation of Beneficiary: It is very important for members to
keep their beneficiary designations current. Failure to do so can result
in possible loss of valuable benefits to your survivors. The RSA 100-C
Change of Beneficiary – Prior to Retirement form is available at www.
rsa-al.gov or you may contact the TRS. You may name more than one
beneficiary and designate them as contingent or co-beneficiaries. If at
the member’s death, there is no beneficiary; the member’s estate will
be paid the appropriate death benefit
Change of Address: Having your current home mailing address on
file with the TRS is very important. Many important documents are
mailed to each member such as your Advisor, TRS Board of Control
Election ballots, Annual Statement of Account, and RSA-1 statement.
You may change your address through Member Online Services at
www.rsa-al.gov. You will need to set up a User ID and Password to
log in. You can also change your address in writing, with signature,
either by letter or Address Change Notification form. The change of
address form can be obtained from the RSA website or requested
from Member Services. Address changes cannot be made through
email or over the phone.
Refund of Contributions: A member’s contributions are only
refundable at the request of the member upon termination of
employment and application for refund (Form 7). There are no partial
refunds; all contributions are refunded in full. Interest on the account
is only refunded if the member has at least three years of membership
service. The employee is not entitled to the total interest credited to
the account. Upon withdrawal, all service credit established with the
TRS is canceled. For vested members, the right to lifetime monthly
retirement benefits is forfeited.
For additional information, please visit www.rsa-al.gov or call
Customer Service at 1-877-517-0020. Employees can also create
their own personal account with The Retirement Systems of Alabama
to view their current account and process address changes through
member online services.
Optional Supplemental
Retirement Plans
Troy University offers optional supplemental retirement
plans with TIAA-CREF, Lincoln National and The
Alabama Teachers’ Retirement System. Employees
may choose to contribute to a 403b plan and/or a 457b
supplemental retirement plan through payroll deduction.
Immediately upon employment, fulltime and parttime
employees may elect to contribute to an optional
supplemental retirement plan on a non-matching basis.
Eligibility for the matching portion requires one year of full
time employment with Troy University. Employees must
contribute 3% or more of their salary. Employees eligible
for the matching program will receive a match of 3% on a
maximum of $18,000 of salary ($540.00 annual maximum
employment [$45.00 monthly for a 12 month employee;
$54.00 monthly for a 10 month employee]) An employee
who earns $60,535.00 or more is considered “highly
compensated” and does not qualify for the university match.
It is the employee’s responsibility to contact Human
Resources after completing the one year eligibility period
to process paperwork for the university match
Employees who are interested in contributing should visit
the appropriate website or additional information:
• TIAA-CREF: www.tiaa-cref.org/troy/
• Lincoln National: https://www.lfg.com/
• Teacher’s Retirement System: www.rsa-al.gov/
Enrollment is not complete without a Salary Reduction
Agreement. As always, if you need assistance, please contact
your Human Resources Department for further information.
2013 Pension Limits Set by the IRS for 403(b) And 457(b) Plans:
• Elective Deferrals – 403(b): $17,500
• Elective Deferrals – 457(b): $17,500
• Age 50 + Catch-up Contributions: $5,500
• Contribution Limits for 2013: $23,000
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 15

important notices
Important Medical Coverage Notices
Medicaid and the Children’s Health Insurance
Program (CHIP) offer free or low-cost health
coverage to children and families
If you are eligible for health coverage from your employer, but
are unable to afford the premiums, some states have premium
assistance programs that can help pay for coverage. These states
use funds from their Medicaid or CHIP programs to help people
who are eligible for employer-sponsored health coverage, but need
assistance in paying their health premiums. For more information
please visit http://www.cms.gov or call 1-877-267-2323, ext. 61565.
Women’s Health and Cancer Rights Act Notice
Under the Women’s Health and Cancer Rights Act of 1998, a
plan participant or beneficiary who elects breast reconstruction
in connection with a covered mastectomy is also entitled to the
following benefits: All stages of reconstruction of the breast on
which the mastectomy was performed; Surgery and reconstruction
of the other breast to produce a symmetrical appearance;
and, Prostheses and treatment of physical complications of
the mastectomy, including lymphedemas. Health plans must
provide coverage of mastectomy-related benefits in a manner
determined in consultation with the attending physician and the
patient. Coverage for breast reconstruction and related services
are subject to deductibles and coinsurance amounts that are
consistent with those that apply to other benefits under the plan.
Newborns’ and Mothers’ Health Protection Act Notice
Group health plans and health insurance issuers generally may
not, under federal law, restrict benefits for any hospital length of
stay in connection with childbirth for the mother or newborn child
to less than 48 hours following a vaginal delivery, or less than 96
hours following a cesarean section. However, federal law generally
does not prohibit the mother's or newborn's attending provider,
after consulting with the mother, from discharging the mother or
her newborn earlier than 48 hours (or 96 hours as applicable). In
any case, plans and issuers may not, under federal law, require
that a provider obtain authorization from the plan or the issuer for
prescribing a length of stay not in excess of 48 hours (or 96 hours).
Important Health Care Reform Notices
Grandfathered Status
Troy University believes this plan is a “grandfathered health
plan” under the Patient Protection and Affordable Care Act (the
Affordable Care Act). As permitted by the Affordable Care Act,
a grandfathered health plan can preserve certain basic health
coverage that was already in effect when that law was enacted.
Being a grandfathered health plan means that your plan may not
include certain consumer protections of the Affordable Care Act
that apply to other plans, for example, the requirement for the
provision of preventive health services without any cost sharing.
However, grandfathered health plans must comply with certain
other consumer protections in the Affordable Care Act, for
example, the elimination of lifetime limits on benefits.
Questions regarding which protections apply and which
protections do not apply to a grandfathered health plan and what
might cause a plan to change from grandfathered health plan
status can be directed to the plan administrator in the Human
Resources Department. You may also contact the Employee
Benefits Security Administration, U.S. Department of Labor at
1-866-444-3272 or www.dol.gov/ebsa/healthreform. This website
has a table summarizing which protections do and do not apply to
grandfathered health plans.
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 16

important notices
Summary Plan Descriptions (SPD)
As required under the Employee Retirement Income Security act (ERISA), all employees and their
covered dependents must be given access to a copy of the Summary Plan Description (SPD) for the
employees welfare benefit plans.
The SPD outlines the eligibility, schedule of benefits and covered/excluded items of the benefit plans
offered by Troy University.
Employees and/or their covered dependents are given 2 options to access/obtain a copy of an SPD:
1. The Enrollment Center - EmpowHR – follow these simple steps.
• Log onto EmpowHR at troyunviversity.empowhr.com using your personal ID and password.
Personal ID - First initial of first name + your full last name + last four digits of SSN
Password – first time logging in will be full SSN – you will be asked to reset this and select a new
password. If you have already done this enter your new password.
• At the top of the page click on “Protection” then choose “Plan Information”. A page will open listing
all available benefits. Listed in each section is an underlined link to both the summary of the
benefit as well as the SPD.
• Click on the link and the document will open. You may view, save or print a copy of the document.
When finished simply close the document and “logoff” of EmpowHR.
2. You may also request a paper copy of a SPD from the Human Resources Benefits Department.
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 17

important notices
Medicare Part D Notice: Prescription Drug Coverage and Medicare
This notice has information about your current prescription drug
coverage with Troy University and 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.
Please note: If you are not Medicare eligible, and none of your
covered family members are Medicare eligible, no action is
required on your part.
There are two important things you need to know about your
current coverage and Medicare’s prescription drug coverage:
• 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.
• Troy University has determined that the prescription drug
coverage offered by The Troy University medical 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 15 through December 7. 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 Troy University medical coverage will not be affected.
Participants may keep this coverage if they elect Part D and this
plan will coordinate with Part D coverage. If you decide to join a
Medicare drug plan and drop your current Troy University medical
plan coverage, be aware that you and your dependents will be able
to get this coverage back.
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 Troy University medical 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 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 benefits department
for further information, 334-670-3338. NOTE: You may receive this
notice at other times in the future such as before the next period
you can enroll in Medicare prescription drug coverage, and if this
coverage changes. You also may request a copy.
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 1-800-MEDICARE (1-800-633-4227). TTY users should
call 1-877-486-2048.
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 1-800-772-1213
(TTY 1-800-325-0778).
Please call 1-866-688-9727. Troy University 2013 Benefits Enrollment Guide 18

Troy University-54395/000 Coverage Period: Beginning on or after 01/01/2012
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Plan Type: PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.bcbsal.org or by calling 1-800-292-8868.
Important Questions Answers Why this Matters:
What is the overall
deductible
Are there other
deductibles for specific
services
Is there an out–of–pocket
limit on my expenses
What is not included in
the out–of–pocket limit
Is there an overall annual
limit on what the plan
pays
Does this plan use a
network of providers
Do I need a referral to see
a specialist
$500 person.
Does not apply to preventive services, physician,
inpatient, drugs, noncovered services, most
copays, balance-billed charges and pre-certification
penalties.
Yes. $300 person Per Admission.
$400 person per admission inpatient deductible
for out of network. There are no other specific
deductibles.
Yes. $400 person.
Premium, balance-billed charges, health care this
plan doesn't cover, copays, out of network
coinsurance, most coinsurance, pre-certification
penalties and pharmacy copays.
No.
Yes, this plan uses in-network providers. For a list
of in-network providers, see www.bcbsal.com or
call 1-800-810-BLUE.
No. You don't need a referral to see a specialist.
You must pay all the costs up to the deductible amount before this
plan begins to pay for covered services you use. Check your policy or
plan document to see when the deductible starts over (usually, but
not always, January 1st). See the chart starting on page 2 for how
much you pay for covered services after you meet the deductible.
You must pay all of the costs for these services up to the specific
deductible amount before this plan begins to pay for these services.
The out-of-pocket limit is the most you could pay during a coverage
period (usually one year) for your share of the cost of covered
services. This limit helps you plan for health care expenses.
Even though you pay these expenses, they don’t count toward the
out-of-pocket limit.
The chart starting on page 2 describes any limits on what the plan
will pay for specific covered services, such as office visits.
If you use an in-network doctor or other health care provider, this
plan will pay some or all of the costs of covered services. Be aware,
your in-network doctor or hospital may use an out-of-network
provider for some services. Plans use the term in-network,
preferred, or participating for providers in their network. See the
chart starting on page 2 for how this plan pays different kinds of
providers.
You can see the specialist you choose without permission from this
plan.
Questions: Call 1-800-292-8868 or visit us at www.bcbsal.org.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-800-292-8868 to request a copy.
1 of 7

Are there services this plan
doesn’t cover
Yes.
Some of the services this plan doesn’t cover are listed on page 5. See
your policy or plan document for additional information about
excluded services.
• Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
• Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the
plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you
haven’t met your deductible.
• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
• This plan may encourage you to use In-Network providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical Event
If you visit a health
care provider’s office
or clinic
Services You May Need
Primary care visit to treat an injury or illness
Specialist visit
Other practitioner office visit
Preventive care/screening/immunization
Your cost if
you use an
In Network
Provider
0% coinsurance &
$25 copay
0% coinsurance &
$40 copay
20% coinsurance
for chiropractor
0% coinsurance &
$25 copay
Your cost if
you use an
Out of Network
Provider
20% coinsurance
20% coinsurance
20% coinsurance
for chiropractor
Not Covered
Limitations & Exceptions
Subject to overall deductible for out of
network
Subject to overall deductible for out of
network
Subject to overall deductible; limited to
a maximum of 12 visits or a $400
maximum payment per member per
calendar year; in Alabama, out of
network coinsurance is 50%
Facility copay may apply; age and visit
limitations will apply
Diagnostic test (x-ray, blood work) No Charge 20% coinsurance
If you have a test
Imaging (CT/PET scans, MRIs) No Charge 20% coinsurance
Subject to overall deductible for out of
network
Subject to overall deductible for out of
network; precertification may be
required for coverage
2 of 7

Common
Medical Event
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at
bcbsal.com/pharmacy.
If you have
outpatient surgery
If you need
immediate medical
attention
If you have a
hospital stay
Services You May Need
Generic drugs
Preferred brand drugs
Non-preferred brand drugs
Specialty drugs
Facility fee (e.g., ambulatory surgery center)
Your cost if
you use an
In Network
Provider
0% coinsurance &
$10 copay
0% coinsurance &
$35 copay
0% coinsurance &
$50 copay
0% coinsurance &
$50 copay
0% coinsurance &
$125 copay
Your cost if
you use an
Out of Network
Provider
Not Covered
Not Covered
Not Covered
Not Covered
20% coinsurance
Physician/surgeon fees No Charge 20% coinsurance
Emergency room services No Charge No Charge
Limitations & Exceptions
Prior authorization for specific drugs
required for coverage; mail order is
available
Prior authorization for specific drugs
required for coverage; mail order is
available
Prior authorization for specific drugs
required for coverage; mail order is
available
Specialty drugs subject to preferred
brand or non-preferred brand copay;
prior authorization for specific drugs
required for coverage; mail order is
available
Subject to overall deductible for out of
network; in Alabama, out of network
not covered
Subject to overall deductible for out of
network
Benefits listed are emergency room
services for the treatment of accidental
injury; physician copay may apply;
other medical emergencies have higher
patient responsibility
Emergency medical transportation 20% coinsurance 20% coinsurance Subject to overall deductible
Urgent care
Facility fee (e.g., hospital room)
0% coinsurance &
$40 copay
0% coinsurance &
$300 per admission
20% coinsurance
20% coinsurance
Physician/surgeon fee No Charge 20% coinsurance
Subject to overall deductible for out of
network; specialist copay may apply
Subject to per admission deductible;
precertification is required for
coverage; in Alabama, out of network
not covered
Subject to overall deductible for out of
network
3 of 7

Common
Medical Event
If you have mental
health, behavioral
health, or substance
abuse needs
If you are pregnant
If you need help
recovering or have
other special health
needs
If your child needs
dental or eye care
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
Mental/Behavioral health outpatient services Not Covered Not Covered –––––––––––none–––––––––––
Mental/Behavioral health inpatient services Not Covered Not Covered –––––––––––none–––––––––––
Substance use disorder outpatient services Not Covered Not Covered –––––––––––none–––––––––––
Substance use disorder inpatient services Not Covered Not Covered –––––––––––none–––––––––––
Prenatal and postnatal care No Charge 20% coinsurance
Delivery and all inpatient services No Charge 20% coinsurance
Home health care No Charge 20% coinsurance
Rehabilitation services 20% coinsurance 20% coinsurance
Subject to overall deductible for out of
network; initial office visit will have
$25 copay for in network services
Subject to overall deductible for out of
network
Subject to overall deductible for out of
network; precertification may be
required for coverage; in Alabama, out
of network not covered
Subject to overall deductible;
occupational therapy is limited to
certain services related to hand and
lymphedema
Habilitation services 20% coinsurance 20% coinsurance Subject to overall deductible
Skilled nursing care Not Covered Not Covered –––––––––––none–––––––––––
Durable medical equipment 20% coinsurance 20% coinsurance Subject to overall deductible
Hospice service No Charge 20% coinsurance
Subject to overall deductible for out of
network; precertification may be
required for coverage; in Alabama, out
of network not covered
Eye exam Not Covered Not Covered –––––––––––none–––––––––––
Glasses Not Covered Not Covered –––––––––––none–––––––––––
Dental check-up Not Covered Not Covered –––––––––––none–––––––––––
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Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
• Acupuncture
• Cosmetic surgery
• Dental care (Adult)
• Dental check-up, child
• Eye exam, child
• Glasses, child
• Hearing aids
• Long-term care
• Mental/Behavioral health
• Private-duty nursing
• Routine eye care (Adult)
• Routine foot care
• Skilled nursing care
• Substance use disorder
• Weight loss programs
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
• Bariatric Surgery (only morbid obesity in
limited circumstances)
• Chiropractic care
• Infertility treatment (Assistive
Reproductive Technology not covered)
• Non-emergency care when traveling
outside the U.S.
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay
while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan administrator at the phone number listed in your benefit booklet. You may also
contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or
www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact Blue Cross and Blue Shield of Alabama at 1-800-292-8868.
SPANISH (Español): Para obtener asistencia en Español, llame al 1-800-292-8868.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
5 of 7

About these Coverage
Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
See the next page for
important information about
these examples.
Having a baby
(normal delivery)
• Amount owed to providers: $7,540
• Plan pays $7,050
• Patient pays $490
Sample care costs:
Hospital charges (mother) $2,700
Routine obstetric care $2,100
Hospital charges (baby) $900
Anesthesia $900
Laboratory tests $500
Prescriptions $200
Radiology $200
Vaccines, other preventive $40
Total $7,540
Patient pays:
Deductibles $0
Copays $340
Coinsurance $0
Limits or exclusions $150
Total $490
Note: These numbers assume the patient has
given notice of her pregnancy to the plan. If
you are pregnant and have not given notice
of your pregnancy, your costs may be higher.
For more information, please contact:
www.bcbsal.com.
Managing type 2 diabetes
(routine maintenance of
a well-controlled condition)
• Amount owed to providers: $5,400
• Plan pays $4,100
• Patient pays $1,300
Sample care costs:
Prescriptions $2,900
Medical Equipment and Supplies $1,300
Office Visits and Procedures $700
Education $300
Laboratory tests $100
Vaccines, other preventive $100
Total $5,400
Patient pays:
Deductibles $20
Copays $910
Coinsurance $0
Limits or exclusions $370
Total $1,300
Note: These numbers assume the patient is
participating in our diabetes wellness
program. If you have diabetes and do not
participate in the wellness program, your
costs may be higher. For more information
about the diabetes wellness program, please
contact: www.bcbsal.com.
6 of 7

Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples
• Costs don’t include premiums.
• Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and aren’t specific to a
particular geographic area or health plan.
• The patient’s condition was not an
excluded or preexisting condition.
• All services and treatments started and
ended in the same coverage period.
• There are no other medical expenses for
any member covered under this plan.
• Out-of-pocket expenses are based only
on treating the condition in the example.
• The patient received all care from innetwork
providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example
show
For each treatment situation, the Coverage
Example helps you see how deductibles,
copayments, and coinsurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
Does the Coverage Example
predict my own care needs
No. Treatments shown are just examples.
The care you would receive for this
condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example
predict my future expenses
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Can I use Coverage Examples
to compare plans
Yes. When you look at the Summary of
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing
plans
Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-ofpocket
costs, such as copayments,
deductibles, and coinsurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.
Questions: Call 1-800-292-8868 or visit us at www.bcbsal.org.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call 1-800-292-8868 to request a copy.
7 of 7

BlueCard PPO: Troy University Coverage Period: 01/01/2013 – 12/31/2013
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: _________ | Plan Type: PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.behavioralhealthsystems.com or by calling 1-800-245-1150.
Important Questions Answers Why this Matters:
What is the overall
deductible
Are there other
deductibles for specific
services
Is there an out–of–
pocket limit on my
expenses
What is not included in
the out–of–pocket
limit
Is there an overall
annual limit on what
the plan pays
Does this plan use a
network of providers
Do I need a referral to
see a specialist
Are there services this
plan doesn’t cover
$
Does not apply to mental health
and substance abuse care.
$
$
Does not apply to mental health
and substance abuse care.
Yes. For a list of mental health
or substance abuse in-network
providers, call Behavioral
Health Systems at 800-245-
1150.
If you use an in-network doctor or other health care provider, this plan will pay some or all
of the costs of covered services. Be aware, your in-network doctor or hospital may use an
out-of-network provider for some services. Plans use the term in-network, preferred, or
participating for providers in their network. See the chart starting on page 2 for how this
plan pays different kinds of providers.
Questions: Call 1-800-245-1150 or visit us at www.behavioralhealthsystems.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.behavioralhealthsystems.com or call 1-800-245-1150 to request a copy.
1 of 2

BlueCard PPO: Troy University Coverage Period: 01/01/2013 – 12/31/2013
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: _________ | Plan Type: PPO
Common
Medical Event
If you have mental
health, behavioral
health, or substance
abuse needs
If you are pregnant
Services You May Need
Mental/Behavioral health outpatient services
Mental/Behavioral health inpatient services
Substance use disorder outpatient services
Substance use disorder inpatient services
Prenatal and postnatal care
Delivery and all inpatient services
Your Cost If
You Use an
In-network
Provider
$13-30 copay/visit
for office visits,
20% coinsurance
for other outpatient
services
$100 deductible
/admission and
20% coinsurance
for inpatient,
20% coinsurance
for intensive
outpatient and
partial
hospitalization
$13-30 copay/visit
for office visits,
20% coinsurance
for other outpatient
services
$100 deductible
/admission and
20% coinsurance
for inpatient,
20% coinsurance
for intensive
outpatient and
partial
hospitalization
Your Cost If
You Use an
Out-of-network
Provider
Not covered
Not covered
Not covered
Not covered
Limitations & Exceptions
Office visits limited to 25 visits/year.
Overall deductible does not apply.
No coverage for services by out-ofnetwork
providers.
No coverage for inpatient, partial
hospitalization, intensive outpatient,
ECT, or psychological testing unless
pre-authorized by Behavioral Health
Systems.
Questions: Call 1-800-245-1150 or visit us at www.behavioralhealthsystems.com.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.behavioralhealthsystems.com or call 1-800-245-1150 to request a copy.
2 of 2

Please note that this guide is a general summary of your benefits. For specific details, you may refer to each carrier’s summary plan
description. Every effort has been made to ensure that this booklet accurately represents the benefits. However, if there are any
discrepancies between the terms in this booklet and the terms in the plan document, the plan document will prevail.