New Employee Benefits Enrollment - Dow Corning

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Cost and Coverage Comparison Chart (continued) Geographic Eligibility All Locations Mid-Michigan Carrollton/ Elizabethtown BCBS PPO CDHP Option In Network Out of Network In Network Out of Network HealthPlus Anthem BPP Greensboro United Healthcare Emergency Room $75 co-pay $ 75 co-pay 90% 70% $ 50 co-pay $ 75 co-pay $ 100 co-pay Non-Emergent use of ER Outpatient Therapy (physical, speech, cardiac & occupational) Chiropractic Services ($1,000 annual max.) Prescription Drug 50% 50% 50% $ 50 co-pay Not covered Not covered $ 15 co-pay 70% 90% 70% $ 15 co-pay 70% 90% 70% In-network Retail Pharmacy (30-day supply) � $10 co-pay generic � $20 co-pay preferred brand � $35 co-pay non-preferred brand Mail Order (90-day supply) � $15 co-pay generic � $30 co-pay preferred brand � $50 co-pay non-preferred brand You pay 100% until the annual deductible is met. Then the following copays apply until you reach the out-ofpocket maximum: In-network Retail Pharmacy (30-day supply) � $10 co-pay generic � $20 co-pay preferred brand � $35 co-pay non-preferred brand Mail Order (90-day supply) � $15 co-pay generic � $30 co-pay preferred brand � $50 co-pay non-preferred brand 100% coverage, office visit copay may apply 100% coverage, office visit copay may apply In-network Retail Pharmacy (30-day supply) � $10 co-pay generic � $20 co-pay preferred brand � $35 co-pay non-preferred brand Mail Order (90-day supply) � $15 co-pay generic � $30 co-pay preferred brand � $50 co-pay non-preferred brand $ 15 co-pay $ 15 co-pay $15 co-pay Not covered In-network Retail Pharmacy (30-day supply) � $10 co-pay generic � $20 co-pay brand � $30 co-pay non-formulary Mail Order (90-day supply) � $20 co-pay generic � $40 co-pay brand � $60 co-pay non-formulary In-network Retail Pharmacy (30-day supply) � $ 7 co-pay generic � $15 co-pay brand � $30 co-pay non- preferred Mail Order (90-day supply) � $17.50 co-pay generic � $37.50 co-pay brand � $75 co-pay non- preferred 11
VISION Coverage is effective on your first day of work. See Benefit Enrollment Information page for details on how to enroll for benefit coverage. If you waive coverage or fail to enroll within two months from your start date, you will receive no coverage for the current calendar year, and you must wait until the next annual enrollment period to enroll for coverage. Plan Highlights The Dow Corning Vision Plan, administered by Spectera, offers coverage for lenses, frames and contact lenses to both full-time and part-time employees. Everyone enrolled in a medical plan is automatically enrolled in Spectera eye exam coverage, at no cost, and is considered a Spectera member. Spectera offers two levels of benefits – Network and Out-of-Network – based on the provider you select. In-Network Benefits Spectera administers the following coverage when services are received from a network provider: � Exam – A comprehensive vision exam from a network optometrist or ophthalmologist is covered in full, once every 12 months, after the exam co-pay of $15. You do not need to be enrolled in the Vision Plan to receive this coverage. Everyone enrolled in a medical plan is automatically enrolled in Spectera eye exam coverage. � Lenses – Plan lenses are covered once every 12 months, with no co-pay. � Frames – One set of Plan frames is covered once every 12 months, with no co-pay. If you choose a frame outside of Spectera’s selection, you will receive a $50 wholesale frame allowance at a private practice provider, or a $130 retail frame allowance at a retail chain provider. � Contact lenses – You may select contact lenses in lieu of lenses and frames. If you use disposable contact lenses, up to six boxes of Plan approved lenses will be covered every 12 months. If you choose non-Plan approved lenses, a $150 allowance will be applied every 12 months. The $150 allowance covers the fitting/evaluation fees, contact lenses and up to two follow-up visits. � To find a network provider, visit the Spectera website at www.spectera.com and click on the Future Member feature. The Spectera website will indicate the providers’ level of participation; use the Key to Services chart below. Exam Only Dispense Only Exam and Dispense 12
Page 1 and 2: Dow Corning Corporation - Multibase
Page 3 and 4: INTRODUCTION Dear Fellow Employee:
Page 5 and 6: BENEFIT ENROLLMENT INFORMATION Dow
Page 7 and 8: DENTAL Coverage is effective on you
Page 9 and 10: MEDICAL Coverage is effective on yo
Page 11: Cost and Coverage Comparison Chart
Page 15 and 16: DEPENDENT LIFE Coverage is effectiv
Page 17 and 18: BASIC & OPTIONAL LIFE Coverage is e
Page 19 and 20: ACCIDENTAL DEATH & DISMEMBERMENT (A
Page 21 and 22: HEALTH SAVINGS ACCOUNT (HSA) The fe
Page 23 and 24: FLEXIBLE SPENDING ACCOUNTS (FSA) Do
Page 25 and 26: LONG TERM DISABILITY (LTD) Coverage
Page 27 and 28: BUSINESS TRAVEL ACCIDENT LIFE Busin
Page 29: BENEFIT ENROLLMENT WORKSHEET After

New Employee Benefits Enrollment - Dow Corning

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