Benefit2016-2017 Plan Year Benefit Plan Year

July 2016 - June 2017

Rates and Medical Plans Bundled with Dental and Vision Coverage Rates reflect per pay period contribution BENEFITS DEDUCTION SCHEDULE

BENEFIT COST FOR 12-MONTHS EMPLOYEES PER PAY PERIOD Deductions 7/1/16 - 6/30/17

EE Only

EE+ Spouse

EE+ Children

EE+ Family

Kaiser EPO

No Cost

$233.9

$199.77

$323.72

Anthem EPO

No Cost

$306.39

$235.85

$426.03

Anthem HSA

No Cost

$263.40

$203.02

$367.40

Anthem PPO

$127.50

$316.29

$243.42

$439.53

BENEFIT COST FOR 10-MONTHS EMPLOYEES PER PAY PERIOD

Important: Your annual benefit premium will be charged and collected within a 9-month period; between September 1st through May 31st (18 pay periods)

Deductions (on 18 pay periods) 9/1/16 - 5/31/17 EE Only

EE+ Spouse

EE+ Children

EE+ Family

Kaiser EPO

No Cost

$311.86

$266.35

$431.62

Anthem EPO

No Cost

$408.52

$314.47

$568.04

Anthem HSA

No Cost

$351.19

$270.69

$489.86

Anthem PPO

$170.00

$421.72

$324.55

$586.03

Eligibility Rules • • • •

All benefit eligible employees working 20+ hours per week. Eligible dependents: spouse (as defined by state law), and children under age 26 . Employees who plan to enroll their dependents in the DSJ health plan will be required to provide documentation of dependent eligibility during enrollment in order for dependent’s coverage to be approved. (Spouse -Marriage certificate, Child- Birth certificate, Adoption/Legal Guardianship – Court documents) For detailed information go to Retatrust.org and review “Eligibility & Enrollment” summary

2016- 2017 Benefits Plan Breakdown

VOLUNTARY OPTIONS

CORE BENEFITS

Health Plans Kaiser

Anthem PPO or EPO

Anthem HSA

Kaiser Vision

VSP Vision

VSP Vision

Kaiser Prescription

Envision Rx Prescription

Anthem Prescription

Delta Dental

Delta Dental

Delta Dental

Waive Medical No vision/presrciption or dental provided Life Insurance, AD&D, LTD are provided

DELTA DENTAL PPO

The Delta Dental PPO* plan makes it easy to find a dentist, visit the dentist of your choice, and save money with a Delta Dental PPO dentist.

VISION – VSP or KAISER VISION

• Anthem will automatically receive the VSP vision plan. • Kaiser will automatically receive the Kaiser vision plan.

LIFE INSURANCE, AD&D, LONG TERM DISABILTY

Employer pays 100% of the premium at no cost to employee on all Health Plan packages.

Term Life and Accidental Death and Dismemberment (AD&D) insurance

Your beneficiary will receive 1x basic annual earnings to a maximum of $125,000.00. Provides a cash benefit to help ensure your loved ones remain financially secure in the event of your death or a covered accident. Benefit reduction commencing at age 65.

Long-term disability (LTD) insurance

LTD is intended to help replace some of your income for an extended period when you cannot work because of a disability. Elimination Period of 180 days. Monthly benefit of 70% of monthly salary up to $5,000 per month. Integrated with other disability benefits you may receive.

DSJ PENSION RETIREMENT

All Benefits Eligible employees hired or rehired are automatically enrolled in the Diocese of San Jose Retirement Plan. The Pension plan is 100% funded by DSJ and administered by Nicolay Pension Services Division (800) 867-0780 x223. A personalized annual statement is available on line after the end of the calendar year at www.hrmecca.com/dsj.

ADDITIONAL LIFE INSURANCE, AD&D

Voluntary Life and Accidental (AD&D) is an employee-paid plan available to all new hires and during open enrollment period. Coverage available to employee and eligible dependents.

FLEXIBLE SPENDING ACCOUNT (FSA)

Participating in FSA can help save you money on taxes. The money you set aside in FSA is not subject to federal income or Social Security tax. This allows you to benefit from more of the money you earn.

Health Care Flexible Spending (HFSA)

HFSA allows you to set aside a portion of your salary, before-tax, to reimburse certain amounts expended for medical care. Contribution may not exceed $1,200.

Dependent Day Care Flexible Spendin (DFSA)

DFSA allows you to set aside a portion of your salary, before-tax, to reimburse amounts spent for eligible dependent day care expenses that are necessary in order for you, and if you are married, your spouse, to work or look for work. Under federal tax law. Maximum annual contribution may be up to $5,000 ($2,500 maximum if you are married, filing separate income tax returns).

403(b) TAX SHELTERED ANNUITY (TSA)

As an employee of the Diocese of San Jose, you are eligible to participate in a 403(b) TaxSheltered Annuity (TSA) plan. An individual’s 403(b) annuity can be obtained only under an employer’s TSA plan. Participation in the 403(b) TSA is voluntary and may be done at any time at the employee’s discretion. The plan is administered by Employee Benefits Services (EBS). Employee may choose any investment company as long as it meets the Information-Sharing Agreement with the Diocese of San Jose as an approved company. Investment options include mutual funds and annuities. To enroll in the 403(b) TSA, please contact a financial advisor of your choice or Employee Benefits Services (EBS) DSJ Plan Administrator at 408-978-1000. There will be no matching contribution.

Visit www.retatrust.org for Plan Summary and Evidence Coverage Booklets Anthem Plan Designs

PREMIUM Plan: PPO 100/80

CORE Plan: EPO

Plan: HSA 80/60

Annual Out-of-Pocket Maximum (Includes Deductible & CoInsuance) per calendar year For any one Member in the same Family Unit

$250 In / $2,950 Out network

$800 No Coverage out of network

$5,000 In / $6,000 Out network

For an entire Family Unit of two or more Members

$500 In / $5,900 Out network $250 Ind / $500 Fam (combined in and out)

$2,400 No Coverage out of network None

$10,000 In / $12,000 Out network $1500 Ind / $3,000 Fam (combined in and out)

Office Visit Co-payments

$20 Copay In (deductible waived) 20% Out

$15 Copay In Network No Coverage out of network

20% In / 40% Out

Preventive Services

100% In/ 80% Out

100% No Copay in Network No Coverage out of Network

0% In / 40% Out (deductible waived)

Well Child Care (Birth to age 2)

100% In/ 80% Out

No Copay In Network No Coverage out of network

0% In / 40% Out (deductible waived for In)

Outpatient surgery

No Copay In / 20% Out

No Copay In Network No Coverage out of network

20% In / 40% Out

Allergy injection visits

No Copay In / 20% Out (deductible waived) $20 Office Visit may apply

No Copay In Network No Coverage out of network $15 Office Visit may apply

20% In / 40% Out

X-rays and lab tests

No Copay In / 20% Out

No Copay In Network No Coverage out of network

20% In / 40% Out

MRI, CT and PET

No Copay In / 20% Out

No Copay In Network No Coverage out of network

20% In / 40% Out

$250 per admission then paid at 100%

20% In / 40% Out

In Network Deductible per Calendar Year Professional Services

Outpatient Services

Inpatient Services ($500 deduct non-preauthorized hospitalization) Room and board, surgery, anesthesia, Xrays, lab tests, and drugs

$100 per admission then 0% In / 20% Out

Emergency Health Coverage ($100 deductible is wavied if admitted to hospital directly from ER) Emergency Department visits

0% In & Out for initial 48 hours / Out 20% thereafter $100 per visit, waived if admitted

0% In & Out for initial 48 hours 20% In / Out / No Out coverage thereafter $100 per visit, waived if admitted

Retail Pharmacy - up to 30 day supply

$10 Generic 30% Brand Formulary 50% Brand Non Formulary $2,000/Member OOP; Based on RVO Program

$10 Generic 30% Brand Formulary 50% Brand Non Formulary $2,000/Member OOP; Based on RVO Program

$10 Generic 30% Brand Formulary 50% Brand Non Formulary Must meet HSA Ded

Mail-order Pharmacy - up to 90 day supply

$20 Generic 30% Brand Formulary 50% Brand Non Formulary $2,000/Member OOP; Based on RVO Program

$20 Generic 30% Brand Formulary 50% Brand Non Formulary $2,000/Member OOP; Based on RVO Program

$20 Generic 30% Brand Formulary 50% Brand Non Formulary Must meet HSA Ded

0% In/ 20% Out network

No Copay in Network

20% In / 40% Out network

Prescription Drug Coverage

Durable Medical Equipment Covered durable medical equipment for home use in accord with our DME formulary

Visit www.retatrust.org for Plan Summary and Evidence Coverage Booklets RETA TRUST - TRUSTOR

Kaiser

RetaTrust – BAS 877-303-7382 www.retatrust.org * Enrollment Process * Password & Username * Benefit Election Assistance * Misc. questions: Medical, Dental, and Vision, FSA, Plans Summary

CORE Plan: EPO Annual Out-of-Pocket Maximum for Certain Services For any one Member in the same Family Unit

$1,500 per calendar year

For an entire Family Unit of two or more Members

$3,000 per calendar year

Deductible

None

MEDICAL PLANS

Anthem Blue Cross www.anthem.com/ca * Order New Cards * Coverage detail PPO Group #1841KA-KM EPO Group #1724V HSA Group #1850

Professional Services (Plan Provider office visits) Office Visit Co-payments

$15 per visit

Preventive Services

100%

Well-child preventive care visits (0-23 months)

100%

Kaiser

888-722-1077

800-663-1771 www.kp.org * Order New Cards * Coverage detail EPO Medical Group #8441

DENTAL PLANS

Delta Dental PPO

800-765-6003 www.deltadentalins.com * Order New Cards * Coverage detail Group #15887 Outpatient Services Outpatient surgery

$15 per procedure

Allergy injection visits

$5 per visit

Lab test

No Charge

MRI, CT and PET

No Charge

VISION PLANS

VSP Vision 800-877-7195 www.vsp.com * Order New Cards * Coverage detail Employee’s Social Security #

Kaiser Vision

800-464-4000 www.kp.org * Order New Cards * Coverage detail EPO Vision Group #8441

PRESCRIPTION PLANS

Inpatient Services

Anthem EPO - PPO

Room and board, surgery, anes$250 per admission thesia, X-rays, lab tests, and drugs, Mental Health and Substance Abuse (Detox)

EnvisionRx

844-852-7437 www.EnvisionRx.com

AnthemHSA Rx 888-722-1077 www.anthem.com/ca Group #1850 DA-DM

Kaiser Rx 800-464-4000 www.kp.org EPO Prescription Group #8441

Emergency Health Coverage Emergency Department visits

$100 per visit (does not apply if admitted directly to the hospital as an inpatient)

Prescription Drug Coverage Retail Pharmacy Mail Order Pharmacy

$10 Generic $20 Brand

RETIREMENTS

Nicolay Pension Services Division

E.B.S. 408-978-1000 800-867-0780 x223 www.hrmecca.com/dsj FLEX SPENDING LIFE INSURANCE

Benny Card RetaTrust – BAS Lincoln National

800-423-2765 www.lfg.com * Life, AD&D, LTD * Critical Illness and Accident

877-303-7382 www.retatrust.org

Same as retail

Durable Medical Equipment Covered durable medical equipment for home use in accord with our DME formulary

403 (B) Savings Plan

20% coinsurance

WebMD Support 877-936-1970 www.webmdhealth.com/reta * Enrollment Process * Password & Username