SCANA Corporation 2017 Benefits...SCANA reserves the right at will to change or terminate any of the...

2017 BenefitsSCANA Corporation

Effective January 1, 2017

This guide serves as the Summary of Material Modifications describing the changes made to the SCANA Corporation Health and Welfare Plan. This guide should be kept with a copy of the applicable summary plan description that was provided to you and which can be found on The Edge. The details of these plans are contained in the official plan documents. The plans are subject to and governed by applicable federal laws and regulations, principally those administered by the Internal Revenue Service and the Department of Labor. SCANA reserves the right at will to change or terminate any of the benefits offered by the Plan, or the Plan itself, as allowed by applicable law. For details on benefits, you are encouraged to view the benefits summaries on the open enrollment website found on The Edge.

Your regular health plan benefits generally will not cover these services. You are responsible for any costs of these services your benefit plan does not cover … but they may help you take charge of your health and save money.

Check out the discounts on items such as:

• Hearing screenings

• Hearing aids

• Cosmetic surgery

• Cosmetic dentistry

• Hair restoration

• Eye care

• Eyewear

• Lasik services

• Weight loss programs

• Allergy relief products

• Companion Global Healthcare

• Companion Global Dental

Are there alternative health services you

find helpful — or want to try?

You also can find discounts on:

• Acupuncture

• Massage therapy

• Chiropractic services

• Fitness centers

• Diet and supplement advisers

For details on discounts:

1. Go to www.SouthCarolinaBlues.com.

2. Select Member Perks, then choose a category.

Besides the health benefits outlined in this booklet, you

have access to discounts on a variety of products and

services to enhance your quality of life. Think of them as

special perks just for being Blue.

Discounts for you — just for being Blue

1

Make the most of your benefits Continuing to offer valuable benefits that are affordable and competitive isn’t

easy. That’s especially true when increasing health care costs and compliance

with health care reform laws are challenging all of us on a personal and

business level. But it’s the right thing to do, and it makes me proud that our

collective team works hard to make the adjustments needed to maintain a

competitive plan for our self-insured company.

How about you? What adjustments have you made – daily, monthly, annually –

to ensure you’re taking full advantage of what your benefits premium buys you? Are you:

• Scheduling your recommended 100%-covered preventive care and screenings, especially an

annual physical?

• Choosing generic medications when available – even getting FREE preventive generic medications,

if applicable, through the SCANA Pharmacy?

• Maximizing the wellness resources SCANA and BlueCross BlueShield make available to help you

achieve or maintain your best health?

• Shopping around for quality care at the best price and choosing in-network providers to get the

lowest rate?

• Investing in a health savings account and funding it now, even if you don’t need it, as a way to save

for health care costs in your retirement? SCANA even provides you seed money to help you get started.

Don’t leave anything on the table. Make the most of the benefits available to you. Enclosed is information

to help you do that.

After reviewing the details contained here, if you have any questions, be sure and call the Employee

Resource Center at 803-217-4444.

Stay well,

Kevin Marsh

SCANA Chairman & Chief Executive Officer

Your Benefits. Your Choice.

3Your Benefits. Your Choice.

How to Enroll . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

What you need to know now . . . . . . . . . . . . . . . . 5Overview of SCANA Choice plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Prescription Drug Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Dental Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Vision Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

HSA and FSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Find the Right Doctor, Choose the Right Plan . . . . . . . . . . . . . . . . . . . . . 17

Life, Accident and Disability Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Employee Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Required Notices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Summary of Benefits and Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Spousal Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Dependent Change Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Life Insurance Beneficiary Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Caremark Mail Service Order Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Enrollment Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Contents

4 Your Benefits. Your Choice.

Use this guide to review your benefit options and determine the coverage you want to

elect. Then log on to PeopleSoft to enroll using your checklist from page 51.

How to enroll online for your 2017 benefits1. Access The Edge from a work computer or home (only if you have an Entrust token). If you need to reset your network

password, call the IST Help Desk at 803-217-7655 and select option 1.

a. From a work computer, click on The Edge and select either the 2017 Benefits Open Enrollment promotion image at thetop of the page or the PeopleSoft (HR) link.

b. From a home computer, go to www.remote.scana.com and log in with your user ID, password and Entrust token. On theJuniper home page, select The Edge and then follow the directions above for accessing online enrollment.

2. Log in to PeopleSoft using your user ID and your network password.

a. If you selected the 2017 Benefits Open Enrollment promotion image, you will be redirected to the online enrollment page.

b. If you selected the PeopleSoft (HR) link, click on the Benefits Enrollment link under Announcements.

3. Make your benefit elections.

4. Certify that you will be eligible in 2017 to make contributions to your HSA. If you fail to do so, you will NOT receive seed money.

5. If you don’t have an existing health savings account (HSA), complete the HSA authorization form to begin the process ofopening your account.

6. Establish pretax payroll deductions for HSA or FSA. (You can have a dependent care FSA and HSA, but you cannot have ahealth care FSA and HSA.)

7. Review your dependent/beneficiary information for accuracy. If you need to make a change, contact theEmployee Resource Center (803-217-4444) and provide the required documentation.(See pages 45-47 for forms.)

8. If you plan to cover your spouse, certify that he/she does not have access to employer-sponsored group medicalcoverage elsewhere. If you fail to certify, your spouse will NOT be covered in 2017.

9. Review your selections.

10. Press “Submit” to complete your transaction.

11. Print your summary of benefit elections. (Note: Printing from home is not available.)

12. You can make changes to your elections until 11:59 p.m. Friday, October 21, 2016.

13. Following the close of open enrollment, all employees will be directed to their individual summary of elections in PeopleSoftto serve as their confirmation statement.


What you need to know nowThere are many resources available to help you make decisions about your 2017 benefits.

Refer to the resources on the inside back cover of this book.

Overview of benefits changes, effective January 1, 2017• There will be a slight increase in medical plan premiums, ranging from $.59-$3.72 per pay period, depending on level of

coverage. See page 7 for details.

• Preventive Generic Medications continue to be free at the SCANA Pharmacy; will be subject to deductible and 30% coinsuranceat retail or mail order.

• A printed confirmation of benefit elections will not be mailed to employees. Following the close of online benefits openenrollment, employees will be directed to their individual summary of elections within PeopleSoft where they will be encouragedto verify their elections and print the summary for their records. Any necessary corrections can also be made at that time.

• Employees who transition to Long-Term Disability on Jan. 1, 2017 and after will continue receiving medical coverage underthe active Choice Plan for up to 24 months. If they remain disabled after that period, they will need to find individual coverageelsewhere, since SCANA will no longer offer LTD medical coverage.

If you have questions about any of these changes, contact the Employee Resource Center at 803-217-4444.

Your Benefits. Your Choice.6

The SCANA Choice plan is a consumer-driven health plan featuring affordable premiums.

In this plan, your medical and prescription costs combine to satisfy the deductible and

out-of-pocket maximum.

As a participant in the SCANA Choice plan, you may be eligible to open a health savings account through HSA Bank to contribute pretax dollars through payroll deduction*. SCANA also contributes seed money – $400 for individual coverage and $800 for any level of family coverage – into your HSA account. The account is yours to use for paying medical expenses as they occur or to save for future needs, like medical expenses in retirement. You may even use the account to pay qualified medical expenses for your spouse who may be covered under another plan, as long as your spouse doesn’t have a health care flexible spending account (FSA).

Prescription coverage is included when you elect medical coverage through SCANA, and preventive services are provided at 100 percent coverage when an in-network provider is used.

* Individuals enrolled in TRICARE or Medicare, or who have received VA medical benefits in the previous 90 days, are not eligibleto make HSA contributions or receive seed money from SCANA.

2017 SCANA Choice Plan In Network Out of Network

Preventive Care 100% Coverage Deductible and coinsurance apply

Deductible $1,500 Individual $3,000 Family

$3,000 Individual $6,000 Family

HSA Seed Money $400 individual/$800 family

Medical care – Inpatient, Outpatient 20% after deductible 40% after deductible

Emergency/Urgent Care/Ambulance 20% after deductible

Annual Out-of-Pocket MaximumDeductible & Coinsurance

$3,000 Individual $6,000 Family Includes Rx

$6,000 Individual $12,000 Family Includes Rx

Overview of SCANA Choice plan

New BlueCross ID cards will be issued by early 2017 for all participants. You may use existing cards until the new ones arrive, but discard them once you receive the new cards in order to have accurate information.

Your Benefits. Your Choice. 7

• For spouses who both work at SCANA and choose familycoverage, a taxable payroll credit will apply to the employeewho waives health care coverage.

• In-network providers are required to precertify all hospitaladmissions, outpatient surgical procedures and someradiological imaging. In-network providers incur a penalty fornon-emergency services that are not precertified.

• If you use an out-of-network provider, precertification is yourresponsibility, and you are responsible for paying the penaltyif you fail to precertify. See Summary of Benefits and Coveragefor more details.

• You may request additional BlueCross ID cards online atwww.SouthCarolinaBlues.com or by calling Member Servicestoll free at 877-705-5428.

• If your spouse has medical coverage through Medicare,TRICARE, VA, a trade or professional association, or anindividually purchased plan, you may cover him/her onSCANA’s plan.

Things to note

Understanding Choice Plan Deductibles and Out-of-Pocket Maximums• Preventive care is covered 100 percent, regardless of deductible.

• The deductible ($1,500/individual; $3,000/family) must be met before SCANA pays any portion of non-preventive care claims.

• One member of the family can meet the entire family deductible.

• Prescription benefits are not paid by SCANA until the Choice plan deductible is met, with the exception of certain preventivegeneric drugs through the SCANA Pharmacy.

• Both medical and prescription claims count toward the deductible and toward out-of-pocket maximums.

• Vision and dental expenses do not contribute to the deductible nor out-of-pocket maximums.

2017 Choice Medical Plan Premiums

Plan Employee Only Employee/Spouse Employee/Dependents Employee/Family

SCANA ChoicePer Pay $10.04 $37.70 $33.92 $62.82

Annual $261.04 $980.20 $881.92 $1,633.32

If you are adding a dependent, see form on page 45.


2017 Prescription Benefits

SCANA PharmacyIn Network

Retail or Mail OrderPer Rx Out-of-Pocket

Maximum

Employee pays amounts below after deductible is met.

Preventive Generic Medications1 Free (not subject to

deductible)30%

$100/31-day $250/90-dayNon-preventive Generic

Medications and Preferred Brand Medication

25% 30%

Non-Preferred Brand 50% None

Specialty Medications 31-day supply only

CVS Specialty Pharmacy2 ONLY 50%

$250/31-day

90-day Prescriptions: Only available at the SCANA Pharmacy or Caremark Mail Order Pharmacy.3

Out-of-Network Benefits: Available with 50% coinsurance for generic and preferred brand only.

1 Specific generic medications included can change from time to time without notice. 2 CVS is an independent company providing specialty pharmacy services on behalf of BlueCross. 3 Caremark is an independent company providing prescription drug benefits on behalf of BlueCross.

Prescription benefits are included in the SCANA Choice plan. You pay negotiated

prescription costs in full until your deductible is met (except certain preventive generics

through SCANA Pharmacy), and these costs count toward your deductible. Once you meet

your out-of-pocket maximum, covered prescription medications are paid in full by the plan.

Drug Card Prescription Drug Coverage

With more than 64,000 network pharmacies to choose from, it’s easy to find one that’s near you. If you don’t present your ID card or don’t use a network pharmacy, you’ll have to file a claim and you may not be reimbursed for the full amount you paid.

SCANA Pharmacy

Employees can save money and time by using the SCANA Pharmacy. Pharmacists are available for in-depth counseling. You can pick up prescriptions at the corporate campus or have them delivered to you through interoffice mail.

Specialty Drugs

Specialty drugs treat conditions such as cancer, hepatitis, multiple sclerosis or rheumatoid arthritis, just to name a few.

The exclusive provider for specialty drugs is Caremark. Visit The Edge for a list of specialty drugs. You may contact CVS Specialty Pharmacy at 800-237-2767.

Mail-Service Program

Caremark Mail Order Pharmacy is convenient and can save you money if you take prescription drugs on a regular basis. You’ll receive up to a 90-day supply of your prescription drugs at one time with free standard shipping. Getting started is easy! Use the form in the back of this booklet.

Over-the-Counter

Except for liquid Zantac and nicotine replacement, medications available over-the-counter, regardless of strength or formulation, are not covered by the prescription benefit.

Convenience and savings


Dental Plan Highlights and RatesWhen you go to the dentist, present your BlueCross ID card to make sure the dentist applies your benefits correctly.

With BlueCross dental benefits, you receive benefits whether or not you and your eligible

dependents visit an in-network dentist. When you visit an in-network dentist, you’ll enjoy

lower out-of-pocket expenses as our providers have agreed to lower their fees. And you

won’t be balance-billed for charges above the allowable amounts.

Dental coverage for you and your family

Benefits Dental Plan

Calendar Year Maximum (Class I, II and III expenses) $1,500 per person

Annual DeductibleIndividual/Family $50 per person/$150 per family

Reimbursement Levels Based on Reasonable and Customary Allowances

Class I - Preventive & Diagnostic Care• Oral Exams (Two per year)• Routine Cleanings (Two per year)• Full Mouth X-rays or Panoramic X-ray (One every three years)• Bitewing X-rays (Two per year)• Fluoride Application (Two per year)• Sealants (Limited to posterior tooth for a person age 6-18/One treatment

per tooth every three years)• Space Maintainers (Limited to non-orthodontic treatment)• Emergency Care to relieve pain

No charge

Class II - Basic Restorative Care Fillings, Root Canal Therapy, Osseous Surgery, Dental Consultation, Periodontal Scaling and Root Planing Denture Adjustments and Repairs, Extractions, Oral Surgery (Surgical removal of impacted wisdom teeth is covered under the Medical Plan)

You pay 20% after deductible

Class III - Major Restorative CareCrowns, Dentures, Bridges, Dental Implants (up to plan maximum)


Class IV – Orthodontia (Limited to dependent children under the age of 19) $1,500 lifetime limit (payments made monthly)


Pretreatment review is suggested when dental work in excess of $300 is proposed. Have your provider send an undated claim form along with the proposed treatment plan to BlueCross for a pretreatment estimate to be sent to you and your dentist detailing what services your plan will cover and how much it will pay.

2017 Dental Plan Premiums

Employee Only Employee/Spouse Employee/Dependents Employee/Family

Per Pay $3.59 $7.64 $6.82 $10.76

Annual $93.34 $198.64 $177.32 $279.76


To find locations near you, visit www.EyeMedVisionCare.com or call Member Services toll free at 866-723-0513. Identify yourself as a member by presenting the BlueCross ID card provided to you. You pay the provider directly for purchases that exceed the covered allowed amounts.The provider files the claim on your behalf.

Vision benefits through EyeMed Vision Care are a separate election from the SCANA Choice medical plan.

Employee Only

Employee/ Spouse

Employee/Dependents

Employee/Family

Per Pay Period

$0.91 $1.74 $1.83 $2.69

Annual Cost

$23.66 $45.24 $47.58 $69.94

Out-of-Network Reimbursements

If you visit an out-of-network provider, you are responsible for paying the provider in full at the time of service. You will need to submit a claim form for reimbursement. To get a claim form, call Member Services at 866-723-0513 or visit our website.

Exams, Contacts and Glasses

You are eligible for a comprehensive eye exam and standard lenses or contacts once every 12 months (from last visit/purchase) from a participating provider.

You have a $135 allowance to purchase frames once every 24 months (from last purchase). If your frames or contacts cost more than the $135 allowance, you are responsible for paying the remaining balance less 20 percent.

With your vision benefit through EyeMed, you have access to a national network of

providers, including LensCrafters, Target Optical, most Pearle Vision and Sears Optical

locations, and many independent doctors of optometry. EyeMed Vision Care is an

independent company that offers vision benefit programs on behalf of BlueCross. With

thousands of locations to choose from, you are certain to find a provider close to your

home or office that offers appointment times convenient for you.

Benefits are valid once per benefit period. Once you have used your in-network benefits, unlimited pairs of eyeglasses and contacts are available at discounted prices through a participating provider. See provider for details. Benefits and/or discounts cannot be used in conjunction with other discounts, coupons or promotions. This information is intended as a summary of benefits only. It does not describe all the terms, provisions and limitations of your plan. Participating providers are independent contractors solely responsible for vision examinations and products. Locations are subject to change. Please call 866-723-0513 to verify participation.

See the savings


Vision Care Services Member CostOut-of-Network Reimbursement

Exam with Dilation as Necessary Covered in full $60

Exam Options

Standard Contact Lens Fit and Follow-Up Up to $55N/A

Premium Contact Lens Fit and Follow-Up 10% off retail price

Frames

Any available frame at provider location $135 allowance, 20% off balance over $135 $82

Standard Plastic Lenses

Single Vision/Bifocal/Trifocal/Lenticular Covered in full $78/$97/$107/$150

Standard Progressive Lens Covered in full $149

Premium Progressive Lens 80% of charge less $120 allowance $149

Lens Options

UV Treatment/Tint (Solid and Gradient) / Standard Plastic Scratch Coating

$15

N/AStandard Polycarbonate - Adults $40

Standard Polycarbonate - Children under 19 $0

Standard Anti-Reflective Coating $45

Polarized/Other Add-Ons 20% off retail price

Contact Lenses (Contact lens allowance includes materials only)

Conventional $135 allowance, 15% off balance over $135 $125

Disposable $135 allowance, plus balance over $135 $125

Medically Necessary Covered in full $210

Laser Vision Correction

Lasik or PRK from U.S. Laser Network 15% off retail price or 5% off promotional price

N/A

Additional Pairs Benefit Members also receive a 40% discount off com-plete pair eyeglass purchases and a 15% discount off conventional contact lenses once the funded benefit has been used.

N/A

Benefit Frequency

Examination/Lenses or Contact Lenses Once every 12 months

Frame Once every 24 months

Either standard lenses or contact lenses are covered every calendar year; not both.

Plan Exclusions:1) Orthoptic or vision training, subnormal vision aids and any

associated supplemental testing; Aniseikonic lenses2) Medical and/or surgical treatment of the eye, eyes or supporting

structures3) Any eye or Vision Examination, or any corrective eyewear required

by a Policyholder as a condition of employment; Safety eyewear4) Services provided as a result of any Workers’ Compensation law,

or similar legislation, or required by any governmental agency orprogram whether federal, state or subdivisions thereof

5) Plano (non-prescription) lenses and/or contact lenses6) Non-prescription sunglasses7) Two pair of glasses in lieu of bifocals

8) Services or materials provided by any other group benefit planproviding vision care

9) Services rendered after the date an Insured Person ceases to becovered under the Policy, except when Vision Materials orderedbefore coverage ended are delivered, and the services renderedto the Insured Person are within 31 days from the date of suchorder

10) Lost or broken lenses, frames, glasses, or contact lenses will notbe replaced except in the next Benefit Frequency when VisionMaterials would next become available

Vision benefits


Health Savings Account (HSA)

• To contribute to an HSA you must be enrolled in the Choiceplan. You cannot be enrolled in Medicare, Medicaid, TRICARE orhave received VA medical benefits in the past three months.

• You must have an account with HSA Bank to receive yourseed money and take advantage of payroll deduction foryour contribution.

• You cannot contribute to both an HSA and a healthcare FSA.

• If you enroll in Medicare after turning age 65, you can nolonger contribute to an HSA, and the annual contribution limitis prorated.

• The maximum amount you can contribute to an HSA isprorated by the number of months you are enrolled in theChoice plan for the year.

• SCANA will contribute $400 for individual and $800 forfamily coverage to new and re-enrolling HSAs. The moneywill be available in all accounts opened at HSA Bank as ofJanuary 2, 2017.

• You cannot use your HSA funds for over-the-countermedications and supplies, unless you have a prescription.

• For tax-free reimbursement of medical expenses fordependents, the dependent must otherwise qualify as a taxdependent of the account holder. Consult your tax adviserfor more details.

• The penalty for nonqualified HSA withdrawals is20 percent.

Health Care FSA

• Available to employees working 32 or more hours per week,specifically those who waive SCANA coverage or who are noteligible to contribute to HSA.

• Health care FSA balances up to $500 carry over at theend of the calendar year.

• You cannot use your FSA funds for over-the-countermedications and supplies, unless you have a prescription.

See next page for a chart summarizing HSAs and health care FSAs.

Dependent Care Flexible Spending Account (FSA)

• All employees may elect to enroll and contribute to adependent care FSA, regardless of whether you participatein SCANA’s medical plan.

• Funds can be used for eligible day care, after-school andelder care expenses and programs.

• Receipts must be submitted for reimbursement.

• Minimum contribution amount per year is $50 and themaximum amount is $5,000.

• Funds must be in account to use.

• Funds not used by the end of the calendar year willbe forfeited.

SCANA offers three types of optional accounts for you to make pretax contributions to

help with health care or dependent care expenses. The IRS determines the maximum

amount of money that can be contributed each year and maintains the list of qualified

expenses. Always keep your receipts so you can verify, if audited, that your purchases

were allowed. If you want to establish an optional account, you must log in to PeopleSoft

and enroll during this open enrollment period. The three account types are:

HSA and FSA


For HSAs • Seed money will be prorated based on

when the HSA is opened: Q1 = $400/$800;Q2 = $300/$600; Q3 = $200/$400;Q4 = $100/$200.

• Seed money cannot exceed $800 per family(includes spouses who both work at SCANA).

For Health Care FSAs • Annual maximum contribution is $2,600.

HSA Health Care FSA

Description Actual bank account owned by employee that allows saving and paying for qualified medical, dental and vision expenses tax-free

Spending account that allows employee to pay for qualified medical, dental and vision expenses tax-free

Medical plan eligibility Choice Plan Not required

Interest earning Yes No

SCANA contribution Seed money ($400/$800)* None

Annual maximum contribution $3,400 single; $6,750 family** $1,000 catch-up if eligible (age 55+)

$2,600 ($50 minimum)

Access funds Debit card, checks or Internet banking Debit card or submit receipts

Account balance carryover Balance rolls from year to year Balances up to $500 carry over at year end

Portability Account is owned and retained by employee upon termination

Employee generally forfeits balance upon termination

Availability of funds Funds must be in account to use Annual designated amount available for use January 1

Contributions Payroll deduction amount set during open enrollment period and changes can be made throughout year via PeopleSoft Self Service; other after-tax contributions can be made via check/money order

Annual amount determined during open enrollment and can only be changed after qualifying event (marriage, birth, death, etc.)

Administered by HSA Bank (see page 14) WageWorks (see page 15)

* Amount prorated based on date account is opened.** Amount prorated based on the number of months you are enrolled in the Choice plan for the year.

For more information, refer to the FSA and HSA information on The Edge, visit the IRS website for rules and regulations, or consult your tax adviser.

Understanding the differences between HSAs and FSAs


What is an HSA?

Health savings accounts (HSAs) work in combination with an HSA-compatible health plan. The HSA allows you to contribute funds on a pretax or tax-deductible basis, which you may use to pay for eligible medical expenses.

What are the advantages of an HSA?

• Funds Roll Over Annually There is no “use it or lose it” rule. If you don’t use your funds, you can save them for future, eligible medical expenses.

• Tax Advantages An HSA provides you triple tax savings: pretax funds can be used to contribute to your account; tax-free earnings through investment; and tax-free withdrawals for qualified medical expenses.

• You Own the Account Even if your HSA-compatible coverage ends, you can still use your HSA funds tax-free for eligible medical expenses.

• Additional Retirement Savings After age 65, you can withdraw funds (subject to applicable taxes) for purposes other than medical expenses, without penalty.

• Long-term Investment Opportunities You can invest your HSA dollars through HSA Bank’s investment partners, who offer stocks, bonds and mutual funds. For more information, visit www.hsabank.com/investments.

Note: Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. All HSAs with HSA Bank are FDIC insured.

• You’re in Charge You choose when to use your HSA or pay out of pocket.

Eligible medical expenses

An eligible medical expense is an expense that pays for health care services, equipment or medications as described in IRS Publication 502*. In general, your HSA can be used for:

• Expenses applied to your health plan deductible

• Dental care services

• Vision care services

• Prescription drugs and medicines

• Certain medical equipment

* A list of Qualified Medical Expenses can be found in IRS Publication 502, www.irs.gov/pub/irs-pdf/p502.pdf.

Learn more

Visit HSA Bank’s website at: www.hsabank.com/hsabank/education/cdh-demos.

HSA Bank Client Assistance Center

800-357-6246, Monday – Friday, 7 a.m. – 9 p.m., CT; and Saturday, 9 a.m. – 1 p.m., CT [email protected] www.hsabank.com 605 N. 8th Street, Suite 320, Sheboygan, WI 53081

What can a Health Savings Account (HSA) do for you?

The Ernst & Young financial planner line can help you understand how an HSA fits into your financial plan. Their assistance is available at no cost to you: 866-724-1946.

HSA Bank is an independent company that administers some health savings accounts on behalf of BlueCross. Please consult your tax adviser regarding your personal

situation and whether this is the right program for you.


All employees are eligible for a health care FSA, specifically those who waive SCANA coverage or are ineligible to contribute to an HSA; however, you cannot contribute to both an HSA and a health care FSA.

Use the WageWorks Health Care Card.

Use your WageWorks Health Care Card instead of cash or credit at health care providers and pharmacies for eligible services, goods and prescriptions. You will only be able to use your card for over-the-counter (OTC) drugs at the pharmacy counter if a valid prescription is presented at the time of purchase. You still will be able to use your card for non-drug OTC items and devices, such as bandages and contact lens solution, as long as you shop at merchants that have an industry standard (IIAS) inventory system that can verify the eligibility of items at checkout. An updated list of IIAS merchants is maintained at www.sigis.com. Always remember to save receipts when using the card. The IRS requires you keep them for your tax records, and you will also need them if we request documentation for verification.

Using your FSA is easy.

When you elect a health care FSA, your account is funded with the full amount you’ve chosen at the beginning of the year. As soon as that happens, it’s ready to use for eligible expenses. Throughout the year, you “pay your account back” with pre-tax contributions from your paycheck.

You can also choose a WageWorks Dependent Care FSA to help with the cost of care for eligible children or aging parents while you are at work. A dependent care FSA works a lot like a health care FSA, but your account is funded several times a year, so funds are available as contributions are taken from your paycheck.

Sign up during open enrollment. See how much you could save at www.FSAWorks4Me.com.

Open a WageWorks® FSA and save on everyday expenses

Health care FSA balances up to $500 carry over at the end of the calendar year.

WageWorks is an independent company that provides FSA administration on behalf of the employer group, SCANA. Please consult your tax adviser regarding your personal situation and

whether this is the right program for you.

Questions?Helpful tips, guides, video tutorials and FAQs are available online at www.wageworks.com. WageWorks Customer Service professionals also are standing by to help you. Just call 877-WageWorks (877-924-3967), Monday – Friday, 8 a.m. – 8 p.m. EST.

16

It’s an emergency! Or … is it?

Emergency roomDefinitely head for the hospital with potentially life-threatening conditions such as:

• Heavy bleeding

• Loss of consciousness

• Major injuries, such as broken bones

• Severe pain or severe allergic reaction

• Suspected heart attack

• Head trauma

Urgent careThese clinics are less costly than an ER and could be a convenient choice for minor emergencies. Most offer shorter waits, walk-in services, and sometimes perks such as online check-in. Urgent care could be good for:

• Cold, cough, sore throat

• Flu, respiratory infections

• Minor fractures and sprains

• Eye, ear or skin infections

• Minor cuts and animal bites

It’s important to get to an emergency

room in a life-or-death situation. But it’s

also smart to know when the ER is really

your best option.

An ER visit could involve hours of

waiting and hundreds of dollars. You’ll

see a doctor who doesn’t know you —

and if you show up for something

minor like a cold or a sprain, you could

delay treatment for others who have

true emergencies.

Your primary care physician should be

your first call for routine medical care.

If your doctor’s office is closed, here

are some guidelines to help you

protect your health while saving time

and money.


It’s a big decision. Who will you turn to when you have a nagging health problem, a sick

child or symptoms that might be serious — or might not? The online Doctor and Hospital

Finder makes the decision a little easier.

You can search by city or ZIP code for providers near your home or work. Or narrow your search to find providers in certain specialties, such as pediatricians or allergists.

If you already have a doctor’s name, you can see whether he or she is in your network. You can even do an advanced search for providers who match your gender or language preferences.

Other tools, such as quality reports and patient reviews, provide extra insight about the doctors and facilities you’re considering. It’s worth taking a little time to check them out — and make sure you end up with exactly the kind of health services you want and need.

Find the right doctor, choose the right care

To use the Doctor and Hospital Finder, log in to your My Health Toolkit account. Select the Resources tab, then click Find a Doctor or Hospital.

Find other in-network providers

• To locate a dentist near you, log in to your My Health Toolkit account. Select the Resources tab, click Find a Doctor or Hospital, then click the Dental Directory link.

• To locate an in-network pharmacy, log in to your My Health Toolkit account. Select the Benefits tab, then click Find a Pharmacy.

My Health Toolkit®

JKL SurgeryCenter

3.4 miles

XYZ Hospital2.2 milesABC Medical

Center1.2 miles


SCANA offers you options for life, accident and disability insurance. If the basic coverage doesn’t meet your needs, you can elect supplemental coverage using payroll deduction to cover the costs. To name or change beneficiaries for life insurance, see form on page 47.

Insurance type Coverage options Cost Notes

Life Basic = 2x base pay, up to $1.25M (hired prior to 1/1/13) 1x base pay, up to $1.25M (hired on or after 1/1/13)

Supplemental available up to 6x base pay pending Evidence of Insurability

Basic coverage at no cost to employee

Supplemental rates on next page; employee pays full cost with after-tax dollars

Beginning Jan. 1 after the employee’s 65th birthday, coverage amount reduces by 35%.

Premium adjusts accordingly.

Current enrollees with supplemental at one times their annual earnings can increase their supplemental coverage by one level, up to $500,000, without Evidence of Insurability, not to exceed the plan maximum of $1.25M when combined with basic life insurance.

Accidental Death & Dismemberment

Basic = 2x base pay, up to $500K (prior to 1/1/13) 1x base pay, up to $500K

(on or after 1/1/13)

Supplemental available up to 2x base pay to a maximum of $500,000 when combined with basic AD&D insurance.


Supplemental rates on next page; employee pays full cost with after-tax dollars

Beginning Jan. 1 after the employee’s 65th birthday, coverage amount reduces by 35%.

Supplemental coverage increases if your salary increases throughout the year; premium adjusts accordingly.

Spouse $10K - $100K Based on employee age and amount of coverage selected (see supplemental life insurance rates)

Employee pays full cost with after-tax dollars

Evidence of Insurability is required if you want to increase your coverage during open enrollment or due to a qualified family status change.

Dependent $10K per child until age 23 $0.55 per pay period, regardless of number of dependents covered

Employee pays full cost with after-tax dollars

For SCANA married couples, only one parent may cover their dependent(s).

Short-term disability

Basic = 66 2/3% base pay replacement

Supplemental available for 100% base pay replacement for up to 6 weeks


Supplemental rates based on salary; employee pays full cost with pretax dollars

Employee may also supplement using: PTO at 2.7 hours per day or transition bank at 8 hours per day

A five-day (40-hour) elimination period applies to all approved cases, except accidents.

Benefits begin on sixth day of absence (or 41st hour) and continue up to 1,040 hours in rolling 12-month period.

Long-term disability

Basic = 50% base pay replacement

Supplemental available for 66 2/3% base pay replacement


Supplemental rates based on salary; employee pays full cost with pretax dollars

Recertification required for continuation of benefits.

Benefits begin after 26 weeks of occupational or non-occupational injury or illness with approved application for benefits.

Life, accident and disability insurance

For help determining your coverage needs, contact the Ernst & Young financial planner line at 866-724-1946.


Supplemental life insurance cost (same for spouse), per $1,000 of coverage

Age Per Pay Period Rate

≤ 34 $0.0212

35-39 $0.0295

40-44 $0.0415

45-49 $0.0628

50-54 $0.0960

55-59 $0.1795

60-64 $0.2585

65-69 $0.4791

70-74 $0.8580

75+ $0.8580

AD&D supplemental cost per pay period, per $1,000 of coverage

Employee-only supplemental coverage option

Rate

1x base pay$ .012

2x base pay

Short-term disability (100 percent of

base pay coverage for the first six weeks) CALCULATION EXAMPLE:

Disability rate is based on salary: $.30 per $100 of salary

Employee has a base salary of $50,000 and chooses to buy-up coverage for STD and/or LTD:

$50,000/$100 = $500 $0.30 x $500 = $150

$150/26 pay periods = $5.77 per pay period

Long-term disability (66 2/3 percent of

base pay coverage)

STD buy-up

$5.77 per pay period

LTD buy-up

$5.77 per pay period

Rates and coverage amounts adjust, as necessary, during the pay period following a change in age or salary.


Life is not a spectator sport — but sometimes it feels like you’re tackling some really tough

problems. We provide an Employee Assistance Program (EAP) that can help, whether or not

your challenges are job-related.

Help getting over life’s hurdles

SCANA employees and family members are eligible for the EAP benefit. Each person receives three counseling sessions and three life management services per contract year free of charge. For more information, call 800-968-8143 or visit www.FirstSunEAP.com.

First Sun EAP administers the Employee Assistance Program. Because First Sun is a separate company, it is responsible for all services related to this program. If you haven’t sought help from the EAP, you might be surprised at all the situations in which it can be helpful. They range from counseling for a family crisis to referrals for pet professionals.

CounselingWe will pay for up to three confidential sessions for you and each of your household members. When you are challenged by personal or emotional issues, licensed counselors are available to help you evaluate the issue and develop a plan for dealing with it. Some examples:

• Marital, relationship or family conflicts

• Crisis intervention

• Mental health or substance abuse issues

• Handling stress, grief, loss or trauma

• Concerns about workplace issues or work-life balance

Life managementThe EAP can provide help with practical problems — how to draw up a living will, for instance. These services include:

• Help finding elder care or child care

• Financial advice for retirement, reorganizing the budget or dealing with a crisis

• Legal consultation from licensed attorneys

• Resources for finding the right school or college

• Adoption assistance

• A pet care program

21

Everyday choices for a happy, healthy life.

Wellness is more than

just seeing a doctor

when you are sick.

It means making

day-to-day decisions

that can put you on

the path to a long,

healthy life. There are

some risk factors you

can’t change — your

age, for example, or

health problems that

run in the family. So it

makes sense to focus

on risk factors you

can change.

MoveAim for 30–60 minutes of physical activity each day. Exercise doesn’t have to take place in a gym — get creative and find activities that you enjoy. Go for a walk, ride your bike, swim, jog, jump rope or even dance!

EatFill half of your plate with fruits and veggies. Swap out sugary sodas with water. Choose whole grains, such as wheat, oatmeal and brown rice, instead of refined grains like white bread and white rice. Reach for lean proteins and calcium-rich foods.

CareTake care of your body. Make sure you get enough sleep at night. Don’t smoke — if you do, find the help you need to quit. Schedule your annual physical. If you notice symptoms of a health issue, don’t procrastinate — see your doctor.

FeelGet mentally fit by finding ways to de-stress. Block off some “me time” in your busy schedule. Stay connected to your friends and family. Volunteer for something you’re passionate about. Read a new book or start a journal. Practice being grateful for one thing each day.


NOTE: Please read this notice carefully and keep it with your important papers. If you enroll in one of the plans approved by Medicare that offers prescription drug coverage, you may need to give a copy of this notice when you join. This notice shows you have been enrolled in a creditable health plan and are not required to pay a higher premium.

Intended AudienceThis notice is intended for anyone eligible for Medicare (employee or dependent) who is eligible for prescription drug coverage through the SCANA Choice Plan.

About This NoticeThis notice has information about your current SCANA prescription drug coverage and Medicare Part D, the prescription drug coverage available through Medicare. Important highlights of this notice are:

• Your next opportunity to enroll in Medicare D is October 15- December 7, 2016. This annual enrollment is available to those eligible for Medicare.

• SCANA has determined that your current prescription drug benefit is, on average for all plan participants, expected to pay out at least as much as the standard Medicare prescription drug coverage. Therefore, the SCANA prescription drug plan is creditable coverage.

• Creditable coverage means you may enroll for Medicare D during the 2017 enrollment period outlined above and not pay higher premiums.

If you or one of your dependents is eligible for Medicare, you or they have the option of continuing your existing health plan with prescription drug coverage from the Company or enrolling in the Medicare prescription drug coverage.

IMPORTANT: If you decide to enroll in Medicare prescription drug coverage, you are not eligible to continue the SCANA medical and prescription drug plans. Your coverage will be terminated. Also, even though your current prescription drug coverage with the Company is creditable, if you drop it and have a break in creditable coverage of 63 days or more before enrolling in the Medicare prescription drug coverage, you could be subject to paying higher premiums for coverage.

Limited Income AssistanceFor people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information about this additional help is available from the Social Security Administration (SSA). For more information about this extra help, visit SSA online at www.socialsecurity.gov, or call them at 800-772-1213 (TTY 800-325-0778).

For More Information About This NoticeContact the SCANA Employee Resource Center at 803-217-4444 if you require further information about this notice. You may receive this notice at other times in the future, such as before the next enrollment period for Medicare prescription drug coverage, or if this coverage changes. You also may request a copy of this notice.

Women’s Health and Cancer Rights Act NoticeThe Women’s Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services including reconstruction and surgery to achieve symmetry between breasts, prostheses, and complications resulting from a mastectomy (including lymphedemas). You may contact the Employee Resource Center at 803-217-4444 for more information.

Special Enrollment NoticeIf you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in the SCANA health plans 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 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

In addition, 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 dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.

If either of the following two events occur, you will have 60 days from the date of the event to request enrollment in your employer’s plan:

• Your dependents lose Medicaid or Children’s Health Insurance Program (CHIP) coverage because they are no longer eligible.

• Your dependents become eligible for a state’s premium assistance program.

To request special enrollment or obtain more information, contact the Employee Resource Center at 803-217-4444.

Important notice from SCANA about your health plan and Medicare


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 July 31, 2014. Contact your State for more information on eligibility –

ALABAMA – Medicaid COLORADO – Medicaid

Website: http://www.medicaid.alabama.gov

Phone: 1-855-692-5447

Medicaid Website: http://www.colorado.gov/

Medicaid Phone (In state): 1-800-866-3513 Medicaid Phone (Out of state): 1-800-221-3943

ALASKA – Medicaid

Website: http://health.hss.state.ak.us/dpa/programs/medicaid/

Phone (Outside of Anchorage): 1-888-318-8890

Phone (Anchorage): 907-269-6529

ARIZONA – CHIP FLORIDA – Medicaid

Website: http://www.azahcccs.gov/applicants

Phone (Outside of Maricopa County): 1-877-764-5437 Phone (Maricopa County): 602-417-5437

Website: https://www.flmedicaidtplrecovery.com/

Phone: 1-877-357-3268

GEORGIA – Medicaid

Website: http://dch.georgia.gov/ - Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP)

Phone: 1-800-869-1150 IDAHO – Medicaid MONTANA – Medicaid

Medicaid Website: http://healthandwelfare.idaho.gov/Medical/Medicaid/Premiu

Website: http://medicaidprovider.hhs.mt.gov/clientpages/ clientindex.shtml


2

mAssistance/tabid/1510/Default.aspx

Medicaid Phone: 1-800-926-2588

Phone: 1-800-694-3084

INDIANA – Medicaid NEBRASKA – Medicaid

Website: http://www.in.gov/fssa

Phone: 1-800-889-9949

Website: www.ACCESSNebraska.ne.gov

Phone: 1-855-632-7633

IOWA – Medicaid NEVADA – Medicaid

Website: www.dhs.state.ia.us/hipp/

Phone: 1-888-346-9562

Medicaid Website: http://dwss.nv.gov/

Medicaid Phone: 1-800-992-0900 KANSAS – Medicaid

Website: http://www.kdheks.gov/hcf/

Phone: 1-800-792-4884

KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid

Website: http://chfs.ky.gov/dms/default.htm

Phone: 1-800-635-2570

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf

Phone: 603-271-5218

LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP

Website: http://www.lahipp.dhh.louisiana.gov

Phone: 1-888-695-2447

Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/

Medicaid Phone: 609-631-2392

CHIP Website: http://www.njfamilycare.org/index.html

CHIP Phone: 1-800-701-0710

MAINE – Medicaid

Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-977-6740 TTY 1-800-977-6741

MASSACHUSETTS – Medicaid and CHIP NEW YORK – Medicaid

Website: http://www.mass.gov/MassHealth

Phone: 1-800-462-1120

Website: http://www.nyhealth.gov/health_care/medicaid/

Phone: 1-800-541-2831

MINNESOTA – Medicaid NORTH CAROLINA – Medicaid

Website: http://www.dhs.state.mn.us/

Click on Health Care, then Medical Assistance

Phone: 1-800-657-3629

Website: http://www.ncdhhs.gov/dma

Phone: 919-855-4100

MISSOURI – Medicaid NORTH DAKOTA – Medicaid

Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

Phone: 573-751-2005

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/

Phone: 1-800-755-2604

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 July 31, 2014. Contact your State for more information on eligibility –

ALABAMA – Medicaid COLORADO – Medicaid

Website: http://www.medicaid.alabama.gov

Phone: 1-855-692-5447

Medicaid Website: http://www.colorado.gov/

Medicaid Phone (In state): 1-800-866-3513 Medicaid Phone (Out of state): 1-800-221-3943

ALASKA – Medicaid

Website: http://health.hss.state.ak.us/dpa/programs/medicaid/

Phone (Outside of Anchorage): 1-888-318-8890

Phone (Anchorage): 907-269-6529

ARIZONA – CHIP FLORIDA – Medicaid

Website: http://www.azahcccs.gov/applicants

Phone (Outside of Maricopa County): 1-877-764-5437 Phone (Maricopa County): 602-417-5437

Website: https://www.flmedicaidtplrecovery.com/

Phone: 1-877-357-3268

GEORGIA – Medicaid

Website: http://dch.georgia.gov/ - Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP)

Phone: 1-800-869-1150 IDAHO – Medicaid MONTANA – Medicaid

Medicaid Website: http://healthandwelfare.idaho.gov/Medical/Medicaid/Premiu

Website: http://medicaidprovider.hhs.mt.gov/clientpages/ clientindex.shtml

25

3

OKLAHOMA – Medicaid and CHIP UTAH – Medicaid and CHIP

Website: http://www.insureoklahoma.org

Phone: 1-888-365-3742

Website: http://health.utah.gov/upp

Phone: 1-866-435-7414

OREGON – Medicaid VERMONT– Medicaid

Website: http://www.oregonhealthykids.gov http://www.hijossaludablesoregon.gov Phone: 1-800-699-9075

Website: http://www.greenmountaincare.org/

Phone: 1-800-250-8427

PENNSYLVANIA – Medicaid VIRGINIA – Medicaid and CHIP

Website: http://www.dpw.state.pa.us/hipp Phone: 1-800-692-7462

Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm

Medicaid Phone: 1-800-432-5924

CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm

CHIP Phone: 1-855-242-8282

RHODE ISLAND – Medicaid WASHINGTON – Medicaid

Website: www.ohhs.ri.gov

Phone: 401-462-5300

Website: http://www.hca.wa.gov/medicaid/premiumpymt/pages/index.aspx

Phone: 1-800-562-3022 ext. 15473

SOUTH CAROLINA – Medicaid WEST VIRGINIA – Medicaid

Website: http://www.scdhhs.gov

Phone: 1-888-549-0820

Website: www.dhhr.wv.gov/bms/

Phone: 1-877-598-5820, HMS Third Party Liability

SOUTH DAKOTA - Medicaid WISCONSIN – Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059

Website: http://www.badgercareplus.org/pubs/p-10095.htm

Phone: 1-800-362-3002

TEXAS – Medicaid WYOMING – Medicaid

Website: https://www.gethipptexas.com/

Phone: 1-800-440-0493

Website: http://health.wyo.gov/healthcarefin/equalitycare

Phone: 307-777-7531

To see if any other states have added a premium assistance program since July 31, 2014, or for more information on special enrollment rights, contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 OMB Control Number 1210-0137 (expires 10/31/2016)

Your Benefits. Your Choice.


This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

I. Introduction

This Notice describes Our1 legal obligations and your legal rights regarding Your Protected Health Information held by Us under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Among other things, this Notice describes how Your Protected Health Information may be used or disclosed to carry out treatment, payment, or health care operations, or for any other purposes that are permitted or required by law.

The HIPAA Privacy Rule protects only certain medical information known as “protected health information.” Generally, protected health information is individually identifiable health information, including demographic information, collected from you or created or received by a health care provider, a health care clearinghouse, a health plan, or your employer on behalf of a group health plan, that relates to:

1. your past, present or future physical or mental health or condition;

2. the provisions of health care to you; or

3. the past, present or future payment for the provision of health care to you.

The Plan provides health benefits to the eligible employees of SCANA Corporation (the “Plan Sponsor”) and their eligible dependents. The SCANA Pharmacy provides covered prescription drugs and services to Plan participants.

II. Our Privacy ObligationsWe are required by federal and applicable state law to protect the privacy of individually identifiable health information about you that We create or receive (“Your Protected Health Information”), to provide you with this Notice of Our legal duties and privacy practices, to provide notice to affected individuals following a breach of unsecured protected health information, and follow the terms of this Notice that are currently in effect. When We use or disclose Your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).

III. Uses and Disclosures Without Your Written Authorization

We may use and disclose to others Your Protected Health Information without your written Authorization for the following purposes. For each category, we will explain what we mean and present some

examples. Not every use or disclosure in a category will be listed. However, the ways We are permitted to use and disclose information will fall within one of the categories. The amount of health information used or disclosed will be limited to information that excludes most direct identifiers, such as name, address, and Social Security number, unless more information is needed. If additional information is needed, it will be limited to the “minimum necessary” to accomplish the purpose of the use or disclosure.

A. Treatment. We may disclose medical information about you to facilitate medical treatment services. For example, the Plan may disclose Your Protected Health Information to your health care provider for its provision, coordination, or management of your health care and related services. SCANA Pharmacy may use or disclose Your Protected Health Information as necessary to maintain a patient profile on you, which may include information about you, your medical condition, medications, and any allergies you may have. SCANA Pharmacy may also use and disclose Your Protected Health Information in dispensing prescription medicines and related products and services, including counseling you and your caregivers about proper use of your medications.

B. Payment. We may use and disclose Your Protected Health Information for payment purposes. For example, the Plan may use or disclose Your Protected Health Information to obtain payment for your coverage and to determine and fulfill the Plan’s responsibility to provide health benefits, to make coverage determinations, administer claims and coordinate benefits with other coverage you may have. The Plan also may disclose Your Protected Health Information to another health plan or a health care provider for its payment activities — for example, for the other health plan to determine your eligibility or coverage, or for the health care provider to obtain payment for health care services provided to you. SCANA Pharmacy may use Your Protected Health Information to obtain payment for covered prescription drugs provided to you, or to assist another provider in obtaining payment for covered services it provides to you.

C. Health Care Operations. We may use and disclose Your Protected Health Information for Our health care operations. For example, We may use and disclose Your Protected Health Information to do business planning, arrange for medical review and conduct quality assessment and improvement activities. We also may disclose Your Protected Health Information to another health plan or a health care provider that has or had a relationship with you for it to conduct quality assessment and improvement activities; accreditation, certification, licensing, or credentialing activities; or for the purpose of health care fraud and abuse detection or compliance — for example, for

SCANA Corporation, Group Health PlansNotice of Privacy Practices


the other health plan to perform case management or evaluate health care provider performance, or for the health care provider to evaluate the outcomes of treatments or conduct training programs to improve health care skills.

D. To Business Associates. We may contract with individuals or entities known as Business Associates to perform various functions on Our behalf or to provide certain types of services. In order to perform these functions or to provide these services, Business Associates will receive, create, maintain, transmit, use and/or disclose Your Protected Health Information, but only after they agree in writing with us to implement appropriate safeguards regarding Your Protected Health Information. For example, We may disclose Your Protected Health Information to a Business Associate to administer claims or to provide support services, such as utilization management, pharmacy benefit management or subrogation, but only after the Business Associate enters into a Business Associate Agreement with Us. Business Associates are required to comply with HIPAA requirements to safeguard Your Protected Health Information.

E. To Comply with the Law. We may use and disclose Your Protected Health Information to the extent required to comply with applicable law.

F. Disclosures to the Health Plan Sponsor. We may disclose Your Protected Health Information to certain employees or other Individuals under the control of the Plan Sponsor as necessary for them to carry out the Plan Sponsor’s responsibilities to administer Plan payment and health care operations activities.

G. Health-Related Communications. We may contact you to give you information about health-related benefits and services that may be of interest to you. We may also contact you to provide appointment or refill reminders or information about treatment alternatives or other health-related benefits and services that may be useful to you.

H. Public Health Activities. As required by law, We may disclose Your Protected Health Information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting births and deaths; notifying people of recalls of products they may be using; reporting child abuse or neglect (only if you agree or when required by law); reporting domestic violence (only if you agree or when required by law); reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.

I. Health Oversight Activities. We may disclose Your Protected Health Information to a government agency that is legally responsible for oversight of the health care system or for ensuring compliance with the rules of government benefit programs such as Medicare or Medicaid, or other regulatory programs for which health information is necessary for determining compliance.

J. Judicial and Administrative Proceedings. We may disclose Your Protected Health Information in the course of a judicial or administrative proceeding in response to a subpoena, discovery request or legal order or other lawful process, but only if efforts have been made to tell you about the request or to obtain an order protecting the requested information.

K. Law Enforcement Officials. We may disclose Your Protected Health Information to the police or other law enforcement officials as required by law or in compliance with a court order or other process authorized by law.

L. Health or Safety. We may disclose Your Protected Health Information to prevent or lessen a serious and imminent threat to the health or safety of an Individual or the public.

M. Organ and Tissue Donation. If you are an organ donor, We may release Your Protected Health Information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

N. Specialized Government Functions. We may disclose Your Protected Health Information to units of the government with special functions, such as the U.S. military or the U.S. Department of State.

O. Workers’ Compensation. We may disclose Your Protected Health Information as necessary to comply with workers’ compensation laws.

P. Research. We may disclose Your Protected Health Information to researchers when:

1. the individual identifiers have been removed; or,

2. when an institutional review board or privacy board has (a) reviewed the research proposal; and (b) established protocols to ensure the privacy of the requested information, and approves the research.

IV. Required Disclosures The following is a description of disclosures of Your Protected Health Information We are required to make.

A. Government Audits. We are required to disclose Your Protected Health Information to the Secretary of the United States Department of Health and Human Services when the Secretary is investigating or determining Our compliance with HIPAA requirements.

B. Disclosures to You. When you request, We are required to disclose to you the portion of Your Protected Health Information that contains medical records, billing records, and any other records used to make decisions regarding your health care or health care benefits. We are also required, when requested, to provide you with an accounting of most disclosures of Your Protected Health Information.


V. Other DisclosuresA. Personal Representatives. We will disclose Your Protected Health

Information to individuals authorized by you, or to an individual designated as your personal representative, attorney-in-fact, etc., so long as you provide us with a written notice/authorization and any supporting documents (i.e., power of attorney). Note: Under the HIPAA Privacy Rule, We do not have to disclose information to a personal representative if We have reasonable belief that:

1. you have been, or may be, subject to domestic violence, abuse or neglect by such person;

2. treating such person as your personal representative could endanger you; or,

3. in the exercise of professional judgment, it is not in your best interest to treat the person as your personal representative.

B. Authorizations. Other uses or disclosures of Your Protected Health Information not described above will only be made with your written authorization. You may revoke your written authorization at any time, so long as the revocation is in writing. Once We receive your written revocation, it will only be effective for future uses and disclosures. It will not be effective for any information that may have been used or disclosed in reliance upon the written authorization and prior to receiving your written revocation.

We will obtain a written authorization for any use or disclosure of psychotherapy notes, except:

1. to carry out the following treatment, payment, or health care operations: use by the originator of the psychotherapy notes for treatment; use or disclosure by the covered entity for its own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; or use or disclosure by the covered entity to defend itself in a legal action or other proceeding brought by the individual; and

2. a use or disclosure that is: required by the Secretary of the United States Department of Health and Human Services when the Secretary is investigating or determining the Plan’s compliance with the HIPAA privacy rule; permitted by law; for health oversight with respect to the oversight of the originator of the psychotherapy notes; to a coroner or medical examiner for the purpose of identifying a decedent; or to avert a serious threat to health or safety.

Please note that We do not use Your Protected Health Information for marketing or fundraising efforts. We do not sell Your Protected Health Information. We do not use or disclose Your Protected Health Information that is genetic information for underwriting purposes as prohibited by the Genetic Information Nondiscrimination Act (GINA) of 2008.

VI. Your Individual RightsA. Right to Inspect and Copy Your Protected Health Information.

You may request access to Our records that contain Your Protected Health Information in order to inspect and request copies of the records. If Your Protected Health Information is maintained or used in an “electronic health record”, you may obtain a copy of the information in an electronic format and direct the copied information to be transmitted to another individual or organization. Under limited circumstances, We may deny you access to a portion of your records. If you desire access to your records, please obtain a record request form from the Privacy Office and submit the completed form to the Privacy Office. If you request copies, We reserve the right to charge you copying and mailing costs.

We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to your medical information, you may request that the denial be reviewed by submitting a written request to the Privacy Office at the address below.

B. Right to Request Amendment of Your Records. You have the right to request that We amend Your Protected Health Information that you believe is incorrect or incomplete. To make such a request, please obtain an amendment request form from the Privacy Office and submit the completed form, including the reason for the amendment, to the Privacy Office. We may deny your request for amendment if it is not in writing or does not include a reason to support the request. In addition, We may deny your request if you ask Us to amend information that:

1. is not part of the medical information kept by or for Us;

2. was not created by Us, unless the person or entity that created the information is no longer available to make the amendment;

3. is not part of the information that you would be permitted to inspect and copy; or,

4. is already accurate and complete.

If We deny your request, you have the right to file a statement of disagreement with Us and any future disclosures of the disputed information will include your statement.

C. Right to Receive An Accounting of Disclosures. You have the right to request an “accounting” of certain disclosures of Your Protected Health Information. The accounting will not include:

1. disclosures for purposes of treatment, payment or health care operations (except to the extent required by law, if the Plan maintains Your Protected Health Information as an electronic health record);

2. disclosures made to you;


3. disclosures made pursuant to your authorization;

4. disclosures made to friends or family in your presence or because of an emergency;

5. disclosures for national security purposes; and,

6. disclosures incidental to otherwise permissible disclosures.

To request this list of accounting of disclosures, you must submit your request in writing to the Privacy Office. Your request must state a time period of not longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, paper or electronic). The first list you request within a 12-month period will be provided free of charge. For additional lists, We may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

D. Right to Request Additional Restrictions. You may request restrictions on Our use and disclosure of Your Protected Health Information. For example, you could ask that We not use or disclose information about a surgery you had or a prescription drug you take. While We will consider requests for additional restrictions carefully, We are not required to agree to a requested restriction unless your request is to restrict Our disclosure of Your Protected Health Information to a health plan when such information would be used for health care operations or payment, the disclosure is not otherwise required by law, and Your Protected Health Information relates solely to a health care item or service paid for entirely out of pocket by you (or a person other than the Plan on your behalf). If you wish to request additional restrictions, please obtain a request form from the Privacy Office and submit the completed form to the Privacy Office. You will be given a written response.

E. Right to Receive Confidential Communications. We will accommodate any reasonable request for you to receive Your Protected Health Information by alternative means of communication or at alternative locations. Your request must specify how or where you wish to be contacted. Please note that in certain situations, such as eligibility and enrollment information, the Plan (but not the SCANA Pharmacy) is obliged to communicate directly with the employee rather than a dependent unless the request clearly states that disclosure of that information to the employee could endanger you.

F. Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you agreed to receive such notice electronically. You may obtain a copy of this Notice at the “Health, Wealth, and Career” Web page on the SCANA Intranet site or you may contact the Privacy Office at the address below.

G. Right to Receive Notification. You are entitled to receive notice from Us if the confidentiality of any of Your Protected Health Information maintained in an unsecured form is compromised.

H. For Further Information; Complaints. If you desire further information about your privacy rights, are concerned that the Plan or SCANA Pharmacy has violated your privacy rights or disagree with a decision that We made about access to Your Protected Health Information, you may contact the Plan’s Privacy Office. You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services. Upon request, the Privacy Office will provide you with the correct address for the Secretary. The Plan will not retaliate against you if you file a complaint with it or the Secretary.

VII. Effective Date and Duration of This Notice

A. Effective Date. This Notice is effective on September 9, 2013.2

B. Right to Change Terms of this Notice. We may change the terms of this Notice at any time. If We change this Notice, We may make the new notice terms effective for all of Your Protected Health Information that We maintain, including any information created or received prior to issuing the new notice. If We change this Notice, We will send the new notice to you if you are then covered by the Plan. You also may obtain any new notice by contacting the Privacy Office.

C. Limitation on Application of Notice. This Notice does not apply to information that does not identify an Individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an Individual. In addition, the Plan may use or disclose “summary health information” to the Plan Sponsor for its purposes of obtaining premium bids (although the Plan will not use or disclose genetic information for this purpose) or modifying, amending or terminating the Plan. Summary health information is information that summarizes claims history, claims expenses or types of claims experienced by Individuals for whom the Plan Sponsor provides benefits under the Plan and from which the Individual identifying information, except for five-digit zip codes, has been deleted. The Plan and Plan Sponsor also may use or disclose eligibility and enrollment information without your Authorization.

VIII. Privacy OfficeSCANA Corporation 220 Operation Way Cayce, SC 29033-3701

Telephone: 1-800-335-6974 Email: [email protected]

1 For purposes of this Notice of Privacy Practices, “Our,” “We,” “Us,” or “Plan” refers to the following components of the SCANA Corporation Organized Health Care Arrangement: the medical benefits, prescription drug benefits, vision benefits, dental benefits, employee assistance program (medical portion only), and SCANA Pharmacy benefits of the SCANA Corporation Health and Welfare Plan; the SCANA Corporation Health Care Flexible Spending Account Plan; and the medical, dental, vision and SCANA Pharmacy benefits under the SCANA Corporation Retiree Welfare Benefits Plan.

2 This Notice was subsequently modified on September 15, 2016, to reflect the adoption of the SCANA Corporation Retiree Welfare Benefits Plan.


New Health Insurance Marketplace Coverage Options and Your Health Coverage

PART A: General Information :

What is the Health Insurance Marketplace?

Can I Save Money on my Health Insurance Premiums in the Marketplace?

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?

How Can I Get More Information?

Form Approved OMB No. 1210-0149 (expires 1-31-201 )

Judy Verona 803-217-7033

New Health Insurance Marketplace Coverage Options and Your Health Coverage

PART A: General Information :

What is the Health Insurance Marketplace?

Can I Save Money on my Health Insurance Premiums in the Marketplace?

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?

How Can I Get More Information?

Form Approved OMB No. 1210-0149 (expires 1-31-201 )

Judy Verona 803-217-7033David Simmons at 803-217-8099


PART B: Information About Health Coverage Offered by Your Employer

3. Employer name 4. Employer Identification Number (EIN)

5. Employer address 6. Employer phone number

7. City 8. State 9. ZIP code

10. Who can we contact about employee health coverage at this job?

11. Phone number (if different from above) 12. Email address

Your eligible Dependents include the following. For your non-spouse who meets one or more of the criteria below, dependent status applies regardless of whether coverage is available through another employer and regardless of student or marital status:

1. Your lawful spouse pursuant to a marriage that is legally recognized under the laws of the issuing state, territory or country. Divorced spouses are not eligible for coverage under the plan even if the employee is ordered by the court to provide health coverage.

2. Your child who is your biological son or daughter under the age of 26, your stepson or stepdaughter under age 26 (under age 23 for dental coverage).

3. Your child who is 26 years of age or older, is primarily supported by you, and is incapable of self-sustaining employment because of a mental or physical disability. You should provide proof of the child’s condition and dependence to the SCANA Benefits Team within 31 days after the child’s 26th birthday. During the next two years, the Plan may, from time to time, ask for proof of continuation of the condition and dependence. After that, the Plan may require proof no more than once a year.

4. An individual for whom you have legal guardianship, who lives with you and depends on you for support and who is under age 26 (under age 23 for dental coverage).

5. An individual who is part of a Qualified Medical Child Support Order.

6. An individual, under age 26 (for medical coverage) and under age 23 for dental coverage, who has been placed with you for foster care by an authorized placement agency or court.

7. Any child under the age of 26 whom you adopt, including a child who is placed with you for adoption, will be eligible for Dependent insurance upon the date of placement with you. A child will be considered placed for adoption when you become legally obligated to support that child, totally or partially, prior to that child’s adoption being finalized. If a child placed for adoption is not adopted, all health coverage ceases when the placement ends, and will not be continued.

SCANA Corporation and its Subsidiaries 57-0784499

220 Operation Way, MC-C131 803-217-9000

Cayce SC 29033

VP of Human Resources c/o Manager of Benefits

803-217-8099 [email protected]

3







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You

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miss

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form

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out e

xclu

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serv

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.

33

Page

2 o

f 11

•C

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ork

Prov

ider

Lim

itatio

ns &

Exc

eptio

ns

If y

ou v

isit

a he

alth

ca

re p

rovi

der’s

offi

ce o

r cl

inic

Prim

ary

care

visi

t to

treat

an

inju

ry o

r illn

ess

20%

coi

nsur

ance

af

ter b

enef

it ye

ar

dedu

ctib

le

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

---

----N

one-

-----

Spec

ialis

t visi

t 20

% c

oins

uran

ce

afte

r ben

efit

year

de

duct

ible

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

-----

--Non

e---

---

Oth

er p

ract

ition

er o

ffic

e vi

sit

20%

coi

nsur

ance

af

ter b

enef

it ye

ar

dedu

ctib

le

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

Chi

ropr

actic

car

e is

limite

d to

12

visit

s per

m

embe

r per

ben

efit

year

.

Prev

entiv

e ca

re/s

cree

ning

/im

mun

izat

ion

Cov

ered

at 1

00%

40

% c

oins

uran

ce a

fter

bene

fit y

ear d

educ

tible

--

-----N

one-

-----

If y

ou h

ave

a te

st

Dia

gnos

tic te

st (x

-ray

, blo

od

wor

k)

20%

coi

nsur

ance

af

ter b

enef

it ye

ar

dedu

ctib

le

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

-----

--Non

e---

---

Imag

ing

(CT/

PET

scan

s, M

RIs

)

20%

coi

nsur

ance

af

ter b

enef

it ye

ar

dedu

ctib

le

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

Pre-

auth

oriz

atio

n is

requ

ired.

Pen

alty

for n

ot

obta

inin

g pr

e-au

thor

izat

ion

is $5

00 fo

r ou

tpat

ient

faci

litie

s. Pe

nalty

app

lies t

o pr

ovid

ers i

n-ne

twor

k an

d m

embe

rs o

ut-o

f-ne

twor

k.

34

Page

3 o

f 11

Com

mon

M

edic

al E

vent

Serv

ices

You

May

Nee

dYo

ur C

ost I

fYou

U

se a

n

In-n

etw

ork

Prov

ider

Your

Cos

t IfY

ou

Use

an

Out

-of-n

etw

ork

Prov

ider

Lim

itatio

ns &

Exc

eptio

ns

If y

ou n

eed

drug

s to

tr

eat y

our i

llnes

s or

co

nditi

on

Mor

e in

form

atio

n ab

out

pres

crip

tion

drug

co

vera

ge is

ava

ilabl

e at

w

ww

.sout

hcar

olin

ablu

es.c

om.

Gen

eric

dru

gs

SCA

NA

Pha

rmac

y:

No

Cha

rge

for

certa

in P

reve

ntiv

e G

ener

ic M

edic

atio

ns

and

25%

coi

nsur

ance

fo

r Non

-Pre

vent

ive

Gen

eric

Med

icat

ions

; 30

% c

oins

uran

ce u

p to

$10

0(re

tail

and

mai

l ord

er)

50%

coi

nsur

ance

(re

tail)

31-d

ay su

pply

SC

AN

A p

harm

acy

and

reta

il 90

-day

supp

ly S

CA

NA

Pha

rmac

y an

d m

ail o

rder

Pr

even

tive

Gen

eric

med

icat

ions

are

free

at t

he

SCA

NA

Pha

rmac

y; su

bjec

t to

dedu

ctib

le a

nd

30%

coi

nsur

ance

at r

etai

l or m

ail o

rder

. N

on P

reve

ntiv

e G

ener

ic M

edic

atio

ns:

$100

/31-

day

Per R

x ou

t-of-

pock

et m

axim

um

$250

/90-

day

Per R

x ou

t-of-

pock

et m

axim

um

At S

CA

NA

Pha

rmac

y or

Mai

l Ord

er

Pref

erre

d br

and

drug

s

SCA

NA

Pha

rmac

y:

25%

coi

nsur

ance

; 30

% c

oins

uran

ce u

p to

$10

0 (re

tail

and

mai

l ord

er)

50%

coi

nsur

ance

(re

tail)

31-d

ay su

pply

SC

AN

A P

harm

acy

and

reta

il 90

-day

supp

ly S

CA

NA

Pha

rmac

y an

d m

ail o

rder

$1

00/3

1-da

y Pe

r Rx

out-o

f-po

cket

max

imum

$2

50/9

0-da

y Pe

r Rx

out-o

f-po

cket

max

imum

Non

-Pre

ferr

ed b

rand

dru

gs

SCA

NA

Pha

rmac

y,

reta

il, a

nd m

ail o

rder

50

% c

oins

uran

ce

Not

Cov

ered

31

-day

supp

ly re

tail

90-d

ay su

pply

mai

l ord

er

No

Per R

x ou

t-of-

pock

et m

axim

um

Spec

ialty

dru

gs

Car

emar

k sp

ecia

lty

phar

mac

y on

ly 5

0%

Not

Cov

ered

Li

mite

d to

a 3

1-da

y su

pply

$2

50 P

er R

x ou

t-of-

pock

et m

axim

um

If y

ou h

ave

outp

atie

nt

surg

ery

Faci

lity

fee

(e.g

., am

bula

tory

su

rger

y ce

nter

)

20%

coi

nsur

ance

af

ter b

enef

it ye

ar

dedu

ctib

le

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

Pre-

auth

oriz

atio

n is

requ

ired.

Pe

nalty

for n

ot o

btai

ning

pre

-au

thor

izat

ion

is $5

00. P

enal

ty a

pplie

s to

prov

ider

s in-

netw

ork

and

mem

bers

out

-of

-net

wor

k.

Phys

icia

n/su

rgeo

n fe

es

20%

coi

nsur

ance

af

ter b

enef

it ye

ar

dedu

ctib

le

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

-----

--Non

e---

---

If y

ou n

eed

imm

edia

te

med

ical

atte

ntio

n

Em

erge

ncy

room

serv

ices

20

% c

oins

uran

ce

afte

r ben

efit

year

de

duct

ible

20%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

-----

--Non

e---

---

Em

erge

ncy

med

ical

tra

nspo

rtatio

n

20%

coi

nsur

ance

af

ter b

enef

it ye

ar

dedu

ctib

le

20%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

-----

--Non

e---

---

35

Page

4 o

f 11

Com

mon

M

edic

al E

vent

Serv

ices

You

May

Nee

dYo

ur C

ost I

fYou

U

se a

n

In-n

etw

ork

Prov

ider

Your

Cos

t IfY

ou

Use

an

Out

-of-n

etw

ork

Prov

ider

Lim

itatio

ns &

Exc

eptio

ns

Urg

ent c

are

20%

coi

nsur

ance

af

ter b

enef

it ye

ar

dedu

ctib

le

20%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

-----

--Non

e---

---

If y

ou h

ave

a ho

spita

l st

ay

Faci

lity

fee

(e.g

., ho

spita

l ro

om)

20%

coi

nsur

ance

af

ter b

enef

it ye

ar

dedu

ctib

le

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

Pre-

auth

oriz

atio

n is

requ

ired.

Pen

alty

for n

ot

obta

inin

g pr

e-au

thor

izat

ion

is de

nial

of r

oom

and

bo

ard.

Pen

alty

app

lies t

o pr

ovid

ers i

n-ne

twor

k an

d m

embe

rs o

ut-o

f-ne

twor

k.

Phys

icia

n/su

rgeo

n fe

e 20

% c

oins

uran

ce

afte

r ben

efit

year

de

duct

ible

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

-----

--Non

e---

---

If y

ou h

ave

men

tal

heal

th, b

ehav

iora

l he

alth

, or s

ubst

ance

ab

use

need

s

Men

tal/

Beha

vior

al h

ealth

ou

tpat

ient

serv

ices

20%

coi

nsur

ance

af

ter b

enef

it ye

ar

dedu

ctib

le

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

Pre-

auth

oriz

atio

n is

requ

ired

exce

pt fo

r off

ice

visit

s. Pe

nalty

for n

ot o

btai

ning

pre

-aut

horiz

atio

n is

$500

. Pen

alty

app

lies t

o pr

ovid

ers i

n-ne

twor

k an

d m

embe

rs o

ut-o

f-ne

twor

k. E

AP

is lim

ited

to

3 C

ouns

elin

g se

ssio

ns o

r Life

Man

agem

ent

sess

ions

per

ben

efit

year

.

Men

tal/

Beha

vior

al h

ealth

in

patie

nt se

rvic

es

20%

coi

nsur

ance

af

ter b

enef

it ye

ar

dedu

ctib

le

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

Pre-

auth

oriz

atio

n is

requ

ired.

Pen

alty

for n

ot

obta

inin

g pr

e-au

thor

izat

ion

is de

nial

of r

oom

and

bo

ard.

Pen

alty

app

lies t

o pr

ovid

ers i

n-ne

twor

k an

d m

embe

rs o

ut-o

f-ne

twor

k.

Subs

tanc

e us

e di

sord

er

outp

atie

nt se

rvic

es

20%

coi

nsur

ance

af

ter b

enef

it ye

ar

dedu

ctib

le

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

Pre-

auth

oriz

atio

n is

requ

ired

exce

pt fo

r off

ice

visit

s. Pe

nalty

for n

ot o

btai

ning

pre

-aut

horiz

atio

n is

$500

. Pen

alty

app

lies t

o pr

ovid

ers i

n-ne

twor

k an

d m

embe

rs o

ut-o

f-ne

twor

k. E

AP

is lim

ited

to 3

C

ouns

elin

g se

ssio

ns o

r Life

Man

agem

ent s

essio

ns

per b

enef

it ye

ar.

Subs

tanc

e us

e di

sord

er

inpa

tient

serv

ices

20%

coi

nsur

ance

af

ter b

enef

it ye

ar

dedu

ctib

le

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

Pre-

auth

oriz

atio

n is

requ

ired.

Pen

alty

for n

ot

obta

inin

g pr

e-au

thor

izat

ion

is de

nial

of r

oom

an

d bo

ard.

Pen

alty

app

lies t

o pr

ovid

ers i

n-ne

twor

k an

d m

embe

rs o

ut-o

f-ne

twor

k.

If y

ou a

re p

regn

ant

Pren

atal

and

pos

tnat

al c

are

20%

coi

nsur

ance

af

ter b

enef

it ye

ar

dedu

ctib

le

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

-----

--Non

e---

---

36

Page

5 o

f 11

Com

mon

M

edic

al E

vent

Serv

ices

You

May

Nee

dYo

ur C

ost I

fYou

U

se a

n

In-n

etw

ork

Prov

ider

Your

Cos

t IfY

ou

Use

an

Out

-of-n

etw

ork

Prov

ider

Lim

itatio

ns &

Exc

eptio

ns

Del

iver

y an

d al

l inp

atie

nt

serv

ices

20%

coi

nsur

ance

af

ter b

enef

it ye

ar

dedu

ctib

le

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

Pre-

auth

oriz

atio

n is

requ

ired.

Pen

alty

for n

ot

obta

inin

g pr

e-au

thor

izat

ion

is de

nial

of r

oom

and

bo

ard.

Pen

alty

app

lies t

o pr

ovid

ers i

n-ne

twor

k an

d m

embe

rs o

ut-o

f-ne

twor

k.

37

Page

6 o

f 11

Com

mon

M

edic

al E

vent

Serv

ices

You

May

Nee

dYo

ur C

ost I

fYou

U

se a

n

In-n

etw

ork

Prov

ider

Your

Cos

t IfY

ou

Use

an

Out

-of-n

etw

ork

Prov

ider

Lim

itatio

ns &

Exc

eptio

ns

If y

ou n

eed

help

re

cove

ring

or h

ave

othe

r spe

cial

hea

lth

need

s

Hom

e he

alth

car

e 20

% c

oins

uran

ce

afte

r ben

efit

year

de

duct

ible

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

Pre-

auth

oriz

atio

n is

requ

ired.

Pen

alty

for n

ot

obta

inin

g pr

e-au

thor

izat

ion

is de

nial

of a

ll ch

arge

s. Pe

nalty

app

lies t

o pr

ovid

ers i

n-ne

twor

k an

d m

embe

rs o

ut-o

f-ne

twor

k.

Reh

abili

tatio

n se

rvic

es

20%

coi

nsur

ance

af

ter b

enef

it ye

ar

dedu

ctib

le

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

Ther

apy

visit

s (up

to 6

0 co

mbi

ned

per y

ear)

now

in

clud

e tre

atm

ent f

or c

hild

ren

with

aut

ism

(spe

ech,

cog

nitiv

e, p

hysic

al, o

ccup

atio

nal o

r oth

er

ther

apy)

. A

pplie

d Be

havi

oral

Ana

lysis

(ABA

) th

erap

y is

still

con

sider

ed in

vest

igat

iona

l and

is

not c

over

ed.

Chi

ropr

actic

visi

ts (u

p to

12

per

year

) are

cou

nted

sepa

rate

ly.

Reh

abili

tatio

n an

d H

abili

tatio

n se

rvic

es a

re c

ombi

ned.

Pr

e-au

thor

izat

ion

is re

quire

d. P

enal

ty fo

r not

ob

tain

ing

pre-

auth

oriz

atio

n is

$500

. Pen

alty

ap

plie

s to

prov

ider

s in-

netw

ork

and

mem

bers

ou

t-of-

netw

ork.

Hab

ilita

tion

serv

ices

20

% c

oins

uran

ce

afte

r ben

efit

year

de

duct

ible

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

Ther

apy

visit

s (up

to 6

0 co

mbi

ned

per y

ear)

now

in

clud

e tre

atm

ent f

or c

hild

ren

with

aut

ism

(spe

ech,

cog

nitiv

e, p

hysic

al, o

ccup

atio

nal o

r oth

er

ther

apy)

. A

pplie

d Be

havi

oral

Ana

lysis

(ABA

) th

erap

y is

still

con

sider

ed in

vest

igat

iona

l and

is

not c

over

ed.

Chi

ropr

actic

visi

ts (u

p to

12

per

year

) are

cou

nted

sepa

rate

ly.

Reh

abili

tatio

n an

d H

abili

tatio

n se

rvic

es a

re c

ombi

ned.

Pr

e-au

thor

izat

ion

is re

quire

d. P

enal

ty fo

r not

ob

tain

ing

pre-

auth

oriz

atio

n is

$500

. Pen

alty

ap

plie

s to

prov

ider

s in-

netw

ork

and

mem

bers

ou

t-of-

netw

ork.

Skill

ed n

ursin

g ca

re

20%

coi

nsur

ance

af

ter b

enef

it ye

ar

dedu

ctib

le

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

No

prio

r hos

pita

lizat

ion

requ

ired.

120

-day

co

mbi

ned

max

imum

visi

ts fo

r ski

lled

nurs

ing

faci

lity,

reha

bilit

atio

n ho

spita

l and

sub-

acut

e fa

cilit

ies.

Dur

able

med

ical

equ

ipm

ent

20%

coi

nsur

ance

af

ter b

enef

it ye

ar

dedu

ctib

le

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

Pre-

auth

oriz

atio

n is

requ

ired

for p

urch

ases

ove

r $1

,000

. Pen

alty

for n

ot o

btai

ning

pre

-au

thor

izat

ion

is de

nial

of a

ll ch

arge

s. Pe

nalty

ap

plie

s to

prov

ider

s in-

netw

ork

and

mem

bers

ou

t-of-

netw

ork.

38

Page

7 o

f 11

Com

mon

M

edic

al E

vent

Serv

ices

You

May

Nee

dYo

ur C

ost I

fYou

U

se a

n

In-n

etw

ork

Prov

ider

Your

Cos

t IfY

ou

Use

an

Out

-of-n

etw

ork

Prov

ider

Lim

itatio

ns &

Exc

eptio

ns

Hos

pice

serv

ice

20%

coi

nsur

ance

af

ter b

enef

it ye

ar

dedu

ctib

le

40%

coi

nsur

ance

afte

r be

nefit

yea

r ded

uctib

le

Lim

ited

to 6

mon

ths p

er m

embe

r per

ben

efit

year

. Pre

-aut

horiz

atio

n is

requ

ired.

Pen

alty

for n

ot

obta

inin

g pr

e-au

thor

izat

ion

for i

n-ne

twor

k an

d ou

t-of-

netw

ork

outp

atie

nt fa

cilit

ies i

s den

ial o

f all

char

ges.

If y

our c

hild

nee

ds

dent

al o

r eye

car

e

Eye

exa

m

Not

Cov

ered

N

ot C

over

ed

See

your

Em

ploy

er fo

r ben

efit

deta

ils.

Gla

sses

N

ot C

over

ed

N

ot C

over

ed

See

your

Em

ploy

er fo

r ben

efit

deta

ils.

Den

tal c

heck

-up

Not

Cov

ered

N

ot C

over

ed

See

your

Em

ploy

er fo

r ben

efits

det

ails.

Excl

uded

Ser

vice

s &

Oth

er C

over

ed S

ervi

ces:

Serv

ices

You

r Pla

n D

oes

NO

T C

over

(Thi

s is

n’t a

com

plet

e lis

t. C

heck

you

r pol

icy

or p

lan

docu

men

t for

oth

er e

xclu

ded

serv

ices

.)

•A

cupu

nctu

re

•C

osm

etic

surg

ery

•D

enta

l Car

e (A

dult)

•D

enta

l Car

e (C

hild

)

•H

earin

g A

ids

•In

ferti

lity

treat

men

t

•R

outin

e E

ye C

are

(Adu

lt)

•R

outin

e E

ye C

are

(Chi

ld)

•Lo

ng-te

rm c

are

•R

outin

e Fo

ot C

are

unle

ss in

the

case

of

diab

etes

or p

erip

hera

l vas

cula

r dise

ase,

whe

n m

edic

ally

nec

essa

ry.

Oth

er C

over

ed S

ervi

ces

(Thi

s is

n’t a

com

plet

e lis

t. C

heck

you

r pol

icy

or p

lan

docu

men

t for

oth

er c

over

ed s

ervi

ces

and

your

cos

ts fo

r the

se

serv

ices

.)

•Ba

riatri

c su

rger

y fo

r tre

atm

ent o

f clin

ical

ly

seve

re o

besit

y, a

s def

ined

by

the

body

mas

s in

dex

(BM

I) is

cov

ered

onl

y at

Blu

e D

istin

ctio

n C

ente

rs

•C

hiro

prac

tic c

are

•M

ost c

over

age

prov

ided

out

side

the

Uni

ted

Stat

es.

See

ww

w.s

outh

caro

linab

lues

.com

.

•N

on-e

mer

genc

y ca

re w

hen

trave

ling

outs

ide

the

U.S

.

•Pr

ivat

e-du

ty n

ursin

g

•W

eigh

t los

s pro

gram

(onl

y if

asso

ciat

ed w

ith

ap

prov

ed b

aria

tric

surg

ery)

39

Page

8 o

f 11

Your

Rig

hts

to C

ontin

ue C

over

age:

If y

ou lo

se c

over

age

unde

r the

pla

n, th

en, d

epen

ding

upo

n th

e ci

rcum

stan

ces,

Fede

ral a

nd S

tate

law

s may

pro

vide

pro

tect

ions

that

allo

w y

ou to

kee

p he

alth

cov

erag

e. A

ny su

ch ri

ghts

may

be

limite

d in

dur

atio

n an

d w

ill re

quire

you

to p

ay a

pre

miu

m, w

hich

may

be

signi

fican

tly h

ighe

r tha

n th

e pr

emiu

m

you

pay

whi

le c

over

ed u

nder

the

plan

. Oth

er li

mita

tions

on

your

righ

ts to

con

tinue

cov

erag

e m

ay a

lso a

pply

.

For m

ore

info

rmat

ion

on y

our r

ight

s to

cont

inue

cov

erag

e, c

onta

ct th

e pl

an a

t 1-8

77-7

05-5

428.

You

may

also

con

tact

you

r sta

te in

sura

nce

depa

rtmen

t, th

e U

.S. D

epar

tmen

t of

Labo

r, E

mpl

oyee

Ben

efits

Sec

urity

Adm

inist

ratio

n at

1-8

66-4

44-3

272

or w

ww

.dol

.gov

/ebs

a, o

r th

e U

.S. D

epar

tmen

t of

Hea

lth a

nd

Hum

an S

ervi

ces a

t 1-8

77-2

67-2

323

x615

65 o

r ww

w.c

ciio

.cm

s.gov

. Yo

ur G

rieva

nce

and

App

eals

Rig

hts:

If

you

hav

e a

com

plai

nt o

r are

diss

atisf

ied

with

a d

enia

l of c

over

age

for c

laim

s und

er y

our p

lan,

you

may

be

able

to a

ppea

l or f

ile a

grie

vanc

e. F

or

ques

tions

abo

ut y

our r

ight

s, th

is no

tice,

or a

ssist

ance

, you

can

con

tact

any

or a

ll of

the

follo

win

g:

•1-

877-

705-

5428

or v

isit u

s at w

ww

.sou

thca

rolin

ablu

es.c

om

•Th

e D

epar

tmen

t of L

abor

’s E

mpl

oyee

Ben

efits

Sec

urity

Adm

inist

ratio

n at

1-8

66-4

44-E

BSA

(327

2) o

r ww

w.d

ol.g

ov/e

bsa/

heal

thre

form

The

Affo

rdab

le C

are

Act N

otic

es:

•Th

e A

ffor

dabl

e C

are

Act

requ

ires m

ost p

eopl

e to

hav

e he

alth

car

e co

vera

ge th

at q

ualif

ies a

s “m

inim

um e

ssen

tial c

over

age.

” T

his p

lan

does

pr

ovid

e m

inim

um e

ssen

tial c

over

age.

•Th

e A

ffor

dabl

e C

are

Act

est

ablis

hes a

min

imum

val

ue st

anda

rd o

f ben

efits

of a

hea

lth p

lan.

The

min

imum

val

ue st

anda

rd is

60

perc

ent (

actu

aria

l va

lue)

. Th

is he

alth

cov

erag

e do

es m

eet t

he m

inim

um v

alue

stan

dard

for t

he b

enef

its it

pro

vide

s.

40

Page

9 o

f 11

Lang

uage

Acc

ess

Serv

ices

:

•Sp

anish

: Pa

ra o

bten

er a

siste

ncia

en

espa

ñol,

llam

e al

núm

ero

de a

tenc

ión

al c

lient

e qu

e ap

arec

e en

la p

rimer

a pá

gina

de

esta

not

ifica

ción

.

•Ta

galo

g: U

pang

mak

akuh

a ng

tulo

ng sa

Tag

alog

, taw

agan

ang

num

ero

ng c

usto

mer

serv

ice

na m

akik

ita sa

una

ng p

ahin

a ng

pau

naw

ang

ito.

•N

avaj

o:

•C

hine

se: 如需中文服务，请致电列于本通知首页的客户服务号码。

–––

––––

––––

––––

––––

–––T

o see

exam

ples o

f how

this

plan

migh

t cov

er cos

ts for

a sa

mple

medi

cal s

ituat

ion, s

ee th

e nex

t pag

e.–––

––––

––––

––––

––––

––

41

Page

10

of 1

1

Hav

ing

a ba

by

(nor

mal

del

iver

y)

Man

agin

g ty

pe 2

dia

bete

s (ro

utin

e m

aint

enan

ce o

f a

wel

l-con

trolle

d co

nditi

on)

Abo

ut th

ese

Cov

erag

e Ex

ampl

es:

Thes

e ex

ampl

es sh

ow h

ow th

is pl

an m

ight

cov

er

med

ical

car

e in

giv

en si

tuat

ions

. Use

thes

e ex

ampl

es to

see,

in g

ener

al, h

ow m

uch

finan

cial

pr

otec

tion

a sa

mpl

e pa

tient

mig

ht g

et if

they

are

co

vere

d un

der d

iffer

ent p

lans

.

A

mou

nt o

wed

to p

rovi

ders

: $7,

540

Pl

an p

ays

$4,7

30

Patie

ntpa

ys $

2,81

0

Sam

ple

care

cos

ts:

Hos

pita

l cha

rges

(mot

her)

$2,7

00

Rou

tine

obst

etric

car

e $2

,100

H

ospi

tal c

harg

es (b

aby)

$9

00

Ane

sthe

sia

$900

La

bora

tory

test

s $5

00

Pres

crip

tions

$2

00

Rad

iolo

gy

$200

V

acci

nes,

othe

r pre

vent

ive

$40

Tot

al

$7,5

40

Patie

ntpa

ys:

Ded

uctib

les

$1,5

00

Cop

ays

$0

Coi

nsur

ance

$1

,160

Li

mits

or e

xclu

sions

$1

50

Tot

al

$2,8

10

Thes

e nu

mbe

rs a

ssum

e th

e pa

tient

has

gi

ven

notic

e of

her

pre

gnan

cy to

the

plan

. If

you

are

preg

nant

and

hav

e no

t gi

ven

notic

e of

you

r pre

gnan

cy, y

our

cost

s m

ay b

e hi

gher

. Fo

r mor

e in

form

atio

n, p

leas

e co

ntac

t: 1-

877-

705-

5428

.

A

mou

nt o

wed

to p

rovi

ders

: $5,

400

Pl

an p

ays

$2,9

50

Patie

nt p

ays

$2,4

50

Sam

ple

care

cos

ts:

Pres

crip

tions

$2

,900

M

edic

al E

quip

men

t and

Sup

plie

s $1

,300

O

ffic

e V

isits

and

Pro

cedu

res

$700

E

duca

tion

$300

La

bora

tory

test

s $1

00

Vac

cine

s, ot

her p

reve

ntiv

e $1

00

Tot

al

$5,4

00

Patie

nt p

ays:

Ded

uctib

les

$1,5

00

Cop

ays

$0

Coi

nsur

ance

$8

70

Lim

its o

r exc

lusio

ns

$80

Tot

al

$2,4

50

This

is

nota

cos

t es

timat

or.

Don

’t us

e th

ese

exam

ples

to

estim

ate

your

act

ual c

osts

un

der t

his p

lan.

The

act

ual

care

you

rece

ive

will

be

diff

eren

t fro

m th

ese

exam

ples

, and

the

cost

of

that

car

e w

ill a

lso b

e di

ffer

ent.

See

the

next

pag

e fo

r im

porta

nt in

form

atio

n ab

out

thes

e ex

ampl

es.

42

1

1of

11

Que

stio

ns: C

all 1

-877

-705

-542

8 or

visi

t us a

t ww

w.s

outh

caro

linab

lues

.com

. For

EA

P ca

ll 1-

800-

968-

8143

or v

isit u

s at w

ww

.firs

tsun

eap.

com

. If

you

are

n’t c

lear

abo

ut a

ny o

f the

und

erlin

ed te

rms

used

in th

is fo

rm, s

ee th

e G

loss

ary.

You

can

vie

w th

e G

loss

ary

at

http

://w

ww

.dol

.gov

/ebs

a/pd

f/SB

CU

nifo

rmG

loss

ary.

pdf o

r cal

l 1-8

77-7

05-5

428

to re

ques

t a c

opy.

Bl

ueC

ross

Blu

eShi

eld

of S

outh

Car

olin

a is

an in

depe

nden

t lic

ense

e of

the

Blue

Cro

ss a

nd B

lue

Shie

ld A

ssoc

iatio

n

Que

stio

ns a

ndan

swer

sab

out t

he C

over

age

Exam

ples

:

Wha

t are

som

e of

the

assu

mpt

ions

beh

ind

the

Cov

erag

e Ex

ampl

es?

•C

osts

don

’t in

clud

e pr

emiu

ms.

•

Sam

ple

care

cos

ts a

re b

ased

on

natio

nal

aver

ages

supp

lied

by th

e U

.S.

Dep

artm

ent o

f Hea

lth a

nd H

uman

Se

rvic

es, a

nd a

ren’

t spe

cific

to a

pa

rticu

lar g

eogr

aphi

c ar

ea o

r hea

lth p

lan.

•

The

patie

nt’s

cond

ition

was

not

an

excl

uded

or p

reex

istin

g co

nditi

on.

•A

ll se

rvic

es a

nd tr

eatm

ents

star

ted

and

ende

d in

the

sam

e co

vera

ge p

erio

d.

•Th

ere

are

no o

ther

med

ical

exp

ense

s for

an

y m

embe

r cov

ered

und

er th

is pl

an.

•O

ut-o

f-po

cket

exp

ense

s are

bas

ed o

nly

on tr

eatin

g th

e co

nditi

on in

the

exam

ple.

•

The

patie

nt re

ceiv

ed a

ll ca

re fr

om in

-ne

twor

k pr

ovid

ers.

If t

he p

atie

nt h

ad

rece

ived

car

e fr

om o

ut-o

f-ne

twor

k pr

ovid

ers,

cos

ts w

ould

hav

e be

en h

ighe

r.

Wha

t doe

s a

Cov

erag

e Ex

ampl

e sh

ow?

For e

ach

treat

men

t situ

atio

n, th

e C

over

age

Exa

mpl

e he

lps y

ou se

e ho

w d

educ

tible

s,

copa

ymen

ts, a

nd c

oins

uran

ce c

an a

dd u

p. It

al

so h

elps

you

see

wha

t exp

ense

s mig

ht b

e le

ft up

to y

ou to

pay

bec

ause

the

serv

ice

or

treat

men

t isn

’t co

vere

d or

pay

men

t is l

imite

d.

Doe

s th

e C

over

age

Exam

ple

pred

ict m

y ow

n ca

re n

eeds

?

N

o. T

reat

men

ts sh

own

are

just

exa

mpl

es.

The

care

you

wou

ld re

ceiv

e fo

r thi

s co

nditi

on c

ould

be

diff

eren

t bas

ed o

n yo

ur

doct

or’s

advi

ce, y

our a

ge, h

ow se

rious

you

r co

nditi

on is

, and

man

y ot

her f

acto

rs.

Doe

s th

e C

over

age

Exam

ple

pred

ict m

y fu

ture

exp

ense

s?

N

o. C

over

age

Exa

mpl

es a

re n

ot c

ost

estim

ator

s. Y

ou c

an’t

use

the

exam

ples

to

estim

ate

cost

s for

an

actu

al c

ondi

tion.

Th

ey a

re fo

r com

para

tive

purp

oses

onl

y.

You

r ow

n co

sts w

ill b

e di

ffer

ent d

epen

ding

on

the

care

you

rece

ive,

the

pric

es y

our

prov

ider

s ch

arge

, and

the

reim

burs

emen

t yo

ur h

ealth

pla

n al

low

s.

Can

I us

e C

over

age

Exam

ples

to c

ompa

re p

lans

?

Y

es. W

hen

you

look

at t

he S

umm

ary

of

Bene

fits a

nd C

over

age

for o

ther

pla

ns,

you’

ll fin

d th

e sa

me

Cov

erag

e E

xam

ples

. W

hen

you

com

pare

pla

ns, c

heck

the

“Pat

ient

Pay

s” b

ox in

eac

h ex

ampl

e. T

he

smal

ler t

hat n

umbe

r, th

e m

ore

cove

rage

th

e pl

an p

rovi

des.

Are

ther

e ot

her c

osts

I sh

ould

co

nsid

er w

hen

com

parin

g pl

ans?

Y

es. A

n im

porta

nt c

ost i

s the

pre

miu

m

you

pay.

Gen

eral

ly, t

he lo

wer

you

r pr

emiu

m, t

he m

ore

you’

ll pa

y in

out

-of-

pock

et c

osts

, suc

h as

cop

aym

ents

, de

duct

ible

s, a

nd c

oins

uran

ce. Y

ou

shou

ld a

lso c

onsid

er c

ontr

ibut

ions

to

acco

unts

such

as h

ealth

savi

ngs a

ccou

nts

(HSA

s), f

lexi

ble

spen

ding

arr

ange

men

ts

(FSA

s) o

r hea

lth re

imbu

rsem

ent a

ccou

nts

(HR

As)

that

hel

p yo

u pa

y ou

t-of-

pock

et

expe

nses

.


Benefits: The items or services covered by your health insurance plan.

Claim: A request for payment that you or your health care provider submits to your health insurance company after you receive services.

Coinsurance: Your share of the costs for a covered health care service, calculated as a percentage. You pay coinsurance plus any deductibles you owe. For example, say your health plan’s allowed amount for an office visit is $100 and you’ve met your deductible. Your coinsurance payment of 20 percent would be $20. Your health plan pays the rest of the allowed amount.

Deductible: The amount you pay for services received before your health plan begins to pay. For example, if your deductible is $1,000, your health plan will not pay for covered services until you’ve met the $1,000 deductible. After that, your health plan will pay for all covered services until the end of that benefit year.

Dependent: A child, spouse or other family member covered by a subscriber’s health plan. For example, an employer- sponsored health plan may cover the employee (subscriber), plus the employee’s spouse and their children (dependents).

Facility: The location where you receive health care services. For example, a medical facility could be a doctor’s office or a hospital.

Network: The facilities, providers and suppliers your health plan contracts with to provide health care services. You will typically pay less for services received in network versus out of network.

Out of pocket: These are your costs for medical care expenses that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance and copayments for covered services plus all costs for services that aren’t covered.

Subscriber: The person who enrolls in a health plan. There is only one subscriber per health plan. The subscriber can add eligible dependents to a family health plan.

Preauthorization: A decision that a service or type of treatment is medically necessary. Certain services require preauthorization before you receive them, except in an emergency. You may also hear this referred to as precertification or prior authorization.

Premium: The amount you pay for your health plan, usually biweekly or monthly.

Preventive services: Routine health care that includes screenings, checkups and counseling to prevent illnesses or other health problems.

Provider: This can refer to the medical professional who delivers care or the location where you receive health care services. For example, your provider could be a doctor, specialist, nurse practitioner or hospital.

Primary care physician (PCP): The main doctor and prima-ry contact for your health care services. Your PCP coordinates care if you need to see other doctors or medical specialists.

Radiology: Procedures such as X-rays, ultrasounds and magnetic resonance imaging (MRI) that are used to detect medical conditions.

Specialist: A doctor or health care professional who focuses on a specific area of medicine. For example, pediatricians, dermatologists and cardiologists are specialists.

Sometimes health care lingo can be confusing. But it’s important to understand your

health benefits and how they work. Here are some common terms to help.

Helpful terms: Words commonly used in health care


Spousal coverage is available only if the SCANA participant’s spouse does not have access to employer-sponsored group health care through his or her former or current employer.

Access to sponsored health care

What does access to sponsored health care mean? Access means that your spouse has the ability to receive health care through a former or current employer, or through a self-employed plan offered to all employees of the company.

Access does not include

• Individual health care plans your spouse purchases as a self-employed person.

• Plans available through membership in a trade or professional organization

Some common examples

Spouse has access to employer-sponsored care Spouse is a teacher and has access to the state’s health plan. You would not be able to cover him/her under SCANA’s plan.

Self-employed spouses who have/or do not have medical plans in their businesses Spouse is a freelance nurse who works for a hospital and is not offered a group medical plan by the hospital. You would be able to cover him/her under SCANA’s plan.

Spouse is a self-employed home builder who employs 12 people and offers a group medical plan to them but elects SCANA coverage You would not be able to cover him/her under SCANA’s plan.

Spouse has access to Medicare or TRICARE For Life Spouse is retired from the Army and has access to TRICARE For Life. You would be able to cover him/her under SCANA’s plan.

Professional associations that offer access to coverage Spouse works as a commercial artist and can purchase medical insurance through a national art guild, of which she is a member. You would be able to cover him/her under SCANA’s plan.

Spousal coverage

If you are a SCANA employee on SCANA’s medical plan and are electing to provide medical coverage for your spouse under SCANA’s health care plan, you will be required to certify that your spouse does not have access to employer-sponsored group medical coverage.

Providing false or misleading information related to this provision may result in loss of coverage under this Plan for you and your dependents retroactive to the date you provided the false or misleading information. You may also be required to repay any amounts paid by the Plan for you and your dependent(s) since you provided the false or misleading information, or if greater, the company share of the premium.


PLEASE PRINT IN INK OR TYPE

Employee Name ________________________________________________ Social Security Number __________________

Address/Mail Code _________________________________________________ Your Employee ID # _________________

Employees wanting to add or change dependent information associated with their benefits coverage must forward the required documentation* to the Employee Resource Center at MC C131 for updates to be made. If you add a dependent or spouse to your insurance coverage, this documentation is required first:

• Adding a spouse – a copy of a marriage license, Social Security card and proof of joint ownership (federal/state tax return, mortgage statement, bank statement, lease agreement, credit card statement, property tax, etc.)

• Adding a dependent – a copy of long form birth certificate and Social Security card

Dependent Information

Name Birthdate SSN RelationMedical

Y/NDental

Y/NLife Ins.

Y/N

I am responsible for the accuracy of the information submitted above and for notifying SCANA of any changes in my spouse’s eligibility for other coverage within 31 days of that change by submitting another Spousal Health Coverage Affidavit to the Benefits Team. I understand that any false information submitted is a violation of SCANA’s Code of Conduct and will be subject to disciplinary action up to and including termination of employment. I also understand that I will not receive a refund for any premiums paid as a result of false information.

Signature:_________________________________________________________ Date: _____________________________

SUBMIT FORM AND REQUIRED DOCUMENTATION TO 220 Operation Way MC C131 Cayce, SC 29033

* Additions/changes will not be made without receipt of this information.

SCANA Corporation Dependent Change FormSee page 31 for definitions of eligible dependents.


PLEASE PRINT IN INK OR TYPE

Employee Name ________________________________________________ Social Security Number __________________

Address/Mail Code _________________________________________________ Your Employee ID # _________________

I reserve the right to change this designation at any time. I revoke any and all previous beneficiary designations prior to the effective date shown below.

TYPES OF BENEFICIARY

1 = Regular or Sole Beneficiary

2 = Co-Beneficiary – Share as Specified

3 = Contingent Beneficiary – To receive in the event of the death of the primary beneficiary.

If more than one contingent beneficiary is designated, payment will be made in equal shares or all to the last survivor.

Designate the distribution of the proceeds as a percentage of the total amount.

Beneficiary Name/AddressThe information below is required for benefit assignment.

Type of Beneficiary

(1, 2, 3)

Whole Percentages

Only

Name _________________________________

Address _______________________________

______________________________________

Date of Birth _____________________

Relationship ______________________

SS# ____________________________

Name _________________________________

Address _______________________________

______________________________________

Date of Birth _____________________

Relationship ______________________

SS# ____________________________

Name _________________________________

Address _______________________________

______________________________________

Date of Birth _____________________

Relationship ______________________

SS# ____________________________

Signature ______________________________________________________ Effective Date ________________________

RETURN TO 220 Operation Way MC C131 Cayce, SC 29033

SCANA Corporation Life Insurance Beneficiary Form

Mail this form to:

Enter ID # below if not shown or if different from above

Number of New prescriptions:

Number of Refill prescriptions:

Please use blue or black ink, capital letters, and fill in both sides of this form.

Shipping Address. To ship to an address different from the one printed above, please make changes here.

New Prescriptions - Mail your new prescriptions with this form.

Refills - Order by Web, phone, or write in Rx number(s) below.

We may package all of these prescriptions together unless you tell us not to.

Refills. To order mail service refills, enter your prescription number(s) here.

A

B

Use this addressfor this order only.

Apt./Suite #

City State ZIP Code

Street Name

-- --Daytime Phone #: Evening Phone #:

Last Name First Name MI Suffix (JR, SR)

1) 2) 3) 4)

5) 6) 7) 8)

Prescription Plan Sponsor or Company Name

BC 27131

CAREMARK PO BOX 94467PALATINE, IL 60094-4467

On behalf of BlueCross, Caremark assists in the administration of the prescription drug program. Caremark is an independent company that provides pharmacy benefits management.

.

Tell us about the people getting prescriptions. If there are more than two people, please complete another form.

1st person with a refill or new prescription. This person needs: Easy open caps Spanish forms and labels

Tell us about new allergies or health information for this person. Only tell us about new information.Allergies:

Health Information:

Special Instructions:

Electronic Check. Pay from your bank account. First time users register online or call Customer Care.

Bill Me Later®. Works like a credit card. First time users register online or call Customer Care.

Credit or Debit Card. (VISA®, MasterCard®, Discover®, or American Express®)Fill in this oval to use your card on file.Fill in this oval to use a new card or to update your card expiration date.

Check or Money Order. Amount: $Regular delivery is free and will take 7 to 10days from the day you send this form.

• Faster delivery charges may change.• Faster delivery is for shipping time, not processing time.• Faster delivery can only be sent to a street address, not a PO box.

C

D

How would you like to pay for this order? Fill in the oval to choose a payment.E

2nd person with a refill or new prescription. This person needs: Easy open caps Spanish forms and labels

ErythromycinCephalosporin CodeineAspirinNoneSulfa Other:

Peanuts

Arthritis Asthma Diabetes Acid Reflux GlaucomaHigh Blood PressureOther:

High Cholesterol Migraine Osteoporosis Prostate Issues

Penicillin

Heart ProblemThyroid

Gender: M F Date of Birth:Date new prescription written:

Doctor’s Last Name Doctor’s First Name Doctor’s Phone #

Tell us about new allergies or health information for this person. Only tell us about new information.Allergies:

Health Information:

ErythromycinCephalosporin CodeineAspirinNoneSulfa Other:

Peanuts

Arthritis Asthma Diabetes Acid Reflux GlaucomaHigh Blood PressureOther:

High Cholesterol Migraine Osteoporosis Prostate Issues

Penicillin

Heart ProblemThyroid

Gender: M F Date of Birth:Your E-Mail:

Your E-Mail:

Date new prescription written:

Doctor’s Last Name Doctor’s First Name Doctor’s Phone #

Fill in this oval if you DO NOT want to use this payment method for future orders.

2nd Business Day ($17)Next Business Day ($23)

If you want faster delivery, choose:

Credit Card Holder Signature/Date

Exp.Date

Suffix(JR,SR)

Suffix(JR,SR)

Business days are only

Monday-Friday


Benefit 2017 Options

Medical SCANA Choice PlanWaive

Spousal coverage m Yes, I am electing to cover my spouse under SCANA’s medical plan and certify that my spouse does not have access to employer-sponsored group medical coverage. I understand that any false information submitted is a violation of SCANA’s Code of Conduct and will be subject to disciplinary action up to and including termination of employment

Dental ComprehensiveWaive

Vision Waive

Supplemental Life (up to 6x base pay) Evidence of Insurability may be required

1x 2x 3x 4x 5x 6x

Supplemental AD&D (up to 2x base pay)

1x 2x

Spouse life Evidence of Insurability required

$10,000 $20,000 $50,000 $100,000

Dependent life (same rate regardless of number of dependents)

Elect Waive

Short-term disability Buy up to 100% base pay replacement for up to 6 weeks

Do not buy up

Long-term disability Buy up to 66 2/3% base pay replacement Do not buy up

Health savings account (HSA) eligibility

m Yes, I am eligible for a health savings account because I am: • Not covered by any other health plan, including my spouse’s health insurance • Not receiving benefits from my own or my spouse’s Health Care FSA • Not enrolled (or have already disenrolled) from any part of Medicare or TRICARE • Have not received Veteran’s medical benefits in the past 90 days • Not claimed as a dependent on another person’s tax return

HSA contribution Annual contribution = $____________ Waive contribution

Dependent care flexible spending account (FSA) contribution

Annual contribution = $____________ Waive contribution

Health care flexible spending account (FSA) contributionAvailable if you waive medical coverage or are not eligible to contribute to an HSA

Annual contribution = $____________ Waive contribution

Go paperless m Yes, I currently receive paper copies of benefits communications (i.e., summary plan descriptions and documents required to be furnished under Section 104(b)(4) of ERISA). I agree to go paperless, with the understanding that I can request a paper copy of a communication at any time by calling 803-217-4444.

Enrollment Checklist for:Employee Name: _______________________________________ Employee ID: _______________

Use the list below to circle your 2017 benefit elections.

For a summary of your current benefits coverage, log in to PeopleSoft (HR) and choose “View Current Benefit Elections” under My Health.

Employee only

Employee/ Spouse

Employee/ Dependents

Employee/ Family

Employee only

Employee/ Spouse


Employee/ Family

Employee only

Employee/ Spouse


Employee/ Family

53

Clip and keep this wallet card.#

When you need medical advice call

877-705-5428 Reliable health care answers

A service brought to you by

24-hour Customer Service

Contact Information

Topic Resource Phone Website

Health, wealth and career related questions

Employee Resource Center 803-217-4444 The Edge

24-hour customer serviceBlueCross BlueShield of South Carolina Customer Service

877-705-5428SouthCarolinaBlues.com My Health Toolkit

Prescription costs, drug lists SCANA Pharmacy803-217-9173 866-769-9039

Health on The Edge

Mail-order prescriptions Caremark Mail Order Pharmacy 888-963-7290 SouthCarolinaBlues.com

Specialty drugs CVS Specialty Pharmacy 800-237-2767 SouthCarolinaBlues.com

Health savings account HSA Bank 800-357-6246 hsabank.com

Flexible spending account WageWorks 877-924-3967FSAworks4me.com wageworks.com

Employee Assistance Program First Sun EAP 800-968-8143 www.FirstSunEAP.com

Disability and FMLA MetLife 877-638-8262 Health on The Edge

Financial planning for spending/savings accounts and benefits coverage

Ernst & Young 866-724-1946 SCANA.eyfpc.com

Two BlueCross representatives are on site at SCANA during normal business hours to help you with your benefits needs.

Visit

www.EyeMedVisionCare.comOr call 866-723-0513.*

* When calling, please provide your full name and date of birth. EyeMed Vision Care is an independent company that offers vision benefits on behalf of your health plan.

Clip and keep this wallet card.#

Questions about your vision benefits?

A service brought to you by

54SCANA-19259-9-2016BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.

We are excited to have you as part of the BlueCross

family. Our goal is to help you get the most out of your

benefit plan. Getting more information or answers to

your questions is easy. Simply visit us online at

www.SouthCarolinaBlues.com

SCANA Corporation 2017 Benefits...SCANA reserves the right at will to change or terminate any of the...

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